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Ralph Ibson

Ralph Ibson, Wounded Warrior Project, Senior Fellow for Policy

Chairman Michaud, Ranking Member Brown and members of the Subcommittee:

Thank you for inviting Wounded Warrior Project (WWP) to offer our views on legislation pending before the Subcommittee. 

Wounded Warrior Project was founded on the concept of warriors helping warriors.  From our outstanding service programs to advocacy, we work to help ensure that this generation of wounded warriors thrives – physically, psychologically and economically.  WWP’s policy objectives are targeted to filling gaps in programs or policies -- and eliminating barriers—that impede warriors from thriving.  As such, we bring an important perspective to this morning’s hearing.

Our public policy positions reflect the experiences and concerns of those wounded warriors and family members we serve on a day to day basis around the country.  Several of the issues that would be addressed by legislation under consideration today are of great interest to our constituency, and we look forward to discussing those bills.  Several other bills address concerns that our warriors and families have simply not encountered, and we will not offer a position on those issues. 

One of the bills before you, H.R. 6123, addresses some of the deepest concerns we have heard from warrior’s families, and we are very pleased to be able to enthusiastically support this important bill.

Traumatic Brain Injury Rehabilitation

Impressive military logistics and advances in military medicine have saved the lives of OEF/OIF combatants who would likely not have survived in previous conflicts.  As a result, servicemembers are returning home in unprecedented numbers with severe polytraumatic injuries.  Among the most complex are severe traumatic brain injuries.   Each case of traumatic brain injury is unique.  Depending on the injury site and other factors, individuals may experience a wide range of problems – from profound neurological and cognitive deficits manifested in difficulty with speaking, vision, eating, or incontinence to marked behavioral symptoms.  While individuals who have experienced a mild or moderate TBI may experience symptoms that are only temporary and eventually dissipate, others may experience symptoms such as headaches and difficulty concentrating for years to come. Those with severe TBI may face such profound cognitive and neurological impairment that they require a lifetime of caretaking.  As clinicians themselves recognize, it is difficult to predict a person’s ultimate level of recovery.[1]  But to be effective in helping an individual recover from a brain injury and return to a life as independent and productive as possible, rehabilitation must be targeted to the specific needs of the individual patient.  In VA parlance, rehabilitation must be “veteran-centered.” 

While many VA facilities have dedicated rehabilitation-medicine staff, the scope of services actually provided to veterans with a severe TBI can be limited, both in duration and in the range of services VA will provide or authorize.  It is all too common for families—reliant on VA to help a loved one recover after sustaining a severe traumatic brain injury -- to be told that VA can no longer provide a particular service because the veteran is no longer making significant progress.  Yet ongoing rehabilitation is often needed to maintain function,[2] and veterans with traumatic brain injury who are denied maintenance therapy can easily regress and lose cognitive, physical and other gains made during earlier rehabilitation. 

Some do make a good recovery after suffering a severe TBI.  But many have considerable difficulty with community integration even after undergoing rehabilitative care, and may need further services and supports.[3]  Medical literature has documented the need to use rehabilitative therapy long after acute care ends to maintain function and quality of life.[4],[5],[6]  While improvement may plateau at a certain point in the recovery process, it is essential that progress is maintained through continued therapy and support.  The literature is clear in demonstrating the fluctuation that severe TBI patients may experience over the course of a lifetime.  One study found that even 10 to 20 years after injury individuals were still suffering from feelings of hostility, depression, anxiety, and further deficiencies in psychomotor reaction and processing speed.[7]  While some are able to maintain functional improvements gained during acute rehabilitative therapy, others continue to experience losses in independence, employability, and cognitive function with increasing intervals of time.[8]  Given such variation in individual progress rehabilitation plans must be dynamic, innovative, and long term—involving patient-centered planning and provision of a range of individualized services.[9]

For this generation of young veterans, reintegration into their communities and pursuing life goals such as meaningful employment, marriage, and independent living may be as important as their medical recovery.  Yet studies have found that as many as 45% of individuals with a severe traumatic brain injury are poorly reintegrated into their community, and social isolation is reported as one of the most persistent issues experienced by such patients.[10]  Yet research has demonstrated that individuals with severe TBI who have individualized plans and services to foster independent living skills and social interaction are able to participate meaningfully in community settings.[11] While improving and maintaining physical and cognitive function is paramount to social functioning, many aspects of community reintegration cannot be achieved solely through medical services.  Other non-medical models of rehabilitative care -- including life-skills coaching, supported employment, and community-reintegration therapy -- have provided critical support for community integration.  But while such supports can afford TBI patients opportunities for gaining greater independence and improved quality of life, VA medical facilities too often deny requests to provide these “non-medical” supports for TBI patients.  While such services could often be provided under existing law through other VA programs[12], it is troubling that institutional barriers stand in the way of meeting veterans’ needs under a “one-VA” approach.  Instead, rigid adherence to a medical model and foreclosing social supports is, unfortunately, a formula for denying veterans with severe traumatic brain injury the promise of full recovery.  This barrier must be eliminated. 

H.R. 6123 would amend current law to clarify the scope of VA’s responsibilities in providing rehabilitative care to veterans with traumatic brain injury.  While current law (codified in sections 1710C and 1710D of title 38, U.S. Code) directs VA to provide comprehensive care in accord with individualized rehabilitation plans to veterans with traumatic brain injury, in some instances warriors with severe traumatic brain injury are not receiving services they need, and in other instances, VA has cut off rehabilitative services prematurely. 

Ambiguities in current law appear to contribute to such problems.   For example, while the above-cited provisions of law do not define the term “rehabilitation,” the phrase “rehabilitative services” is defined for VA health-care purposes (in section 1701(8)) to mean “such professional, counseling, and guidance services and treatment programs as are necessary to restore, to the maximum extent possible, the physical, mental, and psychological functioning of an ill or disabled person.”  That provision could be read to limit services to restoring function, but not to maintaining gains that had been made.  (Yet limiting TBI rehab care in that manner risks setting back progress that has been made.)  The definition is also limited to services to restore “physical, mental and psychological functioning.”  In our view, rehabilitation from a traumatic brain injury should be broader, to include also cognitive and vocational functioning, and, should not necessarily be limited to services furnished by health professionals. 

In essence, H.R. 6123 would provide that in VA’s planning for and providing care to veterans with traumatic brain injuries—

  1. rehabilitative services must be directed not simply to “improving functioning” but to sustaining improvement and preventing loss of functional gains that have been achieved (and, as such, rehabilitation may be continued indefinitely); and
  2. rehabilitative services are not limited to services provided by health professionals but include any other services or supports that contribute to maximizing the veteran’s independence and quality of life.

WWP strongly supports this legislation.  It would eliminate barriers too many have experienced.  Most importantly, it would offer the promise of making good on the profound obligation we owe those who struggle with complex life-changing brain injuries. 

Prosthetic and Orthotic Services

Turning to another area of keen importance, H.R. 5428 would establish new requirements regarding VA provision of prosthetic and orthotic care.  Specifically, it would direct VA to disseminate, display, and educate department employees on an Injured and Amputee Veterans Bill of Rights; and establish a process for collecting, monitoring and resolving complaints.   We applaud this bill’s focus on provision of high quality prosthetic and orthotic technology and service, and concur that the proposed bill of rights aptly captures many concerns voiced by warriors we serve.  But we do not believe that H.R. 5428 goes far enough to resolve those concerns, and would be pleased to work with the Subcommittee to explore avenues for bolstering the bill.

To illustrate the concerns we have encountered, let me share a perspective from retired Army captain Jonathan Pruden, who in 2003 became one of the first IED casualties of Operation Iraqi Freedom.  After 20 operations at 7 different hospitals that included amputation of his right leg, he works with hundreds of wounded warriors in Florida, Georgia, South Carolina and Alabama as one of our Area Outreach Coordinator.  Reflecting his own experience, Captain Pruden reported that –

“VA had attempted three times to make an orthotic for me, but I’m still wearing the delaminating pair I received at Walter Reed in 2004.  I receive my care from a private prosthetist because I feel that the VA practitioners I met were not going to be able to provide the level of expertise, fit, or care I desired. 

“For many years now the majority of VA patients have been middle-aged to elderly.  I can’t tell you how many times I was asked if I lost my leg due to diabetes or vascular disease.  When I went in to my local prosthetics clinic and started to ask about a Renegade foot vs. a flex foot or a Ceterus, I got blank stares and a few ‘Oh, yea, I’ve heard about those.  They’re pretty cool aren’t they?’  As of October about 30 percent of VA prosthetists had no national certifications.  The technology and funding seem to be there but without practitioners who really care it won’t matter.”

He described the experience of having been asked recently by the head of his local VA prosthetics lab to come in and have a socket made using a new computer-aided design (CAD) device.  “I was happy to do it,” he said, “and went in for a training session with the company technician. Unfortunately, the only ones who learned how to use the device were the chief and me.  The other prosthetists were present but clearly showed no interest in learning how to use the new device.  Their attitude seemed to be, that they had been doing this for a long time and could do what they needed without all this high-tech gadgetry.”

While there have been substantial improvements in VA prosthetic and orthotic care over the years, the VA-launched Survey for Prosthetic Use highlights the need for further changes.  It showed, for example, that overall only 16 percent of Vietnam veteran survey participants and 9 percent of OIF/OEF survey participants received prostheses directly from VA, while 78 percent of Vietnam participants and 42 percent of OIF/OEF participants used prostheses from private sources under contract with VA.[13] Among its other findings were that participants experienced lower satisfaction when VA was compared with private and DoD care except for participants with upper-limb loss for whom satisfaction with prosthetic providers was similar across all conflicts.  A concern across all survey participants was the dearth of information on new prosthetic devices.  The study’s findings on differences in satisfaction between sources of care suggest a need for continued provider education and system evaluation.[14] 

H.R. 5428, in listing rights that VA should provide to veterans who have lost a limb, identifies many important expectations VA should be meeting, and unfortunately, often is not – ranging from continuity and comparability of care in the transition from DoD to VA to consistent services and technology at all VA medical facilities.  We share some of the frustration underlying this legislation, and welcome Chairman Filner’s spotlighting these issues.  But we are not confident that enacting this measure would resolve the problems it highlights.  Directing VA to disseminate and display a list of “rights” does not make those expectations enforceable; nor does it require VA to take the kind of steps that would convert amputees’ expectations into reality.  Accordingly, we recommend that the bill be expanded to direct the Department to institute the kind of changes needed to realize the measure’s objectives.

The Federal Recovery Coordinator Program

HR 4041 would direct VA to fund the training of recovery coordinators through a school of nursing or medicine.  We know from the experience of severely wounded warriors and their families how singularly important the Federal Recovery Coordinator (FRC) Program has been.   We have also testified to the need to “grow” that program – to ensure, for example, that those who sustained profound injuries prior to the creation of the FRC program, and who still need such help be assigned a qualified FRC.  The number of FRC’s has not grown commensurately with the need for such support.  So we welcome the vision inherent in the bill that there is a need for additional trained recovery coordinators.  Given the requirements of these demanding positions, FRC’s must be highly experienced health professionals who are knowledgeable about the health and benefits systems on which warriors and their families may depend.  As such, FRCs may need specialized education and training.  But it is not clear that VA needs legislation to mount such training; further we defer to the Director of the FRC program as to whether the model called for under that bill is necessarily the optimal way to meet the program’s training needs. 

Other Legislation

H.R. 5641 would provide specific authority for VA’s medical foster-home program—an initiative under which VA both places veterans who need long-term daily care in family-like settings under contract arrangements and provides those veterans with home-health services.  Such arrangements can provide a good option for chronically ill or severely disabled veterans who cannot live with their own families and do not want to be institutionalized.  While we understand that this program was designed to help older veterans, it may meet a need on the part of some number of much younger OEF/OIF veterans as well.  We support this provision.

H.R. 6127 would provide VA health care eligibility to veterans who have received government notification of possible exposure to a particular carcinogen at or near a specific site in Iraq in 2003 and have enrolled in the VA health care system within five years after such notification.  H.R. 6127 is generally consistent with prior laws, under which Congress has extended health care eligibility to veterans presumed to have been exposed to toxic substances (including herbicides in Vietnam, radiation, and chemical and biological warfare testing).  We have no objection to extending that principle, but question legislating on an incident by incident basis. Given the potential range of toxic substances to which veterans might have been exposed in Iraq and Afghanistan—we recommend that consideration be given to a systematic approach to addressing toxic exposures that are the subject of VA or DoD notifications to veterans or servicemembers.

Homeless Veterans’ draft bill:  The Subcommittee has before it a draft bill that would make revisions to certain grant programs designed to assist homeless veterans.  Among its provisions, the bill would clarify that any public or nonprofit private entity with the capacity to administer a grant is eligible for grant support to assist homeless “special needs’” veterans; would establish specific requirements for such grants; and increase the authorized funding levels for such grants.  It would also revise the framework of the current “grant and per diem” comprehensive service program to eliminate the requirement that payments to grantees be based on a daily cost of care, and would provide for annual adjustments in rates of payment.  WWP applauds the goal of eliminating homelessness among veterans, and recognizes the benefits of VA’s partnering with public and nonprofit entities that are dedicated to helping homeless veterans.  We have no objection to fine-tuning these grant programs, though we have no position on the specific changes proposed in this measure.

H.R. 3843 would require VA to publish on its website an easily accessible, redacted version of all medical quality-assurance records, no later than 30 days after the record is created, to include all such records created during the two years prior to the date of enactment.  As we understand it, such records would be redacted to delete the names and other identifying information of any individual patient or employee. 

This Committee has a long record of concern for ensuring the quality of the care afforded veterans in the VA health care system – a concern WWP certainly shares. A vibrant, healthy medical quality-assurance program is one important element in fostering a culture of quality-improvement in health-care delivery.  Certainly, transparency is an important element in sustaining confidence in the quality of VA care.  At the same time, confidentiality has long been deemed a critical element of ensuring the integrity of an effective medical quality-assurance program.  This bill raises questions in that regard. Would redacted records still contain enough information to lead to unwarranted identification of patients or clinicians, particularly at smaller facilities?  Would providers, fearful of such disclosures, be more likely to compromise the quality-assurance process?  WWP has no position on how best to balance the inherent conflict this bill raises between transparency and ensuring robust systemic health care reviews, but believes this is an area in which to proceed cautiously.

Thank you for considering our views on these bills.  WWP has no position on the other bills under consideration this morning. 

[1] Sharon M. Benedict, PhD, “Polytrauma Rehabilitation Family Education Manual,” Department of Veterans Affairs Polytrauma Rehabilitation Center, McGuire VA Medical Center, Richmond, Virginia; (accessed April 27, 2010).

[2] Ibid.

[3] Nathan D. Cope, M.D., and William E. Reynolds, DDS, MPH; “Systems of Care,” in Textbook of Traumatic Brain Injury (4th ed.), American Psychiatric Publishing (2005), 533-568.

[4] Hoofien D, Gilboa A, Vakils E, et al. “Traumatic brain injury (TBI) 10-20 years later: a comprehensive outcome study of psychiatric symptomatology, cognitive abilities and psychosocial functioning.” Brain Injury 15.3(2001):189-209.

[5] Sander A, Roebuck T, Struchen M, et al. “Long-term maintenance of gains obtained in postacute rehabilitation by persons with traumatic brain injury.” Journal of Head Trauma Rehabilitation 16.4(2001): 356 – 373.

[6] Sloan S, Winkler D, Callaway L. “Community Integration Following Severe Traumatic Brain Injury: Outcomes and Best Practice.” Brain Impairment 5.1(May 2004): 12 – 29.

[7] Hoofien, et al. 201

[8] Sander, et al. 370

[9] Sloan, et al. 22

[10] Sloan, et al. 12

[11] Nathan D. Cope, M.D., and William E. Reynolds, DDS, MPH; “Systems of Care,” 533-568.

[12] See VA’s program of independent living services (administered by the Veterans Benefits Administration) under 38 U.S.C. sec. 3120, and VA’s authority under 38 U.S.C. sec. 1718(d)(2) to furnish supported employment services as part of the rehabilitative services provided under the compensated work therapy program (administered by the Veterans Health Administration).

[13] D.G. Smith and G.E. Reiber, “VA paradigm shift in care of veterans with limb loss,” Journal of Rehabilitation Research and Development, vol. 47, number 4 (2010).

[14] G.M. Berke, J. Fergason, J.R. Milani, J. Hattingh, M. McDowell, V. Nguyen, G.E. Reiber; “Comparison of satisfaction with current prosthetic care in veterans and servicemembers from Vietnam and OIF/OEF conflicts with major traumatic limb loss,” Journal of Rehabilitation Research and Development, vol. 47, number 4 (2010) 361-71.