Lisa Kearney, PhD
Chairman Coffman, Ranking Member Kirkpatrick, and members of the Committee, thank you for the opportunity to appear before you today to discuss access to treatment for Veterans who have suffered from a Traumatic Brain Injury (TBI) or Posttraumatic Stress Disorder (PTSD) once they returned home. I am joined today by
Dr. Joel Scholten, National Director of Special Projects, Physical Medicine and Rehabilitation Service, VHA, Mr. Jonathan H. Gardner, Medical Center, Director Southern Arizona VA Health Care System (SAVAHCS), Mr. Joshua Redlin, Team Leader, Tucson Vet Center, and Mr. Rod Sepulveda, Rural Health Program Manager Northern Arizona VA Health Care System.
VHA TBI Program
VHA provides state-of-the-art comprehensive health care and support services for Veterans with both combat and civilian-related TBI, leveraging its nationwide resources through the Polytrauma System of Care (PSC). Through this program, the Department continues to advance the evaluation, treatment, and understanding of TBI in a variety of ways by developing and implementing best clinical practices for TBI; collaborating with strategic partners including Veterans Service Organizations, community rehabilitation providers, and academic affiliates; providing education and training in TBI-related care and rehabilitation; and conducting research and translating findings into improved clinical care. In fiscal year (FY) 2013, VA invested $231 million in TBI care for Veterans. Of this amount, $49 million was for care of Veterans of Operation Enduring Freedom, Operation Iraqi Freedom, and Operation New Dawn (OEF/OIF/OND).
All OEF/OIF/OND Veterans who receive health care within VA are screened for possible TBI, and from April 13, 2007, through December 31, 2013, over 804,000 OEF/OIF/OND Veterans have been screened. More than 151,000 of these Veterans screened positive for possible TBI and were referred for comprehensive TBI evaluations by specialty teams; over 65,000 of these screened Veterans were diagnosed with sustained mild TBI (mTBI) and received appropriate follow-on care. Veterans, who were initially screened positive but were later determined not to have TBI, were referred for medical follow up as appropriate for their condition. Veterans with moderate to severe TBI receive initial diagnosis and treatment on inpatient hospital wards. Patients who were diagnosed as having sustained a TBI and continued to experience chronic problems requiring rehabilitation and treatment received an Individualized Rehabilitation and Community Reintegration Plan of Care to help coordinate services across episodes and sites of care. In this way, problems that may be related to TBI and polytrauma are addressed early on and proactively so they can be managed effectively before they become chronic disabilities.
The PSC has a four-tier design that ensures access to the appropriate level of rehabilitation services based on the needs of the Veterans recovering from TBI and multiple, co-occurring injuries (i.e., polytrauma). This system of care includes:
- 5 regional Polytrauma Rehabilitation Centers, that serve as regional referral centers for acute medical and rehabilitation care and as hubs for research and education;
- 23 Polytrauma Network Sites (PNS), that coordinate polytrauma services within the Veterans Integrated Service Networks;
- 87 Polytrauma Support Clinic Teams who provide specialized evaluation, treatment, and community reintegration services within their catchment areas; and
- 39 Polytrauma Points of Contact who deliver a more limited range of rehabilitation services and facilitate referrals to the other PSC programs, as necessary.
The tiered model of the PSC helps ensure that Veterans with TBI and polytrauma transition seamlessly between the Department of Defense (DoD) and VHA, and back to their home communities through the provision of evidenced-based rehabilitation services and care coordination.
VHA PTSD Treatment
VA is one of the largest integrated health care systems in the United States that provides specialized mental health treatment for PTSD. In FY 2013, over 530,000 Veterans (including over 140,000 OEF/OIF/OND) received treatment for PTSD in VA medical centers and clinics, up from just over 500,000 Veterans (including over 100,000 OEF/OIF/OND) in FY 2011. VA provides care for PTSD in a variety of settings including inpatient, residential, as well as specialty PTSD outpatient programs and general outpatient care.
VA provides state-of-the-art care for Veterans with PTSD delivered by more than 5,200 VA mental health providers who have received training in Prolonged Exposure and/or Cognitive Processing Therapy, the most effective known therapies for PTSD. Medication treatments also are offered and may be especially helpful for specific symptoms of PTSD.
VA operates a National Center for PTSD (NCPTSD) that provides research, consultation, and education to clinicians, Veterans, family members and researchers. The national PTSD Mentoring Program, which works with every specialty PTSD program across the country is designed to promote evidence-based practice within VA. NCPTSD’s award winning PTSD Web site (www.ptsd.va.gov) provides research-based educational materials for Veterans and families, as well as for the providers who care for them. To help Veterans access needed care, AboutFace, which can be found at http://www.ptsd.va.gov/apps/AboutFace/ was added in 2012, is an online video gallery dedicated to Veterans talking about how PTSD treatment turned their lives around. Each June, NCPTSD runs a national campaign to raise awareness about PTSD and its effective treatment during PTSD awareness month. NCPTSD’s Consultation Program was established in 2011 to reach any VA provider who treats Veterans with PTSD, including those in VA PTSD specialty care, those in other areas of mental health, primary care providers, and case managers. The Consultation Program helps with questions about assessment and treatment services for Veterans with PTSD. By the end of FY 2013, there were over 650 consultations completed, over 550 for PTSD and over 75 for Suicide Risk Management, a feature added this year to the Consultation Program.
Interdisciplinary Pain Management
There has been an ongoing and broadening collaborative approach within the National Pain Management Program Office, Rehabilitation and Prosthetic Services (RPS), Primary Care Services, Mental Health Services, Specialty Care Services and Nursing Services to educate the field on the stepped-care model for pain management. On December 15, 2010, the Under Secretary for Health chartered the Interdisciplinary Pain Management Workgroup to assist Veterans Integrated Service Network (VISN) Directors in establishing which specialty pain services will be available to all Veterans and how best to determine the need for tertiary pain care and pain rehabilitation services. The Pain Medicine Specialty Team Workgroup, chartered on January 26, 2012, is providing support to Patient Aligned Care Teams (PACT)/primary care and pain specialty care services through collaborative care models and participation in provider and team education through telehealth, e-consults, and Specialty Care Access Network-Extension for Community Healthcare Outcomes (SCAN-ECHO). VA SCAN-ECHO experts provide didactics and case-based learning to PACT members using videoconferencing technologies to strengthen the competencies of providers in pain management.
As of January 2014, VA has ten sites in seven VISNs with Commission on Accreditation of Rehabilitation Facilities-accredited pain programs. RPS has collaborated with the Employee Education System to provide a wide variety of TBI and pain- related training offerings to all VA clinicians at their desktop via VA’s Talent Management System, including handouts, management algorithms, video lectures and workshops, and training courses. Other ongoing training venues available to primary care clinicians and nurses include:
- Conference calls and training
- Post-Deployment Integrated Care Initiative (PDICI) Community of Practice (CoP)
- Pain PACT CoP (monthly)
- PSC/TBI System of Care
- Primary Care Mental Health Integration
- Health Services Research and Development (HSR&D) “Spotlight on Pain Management” calls
- List serve Web sites (Physical Medicine and Rehabilitation Program Office Web site, Pain Management Program Office, PDICI Wiki on
- SharePoint sites (Primary Care Staff Educational Resources SharePoint for PACT, OEF/OIF/OND National SharePoint)
- Training applications for clinicians on smart phones and tablets (TBI APP available 4th Quarter of 2013 and T2 mTBI Pocket Guide)
SAVAHCS Mental Health Services
SAVAHCS, in Tucson, Arizona, provides comprehensive mental health services to Veterans in the Tucson metropolitan areas and Southern Arizona. These services include Inpatient Psychiatry, the Evaluation and Brief Treatment of PTSD Unit (EBTPU), Inpatient Geropsychiatry, Primary Care-Mental Health Integration (PC-MHI), Opioid Replacement Treatment, Substance Use Disorder Treatment Programs (SUD-TP), Substance Abuse Residential Treatment Program (SARRTP), General Outpatient Mental Health, Outpatient Primary Care for Seriously Mentally Ill (SMI) Veterans, Homeless programs, Mental Health Intensive Case Management (MHICM), and Psychosocial Rehabilitation and Recovery Center (PRRC).
SAVAHCS monitors access to mental health clinics and programs to enhance access for our Veterans. Access to mental health services is managed through
PC-MHI. This program supports Primary Care PACT by providing a Mental Health psychiatrist and a team of social workers who are co-located in Primary Care Clinics. This team provides same day management of Veterans’ mental health concerns thus reducing time and location barriers to access to care. In FY 2013, the SAVAHCS PC-MHI served 5,168 unique patients. This included 15,699 PC-MHI clinical encounters and 2,752 new PC-MHI patients. In FY 2013, PC-MHI exceeded all Mental Health Screening performance measures related to alcohol use, post-traumatic stress disorder, and depression. In FY 2013, the Mental Health Clinic at SAVAHCS provided 28,003 encounters and treated 7,233 unique patients.
SAVAHCS has established strong relationships with the community. On
August 14, 2013, SAVAHCS hosted a Mental Health Summit which focused on coordination of care for homeless Veterans, and access to mental health services for Veterans and their families. Over 90 community participants attended this summit and provided valuable information about resources available to Veterans in the community. SAVAHCS will be hosting another Mental Health Summit in August 2014 with a focus on mental health access. In addition, SAVAHCS will be hosting a Homeless Summit in May 2014 which will bring together community partners and SAVAHCS staff who work with the homeless. This summit will provide an avenue for developing further outreach activities. SAVAHCS is also participating in the “25 Cities Initiative” which is a collaborative effort between local community leaders, SAVAHCS, VHA’s Homeless Program Office, and our Federal partners, the Department of Housing and Urban Development and U.S. Interagency Council on Homelessness. The goal of this initiative is to identify and prioritize community resources and assist communities in removing barriers.
Our Supportive Education for Returning Veterans (SERV) program provides credit-bearing courses for student Veterans utilizing their GI Bill benefits to increase retention and successful graduation rates at the University of Arizona. SAVAHCS’ SERV program is a best practice, and this model has been adopted at colleges and universities throughout the country, including the Universities of South Dakota, New Mexico, and Mississippi State University. SAVAHCS staff are currently consulting with the Universities of Montana, South Carolina, Rhode Island, Rutgers University, and Massachusetts Institute of Technology to help with the development of SERV programs at these institutions.
The EBTPU is a unique program in VA. It provides evidence-based treatment to cohorts of six Veterans struggling with combat-related PTSD. The program is administered over 4 weeks in an inpatient setting and accepts referrals from all over the country. Outcomes data have demonstrated sustained reductions in PTSD symptoms and high levels of Veteran satisfaction.
SAVAHCS’ Polytrauma Network Site (PNS)
SAVAHCS serves as the PNS in VISN 18 and coordinates key components of post-acute rehabilitation care for individuals with polytrauma and TBI across the VISN. Since 2010, VISN 18 has experienced a 47 percent growth in the number of Veterans treated in polytrauma clinics. The VISN has improved access to interdisciplinary teams of rehabilitation specialists, case management, and psychosocial support services. Rehabilitation services for TBI include screening, comprehensive evaluations, and interdisciplinary treatments that promote independence and community re-integration including various therapies, counseling, vocational rehabilitation, and prescription of prosthetic and adaptive devices.
TBI frequently occurs in polytrauma patients combined with other disabling conditions, including depression, PTSD, and other mental health conditions. The hallmark of rehabilitation care provided at the PNS is the collaboration of specialists from different disciplines in the evaluation and treatment of symptoms related to TBI and polytrauma. Mental health professionals are key members of the interdisciplinary polytrauma teams (IDT) participating in the individualized assessment, planning, and implementation of the plan of care for Veterans served at the PNS.
In order to expand the availability of specialty TBI services across VISN 18, we focused on provider education and on the use of telehealth technologies. The SAVAHCS PNS program has established mini-residencies targeting provider education and training on TBI evaluation, treatment, and care coordination. Clinicians completing this training are mentored via additional telehealth observation until competencies in TBI evaluation and management are demonstrated. We also leveraged the increased availability of telehealth technologies to allow specialists from VA’s larger medical centers to reach out and provide medical services and consultation to Community- Based Outpatient Clinics (CBOC) located in rural and highly rural areas. Since 2010, we have seen a 70 percent increase in TBI and polytrauma visits completed via telehealth. The number of telehealth consultations with Veterans residing in rural and highly-rural areas has also increased steadily to make up as much as 37 percent of the overall telerehabilitation workload in FY 2013.
In addition to the leadership role in coordinating TBI rehabilitation services across VISN 18, the SAVAHCS PNS has implemented innovative programs that facilitate community re-integration of Veterans with TBI and polytrauma. Noteworthy among these are the series of group activities that provide injured Veterans with opportunities to learn new skills and to apply them in community-based environments. These programs have the added benefit of engaging Veterans’ families and services outside VA to support Veterans in their community re-integration efforts.
Through SAVAHCS PNS outreach efforts, other VA programs and community partners have been brought together to develop multidimensional programs that address the complex needs of Veterans with TBI and polytrauma. Among the results of these efforts are the Adaptive Sports Programs, the VISN 18 program for managing Veterans with complex pain, a vision therapy clinic, and the headache management clinic. The SAVAHCS PNS also engages with the Arizona Governor’s Council on Spinal and Head Injuries to link education, rehabilitation, and employment resources together to serve the vocational rehabilitation goals of injured Veterans. Other partners in this effort include VA Vocational Rehabilitation, the Arizona Coalition for Military Families, the University of Arizona, Pima Community College, and the Arizona Department of Economic Security, Rehabilitation Services Administration.
SAVAHCS’ Relationship with Native American Community
Native Americans serve in our Nation’s military at the highest rate per capita of all ethnic groups. We, at SAVAHCS, honor their service through our programs and services for Native American Veterans, our relationships with Indian Health Service https://eop.skillport.com/skillportfe/login.action (IHS) and other Native American community organizations, and cultural awareness training of our staff. In collaboration with IHS, SAVAHCS also honors and celebrates their service and sacrifices with an annual Gathering of American Indian Veterans event, which draws attendees from around the State of Arizona, to help American Indian Veterans learn more about the benefits they have earned.
SAVAHCS respects the unique needs of our Native American Veterans by having a dedicated Native American Veteran Program. SAVAHCS is a place of healing for our Veterans, and through our Native American Veteran Program, we have learned invaluable lessons from Native Americans about the holistic healing process which we have incorporated into our programs. For example, SAVAHCS has a 24-day, inpatient EBTPU which helps Veterans who come from across the country. At graduation, the Veterans are blessed with a Native American cleansing ceremony. We also host weekly Native American Talking Circles.
Our relationship with IHS provides a vital connection to the five local Native American tribes. To better identify the needs of our Native American Veterans, SAVAHCS has trained 250 IHS Benefits Coordinators concerning eligibility for VA health care services.
Additionally, we have completed five (5) VA and IHS local implementation plans under the December 5, 2012, National Reimbursement Agreement between VA and IHS, under which VA reimburses IHS for direct care services provided to eligible American Indian/Alaska Native Veterans in IHS facilities. Under the National Reimbursement Agreement, approximately 700 SAVAHCS Native American Veterans are eligible to receive VA reimbursement to IHS for services provided by IHS.
SAVAHCS is committed to our Native American Veterans and continues to build partnerships with organizations that can bring additional services to all Veterans. Our Rural Health Coordinators and Community Referral Center Case Managers routinely meet with our IHS partners to ensure that all health care needs are meet for the eligible Veterans. We want to be present in our community and actively engage in building a more Veteran-centric community. Since October 1, 2013, SAVAHCS Eligibility and Enrollment outreach staff have conducted 57 outreach events, connecting with over 4,800 Veterans and their family members; several of these events were specifically targeted to Native American Veterans.
Readjustment Counseling Service
VA’s Vet Centers present a unique service environment—a personally engaging setting that goes beyond the medical model—in which eligible, Veterans, Servicemembers, and their families can receive professional and confidential care in a convenient and safe community location. Vet Centers are community-based counseling centers, within Readjustment Counseling Service (RCS), that provide a wide range of social and psychological services including professional readjustment counseling to eligible Veterans, Servicemembers, and their families; military sexual trauma (MST) counseling for Veterans; and bereavement counseling for eligible family members who have experienced an active duty death. The Tucson Vet Center, like those throughout the country, also provides community outreach, education, and coordination of services with community agencies that link Veterans and Servicemembers with other needed VA and non-VA services. A core value of the Vet Center is to promote access to care by helping those who served and their families overcome barriers that may impede them from using those services. For example, all Vet Centers have scheduled evening and/or weekend hours to help accommodate the schedules of those seeking services.
The Vet Center program was the first program in VA, or anywhere, to systematically address the psychological traumas of war in combat Veterans. The program was established a full year before the definition of PTSD was published in the Third Edition of the American Psychiatric Association Diagnostic and Statistical Manual (DSM III) in 1980.
There are currently 300 Vet Centers located throughout the United States, Puerto Rico, Guam, and American Samoa. Vet Center staff provide a wide range of
Veteran-centric psychotherapeutic and social services to eligible Veterans and their families in the effort to help these individuals make a successful transition to life after service in a combat zone or area of hostility. VA has a fleet of 70 Mobile Vet Centers that provide outreach and services to Veterans and families in areas geographically distant from existing VA services. These vehicles also are used to provide early access to Vet Center Services to Veterans newly returning from war via outreach to demobilization active military bases, National Guard, and Reserve locations nationally.
These services include:
- Individual and group counseling for eligible individuals and their families;
- Family counseling for military-related readjustment issues;
- Bereavement counseling for families who experience an active duty death;
- MST counseling and referral, if required;
- Educational classes on PTSD, Couples Communication, Anger and Stress Management, Sleep Improvement, and Transition Skills for Civilian Life;
- Substance abuse assessment and referral;
- Employment assessment and referral;
- Screening and referral for medical issues, including mTBI, depression, etc.; and
- Referrals for Veterans Benefit Administration benefits.
Like Vet Centers throughout the country, the Tucson Vet Center is a small team of six staff members reminiscent of a military squad. The Tucson Vet Center is staffed by a team leader, three readjustment counselors, an office manager, and an outreach specialist. The staff also includes a qualified MST Counselor and a Family Counselor.
The Vet Center’s ability to rapidly and effectively respond to acute PTSD and other post-war readjustment difficulties makes it an integral asset within VA. As the community’s first point of contact with many Veterans returning from combat, Vet Centers also serve as the front door for referring many individuals for other needed VA services. Vet Centers also promote collaborative partnerships with VA health care and mental health professionals to better serve Veterans requiring more complex care. In addition to maintaining a bi-directional referral process with local VHA facilities, Tucson Vet Center staff also participate in weekly care coordination meetings with VA medical center mental health clinicians to ensure that all shared Veteran clients are receiving the best possible care from VA.
For individuals who are distant from the Tucson Vet Center, staff are bringing readjustment counseling to them through the creation of community access points in the communities in which they live. At these locations, counselors can provide services on a regularly-scheduled basis that are in line with the needs of that community. For example, the Tucson Vet Center maintains a community access point in Sierra Vista, Arizona and provides readjustment counseling twice a week to eligible local Veterans and Servicemembers stationed at Fort Huachuca.
The Vet Center Program remains unique in the eyes of those who have served thanks to the ability of Vet Center Staff to personally engage the individual Veteran or Servicemember in a safe and confidential environment that minimizes bureaucratic formalities. Confidentiality with our Veterans and their families is of paramount importance. Vet Center staff respect the privacy of all Veterans and Servicemembers and hold in strictest confidence all information disclosed in the counseling process. No information will be communicated to any person or agency outside of RCS unless authorized by law.
VHA provides comprehensive health care and support services for Veterans with both combat and civilian-related TBI through its nationwide Polytrauma System of Care. VHA also provides care for Veterans with PTSD through a variety of settings including inpatient, residential, specialty PTSD outpatient programs and general outpatient care.
Care for PTSD is delivered by more than 5,200 VA mental health providers who have received training in Prolonged Exposure and/or Cognitive Processing Therapy, the most effective known therapies for PTSD. These TBI and PTSD programs enable timely access to treatment as part of the VA’s efforts to deliver the high quality health care and support our Veterans have earned.
Mr. Chairman, this concludes my testimony. Thank you for the opportunity to appear before you today. At this time, my colleagues and I would be pleased to respond to questions you or the other Members of the Subcommittee may have.