<DOC>
[110 Senate Hearings]
[From the U.S. Government Printing Office via GPO Access]
[DOCID: f:34513.wais]
S. Hrg.110-133
DOD/VA COLLABORATION AND COOPERATION
TO MEET THE HEALTH CARE NEEDS OF
RETURNING SERVICEMEMBERS
=======================================================================
HEARING
BEFORE THE
COMMITTEE ON VETERANS' AFFAIRS
UNITED STATES SENATE
ONE HUNDRED TENTH CONGRESS
FIRST SESSION
__________
MARCH 27, 2007
__________
Printed for the use of the Committee on Veterans' Affairs
Available via the World Wide Web: http://www.access.gpo.gov/congress/
senate
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COMMITTEE ON VETERANS' AFFAIRS
Daniel K. Akaka, Hawaii, Chairman
John D. Rockefeller IV, West Larry E. Craig, Idaho, Ranking
Virginia Member
Patty Murray, Washington Arlen Specter, Pennsylvania
Barack Obama, Illinois Richard M. Burr, North Carolina
Bernard Sanders, (I) Vermont Johnny Isakson, Georgia
Sherrod Brown, Ohio Lindsey O. Graham, South Carolina
Jim Webb, Virginia Kay Bailey Hutchison, Texas
Jon Tester, Montana John Ensign, Nevada
William E. Brew, Staff Director
Lupe Wissel, Republican Staff Director
C O N T E N T S
----------
March 27, 2007
SENATORS
Page
Akaka, Hon. Daniel K., Chairman, U.S. Senator from Hawaii........ 1
Murray, Hon. Patty, U.S. Senator from Washington................. 2
Craig, Hon. Larry E., Ranking Member, U.S. Senator from Idaho.... 4
Rockefeller, Hon. John D., IV, U.S. Senator from West Virginia... 6
Isakson, Hon. Johnny, U.S. Senator from Georgia.................. 7
Obama, Hon. Barack, U.S. Senator from Illinois................... 8
Tester, Hon. Jon, U.S. Senator from Montana...................... 10
Burr, Hon. Richard, U.S. Senator from North Carolina............. 11
WITNESSES
Duckworth, Major Ladda Tammy (Ret.), Director, Illinois
Department
of Veterans Affairs............................................ 12
Prepared statement........................................... 15
Pruden, Jonathan D., Veteran, Operation Iraqi Freedom Veteran.... 16
Prepared statement........................................... 18
Response to written questions submitted by Hon. John D.
Rockefeller IV............................................. 21
Mettie, Denise, Representing the Wounded Warrior Project, and
Mother of Army Spc. Evan Mettie................................ 22
Prepared statement........................................... 25
Gans, Bruce M., M.D., Executive Vice President and Chief Medical
Officer, Kessler Institute for Rehabilitation, New Jersey...... 27
Prepared statement........................................... 29
Response to written questions submitted by Hon. John D.
Rockefeller IV............................................. 31
Attachment, National Institute for Disability and
Rehabilitation
Research (NIDRR):
Model systems for Burn Rehabilitation.................... 32
Model systems for Traumatic Brain Injury Rehabilitation.. 34
Model systems for Spinal Cord Injury Rehabilitation...... 38
List of Rehabilitation Research and Training Centers..... 44
List of Rehabilitation Engineering Research Centers...... 55
Attachment, List of National Center for Medical
Rehabilitation Research (NCMRR) projects................... 64
Kussman, Michael J., M.D., Executive-in-Charge, Veterans Health
Administration, Department of Veterans Affairs................. 97
Prepared statement........................................... 99
Response to written questions submitted by:
Hon. Daniel K. Akaka....................................... 101
Hon. John D. Rockefeller IV................................ 111
Hon. Bernard Sanders....................................... 113
Hon. Johnny Isakson........................................ 115
Embrey, Ellen P., Deputy Assistant Secretary, Health Affairs/
Force Health Protection and Readiness, Department of Defense... 115
Prepared statement........................................... 117
Response to written questions submitted by:
Hon. Daniel K. Akaka....................................... 124
Hon. Patty Murray.......................................... 125
Hon. Bernard Sanders....................................... 128
Hon. Johnny Isakson........................................ 128
APPENDIX
Response to written questions submitted to BVA from March 7, 2007
hearing on resources and TBI................................... 137
Summary of the VA/DOD seamless transition study conducted by:
Government Accountability Office............................. 138
VA Office of Inspector General............................... 138
DOD/VA COLLABORATION AND COOPERATION TO MEET THE HEALTH CARE NEEDS OF
RETURNING SERVICEMEMBERS
----------
TUESDAY, MARCH 27, 2007
U.S. Senate,
Committee on Veterans' Affairs,
Washington, DC.
The Committee met, pursuant to notice, at 9:32 a.m., in
Room SR-418, Russell Senate Office Building, Hon. Daniel K.
Akaka, Chairman of the Committee, presiding.
Present: Senators Akaka, Rockefeller, Murray, Obama, Brown,
Tester, Craig, Burr, and Isakson.
OPENING STATEMENT OF HON. DANIEL K. AKAKA, CHAIRMAN,
U.S. SENATOR FROM HAWAII
Chairman Akaka. The Committee on Veterans' Affairs will
come to order in this hearing on DOD/VA Collaboration and
Cooperation to Meet the Health Care Needs of Returning
Servicemembers. Good morning and aloha.
This is the Committee's second hearing in our series on
seamless transition. The focus today is on how DOD and VA are
working to meet the health care needs of those transitioning
from service, especially those who have sustained serious
trauma. There have been many hearings about Walter Reed since
the story first broke about conditions there. This is not such
a hearing. And yet, at one level, it is.
The servicemembers who were staying in Building 18 at
Walter Reed were in medical hold, awaiting a decision on their
future. Many would soon be separated from the military and
become veterans, and that is exactly what we are talking about
today: how those leaving the service after being injured make
the transition
to VA.
With regard to the medical hold process, I realize that DOD
must have time to make an informed decision on an injured
servicemember's future. However, as soon as it seems likely
that an individual will be unable to return to service, DOD
must work with VA to ensure that the servicemember gets the
care he or she needs and that the actual transfer is carried
out effectively.
There is much talk about seamless transition, but it is far
from clear that the talk is matched by effective action. This
is not a new issue, but it seems that now more than ever, when
the demand is so great, we find that there is more talk than
action.
We have entered the fifth year of this war. I cannot help
but wonder why so many things are still being planned, still
being discussed. Why is it that DOD and VA still cannot make
the handoff of wounded servicemembers more effectively? Why do
budgets still not reflect that caring for veterans is part of
the cost of war?
Another key element in easing the transition is making sure
that servicemembers and their families have someone at both DOD
and VA to whom they can turn and who has responsibility for
making sure that they are getting the care and services they
need. The Committee needs to know where DOD and VA stand on
this.
I remain resolute. For those seriously injured to transfer
from DOD to VA without undue disruption to the wounded
servicemember simply must happen.
We have two panels of witnesses today. The first includes a
number of witnesses who, unfortunately are living every day
with the impact of serious traumas. I have asked Dr. Kussman
and Ms. Embrey to hear the testimony of the first panel so that
when they come forward, they will be able to address issues
raised by the first panel.
In closing, I note that each Senator will be provided
summaries from the IG and GAO on their respective work on
seamless transition, and a copy of these summaries will be in
the record of today's hearing. As you will see, many
suggestions have been made already to VA and DOD on this issue.
Now, I would like to yield to another leader of this
Committee and of our side of the Senate, Senator Murray, for
her opening statement.
STATEMENT OF HON. PATTY MURRAY,
U.S. SENATOR FROM WASHINGTON
Senator Murray. Well, thank you very much, Mr. Chairman,
for holding this really important hearing, and I really want to
thank all of our witnesses who have come here today to join us,
especially for your sacrifices and for coming here today to
speak out. You are helping us get to the truth about what
veterans are really facing and helping us change the system for
the better for everyone else.
I also want to extend a special welcome to Denise Mettie.
She is from Selah, Washington, and her son, Evan, who is
receiving treatment for traumatic brain injury. I visited
Denise and Evan at Bethesda Naval Station last February, a
little more than a year ago, and since then he has faced not
just medical problems but a bureaucratic system that has thrown
up obstacles in his path toward recovery. Denise has been a
tremendous advocate for her son. She had to quit her job so she
could fight for Evan in a system that is failing for too many
of our wounded veterans today.
Denise, our country owes you and your son an apology. Your
son fought a war for our country. You should not have had to
fight every day to give him the care that he deserves. You and
Evan deserve a lot better, and so do a lot of our men and women
who have served us, and that is why your testimony, all of
yours, is so important today, to help us hold the VA and the
Pentagon accountable so that servicemembers never fall through
the cracks and are never denied vital information and are never
left in limbo when they need our help. And we have got a long
way to go because what happened to Evan is really not an
isolated case at all.
Mr. Chairman, one of my biggest frustrations is that we
have been unable, so far, to get all the facts we need to solve
the problems. We hear stories of serious problems from veterans
and their families, but then when we have tried to get answers
from the Administration, we have run into a brick wall. We
cannot get full answers on the number of servicemembers who are
treated for TBI. We cannot get accurate projections on how many
veterans will need inpatient mental health care. We cannot even
get accurate information on the number of amputations. In fact,
I am now hearing that the Administration is not counting as
amputees veterans who lose a finger or a toe. That minimizes
the scope of the problem, and it hides the true cost of this
war.
War is expensive, and if we do not face the full cost of
the war, including caring for our veterans, we will never be
able to have the resources and the right policies to be able to
help families like Evan's and the other ones that we'll hear
about today. We need the truth so we can have the right budget
and the right policies. But if the Administration keeps hiding
the ball, we will never be able to get this right for those who
sacrifice for us. I really thank the witnesses for helping us
today to get to the facts so we can solve this problem.
Now, Mr. Chairman, I have to say that I have about had it
with the Administration officials who keep assuring us that
everything is taken care of. Two years ago, the VA told us
everything was fine when it was, in fact, facing a $3 billion
deficit. We are going to hear from two officials from the VA
and the Pentagon on the next panel, and I want them to know--I
know you have tough jobs, and I know you work very hard, but we
are going to judge you by the results you get for our veterans,
and we are going to hold you accountable for those results.
Two months ago, as the Chairman said, we had a similar
hearing on this Committee. Officials from the VA and the
Pentagon told us about all the progress they were making. They
were improving communication; they were setting up seamless
transition programs. Everything was on track. Well, a month
later we discovered that things were not fine when the Walter
Reed story broke.
It is easy to whitewash a moldy wall. It is a lot harder to
make sure that our veterans are taken care of every step of the
way. That is the challenge that we now face as a country, and
that is why we are going to hold people accountable for the
results, not just creating a new box in an organizational
chart, but what the results are that we are getting for our
servicemembers and our families. Are they getting benefits in a
timely way? Are they getting fair disability ratings? Are they
being screened and treated for both PTSD and TBI? Are they
getting the best care? Are their medical records where they
need to be? And are their families being informed? Because let
me tell you, you can make adjustments to a bureaucracy decade
after decade, but the real results are whether the men and
women who have served us so well are telling us that things are
changed for the better, and that is what we are going to be
looking for.
You know, I have to say that a lot of this misery could
have been avoided. Many of us saw the warning signs years ago.
We saw the VA was not planning for the full cost of this war,
we saw that it was not using realistic projections, and we saw
an overwhelmed and underfunded VA not getting itself on wartime
footing.
Well, we are not going to wait now for the President to fix
the problem. We are facing the costs of this war, and we are
putting the money where it is needed.
Mr. Chairman, as you know, right now on the floor of the
Senate is our supplemental bill. It includes $50 million to
build new polytrauma centers, $100 million for mental health
care, $201 million to treat recent veterans so they do not have
to wait in waiting lines that delays their care, $30 million
for research on the best prosthetics for our amputees, $870
million to fix problems that we have uncovered at VA facilities
across this country now, and $46 million to finally hire new
claims processors so our veterans do not have to wait for years
for their benefits.
Those are the costs of war, and these families know it all
too well. As a Nation, we have to pay for them, so we need to
be honest about what it is going to take so that we can get it
right and give our veterans, servicemembers, and their families
the care and support they deserve.
Mr. Chairman, as you know, I am managing the supplemental
on the floor. I hope to stay for quite a bit of this hearing,
but I want you to know when I leave, my staff will be here to
get your testimony. I will have some more questions that I will
probably submit for the second panel as well. But we want you
to know we want to get this right. Your help in being here is
our path to get there, and we all very much appreciate your
testimony today.
Thank you.
Chairman Akaka. Thank you, Senator Murray.
I need to step away briefly, and I want to hand the gavel
over to Senator Murray, and I shall return.
Madam Chairman, the hearing is yours.
Senator Murray [presiding]. Senator Craig, for your opening
statement.
STATEMENT OF LARRY E. CRAIG, RANKING MEMBER,
U.S. SENATOR FROM IDAHO
Senator Craig. Thank you very much, Chairmen, Chairman and
Madam Chairman. I want to thank you all for our distinguished
panelists who are here today testifying on a critical and
important issue.
Those of you on the first panel in particular have traveled
great distances, and I look forward to this hearing and your
firsthand experiences in leaving the battlefield and
transitioning back into civilian life. Ms. Duckworth, again,
welcome to this Committee. This is not your first appearance
here, and let me congratulate you on your new position. The
veterans in Illinois will be served well with you at the helm,
and so we look forward to your leadership in that capacity.
I also look forward to hearing from our second panel
because of their managerial experiences operating the
transition process. We have all been concerned by recent news
accounts suggesting that our returning servicemen and women are
not experiencing optimum care at our Nation's military and
veterans' hospitals. Like many Members of this Committee, I too
have received complaints from some constituents who suggest
that wait times are too long or quality of care is too poor. I
have also received numerous reactions that it is the very best
that could possibly be received.
However, this Committee also knows of the recognition VA
has received for quality and consumer services over the past
few years. We know the VA has led the University of Michigan's
consumer satisfaction survey for the seventh year in a row. We
also know that Time magazine's cover story of how VA became the
best health care in America also boasts of the quality of VA
care. In fact, all of you here today have included in your
written testimony very positive accounts of your experience at
both military treatment facilities and VA hospitals.
So some of us on this Committee are left to wonder why it
often sounds like two different VAs are being discussed in the
news, or you just heard the opening testimony, as the Ranking
Democratic Member of the Committee, two stories being told here
through two very different sets of glasses.
I for one believe the answer lies in a simple reality.
Medical care is very personal to all of us, including our
veterans, and one person's positive experience may be another
person's negative experience. I know the VA is the system of
choice for millions of our veterans. I say ``system of choice''
because I know that over 3 million veterans have other options
for health care, such as Medicare and TRICARE and private
insurance, but they still choose VA.
Unfortunately, a lot of our most deserving veterans, those
with service-connected disabilities, do not have the power to
choose to go somewhere else. VA is their only avenue to full
health care.
There are the veterans who choose to be able to say loud
and clear, ``I earned the right to be cared for by this
Nation.'' At the same time, I think they should also have the
power to say, ``If you do not treat me right or if someone else
can provide me with a better medical service, I will go
elsewhere.'' And I have introduced legislation that would
provide our service-connected disabled veterans with that
power.
I am not sure nor am I confident that the solution that you
have just heard from Senator Murray of pouring billions and
billions more dollars at the current system is the best
solution. When I introduced the legislation I am talking about,
I said that in many ways the bill was about my confidence in
the VA health care system. If veterans have the ability to
choose and they choose to stay right where they are in the VA
system, well, then, we have learned something about this
system, because right now there is no internal polling or
``voting with one's feet'' because the option simply does not
exist. But I also said that if the veterans leave in droves,
then we have learned something else that is awfully important.
Mr. Chairman, our hearing today is a follow-up on January's
hearing of seamless transition and a series of hearings that I
held with your cooperation two years ago as Chairman on these
very important issues. In fact, this is hearing number four or
five on the issue of seamless transition. We have identified
specific treatment challenges and the need for early
intervention for mental health care and outreach to those still
in need of family therapy services. As I said in January, I do
have concern that DOD's efforts to take care of its own
disabled personnel are complicating efforts by DOD and VA to
coordinate care and benefits. I am hopeful that the President's
new Interagency Task Force on Returning Global War on Terror
Heroes will help us determine what changes, legislation or
otherwise, are needed to make us meet these challenges as they
relate to our young veterans of today.
I also hope this hearing will shed some light on true
personal struggles that some of our military families are
facing today. Nothing is more important to this Committee than
ensuring that our servicemembers return to civilian life, that
they receive the very best possible care and services, and I
acknowledge all of you here today and look forward to your
testimony.
Thank you, Madam Chairman.
Senator Murray. Thank you, Senator Craig.
We will recognize each one of our Senators for an opening
statement before we go to our panelists in seniority order.
Senator Rockefeller, you are next.
STATEMENT OF HON. JOHN D. ROCKEFELLER IV,
U.S. SENATOR FROM WEST VIRGINIA
Senator Rockefeller. Thank you, Madam Chairman. I will be
very brief.
Actually, I think this is the first day in quite a few
months that all four of the Committees I am on meet, many of
them at the same time, so I have to go off, too, but I will be
here for a while.
I think it is long past the time when we think of the
warfighter and then we think of veterans who are physically
wounded, mentally wounded. I think all is part of the cost of
war. Veterans are as much a part of the cost of war as are
Humvees, as are warfighters out there in the desert in 120
degrees. There is no difference. I say directly to the Ranking
Member that I do not think Senator Patty Murray, Chairman
Murray was talking on two tracks. I think she was talking on
one track. I think what she was saying is that veterans for the
most part will say that the treatment they get from their
doctors in VA hospitals, from their rehab people, from their
counselors, from the professionals who work with them on a
medical basis, day in and day out, is very good. I think the
complaint comes about the Administration, and not in all VA
hospitals, but I know in my own State, the case is so clear and
it is so easy to pick out the difference between the two. Part
of the reason is they are all in different VISNs, so, you know,
they are going in all directions, and I regret that. But this
is the cost of war. It is not some kind of special effort.
Just going over the testimony, I really like the idea, Mr.
Pruden, to offer rehabilitation in substance abuse to veterans
who request it. I also think that Dr. Gans' testimony about
using private rehabilitation centers may make good sense. I
have discussed with the Ranking Member the idea that I know
personally of hundreds of physicians, some of whom practice
alternative medicine, which is a--when you walk into a Vet
Center and there are five people standing there in gray suits,
they look like they have come to audit the Vet Center. You ask
them what they are doing there. They are there for PTSD
treatment. And so there are so many. All of these people come
back wounded particularly from this war, more so than any other
war in terms of the psychology, the uranium additions to the
IEDs, and all the rest of it, which are unremovable, agony for
the rest of your life.
So my thought, and I have discussed this with the Ranking
Member, is that there are hundreds of specialists who have--
maybe they are orthopedic surgeons, there are all kinds of
people-- discovered that there are other ways of helping. It is
alternative medicine in a friendly sense, not alternative
medicine in a strange sense. It is not invasive. It works. I
have seen it work on PTSD with Gulf War I veterans. I have seen
it work in a very short period of time. I think that the time
has come for us to think about enlarging that capacity within
the VA. Go to the private sector for some things, go to the
private sector for some pro bono--everybody that I have talked
to, it is all pro bono. We will go anywhere in the country. We
will go to San Diego. We will go to Florida. We will go to West
Virginia, anywhere you want. But we want to show that we can be
helpful and, believe me, they can be. I just want to introduce
that thought into this hearing because we are not throwing
money at a problem. Chairman Murray bailed us out 2 years ago,
and we are doing a little bit better this year. But this is not
a fight between Republicans and Democrats. This is the
treatment of veterans on the same par as we treat our
warfighters, and maybe better.
Thank you.
Senator Murray. Thank you, Senator Rockefeller.
Senator Isakson?
STATEMENT OF HON. JOHNNY ISAKSON,
U.S. SENATOR FROM GEORGIA
Senator Isakson. Thank you very much, Senator Murray. I
appreciate very much your calling this hearing, and I
particularly want to welcome Jonathan Pruden, who we claim to
be a Georgian. I know he is a North Carolinian, but he spent 2
years at Fort Stewart, and that allows you permanent
citizenship, as far as we are concerned. Captain, we appreciate
your service to the country and your being here today.
I also have to tell you that I sat on a mat at Walter Reed
with Tammy Duckworth. She probably does not remember me, but I
go out to Walter Reed whenever there is a wounded Georgia
soldier there in rehabilitation. And there were a couple there
that day, and I saw Tammy with that magnetic smile of hers, and
her courageous recovery was taking place. So I sat on the mat
with her for a while and talked to her about her experience,
and I appreciate her service now to the VA--I guess in
Illinois. Is that correct? Congratulations, Director. We are
proud of you. And I want to apologize as I slip out for a
minute. I am chairing with Senator Kennedy the card check
hearing today, so we have got two extremely important hearings.
I am going to have to bounce back and forth.
For just a second, when we talk about the transition from
DOD to Veterans and Veterans to DOD, I think it is really
important for us to be focusing. And I do not disagree with any
of the comments that I heard said by Senator Rockefeller. We
want to see to it that the treatment of a veteran, active duty
or a retired veteran, is the best that I can be. And to that
end, although there has been a lot of negatives lately
generated with the beginning of Building 18, we cannot forget
the miracles that are done every day at Walter Reed and the
hospitals around the country. I have a young man at Walter Reed
now, Steven Pearson, whose father I called after I visited
Steven to just tell him, ``Here is my number, if there is
anything I can do while you are in Georgia and he is there
recovering, let me know.'' And he said, ``Well, I will.'' And
he said, ``One thing you can do is tell everybody. I stayed the
first 10 days with my son at Walter Reed, and I have never seen
a quality of care equal to that anywhere.'' So that is a good
testimony from someone that is there receiving it today.
Second, I want to mention and commend General Schoomaker,
who is now at Walter Reed and was called upon to take that duty
over. Before he came to Walter Reed, he was at the Eisenhower
Medical Center in Georgia, in Augusta. And it has been a best-
kept secret about what he had done there. And I see you are
nodding your head, Jonathan, so you may know what he has done
there. But what he has done there is he decided that veterans'
facility ought to be a facility that could seamlessly transfer
active DOD soldiers into that facility, rehab them and turn
them around so you would have utilization by both active DOD
troops and the Veterans' Administration service provided.
Dr. Hollings at that Augusta VA Medical Center is the head
of that Center, and he and his employees have done a phenomenal
job. They have a capacity of 30 at any one time. Walter Reed
amputees are now being transferred directly to the VA medical
center at Augusta for their immediate treatment. Since January
of 2007, 431 soldiers, sailors, airmen, and Marines have
received rehab services at the Augusta unit of the veterans
medical center; 26 percent of them have been treated and have
returned to active duty.
So it is a great story about how collaboration and
coordination and this idea of a seamless transition from
Veterans to DOD and back again, if you will, can work.
I appreciate very much Dr. Hollings at Augusta for the
leadership that he is showing and all those employees. I am a
big fan of General Schoomaker, and I think he is going to make
a big difference in the lives of veterans everywhere because of
the attention he will give. And I particularly, again,
appreciate the service and commitment of Tammy Duckworth and
Jonathan Pruden. Thank you both for being here today.
Senator Murray. Thank you, Senator Isakson.
Senator Obama?
STATEMENT OF HON. BARACK OBAMA,
U.S. SENATOR FROM ILLINOIS
Senator Obama. Thank you, Madam Chairman, Ranking Member
Craig.
Let me start by saying I am so pleased to see Director
Tammy Duckworth, who is a dear friend as well as a hero, and
who is doing great work back in Illinois. It is nice to see you
again. I thank all of the other panelists for their outstanding
work on behalf of our veterans.
I know this is the second hearing on seamless transition
issues facing the Department of Veterans Affairs and Department
of Defense during this session. I want to join my colleagues in
recognizing that although Building 18 raised awareness in the
general public, folks on this Committee I think have been
concerned with how we are approaching these problems for quite
some time. The question of how we care for our returning
servicemembers and their families has gained greater
significance given recent revelations. But what we know is that
given the increasingly complex injuries resulting from fighting
in Afghanistan and Iraq, it is clear that our current DOD and
VA health and rehabilitation resource investments are
inadequate.
When it comes to providing the needed health care and
support services to heal our wounded warriors, we owe them and
their families the very best. Later today, I will be offering
an amendment to the Iraq War supplemental to address many of
these systematic problems uncovered at Walter Reed. The
problems may affect DOD's military health care system, but also
exacerbate many of the ongoing challenges to the VA's health
system. And my amendment would boost the number of caseworkers
and mental health counselors and make it far easier for our
troops and family members to navigate the complex disability
review process within DOD.
I think all of us are in agreement that we need to make the
DOD process less complex and better coordinated with the VA
process. As Tammy has pointed out in her testimony, we need a
more robust national engagement with our State VA programs as
well.
I look forward to working with the Chairman and this
Committee as well as DOD, VA, and our private rehabilitation
centers to ensure we are providing the health care and
rehabilitation worthy of the sacrifices so many servicemembers
and family members have made. And I just want to make one last
point. I know that there was some back and forth with respect
to the amount of money that is needed. Senator Craig, I do not
think anybody disagrees with the notion that we should not be
wasting money, and if we can find ways to do things that are
more efficient and more cost-effective, they should be by all
means pursued.
But I do think it is important to note that for quite some
time, at least since I have been on this Committee, the VA has
underestimated both the amount of money and the amount of time
required to get this right. I think DOD, when we start talking
about creating what we would think would be relatively simple
issues, such as setting up medical technology systems that
allow military records to go from DOD to the VA, it seems like
it keeps on stalling. And so on the one hand, I do not want to
waste money. On the other hand, I do not want us to shortchange
people who have made the extraordinary sacrifices on our
behalf. I know you do not either. And I think it is important
for us to recognize that, as Senator Rockefeller stated, this
is part and parcel of the costs of going to war. And I am
fearful that we have continually shortchanged the back-end
costs that are involved.
Thank you, Madam Chairman.
Senator Murray. Thank you, Senator Obama.
Senator Tester?
STATEMENT OF HON. JON TESTER,
U.S. SENATOR FROM MONTANA
Senator Tester. Thank you, Madam Chairman. I appreciate the
opportunity. Thank you, guests, for your testimony. I am going
to make this quick. I do have some comments I want to make
after the first panel. When I was elected to this position--and
maybe it is because of this Committee--I thought the last thing
that I would be doing is talking with veterans about problems
within the medical care system for our veterans when they come
home from the field of battle.
That has not been the case. I have been going home every
weekend, and about half of those weekends, I have been having
hearings with veterans throughout the State of Montana. And I
can tell you what I have been hearing is this: Once you get in
the system, the care is excellent in the VA. But to quote one
veteran, and I hear this over and over and over again--
``Sometimes it appears as if the VA is trying to outlive me''--
and not letting that person through the door. That is a huge
problem. Veterans should not have to fight for their benefits.
They should be granted those benefits for the service that they
gave to this country.
From a DOD perspective, I will just tell you that I have
also heard that the care is very, very good, but the
administrative runaround and red tape is almost unbearable. And
for a lot of these folks that have been injured on the field,
they do not have the ability to be their own advocates. Unless
they have a wife or a father or a mother or a daughter or a son
that is there to help them through this process, it becomes
unbearable.
Let me give you just one example. A fellow from Shelby,
Montana, who is over at Walter Reed, they put him back together
and did a heck of a job, and he would attest to that fact, too.
Went in to get his medical records at Walter Reed. Couldn't get
them. They pushed him to another person. That person pushed him
to another person. That person pushed him to another person.
That person pushed him to another person, who pushed him right
back to the first person that he talked to, 4 hours later, 4\1/
2\ hours later. That is ridiculous, and it is not something
that our military people should have to put up with. And that
is the essence of what I like about this hearing, seamless
transition between active military and the VA, and to put on
something that Senator Obama talked about. The fact that the
Department of Defense still has paper records, still has paper
medical records, and you can use all the excuses of the courts
or whatever, and the second panel may want to respond to this,
it is ridiculous. This is 2007. It is not 1960 anymore. And the
VA has made that transition--I applaud them for that--to
electronic medical records. The DOD needs to do the same thing.
Thank you, Madam Chairman.
Senator Murray. Thank you, Senator Tester.
Senator Burr, opening comments?
STATEMENT OF HON. RICHARD M. BURR,
U.S. SENATOR FROM NORTH CAROLINA
Senator Burr. Thank you, Madam Chairman, and to our
witnesses, let me thank you for your willingness to come in and
share your insight, your experience, and your stories.
I think we all share the same feelings that we want to have
a system that is perfect, and that should be our goal. And the
reality is I hear about stories that Senator Tester said about
an individual, and I hear Senator Obama talk about the transfer
of medical data and health IT. I look outside the DOD world and
the veterans' world and realize that the private system that we
have got is deficient on everything that we are deficient in in
these systems.
So my concern is that our focus stay on how do we make the
system better. How do we make sure that we are able to provide
the level of care that our veterans deserve and that we set out
in legislation to achieve? But also realize that things in
health care happen in real time and that what we designed 2
years ago has significant challenges today because of the
change in the make-up of who walks in the door, the types of
problems that they have, the demographic shift that happens in
America as it relates to the VA.
I happen to represent a State that is the number one choice
of military retirees. I know in real time exactly what that
does to a health care system, and the challenge to get ahead of
the curve and to be able to offer and provide the level of
health care that they deserve and that this Committee, in a
bipartisan way, expects is challenging.
I hope that all of you understand that we are attempting to
get to the bottom of where our problems are and in a bipartisan
way fix those problems. Our goal is to be perfect, but we will
never reach it. But it is also to make sure that the stories of
the runarounds, the stories of the lines, the stories of the
inability to transfer medical data, that we fix these things.
It is unacceptable. But it is also to realize that this is not
just the VA health care system and the DOD health care system.
We have got this bigger animal in America. It is Medicare and
Medicaid and private pay, and they do not do these things very
well either. And they have a tremendous influence on, in fact,
these two systems that we are looking at today.
My hope is that as Members attempt to wade through this to
learn and to fix, we will also realize that we have got
challenges on the private sector side that if, in fact, we do
not fix those, we will find it impossible for the VA and for
the DOD pieces to work as we expect them to work without those
changes.
So, once again, I thank our witnesses for being here. I
thank the Chair for scheduling this. I look forward to hearing
from the witnesses.
Chairman Akaka [presiding]. I want to thank our Members for
their opening statements, and I also want to thank Senator
Murray for being the Chair.
I welcome our first panel of witnesses. We have brought
each of you here for your unique perspectives on VA and DOD and
this kind of care, especially for serious traumas.
First, I welcome back Tammy Duckworth. Since she testified
in 2005, she has been named the Director of Veterans' Affairs
for the State of Illinois. Director Duckworth has a firsthand
perspective on Walter Reed, and she can also share what her
office is doing to help veterans.
Jonathan Pruden sustained serious injuries in Iraq. He,
too, has firsthand knowledge about the various health care
systems for returning servicemembers and veterans.
I welcome as well Ms. Denise Mettie, whose son, Evan,
sustained a very serious brain injury in Iraq last year. I
understand that you are a wonderful advocate for your son.
Finally, I have asked Dr. Bruce Gans from the renowned
Kessler Institute for Rehabilitation to give us the perspective
of a private provider dealing with the same sorts of injuries
so many of our servicemembers are experiencing. Dr. Gans, as
you summarize your testimony, it would be most helpful if you
could build upon what the witnesses before you have said.
I want to thank each of you for being here. Your full
statements will appear in the record of the Committee, and I
would like to first call on Director Duckworth for your
statement.
STATEMENT OF MAJOR LADDA TAMMY DUCKWORTH (RET.), DIRECTOR,
ILLINOIS DEPARTMENT OF VETERANS AFFAIRS
Ms. Duckworth. Thank you, Mr. Chairman, Ranking Member
Craig, Members. It is such a pleasure to be here today. Two
years ago when I testified, I was still an inpatient at Walter
Reed. I came here in my wheelchair, did not have my legs yet,
and I want to tell you that I owe the medical personnel at
Walter Reed my life. I owe them a debt of gratitude I can
never, ever repay. And as we think about what is happening at
Walter Reed, I hope people do remember that, that the personnel
there are amazing.
I would like to talk to you about three main things. First,
I would like to talk about the state of readiness of the VA
system and specific programs within the VA, such as the
prosthetics program. I would also like to speak about
information sharing between the DOD, the USDVA, and the need
also to coordinate with the State VA agencies. And then I would
like to make some recommendations on some testing that should
be done universally across the Nation for all of our veterans
coming home.
Since I have entered the VA system, I must say that the
transition from Walter Reed to Hines VA that I experienced was
very, very easy for me. We have a wonderful lady at Walter
Reed--her name is Brenda Foss--who is the VA coordinator there,
and she had reached out to the local VA hospital from Walter
Reed and had everything coordinated for me even before I left.
I even got a tour of Hines VA Center from the OIF/OEF
coordinator at Hines even before I checked into Hines itself.
So that transition was quite smooth. They are certainly working
with one another, and that went very well.
Where I am experiencing problems is not the major clinics
within Hines. It is with the prosthetics program. I do not know
how it is across the Nation, but if I am talking to my
comrades, my fellow wounded warriors, the prosthetics program
within the VA is simply not ready to handle the high
functioning level of the current war wounded that are coming
home today. They are doing a wonderful job of taking care of
our older veterans who are losing limbs to diabetes, who are
ill, whose goal is to get a prosthetic device and be able to
walk around their home and maybe make it out to the car. They
are not ready for veterans who want to go rock climbing and
running marathons. Many of the veterans coming out of Walter
Reed want to join the Paralympics program. We are going to rock
the Paralympics program at the next Olympics because we have so
many of our young veterans entering that. We are going to
really, I think, win a majority of those Gold Medals for the
United States. But the VA system is simply not ready, and they
do not have time to catch up. They simply do not have time to
take some of those wonderful men and women who work in the
prosthetics program and send them back for the year-long
training that they need to work on the high-tech levels of
prosthetics that we wear. If you do that, those prosthetists
then are not available to take care of the veterans who are
already in the system, and then you will be hurting and harming
the veterans of previous wars who need access to the lower
levels of prosthetic devices. Those of us who need carbon fiber
running legs--and I am getting my scuba legs this week from
Walter Reed. I have a prosthetist down in Florida who is making
me a flying leg so I can get back in a cockpit again. We need
to be able to access that level of care.
So I was so pleased, Senator Craig, to hear you say that it
would be wonderful for us to be able to go to outside sources.
That is important. That is important because the VA simply does
not have time to catch up when it comes to the prosthetics
program.
Once the war is over and the critical first 2 years of an
amputee's life are behind us, then we have time to wait for a
prosthetist to learn to fit us. But in the first 2 years, we
simply do not have time, and that is why it is critical for
those patients to be able to access the prosthetist that we
need to access to get the care that we need.
However, I do think that additional funds are needed for
the VA system. It simply is underfunded, and the problems that
we have with the VA right now come from the fact that while the
personnel are excellent, they want to work hard, they want to
do the best job for us, they cannot because they do not have
the funding for it. And so that is why the supplemental, the
additional spending, will really be a boon to the VA so that
they can indeed do the job that they need to do.
I would like to give you an example. My physical therapist
at Hines wanted to come with me here this week to Walter Reed
to coordinate and to learn to care for me better with my latest
artificial limbs and simply was not able to because there is no
funding for the plane ticket for him to come from Chicago here
to Walter Reed to do that. That is not acceptable.
I also would like to talk about information sharing. We
need to make sure that there is adequate information being
shared between DOD and USDVA. That is starting to happen.
Secretary Nicholson introduced a new program in Florida where
seven people participated, where soldiers voluntarily allowed
the DOD to transfer their personal contact information to the
local USDVA.
There are a lot of State programs available that we cannot
tell the wounded servicemembers that these programs exist
unless we know that they are coming home to us. If they are
part of the National Guard, we can reach out and touch them.
But if they are coming home as a soldier, for example, serving
with the 10th Mountain Division in New York, coming home to
Illinois, I have no way of knowing that that individual soldier
is coming home. And I have no way of telling him that here in
Illinois, Governor Blagojevich has instituted a supplemental
health care program, health insurance for veterans, or that he
just recently signed a bill into law that gives all employers a
$600 tax rebate next year on every OIF, OEF, and Persian Gulf
War veteran that they hired in 2007. What a great thing to be
able to write on your resume, that if you hire me, you get $600
back on your taxes next year. But I cannot even tell those vets
that because I do not even know that they have come home.
So this seamless transition needs to happen down to the
State agency level as well, and there is actually an
organization of State Directors of Veterans Affairs, whom you
addressed, Senator Akaka, just recently, who can help
facilitate that so that we truly do work together, red States,
blue States, Federal, local levels, to really do what we need
to do for our veterans.
I would also like to talk about some universal testing
needs. We need to test universally all wounded veterans for
PTSD, for traumatic brain injury, for hearing loss, and for
vision loss. That is not being done uniformly across the VA
system. Hines VA right now is testing for vision loss all of
the patients that come through its traumatic brain injury unit,
and it is finding that 60 percent of those patients in their
polytrauma center at Hines have some form of functional vision
loss. Vision loss will affect your scores on a traumatic brain
injury test. Hines VA is the only VA hospital in the entire
Nation that is testing for vision loss as a universal thing
that is done for all polytrauma patients. That is very
important because the veteran may be thinking that he is not
understanding what is going on, maybe he has worse TBI than he
really has, because he cannot read the test, he cannot pass
some of the vision aspects of it. So that is important.
I would like to finish by talking about the need for
additional funding and coming back to that. One of the things
that I have not heard people talk about are the Vietnam era
veterans. We have been talking about this large influx of
wounded warriors coming out of this war who are coming home,
who are entering the VA system, and the fact that we need to
take care of them. And this is where the additional spending is
so critical.
What people do not realize is that the Vietnam veterans
have now reached an age, in their mid-60's, that they need
additional medical care. They are reaching a point in their
lives where they are accessing greater levels of medical care.
In fact, in Illinois, the first Vietnam veterans have entered
our nursing homes.
Our VAs are now entering a stage where we talk about the
sandwich generation of people who are taking care of their
children and their parents at the same time. The VA is entering
that stage within the next 5 to 10 years. We will have a large
influx of Vietnam veterans in the next 5 to 10 years demanding
greater access to VA health care at precisely the same time
that you have all of the Iraq and Afghan vets coming in also
accessing it. The VA simply is not ready.
So I thank you for continuing to do this. It is such a
pleasure to see you, Senator Akaka, as the Chairman of this
Committee. You are one of us. You served, and we are so proud
to be here. And, again, thank you so very much for having me
here, and I know that Captain Pruden will have wonderful things
to say as well.
[The prepared statement of Major Duckworth follows:]
Prepared Statement of Major Ladda Tammy Duckworth (Ret.), Director,
Illinois Department of Veterans Affairs
Mr. Chairman, Members of the Committee. It is indeed a pleasure to
be here to testify. I am honored to have the opportunity to follow up
on my March 2005 testimony on the Seamless Transition from DOD to VA
healthcare.
When I last appeared before this Committee, I was newly injured and
still an inpatient at Walter Reed Army Medical Center. The care that I
received and continue to receive at Walter Reed is above the best. The
personnel there are incredibly talented and dedicated. It is
unfortunate that they are not given adequate resources to support our
Wounded Warriors.
Since my last appearance, I have undergone the transition from DOD
to VA healthcare and have had an overall positive experience. However,
compared to the experiences of other servicemembers, I know that mine
is not uniform across the Nation. Even before I left Walter Reed, the
USDVA representative had reached out to me and coordinated with the
OIF/OEF coordinator at Hines VA Hospital. I had an early tour of the
facility and met my future physicians. The one negative experience was
the prosthetics department, which, while eager to meet my needs, was
many decades behind in prosthetics technology. I now receive care at
Hines but also continue to return to Walter Reed. The staff at Hines
have been very helpful, and shown great initiative. For example, even
though my physical therapist at Hines had not treated a high-
functioning amputee like myself before, he prepared for my treatment by
reaching out and coordinating with my Physical Therapist at Walter
Reed. Both therapists did this of their own initiative.
I continue to return to Walter Reed for its prosthetics program. I
also travel to a specialist in Florida for state-of-the-art care.
Recently, Hines sent a prosthetist with me to Florida to learn about
the high-tech artificial legs that I obtain from the private
practitioner there. He was overwhelmed by the technology. The USDVA is
absolutely not ready to treat amputee patients at the high tech levels
set at Walter Reed. Much of the technology is expensive and most of the
VA personnel are not trained on equipment that has been on the market
for several years, let alone the state-of-the-art innovations that
occur almost monthly in this field. I recommend that the VA expand its
existing SHARE program that allows patients to access private
prosthetic practitioners. There is simply not enough time for USDVA to
catch up in the field in time to adequately serve the new amputees from
OIF/OEF during these critical first 2 years following amputation.
Perhaps after the end of the current wars in Iraq and Afghanistan, the
VA will have time to advance its prosthetics program.
In addition to medical treatment, Seamless Transition is also the
passing from one administrative program to another. The Seamless
Transition initiative needs to be expanded to each state's VA, and more
importantly, local counties and municipalities. The current model for
Seamless Transition focuses on transition from the DOD to the USDVA
entities within the state. It is also important to involve each state's
VA agency as there are many state programs that are unique to the
state. For example, in Illinois we provide Veterans' Care, a health
insurance plan for veterans. We also provide additional funds for
accessibility modifications to disabled veterans' homes. New benefits
are added at the state level more quickly than can be tracked by the
USDVA. For example, as of January this year, Illinois gives up to a
$600 rebate on employer's state taxes for each Persian Gulf War, OIF or
OEF veteran, that they hire.
One of the greatest difficulties for state VA agencies is the
tracking of returning servicemembers who come home from active duty
status. We at the states only find out about these individuals if they
self-report to our agency. It appears that a significant difficulty
with the Seamless Transition between DOD and USDVA is the sharing of
servicemember's information. The DOD and USDVA are still negotiating a
Memorandum of Agreement (MOA) for this process. Recently, the USDVA
announced a new program that was pilot-tested in Florida called the
Florida Seamless Transition Program. This program for sharing
information between USDVA and state VA agencies is just now being
expanded to other states. It basically allows wounded servicemembers at
DOD medical facilities to voluntarily give permission to have their
contact information forwarded to their home state's VA agency. Only
seven servicemembers chose to participate, but this is an excellent
start.
A related aspect of information sharing between DOD, USDVA and
state VA agencies is the technical aspect of data sharing. The USDVA
and DOD each have their own excellent medical records keeping system.
Unfortunately, most state agencies that operate health facilities such
as long-term care facilities do not have electronic records keeping due
to the prohibitive costs. At the very least, the USDVA and the DOD
should be able to electronically share data so that the wounded
servicemembers' medical records can simply be transmitted
electronically once they enter the USDVA healthcare system. If there
are issues of patient privacy, the records could be given to the
servicemember on a CD-ROM, to be turned over at the patient's
discretion once they begin seeing their USDVA healthcare provider.
Any Seamless transition program must also include comprehensive
screening for Traumatic Brain Injury (TBI), Post Traumatic Stress
Disorder (PTSD) and vision loss by both the DOD and the USDVA Health
Care systems. I know that efforts are underway to strengthen these
assessments by both the DOD and the USDVA. However, there is no
standard procedure in place to ensure that all war wounded are screened
nationwide.
Currently, there is an issue with TBI screenings. Some
servicemembers who are not screened for TBI, are being identified as
suffering only from PTSD. However, it is possible to have both PTSD and
TBI or either condition alone. My concern is that servicemembers with
TBI are not diagnosed and then return to civilian life without this
medical condition noted on their records. The symptoms of TBI can
result in inability to work or even aggression that results in
homelessness and entry into the criminal justice system. At that time,
these veterans are then often diagnosed as having PTSD and treated for
PTSD even though the main injury is TBI. What is significant about this
situation is that TBI and PTSD have many treatment methods that are the
exact opposites.
One additional screening criteria that is critical is testing for
vision loss. At the Hines USDVA Hospital, all polytrauma patients are
routinely screened for vision loss as soon as they enter the facility.
The result of these screenings is that 60 percent of the polytrauma
patients at Hines have been found to have some form of functional
vision loss. Vision loss, an acute injury on its own terms, can also
negatively affect how patients perform on tests for TBI, which are
heavily reliant on vision. Hines is the only USDVA facility in the
Nation that conducts routine screening of patients in its polytrauma
centers. This is because it is the initiative of the excellent Blind
Rehabilitation program at Hines.
I would like to close by saying that I have had a surprisingly
positive transition to the VA system. I also understand that this may
not be the same across the board for all returning servicemembers.
There are problems that can be resolved such as the establishment of
standard screening criteria for major injuries such as TBI, PTSD and
vision loss. I would also strongly urge this Committee to consider
eliminating the 2-year window for free VA care for OIF/OEF veterans.
This is a new time limit that will limit veterans' ability to access
care for injuries such as PTSD, which may not become evident until over
2 years after their service. We have more work ahead of us, but much of
it can be resolved through information sharing, use of patient
advocates, and a willingness to access private healthcare specialists.
Chairman Akaka. Thank you so much for your testimony.
And now Jonathan Pruden.
STATEMENT OF JONATHAN D. PRUDEN,
OPERATION IRAQI FREEDOM VETERAN
Mr. Pruden. Mr. Chairman, Members of the Committee, good
morning. It is an honor to be here. I strongly agree with Major
Duckworth's assessment of VA prosthetics and have experienced
similar challenges in receiving adequate prosthetic care. I had
my legs made at a private clinic down in Gainesville, Florida.
Part of the problem here may be that VA care has
predominantly become geriatric care, and this is only right
given that most of the veterans are over the age of 50 right
now. VA physicians and clinicians have become very good at
diagnosing and treating chronic diseases associated with this
aging population. However, they have little experience with
blast injuries and young patients. At facilities I have been
asked at least a dozen times if I lost my leg to diabetes or
vascular disease. While re-establishing ADLs for an 80-year-old
veteran is certainly an admirable goal, these young OIF/OEF
veterans, as Major Duckworth said, want to go on and live
fuller lives. They want to go run marathons and climb rocks,
and they need a higher level of care.
On July 1, 2003, I was wounded in Baghdad. Over the next 3
years, I had 20 operations, including the amputation of my
right leg. At Army, Navy, and VA hospitals, I encountered
caring and competent individuals willing to go the extra mile
to care for servicemembers and veterans.
I understand that steps are being taken already to remedy a
lot of the issues that we are discussing here today, but I also
understand that a lot of times there is a substantive gap
between policy change here and the effects on the ground for
the guys implementing it.
Our severely wounded men and women should receive the best
medical care, regardless of the cost. One of my favorite
soldiers, Corporal Robert Bartlet was critically wounded in
Iraq on May 3, 2005. He lost his left eye; the bones and soft
tissue on the left side of his face and his jaw were all blown
away or pulverized; both his hands have nerve damage; he
suffers from PTSD and has a mild TBI. He is about to go in for
his 30th surgery on April 13th.
Currently, Corporal Bartlet must go back and forth between
Walter Reed and Johns Hopkins for separate dental and plastic
surgery care because TRICARE will not authorize dental care at
Johns Hopkins. This is inexcusable. He will have to endure an
extra 8 months of surgeries because TRICARE will not allow his
plastic surgeon and a dental surgeon to tag team and do two
surgeries at once. The practice of tag teaming is very common.
They did that on me a lot at Walter Reed. I would have
vascular, ortho, and neuro all working on me at once, so
instead of having three surgeries at separate times and having
long recoveries, they piled it all into one. This reduces
recovery times and risks associated with anesthesia and so
forth. Military physicians caring for our severely wounded must
be able to base their treatment decisions solely on what is
best for the patient, not TRICARE authorizations.
Rob is a very positive, inspiring individual who wants to
get on with his life and his education. He should not be facing
numerous extra surgeries and putting his life on hold for lack
of a TRICARE authorization. He and other servicemembers like
him have already sacrificed enough.
We also must ensure that servicemembers have advocates who
know the system and can help them and their families navigate
the incredibly complex MEB/PEB process and the VA's benefits
process. When I went to my local VA to apply for benefits when
I was medically retired in December of 2005, I discovered that,
despite what I had been told, an earlier application for a
vehicle adaptive grant had been filed as my disability claim.
My disability claim did not even include the amputation of my
right leg. So I tried to stop the disability claim and find out
what was going on. No one at the Gainesville VA or anyone I
could talk to could get through to the regional office to stop
the claim or, you know, add my amputated leg to my disability
claim.
Finally, I contacted someone up here in VA Central Office
who contacted someone in benefits who contacted St. Pete, and
then they called me. And it worked out in the end, but you
should not have to work the system like that to make this
happen. And a lot of these individuals do not have the
wherewithal because of injuries and medications and so forth to
do that, to work the system, or they do not have the contacts.
You should not have to do that to get your benefits straight.
This is something we really need to work on.
For over 5 years, VA and DOD have been promising IT
miracles that will connect military treatment facilities one to
another, inside DOD, and DOD to the VA. I am wondering when it
is all going to get fixed.
Last summer, GAO reported that two VA polytrauma centers
they visited could not access DOD electronic records. I have
encountered this time and again. When I filled out a post-
deployment health assessment at Walter Reed, I thought that
would be the one time I had to fill it out. I wound up filling
that out five different times at five different medical
facilities because never did another facility have a record of
me filling out this post-deployment health assessment at any
other facility. And to date, the VA still does not have a
record of me having filled out this assessment, which is
supposed to help screen for various health conditions.
We can do better than this. I know a lot is being done. I
appreciate what this Committee is trying to do, and I
appreciate the very caring and competent people in the VA and
DOD and the work that they are doing.
Thank you all very much for having me here today.
[The prepared statement of Mr. Pruden follows:]
Prepared Statement of Jonathan D. Pruden,
Operation Iraqi Freedom Veteran
Mr. Chairman and Members of the Committee, good morning. It is an
honor to be here today.
On July 1, 2003, I was wounded in Baghdad. Over the next 3 years I
had 20 operations, including the amputation of my right leg. At Army,
Navy, and VA hospitals I encountered caring and competent individuals
working diligently to help wounded servicemembers and veterans heal.
There have been some obstacles along the way, but most of my care and
the care of my wounded soldiers has been first rate. This is as it
should be.
Our men and women in uniform deserve nothing but the best care we
can provide when they are wounded in the service of our Nation.
Anything less is not acceptable. Although I will express a number of
concerns about our current system of care, I think we all need to be
very careful when pointing fingers. The vast majority of VA and DOD
employees are extraordinary men and women, willing to go the extra mile
to care for servicemembers and veterans. Individuals like Lieutenant
Colonel Gajewski at Walter Reed, Jim Mayer in VA Outreach, and Karen
Myers at the Gainesville VA have influenced my life and the lives of
countless others in profoundly positive ways.
As this Committee well knows, VA and DOD provide outstanding
medical care and benefits to millions of servicemembers and veterans
each year. The dedicated public servants who provide this care deserve
our utmost respect. That being said, there are still areas that need
improvement to ensure truly seamless care for our wounded warriors. I
understand that steps are already being taken to remedy some of these
issues but I also know that there can be quite a chasm between policy
change and substantive changes ``on the ground.''
in need of an advocate
I've found that soldiers will often ``suck it up'' and not complain
about challenges they face or seek the help they need. At times they
are stymied by an overly complex system that can be challenging to
negotiate even without mental and physical obstacles created by their
wounds or medications. The following cases are a few examples of issues
faced by men I've worked with.
<bullet> I caught one of my men dragging his nerve damaged foot and
asked him why he wasn't wearing a much needed Ankle-foot orthosis
(AFO). He told me that the Sergeant at the orthopedics clinic didn't
have one in his size.
<bullet> One if my old Scout's was seriously wounded and his entire
squad was Killed in Action (KIA) or Wounded In Action (WIA). He denied
having any PTSD and believed those who claimed to have it were faking.
Meanwhile he was consuming ever greater quantities of alcohol and was
having trouble controlling his anger.
<bullet> Another soldier; a bilateral amputee, was rendered
unconscious for an undetermined amount of time by a blast that killed
the driver of his vehicle and grievously wounded the other occupant.
His mother reported he has great difficulty remembering things but he
was not screened for a TBI in nearly 2 years by DOD. This is likely
because his TBI symptoms were masked by symptoms of significant PTSD
and substance abuse.
There was no reason for these men to suffer. In each of cases
resources were available and could have been used to help these men.
Often problems arise, not because of a lack of resources, but a lack of
information. These soldiers all needed more information and an advocate
to ensure they received the services they needed.
not authorized by tricare
Our severely wounded men and women should receive the best medical
care regardless of the cost. One of my favorite soldiers, Corporal
Robert Bartlet, was critically wounded in Iraq on May 3, 2005. He lost
his left eye, the bones and soft tissue of the left side of his face
were pulverized or blown away, both his hands have nerve and tissue
damage, he suffers from PTSD, and a mild TBI. He is about to go in for
his 30th surgery on April 13, 2007.
Currently, Corporal Bartlet must go back and forth between Walter
Reed and Johns Hopkins for separate dental and plastic surgery care.
This is inexcusable.
He will have to endure an extra year of surgeries and time away
from his wife because TRICARE will not pay for dental care at Johns
Hopkins that would allow his plastic surgeon and dental surgeons to
``tag-team'' and do two surgeries at once. The practice of ``tag-
teaming'' is very common and prevents patients from having to endure
extra surgeries, longer recoveries, and increased health risks
associated with multiple surgeries.
Walter Reed has the dental surgeon but not the plastic surgeons to
work on Rob. So he will continue to endure, needless, extra surgeries
as he bounces between Walter Reed and Johns Hopkins. Despite repeated
requests, TRICARE will not allow him to receive dental care at Johns
Hopkins.
This is completely unacceptable. Military physicians caring for our
severely wounded must be able to base their treatment decisions on what
is best for the patient not on TRICARE authorizations. Rob is a very
positive, inspiring individual who wants to get on with his life and
his education. He should not be facing numerous extra surgeries, pain,
and recoveries while his life is put on hold in order to save the
government a few dollars.
He and other soldiers in similar situations have already sacrificed
enough.
the jec
In recent Congressional committee hearings representatives
repeatedly expressed great concern about the complex and confusing
quagmire that the wounded must attempt to navigate as they transition
from DOD to VA care. In light of these concerns it seems important that
Congress consider the actions of the Joint Executive Council (JEC), the
only significant entity that straddles the divide between DOD and the
VA.
Unfortunately this year, Congress will not be receiving its annual
report on the JEC from the Government Accountability Office (GAO) as it
has each March for the past 3 years. The 2003 NDAA required GAO to
present an annual report on the JEC to Congress. According to Laurie
Ekstrand, of GAO's healthcare team, ``GAO asked to have the annual
reporting changed. Given the array of issues we have to cover it seems
more reasonable to report on an as-needed basis and to have reporting
about the JEC considered in relation to the relative importance of the
rest of our requested workload.''
The JEC provides its own annual report to Congress but they have a
vested interest in highlighting the ``good news stories'' and
minimizing the focus on areas in need of improvement. Allowing agencies
to self report without the objective oversight provided by GAO reports
may have contributed to the problems at Walter Reed. Army Leadership
was so focused on all the good that was being done that they failed to
look for, or acknowledge, the bad. In recent Congressional hearings
General Schoomaker, the Army Chief of Staff, addressed the Army's
propensity to believe its own good press about Walter Reed and
acknowledged, ``we have been drinking our own bathwater.''
a complex process
We must ensure that wounded servicemembers have advocates who know
the system and can help them and their families navigate the incredibly
complex MEB/PEB process and the VA benefits process. Secretary
Nicholson's hiring of 100 patient advocates and 400 benefits personnel
is a step in the right direction but much more needs to be done.
The problems with the current system have been highlighted by the
MED HOLD situation at Walter Reed. One of my old troops lived in
Building 18 last year. Neither he nor the others I've been working with
complained about their accommodations. Rather, they were frustrated by
the way they were treated by NCOs, social workers, and administrators
as they worked to recover and either get back to the line or get on
with their lives. One soldier expressed this common sentiment bluntly;
``They treat us like . . . 5 year olds!'' These frustrations are
exacerbated by feelings of powerlessness and an overly complex MEB/PEB
process especially among those suffering from TBI and/or PTSD. One
soldier who was at WRAMC when I was injured in July of 2003 is still in
MED HOLD 3 years and 8 months later.
va benefits
When I went to my local VA to apply for benefits after I was
medically retired in December of 2005 I discovered that, despite what I
had been told, an earlier application for a vehicle adaptive grant had
been submitted as my disability claim. The claim failed to include the
amputation of my right leg! Try as I might, I, nor anyone at the VAMC
could actually contact anyone in the regional claims office who could
address my concerns. Fortunately, I knew a senior VA administrator in
Washington, DC. He had one of the key leaders over VA benefits in VA
Central Office call me. Through them I finally made contact with a
manager in the regional claims office who was able to help correct the
situation. Wounded servicemembers should not have to have to ``work the
system'' to ensure their claims are properly handled.
va care
At VA facilities I have been asked at least a dozen times if I lost
my leg to diabetes/vascular disease. VA practitioners have become
specialists in geriatrics and have very little experience with blast
injuries and young patients. Currently, the majority of their patients
are over 50, however these doctors are facing a new wave of veterans
with different needs. While reestablishing Activities of Daily Living
(ADLs) may be an acceptable goal for an 80-year-old veteran, OEF/OIF
veterans typically want to return to the active lives they led before
being wounded.
<bullet> Seriously wounded veterans should be assigned to the best/
most experienced Primary Care Managers (PCMs) available. Too often it
seems the veterans who have been in the system a long time know who the
best physicians are. This means that the ``best'' PCMs are perpetually
``booked up'' by older veterans. Unfortunately, this leaves the newest
veterans, who may have the most complex and challenging medical issues,
under the care of the least experienced or desirable Nurse
Practitioner.
<bullet> The VA should offer drug rehabilitation to combat veterans
who received an Other Than Honorable discharge from the service for
substance abuse.
clear, accurate, and timely exchange of information
The most significant challenges to a truly seamless transition for
our wounded often result from poor communication. In September of 2002,
a VA news release touted the development of ``a single, reliable, data
source and a single point of integration between VA and DOD.'' Four and
a half years later no such system exists for practitioners ``on the
ground.'' Last summer GAO reported that the two VA Polytrauma centers
they visited could still not access DOD electronic medical records.
(GAO-06-794R Transition of Care for OEF and OIF Servicemembers GAO.)
I have filled out the Post Deployment Health Assessment (PDHA) five
separate times at Walter Reed Army Medical Center, Brooke Army Medical
Center, Eisenhower Army Medical Center, Winn Army Community Hospital,
and Portsmouth Naval Hospital. Never has a facility had a record of me
filling out this form. The VA also has no record of me filling out a
PDHA.
I have requested, in writing, a record of my amputation at
Portsmouth Naval Hospital from PNH, WRAMC, DOD, and the VA. The only
evidence that I had an amputation is my lack of a leg a copy of my
discharge paperwork from PNH.
We can do better than this.
conclusion
Recently, my cousin was severely injured in a helicopter crash in
Afghanistan. I have been impressed by the level of care and support he
and his family have received both medically and administratively. A
great deal has changed since 2003. Over the past 3.5 years I've
witnessesed an evolution in the depth and nature of the health and
social services provided by DOD and the VA for the wounded returning
from combat. These changes will ensure that my cousin and others
wounded today will not face many of the issues faced by those wounded
in 2003.
Fourteen servicemembers on my cousin's helicopter came back to the
United States on stretchers. Eight returned in flag draped caskets.
These wounded, and the families of those who were killed, deserve the
best this Nation has to offer. The work that you all are doing is, and
will continue to be, critical to ensuring wounded servicemembers and
Veterans of every generation receive the best care this Nation can
offer.
Thank you all for all that you are doing and thanks for having me
here today.
______
Response to Written Question Submitted by Hon. John D. Rockefeller IV
to Jonathan D. Pruden, Veteran, Operation Iraqi Freedom
Question 1. I am interested in your suggestion about providing
rehabilitation services to veterans on request for substance abuse. Can
you explain more about why you think it is such a priority, and how you
think your colleagues would react to such an offer? Do you think that
some type of substance abuse screening would be important for veterans
with PTSD or TBI diagnoses?
Response. The extensive substance abuse that devastated so many
lives in the wake of Vietnam should make us consider how we will care
for those with similar issues after combat in Iraq and Afghanistan.
Time and again I have witnessed soldiers slide into substance abuse
after combat. Some ask for help, go through rehabilitation, and return
to duty. Too many however, wind up being discharged when they ``come up
hot'' during drug screens or for behavioral issues secondary to
substance abuse. A large number of those discharged for substance abuse
likely turned to drugs or alcohol to medicate psychological problems
stemming from combat.
After recent policy changes, the VA is now screening all OIF/OEF
veterans for TBIs, PTSD, alcohol abuse, depression, and infectious
diseases. However, there is not a separate screen for drug/substance
abuse. The VA has world class substance abuse rehabilitation programs
but the door to these programs is closed if a veteran left the service
with an ``Other than Honorable'' or ``Dishonorable'' discharge.
Those who believe that veterans who are not honorably discharged do
not deserve any VA care should consider how rehabilitation may reduce
the long term costs of substance abuse for family, community, society,
and the government. I've spoken to several soldiers, VA employees, and
friends about this matter and every person has supported this idea.
Several expressed shock that the VA did not currently offer
rehabilitation to those discharged for substance abuse.
I am not proposing free healthcare for these veterans. However, it
seems that we have an obligation to help these men and women when they
show up at the VA wanting to ``get clean.'' Although DOD and the VA are
taking proactive steps to address post-combat PTSD, TBI, and substance
abuse they cannot change human nature nor the horrors of war. The
entanglement of TBI, PTSD, depression, and substance abuse can make it
difficult to determine what the roots of substance abuse may be.
Veterans who were other than honorably discharged due to substance
abuse may have turned to drugs and alcohol to cope with devastating
combat experiences. They deserve our compassion, not disdain.
Chairman Akaka. Thank you very much, Mr. Pruden.
Denise Mettie?
STATEMENT OF DENISE METTIE, REPRESENTING THE WOUNDED WARRIOR
PROJECT, AND MOTHER OF
ARMY SPC. EVAN METTIE
Ms. Mettie. Mr. Chairman and Members of the Committee, my
name is Denise Mettie, and I am representing my son, Retired
Army Specialist Evan Mettie, who was injured in Iraq on January
1, 2006, and the Wounded Warrior Project, a group that assists
wounded servicemen from Iraq and Afghanistan.
Let me start by giving you some details of Evan's initial
injury and his subsequent treatment.
Chairman Akaka. Would you please turn the microphone on?
Ms. Mettie. But I want to whisper.
[Laughter.]
Ms. Mettie. Evan was injured while on a highway outside of
Baji when his patrol stopped to investigate a car. When they
challenged the driver, he blew himself up. We were told that
Evan was initially reported as killed in action, but when a
medic arrived 15 to 20 minutes later, she discovered he was
still breathing. He was quickly evacuated to the nearest
medical facility. In Balad, doctors performed a left-side
craniectomy and removed shrapnel from his brain. Evan
stabilized very well and was transferred to Landstuhl, Germany,
the next day.
Since I could not be there with him, I had the staff put
the phone to his ear, told him we loved him, hang in there, we
would be with him very soon. The nurse said that as soon as I
started talking to him, she saw his heart rate go up. From that
moment on, I knew he was there and God was with our son and was
bringing him back to us.
Evan arrived at Bethesda on January 3, 2006, just 3 days
after the blast, and we arrived a day later--my husband and two
teenage daughters. Evan spent the next 86 days in ICU at
Bethesda. He endured fevers as high as 106, and his weight
dropped from 190 to 99 pounds. We were told he would most
likely remain in a vegetative state, not breathe or eat on his
own, and be paralyzed on his right side.
Before Evan came out of his coma, approximately 17 days
after his injury, we were approached about his Medical Boards
and the process that would initiate his retirement from the
military. Not knowing or having the time at that time to figure
out what was going on, I just said, ``Do what you have to do.''
During the months of January and February, Evan moved his
head from side to side, opened his right eye, and squeezed my
fingers. When Evan's sister came back for a visit, his response
was amazing. As soon as he heard her voice, he lifted his head
and shoulders and raised his arms out like he was trying to sit
up.
On March 10th, it was like an awakening. Evan was really
alert. He even watched a movie for 2 hours for the first time.
By this time the doctors at Bethesda recommended that we
return home so I could be closer to the family and return to a
more normal life and Evan could go to the Seattle VA. We asked
about rehab and were told he was not ready. At no point did
anyone mention the possibility of going to one of the VA's
polytrauma centers let alone private rehab.
On March 26th, he was medevaced to the Seattle VA. That
night when I kissed him goodnight and turned to leave, he
raised his right hand and hit my arm for the first time. I just
cried for joy. Frustratingly, Evan's records were sent with us
in large packets, but somehow some had been misplaced. So for
the next several days, I was filling the doctors in on his care
that he had received for the previous 3 months.
Four days after being there, the doctors told me that Evan
was too healthy to be in ICU and that we needed to move him out
as soon as possible. Since Evan was still on a ventilator, that
meant he has one of four civilian skilled nursing facilities to
choose from in the State of Washington.
One of the VA doctors told me that Evan's brain injury was
the most devastating that she had seen and hope for recovery
was unlikely. Like all of the other times, I told her, ``We
have seen Evan do amazing things. You have your prognosis and I
have mine, and I am following mine.''
Before being sent to the nursing facility, Evan was making
significant progress. He ultimately went 24 hours breathing on
his own. He was squeezing hands on command, smiling, tried to
lift his left hand several times. He would give little modified
``thumbs up'' when we asked him questions or asked him to do
it, raised his head and would try to lift both hands at the
same time.
Because there was no interim place in the hospital to place
him for a week or even two, to continue his vent weaning, he
was transferred directly to a civilian skilled nursing
facility, a SNF. This was undoubtedly the most horrendous
experience we have ever endured. The medevac nurses were
initially afraid to leave him because they feared for his
safety. After 3 weeks of enduring continuous disregard to his
care, his pain, and the fact that he could not speak for
himself, the VA investigated and moved him back to the Seattle
VA.
I could not even begin to tell you how relieved I was. At
that point I could just take a breath again.
In May, however, because Evan's MEB had been stalled until
we gained guardianship, he was still on active duty. His
medical holding was changed to Fort Lewis. Due to this change,
I was no longer able to get a per diem. I had quit my job with
US Bank to be with him, and now all motel, food, and gas costs
were at our expense.
The people in Seattle treated Evan wonderfully, but he was
the first OIF TBI to come through there, and there was no
overall treatment plan. To this day, I am still unsure how Evan
originally bypassed the entire polytrauma system that could
have potentially provided such a plan. I even asked for
referrals, but was told Palo Alto could not take him because he
was not ready.
At that point Evan's rehab program consisted of a 30-minute
range of motion each morning, Monday through Friday. One to
three times a week a physical therapist would come in and sit
him upright on the side of his bed for approximately 30
minutes. That was it.
During this time I did my own research. I devised my own
coma stimulation program, and I did his extra range-of-motion
activities.
Part of the problem lay with a test, an SSEP test that they
took that measures the impulse activity throughout the nervous
system. And when they did it, the testing resulted normal, up,
through, behind his ears, the electrodes they had placed on top
of his head did not pick up any electrical impulse activity in
the cortex of his brain. In studying these tests, they can be
inaccurate for a variety of reasons. When the rehab doctor met
with me to tell me about this, I told her that it was wrong. I
had seen him do too many things that he would not have been
able to do if he did not have this impulse activity.
On November 30th, almost a year after his initial injury,
Evan finally made it to rehab at Palo Alto and soon started
command responses again. Evan came in for a 30-day evaluation
and was extended 2 more weeks. He occasionally could answer
questions with raising his right hand, and he would move his
head to the left and right, and they extended him for another 2
weeks.
In January, I was advised to take Evan home and put him in
a skilled nursing facility until he reached the next level and
that he could come back for more therapy. My question was: How
can he reach the next level if he is not receiving
rehabilitation therapy? They said they would send videos and
written instructions for the staff at the nursing home to
follow and I would be there to train them. After our experience
with the previous facility, this scared the living daylights
out of me. Evan was to heal himself before he could get further
rehab.
Unfortunately, by mid-February Evan's lack of responses was
noticeable, and I could not figure out what was happening. On
the 16th, I was told the team doctors thought it would be a
good idea to transfer Evan to a VA long-term facility until he
could be transferred elsewhere. I was livid. First, any moves
are extremely hard on Evan, especially if it is just for a week
or two. Second, since mid-January I had not seen a particular
neuropsychologist with Evan. He was an integral part of his
program. He had been seeing him for 3 to 4 weeks prior to this,
and he was making continual progress. I requested a meeting to
address my concerns, and the doctors agreed to check the
records.
On March 14th, I received an apology from the hospital
director as it appeared that Evan's records were not accurate.
They offered another evaluation and therapist for Evan, and in
the meantime, I had requested second opinions from both Tampa
VA and a private rehab facility called Casa Colina.
Representatives from Tampa VA met with me and, without seeing
Evan, told me since he is a year out in his injury they could
not help us. I asked if further therapy would be beneficial and
was told no.
The ironic thing was earlier that day, I asked Evan if he
was going to work with PT today. He raised his right hand for
yes. Therapists came in and asked him questions about what hair
color he liked on girls. Blondes? Right hand raised for yes.
Brunettes? No response. Redheads? Right hand raised for yes.
And this is from the kid who is not worth more therapy.
A recent CT scan showed a buildup of fluid in Evan's brain.
If it is causing the pressure, this could explain his
regression. To date, Casa Colina has not responded to my
inquiries, but the Rehabilitation Institute of Chicago is
sending an evaluator. Although I do not know who will pay for
this care should they accept him, RIC's answer will determine
Evan's future. He will either progress with more rehab or go
home to a local skilled nursing facility until our house is
adapted. Then he will come home where, with my own prognosis,
we will continue his rehab.
This is our story, and I wish it were unique. But,
unfortunately, many of the challenges we face are faced by
other families also. If you take but a few things from this
story, please let it be this: Traumatic brain-injured patients
and families need time to adjust to the reality of their
situations, and it is unfair to quickly begin the retirement
process for individuals with such an unknown and unpredictable
injury, especially when retirement limits care options. Give us
time to get our feet under us and understand what we are
dealing with.
Traumatic brain-injured patients and families need options.
I know that the VA is building their program, and I understand
it continues to make progress. Still, there are many private
hospitals which have many years of experience treating and
rehabilitating patients like my son. It is unfair to deny us
access to the same level of care that you would choose for your
own children. At the same time, the VA must use these private
facilities as the resources they are so that one day, hopefully
soon, the VA will be the facility of choice.
Thank you, and I look forward to your questions.
[The prepared statement of Ms. Mettie follows:]
Prepared Statement of Denise Mettie, Representing the Wounded Warrior
Project, and Mother of Army Spc. Evan Mettie
Mr. Chairman, and Members of the Committee, my name is Denise
Mettie, and I am representing my son, retired Army Spc. Evan Mettie who
was injured in Iraq on January 1st, 2006 and the Wounded Warrior
Project, a group that assists wounded servicemembers from Iraq and
Afghanistan.
Let me start by giving you some of the details of Evan's initial
injury and subsequent treatment. Evan was injured while on a highway
outside of Baji when his patrol stopped to investigate a car. When they
challenged the driver, he blew himself up. We were told that Evan was
initially reported as ``Killed in Action,'' but when a Medic arrived
15-20 minutes later, she discovered he was still breathing. He was
quickly evacuated to the nearest medical facility.
In Balad, doctors performed a left side cranectomy and removed
shrapnel from his brain. Evan stabilized very well and he was
transferred to Landstuhl, Germany the next day. Since I could not be
there with him, I had the staff put the phone up to his ear, I told him
to hang on, we loved him and we would be with him soon. The nurse told
me his heart rate went up as soon as I started speaking--I knew then
the good Lord was watching my guy.
Evan arrived at Bethesda on January 3, 2006, just 3 days after the
blast that injured him, and we arrived a day later. Evan spent the next
86 days in ICU at Bethesda. He endured fevers as high as 106, and his
weight dropped from 190 to 99lbs. We were told he would most likely
remain in a vegetative state, not breathe or eat on his own, and be
paralyzed on his right side.
Before Evan came out of his coma, and just 17 days after his
injury, we were approached about his Medical Boards, the process that
would initiate his retirement from the military. Not knowing or having
the time to figure out what that meant, I said ``do what you have to
do.''
During the months of January and February, Evan moved his head from
side to side, opened his right eye, and squeezed my fingers. When
Evan's sister Kira arrived, and as soon as she started talking to him
there was a huge response. He opened both eye's wide, lifted his head
and shoulders up and outstretched his arms as if he were trying to sit
up. On March 10th , it was like an ``awakening''--Evan was really
alert, he even watched a 2-hour movie and smiled.
By this time the doctor at Bethesda recommended that we return home
so I could be closer to family, return to a more normal life and Evan
could go to the Seattle VA. We asked about rehab and were told he
wasn't ready. At no point did anyone mention the possibility of going
to one of the VA's Polytrauma Centers let alone a private rehab
facility.
On March 26th, he was medivaced to the Seattle VA. That night when
I kissed him goodnight and turned to leave, his right hand reached up
and hit my arm. I cried for joy. Frustratingly, Evan's records had not
arrived at Seattle with him, so for the next few days I was filling
them in on his condition. They then told me Evan was too healthy to be
in the ICU and we needed to get him out ASAP. That meant Evan had to go
to a civilian Skilled Nursing Facility.
One of the VA Doctors told me Evan's brain injury was one of the
most devastating she had seen and hope for recovery was unlikely. Like
all of the other times, I told her ``we've seen Evan do things no one
else has and we have a strong Faith, so you can have your prognosis and
I will have mine.''
Before being sent to the Nursing Facility, Evan seemed to be making
significant progress. He ultimately went 24 hours breathing on his own,
squeezed his hand on command, smiled, lifted his left hand several
times, gave a thumbs up sign, raised his head, and tried to lift both
arms.
Because there was no interim place in the hospital to place him for
a week or two to continue his vent weaning, he was transferred directly
to a civilian Skilled Nursing Facility (SNF). This was a horrendous
experience due mostly to their inattention to Evan's needs, their
disregard for his constant pain, and their blatant disrespect of a
patient unable to speak for himself.
After a month of this substandard care, the VA investigated, and
Evan was transferred back to Seattle. Everyone there was wonderful, and
he was treated with kindness and respect. I could finally breathe
again.
In May, however, because Evan's MEB had been stalled until we
gained guardianship and he was still on active duty, his Medical
holding was changed to Ft. Lewis. Due to this change I was no longer
able to get a per diem. I had quit my job with US Bank to be with him,
and now all motel, food and gas costs were at our own expense.
The people in Seattle treated Evan wonderfully, but he was the
first OIF TBI to come through there, and there was no overall treatment
plan. To this day, I am still unsure how Evan originally bypassed the
entire polytrauma system that could have potentially provided such a
plan. I even asked for referrals but was told Palo Alto wouldn't take
Evan because he was not ready.
At that point, Evan's rehab program consisted of 30 minutes of
Range of Motion each morning Monday thru Friday, and 1-3 times a week a
physical therapist sits him upright on his bed. That was it. I
dedicated my time to research, devising my own Coma Stimulation program
and doing extra ROM activities.
On November 30th, almost a year after his initial injury, Evan
finally made it to rehab at Palo Alto and soon started command
responses again. Evan came in for a 30-day evaluation and was extended
2 more weeks. He occasionally could answer a few questions by raising
his right hand for yes and was extended another 2 weeks.
In January, I was advised to take Evan home and put him into a SNF
until he reached ``the next level'' and then he could come back for
more therapy. How could he reach the next level if he was receiving no
rehabilitation therapy? They said they would send videos and written
instructions for the staff at the nursing home to follow, and I would
be there to train them. After our experience with the previous
facility, this scared the living daylights out of me. Evan was to heal
himself before he could get further rehab.
Unfortunately, by mid-February Evan's lack of responses was
noticeable, and I couldn't figure out what was happening. On the 16th,
I was told the ``team'' doctors thought it would be a good idea to
transfer Evan to a VA long term care facility until he could be
transferred elsewhere. I was livid, first, because moves are very hard
on Evan, especially for a week or two. Second, since mid January I had
not seen a particular Neuro Psychologist with Evan, which was an
integral part of his therapy. He had been seeing her 3-4 times a week
prior to that and was making continual progress. I requested a meeting
to address my concern and the doctors agreed to check the therapist's
records.
On March 14th, I received an apology from the Hospital Director, as
it appeared that Evan's records were not accurate. They offered another
evaluation and therapist for Evan, and in the meantime I had requested
a second opinion from both the Tampa VA and a private rehab facility
called Casa Colina. Representatives from the Tampa VA met with me, and
without seeing Evan, told me since he's a year out in his injury they
could not help us. I asked if further therapy would be beneficial and
was told no. The ironic thing was that earlier that day, I asked Evan
if he was going to work with PT today, he raised his right hand for
yes. Therapists asked him questions about what hair color he liked on
girls, blonde? Right hand raise, yes. Brunettes, no response. Redheads?
Right hand raise, yes. This, from the kid who isn't worth more therapy.
A recent CT scan shows a buildup of fluid in Evan's brain. If it is
causing pressure, this could explain his regression. To date, Casa
Colina has not responded to my inquiries, but the Rehabilitation
Institute of Chicago (RIC) is sending an evaluator. Although I don't
know who will pay for this care should they accept him, RIC's answer
will determine Evan's future--he will either progress with more rehab
or go home to a local Skilled Nursing Facility until our house is
adapted. Then he will come home where with my own prognosis, we will
continue his rehab.
That is our story, and I wish it were unique. Unfortunately, many
of the challenges we faced are being encountered by others in similar
situations. If you take but a few things from this story, please let it
be this:
<bullet> Traumatic Brain Injured patients and families need time to
adjust to the reality of their situations, and it is unfair to quickly
begin the retirement process for individuals with such an unknown and
unpredictable injury, especially when retirement limits care options.
Give us time to get our feet under us and understand what we are
dealing with.
<bullet> Traumatic Brain Injured patients and families need
options. I know that the VA is building their program, and I understand
that it continues to make progress. Still there are many private
hospitals which have many years of experience in treating and
rehabilitating patients like my son. It is unfair to deny us access to
the same level of care that you would choose for your children. At the
same time the VA must use these private facilities as the resources
they are, so that one day, hopefully soon, the VA will be the facility
of choice.
Thank you, and I look forward to your questions.
Chairman Akaka. Thank you very much for your testimony.
Dr. Gans?
STATEMENT OF BRUCE M. GANS, M.D., EXECUTIVE VICE PRESIDENT AND
CHIEF MEDICAL OFFICER, KESSLER
INSTITUTE FOR REHABILITATION, NEW JERSEY
Dr. Gans. Thank you, Mr. Chairman, Members of the
Committee. I am really moved by the testimony of the three
panelists who have preceded me. It makes me remember that we
are here about people and their families and the injuries and
the concerns and the hope and the optimism and opportunity that
they face. And I would like to share you the view from the
private rehabilitation community, the things that we try to do,
the things we would like to be able to do, and the capacity
that we do represent that may be at least in part a way of
helping with the current problem.
We tried over 4 years ago as an institution to reach out to
the DOD when we saw injured soldiers coming back without access
to services. It was visible in the press at that time. We
reached out to the VA. Many of our other organizations in the
private rehabilitation community did so. Unfortunately, we
could not find a way in. We could not find a way to offer our
services. It was not about business. It was about care for
people and the needs. We had the capacity. We wanted to provide
the service. We continue to be frustrated in those regards as a
field for a number of years.
Let me tell you about the private rehabilitation community
capacity in this country. Actually, World War II created much
of what exists, and the VA itself was a leader in creating the
rehabilitation capacity that became a very large part of what
is available in the civilian community. Today there are more
than 217 free-standing rehabilitation hospitals in this
country, more than 1,000 rehabilitation units in acute-care
hospitals, and many thousands of outpatient rehabilitation
therapy centers. Many of those have very specialized programs
for exactly the kinds of injuries and disabling conditions that
our injured warriors are coming back with--amputations,
traumatic brain injuries, spinal cord injuries, and many other
disabling conditions. And we even have organized networks of
research and clinical service that are capable of dealing with
them that are even funded by the Federal Government. The
National Institute on Disability and Rehabilitation Research
funds currently 16 model systems in spinal cord injury and is
re-funding right now 14 systems in traumatic brain injury.
These are model systems that provide research, that
collaborate, provide education services, and advance the state
of the knowledge and the art of rehabilitation. And there is a
smaller network of burn injury rehabilitation programs as well.
I merely mention these to say that the civilian community
has capacity for exactly the kinds of injuries that are being
seen and has ways of identifying those programs that have true
expertise and are uniquely qualified, and that I think is part
of the key to how the civilian sector could be helpful to
augment what the DOD and the VA systems currently have
available to them.
At the same time, it is ironic to think that the VA rehab
capacity has sadly shrunk over the years in response to the
changing needs of its members and service providers while the
civilian community has grown and its capacity has been
enriched. We now serve injured individuals in urban violence,
people in motor vehicle accidents, older people with the same
kinds of problems that the VA is experiencing, but we do have
experience with trauma and all the range of services that are
needed.
What is needed is accessible, excellent quality care that
is organized and where people need to have it accessible to
them, not just the quality but also the location. The civilian
sector is capable of augmenting and complementing the military
and the VA systems if you will find a way to let us help so
that we can do that.
Last week, I had the privilege of meeting with Secretary
Nicholson at his offices with several of his key staff members
to talk about just this issue. We made, on behalf of the
rehabilitation hospital facilities, a proposal that we could
establish a coordinating council that would let the private
sector coordinate and cooperate and plan together with both the
military and the VA systems to identify mechanisms of
identifying service centers of excellence that could be
qualified for participation in serving our servicemembers, that
could be located geographically where they are needed to
complement the existing excellence of the VA facilities and the
military systems, and could arrange for information exchange
and even could organize a research effort so that the
information that is learned about how the private sector and
the publicly sponsored programs can work together can be
enhanced so that the quality of care that we all want to
provide can be made more effective, more efficient, cost even
less, but do even a better job.
I would like to mention one other problem that may seem
irrelevant but is very germane. The rehabilitation capacity in
the civilian sector is starting to fall apart in this country
because of pressure from CMS, the Medicare program, that is
forcing beds to close because of changing views as to where
rehabilitation is appropriate. Over the last year alone, more
than 8 percent of the Nation's rehabilitation beds have closed
because of pressure from the 75 percent rule, which is a
Medicare regulation, and we have only seen the tip of the
iceberg. This is going to be a huge problem that may close as
many as a third to half of the rehab beds and facilities in
this country if it is not addressed.
We are very grateful that Senators Nelson, Bunning,
Stabenow, and Snowe have introduced S. 543, the Preserving
Patient Access to Inpatient Rehabilitation Act of 2007, which
will help stop this problem from continuing. We do not need the
civilian sector to be disassembled the way the VA system was
just at the time that we need it most. The civilian community
wants to help, can make itself available, has services and
resources to complement the VA, and we want to make that
possible so that the kinds of stories that I just heard do not
have to be replicated.
Thank you for your attention.
[The prepared statement of Dr. Gans follows:]
Prepared Statement of Bruce M. Gans, M.D., Executive Vice President and
Chief Medical Officer, Kessler Institute for Rehabilitation, New Jersey
Good morning, Senator Akaka and Members of the Committee. Thank you
for inviting me today to share my experience and recommendations
regarding cooperation among the DOD, the VA, and the civilian
rehabilitation hospitals to provide for the medical rehabilitation
needs of returning servicemembers.
I am Dr. Bruce Gans, a physician who specializes in Physical
Medicine and Rehabilitation (PM&R). I currently am the Executive Vice
President and Chief Medical Officer of the Kessler Institute for
Rehabilitation in New Jersey. I have been president of the Association
for Academic Physiatrists (the society that serves medical school
faculty members and departments), and the American Academy of PM&R,
which represents approximately 8,000 physicians who specialize in PM&R.
I currently serve as a Board member and officer of the American Medical
Rehabilitation Providers Association (AMRPA), the national association
that represents our Nation's rehabilitation hospitals and units. In the
past, I have chaired medical school departments at Tufts University
School of Medicine in Boston, and Wayne State University School of
Medicine, in Detroit. I also served as President and CEO of the
Rehabilitation Institute of Michigan in Detroit for 10 years.
Kessler Institute for Rehabilitation is the largest medical
rehabilitation hospital in the Nation. We operate specialized Centers
of Excellence to treat patients with amputations, traumatic brain
injuries, spinal cord injuries, strokes, and many other neurological
and musculoskeletal diseases and injuries. We also offer more than
fifty sites for outpatient rehabilitation services in New Jersey that
provide services such as medical care, physical therapy, prosthetic
fabrication and fitting, cognitive rehabilitation treatment, high
technology wheelchairs and electronic assistive device fittings, and
many other services.
We are also a major medical rehabilitation education and research
facility. We train physicians, therapists, psychologists, and others as
to how to provide rehabilitation programs and services. We also host
many research programs and projects to advance the knowledge and
science of medical rehabilitation. Much of this research is funded by
Federal grants from the National Institutes of Health (NIH), the
National Institute for Disability and Rehabilitation Research (NIDRR),
other Federal and state organizations, and private foundations.
The reason I am speaking with you today is to share my experience
regarding how in the past we tried, without success, to offer our
medical rehabilitation services to returning military personnel, both
active military and veterans. I will also share my views as to how the
civilian medical rehabilitation provider community can help the DOD and
VA health systems to provide the highest quality immediate and long-
term rehabilitation care to our wounded warriors at facilities that are
close to their homes, while still being cost effective for our Nation.
rehabilitation capacity in the civilian health care system
Over the past 60 to 70 years, our Nation's civilian health care
system has developed a rich capacity to provide sophisticated medical
rehabilitation care through an array of several hundred free-standing
rehabilitation hospitals, more than a thousand rehabilitation units of
acute care hospitals, and thousands of outpatient therapy centers. Many
of these facilities are capable of providing technically advanced care
for patients with traumatic brain injuries, amputations, and all the
other injuries being experienced by our servicemembers. This
rehabilitation care is provided by multidisciplinary teams of
physicians, nurses, therapists, neuropsychologists, and many other
professionals in well organized and goal directed programs.
Highly specialized expertise exists in some of these facilities to
deal with the exact problems our servicemembers have. For example,
there currently is a network of 14 Spinal Cord Injury Model Systems in
a grant supported program funded by NIDRR that provides state-of-the-
art clinical care, as well as conducts cutting edge research to advance
the effectiveness of medical rehabilitation. Similarly, there is a
network of 16 Traumatic Brain Injury Model Systems, and a smaller
network of Burn Rehabilitation Model Systems also funded by NIDRR. Each
of these centers has been able to demonstrate objectively how they
provide exceptional clinical care, as well as community outreach,
education, and research.
In addition to the centers that have received these grant
designations, there are many other equally well-qualified
rehabilitation programs in operation today that are serving patients
with the same injuries. Consider that when the SCI Model System grant
program was recently competed, more than 30 qualified organizations
applied for the 14 awards that were eventually made.
My point is that there is a rich care-giving capacity that already
exists in our country that could be tapped to assist our servicemembers
and their families. There is also an established basis for judging
program quality, to determine which ones can meet rigorous standards of
excellence.
the private, dod and va sectors have not worked
or planned together well
About 4 years ago, when it became apparent that serious injuries
were being incurred by growing numbers of our troops, we at Kessler
tried to reach out to offer our services to the DOD and VA. We called,
wrote, e-mailed, and in other ways tried to engage medical and
administrative leaders in the Departments and individual facilities to
offer our assistance. Unfortunately, at that time we were unable to
find a receptive ear.
One of the reasons we reached out to the VA in particular, is
because we knew that over the last few years, much of the VA's clinical
ability to deliver rehabilitation care in organized units had been
taken out of service, presumably as a response to budget pressures and
a belief that the demand for services was in decline as our veterans
were aging and expiring.
Sadly, in retrospect we can see that dismantling the VA
rehabilitation capacity was an unfortunate choice. The need for
physical medicine and rehabilitation has now grown dramatically. While
I applaud the efforts of the DOD and the VA to create high quality
treatment facilities such as the VA Polytrauma Centers, the current
efforts fall far short of the immediate need for technically excellent,
compassionate rehabilitation care that can be provided to all in need,
in a timely manner, and close to home in the patient's local community.
Having a limited number of centers that can only be accessed by
people if they uproot themselves and their families to live in
temporary housing of variable conditions, only adds insult to injury.
Further, it still leaves patients and families at risk to eventually
return to a home community with no accessible lifelong care capacity
that they can utilize. It seems to me that this is unwise, unnecessary,
and a breach of our moral responsibility to our servicemembers as a
grateful Nation.
In the era following World War II, when there were very few local
rehabilitation care delivery options, it made sense to create a
national network of veteran specific settings to provide care not
otherwise available for our returning GIs. In fact, that early work of
the VA is largely responsible for having trained physicians, supported
important research, and allowed the civilian sector to build upon their
experience to create our rehabilitation capacity today.
Now, however, the situation is reversed. A large and qualified
network of services does exist in the civilian sector, and a limited
distribution of VA and DOD facilities exists. There is no need to
recreate a ``separate but equal'' VA-housed network that will have to
be available for the next 80 years to provide solely for the lifelong
specialized needs of our injured servicemembers.
a recommended course of action
The solution is obvious: establish a mechanism for qualified
civilian rehabilitation hospitals to contract with the VA and DOD to
provide high quality services to our injured, both now and for the long
term. Services should include medical, pharmaceutical, therapy,
psychological, social, Durable Medical Equipment, and especially case
management support. Certainly, we should continue to utilize the
capacity of the VA and DOD where it now exists. But we should not force
people to leave their homes and support systems for many months. And we
should not just drop them back into distant home communities without
access to appropriate ongoing services that they will need indefinitely
(for repairs and replacements for prostheses, ongoing cognitive
rehabilitation therapies, continuing counseling for Post Traumatic
Stress Disorder, or the treatment of other related conditions).
Last week, I had the privilege to meet with Secretary Nicholson and
several members of his senior staff, to discuss these matters. At that
meeting, I recommended to them that a standing Coordinating Council
between the DOD, the VA, and the private medical rehabilitation
hospital community be established. This Council could work together to
Develop standards to qualify appropriate provider organizations to
serve servicemembers:
(1) Target case management resources to oversee these
servicemembers' unique needs;
(2) Establish appropriate contracting and payment mechanisms; and
(3) Provide ongoing monitoring of the programs it would create.
In addition, there should be funds targeted to create a focused
research program to understand how effective this collaboration will
be, and how to improve upon it, based on outcomes of care and
satisfaction of patients and their families.
another problem exists
There is another current problem of enormous importance in the
civilian rehabilitation community that is threatening the ongoing
existence of the care delivery capacity I have just described. It
centers on drastic cutbacks being imposed on the field by the Centers
for Medicare and Medicaid Services (CMS) that are trying to balance
budgets and constrain expenditures by denying access to needed
rehabilitation services. Due to the regulation we know as the ``75
percent Rule,'' more than 8 percent of the Nation's rehabilitation beds
have been closed in just the last year. Those beds closed because of
these pressures, and thousands more are expected to be forced to close
as the regulatory pressures continue.
We desperately need a rational plan for maintaining and nurturing
an appropriate care giving capacity for medical rehabilitation. By
stopping the further escalation of the pressures forcing bed and
facility closures now, we will preserve the availability of services
that can be of enormous help to our soldiers today, and sustain the
availability of those services for their lifetimes. Senators Ben
Nelson, Jim Bunning, Debbie Stabenow, Olympia Snowe, and colleagues
have recently introduced S. 543, the ``Preserving Patient Access to
Inpatient Rehabilitation Hospitals Act of 2007'' to address this
critical problem.
I urge that in addition to creating effective mechanisms to allow
the cooperation of the DOD, the VA, and the private rehabilitation
hospital community, you also support S. 543 to preserve the private-
public rehabilitation hospital resource so that our servicemembers may
readily access it now and in the future.
Thank you very much for giving me the opportunity to address the
Committee. I would be happy to respond to any questions you might have.
______
Response to Written Questions Submitted by Hon. John D. Rockefeller IV
to Bruce M. Gans, M.D., Executive Vice President and Chief Medical
Officer, Kessler Institute for Rehabilitation, New Jersey
Question 1. Can you provide a list and locations of the
rehabilitation centers funded by NIH, and the National Institute for
Disability and Rehabilitation Research (NIDRR), and if possible provide
information on how such centers overlap with existing VA facilities to
help highlight the potential to expand access and coverage?
Response. Attached are listings from the Web site for the National
Institute for Disability and Rehabilitation Research (http://
www.ed.gov/about/offices/list/osers/nidrr/index.html) that describe
their current funded portfolio of Model Systems for Burn
Rehabilitation, TBI Rehabilitation and SCI Rehabilitation. In addition,
I am providing you with a list of its Rehabilitation Research and
Training Centers and Rehabilitation Engineering Research Centers, which
cover many highly relevant clinical areas.
I have also included a project listing from the National Center for
Medical Rehabilitation Research (NCMRR), which is a division of the
National Institute for Child Health and Human Development (NICHD) at
the National Institutes of Health (NIH). These projects are directly
relevant to the TBI problem as well.
Please note that this is only a representative sample of the
locations in the civilian care delivery system where expertise exists
that could be tapped to complement, supplement and enhance the current
VA and DOD capabilities. Many of these civilian programs are located in
larger urban areas, and are associated with universities and academic
medical centers. As such, it is likely that a number will be proximate
to existing VA or military facilities.
In the case of the Kessler Institute for Rehabilitation, we are
very near the East Orange VA (which has recently reached out to us to
explore the potential for clinical collaboration), and also have active
clinical research projects in cooperation with the Bronx VA in New
York.
Many of the civilian clinical programs operate extended networks of
outreach themselves. For example, while Kessler Institute for
Rehabilitation's primary TBI Center of Excellence is located on our
West Orange, New Jersey campus (12 miles from Manhattan); we operate
additional programs in northern New Jersey at our Saddle Brook campus,
and also in western New Jersey at our Chester campus.
It is also common for rehabilitation hospitals to operate
outpatient therapy facilities and clinics. Kessler, for example,
operates more than 50 rehabilitation centers throughout New Jersey.
Many of our sites are capable of delivering specialized programs for
patients who have completed inpatient programs in our Centers of
Excellence. Thus, the private sector is very likely to represent an
extensive distribution channel to reach smaller communities where no VA
or military facilities exist.
I am not familiar with all of the existing 1,266 VA facilities, nor
their specific capabilities, but I suggest that taking stock of them
would best be pursued by a Coordinating Council that included VA, DOD
and civilian representation.
[National Institute for Disability and Rehabilitation Research
(NIDRR) rehabilitation model systems for Burn, TBI and SCI; list of
NIDRR Rehabilitation Research and Training Centers; list of NIDRR
Rehabilitation, Engineering Research Centers; and list of projects for
the National Center for Medical Rehabilitation Research (NCMRR)
follow:]
model systems for burn rehabilitation funded by the national
institute for disability and rehabilitation research
UCHSC Burn Model System Data Coordination Center (BMS/DCC)
Dennis C. Lezotte, Ph.D., University of Colorado Health Sciences
Center, Denver, CO; Project Number: 144; Start Date: October 1, 2002;
Length: 60 months.
Abstract: The BMS/DCC establishes a data management and analytical
support facility for Burn Model Systems clinical and outcomes research
projects.
Objectives include: (1) to serve the clinical, research, and public
communities to which it is responsible; (2) to serve the needs of good
scientific procedure in multi-institutional outcomes research; and (3)
to support the needs for patient safety and data confidentiality as
required by Federal regulations when conducting collaborative clinical
studies. The BMS Project is structured as a set of interacting,
observational, randomized, and quasi-experimental clinical studies run
at different centers that share the common purpose of acquiring and
disseminating knowledge about burn injury care and rehabilitation. The
project offers support in four important areas: project management,
data management, analytical support, and dissemination. Support is
provided in developing appropriate integrated systems to affect
national data collection, project management, data coordination,
technical support, collaborative clinical projects, scientific conduct,
scientific publication, and effective dissemination. The UCHSC BMS/DCC
continues to accumulate and integrate a central repository of data from
the Model Systems to enhance their abilities to make sentinel
statements and change the way burn injury rehabilitation is done. While
the main function of the DCC is to integrate and manage these data, it
also needs to be responsive to the technical and analytical needs of
these individual clinical centers. In addition, the DCC provides and
coordinates statistical support among the clinical and statistical
groups from each Burn Center and is prepared to expand this support,
adding several new protocols and/or clinical studies where appropriate.
Johns Hopkins University Burn Injury Rehabilitation Model System (JHU-
BIRMS)
James A. Fauerbach, Ph.D., Johns Hopkins School of Medicine, Baltimore,
MD; Project Number: 101; Start Date: October 1, 2002; Length: 60
months.
Abstract: This project tests interventions targeting three common
postburn secondary complications affecting health and function:
generalized deconditioning, muscle atrophy, and acute stress disorder.
Testing the effectiveness of these interventions holds promise for
improving the health and function of burn survivors as well as
enhancing their options for workplace and community reintegration. The
JHU-BIRMS includes several projects: (1) testing the efficacy of its
augmented exercise program in rehabilitating people with generalized
deconditioning, (2) testing the efficacy of enhanced cognitive-
behavioral therapy in treating individuals with acute stress disorder
and preventing the development of chronic posttraumatic stress
disorder, (3) developing a new measure that quantifies the degree of
social stigmatization experienced by burn survivors and its impact on
emotional adjustment and integration into the workplace and the
community (this project involves the Phoenix Society, the largest
foundation supporting burn survivors and their significant others), (4)
a collaborative effort with the University of Washington on a workplace
integration study identifying and quantifying those factors interfering
with early and complete return to work, and (5) a collaborative study
on health and function with the University of Texas.
North Texas Burn Rehabilitation Model System (NTBRMS)
Karen Kowalske, M.D., The University of Texas Southwestern Medical
Center, Dallas, TX; Project Number: 143; Start Date: October 1, 2002;
Length: 60 months.
Abstract: This project conducts five research projects, two
collaborative and three site-specific: (1) barriers to return-to-work
following major burn injury; (2) long-term outcome following major burn
injury; (3) outcome following deep, full-thickness hand burns; (4) the
evolution over time of burn-associated neuropathy; and (5) the
socioeconomic determinants of disability in individuals with burn
injury. The North Texas Burn Rehabilitation Model System (NTBRMS) is a
collaboration of Parkland Health and Hospital System (PHHS) and the
University of Texas, Southwestern Medical Center (UTSW). Collaboration
occurs on many levels at the NTBRMS. Clinical collaboration is the
hallmark of the burn team, which includes individuals from several
institutions who work together seamlessly, as well as collaboration
with rural care providers through rural clinics and a biannual seminar.
Research collaboration occurs locally with the surgeons and academic
computing staff, and nationally with the other model systems.
Pediatric Burn Injury Rehabilitation Model System
David Herndon, M.D., University of Texas Medical Branch, Galveston, TX;
Project Number: 102; Start Date: October 1, 2002; Length: 60 months.
Abstract: This program conducts independent and multi-center
projects focusing on evaluating and improving the rehabilitation
provided to the burned child, striving to decrease disability and
improve reintegration into society. The project continues longitudinal
assessments of patients, expanding the database that includes measures
of cardiopulmonary function, physical growth and maturation, bone
density, range of motion, activities of daily living, scar formation,
reconstructive needs, and measures of psychosocial adjustment. This
data is used to identify areas that require improvement and provide
functional outcome measures that can be used in the evaluation of
treatment methods.
Research activities include: (1) a multi-center project assessing
the efficacy of the long-term administration of oxandrolone in the
treatment of burn injury with endpoints of improved strength, lean body
mass, bone density, and growth; (2) improving rehabilitative outcomes
for children by instituting and evaluating major modifications to
current treatment for children with large burns; (3) evaluating the use
of pressure garments in controlling scar following burn injury; (4) a
multi-center study evaluating the relationship between treatment,
injury, patient characteristics, and patient outcome in those patients
sustaining full thickness hand burns; and (5) evaluating acute stress
disorder and posttraumatic stress disorder, including its occurrence,
predictive elements, and efficacy of treatment.
University of Washington Burn Injury Rehabilitation Model System
Loren H. Engrav, M.D., University of Washington, Seattle, WA; Project
Number: 103; Start Date: October 1, 2002; Length: 60 months.
Abstract: This model system conducts five research projects: (1) A
New Approach to the Etiology of Hypertrophic Scarring: develops an
increased understanding of hypertrophic scarring. (2) Effect of Virtual
Reality on Active Range-of-Motion During Physical Therapy: uses
distraction via immersive virtual reality as an adjunctive non-
pharmacologic analgesic. This study tests the hypothesis that virtual
reality allows patients to tolerate greater stretching during physical
therapy compared to no distraction, and that in spite of achieving
greater range-of-motion, patients still experience lower pain levels
while in virtual reality. (3) Determination of Reasons for Distress in
Burn-Injured Adults: identifies reasons behind a burn survivor's
distress at various time-points after hospital discharge. (4) Barriers
for Return to Work: identifies specific barriers to return to work for
burn survivors. (5) Acute Stress Disorder Among Burn Survivors:
evaluates the effectiveness of cognitive-behavioral therapy, relative
to a non-directive, supportive therapy control group, and a national
comparison sample in reducing the prevalence of posttraumatic stress
disorder diagnosis and symptom severity. Projects 4 and 5 are
collaborative. In addition, this project participates in the national
database.
model systems for traumatic brain injury rehabilitation funded by the
national institute for disability and rehabilitation research
UAB TBI Model System
Thomas A. Novack, Ph.D., University of Alabama/Birmingham, Birmingham,
AL; Project Number: 151; Start Date: October 1, 2002; Length: 60
months.
Abstract: The University of Alabama at Birmingham (UAB) is
maintaining and further developing a Traumatic Brain Injury Model
System (TBIMS) that improves rehabilitation services and outcomes for
persons with TBI. This project provides a multidisciplinary system of
rehabilitation care specifically designed to meet the needs of
individuals with TBI, and, as demonstrated over the past 4 years as a
TBIMS, adequately enrolls subjects to complete research projects
successfully. In addition to contributing data to the TBI National
Database, the UAB TBIMS conducts two research projects: (1) an
examination of the use of a serotonin agonist medication (sertraline)
to lessen the incidence and severity of depression during the first
year of recovery following TBI; (2) a study of the impact of a training
program in problems solving for caregivers.
Northern California Traumatic Brain Injury Model System of Care
Tamara Bushnik, Ph.D., Santa Clara Valley Medical Center (SCVMC), San
Jose, CA; Project Number: 159; Start Date: October 1, 2002; Length: 60
months.
Abstract: This project conducts two studies to better characterize
the type and impact of fatigue on the TBI population: (1) a cross-
sectional study of people up to 10 years post-TBI and (2) a
longitudinal study that focuses on the evolution of fatigue over the
first 2 years post-injury. Both studies utilize standardized
measurements of fatigue, as well as those for depression/affective
disorders, sleep disturbance, activity scales, and measurements of
hormone levels reflective of the health of the neuroendocrine system.
Two additional studies characterize the impact of late posttraumatic
seizures on recovery: (1) a study utilizing data already in the TBIMS
National Database that compares the functional, vocational, and medical
complication outcomes of those with and without late posttraumatic
seizures; (2) a study in collaboration with Denver Hospital Medical
Center that interviews individuals at both sites who participated in a
previously funded NIDRR grant on seizure risk identification. This
study further evaluates barriers to the environment, transportation,
and challenges in control of their seizures.
The National Data and Statistical Center for the Traumatic Brain Injury
Model
Systems
Cynthia Harrison-Felix, Ph.D., Craig Hospital, Englewood, CO; Project
Number: 1713; Start Date: October 1, 2006; Length: 60 months.
Abstract: By implementing a comprehensive and innovative program of
new data management technologies and operating procedures that emulate
the best practices of clinical research organizations and data
coordinating centers, the National Data and Statistical Center (NDSC)
increases the rigor and efficiency of scientific efforts to
longitudinally assess the experience of individuals with traumatic
brain injury (TBI) and advances TBI rehabilitation. The TBIMS database
and the NDSC introduce the following innovations: a state-of-the-art
Web-based data management system; a computer-assisted interview system;
a Standard Operating Procedures Manual; training through quarterly Web-
based conferences, as well as more frequent in-person conferences;
comprehensive Data Collector certification; annual data monitoring
visits to each center; analysis of ethnic/racial bias in participant
recruitment and retention and collaboration with the NIDRR-funded
Center for Capacity Building on Minorities with Disabilities Research;
providing more comprehensive methodological as well as statistical
consultation; continuation of the TBIMS survival study; a system for
following participants from defunded centers; and the use of common
procedures, technologies, and training among all Model System Data
Centers.
The Rocky Mountain Regional Brain Injury System (RMRBIS)
Gale G. Whiteneck, Ph.D., Craig Hospital; Englewood, CO; Project
Number: 152; Start Date: October 1, 2002; Length: 60 months.
Abstract: The Rocky Mountain Regional Brain Injury System (RMRBIS)
conducts three research projects: Study 1 examines the effects of
Modafinil on fatigue and excessive sleepiness after TBI. Study 2
assesses the effectiveness of a group therapy intervention for social
pragmatic communication. Study 3 uses the unique database assets of
Craig Hospital and investigates the environmental and clinical factors
that influence outcome over a 40-year time frame to understand the
process of living and aging with a TBI. In addition to clinical
research and service, Craig Hospital, as the RMRBIS, documents an
outstanding record of dissemination, for all customers including
clinical consumers, community agencies and advocacy groups, other
clinical service centers and systems, and professionals engaged in the
treatment of persons with TBI.
The Spaulding/Partners TBI Model System at Harvard Medical School
Mel B. Glenn, M.D., Spaulding Rehabilitation Hospital, Boston, MA;
Project Number: 153; Start Date: October 1, 2002; Length: 60 months.
Abstract: The Spaulding TBI Model System (TBIMS) provides a
comprehensive spectrum of care for people with TBI through the
collaborative efforts of three hospitals that are part of Partners
Health Care System, Inc., and four organizations that operate a variety
of postacute rehabilitation programs. Research at the center includes
development of functional neuroimaging as a tool to guide cognitive
rehabilitation treatment for people with TBI, and use of functional
magnetic resonance imaging (fMRI), with both a cross-sectional and
longitudinal component. The cross-sectional component assesses regional
brain activation during the memorization of word lists, both under
undirected (spontaneous) conditions and following training and cueing
to use a categorization strategy. The longitudinal component studies
the ability of the fMRI findings to predict outcome among people with
TBI who participate in community integration program with a cognitive
rehabilitation focus.
Southeastern Michigan Traumatic Brain Injury System (SEMTBIS)
Robin A. Hanks, Ph.D., Wayne State University and Rehabilitation
Institute of Michigan, Detroit, MI; Project Number: 155; Start Date:
October 1, 2002; Length: 60 months.
Abstract: The Southeastern Michigan Traumatic Brain Injury System
(SEMTBIS) program conducts projects developed with the help of SEMTBIS
consumers, as well as other members of the Detroit community. There are
three principal studies during this grant cycle: (1) a peer-mentoring
intervention: This study is a randomized controlled trial of a peer-
mentoring program for both survivors and their caregivers; (2) a
dynamic system of survivor and significant-other well-being: This
investigation studies 250 community-dwelling adults with TBI and their
caregivers/significant others, exploring the relationship of survivor-
caregiver situations with survivor distress and family dysfunction. It
also studies whether or not social support acts as a moderating
influence upon the well-being of persons with TBI; (3) resumption of
driving after brain injury: This study examines correlates of driving
after brain injury: barriers, fitness to drive, and community rapport.
Participatory action is a central component of project implementation,
evaluation, and dissemination. SEMTBIS participates in clinical and
systems analysis studies of the TBI Model Systems by collecting and
contributing data to the uniform, standardized national database.
Project findings for the studies described above are available at:
TBINDC.org or http://tbindc.org/registry/
searchresults.php?searchparam=project/center/4.
Mayo Clinic Traumatic Brain Injury Model System
James F. Malec, Ph.D., Mayo Medical Center, Rochester, MN; Project
Number: 149; Start Date: October 1, 2002; Length: 60 months.
Abstract: This Traumatic Brain Injury Model System (TBIMS) focuses
on three local research projects: (1) decisionmaking and outcomes of
inpatient and outpatient rehabilitation pathways, (2) very-long-term
(5-15+ years postinjury) process and outcome for people with TBI,
identified through the Rochester Epidemiology Project, and (3)
telehealth-based (Internet) cognitive rehabilitation. Telehealth is a
potentially important innovation in this system's region, where
distance limits access to medical and rehabilitation services and many
consumers have limited access to health care, insurance, employment,
and viable political representation. In addition to professional
publications and presentations, continuing dissemination efforts
include the Mayo Clinic TBIMS Web site, the TBI Hotline, the Messenger
newsletter, contributions to the COMBI Web site and COMBI and TBIMS
newsletters, and regular participation by Mayo Clinic TBIMS staff at
all annual state brain injury association meetings in the extended
five-state geographical region. During the next 5 years, the project
plans to develop an advocacy training program to help people with TBI
and their families and significant others in the region learn self-
advocacy skills. Members of the Mayo TBI Regional Advisory Council were
proactively involved in developing this project.
Traumatic Brain Injury Model System of Mississippi (TBIMSM)
Mark Sherer, Ph.D., ABPP-Cn, Methodist Rehabilitation Center, Jackson,
MS; Project Number: 154; Start Date: October 1, 2002; Length: 60
months.
Abstract: The TBI Model System of Mississippi (TBIMSM) is a
collaborative project of Methodist Rehabilitation Center and the
University of Mississippi Medical Center. This project involves three
studies. The first study investigates two medications in a parallel
group, double blind, placebo controlled, randomized assignment design.
The drugs under investigation have differing neurotransmitter effects,
although each drug has been reported to have therapeutic benefit. The
target population for this study is persons with TBI who are in a state
of posttraumatic confusional state (PCS). This is considered a state-
of-the-art approach to PCS given the severe lack of controlled research
to measure medication usage in PCS. The second study develops and
conducts a trial of an intervention to improve the therapeutic
alliances between persons with TBI and family members and professional
staff serving persons with TBI in a post-acute brain injury
neurorehabilitation program (PABIR). The third research project
investigates the use of transcranial magnetic stimulation (TMS) to
improve the characterization of motor disorders after TBI. Current
research suggests that improved use and better understanding of TMS
technology will lead to new intervention trials to improve motor
function after TBI.
JFK-Johnson Rehabilitation Institute TBI Model System
Keith D. Cicerone, Ph.D., JFK Johnson Rehabilitation Institute, Edison,
NJ; Project Number: 157; Start Date: October 1, 2002; Length: 60
months.
Abstract: This project implements and evaluates innovative
rehabilitation interventions that address the spectrum of severity and
needs of persons with TBI. The first research study investigates the
relationship between neurobehavioral (i.e., standardized rating scale)
and neurophysiologic (i.e., functional MRI data) indices of brain
function in persons with traumatic minimally conscious state (MCS). The
second study addresses current clinical and methodological concerns
over the effectiveness of cognitive rehabilitation on cognitive
functioning, community integration and social participation, return to
school and work, and quality of life after traumatic brain injury. The
third study uses qualitative inquiry to describe the quality of life
after TBI from the perspective of persons at various stages after their
injuries. These findings are triangulated with quantitative indices of
community integration and satisfaction with functioning, which should
provide a richer and more authentic understanding of what it takes to
live a fulfilling life after traumatic brain injury.
New York Traumatic Brain Injury Model System (NYTBIMS)
Wayne A. Gordon, Ph.D., Mount Sinai School of Medicine, New York, NY;
Project Number: 145; Start Date: October 1, 2002; Length: 60 months.
Abstract: This project advances the understanding of TBI and its
consequences and improves rehabilitation outcomes. The research
projects focus on depression and fatigue, impairments that limit
participation in community and vocational activities: Treatment of
Post-TBI Depression is a randomized clinical trial to examine the
efficacy of sertraline (Zoloft) in the treatment of depression and
anxiety after traumatic brain injury. Study of Post-TBI Fatigue and its
Treatment investigates the components, consequences, and correlates of
post-TBI fatigue, and in a randomized clinical trial, evaluates the
benefits of modafinil (Provigil) to treat fatigue in individuals with
TBI.
Carolinas Traumatic Brain Injury Rehabilitation and Research System
(CTBIRRS)
Flora M. Hammond, M.D., Charlotte Mecklenburg Hospital Authority,
Charlotte, NC; Project Number: 158; Start Date: October 1, 2002;
Length: 60 months.
Abstract: This project investigates posttraumatic irritability, its
relationship to the caregiver as a component of the environment, the
reaction to amantadine hydrochloride, and the nature of the problem as
experienced by those in the community. The mission of CTBIRRS is to
improve care and outcomes for survivors of TBI through medical
treatments, services, research, and dissemination to expand and enhance
services throughout their lifetime. The system begins with prevention
and emergency medical services and extends through intensive care,
acute care, and comprehensive medical rehabilitation to long-term
follow-up, community reintegration, and vocational rehabilitation.
Ohio Regional TBI Model System
John D. Corrigan, Ph.D., Ohio Valley Center for Brain Injury Prevention
and Rehabilitation, Columbus, OH; Project Number: 147; Start Date:
October 1, 2002; Length: 60 months.
Abstract: This model system includes two local research projects on
substance abuse and persons with TBI. Study 1 is a randomized clinical
trial testing interventions to promote retention in substance abuse
treatment. This study employs intervention strategies found effective
for clients with TBI when first engaging with a treatment program.
Study 2 tests the concurrent validity of an instrument that documents
the extent of a person's prior history of TBI objectively. This
instrument is intended for research on TBI as a mediating factor in
substance abuse treatment. This model system utilizes innovative
community integration programs: Team Brain Injury (follow-up case
management), the TBI Network (substance abuse treatment), and Community
Capacity Building (education and advocacy operated in conjunction with
the Brain Injury Association of Ohio).
The Moss Traumatic Brain Injury Model System
Tessa Hart, Ph.D., Albert Einstein Healthcare Network, Philadelphia,
PA; Project Number: 148; Start Date: October 1, 2002; Length: 60
months.
Abstract: This project provides cutting-edge care for persons with
TBI, conducts research on treatment of TBI in three key areas, and
disseminates new knowledge to consumer and professional audiences,
using an extensive collaborative network. Seven Trauma Centers and two
nationally renowned rehabilitation facilities, MossRehab and Magee
Rehabilitation, collaborate in the clinical component of the Moss
Traumatic Brain Injury Model System. The Moss Rehabilitation Research
Institute administers the research component, which includes
collaborative longitudinal data collection, as well as three local
research projects on: (1) the use of assistive technology for cognitive
and behavioral disabilities, (2) validation of an observational rating
scale of attention dysfunction in a psychostimulant treatment trial,
and (3) use of botulinum toxin for treating severe spasticity caused by
TBI. The Moss TBIMS emphasizes consumer involvement in clinical program
improvement, research design, and dissemination via collaboration with
the Brain Injury Association of Pennsylvania and other consumers.
University of Pittsburgh Brain Injury Model System (UPBI)
Ross D. Zafonte, D.O., University of Pittsburgh, Pittsburgh, PA;
Project Number: 146; Start Date: October 1, 2002; Length: 60 months.
Abstract: The research focus of the University of Pittsburgh Brain
Injury Model System is on innovation in rehabilitation technology for
persons with TBI. The project evaluates the impact of selected
innovations in technology on service delivery, functional outcome, and
as a therapeutic intervention. It addresses the shortcoming in
wheelchair design for persons with brain injury by evaluating a unique,
personalized powered mobility system. Collaboration with the Robotics
Institute at Carnegie Mellon University allows researchers to perform a
randomized trial evaluating the efficacy of virtual reality and
robotics for persons with TBI. Finally, the project uses intelligent
navigation technology to implement and evaluate a Web-based virtual
case manager support structure for persons with TBI and their families.
North Texas Traumatic Brain Injury Model System (NT-TBIMS)
Ramon R. Diaz-Arrastia, M.D., Ph.D., The University of Texas
Southwestern Medical Center, Dallas, TX; Project Number: 160; Start
Date: October 1, 2002; Length: 60 months.
Abstract: The North Texas Traumatic Brain Injury Model System (NT-
TBIMS) provides a comprehensive continuum of care for TBI patients from
the time of arrival at the emergency department through the intensive
care unit, inpatient and outpatient rehabilitation, and long-term
follow-up after community integration. Additionally, the NT-TBIMS
conducts two research projects aimed at obtaining predictive
information regarding outcome after TBI, which is important to the goal
of developing novel therapies and tailoring these therapies to
individual patients: (1) to determine whether the inheritance of
particular alleles in certain candidate genes is associated with a
greater risk of poor outcome after TBI; and (2) to determine whether
Diffusion Tensor Magnetic Resonance Imaging, a novel imaging technique,
is a more reliable indicator of Diffuse Axonal Injury than standard
structural MRI.
Virginia Commonwealth Traumatic Brain Injury Model System
Jeffrey S. Kreutzer, Ph.D., Virginia Commonwealth University, Richmond,
VA; Project Number: 156; Start Date: October 1, 2002; Length: 60
months.
Abstract: This project, utilizing rigorous scientific methods,
examines the benefits of intervention during the acute and post-acute
periods after brain injury. TBIMS and other researchers have primarily
focused on delineating outcomes. Until recently, concerns about
survivors' emotional well-being and adjustment to injury received scant
attention. Yet, recent studies have identified a high prevalence of
depression, with many survivors reporting feelings of hopelessness,
diminished self-esteem, and social isolation. Brain injury also affects
the family system; family members commonly describe emotional distress,
lack of respite, financial stress, and lack of community support.
Projects in three major research areas focus predominantly on
survivors. One study examines pharmacological approaches to the
treatment of depression, while another examines a structured approach
to the treatment of acute cognitive and neurobehavioral problems.
Examining the benefits of intervention programs for family members is
the third major research area.
University of Washington Traumatic Brain Injury Model System
Kathleen R. Bell, M.D., University of Washington, Seattle, WA; Project
Number: 150; Start Date: October 1, 2002; Length: 60 months.
Abstract: This program conducts research relevant to TBI, enhances
services to consumers, and furthers the National Database and
intersystem collaboration. The program's three research projects are:
(1) a randomized controlled intervention study examining the effect of
exercise on depression after TBI. This low-cost, community intervention
seeks to combat depression and emotional distress in persons with
stable TBI by employing exercise as a positive approach to improved
emotional and physical functioning and socialization. (2) An
examination of the characteristics of TBI survivors who are able to
return to employment and hold jobs that are stable and complex in
nature, utilizing both the UW TBI longitudinal database and the Model
System database. (3) An examination of the impact of the Medicare
prospective payment system for inpatient rehabilitation on TBI
survivors receiving access to acute rehabilitation efforts. The program
also contributes to the National
Database.
model systems for spinal cord injury rehabilitation funded
by the national institute for disability and rehabilitation research
UAB Model Spinal Cord Injury Care System
Amie B. Jackson, M.D., University of Alabama/Birmingham, Birmingham,
AL; Project Number: 1649; Start Date: October 1, 2006; Length: 60
months.
Abstract: The University of Alabama at Birmingham provides
rehabilitation services specifically designed to meet the special needs
of individuals with spinal cord injury (SCI) through its
multidisciplinary, comprehensive Spinal Cord Injury Care System (UAB-
SCICS). The UAB-SCICS spans the clinical continuum from emergency
services through rehabilitation and community re-entry. The System's
research includes one collaborative research module and two in-house
research projects, all of which ultimately aim at improving the health
and function of its constituents. The collaborative research module
involves the validation of an outcome measure for functional recovery.
One in-house research project involves the assessment of the predictive
value of key parts of the neurological exam for return of bladder
function; the second is an investigation of the effect of nicotine on
different types of SCI pain. The project continues to benefit from the
active involvement of persons with SCI in the design and execution of
the proposed activities. Project results are disseminated via a variety
of accessible formats and venues for both professionals and persons
with SCI and their families. A detailed plan of operation ensures
timely completion of project goals and tasks. Finally, an evaluation
plan has been designed to assess the quality and timeliness of project
outcomes and dissemination, as well as short and long term impacts of
project activities. Activities of the UAB-SCICS reflect an active
partnership both within the components of UAB's health system and
between UAB, the Lakeshore Foundation, and the Birmingham VA Medical
Center. The project continues as a participant in data collection
activities for the National Spinal Cord Injury Statistical Center.
Regional Spinal Cord Injury Care System of Southern California
Robert L. Waters, M.D.; Rod Adkins, Ph.D., Los Amigos Research and
Education Institute, Inc. (LAREI), Downey, CA; Project Number: 1029;
Start Date: September 1, 2000; Length: 72 months.
Abstract: The Regional Spinal Cord Injury Care System of Southern
California's primary mission is to collect initial and follow-up data
on persons who have sustained spinal cord injuries and submit it to the
national statistics database at the University of Alabama at
Birmingham. Another component of the project focuses on literacy in
individuals with SCI. Also, the project identifies, evaluates, and
eliminates environmental barriers, particularly cultural and social
barriers, to enable people with SCI to reintegrate fully into their
community, and thus improve their lives. The project has been designed
to meet the needs of the approximately 75 percent minority and
underserved populations that comprise its clientele, and has samples
sufficient for achieving adequate statistical power in the relevant
designs and producing meaningful research. Finally, the System
contributes new and useful information to the current collection of SCI
literature. This project contributes to the national statistics
database at the University of Alabama at Birmingham.
The Rocky Mountain Regional Spinal Injury System
Daniel P. Lammertse, M.D.; Susan Charlifue, Ph.D., Craig Hospital,
Englewood, CO; Project Number: 1652; Start Date: October 1, 2006;
Length: 60 months.
Abstract: The Rocky Mountain Regional Spinal Injury System (RMRSIS)
goals are to: (1) implement a program of research focusing on the
immediate and long-term health, function, and community integration and
participation of people with SCI; (2) improve its existing lifetime
system of care for people with SCI; and (3) continue exemplary
participation in the National SCI Database. A site-specific study
determines if high vs. low tidal volumes are more effective in
achieving ventilator weaning for individuals with high level
tetraplegia, using a randomized clinical trial design. A collaborative
research module study involves the development of a reliable, valid
measurement tool to assess community participation. RMRSIS was first
designated as a Regional Model System in 1974. The system includes two
Level I trauma centers with specialized acute neurotrauma care
facilities (St. Anthony Hospital and Swedish Medical Center) and the
rehabilitation and lifetime follow-up services of Craig Hospital.
National Capital Spinal Cord Injury Model System
Suzanne L. Groah, M.D., National Rehabilitation Hospital/MedStar
Research Institute, Washington, DC; Project Number: 1657; Start Date:
October 1, 2006; Length: 60 months.
Abstract: The National Capital Spinal Cord Injury Model System
(NCSCIMS) serves Washington, DC and the Nation. By focusing on the
frequent and costly complication of pressure ulcers (PU), the NCSCIMS
leverages two unique strengths: an existing Rehabilitation Research and
Training Center on SCI that focuses on reduction of secondary
conditions, and the population of Washington, DC, which is
predominantly composed of underserved individuals. The Center includes
two site-specific and one modular project and describes a system of
care that meets SCIMS priorities: Site Specific Project 1 is a
Practice-Based Evidence (PBE) project specifically focused on PU
prevention for all individuals with SCI and/or disease (SCUD) during
the acute and rehabilitative phases of care (to evolve to the community
in later phases). The PBE approach allows a detailed examination of the
effects of methods, modalities, and therapies utilized in
rehabilitation to prevent PUs, which are often based on evidence-based
medicine, but in reality may not be extrapolated to the broader
population with SCUD. In this project, researchers aim to utilize a PBE
approach to augment evidence based practice while addressing a critical
secondary complication for individuals with SCI. Site Specific Project
2 is an SCI Navigator pilot project that combines elements of Peer
Mentoring and Patient Navigation to decrease the occurrence of PUs once
the individual has returned to the community. In this project, an SCI
Navigator assists people with newly acquired SCI in the transition from
inpatient rehabilitation to the community, within the framework of an,
at times, dysfunctional healthcare system. The NCSCIMS works with the
Model System at the University of Pittsburgh to explore Assistive
Technology for Mobility (ATM). In this project, researchers investigate
the degree to which inadequate wheelchair technology is the factor
preventing people with SCI from doing more, work to understand the
impact of changes in wheelchair reimbursement, and fully explore the
issue of disparity in ATM prescription.
Georgia Regional Spinal Cord Injury Care System
David F. Apple, Jr., M.D., Shepherd Center, Inc., Atlanta, GA; Project
Number: 1659; Start Date: October 1, 2006; Length: 60 months.
Abstract: The Georgia Regional Spinal Cord Injury Care System
admits approximately 200 individuals annually with acute onset
paralysis secondary to spinal cord injury, and collects post-discharge
data on 600 individuals each year. Its patient population comes
primarily from Georgia, the rest of the Southeast, and the Eastern
Seaboard. The continuum of care begins at injury and continues through
transport, assessment, acute care, rehabilitation, emotional
adjustment, community reintegration, and lifetime follow-up. The
project continues a long record of comprehensive and timely collection
of data on subjects who meet the inclusion criteria in three
categories: inpatient hospitalization; longitudinal collection at 1, 5,
10, 15, 20, and 25 years post-injury; and registry. In addition to
continued model system research, the project conducts two site specific
research projects: (1) Psychological Status During Inpatient
Rehabilitation and One Year After Onset: Stress, Coping, and
Expectation Hope for Recovery; (2) Development and Validation of a
Clinical Measure of Wheelchair Seat Cushion Degradation. The project
also manages a collaborative data collection research module entitled
Impact of SCI on Labor Market Participation.
Midwest Regional Spinal Cord Injury Care System (MRSCIS)
David Chen, M.D., Rehabilitation Institute of Chicago, Chicago, IL;
Project Number: 1658; Start Date: October 1, 2006; Length: 60 months.
Abstract: The Spinal Cord Injury Rehabilitation Program at the
Rehabilitation Institute of Chicago and the Acute Spinal Cord Injury
Program at Northwestern Memorial Hospital demonstrate the ongoing
comprehensive, multidisciplinary services that are provided to
individuals with SCI which allow them to optimize their rehabilitation
outcomes and enhance their ability to return to productive, independent
living in the community. In order to contribute to the improvement of
outcomes for persons with SCI, the System conducts two site-specific
research projects: (1) Development of Low-Cost Devices to Increase
Delivery of Intensive Treadmill Training, and (2) Disparities in Access
to and Outcomes of Rehabilitation Care for Medicare and Medicaid
Beneficiaries with Spinal Cord Injury. In addition, the project
includes collaboration on one research project, Assistive Technology
for Mobility (ATM) Module. MRSCICS has the capacity to enroll 140
individuals from culturally diverse backgrounds with new spinal cord
injuries annually into the Spinal Cord Injury Model Systems database,
and collect follow-up data on individuals enrolled between 1973 and
2000.
The New England Regional Spinal Cord Injury Center
Steve Williams, M.D., Boston University Medical Center Hospital,
Boston, MA; Project Number: 1656; Start Date: October 1, 2006; Length:
60 months.
Abstract: The New England Regional Spinal Cord Injury Center
(NERSCIC), based at Boston Medical Center (BMC), continues to forge new
pathways in the care and quality of life of people with traumatic
spinal cord injury (SCI). Additionally, NERSCIC maintains a research
partnership with Boston's Spaulding Rehabilitation Hospital, Northeast
Rehabilitation Hospital in Salem, NH, and Gaylord Hospital in
Wallingford, CT. NERSCIC conducts innovative research projects to
improve health and long-term functioning of patients with SCI through a
site-specific project, Computer Adaptive Testing (CAT) for SCI, and a
collaborative module, Telehealth for Health. NERSCIC's site-specific
research project involves designing an improved outcome instrument in
SCI research using traditional outcome assessment technology that
presents difficult choices between comprehensive breadth and precision
versus acceptable administration time and respondent burden. To solve
this dilemma, this project applies contemporary measurement methods
(CATS) to initiate a major transformation in the outcome assessment
technology used to assess activity limitation frequently monitored in
SCI research. Once the SCI-CAT has been developed using data collected
from a major field study, the project conducts a demonstration of the
SCI-CAT to evaluate its respondent burden, acceptability to patients
and clinicians, as well as its breadth, precision, sensitivity to
change, and validity with inpatients and outpatients with SCI who are
receiving care from NERSCIC. Comparisons are made between the FIM and
SCI-CAT over a 6-month follow-up period. The goal of the collaborative
research project, Telehealth for Health, is the development and
evaluation of an automated, telephone-based screening, referral, and
behavioral intervention system with the long-term objective of
promoting health and function by preventing and decreasing the severity
of important secondary conditions among individuals with acute SCI,
namely pressure ulcers, depression, and substance abuse.
University of Michigan Model Spinal Cord Injury Care System
Denise G. Tate, Ph.D., University of Michigan, Ann Arbor, MI; Project
Number: 1653; Start Date: October 1, 2006; Length: 60 months.
Abstract: The overall purpose of this project is to provide
comprehensive rehabilitation and community participation services and
to generate new knowledge through research, development, and
demonstration designed to improve outcomes for persons with spinal cord
injury (SCI). A site-specific research study is conducted in
partnership with faculty from the University of Michigan Depression
Center, Department of Psychiatry, and the Molecular and Behavioral
Neurosciences Institute. This study is a randomized clinical trial
study designed to evaluate the efficacy of a pharmacological agent,
Duloxetine (Cymbalta<SUP>'</SUP>), as a preventive agent for reducing
depression among persons with SCI. This clinical trial addresses a
major need in the field as there are no randomized clinical trials
currently available on the effectiveness of antidepressants in persons
with SCI. In this study, the drug's effects on pain are also assessed.
An outcome of this study is the formulation of recommendations for
antidepressant medication use in SCI and implications for clinical
practice guidelines. The project continues to operate an efficient data
collection system, facilitating research and contributions to the
National SCI Database.
Missouri Model Spinal Cord Injury System
Laura H. Schopp, Ph.D., ABPP, University of Missouri/Columbia,
Columbia, MO; Project Number: 1019; Start Date: October 1, 2000;
Length: 72 months.
Abstract: The Missouri Model Spinal Cord Injury System (MOMSCIS) is
committed to developing, implementing, and evaluating innovative
research promoting independent living and community integration among
persons with spinal cord impairment. The study focuses on the effect of
a consumer-directed personal assistance services training intervention
on consumer satisfaction, independent living, and community
integration. The study develops, implements and evaluates the in-person
Individualized Management of Personal Assistant/Consumer Teams (IMPACT)
workshop. Workshop participants receive information on preventing and
treating secondary medical conditions, including pressure sores,
urinary tract infections, bowel and bladder management, autonomic
dysreflexia, pain management, chronic fatigue, and thermoregulation,
and information on relationship issues, such as hiring and firing,
communication styles and strategies, assertiveness, and team building.
Study objectives are: (1) to determine the effect of the IMPACT
workshop on consumer satisfaction, the incidence of secondary
conditions, activity, and participation (as defined by the ICF); (2) to
determine the effect of the IMPACT workshop on personal assistants' job
satisfaction, job stress and attrition; and (3) to provide online
resources to the disability community, including an online personal
assistant training manual for consumers and assistants, and an online
resources database. Activity and participation are measured by the
PARTicipation Survey for persons with Mobility Limitations (PARTS/M).
Northern New Jersey Spinal Cord Injury System
David S. Tulsky, Ph.D., Kessler Medical Rehabilitation Research and
Education Corporation (KMRREC), West Orange, NJ; Project Number: 1651;
Start Date: October 1, 2006; Length: 60 months.
Abstract: The Northern New Jersey Spinal Cord Injury System
(NNJSCIS) provides a comprehensive continuum of state-of-the-art care
for persons with spinal cord injury (SCI) and their significant others
from time of injury through long-term follow-up in the community and
conducts spinal cord research, including clinical research and the
analysis of standardized data. NNJSCIS conducts both a site-specific
research study and a collaborative module. These studies contribute to
evidence-based rehabilitation interventions and clinical and practice
guidelines that improve the lives of individuals with SCI and consist
of the following: An innovative rehabilitation intervention utilizing
technology to prevent respiratory disease in persons with SCI, now the
leading cause of death and the third leading cause of hospitalizations
in this population; a collaborative module that adapts, develops, and
validates an innovative and promising outcome system for use in SCI
intervention research; and the NNJSCIS coordinates with the NIDRR-
funded Model Systems Knowledge Translation Center to provide scientific
results and information for dissemination to clinical and consumer
audiences. This project is a cooperative effort of the Kessler Medical
Rehabilitation Research and Education Corporation (KMRREC), the Kessler
Institute for Rehabilitation (KIR), the University of Medicine and
Dentistry of New Jersey-The New Jersey Medical School (UMDNJ-NJMS), and
UMDNJ-University Hospital.
Mount Sinai Spinal Cord Injury Model System
Kristian T. Ragnarsson, M.D., Mount Sinai School of Medicine, New York,
NY; Project Number: 1655; Start Date: October 1, 2006; Length: 60
months.
Abstract: The research program of Mount Sinai Spinal Cord Injury
Model System (MS-SCI-MS) is designed to advance the understanding of
spinal cord injury (SCI) and its consequences, and to develop better
methods of treatment of secondary conditions of SCI, especially pain.
The purpose of this project is to: (1) demonstrate and evaluate a
multidisciplinary system of rehabilitation care for persons with SCI in
the New York City metropolitan area, including innovative programs for
community integration; (2) contribute longitudinal data to the SCI
National Database of the Model Systems program; (3) systematically
collect and analyze extensive information on chronic pain after SCI.
The site-specific project studies modified-release formulation of
morphine sulfate for neuropathic pain after spinal cord injury through
a randomized, double-blind crossover trial of modified-release morphine
and placebo for patients with uncontrolled neuropathic pain of three
types.
Northeast Ohio Regional Spinal Cord Injury System
Gregory A. Nemunaitis, M.D., MetroHealth System, Cleveland, OH; Project
Number: 1662; Start Date: October 1, 2006; Length: 60 months.
Abstract: The Northeast Ohio Regional Spinal Cord Injury System
(NORSCIS) at MetroHealth Rehabilitation Institute of Ohio in
collaboration with Case Western Reserve University and the Cleveland
FES Center conducts research to further develop the effectiveness of an
innovative Model Spinal Cord Injury Care System and to demonstrate how
the application of advanced assistive technology can benefit persons
with disabilities. NORSCIS offers a world-class multi-disciplinary
system of spinal cord injury care and a 40-year tradition of
excellence. Efficiency and effectiveness of care (and research
potential) are enhanced as all components of the continuum of care
(from trauma/emergency care to acute medical/surgical treatment to
inpatient rehabilitation to outpatient rehabilitation and community
support services) are on one campus. A site-specific project studies
advances in functional electrical stimulation (FES) technology to
document improvements in function, health, and wellness. An innovative
focus on trunk muscle stimulation targets specific clinical problems,
including seated stability and mobility, reachable workspace, and
pulmonary function. A collaborative research project with UPMC-SCI, is
directed at testing and collecting the data needed to understand the
impact of coverage changes and to fully explore the issue of disparity
in assistive technology for mobility prescription. A collaborative
project with Craig Hospital involves the development of a reliable,
valid measurement tool to assess community participation. The goal of
these hypothesis-driven research and demonstration projects is to
develop and measure the effectiveness of new intervention strategies at
both the individual patient level and overall systems of care for
persons with spinal cord injury.
Regional Spinal Cord Injury Center of the Delaware Valley
Ralph Marino, M.D., Thomas Jefferson University, Philadelphia, PA;
Project Number: 1660; Start Date: October 1, 2006; Length: 60 months.
Abstract: The Regional Spinal Cord Injury Center of the Delaware
Valley (RSCICDV) provides and evaluates a comprehensive program of
coordinated patient care, education, and research activities for
individuals who have sustained a traumatic spinal cord injury (SCI).
Clinical activities are directed at promoting evidence based practice
to improve outcomes and reduce medical complications in persons with
SCI. Research activities are designed to develop and validate upper and
lower extremity outcome measures for use in clinical trials.
Specifically, RSCICDV: (1) contributes to the National Database by
enrolling an estimated 50 new subjects per year into the database and
by collecting follow-up data on previously enrolled subjects; (2)
conducts an onsite research project whose focus is to develop and
validate the Capabilities of Arm and Hand in Tetraplegia (CAHT), an
objective test of arm and hand functional capabilities needed to
conduct clinical trials for neurological recovery in SCI; (3)
participates in a collaborative module on evaluating an automated phone
follow-up system for people with SCI; (4) participates in a
collaborative module on validation of an outcome measure for motor
recovery in incomplete SCI; and (5) develops educational resources for
patients, healthcare providers
and researchers.
University of Pittsburgh Model Center on Spinal Cord Injury
Michael L. Boninger, M.D., University of Pittsburgh, Pittsburgh, PA;
Project Number: 1650; Start Date: October 1, 2006; Length: 60 months.
Abstract: The UPMC-SCI continues its research focus on assistive
technology (AT) for mobility. Pilot data collected during the previous
funding cycle highlighted disparity in wheelchair prescription.
Individuals from minority groups and people with low socioeconomic
status received less and lower quality equipment. So that interventions
can be developed, the project continues and expands this research to
delve into the reasons for disparity. In addition, it investigates the
impact of recent Centers for Medicare and Medicaid Services (CMS)
changes for AT reimbursement. These changes will likely have a critical
impact on the AT provided to individuals with spinal cord injury (SCI).
Finally, the project develops a tool to determine how far, how fast,
and when people travel in their wheelchairs. This data is related to
the types of wheelchairs used, to the number of wheelchair failures,
and to measures of participation. From these findings, researchers
determine how the wheelchair prescribed impacts participation, and if
greater use leads to greater failures. This data can be used to push
for improvements in manufacturing and changes in coverage. UPMC-SCI
also conducts a randomized, controlled trial to determine if following
the Consortium of Spinal Cord Injury Medicine Guidelines on Upper Limb
Preservation leads to decreased pain. These guidelines are applied to
acutely injured patients who are followed for the first 6 months after
injury. Validation of the guidelines' effectiveness helps assure that
they become the standard of care across the country. SCI care at the
University of Pittsburgh is provided in a multidisciplinary manner with
a high level of communication among the constituent services. The
project has fully implemented a system of continuity of treatment that
begins with the emergency response at the scene of injury and continues
with comprehensive treatment and rehabilitation from medical/surgical
to acute stage rehabilitation through utilization of assistive
technology services and vocational rehabilitation. The research and
Model of Care set forth in this proposal will have a significant impact
on the lives of individuals with SCI, leading to greater participation
and employment. UPMC-SCI continues to enroll and collect long term
follow up data on SCI subjects for the National Spinal Cord Injury
Statistical Center.
Texas Model Spinal Cord Injury System
Daniel Graves, Ph.D.; William Donovan, M.D., The Institute for
Rehabilitation and Research (TIRR), Houston, TX; Project Number: 1661;
Start Date: October 1, 2006; Length: 60 months.
Abstract: The Texas Model Spinal Cord Injury System (TMSCIS)
provides services along the entire continuum of care from emergency
medical service to long-term follow-up and management of secondary
conditions. The TMSCIS includes a site-specific research project that
is designed to provide high level evidence of the efficacy of a novel
treatment to prevent bladder complications. The project is a
randomized, double blind placebo, controlled parallel groups
investigation of the effects of Botulinum toxin A treatment of detrusor
external sphincter dyssynergia (DESD) during early spinal cord injury.
Many patients with SCI develop neurogenic bladder dysfunction
associated with detrusor hyperreflexia and DESD that can lead to long-
term complications in up to 50 percent of patients. These complications
include hydronephrosis, vesicoureteral reflux, nephrolithiasis, sepsis,
renal insufficiency or failure, and even death. This investigation is
intended to determine if the prevention of DESD in the early phase of
recovery can prevent some of these complications. In addition, the
TMSCIS includes a module designed to develop an outcome measure of
trunk and postural control to be utilized in activity-based therapy
programs like locomotor training. The outcomes of large scale clinical
trials of locomotor training highlight the need for outcome measures
that are designed to capture changes brought about by translational
research that may not have been necessary for more traditional therapy
programs. This scale development project incorporates item response
theory methods as well as reliability and validity investigations in a
minimum of four model systems.
VCU Model Spinal Cord Injury Center
William O. McKinley, M.D.; David X. Cifu, M.D., Virginia Commonwealth
University, Richmond, VA; Project Number: 1020; Start Date: October 1,
2000; Length: 72 months.
Abstract: This project develops and implements a Model Spinal Cord
Injury System at Virginia Commonwealth University/Medical College of
Virginia (VCU/MCV), that has a concentrated emphasis on employment.
Researchers within this Model Systems systematically monitor and assess
the impact of interventions, advancing technology, and policy changes
on employment following SCI. In addition to contributing to the
National Statistical Database at the University of Alabama at
Birmingham, the VCU SCI Model System has three research studies. These
studies involve the direct utilization of the SCI National Database, a
major employment policy study across 18 states, and also an evaluation
of technology training on employment of outcome. Involvement of SCI
mentors in training new vocational mentors with SCI is also an
important aspect of the project. By looking at the issues associated
with employment for persons with SCI, this project complements other
resources in place within VCU/MCV, including the RRTC on Workplace
Supports, long-term relationships with the Virginia Department of
Rehabilitation Services, and existing SCI Model Systems delivery of
care. A significant number of persons with disabilities are involved as
project staff as well as on an Advisory Board. A close relationship
with the Mid-Atlantic Paralyzed Veterans Association (PVA) enhances
training, dissemination, and other outreach activities.
Northwest Regional Spinal Cord Injury System
Charles H. Bombardier, Ph.D., University of Washington, Seattle, WA;
Project Number: 1654; Start Date: October 1, 2006; Length: 60 months.
Abstract: The University of Washington's Northwest Regional Spinal
Cord Injury System (NWRSCIS) serves a critical mass of patients with
SCI and has all the necessary disciplines to provide state-of-the-art
medical, surgical, and rehabilitation care. One site-specific project
is a randomized controlled intervention study evaluating the effect of
proactive, structured, telephone-based counseling and care management
on rehospitalization rate and quality of life during the first year
after discharge from acute rehabilitation. This study builds upon
successful experiences with telephone counseling for both people with
traumatic brain injury and multiple sclerosis. This research is
particularly important because the lifestyle changes and health care
behaviors required for successful living after SCI are tremendously
challenging, rates of rehospitalization are high, and many people
(especially in rural regions) lack ready access to knowledgeable
advice, behavior change support, and specialty care sufficient to
maintain their health. A modular project studies the natural history of
major depression under conditions of usual care during the first year
after SCI. This project establishes reliable and valid means of
screening and diagnosing major depression soon after SCI. It examines
the impact of depression on rehabilitation efficiency and compares the
effect of standard treatment to clinical practice guideline level care
of depression. This study describes depression treatment preferences
among people with SCI and lays the foundation for a multi-site clinical
trial. This project contributes to the national statistics database at
the University of
Alabama at Birmingham.
rehabilitation research and training centers of the national institute
for disability and rehabilitation research
Rehabilitation Research and Training Center on Measuring Rehabilitation
Outcomes and Effectiveness
Allen W. Heinemann, Ph.D., Feinberg School of Medicine, Chicago, IL;
Project Number: 1463; Start Date: December 1, 2004; Length: 60 months.
Abstract: The purpose of this RRTC is to provide national
leadership on the functional assessment, outcomes, and health policy
issues facing the medical rehabilitation community and the diverse
consumers it seeks to serve. The Center conducts research; hosts forums
for discussion; publishes in rehabilitation, health policy, and
consumer literature; trains researchers in rehabilitation-focused
health services research; and disseminates information to diverse
consumer, provider, and academic audiences. The RRTC's research seeks
to (1) enable comparison of functional status measures across post-
acute settings so information can be provided to consumers and other
rehabilitation stakeholders about the outcomes and effectiveness of
various post-acute care settings; (2) develop an innovative measure of
community participation in a meaningful, reliable, and valid manner in
order to better describe the long-term outcomes of rehabilitation
services; (3) increase the efficiency of outcome data collection so
more resources can be directed to patient care; (4) examine how format
and presentation style influences patient understanding of
rehabilitation quality outcome indicators in order to provide
information in ways that are helpful for consumers when selecting
rehabilitation services. The project uses recent developments in item
response theory and computer adaptive testing and stakeholder input in
test development, outcomes reporting, and quality indicator reporting.
The expected outcomes are a rational basis for provision of
rehabilitation services post-acute care settings, increased efficiency
of data collection, a better measure of community participation, and
outcome reporting that is responsive to stakeholder needs.
Dissemination activities include post-graduate and post-doctoral
training opportunities, conferences, and a Web site that provides
information on measurement of rehabilitation outcomes across the
continuum of post-acute settings.
Rehabilitation Research and Training Center on Policies Affecting
Families of
Children with Disabilities
H.R. Turnbull, L.L.M.; Ann Turnbull, Ed.D., University of Kansas;
Lawrence, KS; Project Number: 110; Start Date: November 1, 2003;
Length: 60 months.
Abstract: This center conducts eight research projects on the
effects of the policies of governments, systems, networks, and agencies
on the family quality of life and community integration (FQOL/FCI) of
families who have children with developmental disabilities and
emotional-behavioral disabilities or both. Researchers identify four
target populations: families, providers, policy-leaders, and networks
(all at the Federal, state, and local levels). Three policy challenges
are prisms through which the effects of policy on families can be
understood: early intervention, alternative schools, and consumer
control of funding. For each policy challenge, researchers inquire into
whether the applicable Federal and state policies and practices, and
the applicable network policies, advance FQOL/FCI; whether the policies
across education, social services, and health care are mutually
consistent with each other and advance FQOL/FCI; and whether the
practices of agencies in those systems advance FQOL/FCI. The center's
analytical framework holds that the core concepts shape policies,
policies shape services, policies and services should be coordinated
and delivered through partnerships. Enhanced FQOL/FCI occurs when there
is coherence among core concepts, coordinated policies delivered
through partnerships, and coordinated services delivered through
partnerships; and influencing factors must invariably be taken into
account.
Rehabilitation Research and Training Center on Demographics and
Statistics
Andrew J. Houtenville, Ph.D., Cornell University, Ithaca, NY; Project
Number: 269; Start Date: December 1, 2003; Length: 60 months.
Abstract: The RRTC on Demographics and Statistics (Cornell
StatsRRTC) bridges the divide between the sources of disability data
and the users of disability statistics. The project conducts research
exploring the reliability of existing data sources and collection
methods, and studies the potential to improve current and future data
collection efforts. In addition, the project utilizes existing data
sources to provide a comprehensive and reliable set of statistics, and
increase access to and understanding of how statistics can be used
effectively to support decision making. Cornell StatsRRTC works with
key organizations to determine their needs and helps them maximize the
use of disability statistics in their ongoing efforts to improve the
lives of people with disabilities and their families. As members of the
Cornell StatsRRTC, the American Association of People with
Disabilities, the Center for an Accessible Society, and InfoUse provide
vital expertise and resources needed to reach the users of disability
data and statistics. The Cornell StatsRRTC includes researchers from
Cornell University, Mathematica Policy Research, the Urban Institute,
and the Institute for Matching People and Technology, all of which
bring extensive expertise in working with and creating sources of
disability data.
University of Illinois at Chicago National Research and Training Center
on
Psychiatric Disability
Judith A. Cook, Ph.D., University of Illinois at Chicago, Chicago, IL;
Project Number: 1559; Start Date: October 1, 2005; Length: 60 months.
Abstract: The University of Illinois at Chicago National Research
and Training Center on Psychiatric Disability (UIC-NRTC) promotes
access to effective consumer-centered and community-based practices for
adults with serious mental illness. The Center is conducting five
rigorous research projects to enhance the state of evidence-based
practice (EBP) in this field: A randomized controlled trial (RCT) study
of Wellness Recovery Action Planning (WRAP) to gather evidence
regarding its effectiveness; an RCT to evaluate the effectiveness of
BRIDGES, a 10-week peer-led education course designed to provide mental
health consumers with basic education about the etiology and treatment
of mental illness, self-help skills, and recovery principles; an RCT of
peer support services delivered by Georgia's Certified Peer Specialists
(CPS) at consumer-run Peer Support Centers in order to determine the
outcomes of service recipients; a self-directed care program in which
adults with serious mental illnesses are given control of financial
resources to self-direct their own recovery; and a project using data
from 12 clinical trials studies of consumer-operated service programs
to create a national data repository to promote research and develop
scholarship in this area. The Center also conducts state-of-the-art
training, dissemination, and technical assistance projects designed to
enhance the leadership skills of people with psychiatric disabilities,
and evaluate a self-advocacy skills training program delivered to
clients of a large psychosocial rehabilitation agency. Additional
projects evaluate self-advocacy skills training programs and implement
training programs to prepare consumer leaders in the State of
California to take part in systems change in their local communities.
UIC-NRTC is embarking on an academic curriculum transformation project
starting at UIC in the medical, social, and behavioral sciences to
incorporate principles of recovery and EBP for people with psychiatric
disabilities. The UIC-NRTC is designing and administering a no-cost
online certification program, providing comprehensive introduction of
knowledge required by peer providers. Additionally, the UIC-NRTC is
providing training and developing projects and tools to assist
individuals in recovery to gain the skills necessary for community
integration through enhancing the research capacity of three federally
funded consumer-run Technical Assistance Centers. Finally, the UIC-NRTC
is offering an annual series of online workshops; Web-based continuing
education courses; and a state of science national conference (2008)
focusing on EBP, research implementation, consumer-centered systems,
workforce development, and other emerging trends.
Rehabilitation Research and Training Center on Improving Vocational
Rehabilitation Services for Individuals Who Are Deaf or Hard of
Hearing
Douglas Watson, Ph.D., University of Arkansas, Little Rock, AR; Project
Number: 263; Start Date: October 1, 2001; Length: 60 months.
Abstract: This program conducts coordinated research and training
to enhance the rehabilitation outcomes of persons who are deaf or hard
of hearing who are served by VR and related employment programs. When
appropriate, the unique needs of specific subgroups within this diverse
and heterogeneous population are investigated. The ultimate goal of
these efforts is to improve the capacity of the VR system and related
programs to address the career preparation, entry, maintenance, and
advancement, as well as the community living needs, of the target
population. Research activities include: investigating the impact of
changes in Federal employment and rehabilitation legislation and policy
on the delivery of services to the target population; investigating the
impact of business practices that contribute to accessible work and
workplace supports to enhance the employment of the target population;
and identifying, developing, and assessing rehabilitation-related
innovations that enhance employment and community living outcomes of
the target population.
Rehabilitation Research and Training Center on Disability in Rural
Communities
Tom Seekins, Ph.D., University of Montana, Missoula, MT; Project
Number: 265; Start Date: December 1, 2002; Length: 60 months.
Abstract: The research conducted by this project improves the
employment status of people with disabilities in the rural U.S.,
enhances their ability to live independently, and advances the science
of rural disability studies. Four core areas comprise eleven research
projects in rural employment and economic development; rural health and
disability; rural community transportation and independent living; and
rural policy foundations. Projects include: (1) develop scientific
methods to measure how rural environments influence an individual's
community participation; (2) collaborate with very small rural
businesses to employ people with disabilities; (3) improve rural
transportation options; and (4) create programs to prevent or improve
secondary conditions. Other projects explore ways for new partners,
including faith-based organizations, to be involved in improving rural
services. A training program disseminates research findings, trains
students, and sparks the creative engagement of policymakers and social
advocates. The innovative STATE (Same-Time Availability to Everyone)
policy requires that the project provide standard print publications to
the general public only when at least two alternative formats are also
available to individuals with disabilities.
Rehabilitation Research and Training Center on Employment Policy and
Individuals with Disabilities
Susanne Bruyere, Ph.D.; Richard Burkhauser, Ph.D.; David Stapleton,
Ph.D., Cornell University, Ithaca, NY; Project Number: 1466; Start
Date: December 1, 2004; Length: 60 months.
Abstract: The ultimate goal of the Employment Policy Rehabilitation
Research and Training Center (EP-RRTC) is to increase the employment
and economic self-sufficiency of people with disabilities and improve
the quality of their lives. The immediate purpose is to contribute to
the success of the transition from caretaker policies to economic self-
sufficiency policies. Specific goals and objectives are: completion of
new research activities that will generate knowledge about the effects
of past disability policy and other factors on economic self-
sufficiency, the impact of current and future initiatives designed to
promote economic self-sufficiency, and/or the likely success of new
policy options; completion of 20 publishable papers and companion
policy briefs; training of consumers via 12 or more Washington-based
Disability Policy Forums; training of 5 graduate students; a third-year
conference; a conference volume; and technical assistance to consumers
on policy research and evaluation methods and data. Short-term project
outcomes include: annual interpretation of updated employment rate
trends; a synthesis and critique of many relevant evaluation efforts;
three or more significant policy options and ideas for next steps;
reviews of three or more significant policy or program successes;
detailed information on interactions between numerous programs and
policies, and how they discourage employment; estimates of impacts of
two public policies on employment and earnings for state VR clients;
estimates of the impact of the ADA on both employer provision of
accommodations and job retention after disability onset; estimates of
the return to higher education for those with profound hearing loss;
and two additional analyses of the role that human capital plays in
determining economic self-sufficiency for adults with disabilities.
Intermediate outcomes include use of this information in the policy
improvement effort, and long-term outcomes include policy changes that
increase the economic self-sufficiency of people with disabilities.
Rehabilitation Research and Training Center on Improving Employment
Outcomes
John O'Neill, Ph.D., Hunter College of CUNY, New York, NY; Project
Number: 1469; Start Date: October 1, 2004; Length: 60 months.
Abstract: This Employment Service Systems Research and Training
Center develops, enhances, and utilizes partnerships to improve the
quality of employment services, opportunities, and outcomes for people
with disabilities. Five research projects have been designed to meet
this goal and examine partnerships across public agencies, between not
for-profit and public agencies, and between rehabilitation agencies and
businesses. The Consortia for Employment Success (CES) creates and
evaluates fully integrated disability service provider networks in
three local communities. The CES increases access for people with
disabilities to both effective, comprehensive placement services, and a
well-managed and centralized employer network that will increase
employment and career advancement opportunities for persons with
disabilities. The Workplace Socialization Model (WPS) supplements the
CES Model by focusing on job enhancement and retention. The WPS aims to
extend the job tenure of employees with a disability and other positive
work outcomes including the employee's job satisfaction, organizational
commitment, and level of work culture competency, as well as the
employer's satisfaction with the employee's job performance.
Identification of ``Good Practices'' Within Vocational Rehabilitation
is designed to identify a variety of good practices currently being
used in the State-Federal VR system across the U.S. that facilitate
consumer access to services and enhance employment outcomes. Designing
and Testing Comprehensive Employment Practice and Policy Initiatives
within a Vocational Rehabilitation State Agency develops and tests a
model that leads to enhanced employment outcomes. The model includes
the ``human capital'' characteristics of persons with disabilities as
well as what vocational rehabilitation delivery systems add to these
human capital factors to improve outcomes. A Study of Disability
Navigators in One-Stops collects data on Workforce Investment Act
regions in which Navigators operate and compares levels of customer
satisfaction and employment outcomes between regions that use
Navigators and regions that have no such positions.
Rehabilitation Research and Training Center on Substance Abuse,
Disability, and Employment
Dennis C. Moore, Ed.D., Wright State University, Kettering, OH; Project
Number: 1465; Start Date: December 1, 2004; Length: 60 months.
Abstract: This RRTC builds on previous findings to positively
impact persons with disabilities who also experience substance use
disorders, as well as the service providers upon whom they depend. The
highly integrated program of research addresses the following goals and
objectives: (1) Promote widespread use of substance use disorder
screening among persons with disabilities who utilize disability-
related employment services. This is accomplished by developing and
validating a new substance abuse screener called the ``SASSI-VR''.
Following two stages of development and validation, the SASSI-VR is
evaluated in three vocational rehabilitation (VR) programs on a
statewide basis. (2) Conduct a randomized clinical trial of a model of
supported employment, Individualized Placement and Support (IPS), to
test its efficacy among persons with traumatic brain injury or other
severe disabilities that also have a substance use disorder. The two
trial sites are affiliated with rehabilitation programs in the Wright
State and Ohio State medical schools. Utilization of the IPS model with
the study populations holds tremendous potential or impacting services
delivery for consumers who experience very low rates of employment. (3)
Research policy and practices relative to their impact on VR services
for persons with a disability and coexisting substance abuse. Serving
as a critical complement to Rl, the roles of policies, statutes,
guidelines, and VR service delivery practices will be investigated
within the larger community of public agencies. (4) Investigate factors
that specifically contribute to unsuccessful case closure among
consumers of VR services. This component studies recent VR unsuccessful
closures and their counselors, and the study has particular sensitivity
to the role of ``hidden'' substance abuse among unsuccessful closures.
Rehabilitation Research and Training Center on Workplace Supports and
Job
Retention
Paul Wehman, Ph.D., Virginia Commonwealth University, Richmond, VA;
Project Number: 1467; Start Date: November 1, 2004; Length: 60 months.
Abstract: The purpose of the RRTC on Workplace Supports and Job
Retention is to study those supports which are most effective in the
workplace for assisting persons with disabilities to maintain
employment and advance their careers. Research includes two long-term
prospective randomized experimental control research projects: (1)
determining the efficacy of public/private partnerships, and (2)
determining the efficacy of business mentoring and career based
interventions with college students with disabilities. The RRTC is
partnered with Manpower, Inc., several community rehabilitation
programs, and the VCU Business Roundtable. Additional projects look at
disability management practices, extended employment supports, job
discrimination in employment retention, benefits planning and
assistance, and workplace supports. These studies are done in
conjunction with Equal Employment Opportunity Commission, the Society
of Human Resource Professionals, and the U.S. Chamber of Commerce.
Aging-Related Changes in Impairment for Persons Living with Physical
Disabilities
Bryan J. Kemp, Ph.D., Los Amigos Research & Education Institute, Inc.,
Downey, CA; Project Number: 266; Start Date: August 1, 2003; Length: 60
months.
Abstract: This project is a combined effort of Rancho Los Amigos
National Rehabilitation Center and the University of California at
Irvine, with other collaborators including the Center for Disability in
the Health Professions at Western University and two Rehabilitation
Engineering Research Centers. This project evolves from the fact that
persons who have a disability are now living into middle age and late
life in ever-increasing numbers. However, many of these people appear
to be experiencing premature age-related changes in health and
functioning. The project tests a model for improved understanding of
these problems and interventions to help alleviate them. Persons who
are experiencing these kinds of problems and their families are
included in all center projects. The training, dissemination, and
technical assistance activities include clinical training of current
and future health providers, current and future researchers, persons
with disabilities, their families, and policymakers. Both traditional
methods of one-on-one and group training as well as technology-based
distance training techniques are used to reach national audiences and
underserved populations.
Rehabilitation Research and Training Center in Neuromuscular Diseases
(RRTC/NMD)
Craig McDonald, M.D., University of California, Davis, Davis, CA;
Project Number: 273; Start Date: December 1, 2003; Length: 60 months.
Abstract: The purpose of the Rehabilitation Research and Training
Center in Neuromuscular Diseases (RRTC/NMD) is to enhance the health,
function, and quality of lives of persons with neuromuscular diseases
(NMD). The goals of this project are to: (1) develop a program for
multicenter rehabilitation research in NMD through the Cooperative
International Neuromuscular Research Group (CINRG); (2) conduct
research that continues to address rehabilitation needs, particularly
related to exercise, nutrition, pain, secondary conditions, and the
quality of life of individuals with neuromuscular diseases; (3) develop
and evaluate new or emerging technologies and interventions that
provide the information needed to improve employment, community
integration, and quality of life outcomes for this population of
individuals with disabilities; (4) develop and evaluate appropriate
health promotion and wellness programs that enhance the ability of
individuals with neuromuscular disease to be physically active and
participate in recreational activities; and (5) conduct a comprehensive
program of training, dissemination, utilization, and technical
assistance activities that are well-anchored in the research program
and address the needs
of stakeholders.
Rehabilitation Research and Training Center on Spinal Cord Injury:
Promoting Health and Preventing Complications through Exercise
Suzanne L. Groah, M.D., National Rehabilitation Hospital/MedStar
Research Institute, Washington, DC; Project Number: 270; Start Date:
December 1, 2003; Length: 60 months.
Abstract: This project systematically and comprehensively addresses
the role and impact of physical activity in the prevention of secondary
conditions in people with spinal cord injury (SCI). Initially, the
project establishes critical, yet-undefined physiological responses to
exercise in SCI and comprehensively examines cardiovascular disease
risk in individuals with SCI applying accepted guidelines used in the
able-bodied population. The project develops exercise formats
specifically designed according to severity of SCI and chronicity of
SCI to address the prevention of and knowledge regarding osteoporosis
and other secondary conditions. In addition, the project determines
whether regular exercise is related to fewer secondary conditions.
These research findings feed into four training activities that include
a peer mentoring program for newly injured people with SCI, a consumer-
driven education curriculum for physical therapy and medical students,
a state-of-science and training conference, and the development of a
virtual resource network on exercise and prevention. The RRTC is a
collaborative effort of clinical and disability researchers, SCI
consumer organizations, and independent living advocates. The RRTC
maintains a Live Journal site at http://rrtc-sci.livejournal.com/
and a Webcast on Exercise and Physical Activity for Persons with SCI
at http://nrhfoundry.medstar.net/mediasite/viewer/?cid=d8381286-2ad2-
4fed-922c-31464b0cc049.
RRTC on Technology Promoting Integration for Stroke Survivors:
Overcoming
Social Barriers
Elliot J. Roth, M.D., Rehabilitation Institute Research Corporation,
Chicago, IL; Project Number: 275; Start Date: October 1, 2003; Length:
60 months.
Abstract: This project develops and evaluates a sequence of robotic
training and assistive devices that are designed with the idea of
promoting efficient function in the workplace or at home, and with the
further intent that they form a basis for the development of
appropriate technologies to allow people with disabilities ready access
to existing facilities in the community. At each stage the project
engages engineering students as a means to provide intensive effort for
development of novel designs, but also to provide valuable
opportunities for training students in the themes related to recovery
of function and community integration of people with disabilities.
Other projects at this center include: the use of emotionally
expressive and narrative writing to facilitate coping and adaptation
after stroke; computerized training for conversational scripts that
facilitate access to the community and workforce; and a consumer-
directed, dynamic assessment methodology for evaluating community
living and work participation environments and technologies for use by
people who have had a stroke. In addition to these projects, the RRTC
develops and evaluates a comprehensive plan for training directed to
stroke survivors and their families, students, researchers, clinicians,
and service providers. These approaches are implemented through a
variety of mechanisms, including continuing education courses, Web-
based presentations, and intensive training in our research facilities.
Missouri Arthritis Rehabilitation Research and Training Center (MARRTC)
Jerry C. Parker, Ph.D., University of Missouri, Columbia, MO; Project
Number: 274; Start Date: October 1, 2003; Length: 60 months.
Abstract: The purpose of the Missouri Arthritis Rehabilitation
Research and Training Center (MARRTC) is to provide leadership at the
national level in support of three key objectives: to reduce pain and
disability, to improve physical fitness and quality of life, and to
promote independent living and community integration for persons with
arthritis of all ages in the United States. State-of-the-science
rehabilitation research addresses the needs of persons with arthritis
in the following areas: (1) home and community-based self-management
programs, (2) benefits of exercise and physical fitness, and (3)
technologies available to the broad populations of persons with
arthritis in the environments where they live, learn, work, and play.
The MARRTC conducts training and capacity-building programs for
critical stakeholders within the arthritis disability arena, including
consumers, family members, service providers, and policymakers.
Additionally, the MARRTC provides technical assistance for persons with
arthritis and other stakeholders in order to promote utilization of
arthritis-related, disability research. The MARRTC also provides
widespread dissemination of informational materials to persons with
disabilities, their representatives, service providers, and other
target audiences (e.g., editors
and reporters).
Rehabilitation Research and Training Center on Traumatic Brain Injury
Interventions
Wayne A. Gordon, Ph.D., Mount Sinai School of Medicine, New York, NY;
Project Number: 1464; Start Date: October 1, 2004; Length: 60 months.
Abstract: The research program includes two randomized clinical
trials (RCTs) and two projects supportive of better everyday
interventions and better research: Research Study 1 (R1) is an RCT of a
treatment for depression: cognitive behavioral therapy, adapted to
address the unique cognitive and behavioral challenges of people with
TBI that often pose barriers to treating depression, a major factor in
reducing post-TBI quality of life, is compared to supportive therapy.
In R2, a second RCT, a standard day treatment program is compared to a
similar program (Executive Plus), augmented with modules to improve
executive functioning and attention training. R3, Support for Evidence-
Based Practice, evaluates all published research on post-TBI
interventions and assessment of outcomes; it serves as a national
resource for disseminating the results. It also implements three
participatory action research-based analyses of high priority areas,
including meta-analyses if appropriate. In addressing improved outcome
measurement, R4 focuses on the PART instrument, a measure of
participation currently being tested within eight TBI Model Systems. R4
focuses on creating a subjective approach to serve as a complement to
the PART's current focus on objective assessment. A major focus of the
RRTC is placed on capacity building of clinical and research
professionals to address the need for better day-to-day interventions
in the lives of people with TBI. Often their medical needs are misread,
their brain injury goes unidentified, and they find services and
accommodations inappropriate. Capacity building focuses on students
early in their educational career--to help shape career choice and
points of view; graduate and post-graduate students; and practicing
``gate keepers'' in the community, primarily psychologists and
physicians.
Rehabilitation Research and Training Center on Health and Wellness in
Long Term Disability
Gloria Krahn, Ph.D., M.P.H., Oregon Health and Science University,
Portland, OR; Project Number: 1459; Start Date: October 1, 2004;
Length: 60 months.
Abstract: The vision of the RRTC is to contribute to the reduction
of health disparities for person with disabilities through an
integrated program of research, training, technical assistance, and
dissemination. The Center has three inter-related strands of work to
address its three intended outcomes/goals: (1) identify strategies to
overcome barriers that impede access to routine healthcare for
individuals with disabilities; (2) identify interventions in areas such
as exercise, nutrition, pain management, or complementary and
alternative therapies that promote health and wellness and minimize the
occurrence of secondary conditions for persons with disabilities; and
(3) develop improved status measurement tool(s) to assess health and
well-being of individuals with disabilities regardless of functional
ability. In order to achieve these outcomes, the RRTC conducts a
coordinated program of research and training activities using a logic
model framework. RRTC projects summarize and validate existing research
findings on barriers to health care access as well as rigorously test
and compare new strategies to overcoming identified barriers. The RRTC
also examines and evaluates the practices of exemplary generic and
specialized health promotion programs for people with disabilities in
order to create an evidence-based set of evaluation and planning
criteria. In addition, the RRTC organizes and uses panels to assess
current health status measurement tools and develops or refines
measures to more accurately reflect the health and well-being of people
living with disabilities. Throughout these activities the RRTC
disseminates informational materials and provide technical assistance
to individuals with disabilities, their representatives, providers, and
other interested parties.
Multiple Sclerosis Rehabilitation Research and Training Center
George H. Kraft, M.D., University of Washington, Seattle, WA; Project
Number: 109; Start Date: October 1, 2003; Length: 60 months.
Abstract: This center conducts rehabilitation research that: (1)
Develops new interventions and practices in the areas of disease
suppression, strength enhancement, preserving employment, depression
management, and pain control; (2) collects data from an extensive
survey and explores complex interactions among multiple variables,
models factors that predict differing levels of participation by people
with MS, and proposes points of intervention that modify changes in
function; and (3) facilitates enhanced participation through training,
technical assistance, and dissemination through professional meetings,
publications, and a State-of-the-Science conference. In addition, a
Web-based knowledgebase provides technical assistance to individuals
with MS and healthcare providers with respect to caregiver issues,
financial and insurance planning, self-sufficiency and coping, and
assistive technology.
Rehabilitation Research and Training Center on Personal Assistance
Services
Charlene Harrington, Ph.D., R.N., University of California, San
Francisco, San Francisco, CA; Project Number: 267; Start Date: July 1,
2003; Length: 60 months.
Abstract: This project provides research, training, dissemination,
and technical assistance on issues of personal assistance services
(PAS) in the United States. Center projects focus on: (1) the
relationship between formal and informal PAS and caregiving support,
and the role of AT in complementing PAS; (2) policies and programs,
barriers, and new models for PAS in the home and community; (3)
workforce development, recruitment, retention, and benefits; and (4)
workplace PAS models that eliminate barriers to formal and informal PAS
and AT at work. The Center is based at the University of California,
San Francisco, and includes the Topeka Independent Living Resource
Center, InfoUse, the Paraprofessional Healthcare Institute, the
Institute for the Future of Aging Services, as well as faculty members
at the University of Maryland, Baltimore County Policy Sciences
Graduate Program, the West Virginia University Job Accommodation
Network, and the University of Michigan's Institute of Gerontology and
the Department Health Management and Policy. A Blue Ribbon Advisory
Committee of PAS users, disability advocates, business leaders,
independent living center leaders, and academics provide guidance to
the project.
Rehabilitation Research and Training Center for Children's Mental
Health
Robert Friedman, Ph.D., University of South Florida, Tampa, FL; Project
Number: 1454; Start Date: October 1, 2004; Length: 60 months.
Abstract: The Research and Training Center Children's Mental Health
conducts an integrated set of research projects designed, in the short
run, to enhance knowledge about effective implementation of systems of
care, and, in the long run, to make it possible for children with
serious emotional disturbances to live, learn, work, and thrive in
their own communities. The Center has developed a theory of factors
that contribute to effective implementation; within that theory is a
strong emphasis on the importance of understanding from a systemic
perspective the interrelationship between the different factors, and
their relationship to the community culture and context in which a
service delivery system exists. The Center has a set of six
interconnected research projects that use both quantitative and
qualitative methods, and are holistic in their focus, to further test
and develop its theory. The Center translates new knowledge from
research into change in policy and practice through a targeted program
of training, consultation, technical assistance, publication, and
dissemination. To support these efforts, the Center maintains
dissemination partnerships with a range of organizations committed to
help present research findings in formats well-suited for key audiences
of state and local policymakers, family organizations, researchers, and
representatives of related service sectors.
Rehabilitation Research and Training Center on Aging with Developmental
Disabilities
Tamar Heller, Ph.D., University of Illinois at Chicago, Chicago, IL;
Project Number: 276; Start Date: October 1, 2003; Length: 60 months.
Abstract: The mission of the RRTCADD is to have a sustained
beneficial impact on the health and community inclusion of adults with
intellectual and developmental disabilities (I/DD) as they age through
a coordinated set of research, training, and dissemination activities.
Major goals are: (1) improving health and function of adults with I/DD,
(2) enhancing caregiving supports and transition planning among older
caregivers and other family members, and (3) promoting aging and
disability friendly environments that enable adults with I/DD to
participate in community life. Each goal is addressed through
coordinated and complementary sets of activities within the core areas.
Projects promoting health and functioning include: examination of age-
related changes, epidemiological surveys, research on health care
utilization, and development of community-based health promotion
interventions. To enhance caregiving supports and transition planning,
RRTCADD research includes epidemiological surveys on family demographic
and health characteristics, including families of minority backgrounds
and families of persons with dual diagnoses of I/DD and psychiatric
impairments; sibling roles and interventions in transition planning;
and consumer direction in family support. Projects examining aging and
disability-friendly environments include research to identify features
of communities and residences that hinder and assist community
integration as people with I/DD age, state policies regarding nursing
home use, and dementia care in family homes and other community
residences. Training and dissemination activities involve
collaborations with national provider, professional, and consumer
organizations to enhance skills and to promote progressive
interventions and policies.
Rehabilitation Research and Training Center on Full Participation in
Independent Living
Glen W. White, Ph.D., The University of Kansas, Lawrence, KS; Project
Number: 107; Start Date: January 1, 2001; Length: 60 months.
Abstract: Through research, training, and dissemination, this
project makes available person-environment strategies that enable full
participation in society by persons with disabilities from diverse
cultures, varying socioeconomic strata, and emerging disability
populations. This mission is implemented through multiple research and
training activities that are influenced by independent living (IL)
philosophy and values; for example, participatory action research is
emphasized, in which consumers take an active role throughout the
research process. The RRTC develops, tests, and uses measurement tools
to investigate the interactional relationship between personal and
environmental factors and their effects on full participation in IL by
the designated populations. Based on the project's Analytical Research
Framework, the four core areas of intervention development and testing
include: (1) increasing the knowledge base about the emerging universe
of disability, (2) community participation and wellness, (3) cultural
IL accommodations, and (4) personal and systems advocacy.
Rehabilitation Research and Training Center on Measurement and
Interdependence in Community Living RRTC/MICL
Glen W. White, Ph.D., The University of Kansas, Lawrence, KS; Project
Number: 1721; Start Date: October 1, 2006; Length: 60 months.
Abstract: The goal of the Research and Training Center on
Measurement and Interdependence in Community Living (RRTC/MICL) is to
increase the independence and participation of people with disabilities
in their communities through the development and implementation of
scientifically sound, theoretically driven, and evidence-based
interventions. RRTC/MICL researchers accomplish this through six core
projects. Two research projects, one on community participation and a
second on economic utility, involve development of theory-driven
measurement tools. The remaining four projects include the application
of these measurement tools as part of their methods and procedures. Two
of these projects are interventions and two develop model assessments.
The first assessment project uses secondary analysis to develop and
implement a model for assessing the economic utility and health-related
outcomes of participants enrolled in Home and Community-Based Service
(HCBS) waivers. The second assessment project evaluates the effects of
different independent living advocacy-service models to determine the
comparative effectiveness of different models in increasing community
participation. The first intervention project examines the
effectiveness of personal assistance services and enhanced training to
increase consumer participation in the community. Finally, the second
intervention project is a multisite study that examines the effects of
a consumer-led grassroots approach in identifying and removing barriers
to increase community participation. Together, these projects represent
a comprehensive, integrated, and robust set of activities that
recognize that ``disability'' is an interaction between the
characteristics of an individual and his or her environment.
Opening Doors for Children with Disabilities and Special Health Care
Needs
Judith S. Palfrey, M.D., Children's Hospital, Boston, MA; Project
Number: 1643; Start Date: October 1, 2005; Length: 60 months.
Abstract: This rehabilitation research and training center (RRTC)
on children with disabilities who have special health care needs (CYDS)
tests the effectiveness of two intensive interventions, integrated
transition planning and community participation in recreation and
fitness, and demonstrates the viability of a screening tool to promote
access to services and supports for traditionally underserved
communities. Research activities include two intervention projects that
use randomized controlled designs to improve the educational and
recreational activities of CYDS and a demonstration project to improve
the early identification of CYDS from traditionally underserved
communities. Research Study 1 investigates the use of a regional
interagency team that integrates innovative practices in education,
social services, and medical support for transition aged students.
Research Study 2 builds off of innovative practices in recreation and
volunteer training to examine a model that integrates CYDS into
community recreation activities. Research Study 3 models the
integration of a reliable screening mechanism into the flow of activity
at a busy, urban neighborhood health center. The RRTC is a
collaboration of the Massachusetts Consortium for Children with Special
Health Care Needs, the Parent Advocacy Coalition for Educational Rights
(PACER), and six Multicultural Community Based Organizations that serve
traditionally underrepresented communities. RRTC staff and
collaborators include nationally and internationally known experts in
pediatrics, nursing, public policy, education, family advocacy,
rehabilitation, and community organizing.
Rehabilitation Research and Training Center Recovery and Recovery
Oriented
Psychiatric Rehabilitation for Persons with Long Term Mental
Illness
Marianne Farkas, Sc.D.; E. Sally Rogers, Sc.D., Boston University,
Boston, MA; Project Number: 1453; Start Date: November 1, 2004; Length:
60 months.
Abstract: This project focuses on the concepts and dimension of
recovery and the various factors that inhibit and facilitate recovery
from long-term mental illness by a comprehensive and meritorious set of
research projects and training, technical assistance, and dissemination
activities. The research and the training, dissemination, and technical
assistance programs are organized into the following three programmatic
areas of investigation and development: concepts and dimensions of
recovery; factors enhancing recovery, and factors inhibiting recovery.
The research projects are designed to have an impact on the field at
multiple levels, including the personnel level as well as the program
and system levels. Research projects use a participatory research
process with significant input from consumers and other stakeholders,
and culminate in dissemination, training, or technical assistance
activities to maximize the input of the research program. The Training,
Dissemination, and Technical Assistance (TDTA) projects are designed to
provide exposure, experience, and expertise levels of knowledge
transfer. The TDTA program produces new technologies in recovery and
psychiatric rehabilitation, as well as increases the likelihood that
researchers, service providers, and others use the cumulative knowledge
developed by the RRTC. The RRTC is tied together by its programmatic
focus on three specific core areas, strengthened by the use of
appropriate research strategies, and assisted by a vigorous program of
training, technical assistance, and dissemination activities designed
to maximize the impact of the RRTC at all levels in the field of
psychiatric rehabilitation.
Research and Training Center on Community Living (RTC/CL)
Charlie Lakin, Ph.D., University of Minnesota, Minneapolis, MN; Project
Number: 271; Start Date: October 1, 2003; Length: 60 months.
Abstract: The Center conducts research, training, technical
assistance, and dissemination to enhance inclusion and self-
determination of citizens with intellectual and developmental
disabilities (ID/DD). The research program has six outcome areas:
policy studies, data base supports for full participation, self-
determination and consumer-control, workforce development, and quality
assessment and improvement systems. The research program within the
priority areas includes: (1) research syntheses of the state of
knowledge and practice; (2) secondary analyses of high quality,
topically relevant national and state data sets; (3) case studies of
best practices; (4) evaluation of demonstration efforts to improve
policy and practice; (5) survey and interview studies of critical
issues; and (6) group process studies with key constituencies. An
integrated intramural training program addresses the development of
skilled disability researchers and community service professionals.
Outreach training programs provide training and technical assistance to
agencies and individuals providing support to people with ID/DD,
including members of their families. The College of Direct Support
provides online interactive multimedia training to thousands of direct
support professionals across the U.S. Outreach programs include
conferences and workshops for a wide variety of national, regional, and
state audiences, a state-of-the-art conference, annual ``Reinventing
Quality'' conference, and intensive technical assistance with community
organizations, including advocacy and self-advocacy organizations. The
Center disseminates practical information to targeted audiences through
its internal publication program that includes: IMPACT, Policy Research
Brief, DD Data Brief, and Frontline Initiative. It maintains high
standards for scholarly productivity and publication through books,
journal articles and technical reports. About 18,000 people visit
Center Web sites each month for access to view publications or other
information on best practices in person-centered services
(``QualityMall.org''), national statistics on services and
expenditures, the direct support workforce, and other contemporary
topics.
Rehabilitation Research and Training Center for Community Integration
for Individuals with Disabilities, Strengthening Family and
Youth Participation in Child and Adolescent Mental Health
Services
Barbara Friesen, Ph.D., Portland State University, Portland, OR;
Project Number: 1458; Start Date: October 1, 2004; Length: 60 months.
Abstract: This project conducts research, training, and technical
assistance activities to study and promote effective, community-based,
culturally competent, family centered, individualized, and strength-
based services for children and youth with emotional or behavioral
disorders and their families. Projects include: (1) ``Community
Integration (CI) of Transition-Age Youth,'' designed to gain
understanding of CI and related concepts from the perspectives of
transition-age youth, young adults, and caregivers; (2) ``Transforming
Futures: Research on Expanding the Career Aspirations of Youth with
Mental and Emotional Disorders,'' explores transition experiences; (3)
``Partnerships in Individualized Planning'' develops an intervention to
increase youth and family member participation in the individualized
service planning process, a conceptual framework for understanding
recovery in children's mental health, and ways to reduce stigma; (4)
``Work-Life Integration'' addresses CI for adult caregivers of children
and youth with emotional disorders, specifically around maintaining
employment. It is designed to influence human resource professionals'
practice, and aims to reduce stigma and increase organizations' family
friendliness; (5) ``Transforming Transitions to Kindergarten'' focuses
on the preschool-kindergarten transition for young children with
challenging behaviors. It develops and tests an intervention promoting
children's successful school entry while empowering caregivers; (6)
``Practice-Based Evidence: Building Effectiveness from the Ground Up,''
conducts a case study in partnership with a Native American youth
organization and the National Indian Child Welfare Association, and
addresses the need to study practices that are believed to be helpful,
but for which little evidence exists.
Rehabilitation Research and Training Center Promoting Community
Integration of Individuals with Psychiatric Disabilities
Mark Salzer, Ph.D., University of Pennsylvania, Philadelphia, PA;
Project Number: 268; Start Date: October 1, 2003; Length: 60 months.
Abstract: The goal of this Center is to ensure that people with
psychiatric disabilities not only move from institutional care to more
integrated settings but also are free to choose to participate in a
wide range of roles in their communities. The Center's 5-year mission
focuses on three core areas: (1) Factors Associated with Community
Integration develops a coherent conceptual framework for community
integration and identifies key factors, intervention models, and
appropriate instrumentation and research methodologies; (2) Policies
Associated with Community Integration identifies, develops, and
assesses the effectiveness of a range of public policies and system
strategies promoting community integration and engage key stakeholders
in learning about and utilizing the Center's findings; and (3)
Intervention Supports that Assist Community Integration identifies,
develops, and assesses the effectiveness of support service
interventions promoting community integration, and provides training,
technical assistance, and dissemination based on those initiatives to
change behaviors and practices of key stakeholders. This Center
capitalizes upon the longstanding history of collaboration among three
Philadelphia-based central partners: The University of Pennsylvania,
the peer-operated Mental Health Association of Southeastern
Pennsylvania, and The Matrix Center at Horizon House, Inc.
Rehabilitation and Training Center on Community Integration of Persons
with TBI
Angelle M. Sander, Ph.D.; Margaret Struchen, Ph.D., The Institute for
Rehabilitation and Research (TIRR), Houston, TX; Project Number: 272;
Start Date: November 1, 2003; Length: 60 months.
Abstract: The research program of this project includes:
development and evaluation of a social network mentoring program; an
investigation of racial/ethnic differences in acceptance of disability,
community integration needs, barriers, and supports; a distance
learning program to train family members in rural areas as
paraprofessionals; assessment of employers' attitudes toward persons
with TBI and a pilot educational intervention to reduce attitudinal
barriers in the workplace; a randomized clinical trial to assess the
effectiveness of a brief substance abuse intervention; a qualitative
exploration of intimacy following TBI; and a study investigating the
role of social communication abilities and environmental factors on
social integration. Training projects include: a National Information,
Educational Resources, Dissemination, and Technical Assistance Center
for the Community Integration of Individuals with TBI; development of
educational materials for increasing community awareness of TBI and
reducing attitudinal barriers; adoption of a social action network
program from disability studies for improving positive identity;
partnering with artists in the community to implement a Center for
Creative Expressions for Persons with TBI; training of community
healthcare professionals in the community integration needs of persons
with TBI; a rehabilitation fellowship in community integration of
persons with TBI; and a state-of-the-science conference and book on
community integration.
rehabilitation engineering research centers of the national institute
for disability and rehabilitation research
RERC on Spinal Cord Injury: Keep Moving: Technologies to Enhance
Mobility and Function for Individuals with Spinal Cord Injury
Philip Requejo, Ph.D.; Robert Waters, M.D., Los Amigos Research and
Education Institute, Inc. (LAREI), Downey, CA; Project Number: 483;
Start Date: November 1, 2002; Length: 60 months.
Abstract: This RERC improves the lives of individuals with SCI by
promoting their health, safety, independence, and active engagement in
daily activities. Activities include: (1) monitoring trends and
evolving product concepts that represent future directions for
technologies in SCI, (2) conducting research to advance the state of
knowledge, (3) disseminating the information to the population, (4)
developing and testing prototype devices that are useful and effective
and transferring them to the marketplace, (5) advancing employment
opportunities for individuals with SCI, and (6) developing ways to
expand research capacity in the field of SCI. The R&D program is
focused on a key issue for individuals with SCI, the need to maintain
mobility for as long as possible in order to enhance independent
function. A survey of the user population determines where areas of
greatest need exist. An active Mobile Arm Support for adults allows
those with limited arm function greater independence. The shoulder-
preserving wheelchair, gait training robotic assist device, and
adaptive exercise equipment are all specifically geared to preserve or
enhance mobility in individuals with SCI. A project on optimized
wheelchair suspension keeps people mobile by increasing comfort and
reducing tissue loading.
Rehabilitation Engineering Research Center: Develop and Evaluate
Technology for Low Vision, Blindness, and Multi-Sensory Loss
John A. Brabyn, Ph.D., The Smith-Kettlewell Eye Research Institute, San
Francisco, CA; Project Number: 1646; Start Date: August 1, 2006;
Length: 60 months.
Abstract: This Center conducts a program of research and
development to enhance the independence of blind, visually impaired,
and deaf-blind individuals. Research includes investigation of
assessment methods to guide rehabilitation of infant cortical visual
impairment; practical innovations in assessment and interventions for
elders with visual impairments; and development of independent
assessment guidelines for emerging visual prostheses. The Center also
conducts research in access to graphical information for blind,
visually impaired, and deaf-blind persons, developing tools for rapid
screen overview, auditory and tactile graph presentation, image
classification, and on-demand production of tactile street maps. To
address signage and travel information, the project is investigating
information interfaces for travelers who are blind or visually
impaired, and innovative computer vision methods to find and read
existing print signs and labels. To address the rising barriers to
accessing visual displays and appliances for employment and daily
living, there is a designer education campaign and development of a
universal talking LCD/LED display reader, practical consumer tools, and
jobsite adaptations for employees who are blind or visually impaired.
Other projects include development of a new-generation robotic finger-
spelling hand for deaf-blind communication, and pilot investigations of
difficulties in lipreading and sign language reading experienced by
those with combined auditory and visual impairment.
Rehabilitation Engineering Research Center for the Advancement of
Cognitive
Technologies (RERC-ACT)
Cathy Bodine, University of Colorado, Denver, CO; Project Number: 1451;
Start Date: November 1, 2004; Length: 60 months.
Abstract: The goal of this RERC is to research, develop, evaluate,
implement, and disseminate innovative technologies and approaches that
will have a positive impact on the way in which individuals with
significant cognitive disabilities function within their communities
and workplace. The Center incorporates: (1) a consumer-driven model for
identifying the most significant barriers to independent living and
workforce; (2) an approach that is balanced and uses both well-
established and newly emerging technologies in its development
projects; (3) a focus both on functional limitations and specific
disabilities; and (4) mutually beneficial partnerships with private
industry and public agencies. Research activities include: Needs,
knowledge, barriers, and uses of AT by persons with cognitive
disabilities; technology for remote family support for people with
cognitive disabilities; influences on AT use, non-use, and partial, and
inappropriate use by persons with traumatic brain injury; AT
enhancement of written expression for children and adults; needs
assessment for creating affordable, context-aware technologies; and
technology to promote decisionmaking skills and self-determination for
students with cognitive disabilities. Development activities include:
Design, implementation, and deployment of context aware technologies
for persons with cognitive disabilities residing in community living
environments; development of HealthQuest, an Internet-based product
that enables individuals with intellectual disabilities to become
active participants in their own health care; XML repository of common
tasks; batteryless micropower sensors for context aware technologies;
perceptive animated interfaces for workforce training; and
environmentally appropriate behavioral cues for individuals with TBI.
Rehabilitation Engineering Research Center on Hearing Enhancement
Matthew H. Bakke, Ph.D., Gallaudet University, Washington, DC; Project
Number: 484; Start Date: October 1, 2003; Length: 60 months.
Abstract: The mission of this RERC is to build and test components
of a new, innovative model of aural rehabilitation tools, services, and
training, in order to improve assessment and fitting of hearing
technologies and to increase the availability, knowledge, and use of
hearing enhancement devices and services. Component A: (1) develops and
evaluates new methods for field evaluation and fitting of hearing aids;
(2) develops and evaluates techniques to enhance auditory self-
monitoring; and (3) develops methods for predicting the speech-to-
interference ratio and intelligibility of speech for a hearing aid when
used with a wireless telephone. Component B conducts a needs assessment
survey of people who use hearing technologies and evaluates the use of
Bluetooth technology as a means of improving and expanding wireless
connection to a hearing aid. Component C investigates environmental
factors affecting children's speech recognition abilities in classroom
settings. Component D investigates the use of distortion product
otoacoustic emission and reflectance for diagnosis of hearing loss and
tinnitus; and creates and standardizes sets of synthesized nonsense
syllables for use in hearing aid research. Component E develops a new,
innovative model for the delivery of aural rehabilitation services to
adults with hearing loss. In addition the RERC conducts a program of
training and dissemination that will reach a diverse audience of
people, both consumers
and professionals.
Rehabilitation Engineering Research Center on Technology for Successful
Aging
William C. Mann, Ph.D., University of Florida, Gainesville, FL; Project
Number: 475; Start Date: October 1, 2001; Length: 60 months.
Abstract: The RERC-Tech-Aging conducts research, development,
education, and information dissemination work on technology for
successful aging. Projects of the RERC focus on the closely related
areas of communications, home monitoring, and ``smart'' technologies.
The technology driving the focus for this RERC is developing rapidly
and requires an understanding of current and emerging technology areas,
including wireless technology, computers, sensors, user interfaces,
control devices, and networking. Successful integration of this
technology into products and systems for older persons requires an
understanding of their complex health, independence, and quality-of-
life issues. The RERC-Tech-Aging tests currently available home
monitoring products and demonstrates their effectiveness in relation to
independence, quality of life, and health related costs. The RERC-Tech-
Aging also identifies needs and barriers to home monitoring and
communication technology, and addresses needs of special populations
including rural-living, elders, and people aging with disability. The
RERC-Tech-Aging brings together national expertise to meet this
challenge, including major universities, industry leaders working in
this area, major aging or aging-related organizations, major Federal
agencies that relate to funding or services in this area, other NIDRR-
funded RERCs and RRTCs, and service-related organizations that assist
in identifying study participants.
Rehabilitation Engineering Research Center for Wireless Technologies
Helena Mitchell, Ph.D., Georgia Institute of Technology, Atlanta, GA;
Project Number: 1671; Start Date: October 1, 2006; Length: 60 months.
Abstract: The Rehabilitation Engineering Research Center for
Wireless Technologies' mission is to: (1) promote equitable access to
and use of wireless technologies by persons with disabilities; and (2)
encourage adoption of Universal Design in future generations of
wireless technologies. To accomplish these aims, the RERC is organized
into three main project sections: The Research Section is comprised of
four research initiatives: Facilitating User Centered Research is
designed to establish a research portal that communicates to industry
the needs of people with disabilities for wireless technologies.
Customer-driven Usability Assessment enhances the usability of future
generations of cell phones and other wireless products by developing a
methodology for assessing their usability by representative users with
disabilities. Collaborative Policy Approaches to Promote Equitable
Access develops, implements, and evaluates specific policy initiatives
related to accessible wireless technologies and services. Advanced
Auditory Interfaces develops, tests, and disseminates guidelines for
the design of advanced auditory interfaces for cell phones and other
handheld electronic devices. The Development Section includes four
projects that promote equitable access to and use of wireless
technologies by persons with disabilities through the development of
prototype designs: Alternative Interfaces continues its work on the V2
standards for universal remote consoles and Real-time Location-based
Information Services expands on previous work on the RERC's personal
captioning system by addressing the needs of patrons with vision or
hearing impairments in three different venues--exhibit spaces,
airports, and hospitals. Development of Wireless Emergency
Communications and Ensuring Access to Emergency Assistance both focus
on the area of wireless emergency communications for people with
disabilities; developing wireless communication technology to be used
by emergency personnel to contact individuals with disabilities, and by
people with disabilities to signal the need for assistance. The
Training and Dissemination Section promotes the synthesis of new
knowledge into practice with the RERC's State of the Science conference
and a number of initiatives designed to educate consumers, providers,
and other professionals, including: university courses, an annual
student design competition, conference tutorials and workshops, all
geared toward access and usability of mobile wireless technologies.
Rehabilitation Engineering Research Center on Wheeled Mobility
Stephen H. Sprigle, Ph.D., Georgia Institute of Technology, Atlanta,
GA; Project Number: 491; Start Date: November 1, 2003; Length: 60
months.
Abstract: The goal of this RERC is to undertake a major shift in
the way wheeled mobility is conceptualized and understood, from the
design of assistive devices that enable some individuals to perform
some activities, to the design of a broad range of interventions that
enable as many individuals as possible to actively engage and
participate in everyday community life. Research activities include:
(1) User Needs and Design Input uses participatory focus groups to
identify needs of wheelchair users; (2) User Needs of Older Adults
assesses the needs of older adults living at home and in other
residential settings; (3) Effects of Environment and Mobility
Technology on Participation and Activity measures the influences of
environmental barriers and specialized wheelchair technology on
participation and activity in everyday life; (4) Efficacy of Animation
and Visualization Training uses computer simulation techniques to
investigate their efficacy in improving mobility training; and (5)
Clinical and Functional Implications of Seating Standards and
Guidelines studies the relationship between standardized measures of
cushion performance and actual impact on wheelchair users. Development
efforts include: (1) development and marketing of new mobility devices
in collaboration with industry design partners; (2) development of a
wheelchair for frail elders that can be used in any residential
environment; (3) interventions to overcome barriers to participation
including guidelines and technologies to help wheelchair users overcome
environmental and technological barriers; (4) development of animation
and visualization training through computer simulations to improve
training in transfers and outdoor mobility; and (5) development of
valid wheelchair cushion test methods which enables clinicians to
prescribe appropriate wheelchair cushions based on positioning and
aload distribution.
Rehabilitation Engineering Research Center on Workplace Accommodations
Karen Milchus; Jon Sanford, Georgia Institute of Technology, Center for
Assistive Technology & Environmental Access, Atlanta, GA; Project
Number: 480; Start Date: November 1, 2002; Length: 60 months.
Abstract: This RERC identifies, designs, and develops devices and
systems to enhance the workplace productivity of people with
disabilities. Universal design is a primary focus of the Center: making
the design of products and environments usable by all workers to the
greatest extent possible, without the need for adaptation or
specialized design. The RERC's research projects evaluate existing
workplace products and services and determine areas where further
product development is needed. The Center also studies archival
materials to identify factors that contribute to successful or
unsuccessful outcomes, and analyzes policies and practices that may
influence the nature and availability of workplace accommodations for
persons with disabilities. The RERC's development activities focus on
Remote Services and Universal Design in the Workplace. The Remote
Services projects investigate ways that remote technologies such as
videoconferencing and telework can be used to facilitate employment and
provide technical support services to people with disabilities. The
Universal Design projects work with manufacturers to develop new
generations of universally designed and accessible products. Digital
human modeling tools developed by the project provide visualizations of
products or systems with human interaction and movement and reduce the
need for preliminary physical prototypes. Products are developed for
workers in office, manufacturing, retail/sales, service industry, and
other environments. Finally, training, technical assistance, and
dissemination activities on workplace accommodations and universal
design promote the transfer of new knowledge into practice.
RERC on Rehabilitation Robotics and Telemanipulation: Machines
Assisting
Recovery from Stroke (MARS)
W. Zev Rymer, M.D., Ph.D., Rehabilitation Institute Research
Corporation, Chicago, IL; Project Number: 481; Start Date: November 1,
2002; Length: 60 months.
Abstract: MARS-RERC focuses its research and development on
restoring function in hemispheric stroke survivors. Five projects
assess different approaches that have the potential to improve
performance of the upper extremity, and one project attempts to restore
gait and fluid locomotion to the lower extremities. These projects
include: the ARM Guide, a robotic therapy for force training of the
upper extremity in chronic hemiparetic stroke; Lokomat-Gait restoration
in hemiparetic stroke patients using goal-directed, robotic-assisted
treadmill training; Augmented Reality Robotic Rehabilitation, which is
in the development of a robotic system with an augmented reality
interface for rehabilitation retraining of arm function for brain-
injured individuals; Robotic Assisted Finger Extension, rehabilitation
of finger extension in chronic hemiplegia; and T-WREX, a home-based
telerehabilitation system for improving functional hand and arm
movement recovery following stroke utilizing an anti-gravity orthosis
and video games to track progress. In addition to these projects, MARS-
RERC's purpose is to train undergraduate engineering students, medical
students, physician residents, graduate students in engineering and
neuroscience, and allied health clinicians, including physical and
occupational therapists in the area of rehabilitation robotics. The
broad intent of MARS-RERC is to develop robotic devices or machines
that assist the therapist in providing treatments that are rationally
based, intensive, and long in duration. This project is a collaboration
of the Rehabilitation Institute of Chicago (RIC), the Catholic
University of America (CUA) and National Rehabilitation Hospital in
Washington, DC, the University of Illinois at Chicago (UIC), and the
University of California at Irvine (UCI).
Rehabilitation Engineering Research Center in Prosthetics and Orthotics
Steven A. Gard, Ph.D., Northwestern University, Chicago, IL; Project
Number: 490; Start Date: October 1, 2003; Length: 60 months.
Abstract: This Center conducts ten research projects, three of
which are pilot studies. In the area of human locomotion the objectives
are to conduct quantitative studies that include non-disabled gait,
modeling of gait, roll-over shape influence on transtibial amputee
gait, gait initiation, shock absorption studies, the role of the spine
in walking, transfemoral socket design studies, and evaluation of
stance-control orthotic knee joints. Pilot studies, where preliminary
data is not available, are proposed on partial foot prosthesis/orthosis
systems, on evaluation of Ankle Foot Orthoses and on the design of a
Shape & Roll foot for children. Six developmental projects include a
simple gait monitoring instrument (Direct Ultrasound Ranging System), a
new prosthetic ankle joint that adapts to inclines, and a manual
through which individuals in low-income countries can make their own
artificial feet. In addition, two upper-limb prosthetics development
projects are proposed that deal with reaching, manipulation, and
grasping. Finally, an outcomes measurement tool is developed for
prosthetics and orthotics (P&O) facilities in their reporting to the
American Board of Certification. The vision for this RERC is to improve
the quality of life for persons who use prostheses and orthoses through
creative applications of science and engineering to the P&O field. The
goal is to uncover new knowledge and understanding in P&O and to bring
more quantification to the field, which will enable them to develop new
concepts and devices to improve the quality, cost-effectiveness, and
delivery of P&O fittings.
Rehabilitation Engineering Research Center on Recreational Technologies
and
Exercise Physiology Benefiting Persons with Disabilities (RERC
RecTech)
James H. Rimmer, Ph.D., University of Illinois at Chicago, Chicago, IL;
Project Number: 479; Start Date: November 1, 2002; Length: 60 months.
Abstract: This program researches access to recreational
opportunities and physical endurance of people with disabilities,
targeting four primary areas: (1) increased access to fitness and
recreation environments; (2) interventions to increase physical
activity and recreation participation; (3) adherence strategies to
reduce physical activity relapse and dropout rates; and (4) randomized
clinical trials to evaluate improvements in health and function.
Research and development projects include: (1) a comprehensive needs
assessment that involves ongoing assessment of consumer needs as they
pertain to existing and emerging recreational and fitness technologies;
(2) research on the use of information technology and a newly designed
environmental accessibility instrument for facilitating access to
recreational and fitness environments and promoting improved health and
function; (3) research on the use of ``teleexercise'' technology for
promoting participation and for monitoring intensity and physiological/
psychological outcomes of home-based exercise programs; (4) research
and development of technology to create virtual exercise environments
to promote greater adherence to exercise and thereby improved health
and function; (5) development of technology to allow users adaptive
control of exercise machines; (6) development of broadly applicable
aftermarket accessory kits for adapting existing cardiovascular
exercise equipment for use by people with disabilities and determining
the efficacy of the new adaptations in improving fitness; and (7)
development of an online RecTech solutions database of currently
available recreational and fitness technologies to make available
solutions more accessible to consumers. Two training projects promote
capacity building for future recreation, fitness, exercise physiology,
engineering, and rehabilitation professionals, and two additional
training projects support professional development.
Rehabilitation Engineering Research Center on Technology Access for
Landmine
Survivors
Yeongchi Wu, M.D.; Kim Reisinger, Ph.D., Center for International
Rehabilitation, Chicago, IL; Project Number: 487; Start Date: November
1, 2003; Length: 60 months.
Abstract: The Center strives to improve the quality and
availability of amputee and rehabilitation services for landmine
survivors by focusing on the development of ``appropriate technology,''
i.e., technology that is most suitable to the limited technical and
human resources available in most mine-affected regions through the
application of research methodologies, the development of mobility
aids, and the creation of educational materials, all of which are
designed specifically for mine-affected populations and disseminated
through a network of rehabilitation service providers in mine-affected
regions. Laboratory-based research projects investigate issues of
importance relating to transtibial alignment, ischial containment
socket trim lines as they relate to the gait of transfemoral amputees,
and the evaluation of a non-toxic resin for the direct lamination of
prosthetic sockets. Field-based research evaluates an anatomically
based transtibial alignment methodology and a wheelchair prototype
manufacturing and dissemination strategy. Development projects, many of
which contain research components, can be classified into two areas:
those that improve the service delivery through improved fabrication
techniques, and those that develop appropriate prosthetic components
and mobility aids. In order to promote the successful transfer of
techniques and technologies that are developed, the RERC creates
training materials that describe the manufacture, assembly, and use of
the technique or devices developed under the research and development
program. Additionally, because the current number of trained prosthetic
technicians in developing countries is far from sufficient to
adequately meet the needs of landmine survivors, the center produces
education and training materials covering the basic science of
prosthetics and orthotics. All materials are adapted to the specific
languages, culture, and needs of the mine-affected regions served by
the RERC and distributed through a blended distance learning network.
Rehabilitation Engineering Research Center on Wheelchair Transportation
Safety
Lawrence W. Schneider, Ph.D. (Michigan); Patricia Karg, Ph.D.
(Pittsburgh); Gina Bertocci, Ph.D. (Louisville), University of
Michigan, Ann Arbor, MI; Project Number: 1672; Start Date: November 1,
2006; Length: 60 months.
Abstract: Research conducted by the RERC on Wheelchair
Transportation Safety (RERC WTS) advances the safety, usability, and
independence of people who remain seated in their wheelchairs when
traveling in motor vehicles. Research and development projects involve
close collaboration with manufacturers, transit providers, vehicle
modifiers, clinicians, and consumers to ensure quick translation of
results into meaningful solutions that benefit travelers with mobility
disabilities. Projects range from developing innovative solutions for
forward-facing and rear-facing wheelchair passenger stations in large
accessible transit vehicles, to investigating issues of school-bus
transportation for children seated in WC-19 compliant and noncompliant
wheelchairs, and to improving frontal- and rear-crash protection for
occupants in private vehicles. Continuing research from previous
grants, the RERC WTS extends the in-depth investigations of adverse
events involving wheelchair-seated travelers, but also conducts a study
of the transportation experience of wheelchair users in large public
transit vehicles, including the process of entering and exiting the
vehicle, accessing the wheelchair station, securing the wheelchair and
restraining the occupant, and traveling to and from destinations. In
addition to conducting research and development in six project areas,
RERC WTS staff engages in information dissemination, training of future
researchers, transferring innovative technology concepts to the
marketplace, developing and revising voluntary industry standards, and
convening the second State-of-the-Science Workshop on Wheelchair
Transportation Safety. The RERC is a partnership of the University of
Michigan Transportation Research Institute, the University of
Pittsburgh, the University of Louisville, and the University of
Colorado.
Rehabilitation Engineering Research Center on Children with Orthopedic
Disabilities
Richard A. Foulds, Ph.D., New Jersey Institute of Technology, Newark,
NJ; Project Number: 1560; Start Date: November 1, 2005; Length: 60
months.
Abstract: The Rehabilitation Engineering Research Center on
Technology for Children with Orthopedic Disabilities focuses on
research and development assisting children to achieve their full
potential as productive citizens. The work plan includes a roster of
projects designed to enhance the physical skills of these children to
be successful in learning, playing, and living independently. This
project includes three research and three development projects, as well
as training projects serving the needs of children, families, students,
and professionals. Project selection is driven by the RERC on Children
with Orthopedic Disabilities' vision of RERCs as a source of innovation
and of new technologies designed to address the serious problems faced
by children with disabilities. This project is a collaboration of New
Jersey Institute of Technology, the Childrens' Specialized Hospital,
and Rutgers University, bringing together two academic departments of
biomedical engineering with the Nation's largest pediatric
rehabilitation hospital.
Rehabilitation Engineering Research Center on Technology Transfer
(T2RERC)
Steve Bauer, Ph.D., State University of New York (SUNY) at Buffalo,
Buffalo, NY; Project Number: 489; Start Date: October 1, 2003; Length:
60 months.
Abstract: The activities of this project transfer and commercialize
new and improved assistive devices, conduct research to improve
technology transfer practice, and support other stakeholders involved
in the technology transfer process. Four research projects investigate
innovative ways to facilitate and improve the process of technology
transfer for all stakeholders: (1) Identify Innovative Technology
Transfer Practices--draws critical success factors from examples of
retrospective and prospective AT transfer case studies in various
sectors; (2) Identify Innovative Technology Transfer Policies--traces
the outputs and outcomes of Federal transfer programs supporting AT
related projects and assesses their efficacy; (3) Facilitate AT
Industry Innovation through Focused Market Research--provides a context
for transfer opportunities involving the AT industry and for public
policy decision making; and (4) Assess the Efficacy of Transferred
Products--determines the extent to which products previously
transferred through the T2RERC impact the functional capabilities of
consumers. Four development projects increase the number and quality of
successful transfers from RERC's and other sources: (1) Transfer
Products through a Supply Push Approach--facilitates the movement of
new or improved prototype inventions to the marketplace through
licenses, sales, or entrepreneurial ventures; (2) Transfer Technologies
through a Demand Pull Approach--validates technology needs within the
AT industry and introduces advanced technology solutions to address
those needs; (3) Improve the Accessibility of New Mainstream Products--
extends participatory research to integrate consumers' functional
requirements into the design of new mainstream products; and (4)
Facilitate RERC Transfer Activity Through Informatics--establishes a
pilot informatics infrastructure and assesses its utility for
increasing communication, collaboration, and transfers between RERC's.
Rehabilitation Engineering and Research Center (RERC) on Universal
Design and the Built Environment at Buffalo
Edward Steinfeld, Arch.D., State University of New York (SUNY) at
Buffalo, Buffalo, NY; Project Number: 1561; Start Date: November 1,
2005; Length: 60 months.
Abstract: The RERC on Universal Design and the Built Environment is
engaging the public and private sectors across four broad domains of
the built environment: (1) community infrastructure, (2) public
buildings, (3) housing, and (4) products. The RERC-UD generates
strategically important research, development, education, and
dissemination deliverables, to advance the fields of rehabilitation
engineering and environmental design. The RERC-UD deliverables
integrate universal design principles within the generally accepted
models, methods, and metrics of design and engineering professionals in
the building and manufacturing industries. Research projects document
the efficacy of existing universally designed environments, and
generate critical human factors data essential to resolving design and
engineering problems. Development projects create evidence-based
guidelines to implement universal design concepts within the tools of
the design professions, and formulate methods to evaluate the usability
of designs for people with mobility, sensory, and cognitive
impairments. The usefulness of the guidelines and evaluation methods
are demonstrated by applying them to the development of innovative
products and environments with industry partners. Training activities
emphasize online certificate programs in universal design for design
professionals, builders, manufacturers, and consumer advocates; a Web
portal and site for students and educators; and graduate programs that
train researchers in advanced methods. Dissemination outputs include
traditional refereed and trade publications, an extensive Web site with
downloadable information products and design tools, model home
demonstrations in local communities across the country, and outreach
activities with professional, business, and standards development
organizations. The RERC-UD's state-of-the-science conference includes
stakeholders in a plan to elevate universal design to an integral
component of the mainstream design and engineering disciplines.
Rehabilitation Engineering Research Center on Communication Enhancement
Frank DeRuyter, Ph.D., Duke University, Durham, NC; Project Number:
488; Start Date: November 1, 2003; Length: 60 months.
Abstract: The mission of this RERC is to assist people who use
augmentative and alternative (AAC) technologies in achieving their
goals across environments. The goals and objectives of the RERC are to
advance and promote AAC technologies through the outputs and outcomes
of research and development activities and to support individuals who
use, manufacture, and recommend these technologies in ways they value.
Research projects cover the following areas: (1) improving AAC
technology to better support societal roles; (2) enhancing AAC access
by reducing cognitive/linguistic load; and (3) enhancing AAC usability
and performance. Projects address issues of literacy, telework,
specialized vocabulary, contextual scenes and intelligent agents,
improving interface performance, and monitoring and simulating
communication performance. Development activities include: (1)
technology and policy watch; (2) new interfaces; and (3) reducing the
cognitive/linguistic burden on AAC users. Activities address monitoring
emerging technologies, standards, and policies; technologies to
supplement intelligibility of residual speech, dysarthric speech, and
gesture recognition; brain interface; AAC WebCrawling; and enhancing
the role of listeners in AAC interactions.
National Center for Accessible Public Transportation
Katharine Hunter-Zaworski, Ph.D., Oregon State University, Corvallis,
OR; Project Number: 485; Start Date: October 1, 2003; Length: 60
months.
Abstract: This RERC addresses the need for improvements in the
accessibility of public transportation. This center is both important
and timely because of major changes in the travel industry, and the
need to adapt to those changes in a way that provides safe and
dignified travel for persons with disabilities. The transportation
focus of this RERC is inter-city travel via air, rail, and bus. Air,
rail, and over-the-road buses (OTRB) account for nearly all of the
inter-city public transportation. Accessibility issues focus on persons
with mobility, agility, and hearing disabilities and account for a
large percentage of persons with disabilities. Two areas of research
are addressed: (1) the biomechanics of wheelchair transfers in confined
spaces; and (2) the perceptions, reactions, and attitudes of subjects
toward existing and proposed accessibility solutions. The biomechanics
studies include the use of a sophisticated eight-camera motion analysis
system in conjunction with force plates to determine the motions and
forces involved in dependent and independent transfers in confined
spaces, such as an aircraft aisle. The survey-based study includes
comprehensive surveys of groups that are directly involved with
accessibility issues including travelers with disabilities, non-
travelers with disabilities, and employees of airlines and airports.
Drawing on results of their research, the RERC focuses on four
development topics: (1) vehicle boarding technologies; (2) real time
passenger information and communications systems; (3) accessible
lavatories; and (4) passenger assistance training tools and techniques.
The accessible lavatory project has two main components; regulations
and new designs for the next generation of aircarft.
Rehabilitation Engineering Research Center on Telerehabilitation
David M. Brienza, Ph.D., University of Pittsburgh, Pittsburgh, PA;
Project Number: 1450; Start Date: December 1, 2004; Length: 60 months.
Abstract: The vision of this RERC is to serve people with
disabilities by researching and developing methods, systems, and
technologies that support remote delivery of rehabilitation and home
health care services for individuals who have limited local access to
comprehensive medical rehabilitation outpatient and community-based
services. Research and development activities include: (1)
Telerehabilitation Infrastructure and Architecture: development of an
informatics infrastructure and architecture that builds on existing
programs and technologies of the University of Pittsburgh Medical
Center's e-Health System, supports the RERC's research and development
activities, meets HIPAA requirements, provides a test-bed for third
party telerehabilitation applications, and can be used as a model for
future telerehabilitation infrastructure; (2) Telerehabilitation
Clinical Assessment Modeling: development of a conceptual model for
matching consumers with telerehabilitation technology. The model is
user-oriented and driven by consumer experiences regarding
satisfaction, simplicity, and reimbursability of telerehabilitation;
(3) Teleassessment for the Promotion of Communication Function in
Children with Disabilities: development of a Web-based teleassessment
infrastructure that links therapists and child participants, allowing
therapeutic content to be adapted to the child's individual progress
and abilities; (4) Remote Wheeled Mobility Assessment: determines if
individuals with mobility impairments can obtain appropriate
prescriptions for wheeled mobility devices through the use of a
telerehabilitation system based upon information and telecommunications
technologies; (5) Behavioral Monitoring and Job Coaching in Vocational
Rehabilitation: researches technologies to conduct remote delivery of
rehabilitation services to individuals who have limited access to
rehabilitation services that are necessary to participate in and
achieve education and employment outcomes in their community; and (6)
Remote Accessibility Assessment of the Built Environment: determines
the effectiveness of a remote accessibility assessment system in
evaluating the built environment of wheeled mobility device users.
Rehabilitation Engineering Research Center on Wheelchair Transportation
Safety
Patricia Karg, University of Pittsburgh, Pittsburgh, PA; Project
Number: 477; Start Date: November 1, 2001; Length: 60 months.
Abstract: This RERC aims to improve the safety of wheelchair users
who remain seated in their wheelchair while using public and private
motor-vehicle transportation. RERC tasks investigate and develop new
wheelchair tiedown and occupant restraint system technologies,
including wheelchair-integrated restraints and universal docking
concepts, that enable wheelchair users to secure and release their
wheelchair independently and quickly, and use an effective occupant
restraint system without the need for assistance. The RERC also
researches the issues and factors involved in providing improved
occupant protection to wheelchair-seated drivers and passengers in rear
and side impacts, and uses a multifaceted approach, including in-depth
investigations of real-world accidents, to investigate the incidence,
severity, and causes of injuries to wheelchair-seated occupants in
different sizes of vehicles and in different types of crashes and non-
impact incidents experienced during vehicle motion. In particular, this
RERC explores the need for, and suitability of, using different levels
of wheelchair securement and occupant restraint in larger public
transit vehicles, with the goal of recommending and developing
equipment and systems that provide for a safe ride and that are more
compatible with the operational needs of the transit environment. The
program includes a comprehensive research and development effort that
involves consumers, manufacturers, students, clinicians, transport
providers, and rehabilitation technology experts. The RERC also has
active programs of information dissemination, training, and technology
transfer using personnel, mechanisms, and facilities that have been
previously established at the University of Pittsburgh/University of
Michigan.
Rehabilitation Engineering Research Center on Accessible Medical
Instrumentation
Jack Winters, Ph.D.; Molly Follette Story, M.S. , Marquette University,
Milwaukee, WI; Project Number: 482; Start Date: November 1, 2002;
Length: 60 months.
Abstract: The RERC on Accessible Medical Instrumentation: (1)
increases knowledge of, access to, and utilization of healthcare
instrumentation and services by individuals with disabilities; (2)
increases awareness of and access to employment in the healthcare
professions by individuals with disabilities; and (3) serves as a
national center of excellence for this priority topic area. Specific
research projects include: (1) needs analysis for people with
disabilities as both recipients and providers of healthcare services,
and for manufacturers of healthcare instrumentation; (2) usability
analyses to determine what makes certain medical instrumentation either
exemplary or problematic yet essential to healthcare service delivery;
(3) accessibility and universal usability analysis to identify
classification and measurement approaches that could be used to explore
metrics for accessibility of medical instrumentation; and (4) policy
analyses to explore how medical policies affect healthcare utilization
and employment in the healthcare professions of persons with
disabilities. Specific development projects include: (1) development of
tools for usability and accessibility analysis; (2) development of
modified and new accessible medical instrumentation; (3) monitoring of,
and involvement in development of, emerging, accessible healthcare
technologies; and (4) development of design guidelines for accessible
medical instrumentation and model policies for healthcare service
delivery.
Rehabilitation Engineering Research Center on Telecommunication Access
Gregg C. Vanderheiden, Ph.D. (Trace); Judy Harkins, Ph.D. (Gallaudet
University), University of Wisconsin/Madison, Madison, WI; Project
Number: 1435; Start Date: October 1, 2004; Length: 60 months.
Abstract: The focus of this RERC is on advancing accessibility and
usability in existing and emerging telecommunications products for
people with all types of disabilities. Telecommunications accessibility
is addressed along all three of its major dimensions: user interface,
transmission (including digitization, compression, etc.), and modality
translation services (relay services, gateways, etc.). Research and
development projects cover three areas: (1) development of tools,
techniques, and performance-based measures that can be used to evaluate
current and evolving telecommunication strategies including visual
communication and cognitive access; (2) solving the problems faced by
individuals using hearing aids or cochlear implants with digital phones
(including development of tools that users can employ to match
appropriate hearing technologies with telecommunication technologies);
and (3) improving access to emerging telecommunications for people with
visual, hearing, physical, and cognitive disabilities' particularly
digital and IP-based systems including emergency communication. The
RERC looks at advances that have both short- and long-term outcomes
related to assistive technologies (AT), interoperability, and universal
design of telecommunications. In addition, the RERC provides technical
assistance to government, industry, and consumers, training for
industry, and education for new researchers in this field. The RERC is
a collaboration of the Trace Center at the University of Wisconsin and
the Technology Access Program at Gallaudet University.
Rehabilitation Engineering Research Center on Universal Interface and
Information Technology Access
Gregg C. Vanderheiden, Ph.D., University of Wisconsin/Madison, Madison,
WI; Project Number: 486; Start Date: October 1, 2003; Length: 60
months.
Abstract: The focus of this RERC is on both access to information
(e.g., content) in its various forms, as well as access to interfaces
used within content and by electronic technologies in general. The
research and development program is carefully designed to provide an
interwoven set of projects that together advance accessibility and
usability in a fashion that takes into account, and supports, the full
range of access strategies used by manufacturers and people with
disabilities. These strategies range from enhancing the design of
mainstream products that can be used by individuals with different
ability sets to enhancing the ability of users to deal with the
information and interfaces as they encounter them. Key to these
projects are the development of new models and approaches for
characterization of the functional requirements of current and future
interfaces, and a better understanding of the type, diversity, and
similarity of functional limitations across etiologies and
disabilities. Research activities include: model generation and initial
pilot studies for the characterization of interface requirements
(current and emerging) and cross-disability user abilities; abstract
user interfaces and human interface sockets; emerging technologies and
future research needs; and accessible real-time visual information
presentation in meetings and virtual meetings. Development projects
include: tools to facilitate the incorporation of cross-disability
interface features in public information technologies; tools to
facilitate AT-IT interoperability; server-based and ``virtual assistive
technology''; and support for national and international standards and
guidelines efforts.
national center for medical rehabilitation research (ncmrr) projects
list
------------------------------------------------------------------------
Project Number Description
------------------------------------------------------------------------
F31--Predoctoral Individual National
Research Service Award:
1F31HD053986-01........................ COWAN, RACHEL E
UNIVERSITY OF PITTSBURGH AT
PITTSBURGH
PREDOCTORAL FELLOWSHIPS FOR
STUDENTS WITH DISABILITIES
SHINOWARA, NANCY
5F31HD049319-02........................ AJIBOYE, ABIDEMI B
NORTHWESTERN UNIVERSITY
MINORITY PREDOCTORAL FELLOWSHIP
PROGRAM
QUATRANO, LOUIS A
5F31HD049326-02........................ JAGODNIK, KATHLEEN M
CASE WESTERN RESERVE UNIVERSITY
UPPER EXTREMITY CONTROL USING
REINFORCEMENT LEARNING
NITKIN, RALPH M
F32--Postdoctoral Individual National
Research Service Award:
3F32HD047099-02S1...................... LOVERING, RICHARD M.
UNIVERSITY OF MARYLAND BALT
PROF SCHOOL
THE ROLE OF CYTOKERATINS IN
SKELETAL MUSCLE INJURY
NITKIN, RALPH M
5F32HD049217-02........................ KLUZIK, JOANN
KENNEDY KRIEGER RESEARCH
INSTITUTE, INC.
LEARNING POSTURAL DYNAMICS IN A
NOVEL REACHING TASK
QUATRANO, LOUIS A
K01--Research Scientist Development
Award--Research & Training:
1K01HD049476-01A2...................... ZACKOWSKI, KATHLEEN
KENNEDY KRIEGER RESEARCH
INSTITUTE, INC.
MECHANISMS OF LOCOMOTOR
RECOVERY IN MULTIPLE SCLEROSIS
SHINOWARA, NANCY
1K01HD049593-01A1...................... PURSER, JAMA L
DUKE UNIVERSITY
CANDIDATE GENES AND
LONGITUDINAL DIABILITY
PHENOTYPES
NITKIN, RALPH M
1K01HD050369-01A1...................... MORTON, SUSANNE M
UNIVERSITY OF MARYLAND BALT
PROF SCHOOL
EFFECT OF CONTRALATERAL LEG ON
MOTOR OUTPUT POST STROKE
ANSEL, BETH
1K01HD050582-01A1...................... REISMAN, DARCY S
UNIVERSITY OF DELAWARE
LOCOMOTOR ADAPTATIONS FOLLOWING
STROKE
NITKIN, RALPH M
5K01HD042057-06........................ AGUILAR, GUILLERMO
UNIVERSITY OF CALIFORNIA
RIVERSIDE
PORT WINE STAIN TREATMENT FOR
INFANTS AND YOUNG CHILDREN
NITKIN, RALPH M
5K01HD042491-04........................ LUDEWIG, PAULA M
UNIVERSITY OF MINNESOTA TWIN
CITIES
BIOMECHANICALLY BASED SHOULDER
REHABILITATION STRATEGIES
NITKIN, RALPH M
5K01HD043352-04........................ SALSICH, GRETCHEN B
SAINT LOUIS UNIVERSITY
PATELLOFEMORAL PAIN:
TIBIOFEMORAL ROTATION
IMPAIRMENTS
NITKIN, RALPH M
5K01HD045293-03........................ MURPHY, SUSAN L
UNIVERSITY OF MICHIGAN AT ANN
ARBOR
CLINICAL STRATEGIES TO REDUCE
OSTEOARTHRITIS DISABILITY
NITKIN, RALPH M
5K01HD046602-02........................ KALPAKJIAN, CLAIRE ZABELLE
UNIVERSITY OF MICHIGAN AT ANN
ARBOR
MENOPAUSAL TRANSITION IN WOMEN
WITH SPINAL CORD INJURY
NITKIN, RALPH M
5K01HD046682-02........................ OSTIR, GLENN V
UNIVERSITY OF TEXAS MEDICAL BR
GALVESTON
ASSESSING QUALITY OF LIFE FOR
REHABILITATION PATIENTS
QUATRANO, LOUIS A
5K01HD047148-02........................ QUANEY, BARBARA M
UNIVERSITY OF KANSAS MEDICAL
CENTER
MOTOR PERFORMANCE AND CORTICAL
CHANGES IN CHRONIC STROKE
NITKIN, RALPH M
5K01HD047669-02........................ LANG, CATHERINE E
WASHINGTON UNIVERSITY
MECHANISMS UNDERLYING LOSS OF
HAND FUNCTION AFTER STROKE
ANSEL, BETH
5K01HD048437-02........................ EARHART, GAMMON M
WASHINGTON UNIVERSITY
PARKINSONIAN GAIT DISORDERS:
MECHANISMS AND TREATMENT
NITKIN, RALPH M
K02--Research Scientist Development
Award--Research:
5K02HD044099-04........................ YEATES, KEITH O
CHILDREN'S RESEARCH INSTITUTE
OUTCOMES OF TRAUMATIC BRAIN
INJURY IN CHILDREN
QUATRANO, LOUIS A
5K02HD045354-03........................ HALEY, STEPHEN M
BOSTON UNIVERSITY
COMPUTER ADAPTIVE TESTING OF
FUNCTIONAL STATUS
QUATRANO, LOUIS A
7K02HD045354-04........................ HALEY, STEPHEN M
BOSTON UNIVERSITY MEDICAL
CAMPUS
COMPUTER ADAPTIVE TESTING OF
FUNCTIONAL STATUS
QUATRANO, LOUIS A
K08--Clinical Investigator Award:
1K08HD049459-01A2...................... SNOW, LEANN
UNIVERSITY OF MINNESOTA TWIN
CITIES
SKELETAL MUSCLE PLASTICITY POST-
STROKE
NITKIN, RALPH M
1K08HD049616-01A2...................... EVANS, MELISSA C
VIRGINIA COMMONWEALTH
UNIVERSITY
ARTERIAL CELL SIGNALING IN
VASODILATORY SHOCK.
NICHOLSON, CAROL E
1K08HD051609-01A1...................... FAIRCHILD, KAREN D
UNIVERSITY OF VIRGINIA
CHARLOTTESVILLE
HYPOTHERMIA ENHANCES
INFLAMMATORY CYTOKINE
EXPRESSION VIA NF-KAPPA B
NICHOLSON, CAROL E
1K08HD052619-01........................ BURNS, ANTHONY S
THOMAS JEFFERSON UNIVERSITY
THE LOWER MOTOR NEURON & SPINAL
CORD INJURY: IMPLICATIONS FOR
REHABILITATION
NITKIN, RALPH M
1K08HD052885-01........................ SHEW, STEPHEN BRIAN
UNIVERSITY OF CALIFORNIA LOS
ANGELES
EFFECT OF CYSTEINE ON
GLUTATHIONE PRODUCTION IN
CRITICALLY ILL NEONATES
NITKIN, RALPH M
5K08HD044558-03........................ DE PLAEN, ISABELLE G
CHILDREN'S MEMORIAL HOSPITAL
(CHICAGO)
MECHANISMS OF ACUTE BOWEL
INJURY ROLE OF NF-KB
NICHOLSON, CAROL E
K12--Physician Scientist Award
(Program):
2K12HD001097-11........................ WHYTE, JOHN
MOSS REHABILITATION HOSPITAL
REHABILITATION MEDICINE
SCIENTIST TRAINING (RMST)
PROGRAM
NITKIN, RALPH M
5K12HD047349-03........................ DEAN, JONATHAN MICHAEL
UNIVERSITY OF UTAH
PEDIATRIC CRITICAL CARE
SCIENTIST DEVELOPMENT PROGRAM
NICHOLSON, CAROL E
K23--Mentored Patient-Oriented
Research Devel Award:
1K23HD049472-01A1...................... RAGHAVAN, PREETI
MOUNT SINAI SCHOOL OF MEDICINE
OF NYU
INTERHEMISPHERIC TRANSFER OF
GRASP CONTROL AFTER STROKE
ANSEL, BETH
1K23HD049552-01A2...................... VARGUS-ADAMS, JILDA N
CHILDREN'S HOSPITAL MED CTR
(CINCINNATI)
TOWARDS IMPROVED CLINICAL
TRIALS IN CEREBRAL PALSY
NICHOLSON, CAROL E
5K23HD041040-05........................ KEENAN, HEATHER T
UNIVERSITY OF UTAH
OUTCOMES OF TRAUMATIC BRAIN
INJURY
NICHOLSON, CAROL E
5K23HD042014-05........................ TRAUTNER, BARBARA W
BAYLOR COLLEGE OF MEDICINE
E. COLI FOR PREVENTION OF
CATHETER UTI IN SCI PATIENTS
NITKIN, RALPH M
5K23HD042128-04........................ LENGENFELDER, JEAN
KESSLER MEDICAL REHAB RES &
EDUC CORP
USING FMRI TO IDENTIFY ENCODING
DEFICITS IN TBI
NITKIN, RALPH M
5K23HD042702-04........................ CHEN, CHRISTINE C
NEW YORK UNIVERSITY
MEASURING HAND FUNCTION--
DEVELOPMENT OF OUTCOME MEASURE
QUATRANO, LOUIS A
5K23HD043843-04........................ BERGER, RACHEL P
CHILDREN'S HOSP PITTSBURGH/UPMC
HLTH SYS
USING BIOCHEMICAL MARKERS TO
DETECT ABUSIVE HEAD TRAUMA
NICHOLSON, CAROL E
5K23HD044425-04........................ SCHAECHTER, JUDITH DIANE
MASSACHUSETTS GENERAL HOSPITAL
FMRI AND TMS OF MOTOR RECOVERY
AFTER HEMIPARETIC STROKE
NITKIN, RALPH M
5K23HD044632-04........................ VAVILALA, MONICA S
UNIVERSITY OF WASHINGTON
HEMODYNAMICS AND OUTCOME IN
PEDIATRIC BRAIN INJURY
NICHOLSON, CAROL E
5K23HD046489-03........................ WATSON, R SCOTT
UNIVERSITY OF PITTSBURGH AT
PITTSBURGH
CONSEQUENCES OF SURVIVING
CRITICAL ILLNESS IN CHILDHOOLD
NICHOLSON, CAROL E
5K23HD046690-02........................ WALZ, NICOLAY C
CHILDREN'S HOSPITAL MED CTR
(CINCINNATI)
SOCIAL DEVELOPMENT FOLLOWING
PRESCHOOL BRAIN INJURY
NITKIN, RALPH M
5K23HD047634-03........................ MORRIS, MARILYN C
COLUMBIA UNIVERSITY HEALTH
SCIENCES
EXCEPTION FROM INFORMED CONSENT
IN PEDIATRICS
NICHOLSON, CAROL E
5K23HD048637-02........................ MARINO, BRADLEY S
CHILDREN'S HOSPITAL OF
PHILADELPHIA
TESTING THE PEDIATRIC CARDIAC
QUALITY OF LIFE INVENTORY
NICHOLSON, CAROL E
5K23HD048817-02........................ ZUPPA, ATHENA F
CHILDREN'S HOSPITAL OF
PHILADELPHIA
IMPROVING DRUG DEVELOPMENT FOR
THE CRITICALLY ILL CHILD
NICHOLSON, CAROL E
K24--Midcareer Investigator Awd in
Patient-Oriented Res:
5K24HD041504-04........................ STEVENSON, RICHARD D
UNIVERSITY OF VIRGINIA
CHARLOTTESVILLE
GROWTH AND PHYSICAL MATURATION
IN CEREBRAL PALSY
NITKIN, RALPH M
5K24HD043819-03........................ CAMPAGNOLO, DENISE I
ST. JOSEPH'S HOSPITAL AND
MEDICAL CENTER
HEALTH AND IMMUNITY FOLLOWING
SPINAL CORD INJURY
NITKIN, RALPH M
K25--Mentored Quantitative Research
Career Development:
1K25HD048643-01A1...................... MONSON, KENNETH L
UNIVERSITY OF CALIFORNIA SAN
FRANCISCO
VASCULAR MECHANOTRANSDUCTION IN
TRAUMATIC BRAIN INJURY
NICHOLSON, CAROL E
5K25HD043993-02........................ ERIM, ZEYNEP
REHABILITATION INSTITUTE OF
CHICAGO
IMPAIRED MOTOR UNIT CONTROL IN
BRAIN AND SPINAL INJURY
NITKIN, RALPH M
5K25HD044720-04........................ PERREAULT, ERIC J
NORTHWESTERN UNIVERSITY
REFLEX CONTROL OF MULTI-JOINT
MECHANICS FOLLOWING STROKE
NITKIN, RALPH M
5K25HD047194-02........................ STERGIOU, NICK
UNIVERSITY OF NEBRASKA OMAHA
NONLINEAR ANALYSIS OF POSTURAL
FUNCTION IN INFANTS
NICHOLSON, CAROL E
P01--Research Program Projects:
5P01HD033988-10........................ JENSEN, MARK P
UNIVERSITY OF WASHINGTON
MANAGEMENT OF CHRONIC PAIN IN
REHABILITATION MEDICINE
QUATRANO, LOUIS A
R01--Research Project:
1R01AR052113-01A1...................... WEINSTEIN, STUART L
UNIVERSITY OF IOWA
BRACING IN ADOLESCENT
IDIOPATHIC SCOLIOSIS (BRAIST)
SHINOWARA, NANCY
1R01HD046570-01A2...................... MOSSBERG, KURT A
UNIVERSITY OF TEXAS MEDICAL BR
GALVESTON
PHYSICAL WORK CAPACITY AFTER
TRAUMATIC BRAIN INJURY
ANSEL, BETH
1R01HD047242-01A2...................... MCALLISTER, THOMAS W
DARTMOUTH COLLEGE
RCT METHYLPHENIDATE & MEMORY/
ATTENTION TRAINING IN TBI
ANSEL, BETH
1R01HD047516-01A2...................... ISKANDAR, BERMANS
UNIVERSITY OF WISCONSIN MADISON
FOLIC ACID ENHANCES REPAIR
MECHANISM IN THE ADULT CNS
SHINOWARA, NANCY
1R01HD047709-01A2...................... VAN DILLEN, LINDA
WASHINGTON UNIVERSITY
CLASSIFICATION--DIRECTED
TREATMENT OF LOW BACK PAIN
SHINOWARA, NANCY
1R01HD047761-01A2...................... CHENG, MEI-FANG
RUTGERS, THE STATE UNIV OF NJ-
NEWARK
BRAIN DAMAGE AND RECOVERY OF
FUNCTION IN THE ADULT SYSTEM
ANSEL, BETH
1R01HD048741-01A2...................... BASTIAN, AMY J.
KENNEDY KRIEGER RESEARCH
INSTITUTE, INC.
HUMAN LOCOMOTOR PLASTICITY IN
HEALTH AND DISEASE
ANSEL, BETH
1R01HD048946-01A2...................... YEATES, KEITH
CHILDREN'S RESEARCH INSTITUTE
SOCIAL OUTCOMES IN PEDIATRIC
TRAUMATIC BRAIN INJURY
ANSEL, BETH
1R01HD049471-01A2...................... SUMAN, OSCAR E
UNIVERSITY OF TEXAS MEDICAL BR
GALVESTON
EXERCISE AND QUALITY OF LIFE IN
SEVERELY BURNED CHILDREN
NICHOLSON, CAROL E
1R01HD049774-01A2...................... MULROY, SARA J
LOS AMIGOS RESEARCH/EDUCATION
INSTITUTE
SHOULDER PAIN IN SCI: A
LONGITUDINAL STUDY
SHINOWARA, NANCY
1R01HD051844-01A1...................... PROTAS, ELIZABETH J
UNIVERSITY OF TEXAS MEDICAL BR
GALVESTON
GAIT AND STEP TRAINING TO
PREVENT FALLS IN PARKINSON'S
DISEASE
SHINOWARA, NANCY
1R01HD052127-01........................ CRISCO, JOSEPH J
RHODE ISLAND HOSPITAL
(PROVIDENCE, RI)
3-D MULTI-ARTICULAR MODELS OF
THE CARPUS
SHINOWARA, NANCY
2R01HD032943-06A2...................... DILLER, LEONARD
NEW YORK UNIVERSITY SCHOOL OF
MEDICINE
PROBLEM-SOLVING TREATMENT/ADULT/
ACQUIRED BRAIN DAMAGE
QUATRANO, LOUIS A
2R01HD037433-05A1...................... CAVANAGH, PETER R
CLEVELAND CLINIC LERNER COL/MED-
CWRU
DESIGN CRITERIA FOR THERAPEUTIC
FOOTWARE IN DIABETES
QUATRANO, LOUIS A
2R01HD037985-05........................ SNYDER-MACKLER, LYNN
UNIVERSITY OF DELAWARE
DYNAMIC STABILITY OF THE ACL
DEFICIENT KNEE
SHINOWARA, NANCY
2R01HD040289-05A1...................... BASTIAN, AMY J
KENNEDY KRIEGER RESEARCH
INSTITUTE, INC.
MECHANISMS AND REHABILITATION
OF CEREBELLAR ATAXIA
NITKIN, RALPH M
3R01HD034273-10S1...................... TAUB, EDWARD
UNIVERSITY OF ALABAMA AT
BIRMINGHAM
A TREATMENT FOR EXCESS MOTOR
DISABILITY IN THE AGED
ANSEL, BETH
3R01HD045798-03S2...................... CHIARAVALLOTI, NANCY D.
KESSLER MEDICAL REHAB RES &
EDUC CORP
IMPROVING LEARNING IN MS: A
RANDOMIZED CLINICAL TRIAL
QUATRANO, LOUIS A
3R01HD048628-01A1S1.................... FROEHLICH-GROBE, KATHERINE
UNIVERSITY OF KANSAS MEDICAL
CENTER
A RANDOMIZED EXERCISE TRIAL FOR
WHEELCHAIR USERS
QUATRANO, LOUIS A
5R01AR048781-06........................ AGARWAL, SUDHA
OHIO STATE UNIVERSITY
EXERCISE DRIVEN MOLECULAR
MECHANISMS OF JOINT REPAIR
NITKIN, RALPH M
5R01EB001672-04........................ WEIR, RICHARD FERGUS FFRENCH
NORTHWESTERN UNIVERSITY
MULTIFUNCTION PROSTHESIS
CONTROL USING IMPLANTED
SENSORS
SHINOWARA, NANCY
5R01HD030149-11........................ SIPSKI, MARCA L
UNIVERSITY OF ALABAMA AT
BIRMINGHAM
EFFECTS OF SCI ON FEMALE SEXUAL
RESPONSE
SHINOWARA, NANCY
5R01HD031476-08........................ KAUFMAN, KENTON R.
MAYO CLINIC COLL OF MEDICINE,
ROCHESTER
MICROSENSOR FOR INTRAMUSCULAR
PRESSURE MEASUREMENT
QUATRANO, LOUIS A
5R01HD032116-12........................ ALVAREZ-BUYLLA, ARTURO
UNIVERSITY OF CALIFORNIA SAN
FRANCISCO
ORIGINS OF NEW NEURONS AND GLIA
IN THE POSTNATAL BRAIN
NITKIN, RALPH M
5R01HD034273-11........................ TAUB, EDWARD
UNIVERSITY OF ALABAMA AT
BIRMINGHAM
A TREATMENT FOR EXCESS MOTOR
DISABILITY IN THE AGED
ANSEL, BETH
5R01HD035047-07........................ STUIFBERGEN, ALEXA K
UNIVERSITY OF TEXAS AUSTIN
HEALTH PROMOTION FOR WOMEN WITH
FIBROMYALGIA
QUATRANO, LOUIS A
5R01HD036019-13........................ FRIEDMAN, RHONDA B
GEORGETOWN UNIVERSITY
COGNITIVELY BASED TREATMENTS OF
ACQUIRED DYSLEXIAS
QUATRANO, LOUIS A
5R01HD036020-09........................ CHEN, XIANG YANG
WADSWORTH CENTER
SUPRASPINAL CONTROL OF SPINAL
CORD PLASTICITY
SHINOWARA, NANCY
5R01HD036895-07........................ MUELLER, MICHAEL J
WASHINGTON UNIVERSITY
VISUALIZING DIABETIC FEET TO
OPTIMIZE ORTHOTIC FITTING
QUATRANO, LOUIS A
5R01HD037661-05........................ RIVERA, PATRICIA A
UNIVERSITY OF ALABAMA AT
BIRMINGHAM
PROBLEM-SOLVING FOR CAREGIVERS
OF WOMEN W/ DISABILITIES
QUATRANO, LOUIS A
5R01HD037880-07........................ COLLINS, JAMES J
BOSTON UNIVERSITY
NONLINEAR DYNAMICS AND ENHANCED
SENSORIMOTOR FUNCTION
ANSEL, BETH
5R01HD038107-06........................ KRUPP, LAUREN B
STATE UNIVERSITY NEW YORK STONY
BROOK
INTERVENTIONS TO IMPROVE MEMORY
IN PATIENTS WITH MS
ANSEL, BETH
5R01HD038582-05........................ BUCHANAN, THOMAS S
UNIVERSITY OF DELAWARE
FES AND BIOMECHANICS: TREATING
MOVEMENT DISORDERS
QUATRANO, LOUIS A
5R01HD038878-06........................ LAWLOR, MARY C
UNIVERSITY OF SOUTHERN
CALIFORNIA
BOUNDARY CROSSINGS: RE-
SITUATING CULTURAL COMPETENCE
QUATRANO, LOUIS A
5R01HD040692-04........................ TAUB, EDWARD
UNIVERSITY OF ALABAMA AT
BIRMINGHAM
RANDOMIZED CONTROLLED TRIAL OF
PEDIATRIC CI THERAPY
NICHOLSON, CAROL E
5R01HD040909-04........................ HENRY, SHARON M
UNIVERSITY OF VERMONT & ST
AGRIC COLLEGE
MECHANISMS OF SPECIFIC TRUNK
EXERCISES IN LOW BACK PAIN
SHINOWARA, NANCY
5R01HD041055-05........................ SNYDER-MACKLER, LYNN
UNIVERSITY OF DELAWARE
NMES FOR OLDER INDIVIDUALS
AFTER TOTAL KNEE ARTHROPLASTY
SHINOWARA, NANCY
5R01HD041487-05........................ FIELD-FOTE, EDELLE C.
UNIVERSITY OF MIAMI-MEDICAL
SCHOOL
COMPARISON OF POST-SCI
LOCOMOTOR TRAINING TECHNIQUES
SHINOWARA, NANCY
5R01HD041490-04........................ BRIENZA, DAVID M.
UNIVERSITY OF PITTSBURGH AT
PITTSBURGH
RCT ON PREVENTING PRESSURE
ULCERS WITH SEAT CUSHIONS
QUATRANO, LOUIS A
5R01HD042141-05........................ GARSHICK, ERIC HARVARD
UNIVERSITY (MEDICAL SCHOOL)
RESPIRATORY FUNCTION AND
ILLNESS IN SPINAL CORD INJURY
SHINOWARA, NANCY
5R01HD042385-05........................ LEVINE, BRIAN T
ROTMAN RESEARCH INSTITUTE
THE NEUROANATOMY OF COGNITION
IN TRAUMATIC BRAIN INJURY
NITKIN, RALPH M
5R01HD042527-05........................ CLARK, JANE E.
UNIVERSITY OF MARYLAND COLLEGE
PK CAMPUS
ADAPTIVE SENSORIMOTOR CONTROL
IN CHILDREN WITH DCD
NICHOLSON, CAROL E
5R01HD042588-04........................ STINEMAN, MARGARET G
UNIVERSITY OF PENNSYLVANIA
DO AMPUTEES BENEFIT FROM
REHABILITATION SERVICES?
QUATRANO, LOUIS A
5R01HD042705-03........................ MARTIN, ANATOLE D
UNIVERSITY OF FLORIDA
RESPIRATORY MUSCLE TRAINING IN
VENTILATOR DEPENDENT PTS.
ANSEL, BETH
5R01HD042729-05........................ WADE, SHARI L
CHILDREN'S HOSPITAL MED CTR
(CINCINNATI)
CHILD AND FAMILY SEQUELAE OF
PRESCHOOL BRAIN INJURY
QUATRANO, LOUIS A
5R01HD042838-05........................ JENSEN, MARK P
UNIVERSITY OF WASHINGTON
REHABILITATION OF SPINAL CORD
INJURY-RELATED PAIN
SHINOWARA, NANCY
5R01HD043137-04........................ KUIKEN, TODD A
REHABILITATION INSTITUTE OF
CHICAGO
EMG PROPAGATION IN PLANAR
MUSCLES FOR PROSTHESIS CONTROL
QUATRANO, LOUIS A
5R01HD043249-03........................ LAZAR, RONALD M
COLUMBIA UNIVERSITY HEALTH
SCIENCES
NEUROCHEMICAL CHALLENGE IN
HUMAN STROKE RECOVERY
ANSEL, BETH
5R01HD043323-04........................ MOHR, DAVID C
NORTHERN CALIFORNIA INSTITUTE
RES & EDUC
A CONTROLLED TRIAL OF CBT FOR
MS INFLAMMATION
QUATRANO, LOUIS A
5R01HD043378-04........................ LYSACK, CATHERINE L
WAYNE STATE UNIVERSITY
COMMUNITY LIVING AFTER SPINAL
CORD INJURY
SHINOWARA, NANCY
5R01HD043499-05........................ LEWIS, CORA E
UNIVERSITY OF ALABAMA AT
BIRMINGHAM
LAXITY AND MALALIGNMENT IN A
LARGE COHORT STUDY OF OA
SHINOWARA, NANCY
5R01HD043500-05........................ SHARMA, LEENA
NORTHWESTERN UNIVERSITY
LAXITY AND MALALIGNMENT IN A
LARGE COHORT STUDY OF OA
SHINOWARA, NANCY
5R01HD043501-05........................ TORNER, JAMES C
UNIVERSITY OF IOWA
LAXITY AND MALALIGMENT IN A
LARGE COHORT STUDY OF OA
SHINOWARA, NANCY
5R01HD043502-05........................ NEVITT, MICHAEL C
UNIVERSITY OF CALIFORNIA SAN
FRANCISCO
LAXITY AND MALALIGNMENT IN A
LARGE COHORT STUDY OF OA
SHINOWARA, NANCY
5R01HD043770-04........................ SCHENKMAN, MARGARET L
UNIVERSITY OF COLORADO DENVER/
HSC AURORA
EXERCISE, PHYSICAL FUNCTION,
AND PARKINSON'S DISEASE
SHINOWARA, NANCY
5R01HD043859-03........................ LEE, SAMUEL C
UNIVERSITY OF DELAWARE
STRENGTH TRAINING USING NMES
FOR CHILDREN WITH CP
NICHOLSON, CAROL E
5R01HD043943-03........................ DAROUICHE, RABIH O
BAYLOR COLLEGE OF MEDICINE
PREVENTION OF UTI IN PERSONS
WITH SPINAL CORD INJURY
SHINOWARA, NANCY
5R01HD043988-04........................ HAPP, MARY E
UNIVERSITY OF PITTSBURGH AT
PITTSBURGH
IMPROVING COMMUNICATION WITH
NONSPEAKING ICU PATIENTS
ANSEL, BETH
5R01HD043991-04........................ SCHWARTZ, MYRNA F
ALBERT EINSTEIN HEALTHCARE
NETWORK
AAC PROCESSING SUPPORT FOR
SPOKEN LANGUAGE IN APHASIA
ANSEL, BETH
5R01HD044295-04........................ ZHANG, LI-QUN
REHABILITATION INSTITUTE OF
CHICAGO
NEUROMECHANICAL CHANGES CAUSED
BY STROKE & STRETCHING
ANSEL, BETH
5R01HD044444-02........................ AW, MARY C
MCMASTER UNIVERSITY
FAMILY-CENTRED FUNCTIONAL
THERAPY FOR CEREBRAL PALSY
NICHOLSON, CAROL E
5R01HD044772-04........................ WOLF, WILLIAM A
UNIVERSITY OF ILLINOIS AT
CHICAGO
DRUG-ENHANCED REHABILITATION IN
RECOVERY FROM STROKE
NITKIN, RALPH M
5R01HD044775-04........................ PARENT, JACK M
UNIVERSITY OF MICHIGAN AT ANN
ARBOR
AUGMENTATION OF NEUROGENESIS
AND RECOVERY AFTER STROKE
NITKIN, RALPH M
5R01HD044816-02........................ CHAE, JOHN
CASE WESTERN RESERVE UNIVERSITY
FES FOR FOOT-DROP IN
HEMIPARESIS
ANSEL, BETH
5R01HD044830-04........................ EDGERTON, V. REGGIE
UNIVERSITY OF CALIFORNIA LOS
ANGELES
SEROTONERGIC FACILITATION &
ROBOTICS IN SPINAL LEARNING
NITKIN, RALPH M
5R01HD044831-04........................ HODGE, CHARLES J
UPSTATE MEDICAL UNIVERSITY
CORTICAL PLASTICITY: MECHANISMS
AND MODULATION
NITKIN, RALPH M
5R01HD045343-03........................ KREBS, HERMANO IGO
MASSACHUSETTS INSTITUTE OF
TECHNOLOGY
THE EFFECT OF PROXIMAL AND
DISTAL TRAINING ON STROKE REC
QUATRANO, LOUIS A
5R01HD045364-03........................ DUHAIME, ANN-CHRISTINE
DARTMOUTH COLLEGE
TRAUMA TO IMMATURE BRAIN:
RESPONSE REPAIR & TREATMENT
NICHOLSON, CAROL E
5R01HD045412-03........................ DUNLOP, DOROTHY D
NORTHWESTERN UNIVERSITY
FUNCTIONAL LIMITATION,
ARTHRITIS, DEPRESSION, & RACE
QUATRANO, LOUIS A
5R01HD045512-03........................ THOMAS, JAMES S
OHIO UNIVERSITY ATHENS
PREDICTING RECURRENCE OF LOW
BACK PAIN--STUDY #2 SHINOWARA,
NANCY
5R01HD045639-03........................ STERNAD, DAGMAR
PENNSYLVANIA STATE UNIVERSITY-
UNIV PARK
VARIABILITY AND STABILITY IN
SKILL ACQUISITION
SHINOWARA, NANCY
5R01HD045694-02........................ ALONSO, ESTELLA M
CHILDREN'S MEMORIAL HOSPITAL
(CHICAGO)
FUNCTIONAL OUTCOMES IN
PEDIATRIC LIVER
TRANSPLANTATION
NICHOLSON, CAROL E
5R01HD045751-02........................ LIGHT, KATHYE E
UNIVERSITY OF FLORIDA
EXAMINING PARAMETERS OF
CONSTRAINT-INDUCED THERAPY
ANSEL, BETH
5R01HD045798-03........................ CHIARAVALLOTI, NANCY D.
KESSLER MEDICAL REHAB RES &
EDUC CORP
IMPROVING LEARNING IN MS: A
RANDOMIZED CLINICAL TRIAL
QUATRANO, LOUIS A
5R01HD045834-03........................ GREENDALE, GAIL A
UNIVERSITY OF CALIFORNIA LOS
ANGELES
THE YOGA FOR HYPERKPHOSIS TRIAL
ANSEL, BETH
5R01HD045968-02........................ CLARK, ROBERT S.
UNIVERSITY OF PITTSBURGH AT
PITTSBURGH
GENDER-SPECIFIC TREATMENT OF
PEDIATRIC CARDIAC ARREST
NICHOLSON, CAROL E
5R01HD046442-02........................ ALEXANDER, MICHAEL P
BETH ISRAEL DEACONESS MEDICAL
CENTER
COGNITION AND FUNCTIONAL
RECOVERY AFTER CARDIAC ARREST
ANSEL, BETH
5R01HD046700-02........................ KLINE, ANTHONY E
UNIVERSITY OF PITTSBURGH AT
PITTSBURGH
NOVEL REHABILITATIVE APPROACHES
FOR RECOVERY FROM TBI
ANSEL, BETH
5R01HD046740-02........................ DOBKIN, BRUCE H
UNIVERSITY OF CALIFORNIA LOS
ANGELES
FMRI PREDICTOR MODEL FOR STROKE
LOCOMOTOR REHABILITATION
QUATRANO, LOUIS A
5R01HD046774-03........................ MURRAY, WENDY M
PALO ALTO INSTITUTE FOR RES &
EDU, INC.
BIOMECHANICAL MODELING OF
TENDON TRANSFER IN TETRAPLEGIA
QUATRANO, LOUIS A
5R01HD046814-03........................ DELP, SCOTT L
STANFORD UNIVERSITY
SIMULATION-BASED TREATMENT
PLANNING FOR GAIT DISORDERS
QUATRANO, LOUIS A
5R01HD046820-03........................ KAUTZ, STEVEN A
UNIVERSITY OF FLORIDA
INTERMUSCULAR COORDINATION OF
HEMIPARETIC WALKING
QUATRANO, LOUIS A
5R01HD046922-03........................ TING, LENA H
GEORGIA INSTITUTE OF TECHNOLOGY
NEUROMECHANICAL MODELING OF
POSTURAL RESPONSES
QUATRANO, LOUIS A
5R01HD047447-02........................ MOORE, JASON H.
DARTMOUTH COLLEGE
GENETICS BASIS OF TRAUMA
RECOVERY
NITKIN, RALPH M
5R01HD047569-02........................ DEWALD, JULIUS P
NORTHWESTERN UNIVERSITY
THE ROLE OF THE CORTEX IN
DISCOORDINATION AFTER STROKE
ANSEL, BETH
5R01HD048051-03........................ VANDENBORNE, KRISTA H
UNIVERSITY OF FLORIDA
MOLECULAR SIGNATURES OF MUSCLE
REHABILITATION
NITKIN, RALPH M
5R01HD048162-03........................ WAGNER, AMY K
UNIVERSITY OF PITTSBURGH AT
PITTSBURGH
DOPAMINE GENETIC VARIANTS
MODULATING RECOVERY AFTER TBI
NITKIN, RALPH M
5R01HD048176-03........................ MCALLISTER, THOMAS
DARTMOUTH COLLEGE
ROLE OF CANDIDATE ALLELES IN
COGNITIVE OUTCOME AFTER TBI
NITKIN, RALPH M
5R01HD048179-03........................ DIAZ-ARRASTIA, RAMON R
UNIVERSITY OF TEXAS SW MED CTR/
DALLAS
GENETIC FACTORS IN OUTCOME FROM
TRAUMATIC BRAIN INJURY
NITKIN, RALPH M
5R01HD048501-02........................ LIEBER, RICHARD L
UNIVERSITY OF CALIFORNIA SAN
DIEGO
DIRECT DETERMINATION OF LOWER
EXTREMITY OF MUSCLE DESIGN
SHINOWARA, NANCY
5R01HD048628-02........................ FROEHLICH-GROBE, KATHERINE
UNIVERSITY OF KANSAS LAWRENCE
A RANDOMIZED EXERCISE TRIAL FOR
WHEELCHAIR USERS
QUATRANO, LOUIS A
5R01HD048781-02........................ AN, KAI-NAN
MAYO CLINIC COLL OF MEDICINE,
ROCHESTER
BIOMECHANICS OF WHEELCHAIR
PROPULSION
SHINOWARA, NANCY
5R01HD048924-02........................ OSTRY, DAVID J
MC GILL UNIVERSITY
MOTOR CONTROL OF HUMAN ARM
STIFFNESS
NITKIN, RALPH M
5R01HD049773-02........................ ABBAS, JAMES J
ARIZONA STATE UNIVERSITY
ADAPTIVE ELECTRICAL STIMULATION
FOR LOCOMOTOR RETRAINING
SHINOWARA, NANCY
5R01HD049777-02........................ CHAE, JOHN
CASE WESTERN RESERVE UNIVERSITY
ELECTRICAL STIMULATION FOR
UPPER LIMB RECOVERY IN STROKE
ANSEL, BETH
5R01HD050385-02........................ DAHLQUIST, LYNNDA M
UNIVERSITY OF MARYLAND BALT
PROF SCHOOL
VIRTUAL REALITY AND ACUTE PAIN
MANAGEMENT FOR CHILDREN
QUATRANO, LOUIS A
5R01HD052891-02........................ RIMMER, JAMES H
UNIVERSITY OF ILLINOIS AT
CHICAGO
BUILDING HEALTH EMPOWERMENT
ZONES FOR PEOPLE WITH
DISABILITIES
QUATRANO, LOUIS A
5R01NS050506-02........................ DUNCAN, PAMELA W.
UNIVERSITY OF FLORIDA
LOCOMOTOR EXPERIENCE APPLIED
POST-STROKE (LEAPS)
NITKIN, RALPH M
7R01EB001672-05........................ WEIR, RICHARD FERGUS FFRENCH
REHABILITATION INSTITUTE OF
CHICAGO
MULTIFUNCTION PROSTHESIS
CONTROL USING IMPLANTED
SENSORS
SHINOWARA, NANCY
R03--Small Research Grants:
1R03HD044534-01A2...................... CAURAUGH, JAMES H
UNIVERSITY OF FLORIDA
SUBACUTE STROKE RECOVERY:
BIMANUAL COORDINATION TRAINING
ANSEL, BETH
1R03HD049408-01A1...................... SAWAKI, LUMY
WAKE FOREST UNIVERSITY, HEALTH
SCIENCES
DRIVING NEUROPLASTICITY WITH
NERVE STIMULATION AND MODIFIED
CIT
NITKIN, RALPH M
1R03HD049735-01A1...................... BONINGER, MICHAEL L
UNIVERSITY OF PITTSBURGH AT
PITTSBURGH
WHEELCHAIR PROPULSION TRAINING
SHINOWARA, NANCY
1R03HD049885-01A1...................... CLENDANIEL, RICHARD A
DUKE UNIVERSITY
COMPENSATORY MECHANISMS
FOLLOWING VESTIBULAR LOSS
ANSEL, BETH
1R03HD050530-01A1...................... MODLESKY, CHRISTOPHER M
UNIVERSITY OF DELAWARE
VITAMIN K AND BONE IN CHILDREN
WITH CEREBRAL PALSY
NITKIN, RALPH M
1R03HD050532-01A1...................... SHARKEY, NEIL A
PENNSYLVANIA STATE UNIVERSITY-
UNIV PARK
AN OBJECTIVE EVALUATION OF
SEGMENTED FOOT MODELS
SHINOWARA, NANCY
1R03HD051717-01A1...................... CHEN, YUYING
UNIVERSITY OF ALABAMA AT
BIRMINGHAM
INTERVENTION ON WEIGHT CONTROL
OF PERSONS:SPINAL INJURY
QUATRANO, LOUIS A
1R03HD051825-01........................ KRAMER, ANDREW M
UNIVERSITY OF COLORADO DENVER/
HSC AURORA
TWO-YEAR OUTCOMES OF OLDER
PERSONS WITH STROKE
ANSEL, BETH
1R03HD053135-01........................ HILLSTROM, HOWARD J
HOSPITAL FOR SPECIAL SURGERY
DEVELOPMENT OF A GEOMETRIC
FOREFOOT MODEL: A TOOL FOR
CLINICAL DECISION MAKING
SHINOWARA, NANCY
1R03HD053163-01A1...................... BOYD, LARA A
UNIVERSITY OF KANSAS MEDICAL
CENTER
COMPENSATORY BRAIN ACTIVATION
AFTER STROKE
NITKIN, RALPH M
5R03HD046930-02........................ STEFANATOS, GERRY A.
ALBERT EINSTEIN HEALTHCARE
NETWORK
NEUROPHYSIOLOGICAL EFFECTS OF
AMPHETAMINE APHASIA
ANSEL, BETH
5R03HD048457-02........................ BOGNER, JENNIFER A
OHIO STATE UNIVERSITY
SELF-REGULATION IN CO-OCCURRING
TBI AND SUBSTANCE ABUSE
ANSEL, BETH
5R03HD048465-02........................ COOPER, RORY A
UNIVERSITY OF PITTSBURGH AT
PITTSBURGH
ADVANCED 3D CONTROL TECHNIQUES
FOR POWERED WHEELCHAIRS
SHINOWARA, NANCY
5R03HD048481-02........................ JARIC, SLOBODAN
UNIVERSITY OF DELAWARE
HAND FUNCTION IN MULTIPLE
SCLEROSIS
QUATRANO, LOUIS A
5R03HD050591-02........................ SCHWEIGHOFER, NICOLAS
UNIVERSITY OF SOUTHERN
CALIFORNIA
TASK PRACTICE SCHEDULES TO
ENHANCE RECOVERY AFTER STROKE
ANSEL, BETH
7R03HD053163-02........................ BOYD, LARA A
UNIVERSITY OF BRITISH COLUMBIA
COMPENSATORY BRAIN ACTIVATION
AFTER STROKE
NITKIN, RALPH M
R13--Conferences:
1R13HD048157-01A1...................... CREPEAU, ELIZABETH B
MERICAN OCCUPATIONAL THERAPY
ASSN
HABITS AND REHABILITATION:
PROMOTING PARTICIPATION
QUATRANO, LOUIS A
1R13NS056636-01........................ GRIGGS, ROBERT C
UNIVERSITY OF ROCHESTER
NOVEL TREATMENT FOR MUSCLE
DISEASE: FUELING THE PIPELINE
AND FINDING THE PRODUCT
SHINOWARA, NANCY
2R13DC006295-04........................ TOMPKINS, CONNIE A
UNIVERSITY OF PITTSBURGH AT
PITTSBURGH
RESEARCH SYMPOSIUM IN CLINICAL
APHASIOLOGY
ANSEL, BETH
R21--Exploratory/Developmental Grants:
1R21HD046628-01A2...................... HEISS, DEBORAH G
OHIO STATE UNIVERSITY
EFFICACY OF THERAPEUTIC
EXERCISE FOR RECURRENT BACK
PAIN
QUATRANO, LOUIS A
1R21HD047405-01A1...................... MATSUOKA, YOKY
UNIVERSITY OF WASHINGTON
ROBOTIC STROKE REHABILITATION
USING PERCEPTUAL FEEDBACK
ANSEL, BETH
1R21HD047756-01A2...................... WHITALL, JILL
UNIVERSITY OF MARYLAND BALT
PROF SCHOOL
BILATERAL AND UNILATERAL
TRAINING IN CHRONIC STROKE
ANSEL, BETH
1R21HD049842-01A2...................... KIPKE, DARYL R
UNIVERSITY OF MICHIGAN AT ANN
ARBOR
CORTICAL CONTROL USING MULTIPLE
SIGNAL MODALITIES
NITKIN, RALPH M
1R21HD050457-01A1...................... ARUIN, ALEXANDER S
UNIVERSITY OF ILLINOIS AT
CHICAGO
COMPELLED BODY WEIGHT SHIFT
THERAPY IN INDIVIDUALS WITH
STROKE RELATED
SHINOWARA, NANCY
1R21HD050717-01A1...................... RIVIERE, CAMERON N
CARNEGIE-MELLON UNIVERSITY
NONLINEAR FILTERING OF ATHETOID
MOVEMENT
SHINOWARA, NANCY
1R21HD051861-01........................ CERMAK, SHARON
BOSTON UNIVERSITY
PHYSICAL ACTIVITY, FITNESS AND
OBESITY IN CHILDREN WITH
COORDINATION DISORDERS
SHINOWARA, NANCY
1R21HD051988-01........................ SUGAR, THOMAS G
ARIZONA STATE UNIVERSITY
ROBOTIC SPRING ANKLE FOR GAIT
ASSISTANCE
SHINOWARA, NANCY
1R21HD052197-01A1...................... LEWIS, GWYN N
REHABILITATION INSTITUTE OF
CHICAGO
THE UTILITY OF RTMS TO ENHANCE
HAND FUNCTION IN STROKE
NITKIN, RALPH M
1R21HD053669-01........................ ENGLISH, ARTHUR W
EMORY UNIVERSITY
PROTEOGLYCAN DEGRADATION AND
FUNCTIONAL RECOVERY AFTER
PERIPHERAL NERVE INJURY
NITKIN, RALPH M
5R21HD045841-03........................ WARE, JOHN E
UALITYMETRIC, INC.
DYNAMIC ASSESSMENT OF PEDIATRIC
HEALTH AND FUNCTIONING
QUATRANO, LOUIS A
5R21HD045855-03........................ GRAY, DAVID B
WASHINGTON UNIVERSITY
REHABILITATION OUTCOMES,
COMMUNITY PARTICIPATION AND
ICF
QUATRANO, LOUIS A
5R21HD045864-03........................ SATISH, USHA G
UPSTATE MEDICAL UNIVERSITY
SIMULATION BASED MAPPING OF
DECISION MAKING IN CHILDREN
QUATRANO, LOUIS A
5R21HD045869-03........................ VELOZO, CRAIG A
UNIVERSITY OF FLORIDA
DEVELOPING A COMPUTER ADAPTIVE
TBI COGNITIVE MEASURE
QUATRANO, LOUIS A
5R21HD045873-03........................ BONATO, PAOLO
SPAULDING REHABILITATION
HOSPITAL
FIELD MEASURES OF FUNCTIONAL
TASKS FOR CIT INTERVENTION
QUATRANO, LOUIS A
5R21HD045881-03........................ STINEMAN, MARGARET G
UNIVERSITY OF PENNSYLVANIA
VIRTUAL RECOVERY SIMULATION
QUATRANO, LOUIS A
5R21HD045882-03........................ YORKSTON, KATHRYN M
UNIVERSITY OF WASHINGTON
DEVELOPING A SCORE OF
COMMUNICATIVE PARTICIPATION
QUATRANO, LOUIS A
5R21HD045887-03........................ RILEY, BARTH B
UNIVERSITY OF ILLINOIS AT
CHICAGO
A DYNAMIC DISABILITY SPECIFIC
PHYSICAL ACTIVITY SCALE
QUATRANO, LOUIS A
5R21HD046540-02........................ LEVY, CHARLES E
UNIVERSITY OF FLORIDA
THE IMPACT OF POWER-ASSIST
WHEELCHAIR ON QOL
QUATRANO, LOUIS A
5R21HD046844-02........................ MAKHSOUS, MOHSEN
REHABILITATION INSTITUTE OF
CHICAGO
PRESSURE RELIEF SYSTEM FOR
PREVENTING PRESSURE ULCERS
QUATRANO, LOUIS A
5R21HD046876-02........................ HORNBY, T GEORGE
REHABILITATION INSTITUTE OF
CHICAGO
PHYSICAL AND PHARMACOLOGICAL
EFFECTS ON MOVEMENT IN SCI
SHINOWARA, NANCY
5R21HD046903-02........................ SAPIENZA, CHRISTINE M
UNIVERSITY OF FLORIDA
EXPIRATORY MUSCLE TRAINING IN
PATIENTS WITH PARKINSON'S
SHINOWARA, NANCY
5R21HD046938-02........................ MOSES, PAMELA A
UNIVERSITY OF CALIFORNIA SAN
DIEGO
WHITE MATTER DIFFUSION MRI IN
CHILDREN WITH EARLY STROKE
ANSEL, BETH
5R21HD047263-02........................ COHEN, LINDSEY L
GEORGIA STATE UNIVERSITY
AUTOMATED TRAINING FOR
PEDIATRIC PAIN MANAGEMENT
QUATRANO, LOUIS A
5R21HD047463-02........................ THOMAS, NEAL J
PENNSYLVANIA STATE UNIV HERSHEY
MED CTR
SURFACTANT PROTEIN VARIANTS IN
PEDIATRIC LUNG INJURY
NICHOLSON, CAROL E
5R21HD047643-02........................ HERMANN, GERLINDA E
LSU PENNINGTON BIOMEDICAL
RESEARCH CTR
THROMBIN AND CNS: GASTRIC
DYSFUNCTION AFTER HEAD TRAUMA
ANSEL, BETH
5R21HD047754-02........................ FRIED-OKEN, MELANIE
OREGON HEALTH & SCIENCE
UNIVERSITY
AAC REHABILITATION FOR
CONVERSATION IN DEMENTIA
ANSEL, BETH
5R21HD048566-02........................ VALERO-CUEVAS, FRANCISCO J
CORNELL UNIVERSITY ITHACA
DEVELOPING A CLINICALLY USEFUL
MEASURE OF DYNAMIC PINCH
QUATRANO, LOUIS A
5R21HD048742-02........................ MORGAN, DON W
MIDDLE TENNESSEE STATE
UNIVERSITY
UNDERWATER TREADMILL TRAINING
IN SPASTIC DIPLEGIA
SHINOWARA, NANCY
5R21HD048944-02........................ DAMIANO, DIANE L
WASHINGTON UNIVERSITY
EFFECTS OF MOTOR-ASSISTED
CYCLING IN CEREBRAL PALSY
SHINOWARA, NANCY
5R21HD048972-02........................ HASTINGS, MARY K
WASHINGTON UNIVERSITY
BOTULINUM TOXIN EFFECTS ON
PLANTAR ULCER RECURRENCE
QUATRANO, LOUIS A
5R21HD049019-03........................ WITTENBERG, GEORGE
UNIVERSITY OF MARYLAND BALT
PROF SCHOOL
MOTOR-FUNCTIONAL NEUROANATOMY
IN CEREBRAL PALSY
NICHOLSON, CAROL E
5R21HD049020-02........................ GIORDANO, LOUIS A
DUKE UNIVERSITY
BEHAVIOR ANALYSIS OF CHRONIC
LOW BACK PAIN
QUATRANO, LOUIS A
5R21HD049135-02........................ CHASE, THERESA M
CRAIG HOSPITAL
MASSAGE TO REDUCE PAIN IN
PEOPLE WITH SPINAL CORD INJURY
SHINOWARA, NANCY
5R21HD049662-02........................ VAN DEN BOGERT, ANTONIE J
CLEVELAND CLINIC LERNER COL/MED-
CWRU
INTELLIGENT CONTROL OF UPPER
EXTREMITY NEURAL PROSTHESES
QUATRANO, LOUIS A
5R21HD049832-02........................ VAVILALA, MONICA S
CHILDREN'S HOSPITAL AND REG
MEDICAL CTR
CEREBRAL EDEMA IN PEDIATRIC
DIABETIC KETOACIDOSIS
NICHOLSON, CAROL E
5R21HD049883-02........................ LEWIS, GWYN N
REHABILITATION INSTITUTE OF
CHICAGO
BILATERAL ACTIVATION IN UPPER-
LIMB STROKE REHABILITATION
ANSEL, BETH
5R21HD049893-02........................ WANG, JIONGJIONG
UNIVERSITY OF PENNSYLVANIA
HEMODYNAMIC NEUROIMAGING OF
PEDIATRIC STROKE
NICHOLSON, CAROL E
5R21HD050655-02........................ ODDSSON, LARS I E
BOSTON UNIVERSITY
TREATMENT OF MOTOR FUNCTION AND
BALANCE- A NEW TOOL
SHINOWARA, NANCY
5R21HD050707-02........................ MATHERN, GARY W
UNIVERSITY OF CALIFORNIA LOS
ANGELES
CORTICAL PLASTICITY AFTER
HEMISPHERECTOMY
NITKIN, RALPH M
7R21HD046938-03........................ MOSES, PAMELA A
SAN DIEGO STATE UNIVERSITY
WHITE MATTER DIFFUSION MRI IN
CHILDREN WITH EARLY STROKE
ANSEL, BETH
R24--Resource-Related Research
Projects:.
5R24HD050821-02........................ RYMER, WILLIAM Z
REHABILITATION INSTITUTE OF
CHICAGO
ENGINEERING FOR NEUROLOGIC
REHABILITATION
NITKIN, RALPH M
5R24HD050836-02........................ WHYTE, JOHN
ALBERT EINSTEIN HEALTHCARE
NETWORK
RESEARCH METHODS FOR COGNITIVE
REHABILITATION
NITKIN, RALPH M
5R24HD050837-02........................ LIEBER, RICHARD L
UNIVERSITY OF CALIFORNIA SAN
DIEGO
NATIONAL CENTER FOR MUSCLE
REHABILITATION RESEARCH
NITKIN, RALPH M
5R24HD050838-02........................ SELZER, MICHAEL E
UNIVERSITY OF PENNSYLVANIA
CENTER FOR EXPERIMENTAL
NEUROREHABILITATION TRAINING
NITKIN, RALPH M
5R24HD050845-02........................ BREGMAN, BARBARA S
GEORGETOWN UNIVERSITY
NATIONAL CAPITAL AREA
REHIBILIATION RESEARCH NETWORK
NITKIN, RALPH M
5R24HD050846-02........................ HOFFMAN, ERIC P
CHILDREN'S RESEARCH INSTITUTE
INTEGRATED MOLECULAR CORE FOR
REHABILITATION MEDICINE
NITKIN, RALPH M
R34--Clinical Trial Planning Grant:
1R34HD050531-01A1...................... MOLER, FRANK W
UNIVERSITY OF MICHIGAN AT ANN
ARBOR
PLANNING HYPOTHERMIA TRIAL FOR
PEDIATRIC CARDIAC ARREST
NICHOLSON, CAROL E
R37--Method to Extend Research in Time
(MERIT) Award:
5R37HD031550-25........................ GOSHGARIAN, HARRY G
WAYNE STATE UNIVERSITY
FUNCTIONAL PLASTICITY IN THE
MAMMALIAN SPINAL CORD
NITKIN, RALPH M
5R37HD037100-08........................ OLNEY, JOHN W
WASHINGTON UNIVERSITY
ACUTE BRAIN INJURY, MECHANISMS
AND CONSEQUENCES
NITKIN, RALPH M
R41--Small Business Technology Transfer
(STTR) Grants--Phase I:
1R41HD052318-01A1...................... HALEY, STEPHEN M
CRECARE, LLC
COMPUTER ADAPTIVE TESTING OF
PEDIATRIC SELF-CARE AND SOCIAL
FUNCTION
QUATRANO, LOUIS A
5R41HD047726-02........................ BARBOUR, RANDALL LOCKE
PHOTON MIGRATION TECHNOLOGIES
CORP
OPTICAL TOMOGRAPHY FOR
DIAGNOSIS OF NEC
NICHOLSON, CAROL E
5R41HD049224-02........................ RIMMER, JAMES H
EXERSTRIDER PRODUCTS, INC.
UNIVERSAL EXERCISE KITS FOR
MANUAL WHEELCHAIR USERS
SHINOWARA, NANCY
R42-- Small Business Technology
Transfer (STTR) Grants--Phase II:
4R42HD051240-02........................ PESHKIN, MICHAEL A
CHICAGO PT, LLC
DEVICE FOR OVERGROUND GAIT/
BALANCE TRAINING POST-STROKE
SHINOWARA, NANCY
5R42HD043664-03........................ ZHANG, LI-QUN
REHABTEK, LLC
DEVELOPING AN INTELLIGENT &
PORTABLE STRETCHING DEVICE
SHINOWARA, NANCY
R43--Small Business Innovation Research
Grants (SBIR)--Phase I:
1R43HD047493-01A2...................... PITKIN, MARK R
POLY-ORTH INTERNATIONAL
NEW IIZAROV TECHNIQUE FOR
PEDIATRIC CRITICAL CARE
NICHOLSON, CAROL E
1R43HD049211-01A1...................... GOLDIE, JAMES H
INFOSCITEX CORPORATION
ROBOTICALLY-AIDED HAND
REHABILITATION
QUATRANO, LOUIS A
1R43HD049960-01A1...................... THROPE, GEOFFREY B
NDI MEDICAL, LLC
NEUROSTIMULATION FOR ELBOW
EXTENSION IN TETRAPLEGIA
SHINOWARA, NANCY
1R43HD050006-01A1...................... HARTMAN, ERIC C
CUSTOMKYNETICS, INC.
STIMULATION-AUGMENTED EXERCISE
AND NEUROMOTOR THERAPY
SHINOWARA, NANCY
1R43HD051014-01A1...................... GREELEY, HAROLD P
CREARE, INC.
PHYSICAL ACTIVITY MONITOR
QUATRANO, LOUIS A
1R43HD052310-01........................ SCHERER, MARCIA J
INSTITUTE/MATCHING PERSON &
TECHNOLOGY
IMPROVING MATCH OF PERSON/
ASSISTIVE COGNITIVE TECHNOLOGY
QUATRANO, LOUIS A
1R43HD052311-01........................ RICHTER, W MARK
MAX MOBILITY
OPTIPUSH WHEELCHAIR TRAINING
SYSTEM
SHINOWARA, NANCY
1R43HD052313-01........................ VEATCH, BRADLEY D
ADA TECHNOLOGIES, INC.
A BIOACTUATOR-DRIVEN ANKLE
DORSIFLEXOR UNIT
QUATRANO, LOUIS A
1R43HD052327-01........................ TOWNSEND, WILLIAM T
BARRETT TECHNOLOGY, INC.
ADVANCED ROBOTIC DEVICE FOR THE
SAFE REHABILITATION FOR STROKE
AND BRAIN INJURY
QUATRANO, LOUIS A
1R43HD053196-01........................ HERMES, MATTHEW E
TURBO WHEELCHAIR COMPANY, INC.
LIGHTWEIGHT, COMPLIANT MANUAL
WHEELCHAIR HIGH-TONE CHILD
SHINOWARA, NANCY
1R43HD053211-01........................ SCHAEFER, PHILIP R
VORTANT TECHNOLOGIES, LLC
A LIP READING CLICK DEVICE FOR
DISABLED COMPUTER USERS
SHINOWARA, NANCY
1R43HD054091-01........................ VEATCH, BRADLEY D
ADA TECHNOLOGIES, INC.
A LOW-COST UPPER-EXTREMITY
PROSTHESIS FOR UNDER-SERVED
POPULATIONS
QUATRANO, LOUIS A
1R43HD054262-01........................ SELBIE, W. SCOTT
C-MOTION, INC.
ANALYTICAL TOOLS FOR OPTIMIZING
NEUROREHABILITATION OF GAIT
SHINOWARA, NANCY
1R43HD054313-01........................ EDELL, DAVID J
INNERSEA TECHNOLOGY
ULTRA-LOW-POWER WIRELESS
IMPLANT STIMULATOR FOR
PROSTHESIS SENSORY FEEDBACK
QUATRANO, LOUIS A
1R43HD055110-01A1...................... FLYNN, LOUIS L
LIGHTNING PACKS, LLC GENERATION
OF ELECTRICITY BY NORMAL HUMAN
MOVEMENT
SHINOWARA, NANCY
5R43HD044271-02........................ GREEN, STEVE C
GREEN TECHNOLOGIES, INC.
A MANUAL STANDUP WHEELCHAIR
QUATRANO, LOUIS A
5R43HD047071-02........................ AXELSON, PETER WILLIAM
BENEFICIAL DESIGNS, INC.
OPTIFIT WHEELCHAIR FITTING
SYSTEM
SHINOWARA, NANCY
5R43HD047086-02........................ GIUFFRIDA, JOSEPH P
LEVELAND MEDICAL DEVICES, INC.
ADAPATIVE WIRELESS COMPUTER
MOUSE FOR MOVEMENT DISORDERS
SHINOWARA, NANCY
5R43HD049251-02........................ MERZENICH, MICHAEL M
POSIT SCIENCE CORPORATION
BRAIN PLASTICITY BASED TRAINING
FOR FOCAL DYSTONIA
SHINOWARA, NANCY
5R43HD051061-02........................ RENSING, NOA M
MICROOPTICAL ENGINEERING
CORPORATION
VISIONKEY+: ADVANCED EYE
ACTIVATED KEYBOARD
QUATRANO, LOUIS A
8R43HD054291-02........................ RIFKIN, JEROME R
TENSEGRITY PROSTHETICS, INC.
TENSEGRITY FOOT WITH
COORDINATED JOINT MOTION
SHINOWARA, NANCY
R44--Small Business Innovation Research
Grants (SBIR)--Phase II:
1R44HD050047-01A1...................... TUEL, STEPHEN M
PHASE V PHARMACEUTICALS, INC.
TIZANIDINE FORMULATION FOR
SPASTICITY WITH DYSPHAGIA
QUATRANO, LOUIS A
1R44HD053176-01........................ JAKOBS, THOMAS
INVOTEK, INC.
RELIABLE/SAFE LASER POINTING-
PEOPLE LOCKED-IN SYNDROME
QUATRANO, LOUIS A
1R44HD054401-01........................ RICHTER, W MARK
MAX MOBILITY
ERGOCHAIR SMART MANUAL
WHEELCHAIR
SHINOWARA, NANCY
2R44HD037776-02A1...................... HAMILTON, PATRICK
S.E.P., LTD
AN AMBULATORY LORDOSIMETER FOR
POSTURE CONTROL
QUATRANO, LOUIS A
2R44HD040023-02A2...................... LOPRESTI, EDMUND F
AT SCIENCES
SMART WHEELCHAIR COMPONENT
SYSTEM
QUATRANO, LOUIS A
2R44HD042334-02........................ BENJAMIN, MALVERN J
RHEOMEDIX, INC.
PULMONARY AIRFLOW MONITOR IN
TRACHEOSTOMIZED CHILDREN
QUATRANO, LOUIS A
2R44HD046319-02........................ KLEDARAS, JOANNE B
PRAXIS, INC.
MONETARY EQUIVALENCE: READINESS
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QUATRANO, LOUIS A
2R44HD047044-02........................ JAKOBS, THOMAS
INVOTEK, INC.
SPEECH SUPPLEMENTED WORD
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QUATRANO, LOUIS A
2R44HD049205-02........................ KYLSTRA, BART
DAEDALUS WINGS, INC.
POWER PROPULSION ATTACHMENT FOR
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SHINOWARA, NANCY
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MEALTIME PARTNERS, INC.
ADD REGULATORY COMPLIANCE AND
COST (REV A)
QUATRANO, LOUIS A
5R44HD035793-06........................ MEGINNISS, STEVE M
MAGIC WHEELS, INC.
TWO-SPEED MANUAL WHEELCHAIR
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QUATRANO, LOUIS A
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THREE RIVERS HOLDINGS, LLC
DEVELOPMENT OF AN ERGONOMIC
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QUATRANO, LOUIS A
5R44HD041805-03........................ KOENEMAN, JAMES B
KINETIC MUSCLES, INC.
CLINICAL ASSESSMENT OF A MASSED
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SHINOWARA, NANCY
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CUSTOMKYNETICS, INC.
ADAPTIVE STIMULATOR FOR
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QUATRANO, LOUIS A
5R44HD042367-03........................ VAIDYANATHAN, RAVI
THINK-A-MOVE, LTD
AN EAR DEVICE ENABLING HANDS
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QUATRANO, LOUIS A
5R44HD042892-03........................ IRVINE, BLAIR
OREGON CENTER FOR APPLIED
SCIENCE, INC.
TRAINING PARENTS TO ADVOCATE
FOR STUDENTS WITH TBI
QUATRANO, LOUIS A
5R44HD043513-03........................ SEARS, HAROLD H
MOTION CONTROL, INC.
ELECTRIC HEAVY-DUTY WORK HAND
QUATRANO, LOUIS A
5R44HD043516-03........................ GREEN, STEVE C
GREEN TECHNOLOGIES, INC.
A MODAL RECIPROCATING PUSHRIM
DRIVE WHEELCHAIR
QUATRANO, LOUIS A
5R44HD043567-03........................ KYLSTRA, BART
DAEDALUS WINGS, INC.
MANUAL WHEELCHAIR UTILIZING
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SHINOWARA, NANCY
5R44HD044288-03........................ BEHRMANN, GREGORY P
EM PHOTONICS, INC.
FIBER OPTICAL MICRO-SENSOR FOR
MEASURING TENDON FORCES
QUATRANO, LOUIS A
5R44HD047119-03........................ BOONE, DAVID A
CYMA CORPORATION
COMPUTERIZED PROSTHETIC
ALIGNMENT SYSTEM (COMPAS)
QUATRANO, LOUIS A
5R44HD049252-03........................ TUEL, STEPHEN M
PHASE V PHARMACEUTICALS, INC.
BACLOFEN FORMULATION FOR
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QUATRANO, LOUIS A
5R44HD051157-03........................ GOODWIN, DIANNE M
BLUE SKY DESIGN, INC.
ACCESSIBLE MOUNTING AND
POSITIONING TECHNOLOGY
SHINOWARA, NANCY
T15--Continuing Education Training
Program:
1T15HD050255-01A1...................... BLACKMAN, JAMES A
UNIVERSITY OF VIRGINIA
CHARLOTTESVILLE
NIH GRANT PREP. WORKSHOPS FOR
REHABILITATION RESEARCH
NITKIN, RALPH M
T32--Institutional National Research
Service Award:
1T32HD049303-01A1...................... FINEMAN, JEFFREY R
UNIVERSITY OF CALIFORNIA SAN
FRANCISCO
RESEARCH TRAINING IN PEDIATRIC
CRITICAL CARE MEDICINE
NICHOLSON, CAROL E
1T32HD049350-01A1...................... LEVIN, HARVEY S
BAYLOR COLLEGE OF MEDICINE
MENTORED RESEARCH TRAINING IN
REHABILITATION SCIENCE
NITKIN, RALPH M
2T32HD007422-16........................ TATE, DENISE G
UNIVERSITY OF MICHIGAN AT ANN
ARBOR
U MICHIGAN MED REHABILITATION
RESEARCH TRAINING PROGRAM
NITKIN, RALPH M
2T32HD007539-06........................ OTTENBACHER, KENNETH J
UNIVERSITY OF TEXAS MEDICAL BR
GALVESTON
INTERDISCIPLINARY PREDOCTORAL
REHABILITATION RESEARCH
TRAINING
NITKIN, RALPH M
2T32HD040686-06A1...................... KOCHANEK, PATRICK M
UNIVERSITY OF PITTSBURGH AT
PITTSBURGH
PEDIATRIC NEUROINTENSIVE CARE
AND RESUSCITATION RESEARCH
NICHOLSON, CAROL E
5T32HD007414-14........................ JOHNSTON, MICHAEL V
KENNEDY KRIEGER RESEARCH
INSTITUTE, INC.
RESEARCH TRAINING IN BRAIN
INJURY REHABILITATION
NITKIN, RALPH M
5T32HD007418-15........................ RYMER, WILLIAM Z
NORTHWESTERN UNIVERSITY
PATHOPHYSIOLOGY AND
REHABILITATION OF NEURAL
DYSFUNCTION
NITKIN, RALPH M
5T32HD007425-15........................ SALCIDO, RICHARD
UNIVERSITY OF PENNSYLVANIA
RESEARCH TRAINING IN
NEUROLOGICAL REHABILITATION
NITKIN, RALPH M
5T32HD007434-14........................ MUELLER, MICHAEL J
WASHINGTON UNIVERSITY
DOCTORAL TRAINING PROGRAM IN
MOVEMENT SCIENCE
NITKIN, RALPH M
5T32HD007447-14........................ BASFORD, JEFFREY R
MAYO CLINIC COLL OF MEDICINE,
ROCHESTER
MAYO REHABILITATION RESEARCH
TRAINING CENTER
NITKIN, RALPH M
5T32HD007459-13........................ BREGMAN, BARBARA S
GEORGETOWN UNIVERSITY
TRAINING IN RECOVERY OF
FUNCTION AFTER CNS INJURY
NITKIN, RALPH M
5T32HD007490-09........................ BINDER-MACLEOD, STUART A.
UNIVERSITY OF DELAWARE
PT/PHD PREDOCTORAL TRAINING
PROGRAM
NITKIN, RALPH M
5T32HD041899-04........................ RODGERS, MARY M
UNIVERSITY OF MARYLAND BALT
PROF SCHOOL
ADVANCE REHABILITATION RESEARCH
TRAINING PROJECT
NITKIN, RALPH M
5T32HD043730-04........................ VANDENBORNE, KRISTA H
UNIVERSITY OF FLORIDA
TRAINING IN REHABILITATION AND
NEUROMUSCULAR PLASTICITY
NITKIN, RALPH M
U01--Research Project (Cooperative
Agreements):
3U01AR052171-02S1...................... AMTMANN, DAGMAR
UNIVERSITY OF WASHINGTON
UW CENTER ON OUTCOMES RESEARCH
IN REHABILITATION (RMI)
QUATRANO, LOUIS A
5U01AR052171-03........................ AMTMANN, DAGMAR
UNIVERSITY OF WASHINGTON
UW CENTER ON OUTCOMES RESEARCH
IN REHABILITATION(RMI)
QUATRANO, LOUIS A
5U01HD042652-04........................ DIAZ-ARRASTIA, RAMON R
UNIVERSITY OF TEXAS SW MED CTR/
DALLAS
TRAUMATIC BRAIN INJURY CLINICAL
TRIALS NETWORK
ANSEL, BETH
5U01HD042653-05........................ TEMKIN, NANCY R
UNIVERSITY OF WASHINGTON
TRAUMATIC BRAIN INJURY CLINICAL
TRIALS NETWORK
ANSEL, BETH
5U01HD042678-05........................ ZAFONTE, ROSS
UNIVERSITY OF PITTSBURGH AT
PITTSBURGH
TRAUMATIC BRAIN INJURY CLINICAL
TRIALS NETWORK
ANSEL, BETH
5U01HD042686-04........................ TIMMONS, SHELLY D
UNIVERSITY OF TENNESSEE HEALTH
SCI CTR
TRAUMATIC BRAIN INJURY CLINICAL
TRIALS NETWORK
ANSEL, BETH
5U01HD042687-05........................ NOVACK, THOMAS
UNIVERSITY OF ALABAMA AT
BIRMINGHAM
TRAUMATIC BRAIN INJURY CLINICAL
TRIALS NETWORK
ANSEL, BETH
5U01HD042689-05........................ BULLOCK, M ROSS
VIRGINIA COMMONWEALTH
UNIVERSITY
TRAUMATIC BRAIN INJURY CLINICAL
TRIALS NETWORK
ANSEL, BETH
5U01HD042736-04........................ EISENBERG, HOWARD M.
UNIVERSITY OF MARYLAND BALT
PROF SCHOOL
TRAUMATIC BRAIN INJURY CLINICAL
TRIALS NETWORK
ANSEL, BETH
5U01HD042738-05........................ JALLO, JACK
TEMPLE UNIVERSITY
TRAUMATIC BRAIN INJURY CLINICAL
TRIALS NETWORK
ANSEL, BETH
5U01HD042823-05........................ RIEDEWALD, WILLIAM T
COLUMBIA UNIVERSITY
HEALTH SCIENCES
TRAUMATIC BRAIN INJURY CLINICAL
TRIALS NETWORK-DCC
ANSEL, BETH
5U01HD049934-02........................ DEAN, JONATHAN MICHAEL
UNIVERSITY OF UTAH
CENTRAL DATA MANAGEMENT AND
COORDINATING CENTER
NICHOLSON, CAROL E
U10--Cooperative Clinical Research
(Cooperative Agreements):
5U10HD049945-02........................ ZIMMERMAN, JERRY J
CHILDREN'S HOSPITAL AND REG
MEDICAL CTR
1ST TIER DRUGS+THEOPHYLLINE IN
PEDIATRIC SEVERE ASTHMA
NICHOLSON, CAROL E
5U10HD049981-02........................ POLLACK, MURRAY M
CHILDREN'S RESEARCH INSTITUTE
ASSESSMENT AND PREDICTION OF
FUNCTIONAL STATUS
NICHOLSON, CAROL E
5U10HD049983-02........................ CARCILLO, JOSEPH A
UNIVERSITY OF PITTSBURGH AT
PITTSBURGH
METOCLOPRAMIDE PREVENTS PICU
NOSOCOMIAL INFECTION
NICHOLSON, CAROL E
5U10HD050009-02........................ ANAND, KANWALJEET S
ARKANSAS CHILDREN'S HOSPITAL
RES INST
PCCM NETWORK: REMEDIES FOR
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NICHOLSON, CAROL E
5U10HD050012-02........................ NEWTH, CHRISTOPHER J
CHILDREN'S HOSPITAL LOS ANGELES
PHYSIOLOGICALLY GUIDED
VENTILATOR STRATEGIES IN
CHILDREN
NICHOLSON, CAROL E
5U10HD050096-02........................ MEERT, KATHLEEN L
WAYNE STATE UNIVERSITY
COLLABORATIVE PEDIATRIC
CRITICAL CARE RESEARCH NETWORK
NICHOLSON, CAROLE
U13--Conference (Cooperative
Agreement):
5U13NS043180-05........................ SANGER, TERENCE D
STANFORD UNIVERSITY
NIH TASK FORCE ON CHILDHOOD
MOTOR DISORDERS
ANSEL, BETH
------------------------------------------------------------------------
Question 2. What would be the key components for a successful
collaboration with the VA?
Response. I recommend creating an enduring administrative structure
for ongoing collaboration. A Coordinating Council should be established
and staffed by the VA, and include representation from the DOD and the
organizations that represent the civilian rehabilitation hospitals and
the specialty of Physical Medicine and Rehabilitation. At a minimum,
the American Medical Rehabilitation Providers Association (AMRPA), the
American Hospital Association (AHA), the Federation of American
Hospitals (FAH), and the American Academy of Physical Medicine and
Rehabilitation (AAPM&R) should be invited to participate. The charge to
this Council should include the following:
<bullet> Work collaboratively to create a short-term and long-term
sustainable plan for how to allow the civilian provider community to
augment, strengthen, and complement the DOD and VA in providing medical
rehabilitation services (both inpatient and outpatient) to current and
former members of the armed services who qualify.
<bullet> Establish attributes and criteria to define rehabilitation
service delivery capacity (both qualitatively and quantitatively) for
specific disabling conditions, including, but not limited to:
<all> TBI
<all> SCI
<all> Amputation
<all> Burn
<all> Low Vision
<all> Hearing Impairment
<all> Post Traumatic Stress Disorder (PTSD)
<bullet> Determine the DOD, VA, and civilian care delivery settings
that are capable of providing services that meet or exceed these
criteria.
<bullet> Establish the relative locations of VA and civilian
programs, with the hope of identifying locations where collaboration
might be possible, and where the civilian sector could broaden access
for servicemembers.
<bullet> Define which areas of the VA and DOD need enhancement
through cooperating with civilian providers.
<bullet> Create or adopt a qualifying and contracting methodology
to allow civilian providers to contract with the DOD and/or VA.
<bullet> Identify the appropriate payment methods and practices to
utilize the civilian providers and provide adequate and timely
reimbursement for the services they offer.
<bullet> Establish the research questions and activities needed to
better understand the rehabilitation care delivery needs of these
servicemembers, and how to improve the efficiency and effectiveness of
the collaboration to achieving more successful outcomes.
<bullet> Oversee the implementation and operation of the
collaboration and refine it over time as appropriate.
Question 3. What difference in care and support do you anticipate
in serving returning veterans, rather than the Institute's existing
patients? Would your facilities have the expertise to also deal with
TBI, PTSD, or other unique health and readjustment issues for returning
veterans?
Response. Kessler Institute for Rehabilitation currently provides
comprehensive care and treatment for patients who are identical to
those being injured in our country's service. Our multidisciplinary
team includes:
<bullet> Physiatrists and Neurologists, who are expert at
diagnosing and treating the behavioral, cognitive and medical problems
these patients face.
<bullet> Neuropsychologists to assess, treat and support brain
injured patients and their families.
<bullet> Rehabilitation Psychologists, who can assess and treat
PTSD, substance abuse, adjustment to disability and the other common
psychological problems associated with health catastrophes.
<bullet> Rehabilitation Nurses, who can manage wound care, provide
bladder and bowel retraining, contribute to restoring function for real
world application, and provide patient and family education.
<bullet> Physical Therapists, Occupational Therapists, Speech
Language Pathologists and many other disciplines to effectively address
the range of physical and functional problems individuals face, as well
as goals to be achieved.
<bullet> Prosthetists and Orthotists to provide prostheses and
orthoses, including C-legs and other state-of-the-art devices.
<bullet> Rehabilitation Technologists to provide sophisticated
power wheelchairs, electronic environmental control systems, computer
access and other high tech devices that are needed by the most severely
injured and disabled.
Our West Orange campus has the current capacity to care for 48 TBI
inpatients and 48 SCI inpatients at any given time. Our outpatient
programs include therapies by all the disciplines mentioned above, as
well as a specialized Cognitive Rehabilitation Program that provides
individually tailored, multidisciplinary care for patients with TBI
scheduled a few times a week or as intensively as a day hospital,
depending on needs and goals. We offer similar services at our Saddle
Brook and Chester campuses as well.
We operate two additional programs of special interest: a program
for Severe Disorders of Consciousness (SDOC), and a dual-diagnosis
program for patients with concomitant TBI and SCI. The SDOC program
offers highly innovative and advanced evaluative and treatment services
for the most severely brain injured patients. This program is having a
remarkable impact on many or our patients. Our dual-diagnosis program
is also capable of handling other combinations of disabling conditions,
such as amputations that occur in addition to a TBI.
In addition to the clinical services we offer, we serve as a major
research and educational center for TBI, SCI and other rehabilitation
conditions. For example, with our partners, the Kessler Medical
Rehabilitation Research and Education Center (KMRREC) and UMDNJ-New
Jersey Medical School, we are funded as an SCI Model System. We have
been previously funded as a TBI Model System, and are currently
reapplying for that award as well.
These and other resources make the medical and rehabilitation care
we would provide to injured servicemembers excellent, goal directed,
and efficient. What would differ from our typical patient experience
are the insurance, funding and administrative aspects of working with
the VA or military under whatever contract mechanisms that would be
developed. We do have experience in working with TRICARE already, so
that would not be an issue.
I suspect that all these matters would be favorably accommodated if
there were an identified case manager from the VA or DOD, who would be
actively engaged and involved with us in a way that would enable the
economic and other administrative needs of the patients and their
families to be dealt with efficiently and effectively.
I am sure that the capabilities I described of Kessler Institute
for Rehabilitation are also available at a number of other centers that
have become specialized in managing the most complexly injured and
disabled patients. From my conversations with the leadership of many
rehabilitation programs, I am certain a strong enthusiasm exists to
offer their capacity to enhance access to care by our servicemembers.
Chairman Akaka. Thank you very much, Dr. Gans.
I want to tell you that your testimonies have been
excellent.
Director Duckworth, you testified that the prosthetics
service at Walter Reed is better than VA care, and, Dr. Gans,
your Institute is consistently ranked as one of the top
rehabilitation facilities in this country. I would like for
both of you to comment. What do we need to do to make VA care
the very best?
Ms. Duckworth. Senator Akaka, I think for those programs
that are already in existence in the VA, the polytrauma
centers, the blind rehabilitation program, the spinal cord
injury centers that are already state-of-the-art certainly
maintain, but also give them more funds so that they can really
reach out and do the job that they are trying to do.
For those programs where the VA is behind, such as the
prosthetics program, to try to help them catch up at this
point, it is too late into the war; it is too late into the
game. And you would negatively affect the new amputees who are
within their first 2 years of amputation. Allow those new
patients to go back to Walter Reed or to go to a civilian
prosthetist. That way you also maintain the quality of care for
the veterans already in the system. I cannot really speak as
much about the rehabilitation programs, but I know that the
rehab program, the spinal rehab, the blind rehab centers, and
the polytrauma centers in the VA are certainly state-of-the-art
and capable of doing the job.
Chairman Akaka. Dr. Gans?
Dr. Gans. I think coordination and cooperation is the key.
Very happily, we had the opportunity to have a conversation
with the New Jersey VA just last week regarding the traumatic
brain injury patients and are now starting discussions about
how we can be useful as a service delivery supplement to their
resources and how we can cooperate. Many of the VAs are medical
school facilities. They are training centers. We have all sorts
of interactions between the civilian community and the VA. And
we can build upon those strengths to provide educational
programs, to provide resources, identify where the private
sector has knowledge and expertise that could be tapped by the
VA to help build and strengthen programs, where it simply does
not make sense because the need is to transient, and to let the
VA contract out with the private sector for specialized
services. The high-tech kinds of prosthetic devices that are
being discussed are really very high-end, very complicated,
sophisticated devices. The military experience has dramatically
expanded our knowledge and ability about how to use these
devices in the civilian sector as well, and it is a small
enough number in the size of the entire health care community
that that kind of expertise really does need to be concentrated
in centers of excellence that should be shared resources.
Chairman Akaka. It seems as though VA is geared toward
older patients. We are concerned that younger veterans may be
having difficulties as a minority within the VA system.
Mr. Pruden and Director Duckworth, have you seen
improvement in the ability of VA health care providers to treat
younger patients returning from Iraq and Afghanistan? And do
you think that VA, on the whole, is now ready to manage this
younger population? Mr. Pruden?
Mr. Pruden. Sir, I believe that the VA is doing a lot and
making a lot of steps toward that goal, but they are not there
yet.
I had an infection last spring due to a bacteria that I
picked up in Iraq called acinetobacter, and when I came back in
2003, there had not been very many cases of this at all in the
United States, this particular strain. It has become very
common now to see it in blast injuries coming back from Iraq
and Afghanistan. Infectious Disease at Walter Reed is very
familiar with this problem. But when I went to Infectious
Disease at the local VA, they had no idea what I was talking
about. So I brought them printouts from CDC and showed them
what was going on. Long story short, I wound up coming back to
Walter Reed and having treatment here for that, a regimen of
antibiotics. But the Infectious Disease chief down there said,
``If you had stayed here, we would have had to amputate your
foot.'' That was my other leg, and I definitely wanted to keep
that one.
You know, they are not quite there yet. I think there is a
lot of information that needs to be grasped, specifically with
regards to diseases endemic to Central Asia and Iraq, where
these guys are going to be picking up things, also with regards
to the types of blast injuries and, again, TBI, PTSD, those
kinds of things. They need to be more educated and prepared for
us.
Chairman Akaka. Thank you.
Director?
Ms. Duckworth. Mr. Chairman, I think in some programs the
VA certainly has state-of-the-art capability, and I would like
to cite again this spinal cord injury center in Hines and the
blind rehab center. Those are, in fact, two places where Walter
Reed sends its patients for rehabilitation, so those are
certainly up there. Those other programs with information
sharing such as learning about these bacteria--I also suffer. I
think about 90 percent of us now have this bacteria. That is an
easy information-sharing kind of thing. But other things,
traumatic brain injury, some of these things, the high-tech
prosthetics, we do not have the time to play catch-up, not when
the care is needed now with the traumatic brain injury
patients. As Mrs. Mettie was saying, you lose ground so quickly
that you may never regain if they do not access that high-
quality care right away. And in those instances, I think a
cooperative agreement between DOD, VA, and civilian
practitioners, civilian providers, is critical because when you
lose ground that early into your injury, you may never regain
that ground back.
Chairman Akaka. Thank you. My time in the first round has
expired.
Senator Craig?
Senator Craig. Well, thank you very much, Mr. Chairman.
I am a little overwhelmed with all of your testimony, and I
say that in the positive sense, as someone who, in cooperation
with this Chairman and he with me when I was Chairman, has
spent a great deal of time attempting to make VA better, and we
think we have.
You are saying something that I began to recognize a year
ago, and it resulted in the introduction of legislation, S.
815, a few weeks ago. And I think, Tammy, you have said it
well. There is no time to catch up. There is a huge private
sector capability out there that is needed now, today. It was
needed yesterday. And all of you are speaking to that.
But here is our problem. I did not condemn. I simply
offered some degree of observation as to what the Ranking
Member here Patty Murray is doing. That is catch-up money. And
it may not be well used today in a way that it should be used.
And I do not say that in any condemnation of the VA at all.
What we have is a wonderful health care delivery system
within the VA, but you are speaking of its limitations. And yet
every organization that is out there in support of it is also
in defense of it. And when I offer a way for those who cannot
get the public service, the VA service they need, a way to gain
the private sector access, I am roundly criticized as someone
who wants to tear down the current system or not adequately
fund it. I think quite the opposite.
Your response to an opportunity to have those who are
eligible for VA health care to also have, if they are service-
connected disabled, access to selected and/or other private
facilities, you have all given testimony to it at this moment.
Your reaction to a piece of legislation that would qualify a
veteran or an active servicemember for that kind of potential
health care.
Ms. Duckworth. Senator Craig, I certainly would support
that; however, not at the expense of more funds going to the
VA. I have to respectfully disagree with you that what Senator
Murray is proposing is catch-up money. It is money that is
badly needed in the system. At the same time as that funding,
we also need access to private practices. As I mentioned
earlier, we have a large generation of Vietnam veterans
entering the system that we need to be ready to care for them
as well. So we need both. The VA is already underfunded, and to
take away those funds that they need to do their job so that
they can support those state-of-the-art facilities--the blind
rehab, the spinal cord, taking care of our older veterans--you
know, it is not an either/or. We need both.
Senator Craig. Well, you know, I appreciate that. Please go
ahead, Jonathan.
Mr. Pruden. Sir, I do not know if I have a good answer for
you. I agree with Major Duckworth's statement that the VA needs
more funds to adequately address the needs of veterans
currently.
I think great care has to be taken. Like you said, if they
leave in droves, we will know something else. And I do not
believe they will leave in droves, either, but if they do--or
there is a significant number that leave, I guess my question
is: What happens to VA if a significant number do choose the
private practice? That would be a concern for me.
Senator Craig. Yes, please.
Ms. Mettie. An observation that I have made throughout this
past year is for the acute care----
Senator Craig. Just a moment. Mr. Chairman, do we know what
the noise source is here?
We are either under construction or destruction.
[Laughter.]
Senator Craig. Please continue, and hover close to that
mike.
Ms. Mettie. All right. Something I have noticed in the
acute care is that if there could be an established place for
these soldiers to go to in the beginning, instead of saying you
have got to go to a nursing home, we do not know what progress
they are going to make, and those first 6, 8 months, they make
tremendous progress. My son had leaps and bounds in April and
May. He was tapping his toe to music. He would raise his hand
to anybody who walked in the room. We lost it all in May.
Nobody knows why.
So we look at that part and say we need more aggressive
therapy in the beginning, but also, now that we are a year down
the road, I look at Palo Alto and previously was told, well, we
are filled, you cannot get in. Over half of the beds are empty
because they do not have adequate staff. They do not have
enough therapists to work with the patients. So how are we
going to help all of these TBI-injured soldiers if they do not
have the staff to work with them?
Senator Craig. Well said. Thank you.
Doctor Gans?
Dr. Gans. Senator, as I mentioned earlier, the VA is a very
important health care delivery system for those who use it, and
it is also an important resource for medical education, for
research, and I certainly would not want to see that harmed in
any way. I think that my perspective is that we can augment and
complement, and for those unique specialized and relatively
rare things where there are pockets of capacity and expertise
outside of the VA, where it does not really make sense to re-
establish a large capacity that is going to be only transiently
needed, it makes much more sense to just collaborate and
cooperate. My perspective is let's come up with a plan. Let's
have the leadership of the civilian community and the veterans
and the military plan together and identify those areas where
augmentation and complementation make sense, plan together
where it makes sense for the private sector to help support the
development of the reinvigorated larger capacity within the
system, but just have it make sense and serve the common good.
Senator Craig. Well, Doctor, I think you have said it
better than I did. I appreciate that very much.
My time is up. Thank you, Mr. Chairman.
Chairman Akaka. Thank you very much, Senator Craig.
Senator Murray?
Senator Murray. Thank you very much, and thank you so much
to all of you for really excellent testimony and helping us
wade through these challenges that we have in front of us. I do
not think any of us disagree that once you get into the VA
system, you get good care, and it is critical that we get to
the point, Tammy, where we are not having to play catch-up,
because these men and women are there, they are coming back,
and we have to have the capacity to do that.
There is a system in place that does allow us to contract
out within the VA for care. Oftentimes, people do not know
about it. Nobody has told them. The paperwork gets lost. And I
think we have to be very careful not to just say, well, abandon
the VA, we will go to private care, when, Dr. Gans, you very
precisely told us that that kind of capacity is already a
problem within the private system of care, and we do not want
to pass people off. They get stuck like Denise did at a private
facility that was not capable of dealing with them, and the
paperwork gets behind, and the payments do not get there, and
we do not support the resources that are needed for private
care. So there are a lot of dangerous red flags as we look at
how we deal with this.
But our responsibility here is to make sure that the VA has
the capacity it needs for the men and women who are coming back
today and for our older veterans as they are, as you precisely
told us, now really getting into our VA system as well.
Tammy, I wanted to ask you in particular--you mentioned
testing, and I am deeply concerned that we are not within the
military testing soldiers for--I think you said PTSD and TBI in
particular. You mentioned several other things. Ninety percent
of our soldiers are coming back with this bacterial infection.
Is that being tested for?
Ms. Duckworth. You get the infection, and it is very
quickly you are known to have it. It is just in the soil over
there, and it gets in your wounds. About 90 percent--I think
that was the number I was given when I was going through Walter
Reed--who come through with open wounds have this infection in
some form or another.
Senator Murray. And were you recommending that they get
tested when they went into the VA? Or were you recommending
that they get tested before they were separated from the
military?
Ms. Duckworth. I think that when they enter the VA system,
there needs to be another round of comprehensive testing for
traumatic brain injury, post-traumatic stress disorder, vision,
and hearing, because as scientists found out, a lot of the
polytrauma patients who come through, they are tested for
everything else, and sometimes they forgot--``Oh, maybe we need
to check their vision.'' And they are finding that 60 percent
of the patients who have entered Hines polytrauma center have
had some form of functional vision loss that was not----
Senator Murray. But wouldn't it make sense that they get
tested before they leave the military--if we get an adequate
system that makes sure that our military and our VA records are
copacetic, another challenge. But wouldn't it make sense that
they get that testing before they are ever separated?
Ms. Duckworth. Yes, ma'am, but for some of these injuries,
TBI and post-traumatic stress disorder, they may not reoccur
for a while, PTSD especially, and this is where the 2-year rule
is so vitally important, because with the vets of this war, if
they do not get care for war-related illnesses for 2 years----
Senator Murray. Well, some of our veterans who are
returning when they get separated, if they are not tested, may
not think of going to a VA facility and may show up, you know,
6 months later not being able to remember.
Ms. Duckworth. They should be tested both times.
Mr. Pruden. Can I comment on that, ma'am? I have been
working with some guys over the past few years who came back
from 3rd ID with me. Several of them were injured in 2005. One
of these young men lost both his legs. The guy beside him was
killed. He was unconscious for an unknown amount of time. I
believe he suffers from PTSD and has substance abuse issues,
which I think may have masked some of the symptoms of TBI. His
mother tells me he cannot remember anything he used to be able
to remember.
It was not until 2 weeks ago now, after almost 2 years in
DOD care, that we got him into the VA system, enrolled, and he
is just now--we just got him back up to Walter Reed to be
screened for a TBI just 2 weeks ago.
Senator Murray. After 2 years of being out?
Mr. Pruden. Yes, ma'am, and yet he was unconscious--and it
was after I talked to him, I said, ``Do you think you might
have a TBI?'' And he said, ``Well, you know, I don't think so.
I am OK.'' And his Mom said, ``But you can't remember
anything.'' Sometimes soldiers are not willing or able to
understand what is going on with them, and especially if they
have a TBI and PTSD. And it takes someone coming along and
saying, ``Maybe we should screen you for this.''
Senator Murray. Yes. Mr. Chairman, I am going to have to
run to the floor. But I think part of what we do is mandatory
testing before they separate as well as when they enter the VA
because we are losing a lot of people out there. That is
critical.
Before I run, Denise, if you wanted to comment on that?
Ms. Mettie. I just wanted to interject something quickly.
My son spent 15 months in Iraq the first time. When he got
back, they did a quick PTSD test, and he suffered extreme PTSD.
They said they could not medicate him because he would not be
deployable again and that----
Senator Murray. If they medicated him, he would not be----
Ms. Mettie. If they medicated----
Senator Murray. So they did not because----
Ms. Mettie. No, and so he self-medicated by alcohol. He
could not sleep at night, and this was what he did for the
whole year until he was redeployed. And one of his comments,
``Well, you know, I won't drink anymore because there is no
alcohol over there.'' That needs to be addressed.
Senator Murray. And one last question for you, Denise. You
navigated this system and were an advocate on your own, it
sounds like, quite a bit of the time.
Ms. Mettie. Yes.
Senator Murray. Thank God your son had a family that was
able to be there. I am certain you have seen many people who do
not have a close family member who can----
Ms. Mettie. And that is what scares me. You know, there are
many members who are probably in nursing homes because they
have no one to be their advocate. I think these people in
particular need to be looked at again.
Senator Murray. Were there any VA case managers that worked
with you throughout this time?
Ms. Mettie. Yes.
[Laughter.]
Senator Murray. That does not sound positive. Do you want
to----
Ms. Mettie. I cannot say I received a lot of help.
Senator Murray. Well, Mr. Chairman, again, I want to thank
all of you, and I do have questions for the second panel. I
have to manage the supplemental on the floor, but I hope that
the VA and DOD officials who are testifying today will quickly
respond to our questions. You have heard what these witnesses
have had to say. We do not want any platitudes. We want to know
what real solutions are, and we want to be able to support them
from this Committee.
So thank you very much, Mr. Chairman.
Chairman Akaka. Thank you very much, Senator Murray.
Senator Burr?
Senator Burr. Thank you, Mr. Chairman.
I think we are all struck by the testimony--not surprised,
but we are struck in, as I think Senator Craig put it, a very
positive way. The challenge for us is that we all agree that we
need more money in the system. We all agree that we need to
look at the services provided, and that they need to represent
the cases that are walking in the door, but that we cannot
forget about that last generation that is walking through.
We all agree that we need to do much better on the health
IT, that records should follow individuals, whether they are at
Walter Reed or Bethesda, to the communities they go to and
potentially to the private sector stops that they make along
the way.
Jonathan, I will take one objection with something you
said. Over 50 is not old, OK?
[Laughter.]
Senator Burr. But our big challenge is to try to take
everything that you have presented to us that are personal
experiences, personal observations, and extrapolate that out to
the entire population and make it work. And I want to challenge
my colleagues here that I do not think this is a construct that
we can take and just put in legislative language and all of a
sudden mandate this, this, and this happens.
We recognized very early on in North Carolina that we were
going to have a bigger deployment of Guard and reservists in
this mission, and certainly we have seen it from every State.
One of the smartest things I think we did was that we started a
program at UNC-Chapel Hill to follow the deployments and the
returns of all these Guard and reservists, and to try to
accumulate the data in real time as we went along as to how we
do each one better the next time. How do we make the deployment
smoother? How do we make the return better? And I think
progressively we have changed that process.
And I would suggest to my colleagues that we need to look
at how we turn outside and ask an outside entity to look at the
VA, to look at Walter Reed and Bethesda, to look at the private
sector, and to try to figure out how we design this in a way
that we maximize the care that we provide.
Ms. Mettie, I wish I could tell you how we can take
individuals that may not have been as responsive as they should
have, who work within the VA, who maybe do not make the
individual assessments that they should, even with a persistent
parent or persistent spouse. I think all of us would hope that
it would work beautifully, and the fact is that we hear too
many stories where it does not, so we know we have still got a
tremendous amount of work to do.
But some of the things, maybe most of the things you have
talked about today, these are fixable, that we can integrate
them into a seamless process that does not distinguish between
public and private, that does not distinguish between this
location or that location, that maximizes the talents that we
have throughout the health care delivery system in this
country. It will take some effort on our part to do that in a
way that, quite frankly, it would work successfully and it
would protect the VA system, which I know many want to. I think
every Member of this Committee wants to.
Ms. Mettie, if there was one point in your process that you
sit there today and you say, ``If the decision had been
different here, we would be dealing with a different outcome,
possibly,'' what would that one point be?
Ms. Mettie. Oh, no doubt about it, that would be last April
when we transferred Evan to the private skilled nursing
facility. We were seeing tremendous progress at that time. He
was smiling. He was giving thumbs up. He was lifting and
raising his hands to command.
My feeling is, if he would have been in a VA facility that
had acute care, we would have seen progress continue. But as it
was, by the first or mid-May, he had developed five types of
infections from being in this facility for 3 weeks, and when he
was sent back to the VA, he had to recover from all of these
infections, and we lost everything.
I strongly feel that if he would have been taken better
care of at that point, we would see a different person today.
Senator Burr. It is my hope that our system will get better
at identifying those critical decision points for these
warriors that come back and for the families, and that we learn
from each one how to do it better in the future.
Mr. Chairman, if I could, I would like to go to Jonathan
for just a second, because I think, Jonathan, your recovery
probably mirrors to some degree, I think, what Senator Craig
was talking about. You were at Johns Hopkins receiving some
care. You were going back to Walter Reed for some things--or
was that your buddy that you were talking about?
Mr. Pruden. That was one of my soldiers.
Senator Burr. That was one of your soldiers.
Mr. Pruden. Yes, sir.
Senator Burr. You know, your question was: Why couldn't you
do multiple things at the same place? I think that is what
Senator Craig is getting at. Why can't we do multiple things?
And I think this fear that there is an attempt to lessen our
emphasis on the VA or on DOD hospital we have to get over if we
want to successfully try to create a pathway that fits every
soldier that comes back in the system. Unfortunately, your
pathway was a little bit different than your soldier's, and
Tammy's pathway was a little bit different than your pathway,
and certainly Evan's has been different than yours.
Each one is unique, and there is no doubt that when you
walk in an emergency room as a private citizen, there is a
triage person that makes an assessment of you and your symptoms
and a decision that is made hopefully by a group as to what
their treatment is going to be.
My fear is that we are not evaluating the patient for the
problem and try and determine what the best course for that
individual patient, that individual soldier, that individual
Marine that is coming back, that we are trying to fit them into
a system that we have already designed. And that makes
treatment bifurcated. It makes crucial points of decision not
make sense. And it changes, more importantly, outcomes.
I would only suggest to my colleagues, the only thing we
need to be concerned with is the outcome. Let's not be
concerned with how we get there. Let's try to raise our success
rate of the outcomes of these troops that come back with very
different injuries, very different circumstances, and let's
make sure that the outcome is more positive tomorrow.
I once again want to thank each of you.
Chairman Akaka. Thank you very much, Senator Burr.
Senator Tester?
Senator Tester. Thank you, Mr. Chairman, and I, too, want
to thank the panel members for your testimony and your ideas. I
think they are outstanding, and we just need to figure out a
way we can apply them, which I think is what Senator Burr was
talking about.
First of all, to Tammy and Jonathan, thank you for your
service, thank you for your sacrifice. I appreciate that a lot.
To Denise, you know, the Good Lord gave us the ability to
love, and a mother's love for her son is pretty special, and I
thank you for what you have done for your son.
And thank you, Dr. Gans, for your perspective.
I just want to touch on a couple of things, and I am not
going to ask--most of the questions have been asked. I just
want to touch on a couple of things, because each one of you
brought up the fact, the need for potential outsourcing of
services. And, I guess, if I was going to ask a question, it
would be what kind of parameters would you put around that.
From previous questions it is apparent that it should not be
wide open, and I agree with that, by the way. But if it deals
with prosthetics, if it deals with traumatic brain injury, if
it deals with other areas by which we can outsource, that would
be great to really put that into policy.
I come from a State where it is a long ways to the
veterans' hospital. Maybe distance should also apply in there.
But if there are ways we can figure out how to outsource in a
reasonable way, I think you are right on. And, quite frankly, I
am glad every one of you brought it up, because that tells me
that that is probably one of the solutions.
The other thing deals with testing, and I think, Tammy, you
brought it up, and I think we need to have our testing very
complete, and I appreciate that information.
I am not going to be able to be here for the second panel,
and I really wanted to be, but I have got a conflict. And so
for Michael and Ellen, I just want to tell you that my first
statements stand. Once you get into the system, they do some
pretty good work, but there are some problems that we have to
deal with, and these problems cannot be addressed, I do not
think, by us alone. I think it is going to take a collaborative
effort. I think it is going to take some honest assessment on
services rendered, dollars needed, and human resources in the
kind of job they are doing in the field, and both at the DOD
level and at the VA level. And I think that is critically
important.
Technological and medical transfer, I think Jonathan talked
about it, with the bacteria, or whatever you got, from the
Department of Defense to the VA, I think that has got to
happen. That is as important as passing the medical records
along so we can get these folks the kind of treatment they
need.
But ultimately, in the end, I will just tell you this: As a
policymaker in the U.S. Senate, it is going to be virtually
impossible to fix this problem without the bureaucracy's help.
Senator Burr talked about it, the fact that if we make policies
and force policies down on the bureaucracy, it is not going to
fix the problem. We need to work together. And the fact that
these folks are sitting right here today, I hope that there is
not one person in the bureaucracy that says these are
individual cases and this is not the rule. The fact is that the
reason these folks are here today is because we do have some
problems and we need to work on the outcomes to make sure that
we have successes right down the line.
So with that, thank you very much. I really appreciate
these panelists coming up today. I appreciate your time. Thank
you.
Chairman Akaka. Senator Brown?
Senator Brown. Thank you, Chairman Akaka. And thank you. I
was at another hearing and could not hear your testimony,
although I have read much of all of your testimony.
Mr. Pruden, you said something that intrigued me about
having an advocate, and my mother several years ago--she was in
her early 80's. This is a very different situation. But she
fell and fractured or shattered her shoulder, and she had my
brother and me and my wife in the hospital with her in the
emergency room as an advocate. People were nearby. The hospital
was crowded, as city emergency rooms often are, or all medical
facilities are. And because she had family members there really
advocating for her with doctors and nurses to get pain
medication, to do all that was needed, she got better
treatment, frankly, than some others that were there that did
not have family members.
I heard you talk about your son a little. I am sorry I did
not hear the rest of your testimony. And, Director Duckworth,
you seem to be generally pretty pleased with the treatment you
got. Talk to me, the three of you, because you have all been so
much a part of this, how important that would be to whether
your experience was you had somebody there for you that was an
advocate. If you read the Post stories about Walter Reed, there
was the absence of that for them in many cases, too, and how
our system, how the VA should do this so that every patient
feels like they have someone there to make sure they get the
care they need.
Since you talked about it, Mr. Pruden, do you want to
start? And then Director Duckworth and then Ms Mettie, if you
would.
Mr. Pruden. Thank you. Having an advocate is vitally
important. I had my wife, Amy, there right along, and, you
know, in my early days I was in ICU and on a lot of morphine,
and I did not understand what was going on exactly. And my wife
was there to make sure things were happening for me.
I think a lot of times the gap that we see, the problems
that I addressed for a lot of my soldiers as they were coming
back wounded have not been because the resources were not
available to them, but because the information was not
available or there was a lack of communication somewhere, and
they could not get from Point A to Point B.
I had a soldier dragging his foot around for weeks until I
saw him and said, ``Why are you dragging your foot around?''
``Well, sir,'' he said, ``they didn't have an AFO for me.'' It
is a foot orthosis to correct nerve damage. And he had been
dragging his foot around because he did not know any better.
Nobody told him that he could get an AFO.
And I can give you countless examples of incidents like
that where people just did not know what was available.
Secretary Nicholson's hiring of 100 OIF/OEF patient advocates
is a step in the right direction, and I think we need to see
more of that on both sides of the house.
Senator Brown. Director Duckworth?
Ms. Duckworth. Senator, I have to say the same thing, and
the reason Jonathan and I are here today is because we did what
a lot of patients are doing at the medical treatment
facilities, whether it is DOD or VA. Those of us who are more
capable of advocating are advocating not just for ourselves but
for our buddies as well.
When I was in the ICU, I had my husband,--he is now a major
as well, but at the time a captain. When somebody told him that
this is the way things were with the bureaucracy--for example,
in the first couple of days, they told my 65-year-old mom there
was no room. She had to sleep on the floor of the ICU waiting
room. He had 15 years in the military, just saying wrong
answer, that is not what you do, and fight the bureaucracy.
When I am at Hines and I go into the prosthetics lab, and
as I walk through, the prosthetists look at me and say, ``Wow,
is that a C-leg? Can I touch it?'' I had the wherewithal to
say, ``This is not acceptable,'' and worked the system myself
to get to a place where I could go to the prosthetist of my
choice. But a young troop with a brain injury who does not have
that cannot make their way through the system. The patient
advocate at Hines, the ones that I use, Ivy Bryant, is
excellent. But part of her doing her job is going to be an
understanding of the military system and also an understanding
of the medical pipeline, because she is a caseworker, she does
not necessarily understand that a patient needs a particular
medical procedure. So there is definitely need for that, and
that is why you find people like Jonathan and me here, is
because we found ourselves advocating for our buddies, just
like there were guys who advocated for us when we were not
capable of taking care of ourselves.
Senator Brown. Ms. Mettie?
Ms. Mettie. I don't know if you were here when I was
talking about a particular test that was done on Evan last May,
SSEP, that measures electric impulse activity. And on that one,
the one on the top of the head that measures the cortical
impulse was not registering anything, so the rehab doctor said
it is unlikely that he will ever regain anything. And because
of movements that we had seen and commands that he had done, I
just told her that her test was wrong. I have my own faith, and
we are going on my prognosis.
Well, from that point on where we were at the VA, it was,
Let's see more Mom, and took care of Evan to the best of our
ability. They took personal care of him, but there was no
therapy.
In October, he had his cranioplasty done to replace his
skull, and when we got back to the VA, they redid the SSEP
test. The rehab doctor called me and apologized for ever doing
the first one because this one was normal. It was an immediate
difference on how he was treated. All of a sudden, OT, speech,
everybody was coming in to work with him. And all of these
months I had been pushing saying he is there, all you got to do
is work with him. But nobody would.
Senator Brown. I guess that answers it. Thank you.
Thank you, Mr. Chairman.
Chairman Akaka. Thank you very much, Senator Brown.
I want to thank this panel very much. We have further
questions. We will place them in the record, and we will keep
the record open for a week. But let me tell you, your
testimonies have been excellent. It has been helpful to us, and
as you know, we are trying to do our best to help the veterans
of our country. And you have really helped us to do that.
So, again, thank you very much for coming. Some of you had
to travel to get here, and we really do appreciate that. And so
I want to thank you for your testimonies again and thank the
audience for being so patient.
Thank you to the first panel.
I would like to call the second panel to the desk. I
welcome our second panel of witnesses. Dr. Kussman is acting
head of the Veterans Health Administration, though I have been
informed that your new title is Executive-in-Charge. I hope
that the Administration will soon send up a nomination for the
Under Secretary of Health position.
Ms. Embrey is the Deputy Assistant Secretary of Defense for
Force Health Protection and Readiness, and Director of
Deployment Health Support.
Dr. Kussman and Ms. Embrey, thank you so much for your
presence. I know that it was a bit unusual to have
Administration witnesses not testify first, but as I said in my
opening statement, it is my desire to have you address the
testimony of the witnesses who preceded you. So I thank both of
you for being here today. I want you to know that your full
statements will appear in the record of the Committee.
So we will begin with testimony from Dr. Kussman.
STATEMENT OF MICHAEL J. KUSSMAN, M.D., EXECUTIVE-
IN-CHARGE, VETERANS HEALTH ADMINISTRATION, DEPARTMENT OF
VETERANS AFFAIRS
Dr. Kussman. Good morning, Mr. Chairman. Before I give my
prepared remarks, if you will indulge me for a second, I do not
know if anybody from the first panel is still here, but for the
record I would like to say that our job is make things better,
not more complicated. And when I hear these stories where we
clearly have not met the expectations and done things in the
manner that I would like to see them, it pains me both
professionally and personally.
As you know, I am a veteran and a retiree myself, and so I
appreciated the testimony of the first panel. I can assure you
that we will continue to do everything that we can to improve
the system.
Mr. Chairman and Members of the Committee, good morning.
Mr. Chairman, thank you for the opportunity to testify today on
the polytrauma and prosthetics issues on behalf of the
Department. While we have learned a great deal on these
subjects in the past few years, with your help and the help of
many others, both inside and outside the Government, we
continue to try to improve our performance. Never in the 75-
year history of the Department of Veterans Affairs has there
been a greater level of collaboration and cooperation between
VA and the Department of Defense.
VA has coordinated the transfer of over 6,800 injured or
ill active-duty servicemembers and veterans from DOD to the VA.
Our highest priority is to ensure that those returning from the
Global War on Terror who transition directly from DOD military
treatment facilities to VA medical centers continue to receive
the best care available anywhere.
This month, we are calling each of those severely injured
servicemembers and veterans to see if they need additional
support, and we are directing facilities to provide OIF/OEF
program managers at each facility. VA social workers, benefits
counselors, and outreach coordinators advise and explain the
full array of VA services and benefits to servicemembers while
they are still being cared for by DOD. In addition, our social
workers help newly wounded soldiers, sailors, airmen, and
Marines and their families plan a future course of treatment
for their injuries after they return home.
Case management of our patients begins at the time of
transition from DOD and continues as their medical and
psychological needs dictate. VA requires that every medical
center will have full-time nurse and social worker case
managers for OIF/OEF veterans' needs, and we are in the process
of hiring 100 OIF/OEF veterans to serve as ombudsmen to support
severely wounded veterans and their families.
Each VA medical center also has an OIF/OEF program manager
to coordinate activities locally for OIF/OEF veterans and to
ensure the health care and benefits needs of returning
servicemembers and veterans are fully met. VA has distributed
specific guidance to field staff to ensure that the roles and
functions of the OIF/OEF program managers and case managers are
fully understood and that proper coordination of benefits and
services occurs at the local level.
Mr. Chairman, 15 years ago, VA, in collaboration with the
Defense and Veterans Brain Injury Center, established 4
comprehensive centers to care for veterans with traumatic brain
injury. These centers are located in Richmond, Tampa,
Minneapolis, and Palo Alto and provide exemplary clinical care
for brain-injured patients and are recognized as leaders in
their field.
Today our Polytrauma System of Care provides the highest
quality of medical and rehabilitation case management and
support services for veterans and active-duty servicemembers
who have sustained complex injuries, including traumatic brain
injury, while in service to our country. Our ability to
successfully integrate medical care and rehabilitative medicine
makes our centers unique among health care facilities in the
United States and possibly the world. We are a flexible,
dynamic system able to adjust to the changing needs of combat-
injured veterans and proud of the service we provide them.
Last year, VA's Prosthetic and Sensory Aids Service
provided service to over 22,000 unique OIF/OEF veterans for a
variety of services and products. When viewing amputee care
alone since the beginning of the war, VA's Prosthetic and
Sensory Aids Service has served a total of 157 of the 560 OIF/
OEF major amputees. Some of these amputees have come to us
through the Polytrauma Rehabilitation Centers.
Finally, VA provides outreach to our newest veterans
through our Vet Center Program. Vet Centers were created by
Congress as the outreach element in VA's Veterans Health
Administration. Our Vet Centers have served 180,000 combat
veterans to date and have provided bereavement services to the
families of over 900 fallen warriors. VA will open 15 new Vet
Centers and 8 new Vet Center outstations at locations
throughout the Nation by the end of 2008. At that time Vet
Centers will total 232. We also expect to add staff to 61
existing facilities to augment the services they provide. Seven
of the 23 new centers will open during calendar year 2007.
Mr. Chairman, that concludes my presentation, and at this
time I would be pleased to answer any questions you may have.
[The prepared statement of Dr. Kussman follows:]
Prepared Statement of Michael J. Kussman, M.D., Executive-in-Charge,
Veterans Health Administration, Department of Veterans Affairs
Mr. Chairman and Members of the Committee, good afternoon. Thank
you for this important opportunity to discuss on the Veterans Health
Administration's (VHA) efforts to ensure a seamless transition process
for our injured service men and women, and our ongoing efforts to
continuously improve this process.
VHA's work to create a seamless transition for men and women as
they leave the service and take up the honored title of ``veteran''
begins early on. Our Benefits Delivery at Discharge Program enables
active duty members to register for VA health care and to file for
benefits prior to their separation from active service. Our outreach
network ensures returning servicemembers receive full information about
VA benefits and services. And each of our medical centers and benefits
offices now has a point of contact assigned to work with veterans
returning from service in Operation Enduring Freedom (OEF) and
Operation Iraqi Freedom (OIF).
VHA has coordinated the transfer of over 6,800 severely injured or
ill active duty servicemembers and veterans from DOD to VA. Our highest
priority is to ensure that those returning from the Global War on
Terror transition seamlessly from DOD Military Treatment Facilities
(MTFs) to VA Medical Centers (VAMCs) and continue to receive the best
possible care available anywhere. Toward that end, we continually
strive to improve the delivery of this care.
In partnership with DOD, VA has implemented a number of strategies
to provide timely, appropriate, and seamless transition services to the
most seriously injured OEF/OIF active duty servicemembers and veterans.
VA social workers, benefits counselors, and outreach coordinators
advise and explain the full array of VA services and benefits. These
liaisons and coordinators assist active duty servicemembers as they
transfer from MTFs to VA medical facilities. In addition, our social
workers help newly wounded soldiers, sailors, airmen and Marines and
their families plan a future course of treatment for their injuries
after they return home. Currently, VA Social Worker and Benefit
Liaisons are located at 10 MTFs, including Walter Reed Army Medical
Center, the National Naval Medical Center Bethesda, the Naval Medical
Center San Diego, and Womack Army Medical Center at Ft. Bragg.
Since September 2006, a VA Certified Rehabilitation Registered
Nurse (CRRN) has been assigned to Walter Reed to assess and provide
regular updates to our Polytrauma Rehabilitation Centers (PRC)
regarding the medical condition of incoming patients. The CRRN advises
and assists families and prepares active duty servicemembers for
transition to VA and the rehabilitation phase of their recovery.
VA's Social Worker Liaisons and the CRRN fully coordinate care and
information prior to a patient's transfer to our Department. Social
Worker Liaisons meet with patients and their families to advise and
``talk them through'' the transition process. They register
servicemembers or enroll recently discharged veterans in the VA health
care system, and coordinate their transfer to the most appropriate VA
facility for the medical services needed, or to the facility closest to
their home.
In the case of transfers of seriously injured patients, both the
CRRN and the Social Worker Liaison are an integral part of the MTF
treatment team. They simultaneously provide input into the VA health
care treatment plan and collaborate with both the patient and his or
her family throughout the entire health care transition process. Video
teleconference calls are routinely conducted between DOD MTF treatment
teams and receiving VA PRC teams. If feasible, the patient and family
attend these video teleconferences to participate in discussions and to
``meet'' the VA PRC team.
I should note that one important aspect of coordination between DOD
and VA prior to a patient's transfer to VA is access to clinical
information. This includes a pre-transfer review of electronic medical
information via remote access capabilities. The VA polytrauma centers
have been granted direct access into inpatient clinical information
systems from Walter Reed Army Medical Center (WRAMC) and National Naval
Medical Center (NNMC). VA and DOD are currently working together to
ensure that appropriate users are adequately trained and connectivity
is working and exists for all four polytrauma centers. For those
inpatient data that are not available in DOD's information systems, VA
social workers embedded in the military treatment facilities routinely
ensure that the paper records are manually transferred to the receiving
polytrauma centers.
Another data exchange system, the Bidirectional Health Information
Exchange (BHIE) allows VA and DOD clinicians to share text-based
outpatient clinical data between VA and the ten MTFs, including Walter
Reed and Bethesda.
VA case management for these patients begins at the time of
transition from the MTF and continues as their medical and
psychological needs dictate. Once the patient transfers to the
receiving VAMC, or reports to his or her home VAMC for care, the VA
Social Worker Liaison at the MTF continues to coordinate with VA to
address after-transfer issues of care. Seriously injured patients
receive ongoing case management at the VA facility where they receive
most of their care. Since April of 2006, points of contact or case
managers have been identified in every VA medical center. In response
to the Secretary's request this week, VA is in the process of hiring
the 100 OIF/OEF veterans to serve as case advocates to support their
severely injured fellow veterans and their families.
Moreover, VA's Prosthetic and Sensory Aids Service (PSAS) provided
service to over 22,000 OIF/OEF unique veterans for a variety of
services and products. \1\ When viewing amputee care alone since the
beginning of the war, Prosthetics has served a total of 187 of the
current 554 OIF/OEF major amputees, including veterans and active duty
servicemembers. Some of these amputees have come to us through the
Polytrauma Rehabilitation Centers.
---------------------------------------------------------------------------
\1\ These services include but are not limited to wheelchairs,
eyeglasses, hand-cycles, running legs (prostheses), mono-skis,
prosthetic hands, talking GPS systems for the blind, and Personal
Digital Assistants for Traumatic Brain Injury patients.
---------------------------------------------------------------------------
VA has four Polytrauma Rehabilitation Centers, located at Tampa,
FL; Richmond, VA; Minneapolis, MN; and Palo Alto, CA. The Army has
assigned full time active duty Liaison Officers to each one in order to
support military personnel and their families from all Service
branches. The Liaison officers address a broad array of issues, such as
travel, housing, military pay, and movement of household goods.
In addition, Marine Corps representatives from nearby local
Commands visit and provide support to each of the Polytrauma
Rehabilitation Centers. At VA Central Office in Washington, DC, an
active duty Marine Officer and an Army Wounded Warrior representatives
are assigned to the Office of Seamless Transition to serve as liaisons.
Both the Army and the Marine Liaisons play a vital role in ensuring the
provision of a wide bridge of services during the critical time of
patient recovery and rehabilitation.
VHA understands the critical importance of supporting families
during the transition from DOD to VA. We established a Polytrauma Call
Center in February 2006, to assist the families of our most seriously
injured combat veterans and servicemembers. The Call Center operates 24
hours-a-day, 7 days-a-week to answer clinical, administrative, and
benefit inquiries from polytrauma patients and family members. The
Center's value is threefold. It furnishes patients and their families
with a one-stop source of information; it enhances overall coordination
of care; and, very importantly, it immediately elevates any system
problems to VA for resolution.
VA's Office of Seamless Transition includes two Outreach
Coordinators--a peer-support volunteer and a veteran of the Vietnam
War--who regularly visit seriously injured servicemembers at Walter
Reed and Bethesda. Their visits enable them to establish a personal and
trusted connection with patients and their families.
These Outreach Coordinators help identify gaps in VA services by
submitting and tracking follow-up recommendations. They encourage
patients to consider participating in VA's National Rehabilitation
Special Events or to attend weekly dinners held in Washington, DC, for
injured OEF/OIF returnees. In short, they are key to enhancing and
advancing the successful transition of our service personnel from DOD
to VA, and, in turn, to their homes and communities.
In addition, VA has developed a vigorous outreach, education, and
awareness program for the National Guard and Reserve. To ensure
coordinated transition services and benefits, VA signed a Memorandum of
Agreement (MOA) with the National Guard in 2005. Combined with VA/
National Guard State Coalitions in 54 states and territories, VA has
significantly improved its opportunities to access returning troops and
their families. We are continuing to partner with community
organizations and other local resources to enhance the delivery of VA
services. At the national level, MOAs are under development with both
the United States Army Reserve and the United States Marine Corps.
These new partnerships will increase awareness of, and access to, VA
services and benefits during the demobilization process and as service
personnel return to their local communities.
VA is also reaching out to returning veterans whose wounds may be
less apparent. VA is a participant in the DOD's Post Deployment Health
Reassessment (PDHRA) program. DOD conducts a health reassessment 90-180
days after return from deployment to identify health issues that can
surface weeks or months after servicemembers return home.
VA actively participates in the administration of PDHRA at Reserve
and Guard locations in a number of ways. We provide information about
VA care and benefits; enroll interested Reservists and Guardsmen in the
VA health care system; and arrange appointments for referred
servicemembers. As of December 2006, an estimated 68,800 servicemembers
were screened, resulting in over 17,100 referrals to VA. Of those
referrals, 32.8 percent were for mental health and readjustment issues;
the remaining 67.2 percent for physical health issues.
Congress created the Readjustment Counseling Service (RCS),
commonly known to veterans as the Vet Center Program, as VHA's outreach
element. Program eligibility was originally targeted to Vietnam
veterans; today it serves all returning combat veterans. The Vet Center
Program receives high ratings in veterans' satisfaction, employee
satisfaction, and other measurable indicators of quality and effective
care.
The approximate number of OEF/OIF combat veterans served by Vet
Centers to date is 165,000 (119,600 through outreach; 45,400 seen at
centers). In February of 2004, the Secretary of Veterans Affairs
approved the hiring of 50 OEF/OIF combat veterans to support the
Program by reaching out actively to National Guard, and Reserve
servicemembers returning from combat. An additional 50 were hired in
March of 2005. This action advanced the continuing success of our Vet
Centers in their ability to assist our newest veterans and their
families. VA Vet Centers have provided bereavement services to 900
families of fallen warriors.
VA plans to expand its Vet Center Program. We will open 15 new Vet
Centers and eight new Vet Center outstations at locations throughout
the Nation by the end of 2008. At that time, Vet Centers will total
232. We expect to add staff to 61 existing facilities to augment the
services they provide. Seven of the 23 new centers will open this
Calendar Year 2007.
In addition, the President has created an Interagency Task Force on
Returning Global War on Terror Heroes (Heroes Task Force), chaired by
the Secretary of Veterans Affairs, to respond to the immediate needs of
returning Global War on Terror servicemembers. The Heroes Task Force,
which had its first meeting in early March, will work to identify and
resolve any gaps in service for servicemembers. As Secretary Nicholson
said, no task is more important to the VA than ensuring our heroes
receive the best possible care and services.
Finally, The VA is partnering with the State VA Directors in the
``State Benefits Seamless Transition Program'' in which severely
injured servicemembers can release their contact information to their
home State VA Office to be educated about their State Benefits.
VA staff assigned to major MTFs are coordinating with Heroes to
Hometown as a resource to provide to servicemembers returning to
civilian life.
Mr. Chairman, this concludes my presentation. At this time, I would
be pleased to answer any questions you may have.
______
Response to Written Questions Submitted by Hon. Daniel K. Akaka
to Michael J. Kussman, M.D., Executive-in-Charge, Veterans Health
Administration, Department of Veterans Affairs
Question 1. In response to [vet] account of VA's inability to deal
with his recent infection (acinetobacter), you stated that all relevant
VA clinicians are competent to handle this bacterium. You also promised
to look into [vet] case in order to identify any shortcomings. Please
provide the Committee with a brief, informal summary of your
conclusions as they become available.
Response. Dr. Gary Roselle, National Program Director for
Infectious Diseases, has reviewed the veteran's health record and has
prepared a report. As the report does have protected personal
information it has been provided under separate cover to the Chairman
only.
Question 2. Four times a year, VA submits to Congress a mandated
report on medical service utilization by veterans of Operations
Enduring Freedom and Iraqi Freedom. We have not received the latest
report, which we were expecting in February. I would appreciate you
looking into this and expediting the production, clearance and
forwarding of this document to Committee staff.
Response. Attached is the Veterans Health Administration's (VHA)
most recent report, Analysis of VA Healthcare Utilization Among US
Southwest Asian War Veterans, dated April 2007.
[The Veterans Health Administration's (VHA) report follows:]
Analysis of VA Health Care Utilization Among
US Southwest Asian War Veterans
operation iraqi freedom
operation enduring freedom
(VHA Office of Public Health and Environmental Hazards, April 2007)
current dod roster of recent war veterans
<bullet> Evolving roster development by DOD Defense Manpower Data
Center (DMDC)
<all> In September 2003, DMDC developed initial file of
``separated'' .Iraqi and Afghan troops using proxy files: Active Duty
and Reserve Pay files, Combat Zone Tax Exclusion, and Imminent Danger
Pay data.
<all> In September 2004, DMDC revised procedures for creating
periodic updates of the roster and now mainly utilizes direct reports
from service branches of deployed OIF (Operation Iraqi Freedom) and OEF
(Operation Enduring Freedom) troops.
<all> DMDC is actively addressing the limitations of the current
roster to improve the accuracy and completeness of future rosters
current dod roster of recent war veterans
<bullet> Latest Update of roster
<all> Provided to Dr. Kang, Veterans Health Administration (VHA)
Environmental Epidemiology Service, on January 11, 2007.
<bullet> Qualifications for OIF/OEF deployment roster
<all> Contains list of veterans who have left active duty and
does not include currently serving active duty personnel
<all> Does not distinguish OIF from OEF veterans
<all> Roster only includes separated OIF/OEF veterans with out-
of-theater dates through November 2006
<all> 3,011 veterans who died in-theater are not included
updated roster of sw asian war veterans who have left active duty
<bullet> 686,306 OIF and OEF veterans who have left active duty and
become eligible for VA health care since Fiscal Year 2002
<all> 46 percent (316,562) Former Active Duty troops
<all> 54 percent (369,744) Reserve and National Guard
use of dod list of war veterans who have left active duty
<bullet> This roster is used to check the VA's electronic inpatient
and outpatient health records, in which the standard ICD-9 diagnostic
codes are used to classify health problems, to determine which OIF/OEF
veterans have accessed VA health care as of December 31, 2006.
<bullet> The data available for this analysis are mainly
administrative information and are not based on a review of each
patient record or a confirmation of each diagnosis. However, every
clinical evaluation is captured in VHA's computerized patient record.
The data used in this analysis are excellent for health care planning
purposes because the ICD-9 administrative data accurately reflects the
need for health care resources, although these data cannot be
considered epidemiologic research data.
<bullet> These administrative data have to be interpreted with
caution because they only apply to OIF/OEF veterans who have accessed
VHA health care due to a current health question. These data do not
represent all 686,306 OIF/OEF veterans who have become eligible for VA
healthcare since Fiscal Year 2002 or the approximately 1.4 million
troops who have served in the two theaters of operation since the
beginning of the conflicts in Iraq and Afghanistan.
use of dod list of war veterans who have left active duty (2)
<bullet> Because VA health data are not representative of the
veterans who have not accessed VA health care, formal epidemiological
studies will be required to answer specific questions about the overall
health of recent war veterans.
<bullet> Analyses based on this updated roster are not directly
comparable to prior reports because the denominator (number of OIF/OEF
veterans eligible for VA health care) and numerator (number of veterans
enrolling for VA health care) change with each update.
<bullet> This report presents data from VHA's health care
facilities and does not include Vet Center data or DOD health care
data.
<bullet> The following data are ``cumulative totals'' since Fiscal
Year 2002 and do not represent data from any single year.
<bullet> The numbers provided in this report should not be added
together or subtracted to provide new data without checking on the
accuracy of these statistical manipulations with VHA's Office of Public
Health and Environmental Hazards.
va health care utilization from fiscal year 2002 to 2007 (1st qt)
among sw asian war veterans
<bullet> Among all 686,306 separated OIF/OEF Veterans
<all> 33 percent (229,015) of total separated veterans have
sought VA health care since Fiscal Year 2002
<all> 97 percent (221,255) of 229,015 evaluated OIF/OEF patients
have been seen as outpatients only by VA and not hospitalized
<all> 3 percent (7,760) of 229,015 evaluated OIF/OEF patients
have been hospitalized at least once in a VA health care facility
va health care utilization for fiscal year 20022007 (1st qt) by service
component
<bullet> 316,562 Former Active Duty Troops
<all> 35 percent (112,301) have sought VA health care since
Fiscal Year 2002
<bullet> 369,744 Reserve/National Guard Members
<all> 32 percent (116,714) have sought VA health care since
Fiscal Year 2002
comparison of va health care requirements
The 229,015 OIF/OEF veterans evaluated by VA over approximately 5
years from Fiscal Year 2002 to Fiscal Year 2007 (1st QT) represents
about 4 percent 5.5 million individual patients who received VHA health
care in anyone year (total VHA population of 5.5 million in 2006).
Frequency Distribution of SW Asian War Veterans According to the VISN
Providing the Treatment
------------------------------------------------------------------------
OIF/OEF Veterans
Treated at a VA
Treatment Site Facility \1\
-----------------------
Frequency Percent
------------------------------------------------------------------------
VISN 1 VA New England Healthcare System........ 11,163 4.9
VISN 2 VA Healthcare Network Upstate New York.. 6,728 2.9
VISN 3 VA New York/New Jersey Healthcare System 9,242 4.0
VISN 4 VA Stars & Stripes Healthcare System.... 11,021 4.8
VISN 5 VA Capital Health Care System........... 5,821 2.5
VISN 6 VA Mid-Atlantic Healthcare System....... 12,224 5.3
VISN 7 VA Atlanta Network...................... 16,597 7.2
VISN 8 VA Sunshine Healthcare Network.......... 19,289 8.4
VISN 9 VA Mid-South Healthcare Network......... 13,660 6.0
VISN 10 VA Healthcare System of Ohio........... 6,351 2.8
VISN 11 Veterans in Partnership Healthcare 8,275 3.6
Network........................................
VISN 12 VA Great Lakes Health Care System...... 14,490 6.3
VISN 15 VA Heartland Network................... 7,645 3.3
VISN 16 South Central VA Health Care Network... 19,871 8.7
VISN 17 VA Heart of Texas Health Care Network.. 13,683 6.0
VISN 18 VA Southwest Healthcare Network........ 11,636 5.0
VISN 19 VA Rocky Mountain Network.............. 9,222 4.0
VISN 20 VA Northwest Network................... 13,186 5.8
VISN 21 VA Sierra Pacific Network.............. 9,781 4.3
VISN 22 VA Desert Pacific Healthcare Network... 18,226 8.0
VISN 23 VA Midwest Health Care Network......... 12,749 5.6
------------------------------------------------------------------------
\1\ Veterans can be treated in multiple VISNs. A veteran was counted
only once in any single VISN but can be counted in multiple VISN
categories. The total number of OIF-OEF veterans who received
treatment (n = 229,015) was used to calculate the percentage treated
in any one VISN.
Demographic Characteristics of Iraqi and Afghan Veterans Utilizing VA
Health Care
------------------------------------------------------------------------
Percent SW
Asian
Veterans (n
= 229,015)
------------------------------------------------------------------------
Sex
Male................................................... 88
Female................................................. 12
Age Group
<20.................................................... 4
20-29.................................................. 52
30-39.................................................. 23
40..................................................... 20
Branch
Air Force.............................................. 12
Army................................................... 66
Marine................................................. 12
Navy................................................... 10
Unit Type
Active................................................. 49
Reserve/Guard.......................................... 51
Rank
Enlisted............................................... 92
Officer................................................ 8
------------------------------------------------------------------------
diagnostic data
<bullet> Veterans of recent military conflicts have presented to
VHA with a wide range of possible medical and psychological conditions.
<bullet> Health problems have encompassed more than 7,990 discrete
ICD-9 diagnostic codes.
<bullet> The three most common possible health problems of war
veterans were musculoskeletal ailments (principally joint and back
disorders), mental disorders, and ``Symptoms, Signs and Ill-Defined
Conditions.''
<bullet> As in other outpatient populations, the ICD-9 diagnostic
category, ``Symptoms, Signs and III-Defined Conditions,'' was commonly
reported. It is important to understand that this is not a diagnosis of
a mystery syndrome or unusual illness. This ICD-9 code includes
symptoms and clinical finding that are not coded elsewhere in the IC-
D9. It is a diverse, catch-all category that is commonly used for the
diagnosis of outpatient populations. It encompasses more than 160 sub-
categories and primarily consists of common symptoms that do not have
an immediately obvious cause during a single clinic visit or isolated
laboratory abnormalities that do not point to a particular disease
process and may be transient.
Frequency of Possible Diagnoses Among Recent Iraq and Afghan Veterans
------------------------------------------------------------------------
(n = 229,015)
Diagnosis (Broad ICD-9 Categories) ---------------------------
Frequency \1\ Percent
------------------------------------------------------------------------
Infectious and Parasitic Diseases (001-139). 24,114 10.5
Malignant Neoplasms (140-208)............... 1,801 0.8
Benign Neoplasms (210-239).................. 7,506 3.3
Diseases of Endocrine/Nutritional/Metabolic 41,911 18.3
Systems (240-279)..........................
Diseases of Blood and Blood Forming Organs 4,175 1.8
(280-289)..................................
Mental Disorders (290-319).................. 83,889 36.6
Diseases of Nervous System/Sense Organs (320- 69,767 30.5
389).......................................
Diseases of Circulatory System (390-459).... 33,218 14.5
Disease of Respiratory System (460-519)..... 41,144 18.0
Disease of Digestive System (520-579)....... 70,350 30.7
Diseases of Genitourinary System (580-629).. 21,484 9.4
Diseases of Skin (680-709).................. 32,735 14.3
Diseases of Musculoskeletal System/ 99,484 43.4
Connective System (710-739)................
Symptoms, Signs and III Defined Conditions 77,275 33.7
(780-799)..................................
Injury/Poisonings (800-999)................. 40,708 17.8
------------------------------------------------------------------------
\1\ Hospitalizations and outpatient visits as of 12/31/2006; veterans
can have multiple diagnoses with each healthcare encounter. A veteran
is counted only once in any single diagnostic category but can be
counted in multiple categories, so the above numbers add up to greater
than 229,015.
Frequency of Possible Mental Disorders Among OIF/OEF Veterans since 2002
\1\
------------------------------------------------------------------------
Total Number
of SW Asian
Disease Category (ICD 290-319 code) War Veterans
\2\
------------------------------------------------------------------------
PTSD (ICD-9CM 309.81) \3\................................. 39,243
Nondependent Abuse of Drugs (ICD 305) \4\................. 33,099
Depressive Disorders (311)................................ 27,023
Neurotic Disorders (300).................................. 21,084
Affective Psychoses (296)................................. 14,489
Alcohol Dependence Syndrome (303)......................... 6,329
Sexual Deviations and Disorders (302)..................... 3,735
Special Symptoms, Not Elsewhere Classified (307).......... 3,701
Drug Dependence (304)..................................... 2,798
Acute Reaction to Stress (308)............................ 2,643
------------------------------------------------------------------------
\1\ Note: ICD diagnoses used in these analyses are obtained from
computerized administrative data. Although diagnoses are made by
trained healthcare providers, up to one-third of coded diagnoses may
not be confirmed when initially coded because the diagnosis is ``rule-
out'' or provisional, pending further evaluation.
\2\ A total of 83,889 unique patients received a diagnosis of a possible
mental disorder. A veteran may have more than one mental disorder
diagnosis and each diagnosis is entered separately in this table;
therefore, the total number above will be higher than 83,889.
\3\ This row of data does not include information on PTSD from VA's Vet
Centers and does not include veterans not enrolled for VHA health
care. Also, this row of data does not include veterans who did not
have a diagnosis of PTSD (ICD 309.81) but had a diagnosis of
adjustment reaction (ICD-9 309).
\4\ 82 percent of these veterans (26,998) had a diagnosis of tobacco use
disorder (ICD-9 305.1).
summary
<bullet> Recent Iraq and Afghan veterans are presenting to VA with
a wide range of possible medical and psychological conditions.
<bullet> Recommendations cannot be provided for particular testing
or evaluation--veterans should be assessed individually to identify all
outstanding health problems.
<bullet> 33 percent of separated OIF/OEF veterans have enrolled for
VA health care since 2002 compared to 32 percent in the last quarterly
report 3 months ago. As in other cohorts of military veterans, the
percentage of OIF/OEF veterans receiving health care from the VA and
the percentage with any type of diagnosis will tend to increase over
time as these veterans continue to enroll for VA health care and to
develop new health problems.
summary (2)
<bullet> Because the 229,015 Iraqi and Afghan veterans who have
accessed VA health care were not randomly selected and represent just
16 percent of the approximately 1.4 million recent U.S. war veterans,
they do not constitute a representative sample of all OIF/OEF veterans.
<bullet> Reported diagnostic data are only applicable to the
229,015 VA patients--a population actively seeking health care--and not
to all OIF/OEF veterans.
For example, the fact that about 37 percent of VHA patients'
encounters were coded as related to a possible mental disorder does not
indicate that \1/3\ of all recent war veterans are suffering from a
mental health problem. Only well-designed epidemiological studies can
evaluate the overall health of Iraqi and Afghan war veterans.
summary (3)
<bullet> High rates of VA health care utilization by recent Iraqi
and Afghan veterans reflect the fact that these combat veterans have
ready access to VA health care, which is free of charge for 2 years
following separation for any health problem possibly related to wartime
service.
Also, an extensive outreach effort has been developed by VA to
inform these veterans of their benefits, including the mailing of a
personal letter from the VA Secretary to war veterans identified by DOD
when they separate from active duty and become eligible for VA
benefits.
<bullet> When a combat veteran's 2-year health care eligibility
passes, the veteran will be moved to their correct priority group and
charged all copayments as applicable. If their financial circumstances
place them in Priority Group 8, their enrollment in VA will be
continued, regardless of the date of their original VA application.
follow-up
<bullet> VA will continue to monitor health care utilization of
recent Iraq and Afghan veterans using updated deployment lists provided
by DOD to ensure that VA tailors its health care and disability
programs to meet the needs of this newest generation of war veterans.
Question 3(a). What steps has VA taken to address the Inspector
General's recommendations regarding VA's case management for victims of
Traumatic Brain Injury (TBI)?
Response. The Department of Veterans Affairs (VA) developed the
Polytrauma System of Care (PSC) to improve access to specialized
rehabilitation services for polytrauma and TBI patients. PSC will also
facilitate delivery of care closer to home, and provide life-long case
management services to veterans of Operations Enduring Freedom and
Iraqi Freedom (OEF/OIF) and active duty service members. VA facilities
participating in the PSC are distributed geographically throughout the
country so as to facilitate access to specialized care closer to the
home, and to help veterans and their families to transition back into
their home communities. Interdisciplinary teams of professionals have
been designated at these facilities to work together to develop an
integrated plan of medical and rehabilitation treatment for each
veteran. In some cases, polytrauma may cause long-term impairments and
functional disabilities. VA is committed to providing services and
coordinating the lifelong care needs of these individuals.
The four components of the PSC include:
<bullet> Polytrauma Rehabilitation Centers (PRC)--These four
regional centers (Richmond, Virginia; Tampa, Florida; Palo Alto,
California; and Minneapolis, Minnesota) are fully operational. They
provide acute comprehensive medical and rehabilitation care for complex
and severe injuries and serve as resources for other facilities in
the PSC.
<bullet> Polytrauma Network Sites (PNS)--These 21 sites including
the four PRCs, one in each of the Veterans Integrated Service Networks
(VISN), are also fully operational. Its role is to manage the post-
acute effects of TBI and polytrauma and to coordinate lifelong
rehabilitation services for patients within their VISN.
<bullet> Polytrauma Support Clinic Teams (PSCT)--VA has designated
72 medical centers as sites for PSCTs. These are local teams of
providers with rehabilitation expertise that manage patients with
stable polytrauma sequelae and respond to new problems that might
emerge in consultation with regional and network specialists. They
provide proactive case management and assist with patient and family
support services.
<bullet> Polytrauma Points of Contact (PPOC)--All other facilities
provide local PPOCs. These are smaller facilities without the expertise
or resources to meet the rehabilitation and prosthetic needs of the
polytrauma patients. The PPOCs are knowledgeable of the services
available for veteran with TBI within the VHA system of care and have
the ability to coordinate care. Each of these facilities ensures that
at least one person is identified to serve as point of contact for
consultation and referral of polytrauma patients to a facility capable
of providing the level of services required.
The Inspector General's report included four specific
recommendations, below is VHA response to each of the recommendations:
Recommended Improvement Action(s) A. The Under Secretary for Health
should improve case management for TBI patients to ensure lifelong
coordination of care.
Case management has a crucial role in ensuring lifelong
coordination of services for patients with polytrauma and TBI, and is
an integral part of the system at each polytrauma care site. PSC uses a
proactive case management model, which requires both nurse and social
work case managers to maintain regular contact 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 case manager at
the referring facility is responsible for a ``warm hand off'' of care
to the case manager at the receiving facility closer to the veteran's
home. Every combat injured veteran with TBI is assigned a case manager
at the polytrauma system of care facility closest to his or her home.
The assigned case manager handles the continuum of care and care
coordination, acts as the point of contact for emerging medical,
psychosocial, or rehabilitation problems, and provides patient and
family advocacy.
The Office of Social Work (OSW) released VHA Handbook 1010.01,
``Transition Assistance and Case Management for Operation Enduring
Freedom and Operation Iraqi Freedom Veterans'' in March 2007 which
details care and services provided to all returning veterans including
those with seriously and mild TBI. Each combat injured veteran with TBI
is assigned a case manager at the PSC facility closest to his or her
home. The assigned case manager handles the continuum of care and care
coordination, acts as the POC for emerging medical, psychosocial or
rehabilitation problems and provides patient and family advocacy.
A Polytrauma Telehealth Network (PTN) links facilities in the PSC
available to support care coordination and case management. The PTN
ensures that polytrauma and TBI expertise are available throughout the
PSC and that care is provided at a location and time that is most
accessible to the patient. The PTN allows provision of specialized
expertise available at the PROs and PNSs to be delivered at facilities
close to the veteran's home.
Specialized rehabilitation care for patients with polytrauma and
TBI requires a continuum of services that may include inpatient and
outpatient rehabilitation, long-term care, transitional living and
community re-entry programs, and vocational rehabilitation and
employment services. The 21 PNSs have completed inventories of VA and
non-VA TBI specific services within its VISNs. These are used to
coordinate resources to meet individualized treatment needs of patients
closer to home. The case managers dedicated to the PSC are responsible
for identifying and coordinating these services for the individual
patient as close to home as possible.
During the August 2006 Polytrauma System of Care Conference,
polytrauma social work case managers received training on expectations
for proactive and continuing case management of active duty personnel
and veterans with brain injury and polytrauma. Monthly conference calls
are held to mentor and educate the PNS case managers.
The OSW, in collaboration with Physical Medicine & Rehabilitation
Service (PM&RS), has established a social work case management work
group. This group is developing a new model of social work TBI and
polytrauma case management that will address the care coordination,
psychosocial and family support issues of this special population
across different sites, levels of rehabilitation, and health care
service delivery. This group is also identifying training needs and is
working with the Employee Education System to offer a variety of
educational programs. A 1-hour training session was held in January
2007 via conference call to educate social workers concerning the signs
and symptoms of mild to moderate TBI.
VHA is publishing a new VHA Handbook on Transition Assistance and
Case Management of OEF/OIF Veterans. The Handbook requires each VA
medical center (VAMC) to appoint a master's prepared nurse or social
worker to serve as the OEF/OIF program manager to oversee all seamless
transition activities, coordination of care for OEF/OIF service members
and veterans, and coordination of case management services for severely
injured OEF/OIF service members/veterans, including those with TBI. The
Handbook also describes the functions of 100 new transition patient
advocates, who will be assigned to severely injured service members/
veterans, including those with TBI, and their families. Recruitment for
the new positions is already underway.
The Office of Seamless Transition (OST) implemented a seamless
transition performance measure for Fiscal Year (FY) 2007. Severely
injured OEF/OIF service members/veterans who are transferred by VA/
Department of Defense (DOD) liaisons at the military treatment
facilities (MTF) must be assigned a VAMC case manager prior to
transfer. This VAMC case manager must contact the service member/
veteran within 7 calendar days of notification of the transfer. OST
developed a tracking system which the VA/DOD social work liaisons,
stationed at the MTF, enter the patients transferring to VA into. As of
October 2006, the tracking system automatically generates an e-mail to
the receiving facility when the VA/DOD liaison enters a potential
transfer date. The receiving facility assigns a case manager in the
tracking system and the case manager must contact the patient within 7
calendar days of notification of the transfer.
VA has partnered with the Army Wounded Warrior (AW2) Program to
assign an AW2 soldier and family management specialist to 22 VAMCs
located in the VISN 21. The AW2 staff will integrate with existing
polytrauma teams and will function as case managers for both soldiers
and their families. They will work with soldiers, veterans and their
families to ensure they are fully linked to VA care and benefits.
Currently, 17 AW2 staff members are in place, with 5 more scheduled to
begin their assignments by the end of 3rd quarter Fiscal Year 2007.
Recommended Improvement Action(s) B: The Under Secretary for Health
should work with DOD to establish collaborative policies and procedures
to ensure that TBI patients receive necessary continuing care
regardless of their active duty status, and that appropriate medical
records are transmitted.
The revised VA/DOD memorandum of agreement (MOA) entitled,
``Department of Veterans Affairs (VA) and Department of Defense
Memorandum of Agreement Regarding Referral of Active Duty Military
Personnel Who Sustain Spinal Cord Injury, Traumatic Brain Injury, or
Blindness to Veterans Affairs Medical Facilities for Health Care and
Rehabilitative Services'' is currently in the Office of the Assistant
Secretary of Defense for Health Affairs. DOD is shifting billing and
reimbursement under this MOA from the Military Medical Support Office
to the three TRICARE regional offices. There are no changes that impact
the transfer of clinical care between the two agencies.
VA and DOD have developed the capability to share electronic
medical records bidirectionally to coordinate the care of shared
patients. The VA/DOD Bidirectional Health Information Exchange (BHIE)
supports the real-time bidirectional exchange of outpatient pharmacy
data, allergy information, lab results, and radiology reports between
all VA facilities and select DOD host sites receiving large numbers of
OEF/OIF combat veterans such as the Walter Reed Army Medical Center
(WRAMC), the Bethesda National Naval Medical Center (BNNMC), and the
Landstuhl Army Medical Center in Germany. All VAMCs have the capability
to view the DOD BHIE data. In addition to BHIE capability, VA and DOD
have made significant progress toward sharing inpatient data. VA and
DOD have developed the capability to permit the four VA regional
polytrauma centers to view DOD inpatient data stored in DOD's clinical
information system (CIS). This capability provides unprecedented access
to electronic DOD inpatient data by VA clinicians treating patients
transferred from DOD and enhances continuity of care between DOD and
VA. VA and DOD also conducted successful testing of the bidirectional
sharing of inpatient narrative and discharge summaries.
Recommended Improvement Action(s) C: The Under Secretary for Health
should develop new initiatives to support families caring for TBI
patients, such as those identified by patients and family members we
interviewed.
VA and DOD provided a national satellite broadcast, ``Serving our
Newest Generation of Veterans'' in May 2006. This live broadcast was
repeated on multiple dates and times to provide VA staff opportunities
for viewing. The continuing education program included presentations on
understanding the military culture, providing appropriate care across
the lifespan; addressing the needs of families of polytrauma patients
through supportive services; educating patients, families and staff
about polytrauma rehabilitation (which includes a video about the four
PRCs), amputation care, cognitive issues, physical and recreation
therapy needs of polytrauma patients; and transforming the
rehabilitation environment to better meet the unique needs of young
polytrauma patients.
PM&RS National Program Office identified a subject matter expert in
the area of therapeutic support for families dealing with stress and
loss. During the August 2006 ``Polytrauma System of Care Conference,''
a nationally recognized expert, provided an educational session on the
impact of trauma on the family, assisting families with coping and
providing strategies for VA providers. VHA is continuing to work with
this nationally recognized expert as a consultant. She presented at a
conference for Polytrauma Rehabilitation Center staff and VA leadership
in December 2006.
OSW has held four quarterly educational conference calls for VHA
social workers on polytrauma and seamless transition. Each call
stressed different aspects of assessing and meeting the needs of
families of polytrauma and other OEF/OIF patients.
VHA has hired seven clinical staff members who are assigned to the
Center for Intrepid Joint Services Rehabilitation Facility (Center) at
Brooke Army Medical Center in San Antonio, Texas. VHA staff will
provide clinical services and seamless transition services to active
duty service members undergoing rehabilitation at the Center. VHA staff
further provide supportive services to families such as logistical
support (e.g., transportation), education regarding VA services, and
case management support. An MOA for VA's role in the operation of the
Center was signed by Secretary Nicholson in September 2006, and by the
Secretary of the Army in January 2007. The Center was dedicated on
January 29, 2007, and is currently receiving active duty patients for
rehabilitation.
The PRCs at Minneapolis, Minnesota and Palo Alto, California have
Fisher Houses to lodge the families of active duty service members and
veterans undergoing polytrauma rehabilitation. A Fisher House is under
construction at the James A. Haley VA Hospital in Tampa, Florida with
an estimated completion date of June 2007. The Fisher House Foundation
will break ground for a new Fisher House at the PRC in Richmond,
Virginia in late Spring/early Summer 2007, with an estimated completion
date of Fall 2007.
The Fisher House Foundation has plans to build three additional
Fisher houses in 2007 (Dallas, Los Angeles, and Seattle) and 10
additional in 2008 and 2009. The Fisher houses will support families of
OEF/OIF patients, including polytrauma and TBI patients at the PNS.
Each PRC and PNS has established a General Post Fund for family
lodging and associated needs. Voluntary Service accepts donations made
to VAMCs for family lodging into the Family Lodging General Post Fund.
Social workers access the funds to help families defray the costs of
hotel lodging, meals, and local transportation at facilities without
Fisher Houses or when the Fisher House is full.
OSW is working with the Fisher House Foundation's Hero Miles
Program to provide free airline ticket vouchers for the families of
polytrauma patients so they can visit the patient.
More than 200 VHA social workers attended the Uniformed Services
Social Work & Seamless Transition Conference in August 2006. VA hosted
conference offered a seamless transition track with workshops on
transferring care from DOD to VA facilities, meeting the needs of
families, treating combat stress and post traumatic stress disorder
(PTSD), and working with veterans suffering from polytraumatic
injuries.
Recommended Improvement Action(s) D: The Under Secretary for Health
should work with DOD to ensure that rehabilitation for TBI patients is
initiated when clinically indicated.
In April 2006, a VA/DOD TBI Executive Board was established. A TBI
Summit was held in September 2006 that brought together non-VA, DOD,
and VA subject matter experts to discuss contemporary practice
concerning the identification and treatment of individuals with brain
injuries. Outcomes of this meeting included identification of priority
issues, and building consensus across DOD and VA concerning case
management, assessment and treatment.
In April 2007, VA sponsored a conference to educate VA and DOD
staff about services and programs for OEF/OIF veterans. Specialized
educational tracts included mental health, polytrauma and TBI,
diversity and women's health, pain management, seamless transition, and
prosthetics and sensory aids. Each VISN developed an action plan for
management of OEF/OIF veterans.
A VA/DOD rehabilitation nurse liaison has been hired and assigned
to WRAMC in September 2006. This individual monitors and follows the
severely injured, assesses readiness for rehabilitation, communicates
closely with the rehabilitation nurse admission case managers at the
PRCs, provides updates on medical status, functional status, recovery
progress, and nursing care issues. The rehabilitation nurse liaison
will have close contact with families, providing education concerning
impairments, rehabilitation process, and orientation to VA PRCs. A
second nurse liaison is being hired for BNNMC, and should be in place
by September 2007.
Question 3b. Additionally, can you please address Denise Mettie's
concerns about the care afforded to her severely brain injured son,
including the fact that he was not initially referred to a Polytrauma
Center?
Response. While at National Naval Medical Center, this severely
injured veteran was referred to the PSC and evaluated by the Palo Alto
VA PRC. Considering the medical presentation of the patient, plans were
made to move him to a PNS closer to his family--the Puget Sound VA
Medical Center. The Polytrauma case manager has worked closely with the
veteran's family, coordinating evaluations from another VA PRC and two
private sector facilities. All consulting medical facilities concur
that his care needs are currently best met by a skilled nursing
facility. The case manager continues to be actively involved in his
care and support of his family.
Question 4. I am concerned that some younger veterans have been
placed into long-term care facilities intended for older patients with
dementia or other age-related conditions. It seems that the need for
age-appropriate care for some of our younger veterans has been well
established. What is VA doing to ensure that younger veterans with
traumatic brain injuries receive this type of long-term care, including
opportunities for continued therapy and mental stimulation, if
warranted?
Response. VA is taking measures to recognize the generational
differences of this population and incorporate them into the care
routines as well as cohort them in the nursing home with populations
that are similar in ability to communicate and interact. In VA nursing
homes, transforming the culture of care to make the living space more
home-friendly is important. Having an Internet cafe, computer games, or
age appropriate music and videos available for nursing home residents
is necessary. Allowing for family, especially children, to visit, and
perhaps even stay over when needed; personalizing care routines such as
bathing and dining times; offering food items that are palatable to
younger persons are examples of the changes occurring in VA nursing
home care. Unlike other cohorts of veterans in nursing home care, this
cohort thrives on independence, is physically strong, and is part of a
generation socialized differently than their older counterparts.
VA has and will continue to admit young veterans into VA nursing
homes when the veteran presents with sufficient functional impairment
or health care needs that cannot be adequately addressed in a home and
community based setting. Many returning veterans are presenting with
multiple and severe disabilities including speech, hearing and visual
impairment as well as loss of limbs and compounded with behavioral
issues due to the stress of combat as well as brain injury. In
addition, they have families, including children, who want to be
actively involved in their care.
Question 5. Denise Mettie's testimony touched on the need of
families of veterans with traumatic brain injuries for support and
assistance during the initial rehabilitation stage and throughout
subsequent years. How does VA plan to provide these families with the
support and training that they need in order to successfully care for
their loved ones?
Response. Consistent with VA's legal authorities, while patients
are being treated in an inpatient setting at a PRC, their families have
access to the following services:
<bullet> A social work case manager who is responsible for
coordinating care, ensuring access to psychosocial services for patient
and family, providing caregiver support within their scope of practice,
and coordinating support services to meet family needs.
<bullet> Accommodations at a Fisher House, if available, hotel
accommodations where a Fisher House is not yet available,
transportation, telephone cards, and gift certificates for meals and
entertainment.
<bullet> Clinical psychologists and social work case managers who
facilitate caregiver support groups and/or individual interventions to
address issues such as the role of bereavement in family transition,
expected role changes within the family, intra-familial conflicts,
marital strife, and other family stressors.
<bullet> Referrals as appropriate to mental health or medical
resources.
<bullet> Chaplain services providing counseling and spiritual
support for families and caregivers.
Consistent with VA's legal authorities, while patients are being
treated in the outpatient setting at a PNS or by a PSCT, their families
have access to the following services:
<bullet> Interdisciplinary team that includes a social work and
nurse case manager. Clinical and psychosocial case management and
coordination of the veteran's lifelong care needs by an
interdisciplinary team.
<bullet> VA paid home care services (skilled home nurse care, home
health aide, homemaker, respite care, adult day health care) required
by the veteran.
<bullet> VA Home and Community Care Services (home based primary
care, adult day health care).
<bullet> A 24/7 Polytrauma helpline through the call center
operated by the Dayton VAMC.
<bullet> VA Vet Centers that offer counseling services to combat
veterans and their families/significant others to help with
readjustment issues, including treating combat stress and PTSD and
helping families and caregivers deal with the effects of combat
service.
For those patients that require long term care, VA provides access
to the following services:
<bullet> VA nursing home care units with access to rehabilitation
therapies.
<bullet> Contract nursing home care in the local community.
<bullet> VA medical foster care.
<bullet> Veterans and their families continue to receive
psychosocial support and case management throughout the continuum of
care.
______
Response to Written Questions Submitted by Hon. John D. Rockefeller IV
to Michael J. Kussman, M.D., Executive-in-Charge, Veterans Health
Administration, Department of Veterans Affairs
Question 1. What is the VA policy regarding health care
professionals and research experts who are willing to volunteer their
expertise for the care of returning veterans?
Response. VHA Handbook 1620.1, dated July 15, 2005 provides
direction for healthcare professional volunteers. Volunteer assistance
by physicians, dentists, nurses, and other professionally licensed
persons to assume full responsibility for professional services in
their respective fields may be accepted under certain circumstances.
All such volunteer assignments must first be approved in advance by the
facility chief of staff, or designee, who must ensure that any
resulting volunteer appointment is first processed through all
applicable credentialing and privileging procedures as described in VHA
Handbook 1100.19. Any volunteer serving in this capacity must have
appropriate training, work under the supervision of a VA compensated
clinical staff member, and meet the other criteria for acceptance as a
volunteer in VA's Voluntary Service (VAVS) program. Limited health care
procedures, not requiring certification, can be approved as volunteer
assignments by the clinical service involved. Any volunteer serving in
this capacity must have appropriate training, work under the
supervision of a VA compensated clinical staff member, and meet the
other criteria for acceptance as a volunteer in the VAVS Program. The
assignment must be in the area of supplementary assistance, and may be
performed by either a lay or professionally licensed person working as
a volunteer.
In addition, the professional may not be assigned to their ``area
of expertise.'' For example, a surgeon may not be assigned to be in an
area where they would perform surgery. We would use them where their
skills could best serve the veteran and enhance patient care.
Question 2(a). Can you provide information on the number of VA
rehabilitation beds and services?
Response. VA supports 1768 rehabilitation beds nationwide--578
inpatient rehabilitation beds, 241 beds allocated for blind
rehabilitation, and 949 spinal cord injury (SCI) specialty beds.
Additionally, VA has implemented a rehabilitation treatment specialty
within nursing homes to further expand availability of rehabilitation
services for veterans as necessary.
VA provides highly specialized acute inpatient rehabilitation for
veterans and active duty service members with TBI and polytrauma at
four Level I PRCs. Each PRC has 12 rehabilitation beds (48 of the total
578 inpatient beds) that are accredited for brain injury rehabilitation
and comprehensive rehabilitation by the Commission for Accreditation of
Rehabilitation Facilities (CARF). Referral patterns and bed occupancy
at the PRC are monitored on a weekly basis and VA has consistently
maintained adequate capacity for patients with polytrauma/TBI.
An additional 245 rehabilitation beds (of the total 578 inpatient
beds) are located across 17 Component II PNS that are not co-located
with a PRC. These beds are CARF accredited for comprehensive inpatient
rehabilitation and have not required a high demand for inpatient care
to date; i.e., typically one or two OIF/OEF inpatients at a time.
Question 2(b). What action has VA taken to date to provide for such
care, and what are the long term costs to maintain such capacity?
Response. VA's General Purpose Funding is distributed to its
facilities based on the Veterans Equitable Resource Allocation (VERA)
model, which includes funding to maintain capacity for rehabilitation
care. Conditions such as TBI, SCI and blindness are specifically
addressed for funding as separate patient classes within the complex
care group. Long range planning models for these groups of patients use
higher incidence and prevalence statistics to account for combat-
related injuries.
Additionally, the PRC and PNS receive Special Purpose Funding from
VA Central Office to support a portion of the rehabilitation
specialists, consultants, staff training, and equipment used in
rehabilitation care. The VISNs and medical centers have also provided
additional resources to meet specific program needs.
Question 2(c). Has VA considered other rehabilitation centers to
meet immediate needs?
Response. VA contracts with the private sector to provide services
to eligible veterans as a complement to its system of care whenever
indicated and authorized. Decisions to contract care are determined
based on the needs of the individual patient, and VA staff coordinates
episodes of contracted civilian care in support of the continuum of
lifelong care for veterans with long-lasting disabilities.
Question 3. What new research is VA undertaking or commissioning to
study the interactions of TBI and PTSD? What research is VA doing on
the effects of vision loss and hearing loss on TBI diagnosis and care?
Response. VA's Office of Research and Development (ORD) supports a
broad portfolio in TBI and related neurotrauma research and estimates
devoting over $29.6 million to this research in Fiscal Year 2007.
This includes studying the interactions of TBI and PTSD. In one
ongoing study, VA researchers collaborating with DOD are collecting
risk factor and health information from military personnel prior to
their deployments to Iraq. These soldiers will be reassessed upon their
return and several times after that to identify possible changes that
occurred in emotions or thinking as a result of their combat exposures,
and to identify predisposing factors to PTSD as well as other health
conditions. A goal of this study is to determine whether
neuropsychological findings observed from pre- to post-deployment
persist until long-term follow-up, and to examine the associations at
long-term follow-up of neuropsychological changes and self-reported
traumatic brain injury with the development of PTSD.
ORD has also issued a solicitation for new research in combat
casualty neurotrauma seeking to advance treatment and rehabilitation
for veterans who suffer TBI and other traumas from improvised explosive
devices and other blasts. The solicitation is still active and
applicants are asked to pay special attention to cooperative projects
in TBI with DOD, including co-morbid conditions with TBI such as PTSD.
ORD has also issued a special solicitation for new research on TBI and
polytrauma (i.e., combinations of multiple injuries, including brain
injuries, sensory loss, nerve damage, infections, emotional problems,
amputations and/or spinal cord injuries) that includes studying the
interactions of TBI and PTSD.
These solicitations are also seeking new research examining sensory
loss and TBI. Ongoing ORD projects in this area are aiming to identify
and characterize deficits in neural processing relevant to vision and
hearing among veterans suffering from blast-related injuries, including
those with TBI, and to develop effective rehabilitation therapies that
improve visual and hearing functions important to everyday life. The
overarching goals of these projects are to develop earlier detection
strategies and enhanced treatment of blast-related injuries with
respect to hearing, vision and potentially other important neural
consequences.
In addition, VA recently established a Polytrauma and Blast-Related
Injury Quality Enhancement Research Initiative (PT/BRI QUERI)
coordinating center to use the results of research to promote the
successful rehabilitation, psychological adjustment and community
reintegration of OEF/OIF veterans. The scope of the PT/BRI QUERI
includes the full range of health problems, healthcare system and
psychosocial factors that impact returning veterans, and focuses on the
complex pattern of co-morbidities and related functional problems and
healthcare needs among the combat-injured. The PT/BRI QUERI links VA
investigators with VA's polytrauma system of care, including the four
lead centers located in Minneapolis, Richmond, Tampa, and Palo Alto.
The polytrauma QUERI has two particular emphases: (1) to accelerate the
diffusion and use of new knowledge generated by VA research in the
areas of traumatic brain injury, sensory loss, prosthetics and
amputation, and (2) to identify and address the needs of informal
caregivers such as spouses or parents in order to allow veterans to
remain in home and community-based settings.
Question 4. What type of comprehensive screening is VA doing for
returning veterans on 161, PTSD, vision loss, and hearing loss?
Response. In regards to screening veterans for TBI, VA has
developed a comprehensive approach to screening and evaluation of TBI
by implementing a mandatory TBI screening clinical reminder across the
VA. This includes a screening instrument that uses a data system prompt
with an algorithm to refer patients with positive screens to a Level II
or Level Ill polytrauma team for complete evaluation. All OIF/OEF
veterans receiving medical care in VA facilities will be screened for
possible TBl. The patient's medical record is checked at every visit
through the use of computerized clinical reminders, software built into
VHA's electronic medical record, to determine if screening has been
completed. If screening was missed or has not yet done, VA providers
will be ``reminded'' through the use of the computerized clinical
reminder to perform screening. This approach helps ensure that patients
who may have been missed or came before screening was mandatory get
screened. Those who screen positive for TBI will be offered further
evaluation and treatment by clinicians with expertise in the area of
TBI.
Veterans receive comprehensive eye examinations by ophthalmologists
and/or optometrists in VAMC Eye Clinics. Veterans documented with
vision loss are referred to VAMC Low Vision Clinics and Blind
Rehabilitation Centers, where they receive clinical visual
rehabilitation examinations by Optometrists or Ophthalmologists. Vision
rehabilitation therapists at these centers conduct functional vision
assessments to determine veterans' abilities in activities of daily
living, literacy abilities, orientation and mobility, etc. Patients
with moderate to severe polytrauma and TBI receive vision evaluations
as part of the comprehensive rehabilitation management procedures.
VA does not routinely screen returning veterans for hearing loss;
however, active duty service members receive a post-deployment health
survey that addresses hearing-related concerns. Audiology services are
routinely provided for veterans injured on active duty and undergoing
physical evaluation boards within MTFS. Injured veterans transferred to
the VA health care system are typically screened for hearing loss by an
audiologist or speech-language, and more comprehensive evaluation and
treatment is completed by an audiologist as warranted (e.g., hearing
aids, assistive alerting and listening devices, cochlear implants). All
veterans with hearing concerns may file a claim for military service-
related disability with the Veterans Benefits Administration.
VA screens all returning veterans who come to VA for care for PTSD,
depression and alcohol abuse using questions that are used annually for
all veterans. A screening tool for mild TRI is currently being released
nationally.
______
Response to Written Questions Submitted by Hon. Bernard Sanders
to Michael J. Kussman, M.D., Executive-in-Charge, Veterans Health
Administration, Department of Veterans Affairs
Question 1. Is screening for TBI and PTSD currently mandatory at
VA? If so, then what efforts are being made to re-screen those veterans
that may have been missed or misdiagnosed, when they first returned,
before screening was mandatory?
Response. Screening for PTSD has been mandatory since 2004 for all
veterans, and screening for TBI in OEF/OIF veterans became mandatory as
of April 2, 2007.
Enrolled veterans who screen positive for PTSD or other mental
disorders are assessed to determine if the diagnosis is accurate or if
there are other problems which need treatment. If a patient is found to
have a problem other than PTSD, that condition is treated. Also there
is re-screening of all enrolled OEF/OIF veterans for PTSD every year
for the first 5 years after the initial screen. There is also annual
re-screening for depression and alcohol abuse.
In regards to screening veterans for TBI, VA has developed a
comprehensive approach to screening and evaluation of TBI by
implementing a mandatory TBI screening clinical reminder across VA.
This includes a screening instrument that uses a data system prompt
with an algorithm to refer patients with positive screens to a Level II
or Level III polytrauma team for complete evaluation. All OEF/OIF
veterans receiving medical care within the VA will be screened for
possible TBI. The patient's medical record is checked at every visit
through the use of computerized clinical reminders, software built into
VHA's electronic medical record, to determine if screening has been
completed. If screening was missed or has not yet done, VA providers
will be ``reminded'' through the use of the computerized clinical
reminder to perform screening. This approach helps ensure that patients
who may have been missed or came before screening was mandatory get
screened. Those who screen positive for TBI will be offered further
evaluation and treatment by clinicians with expertise in the area of
TBI.
Question 2. Can you tell me how many veterans in Vermont are
currently being treated for TBI? And PTSD? Since there are reports of
reoccurrence of PTSD with older veterans, please break down the answers
for PTSD into two categories: OEF/OIF and all other veterans. Please
also provide the answers to the above questions for New England as a
whole. In addition, how many veterans have been diagnosed with TBI or
PTSD but have not sought treatment? Again, please break down the
answers for PTSD into two categories: OEF/OIF and all other veterans.
Please also provide the answers to the above questions for New England
as a whole. My staff has asked VA for this data but has not received
it. This information is crucial for my office to understand the patient
levels that the facilities in my state and surrounding states should
plan for and are currently serving.
Response. The Defense Manpower Data Center roster of 686,306 OEF/
OIF veterans was matched against VA's inpatient (PTF) and outpatient
(OPC) treatment records to retrieve all VA treatment data as of
December 31, 2006. A total of 229,015 veterans have sought care from a
VAMC from the start of OEF in October 2001 to December 2006. Using
these health care records, 129 OEF/OIF veterans were identified as
having been evaluated or treated for a condition possibly related to a
TBI from VISN 1.
These conditions are listed as follow:
<bullet> ICD-9-CM 310.2: Postconcussion Syndrome: n=21
<bullet> ICD-9 CM 800: Fracture of skull: n=0
<bullet> ICD-9 CM 801: Fracture of base of skull: n=0
<bullet> ICD-9 CM 802: Fracture of face bones: n=27
<bullet> ICD-9 CM 803: Other and unqualified skull fracture: n=0
<bullet> ICD-9 CM 804: Multiple fractures involving skull or face
with other bones: n=1
<bullet> ICD-9 CM 850: Concussion: n=47
<bullet> ICD-9 CM 851: Cerebral laceration and contusion: n=1
<bullet> ICD-9 CM 852: Subarachnoid, subdural, and extradural
hemorrhage, following injury: n=0
<bullet> ICD-9 CM 853: Other and unspecified intracranial
hemorrhage following injury: n=0
<bullet> ICD-9 CM 854: Intracranial injury of other and unspecified
nature: n=41
<bullet> ICD-9 CM 950: Injury to optic nerve and pathways: n=2
Of these 129 veterans, 18 patients resided in Vermont.
Because there is no ICD-9 code specific to TBI, the above number
should be considered tentative and provisional. The sum of the number
of patients corresponding to each ICD-9 code (n=140) is more than 129
because a patient may carry more than one ICD-9 code.
VHA does not have data on veterans diagnosed with TBI or PTSD who
have not sought treatment.
VISN 1 specific OIF/OEF veterans coded with potential PTSD through
1st Qt Fiscal Year 2007
Number of Unique OIF/OEF Veterans with PTSD Using VA Facilities During Fiscal Year 2002-1st Qt Fiscal Year 2007
--------------------------------------------------------------------------------------------------------------------------------------------------------
Inpatients Outpatients Total Patients\1\ Vet Centers\4\
------------------------------------------------------------------------------------------ Grand
VISN-Facility Sub- Total\5\
Primary\2\ Any\3\ Primary\2\ Any\3\ Primary\2\ Any\3\ PTSD PTSD Other
--------------------------------------------------------------------------------------------------------------------------------------------------------
1-BEDFORD........................................... 9 29 162 181 62 186 44 6 51 222
1-BOSTON............................................ 25 66 485 565 488 581 270 18 430 713
1-MANCHESTER........................................ 142 179 142 179 123 9 441 261
1-NORTHAMPTON....................................... 18 24 159 171 160 172 77 1 1,416 209
1-PROVIDENCE........................................ 11 30 296 348 297 352 106 1 676 404
1-TOGUS............................................. 2 12 240 282 240 285 220 78 373 410
1-WEST HAVEN........................................ 6 17 441 483 441 484 186 8 543 556
1-WHITE RIVER JCT................................... 10 15 180 229 180 230 110 726 539 306
VISN 1.......................................... 77 178 2,008 2,312 2,010 2,329 1,136 847 4,469 2,906
--------------------------------------------------------------------------------------------------------------------------------------------------------
\1\ The ``total patient'' counts were generated by matching a cumulative roster of 686,306 unique OIF/OEF veterans, who had been separated from active
duty as of November 30, 2006, with VA inpatient (PTF) and outpatient (OPC) databases for Fiscal Year 2002, 2003, 2004, 2005, 2006 and through 1st Qt
Fiscal Year 2007. The DOD Defense Manpower Data Center identified and provided the identity of these veterans to the VA Environmental Epidemiology
Service on January 11, 2007.
\2\ The number for ``Primary'' indicates the total number of unique veterans whose primary reason for the inpatient or outpatient visit was for
treatment or evaluation of PTSD.
\3\ The number for ``Any'' indicates the total number of unique veterans with PTSD, whether or not the primary reasons for the inpatient or outpatient
visit was for treatment or evaluation of PTSD.
\4\ The Vet Center counts were based on matching the DMDC OIF/OEF roster with Vet Center user's record through 1st Qt Fiscal Year 2007.
\5\ The number for ``Grand Total'' (n=4552l) indicates the sum of ``Any Total Patients''(n=39243) and ``Vet Center PTSD'' (n=11660) after excluding
known duplicates (n=5382).
The overall number of unique veterans in VISN 1 who received
treatment for PTSD in FY 2006 was 19,356.
Question 3. What do you think of mandatory mental health screening
by DOD for all service members that are deployed, when they return from
service? Could this help remove the stigma of service members having to
ask for mental health treatment, if everyone was required to be
screened for mental health issues?
Response. DOD currently screens all returning service members for
health issues when they return from deployment using the Post
Deployment Health Assessment (PDHA) and again 3-6 months post
deployment using the Post Deployment Health Reassessment (PDHRA). Both
the PDHA and PDHRA include mental health questions. VA also has
mandatory screening of OEF/OIF veterans who come to VA for care using
questions on PTSD, depression and alcohol abuse. These questions are
the same as those used annually to screen all veterans. It is believed
that screening all service members and veterans is an approach that can
reduce stigma and at the same time ensure assessment of the population
at risk.
______
Response to Written Questions Submitted by Hon. Johnny Isakson
to Michael Kussman, M.D., Executive-in-Charge, Veterans Health
Administration, Department of Veterans Affairs
Question 1: Do you have any plans to expand the Active Duty
Rehabilitation program at the Augusta VA Medical Center?
Response: The Department has no current plans to expand the Active
Duty Rehabilitation program at the Augusta Veterans Affairs Medical
Center (VAMC). The Augusta Department of VAMC has been able to meet the
military's needs for all inpatient rehabilitation referrals; 93 percent
of the referrals come from the southeast regional medical command. Fort
Gordon remains the primary referral source with 66 percent of
referrals, followed by 10 percent from Fort Campbell and 7 percent from
Fort Stewart. The occupancy rate for the 30-bed active duty
rehabilitation (ADR) inpatient unit at the Augusta VAMC has increased
in recent months from 35 percent to 86 percent, VA will continue to
monitor occupancy rates to determine the need for additional
rehabilitation services in the future.
Question 2: Do you have any plans to expand the Active Duty
Rehabilitation program to other VA Medical Centers across the country?
Response: The Veterans Health Administration (VHA), in consultation
with the Department of Defense (DOD), is presently evaluating the need
for additional polytrauma rehabilitation centers (PRC) to augment the
services currently being provided at VAMCs across the country. VHA
currently provides the highest quality medical, rehabilitation, and
support services for veterans and active duty servicemembers through
the VHA integrated polytrauma/traumatic brain injury (TBI) system of
care, consisting of: (1) four regional polytrauma/TBI rehabilitation
centers providing acute intensive medical and rehabilitation care for
complex and severe polytraumatic injuries; (2) 21 polytrauma/TBI
rehabilitation network sites, which implement the post-acute
rehabilitation plan of care; and (3) 72 polytrauma/TBI support clinic
teams located at local medical centers throughout the 21 Veterans
Integrated Service Networks (VISN), which provide routine follow-up of
care for veterans with a history of TBI and polytrauma.
Question 3: Do you feel that treating active duty troops at VA
medical centers benefits the Department of Veterans Affairs?
Response: VA mission is to ``care for him who has borne the
battle.'' Meeting the comprehensive health care needs of returning
Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF)
veterans and servicemembers is the Departments highest priority. VA
works closely with the Department of Defense to ensure our returning
servicemen and women receive the highest quality of care and seamless
transition of benefits, without regard to where their care is provided.
Chairman Akaka. Thank you very much, Dr. Kussman.
Ms. Embrey?
STATEMENT OF ELLEN P. EMBREY, DEPUTY ASSISTANT
SECRETARY, HEALTH AFFAIRS/FORCE HEALTH PROTECTION AND
READINESS, DEPARTMENT OF DEFENSE
Ms. Embrey. Mr. Chairman, thank you very much the
opportunity to be here today. On behalf of the Assistant
Secretary of Defense for Health Affairs, I am going to be
talking to you about health care needs of returning
servicemembers and new veterans.
The Department of Defense, and the military health system
specifically, is committed to protecting the health of our
servicemembers, providing the best and world-class health care
to more than 9 million beneficiaries and coordinating the
transition of servicemembers' medical care to the Department of
Veterans Affairs whenever necessary and appropriate.
Over the last several years, our two Departments have
fostered a more effective, aligned Federal health care
partnership by coordinating and developing common health care
and support services along the continuum of care. The Global
War on Terrorism has posed a particular challenge to both
Departments in adapting particularly for long-term
rehabilitative care for our complex wounded, injured, and ill
combat veterans. We owe very much to them, as demonstrated by
the first panel, for their sacrifice to our Nation, and we are
committed to working together to ensure that they get the very
best that our health systems can offer and, consistent with Dr.
Gans' testimony, working with the civilian industry if that is
appropriate to get them the best care that they need.
The DOD/VA Joint Executive Council established the core
partnership, a strategic plan and goals to better align and
coordinate the health and benefits services of each of our two
Departments.
Before continuing more about these efforts, I would like to
briefly discuss the Department of Defense response to the
recent findings of inadequate administration of support
services, care coordination, and disability processing.
The Department of Defense is strongly committed to taking
corrective actions to improve performance in these areas.
Secretary Gates has formed an Independent Review Group to
advise him on the actions that need to be taken, and they have
45 days to complete their assessment, and that is coming up
here very shortly.
In addition, each military department has undertaken a
focused review to take actionable actions immediately as they
find them. And the Under Secretary of Defense for Personnel and
Readiness, Dr. David Chu, has convened a working group to
assess ways to improve the policies and programs of the
Department based on the results of these ongoing reviews.
DOD is also cooperating with the President's Commission, as
well as the interagency Veterans Affairs task force that was
established to review these matters as well.
DOD's collective focus in these areas is on five major
programs: facilities; caseworkers and case managers, along with
the family support that goes with that; the disability
determination process; traumatic brain injuries and treatment
of severely injured; and post-traumatic stress disorders and
mental health.
With respect to TBI, or traumatic brain injury, I thank you
very much and your distinguished colleagues in Congress for
your interest and support in expanding TBI research and
treatment within the Department.
Now, I would like to refocus my remarks on overall DOD and
VA partnerships in health care. The VA and DOD established and
collaborated on the use of Joint Incentive Fund to eliminate
budgetary constraints as a possible determinant for that
sharing. Designated funding covers startup costs associated
with innovative and unique sharing agreements, and at the end
of 2006, 47 Joint Incentive Fund projects accounting for $88.8
million of the $90 million in the fund has been approved by the
Executive Health Council. We are jointly staffing DOD and VA
Federal health facilities at several locations around the
country and have sharing agreements between DOD medical
treatment facilities and Reserve component units with 157 VA
medical centers.
This increased sharing has facilitated improved but not
perfect coordinated transition of servicemember care from DOD
to VA. This transition involves effectively managing medical
care and benefits during the transition from active duty to
veteran status to ensure continuity of care and services.
The Department has been working with VA on streamlining and
better aligning our support for coordinated transition in three
main areas: medical care and disability benefits, transition to
home and community, and sharing servicemember personnel and
health information. The first panel spoke to all three of these
and the issues that are at hand and the challenges before us.
Servicemembers who transition directly from DOD medical
treatment facilities to one of the VA polytrauma centers are
met by a familiar face in uniform. In 2006, the VA expanded
their 4 centers for polytrauma to a polytrauma network with an
additional 21 sites, and DOD assets will be there as well. The
VA has placed their assets in our military treatment
facilities. Their Joint Seamless Transition Program has been
worked by the VA in coordination in with the military services
and which facilitates a more timely receipt of benefits for the
severely injured servicemembers while they are still on active
duty. There are currently 12 VA social workers and counselors
assigned at 10 military treatment facilities.
As of the end of last month, VA social workers supported
7,082 new patient transfers to the Veterans Health
Administration from participating military hospitals. The VA
has also placed liaisons at each of our three TRICARE regional
offices to enhance communications and coordination between us
to better support our shared beneficiaries.
DOD and VA partnering has been a key focus with respect to
shaping common clinical services for our beneficiaries. An area
of particular concern is our shared clinical focus on
identification and treatment and follow-up for traumatic brain
injuries. DOD fielded a clinical practice guideline for the
management of mild TBI in CENTCOM, the theater of operations,
in August of 2006, including requiring field use of a standard
military acute concussion evaluation tool to assess in the
field and document TBI for medical records upon return.
Efforts to build a more comprehensive DOD-wide program,
including VA experts, is now underway to establish common
protocols and procedures to identify, treat, document, and
follow up on those who have suffered a TBI while either
deployed or in garrison.
I see that my time is up, and I would be happy to yield the
floor back to the Chairman for further questions.
[The prepared statement of Ms. Embrey follows:]
Prepared Statement of Ellen P. Embrey, Deputy Assistant Secretary,
Health Affairs/Force Health Protection and Readiness, Department of
Defense
Thank you, Mr. Chairman, for the opportunity to speak to you today
on behalf of the Assistant Secretary of Defense for Health Affairs
regarding the health care needs of returning servicemembers and new
veterans.
The Department of Defense, and the military health system in
particular, is committed to protecting the health of our
Servicemembers, providing world-class healthcare to more than 9 million
beneficiaries, and, seamlessly coordinating the transition of
Servicemembers' medical care to the Department of Veterans Affairs (VA)
whenever necessary.
Over the last several years, our two Departments have made
significant strides in coordinating and developing common health care
and support services along the entire continuum of care. Both agencies
have been making concerted efforts to work closely to maintain and
foster a more effective, aligned Federal healthcare partnership. The
Global War on Terrorism poses a challenge to both Departments, as the
severity and complexity of wounds, and the increased survival rates
yield increasing demands on our system for long term rehabilitative
care for our wounded, injured and ill combat veterans. We owe much to
them for their sacrifice to our nation, and we are committed to work
together to ensure they get the very best that our health systems can
offer, and keeping their associated bureaucratic burdens to a minimum.
In April 2003, a DOD-VA Joint Executive Council (JEC), chaired by
the Under Secretary of Defense for Personnel and Readiness and the
Deputy Secretary of the Department of Veterans Affairs, was established
to jointly set strategies, goals and plans to better align and
coordinate the health and benefit services of the two Departments. The
JEC meets quarterly to review progress against the mutually developed
plans.
The VA/DOD Joint Strategic Plan reflects common goals from both the
VA Strategic Plan and the Military Health System (MHS) Strategic Plan--
and specifically articulates the shared goals and objectives developed
and ratified by DOD/VA leadership. Three weeks ago, Dr. David S.C. Chu,
Under Secretary of Defense for Personnel and Readiness, and Mr. Gordon
H. Mansfield, Deputy Secretary, Department of Veterans Affairs,
directed additional joint initiatives to improve alignment, leverage
shared resources, and improve delivery of care to our returning combat
veterans.
The spectrum of DOD-VA collaboration and sharing activities
encompasses clinical services, education and training, research and
development, patient administration, and information/data technology
sharing. Before providing an overview of these activities, I'd like to
briefly highlight the Departments' response to the recent findings of
inadequate administration of support services, care coordination, and
disability processing. The Department is strongly committed to taking
corrective actions to improve performance in these areas. Secretary
Gates has formed an Independent Review Group (IRG) to advise him on
actions that need to be taken, each Military Department has undertaken
a focused review of these matters, and the Under Secretary of Defense
for Personnel and Readiness Dr. Chu, has convened a working group to
assess ways to improve policies and programs based on the results of
these ongoing reviews. DOD is also cooperating with the President's
Commission on Care for America's Returning Wounded Warriors and is
participating actively in the Interagency Task Force on Returning
Global War on Terror Heroes.
DOD's collective focus is centered on five major program areas:
1. Facilities. DOD's medical facilities, outpatient housing,
medical barracks, and the full spectrum of hotel services provided by
the Department are being assessed to ensure standards of quality our
Servicemembers and families expect and deserve are met.
2. Case Workers/Case Managers and Family Support. Practices for
case management, including care coordination, case-manager-to-patient
ratios, family support models, and related support services are being
assessed to ensure our wounded and ill Servicemembers get needed
support throughout their healthcare delivery and rehabilitation,
regardless of whether their care is delivered in DOD or VA facilities.
In some instances, patients will continue to obtain care in both
systems. For that reason, establishing case-management protocols and
systems that seamlessly support all configurations of care in both
systems is a high priority.
3. Disability Determination Processes. Medical, personnel, and
disability-benefit determination experts within and outside the DOD are
actively involved in an effort to develop and recommend a streamlined
process that minimizes delay while providing fair, consistent, and
timely determinations for all Servicemembers.
4. Traumatic Brain Injuries (TBI) and Treatment of the Severely
Injured. Since the Global War on Terrorism began, DOD has been
collaborating with VA on the full spectrum of combat wounds, injuries
and associated illnesses, particularly those occurring as a result of
improvised explosive devices. Both Departments are working together to
identify best practices for providing and supporting highest quality
acute and long term care for severely injured and ill servicemembers,
as well as to determine the most effective means to screen, diagnose,
and treat individuals who experience a TBI. Civilian TBI experts and
researchers are important collaborators to both Departments in shaping
how to apply available research outcomes in establishing an evidence-
based, comprehensive program in both systems to detect, diagnose and
treat this health risk to our servicemembers and veterans.
5. Post-Traumatic Stress Disorder (PTSD)/Mental Health. The short-
term and long-term mental health needs of our Servicemembers and
veterans are major priorities of both Departments. To further
transition support, a VA/DOD Mental Health Working Group was formed in
2003 under the Joint Executive Council to focus specifically on mental
health initiatives and transition of care. DOD continues to critically
evaluate its capabilities, policies and programs to ensure effective
support for returning servicemembers and new veterans' mental health
needs, including their families. This includes looking at improved
methods of information sharing from VA medical records regarding mental
health conditions and treatments for Reserve Component members that may
contraindicate future deployments. With the renewed support of the line
commanders and leaders, new approaches to reducing the stigma of
seeking mental-health treatment will be explored. We will continue to
pursue expanded opportunities for collaboration with VA to ensure the
coordinated transition of veterans with mental-health needs.
Supporting all of these collaborative efforts, we will continue to
grow, enhance, align, and integrate the technology infrastructure that
supports both systems, enabling greater access to clinical and
administrative information for the benefit of the people we serve.
The following provides greater detail on our comprehensive sharing
initiatives:
overall dod-va sharing efforts
As a result of the National Defense Authorization Act for Fiscal
Year 2003, VA and DOD have been actively collaborating on a wide
spectrum of joint initiatives. Section 721 of that Act required that
the departments establish, and fund on an annual basis, an account in
the Treasury referred to as the Joint Incentive Fund (JIF). The JIF
provides a means to eliminate budgetary constraints as a possible
deterrent to sharing initiatives by providing designated funding to
cover the startup costs associated with innovative and unique sharing
agreements. At the end of Fiscal Year 2006, 47 JIF projects--accounting
for $88.8 million of the $90 million in the fund--had been approved by
the Health Executive Council out of a total of more than 200 proposals.
The 2006 projects cover such diverse areas of medical care as mental-
health counseling, Web-based training for pharmacy technicians, cardio-
thoracic surgery, neurosurgery, and increased physical therapy services
for both DOD and VA beneficiaries.
We also are jointly staffing a number of Federal health facilities.
These include:
<bullet> The Center for the Intrepid--opened in January 2007,
provides a state-of-the-art facility in San Antonio, Texas, explicitly
to rehabilitate wounded warriors. This follows the Walter Reed Amputee
Training Center's example of onsite collaboration.
<bullet> Integrated DOD-VA operations in several locations, for
example: North Chicago (Great Lakes Naval Station); New Mexico
(Kirtland AFB); Nevada (Nellis AFB); Texas (Fort Bliss); Alaska
(Elmendorf AFB); Florida (NAS Key West); Hawaii (Tripler AMC), and
California (Travis AFB).
<bullet> At the end of Fiscal Year 2006, DOD military treatment
facilities and Reserve Units were involved in sharing agreements with
157 VA Medical Centers, enabling improved visibility of medical needs
in VA for reservists entitled to VA care after returning from combat
operations.
coordinated transition
Coordinated transition involves effectively managing medical care
and benefits during the transition from active duty to veteran status
to ensure continuity of services and care. Efforts to date have focused
on enabling Servicemembers to enroll in VA healthcare programs and file
for VA benefits before separation from active duty status.
Additionally, the Department has been engaged with VA on initiatives
and programs supporting coordinated transition focused on three general
areas: (1) medical care and disability benefits, (2) transition to home
and community, and (3) sharing Servicemember personnel and health
information. The Joint Executive Council has established a Coordinated
Transition Working Group to examine and make recommendations for
improvement to the transition process.
For Servicemembers who transition directly from DOD military
treatment facilities to VA medical centers, DOD and VA implemented the
Army Liaison/VA Polytrauma Rehabilitation Center Collaboration
program--also called ``Boots on the Ground''--in March 2005. This
program is designed to ensure that severely injured Servicemembers
(primarily Army soldiers) who are transferred directly from a military
treatment facility to one of the four VA Polytrauma Centers--in
Richmond, Tampa, Minneapolis, and Palo Alto--are met by a familiar face
and a uniform. A staff officer or non-commissioned officer assigned to
the Army Office of the Surgeon General is detailed to each of the four
locations, to provide support to the family through assistance and
coordination with a broad array of such issues as travel, housing, and
military pay. This coordination process has been working exceptionally
well. However, this transition has not always worked as well when
Servicemembers are transferred to other locations around the country.
In response, VA opened 21 new Polytrauma Network Sites in Fiscal Year
2006 to provide continuity of care to injured Servicemembers. The
Department deeply values the sacrifices that these veterans and their
families have made. With our VA colleagues, we are committed to doing
all we can to improve our coordination and case management of
Servicemembers who transition to any VA facility.
VA also is placing personnel in our medical facilities. The Joint
Seamless Transition assists severely injured Servicemembers while they
are still on active duty so that they can receive benefits in a timely
manner. There are 12 VA social workers and counselors assigned at 10
military treatment facilities, including Walter Reed Army Medical
Center and the National Naval Medical Center in Bethesda. These social
workers ensure the seamless transition of healthcare, including a
comprehensive plan for treatment. Veterans Benefits Administration
counselors visit all severely injured patients and inform them of the
full range of VA services, including readjustment programs, educational
and housing benefits. As of February 28, 2007, VA social worker
liaisons had processed 7,082 new patient transfers to the Veterans
Health Administration from participating military hospitals.
VA also partners with DOD medical facilities through a Cooperative
Separation Physical Examination and Benefits Delivery at Discharge
(BDD) program which began in 2004. The BDD program eliminates the
disadvantage of previous procedures, in which Servicemembers were
required to undergo two physical examinations within months of each
other. Under VA's BDD program, Servicemembers can begin the claims
process with VA up to 180 days before separation at any of the 131 DOD
sites where local agreements have been established.
Finally, VA has placed liaisons in each of our three TRICARE
Regional Offices in Washington, DC, San Antonio, TX, and San Diego, CA,
providing an important communications and coordination link between the
DOD and VA to better support our shared beneficiaries.
Within DOD, providing assistance and support to the families of
wounded or ill servicemembers during this tumultuous time of transition
continues to be a high priority. Thus, the Military Severely Injured
Center (MSIC), established in February 2005 within the Military
Community and Family Policy Office, operates a hotline center which
functions 24 hours a day, 7 days a week. The Center's mission is to
identify and resolve policy and program gaps in support and augments
and reinforces the support that each of the Service-specific programs
--the Army Wounded Warrior Program, the Navy Safe Harbor program, the
Air Force Helping Airmen Recover Together (Palace HART) program, and
Marine4Life--provide.
clinical services
DOD and VA are working together on some of the most complex
clinical matters emerging from the current war. We are developing joint
Evidenced-Based Clinical Practice Guidelines that are means for
disseminating throughout our systems the most current scientific and
medical knowledge. These guidelines allow our organizations to provide
fact-based state-of-the-art medical care that is easily transferable
between the two medical care delivery systems.
Although our range of shared clinical activity spans most specialty
areas, we are placing a particular focus in the following areas:
Mental Health
Mental-health services are available for all Servicemembers and
their families before, during, and after deployment. Servicemembers are
trained to recognize sources of stress and the symptoms of distress in
themselves and others that might be associated with deployment. Combat-
stress control and mental healthcare are available in-theater. In
addition, before returning home, we brief Servicemembers on how to
manage their reintegration into their families, including managing
expectations, the importance of communication, and the need to control
alcohol use.
After returning home, Servicemembers are provided easy and direct
access to mental healthcare services following a continuum of care
model. Same-day appointments and daily walk-in appointments are
available in military mental health clinics, and behavioral healthcare
providers are integrated into primary care clinics in both the DOD and
VA. TRICARE also is available for 6 months after return for Reserve and
Guard members and TRICARE Reserve Select programs are available for
continuing health insurance coverage for Reserve and Guard members and
their families after the 6-month transition period. To facilitate
access for all Servicemembers and family members, especially Reserve
Component personnel, the Military OneSource Program--a 24/7 referral
and assistance service--is available by telephone and on the Internet.
In addition, we provide face-to-face counseling in the local community
for all Servicemembers and family members. We provide this non-medical
counseling at no charge to the member, and it is completely
confidential. For clinical care, family members can access mental
health services directly in the TRICARE network. Up to eight sessions
are available without a referral from a primary care manager and
without pre-authorization requirements from TRICARE.
The Periodic Health Assessment (PHA) was added to the continuum of
assessments in February 2006. This annual requirement for all
deployable assets of the Department includes a robust mental health
section that complements the deployment health assessment process,
allowing the opportunity for assessment, referral to care, and
treatment outside the deployment cycle.
To supplement mental-health screening and education resources, we
added the Mental Health Self-Assessment Program (MHSAP) in 2006. This
program provides Web-based, phone-based, and in-person screening for
common mental health conditions and customized referrals to appropriate
local treatment resources. The program also includes parental screening
instruments to assess depression and risk for self-injurious behavior
in their children, along with suicide prevention programs in DOD
schools. Spanish versions of the screening tools are available as well.
Traumatic Brain Injury (TBI)
The Department is working on a number of measures to evaluate and
treat Servicemembers affected or possibly affected with traumatic brain
injury (TBI). For example, in August 2006, a clinical practice
guideline for management of mild TBI in-theater for the Services was
developed and fielded. Detailed guidance was provided to Army and
Marine Corps line medical personnel in the field to advise them on ways
to deal with TBI. The clinical practice guideline included a standard
Military Acute Concussion Evaluation (MACE) tool to assess and document
TBI for the medical record. TBI research in the inpatient medical area
is also underway.
A program to integrate the outstanding work completed in TBI by the
military departments has been initiated to establish a comprehensive
DOD program, and experts from VA are included in this effort. This
comprehensive program will provide system-wide common protocols and
procedures to identify, treat, document, and follow up on those who
have suffered a TBI while either deployed or in garrison. In addition,
it will address TBI surveillance, transition to non-DOD care, long-term
care, education and training, and research.
DOD has also modified the questions asked during the Post-
deployment Health Assessment, the Post-deployment Health Reassessment,
and the Periodic Health Assessment to help identify individuals who may
have suffered a TBI.
administration and logistics
The DOD/VA Health Executive Council worked with industry to
synchronize data on approximately 16,000 items from 17 manufacturers
and more than 160,000 items from Prime Vendor distributors. A contract
was awarded for a data synchronization pilot study to determine the
best purchase of medical items from the healthcare industry. We
continue to make progress on joint procurement activities. As of
September 2006, there were 77 joint National contracts, 7 Blanket
Purchase Agreements (BPAs) and 46 medical/surgical shared contracts.
Both Departments face a challenge familiar to health organizations,
insurers, employers and individuals across the country--the rising
costs of healthcare. One area--pharmacy--is particularly noteworthy.
Nearly 6.7 million beneficiaries use our pharmacy benefit, and in
Fiscal Year 2006, our total pharmacy cost was more than $6 billion. Our
partnership with VA on joint contracting for prescription drugs is part
of this solution, and our collective purchasing efforts have saved DOD
more than $784 million in Fiscal Year 2006.
occupational exposures
DOD and VA have collaborated on a number of recent projects related
to occupational and environmental exposures. Projects related to
chemical warfare agents and depleted uranium are two examples. DOD
undertook a wide-ranging initiative to identify all exposures to
chemical and biological agents from World War II to the present. To
date, DOD has provided more than 19,000 names of test participants to
VA. As part of this effort, DOD declassified the medically relevant
information from test records and identified the records of
approximately 6,700 soldiers who were involved in testing of chemical
agents, placebos, and/or pharmaceuticals in Edgewood, MD, during the
period of 1955-75. DOD provided the names of these individuals, the
dates of the tests, and the types of exposures to VA. VA and DOD
collaborated on writing a letter to veterans to explain the history of
the testing program and to provide information about the availability
of VA healthcare. VA started mailing notification letters in June 2006.
We continue to monitor the health affects of our Servicemembers
exposed to depleted uranium (DU) munitions. DOD policy requires urine
uranium testing for those wounded by DU munitions. We also test those
in, on, or near a vehicle hit by a DU round, as well as those
conducting damage assessments or repairs in or around a vehicle hit by
a DU round. The policy directs testing for any Servicemember who
requests it. More than 2,215 Servicemember veterans of Operation Iraqi
Freedom have been tested for DU exposures. Of this group, only nine had
positive tests, and these all had fragment exposures.
Testing continues for veterans exposed to DU munitions from the
1990-1991 Persian Gulf War. The 74 individuals with the most
significant exposures to DU in a Department of Veterans Affairs medical
follow-up program have been extensively studied with physical exams and
laboratory analyses for over 12 years. To date, none have developed any
uranium-related health problems. This DU follow-up program is in place
today for all Servicemembers with similar exposures.
health information technology and data sharing
In the health information technology arena, DOD and VA have engaged
in a number of important efforts to share essential clinical and
management information in support of health care services to our
wounded servicemembers and all eligible former military members who
seek care from VA.
The work of capturing and sharing relevant clinical information
between the DOD and VA begins on the battlefield. With the expanded use
of the Web-based Joint Patient Tracking Application (JPTA), our medical
providers should have improved visibility into the continuum of care
across the battlefield, and from theater to sustaining base. DOD grants
access to JPTA for VA providers who are treating Servicemembers in VA.
In addition, we are working with VA to explore ways to share relevant
patient injury/wound trend data to assist VA in predicting and
preparing for treatment of OIF and OEF combat veterans.
Since September 2003, DOD has provided a roster to VA periodically,
which lists OIF and OEF veterans who have either deactivated back to
the Reserve/National Guard, or who have separated entirely from the
military. VA uses this roster to evaluate the healthcare utilization of
OIF/OEF veterans. VA performed its most recent analysis related to
631,174 veterans in November 2006. Thirty-two percent of these
individuals had sought VA healthcare at least once. The three most
common diagnostic categories were musculoskeletal disorders (mostly
joint and back disorders), mental disorders, and dental problems. These
data are quite useful in VA's planning for allocation of healthcare
resources.
Servicemembers who have substantial medical conditions are
evaluated in the Physical Evaluation Board (PEB) process to determine
if they are fit to stay on active duty or if they should be medically
separated. DOD provides the names of individuals who enter the PEB
process to VA, to facilitate the transition of care and to assist in
starting the paperwork to provide VA benefits. In 2005, DOD and VA
signed a memorandum of understanding that stated that DOD would send
these data to VA. In October 2005, DOD delivered the first list to VA
of names, current locations, and medical conditions. Since then, DOD
has sent a list of names to VA periodically, which will continue in the
future. Data on more than 16,000 individuals have been transferred to
VA. The Veterans Health Administration and Veterans Benefit
Administration plan to send letters to these individuals to inform them
about the availability of VA healthcare and disability benefits,
respectively.
The Federal Health Information Exchange (FHIE) enables the transfer
of protected electronic health information from DOD to VA at the time
of a Servicemember's separation. Every month, DOD transmits laboratory
results, radiology results, outpatient pharmacy data, allergy
information, discharge summaries, consult reports, admission,
disposition and transfer information, elements of the standard
ambulatory data records, and demographic data on separated
Servicemembers. As of February 2007, DOD had transmitted more than 182
million messages to the FHIE data repository on more than 3.8 million
retired or discharged Servicemembers. This number grows each month.
DOD expanded the breadth of data transferred under the FHIE in
recent years. In September 2005, we began monthly transmission of the
electronic Pre- and Post-Deployment Health Assessment information to
VA, followed in November 2006 with monthly transmission of Post-
Deployment Health Reassessments (PDHRAs) for separated Servicemembers
and demobilized National Guard and Reserve members. Weekly transmission
of PDHRAs for individuals referred to VA for care or evaluation started
in December 2006. As of February 2007, VA has access to more than 1.6
million assessment forms on more than 681,000 separated Servicemembers
and demobilized Reserve and National Guard members.
The FHIE has been successful in improving data sharing as
Servicemembers' transition from DOD to VA care. In some communities,
however, beneficiaries eligible for both DOD and VA care may obtain
care from both systems. The Bidirectional Health Information Exchange
(BHIE) enables the real-time sharing of allergy, outpatient pharmacy,
demographic, laboratory, and radiology data between DOD BHIE sites and
all VA treatment facilities for patients treated in both DOD and VA
facilities. As of January 2007, BHIE was operational at 14 DOD medical
centers, 17 hospitals, and more than 170 outlying clinics. In the 3rd
Quarter Fiscal Year 2007, all DOD sites and all VA sites will be able
to view allergy information, outpatient pharmacy data, radiology
reports, and laboratory results (chemistry and hematology) on shared
patients.
We have begun testing our ability to share inpatient information,
and successfully completed initial testing at Madigan Army Medical
Center (AMC) and VA Puget Sound Health Care System (HCS) in August
2006--enabling access to inpatient discharge summaries from Madigan
AMC's Clinical Information System (CIS) and VA's VistA system. We
implemented this functionality in November 2006 at Tripler AMC where we
make emergency department discharge summaries available to VA on shared
patients. We also installed this functionality at Womack AMC in
February 2007. We plan further deployment in additional DOD sites in
Fiscal Year 2007. In the future, we will make additional inpatient
documentation, such as operative notes and inpatient consultations
available to VA.
We also began the exchange of important clinical information
between each of our clinical data repositories. The Clinical Data
Repository/Health Data Repository (CHDR) establishes interoperability
between DOD's Clinical Data Repository (CDR) and VA's Health Data
Repository (HDR). In September 2006, the CHDR interface successfully
exchanged standardized and computable pharmacy and medication allergy
data between William Beaumont AMC and El Paso VA HCS on patients who
receive medical care from both healthcare systems. Exchanging
computable pharmacy and allergy data supports drug-drug and drug-
allergy order checking for shared patients using data from both DOD and
VA.
In December 2006, DOD also began deployment and VA continued field
testing at Eisenhower AMC and Augusta VA Medical Center (MC) and at
Naval Hospital Pensacola and VA Gulf Coast HCS. During the 2nd Quarter
Fiscal Year 2007, the organizations implemented CHDR at Madigan AMC and
VA Puget Sound HCS, Naval Health Clinic Great Lakes and North Chicago
VA HCS, Naval Hospital San Diego-Balboa and VA San Diego HCS, and Mike
O'Callaghan Federal Hospital and VA Southern Nevada HCS. By July 2007,
DOD will send out instructions to sites to allow remaining DOD AHLTA
locations to begin using CHDR.
Finally, the Laboratory Data Sharing Initiative (LDSI) facilitates
the electronic sharing of laboratory order entry and results retrieval
between DOD, VA, and commercial reference laboratories for chemistry
tests. LDSI is available to all DOD and VA sites with a business case
for its use. Either Department may function as a reference lab for the
other. We are currently testing the addition of laboratory anatomic
pathology and microbiology orders and results retrieval using the
Logical Observation Identifiers Names and Codes (LOINC) and
Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT)
standards.
While the DOD and VA are pleased with this accelerated data sharing
over the last several years, we remain interested in even more
collaborative efforts in the information technology arena. Both Federal
health systems are proud of their successful deployments of enterprise-
wide health information technologies, AHLTA and VistA, yet we both are
seeking a new inpatient electronic medical record system. Consequently,
we have embarked on a study to explore the potential for a joint
inpatient system. This would offer several potential benefits. First
and foremost, electronic sharing of inpatient data would enhance our
ability to provide ``seamless transition'' of medical data for our
severely injured and wounded Servicemembers to VA care. Second, there
are potential cost efficiencies that would derive from joint-license
procurements and joint-development activities. Finally, such an effort
would likely proliferate opportunities for additional data sharing
between DOD and VA. The Departments have embarked on a joint assessment
that will recommend to DOD and VA leadership the best strategy for
accomplishing these objectives.
Our efforts in enhancing DOD-VA collaboration over the last several
years have been successful. Yet, we are not satisfied that we have
achieved all that is possible. We have an aggressive plan to work
through some of the greater technological and management challenges in
the coming year. With the support of the Congress, we are confident we
will be successful.
______
Response to Written Questions Submitted by Hon. Daniel K. Akaka to
Ellen Embrey, Deputy Assistant Secretary, Health Affairs/Force Health
Protection and Readiness, Department of Defense
Question 1. What are your thoughts on providing seriously injured,
separating servicemembers or their families with an electronic medium
containing as complete a medical record as possible, perhaps to include
scanned representations of paper records? This matter was raised by
Senator Burr at the Committee's hearing. I would appreciate your
thoughts on the feasibility of this additional precaution on behalf of
our injured veterans.
Response. Separating Servicemembers may receive a copy of their
medical records now. Further, providing Servicemembers with their
electronic health information is part of the Military Health System
strategic plan. But it is not clear that scanning older paper records
for all is the best approach. Rather, we should focus on those with
serious injuries, as we are doing with patients going to the VA
polytrauma clinics.
Question 2. The Fiscal Year 2007 Defense Authorization Bill
mandated that DOD include brain injury-related questions on its Post-
Deployment Health Assessment (PDHA) questionnaire, which is
administered to all returning servicemembers. This action was supposed
to have occurred within 6 months of the bill's passage. As we have now
reached this deadline, has DOD added this requirement to the PDHA in
compliance with the law? Additionally, has DOD begun to distribute the
new questionnaire for use by returning units?
Response. The existing Post-Deployment Health Assessment (PDHA)
questionnaire has always contained questions about several general
symptoms that are often associated with traumatic brain injury (TBI) or
post-concussive syndrome. Also, the Post-Deployment Health Re-
Assessment (PDHRA) questionnaire specifically asks if the servicemember
was exposed to a blast or explosion during their deployment. The DOD
issued policy guidance to add two TBI-specific screening questions to
all assessments, and is in the process of modifying the various
electronic versions of these assessment tools. The Assistant Secretary
of Defense for Health Affairs' policy memo mandating the use of these
screening questions set an implementation date of June 1, 2007.
In addition, in August 2006, a clinical practice guideline for
management of mild TBI in-theater was developed and fielded. The
clinical practice guideline included a standard Military Acute
Concussion Evaluation (MACE) tool to assess and document TBI for the
medical record. This clinical practice guideline and the MACE are in
use in the USCENTCOM Theater of Operation today.
Question 3. Several weeks ago, the Committee staff requested from
DOD's legislative office a detailed listing of non-mortal casualties of
the Global War on Terror, by specific type of injury or condition. They
were told that such information will take some time to obtain, as each
service keeps its own detailed casualty records. Please expedite the
collection of the data that staff has requested, and forward it as soon
as possible.
Response.
Injuries and Wounded in Action
------------------------------------------------------------------------
Operation Operation
Enduring Iraqi
Freedom Freedom Total
(OEF) (OIF)
------------------------------------------------------------------------
Total............................ 1,133 24,187 25,320
Returned to duty within 72 hours. 40% 56% 55%
------------------------------------------------------------------------
Source: Defense Manpower Data Center, as of March 17, 2007.
Disease and Non-Battle Injuries (DNBI) USCENTCOM (OEF/OIF) Combined
[Overall DNBI rate--4% of forces per week]
------------------------------------------------------------------------
------------------------------------------------------------------------
Injuries, all types........................................ 26%
Respiratory (colds, allergies, etc.)....................... 13%
Dermatologic (rashes, lesions, etc.)....................... 12%
Diarrhea and other abdominal problems...................... 6%
Mental Health.............................................. 3%
Combat Stress.............................................. 2%
All other categories combined.............................. 38%
------------------------------------------------------------------------
Source: Air Force Institute for Operational Health, as of March 10,
2007.
Question 4. Director Duckworth testified at the Committee's hearing
about the need for States to be able to track returning servicemembers
and new veterans. What is DOD doing to ensure that State Directors of
Veterans Affairs have the most complete and up-to-date information on
separating servicemembers?
Response. The Department of Defense (DOD) is coordinating with the
Department of Veterans Affairs (VA) and State Directors of Veterans
Affairs in the ``State Benefits Seamless Transition Program.'' This
initiative expands the communication links and coordination between VA,
DOD, and the State departments of Veterans Affairs. This program began
as a pilot project with the Florida State Department of Veterans'
Affairs in September 2006. The Defense Veterans Program Coordination
Office, in DOD, has participated in the planning of this program since
its inception.
The State Benefits Seamless Transition Program involves VA staff
located at ten DOD medical facilities around the country. The VA
personnel at the military hospitals identify injured servicemembers who
will transfer to VA facilities, such as the four VA Polytrauma Centers.
After veterans sign an informed consent form, VA staff contact State
Veterans' Affairs offices on behalf of the veterans. The State offices,
in turn, contact the veterans to inform them about available State
benefits. This should facilitate earlier access to State benefits and
enhance the States' capabilities to provide long-term support to
veterans and their families.
______
Response to Written Questions Submitted by Hon. Patty Murray to Ellen
Embrey, Deputy Assistant Secretary, Health Affairs/Force Health
Protection and Readiness, Department of Defense
traumatic brain injury
Secretary Embrey, I've been having a very hard time getting real
numbers from your department on how many servicemembers need treatment
for Traumatic Brain Injury (TBI).
I asked the Defense Secretary last month. He got back to me last
week with a preliminary figure. He said that 2,121 Iraq and Afghanistan
war veterans have been treated for TBI since October 2001.
But--and this is important--he said that number is incomplete
because it does NOT include cases from every Pentagon medical facility.
And it does NOT include all mild-to-moderate cases of TBI that occur in
the field.
As I said, if we don't have accurate numbers, we can't set the
right budgets, and we can't solve the problem.
One solution is to document any time that a servicemember is
exposed to an IED incident. This would be noted in their medical
records--so even if they don't suffer an immediate injury--we can
follow up with them later to see if they have TBI.
I understand that in August 2006--your office received a report
from an Armed Forces advisory board outlining a comprehensive plan to
address the TBI problems.
Question 1. Is that system up and running today? If not, why not?
Response. The Department of Defense (DOD) has responded to the
recommendations of the Armed Forces Advisory Board. In November, we
convened a panel of experts to address detection and treatment of mild
traumatic brain injury. From that meeting and other efforts in the DOD,
we now have clinical practice guidelines for in-theater management of
mild traumatic brain injury as well as a tool, the Military Acute
Concussion Evaluation (MACE), to help assess the severity of a possible
traumatic brain injury. Both the clinical practice guidelines and the
MACE are in use in the Operation Iraqi Freedom and Operation Enduring
Freedom theaters of operation.
In addition, the Assistant Secretary of Defense for Health Affairs
has requested a comprehensive plan to address TBI within the DOD. I am
the lead, with Vice Admiral Arthur, the Navy Surgeon General in
support. We have planned meetings in April and May with the Service
Surgeons General and personnel from the Services' Manpower and Reserve
Affairs offices, along with representatives from the Department of
Veterans Affairs and the principal supporting DOD organizations such as
the U.S. Army Medical Research and Materiel Command, and the Defense
and Veterans Brain Injury Center. The goal is to coordinate all current
Service and DOD efforts to develop a comprehensive program from the
point of injury to resolution. This will include attention to baseline
assessment, field evaluation, and treatment, screening post-deployment
and in the periodic health assessment, education for military and
family members, and research into protective, mitigating, and post-
incident treatment and rehabilitation techniques that will maximize
recovery.
Question 2. Have you run into anyone at the Pentagon who's opposed
to tracking IED exposure in medical records for servicemembers who are
not visibly injured on the battlefield?
Response. No. The primary issue regarding recording exposure to IED
explosions in the medical record is setting boundaries for what is
determined to be an IED exposure. Any person injured or symptomatic
after an exposure is considered exposed. For those not injured and not
symptomatic, we do not have a methodology to decide who was
``exposed.'' Such a determination might be dependent on distance from
the explosion, whether the explosion occurred near buildings or in an
open environment, etc.
joint patient tracking application (jpta)
Secretary Embrey, today we don't have a ``seamless transition''
between the Pentagon and the VA. More than two years ago, Congress
required the Pentagon to improve patient tracking and management. This
would ensure that servicemembers do not fall through the cracks and
that their records move with them so they can get timely, complete
care. It would create one record of all medical services a patient
receives from the battlefield onward. It's known as the Joint Patient
Tracking Application.
Question 3. Is this system up and running today? If not, why not?
Response. The DOD has improved patient tracking and management from
the theater to definitive care facilities. The Theater Medical
Information Program (TMIP) is running today on the battlefield, and it
includes capabilities to document inpatient, outpatient, and ancillary
care in an electronic health record. The Joint Patient Tracking
Application (JPTA) is also up and running today and it tracks patients
as they move from our combat support hospitals into receiving
facilities. The JPTA is only one of several information sources the DOD
makes available to the Department of Veterans Affairs (VA) to provide
information that helps VA providers care for our wounded
servicemembers. The JPTA is a Web-based patient tracking application
that gives DOD and VA providers an ability to track and report some of
their patient data, but it is not an electronic health record. When DOD
patients transfer to the VA for care, the DOD sends copies of all
medical records documenting treatment provided by the referring DOD
facility along with them. Other sources of medical records for the VA
are available through the Bidirectional Health Information Exchange and
the Federal Health Information Exchange, where we have transferred over
182 million messages on more than 3.8 million retired or discharged
servicemembers. Through these systems, the VA has access to patients'
electronic health records and medical histories.
Question 4. Why didn't your office follow through with the new
policy?
Response. The Department has made great strides to assure
compliance with the law as documented in the Joint Medical Readiness
Oversight Committee Report to Congress on our implementation of the
National Defense Authorization Act of Fiscal Year 2005. The Joint
Patient Tracking Application (JPTA) was developed at Landstuhl Regional
Medical Center to streamline the process of tracking patients for
Operations Enduring Freedom and Iraqi Freedom as they moved from the
USCENTCOM Theater. The system was piloted and put into use to track
patients from USCENTCOM to Landstuhl beginning in January 2004. In
November 2004, the Assistant Secretary of Defense for Health Affairs
issued a memorandum directing JPTA be implemented for patient tracking
throughout the Military Health System by November 2007.
Question 5. How many stateside military hospitals do not use JPTA
as required by law?
Response. Currently all 21 receiving facilities in CONUS that
support movement/transition of servicemembers from theater use the
Joint Patient Tracking Application (JPTA). More facilities will
implement the tracking capabilities when required. Additionally, there
are currently 17 Department of Veterans Affairs (VA) receiving
facilities using the JPTA for tracking VA eligible patients coming from
the Department of Defense.
Question 6. What reason would they have for not using it?
Response. The Joint Patient Tracking Application (JPTA) is but one
of several capabilities used to meet our force health protection
imperatives, and it is not an electronic health record. Most physicians
are aware of JPTA as a patient tracking system to assist in transfer of
essential patient information to the next level of care. The physicians
who do use JPTA as a means to capture electronic information do so if
no other primary or authoritative system for patient care is available,
e.g., Theater Medical Information Program systems or Service-specific
health care applications. Common JPTA users are patient administrators,
clinicians, case managers, and the medical liaisons who track
servicemember locations for commanders.
Question 7. Do you agree that not following the law places the
wounded soldier at a disadvantage and creates delays in data collection
while denying access to care and compensation?
Response. The Department has made great strides to assure
compliance with the law as documented in the Joint Medical Readiness
Oversight Committee Report to Congress on our implementation of the
National Defense Authorization Act of Fiscal Year 2005. I believe our
ongoing initiatives address Congressional direction and enable us to
increase responsiveness to medical situations from the point-of-injury
through the health care continuum. The Theater Medical Information
Program systems are a critical part of AHLTA that empowers us to
collect information to provide the most complete electronic medical
record possible. This helps to promote quality and efficient health
care for our servicemembers throughout the continuum of care.
Question 8. If you truly want a seamless transition why have you
not implemented the law?
Response. The Department has made great strides to assure
compliance with the law as documented in the Joint Medical Readiness
Oversight Committee Report to Congress on our implementation of the
National Defense Authorization Act of Fiscal Year 2005. DOD initiatives
directly support coordinated transition and title 10 (Subtitle A, Part
II, Chapter 55, Section 1074f) requirement for electronic capture of
medical data in theater. It supports Public Law 105-85, subtitle F,
section 765, which states that the ``Secretary of Defense shall
establish a system to assess the medical condition of members of the
Armed Forces . . . who are deployed outside the United States . . . as
part of a contingency operation . . . or combat operation.'' DOD
initiatives also support the Presidential Executive Order Promoting
Quality and Efficient Health Care in Federal Government Administered or
Sponsored Health Care Programs, Presidential Special Directive, dated
April 2004, and Presidential Directive/Endorsement, dated November
1997.
Question 9. What do you think happens when soldiers have to wait on
paperwork the DOD is required by law to collect and produce?
Response. The Department is committed to protect the health of our
servicemembers as one of our highest priorities. With or without the
Joint Patient Tracking Application (JPTA), the Department of Defense
(DOD) provides information on servicemembers who are treated in
Department of Veterans Affairs (VA) facilities or are on their way to
the VA for care. When our patients are referred to the VA for care, DOD
sends with them copies of all paper and electronic records from AHLTA
and JPTA, documenting treatment provided by the referring DOD facility.
Normally, a discussion of the details of the case takes place between
the referring DOD physician and the receiving VA physician.
It is important to note that JPTA does not contain all patient
medical information and, therefore, must be included with other data
system information to ensure a more complete transfer of patient
information to the VA.
In addition, the Bidirectional Health Information Exchange and the
Federal Health Information Exchange support information exchange
between DOD and VA, and the DOD has transferred over 182 million
messages on more than 3.8 million retired or discharged servicemembers.
Through these systems, the VA has access to patients' electronic health
records and medical histories.
The DOD welcomes the opportunity to brief Members of the Committee
on DOD's strategy and current capabilities for managing in-theater
medical tracking and surveillance.
amputation
Question 10. Please define the locations and dates for the ``Global
War on Terror (GWOT),'' ``Operation Iraqi Freedom (OIF),'' ``Operation
Enduring Freedom (OEF),'' the Iraq War, the Afghanistan War, and
``Operation Noble Eagle'' (ONE).
Response. Global War on Terror (GWOT): September 11, 2001--current,
multiple locations.
Operation Iraqi Freedom (OIF): March 19, 2003--current, location:
Iraq.
Operation Enduring Freedom (OEF): October 7, 2001--current,
location: Afghanistan.
The Iraq War is the same as Operation Iraqi Freedom.
The Afghanistan War is the same as Operation Enduring Freedom.
Operation Noble Eagle: September 11, 2001--current, location:
various, primarily homeland defense and civil support.
______
Response to Written Questions Submitted by Hon. Bernard Sanders to
Ellen Embrey, Deputy Assistant Secretary, Health Affairs/Force Health
Protection and Readiness, Department of Defense
Question 1. Is screening for TBI and PTSD currently mandatory at
DOD? If so, then what efforts are being made to re-screen those
servicemembers that may have been missed or misdiagnosed when they
first returned, before screening was mandatory?
Response. The existing Post-Deployment Health Assessment (PDHA)
questionnaire always contained questions about several general symptoms
that are often associated with traumatic brain injury (TBI) or post-
concussive syndrome. Also, the Post-Deployment Health Re-Assessment
(PDHRA) questionnaire specifically asks if the servicemember was
exposed to a blast or explosion during their deployment. On March 8,
2007, the Assistant Secretary of Defense for Health Affairs issued
policy guidance that requires the addition of two TBI-specific
screening questions to both the PDHA and PDHA self-reporting tools as
well as the Health Assessment Review Tool (a required part of each
servicemember's annual Periodic Health Assessment), with an effective
date of June 1, 2007. All three of these assessment tools already
include the validated four-question Primary Care Post-Traumatic Stress
Disorder screening scale. In addition, in August 2006, a clinical
practice guideline for management of mild TBI in-theater was developed
and fielded. The clinical practice guideline included a standard
Military Acute Concussion Evaluation (MACE) tool to assess and document
TBI for the medical record. This clinical practice guideline and the
MACE are in use in the USCENTCOM Theater of Operation today.
There is no plan to re-screen servicemembers, except at the time of
their Periodic Health Assessments or next deployments. Because the
Periodic Health Assessment is an annual requirement, all servicemembers
will have been screened after the passage of one year.
Question 2. What do you think of mandatory mental health screening
by the DOD for all servicemembers that are deployed, when they return
from service? Could this help remove the stigma of servicemembers
having to ask for mental health treatment, if everyone was required to
be screened for mental health issues?
Response. There already is mandatory mental health screening
accomplished during every Post-deployment Health Assessment and the
Post-deployment Health Re-assessment. This is accomplished through the
inclusion of various mental health screening questions on the two self-
reporting tools, the responses of which are then evaluated by primary
care providers who interview the individuals and make clinical
judgments regarding the need for additional evaluation or treatment,
including potential referral to mental health specialists. We have no
evidence that a mandatory screening by a mental health professional
would be more effective than the current approach. A trial program is
underway at Fort Lewis and a formal validation study is underway to
compare mental health outcomes of the two different approaches. The
results of the study are expected in 2008.
Question 3. How many OIF/OEF soldiers, who have their home of
record in Vermont, has the DOD diagnosed with PTSD or some form of TBI?
Response. From 2002, the number of servicemembers from Vermont with
a PTSD diagnosis is 73. For TBI, there have been 11.
______
Response to Written Question Submitted by Hon. Johnny Isakson to Ellen
Embrey, Deputy Assistant Secretary, Health Affairs/Force Health
Protection and Readiness, Department of Defense
Question. Do you feel that treating active duty troops at
Department of Veterans Affairs (VA) medical centers benefits the
Department of Defense (DOD)?
Response. The VA's treatment of active duty personnel continues to
be of great benefit to DOD. VA medical facilities have been providing a
wide range of health services to active duty personnel under agreements
with the military services and DOD for more than twenty years. These
agreements range from basic medical services in geographically remote
areas to specialized care for personnel with severe brain and spinal
cord injuries.
Chairman Akaka. Well, I thank you both very much for your
testimony.
One of the concerns has been medical hold. Mr. Pruden's
testimony discussed a veteran who was in medical hold for 3
years and 8 months, and it is difficult to think that that has
happened.
Ms. Embrey, both Mr. Pruden and Ms. Mettie talked about
lengthy medical holds and holdovers. It is our understanding
that the Army maintains patients in medical hold much longer
than the Navy and the Marines.
What is DOD doing to ensure that medical holds are
appropriate and are not unnecessarily long?
Ms. Embrey. Mr. Chairman, I believe that the Army was
dedicated to giving the most time possible for injured and ill
reservists who are put on medical holdover--those are the
principal population that are retained on active duty--to give
them an opportunity to heal so that they could return to duty.
And medical hold is a status for individuals where they are
allowed the time to heal until such time that no further or
additional medical treatment would improve their outcome. And
for some individuals, that is a very long time, and for others
it is a very short time.
In 2004, the Department initiated a monthly reporting
process where we reviewed the number of gains and losses to the
medical hold process from each of the services, and we get that
monthly report and we actively engage each of the Surgeons
General in the Departments to ask what they are doing to
address the time that is involved while these individuals are
in the medical hold status.
So, I think, we have actively working with the services to
make sure that it is being effectively managed. It is clear
that we could do a better job.
Chairman Akaka. I am glad to note that. We know that VA's
prosthetics services are geared toward patients with diabetes
and other diseases rather than combat wounds. DOD has the best
prosthetics around, but at some point DOD will shed some of its
prosthetic and rehabilitation functions.
Dr. Kussman, the Department of Defense has taken primary
responsibility for rehabilitating young combat amputees and for
fitting them with state-of-the-art prosthetic devices. Director
Duckworth testified about her view that the Hines VA does not
have the same level of prosthetic care that exists at Walter
Reed.
We also know about the state-of-the-art work being done at
the Center for the Intrepid. In time, some of the newer
veterans will come to VA for prosthetic replacements or for
other reasons.
What steps is VA taking to ensure that VA will be prepared
to take over the care of these amputees from war zones?
Dr. Kussman. Thank you, Mr. Chairman, for the question. I
also obviously listened to the testimony that was given by the
first panel.
We have been a national leader with prosthetics for a long
time, as you know, and there is no argument about the fact that
prior to the war, half of our patients were over 60 years of
age, and by that mere nature, most of the amputees.
But we have adapted to do that. We have over 600 contracts
with private contractors around the country to provide the
care, 63 labs, 125 certified prosthetists throughout the
system.
One of the challenges has been that some of the care that
comes at Walter Reed, for instance, is truly state-of-the-art
and only available there because it is research. And so a lot
of times when somebody comes to us, it is done in a partnership
with the handoff, and the patients go back to Walter Reed
because the expertise and the technology is not available
anywhere but at Walter Reed.
With our leadership of Fred Downs, who is there on a weekly
basis, who runs our prosthetic services, he meets with all the
amputees, explains to them the services that are available. In
truth, Walter Reed contracts a large amount of its prosthetic
care, just like we do. And so we believe that we have the
services available.
As Major Duckworth talked about, she preferred to see a
specialist down in Florida--which, by the way, we are paying
for--and she also commented on a physical therapist not being
able to come with her today. I do not know the specifics about
that, but we sent the prosthetists from Hines with her down to
Orlando, I believe, to see what was going on and to be sure
that we could provide her the same level of care in Hines.
So I think that we are continuing to improve. I think we
have a robust program. For somebody to say, a prosthetist in
our system to say they have never seen a C-leg or whatever, I
can't--I wouldn't take umbrage with the comment except that we
certainly provide a large number of C-legs and anything else
that is commercially available.
Chairman Akaka. Thank you very much. We will have a second
round.
Now I would like to call on Senator Burr.
Senator Burr. Thank you, Mr. Chairman.
I want both of you to know how much we appreciate your
service. You are in two vitally important areas to this country
and, more importantly, to our military and to our veterans.
Having said that, I hope that both of you really did listen
to the witnesses before--and I appreciate the recap of
everything we are doing. Ms. Embrey, your testimony is filled
with a tremendous detail of collaboration between the VA and
DOD in so many areas--clinical service, education, training,
research and development, patient administration, joint
initiatives to improve alignment, leverage shared resources.
We are now in the fifth year of this current conflict. At
what point do we actually look at what is going on and
implement changes? I get the impression--and I say this to you,
Dr. Kussman, with the firm reality you have not been there that
long from the standpoint of what you are doing now. How many
real-life experiences do we have to listen to before we do away
with the committees and the working groups and the interagency
collaboration efforts and we actually implement some of this in
the system?
So my question, Ms. Embrey, is real simple. Does DOD have
the capabilities today to electronically transfer the records
to VA of people that we are transferring over into that system?
Ms. Embrey. Yes.
Senator Burr. And do we do that?
Ms. Embrey. Yes.
Senator Burr. Then how can somebody enter the VA system or
how can a mother be entrusted to be the delivery point of a
son's medical records if we have got a system that
electronically transfers that into the other side that works?
Ms. Embrey. That is a good question.
Senator Burr. It is an important question.
Ms. Embrey. I think that both Departments have implemented
initiatives in their electronic health systems that allow them
to capture electronic health records, but they do not
necessarily transfer along--they have laboratory information
and things like that, but they do not give that electronically
directly to the individual, and the individual is entitled to
their medical records, copies of their medical records as well.
Senator Burr. But do you not agree that the single most
important thing in that transfer to the VA is to transfer all
of the medical data that is pertinent to that patient?
Ms. Embrey. And we believe we are doing that. We have
extensive meetings. We have a comprehensive management plan
that we discuss DOD providers are the individual to be
transitioned to the VA. There are conference calls. There are
dialogues between the losing provider and the gaining
providers. There is a plan for how that individual is supposed
to be managed, and the records that go along with that are
transferred electronically.
Senator Burr. Does it concern you that out of the two
witnesses that spoke on today, they had trouble having their
medical records provided in the VA system?
Ms. Embrey. I think that is absolutely evident, and I would
wonder what the root cause is. I think we have institutional
structures in place to make that happen, but at the individual
level, I believe some things don't get included because
somebody didn't update something.
Senator Burr. Well, let me suggest rather than to make this
complicated, if we admit there is a problem, and if, in fact,
DOD has the capacity today to download the medical records of
any patient, why don't we invest in little flash drives and why
don't we download the information to the patient, to the
parent, to the spouse, to whoever, as well as transferring it
to the VA so that at least in full detail we have got some
redundancy? Because, clearly, the system of electronically
transferring it isn't either doing it successfully or in total
or, in fact, we need to look at the DOD system and, in fact,
ask ourselves, ``Does it truly capture all the medical data
that is needed by the patient or by the next facility, VA or
private sector?''
Let me ask you, Dr. Kussman: Are you getting the medical
records for all the----
Dr. Kussman. I believe that we are getting all the
information that is available. As you know, the Secretary made
an announcement a few weeks ago, concurrently with Dr.
Winkenwerder, to work on a combined single inpatient electronic
health record. The information that is presently available is
lab tests and x-rays and other things, and both Departments
have worked hard to get that going. But the record itself still
is in paper.
Senator Burr. And I have tremendous respect for the
Secretary and Dr. Winkenwerder, whom I talk to on an occasional
basis. But let me go back to you, Ms. Embrey. We do have the
capabilities within DOD to produce all the medical records
electronically. Is that correct?
Ms. Embrey. We do not have a common inpatient system,
electronic system. Each of the services uses different
applications, and so that is, again, going back to what Dr.
Kussman just said, both of us need to and have agreed to
collaborate on acquiring or developing a joint application for
inpatient care that would provide complete seamless transaction
inpatient care to both systems.
Senator Burr. So the data exists within DOD. We just cannot
pull it all together. Is that what you are saying? Or part of
the DOD is still paper and part is electronic?
Ms. Embrey. That is correct.
Senator Burr. OK. So that makes it impossible to capture
all the data.
Ms. Embrey. Some of the military treatment facilities
capture inpatient data electronically, but it differs between
services. And so there is no common way for us to set up an
exchange electronically with the VA. Our solution to that has
been to capture as much information as has been available to
capture electronically and put it into a central data
repository, and it is that repository we use to provide VA with
the information.
Senator Burr. You know, an amazing thing happened before I
came to this hearing. I need to know something real quick, and
I went to my computer, and I Googled it. And instantaneously it
looked at a lot of different databases around the world, and it
came up with the information that I needed.
We are way past needing to combine databases, if, in fact,
we want to glean the information out of multiple databases. If
we are trying to merge databases, whether it is DOD or whether
it is CMS, we are going to be sitting here years from now not
having the capabilities to extract the information we need for
somebody who really needs the information.
So, one, we have learned something today. If, in fact, even
though they are different, each area electronically stores the
information, we can get it today. If we cannot figure it out,
call Google. They can tell us how to do it.
If, in fact, we are not electronically storing it today,
then we know the first step. We do not need the collaboration
between the Secretary and Dr. Winkenwerder. We know exactly
what we need to do, and we probably ought to have done that
years ago.
The transfer between the two of you, if, in fact, we fix
those first two pieces, is easy. It did not take a working
group to do it. It did not take any collaborative agreement. It
took sitting down and figuring out what is it we need to do to
have this capability. And, Mr. Chairman, it frustrates me.
Again, I have great respect for both of you for everything
that you commit to do. I pledge continually, whether it is DOD
or VA, to be here as an ally to make sure that we have got
sufficient resources. But to me, for us not to move forward as
quickly as we can at a time that you have heard witnesses say
we are not doing it, time is absolutely essential to the
outcome of the individuals that are affected, and we are
dealing with something as it relates to medical records that
does not really need a tremendous amount more study.
And as I said at the beginning, the thing that frustrates
me is the road blocks that you are currently running into. We
cannot even get a piece of legislation out of this body that
addresses health IT from the standpoint of the private sector
because of the competing--so I understand how difficult it is,
but the difficulty is both of you are in areas that have very
specific responsibilities. You can do this tomorrow if, in
fact, you will just commit to doing it. And I will follow up
with Secretary Nicholson, and I will follow up with Dr.
Winkenwerder to make sure that at least this piece is
emphasized with them, and my hope is that you will take to
heart the fact that three of these witnesses told very personal
stories today. And I believe that we could rotate those chairs
and you could hear personal stories, like I do, as long as we
are willing to sit here. And each of those stories are unique
and they are different, and all of them we have made the same
promise to, that this will be the best, that this will address
their needs, and the fact that we still fall short--and we
probably always will in some cases--just lets us know how
important the work that we are going to do is.
So, again, I thank both of you. I thank you, Mr. Chairman,
because I know I went over my time.
Chairman Akaka. Thank you very much, Senator Burr. I want
to thank you for your thoughtful questions and your remarks
that touch on collaboration and coordination that we are
seeking here.
Let me go on to a second round and touch on the diseases
that were mentioned by our first panel.
A program has been developed by medical staff at Fort Sam
Houston in conjunction with Walter Reed to provide guidance to
military clinicians on diagnosing and treating severe
infection. We heard Mr. Pruden and Director Duckworth talk
about this issue.
Ms. Embrey, what is DOD doing about serious illnesses and
fatalities in DOD facilities resulting from antibiotic-
resistant infections, some of which may have been picked up in
Iraq? Has DOD shared this expertise with VA?
Ms. Embrey. The acinetobacter infection that was referred
to is endemic in Iraq. It does embed in the wounds of injured
and wounded soldiers. Early in the conflict, we did discover
this, and an aggressive infection control program was developed
and issued and is abided by in theater and at every receiving
facility in the United States because it could spread,
especially if it is resistant to antibiotics.
We have issued bulletins. We have clinical working groups
with the VA who participate with us on all of the protocols
that we learn as we care for our wounded servicemembers, and we
share that with the VA. VA is well aware of the acinetobacter
threat, and they issue guidance to their community as well.
So I believe we are doing everything we can to aggressively
address infection control in our treatment facilities.
Chairman Akaka. Yes. Another seeming problem that has
occurred has been tracking of veterans. Dr. Kussman and Ms.
Embrey, Director Duckworth testified about the need for States
to be able to track returning servicemembers and veterans. What
is being done to ensure that State Directors have the best and
most up-to-date information?
Dr. Kussman?
Dr. Kussman. Mr. Chairman, before I answer the question, if
I could go back for just a second to the acinetobacter thing.
As Ms. Embrey said, we have had combined teams looking at the
protocols and clinical guidance we put out to all our
facilities years ago when this first came up. So I was really
disturbed about Captain Pruden's comment that an infectious
disease specialist there said he did not know what to do about
that, and I certainly will look into it because it is well
known as a problem, and we have certainly disseminated that
knowledge.
Major Duckworth raised the issue. We had a test case in
Florida. The Governor of Florida approached the VA and said,
look, we do not have any exposure of when people are going to
leave your facilities and come home. And we tested that for
about 3 or 4 months, and it was a great success. We now have
agreements with 19 States. I don't know why exactly Illinois is
not part of that, but I will certainly contact Major Duckworth
and see how we can move Illinois. But our hope is that all 50
or 52 jurisdictions--we take Puerto Rico and the District, and
others--that we will have that in place where all the States--
we have a very robust memorandum of agreement with the States,
as well as the Reserve and National Guard, to be sure that we
are communicating with them regularly.
When it does not work, we need to know about it, and we
need to fix it.
Chairman Akaka. Yes, Ms. Embrey, would you like to comment
on that?
Ms. Embrey. I just want to say that Guard and Reserve
individuals who continue to serve in the Department of Defense,
we are very interested in maintaining visibility on their
treatment and continuing health and wellness to continue to
serve. And so I took and listened with interest on the State
VA's role in helping us work with our Reserve component members
and sustaining their health. And so we will be doing that. We
will be looking into that.
Chairman Akaka. Well, thank you.
Director Duckworth made the case for increasing the window
of automatic eligibility for VA care from 2 to 5 years. This is
something that I believe is important for dealing with what we
call ``invisible wounds,'' which sometimes do not manifest
itself for many, many years.
Secretary Nicholson has testified before this Committee
that the current 2-year period provides ample opportunity for a
veteran to apply for enrollment in the VA system, and that an
expansion of this window is not necessary.
Dr. Kussman, has VA's position changed on this?
Dr. Kussman. I think it is under review, but if I could
comment on it, when the 2 years pass, these patients are not
refused or not eligible for care. As you know, they are all
veterans. They all have got a DD214. So whether it is 3 years
or 10 years later, you can come to the VA, be evaluated, and if
it is for--certainly for TBI that is related to things that
have happened when you are on active duty or PTSD, it will be
determined to be service connected and the person would
continue to get care.
The only difference of the 2 years or greater is that for
those 2 years we automatically enroll the person as a Priority
6, a level 6, with no copays, regardless of what their income
status or anything else is. But after that, they still could
come and regardless of what their income status is, if they
have a service connection, they would still be eligible to
enroll and get compensation and pension for that injury.
Chairman Akaka. Dr. Kussman, as Mr. Pruden testified, VA
seems to be out of practice in dealing with injuries resulting
from war rather than from diseases or illness. What can be done
about this so that we are giving our younger veterans the care
they need in the most sensitive manner?
Dr. Kussman. As I mentioned, there are some learning things
related to some of the new prosthetics and everything. But as
far as the injuries related, we have been a national and
international expert for the last almost 30 years on PTSD, and
since 1991 when we developed our four traumatic brain injury
centers in partnership with DOD, the Defense and Veterans Brain
Injury Center, we have actually been leading the country in the
treatment of that. And as you know, Major Duckworth did mention
about screening and things and checking. For quite a while now,
we have had an automatic screen in our electronic health record
for PTSD. So whenever an OIF/OEF veteran comes in, regardless
of what the symptoms are--because generally they will not come
and say, ``I have got PTSD,'' or ``I have got a mental health
problem.'' They come for something else. We have an automatic
drop-down menu that requires the primary care person, who
generally sees that person, to ask the questions related to
PTSD.
As you probably know, we have developed that same thing for
TBI. We have tested it in 12 sites, and the only reason we did
not implement it right away totally was that we have a very
robust electronic health record, probably the world's leader in
that, and that we wanted to be sure that when we put this
electronic drop-down menu we did not break something in the
electronic health record.
But as of April 1st, this electronic reminder for TBI as
well as PTSD will be implemented around our system because,
obviously, people don't come and say, ``I have got TBI,'' just
as they do not say--and I applaud your comments on invisible
illness. So we need to be aggressive in our outreach to
determine whether the individuals have it. If they are positive
for the screen, then they are referred to more sophisticated
neuropsychiatric evaluation. As you know, it is difficult. We
all know what to do with significant, severe traumatic brain
injury. Those are the ones that come back in the medical
evacuation chain and then come to us generally through our
polytrauma centers. But mild to moderate TBI is a challenge in
the civilian community as well as in the DOD and VA. And we are
trying to develop--we have worked with DOD and the civilian
community to develop this screening mechanism that will allow
us to try to determine mild to moderate TBI where the
individual might not even know they have got a problem, no one
has picked it up. And we need to track these people to be sure
that whatever we can do to help them, we should do it.
Chairman Akaka. I would tell you that this has been a good
hearing today, and I thank you so much for your responses. I
want to thank all the witnesses for appearing at today's
hearing. We truly appreciate your taking the time to give us
all a better understanding of the issues that our servicemen
and women are facing.
My hope is that today's hearing will help promote more
thoughtful and focused interaction between VA and DOD,
particularly when they are taking care of seriously injured
servicemembers. And, again, I want to thank you so much for
being helpful to the cause, and we are here to try to improve
the system. And we can do well doing it together.
Thank you very much, and this hearing is adjourned.
[Whereupon, at 12:12 p.m., the Committee was adjourned.]
A P P E N D I X
------
[Note: The following questions were submitted by Hon. Daniel K.
Akaka to Hon. Daniel L. Cooper at the hearing held on March 7, 2007,
which was already at press when the Committee received VBA's response.]
Questions Submitted by Hon. Daniel K. Akaka to Hon. Daniel L. Cooper,
Under Secretary for Benefits, Department of Veterans Affairs
Question 1. What would be the cost of expanding the BDD program to
all OIF/OEF veterans?
Response. Resources necessary to open additional intake sites
include dedicated funds, staffing reallocation, support infrastructure,
equipment, and telecom needs. DOD is required to establish a Memorandum
of Understanding with VA at each site and the military installation
must provide space. Given the significant level of investment, one of
the criteria in establishing the current BDD intake sites was the size
of the separation site.
A BDD claim is a pre-discharge claim taken from a servicemember at
one of the 140 BDD intake sites and processed through the BDD program.
There are specific criteria for BDD claims to include servicemembers
having 60-180 days remaining on active duty and availability for all
required medical examinations. However, any servicemember may file a
pre-discharge claim for disability compensation. A pre-discharge claim
may be accepted from a servicemember with 180 days or less remaining on
active duty. All claims from servicemembers who have participated in
the Global War on Terrorism receive priority handling of their claim.
Question 2. What is VBA's rationale for rating headaches associated
with traumatic brain injury at 10 percent while migraines are rated at
50 percent? What type of guidance has VBA provided to the field
concerning rating headaches that stem from traumatic brain injuries?
Response. The diagnostic code for rating headaches is 8100.
Although it is titled ``Migraine,'' any type of headache can be
evaluated analogously under this diagnostic code. The possible
evaluation levels are 0, 10, 30, and 50 percent, depending on the
severity (the frequency and duration of attacks and whether or not they
are prostrating).
There is not currently a special diagnostic code or set of
evaluation criteria for headaches from traumatic brain injury.
Subjective complaints such as headache, dizziness, insomnia, etc.,
recognized as symptomatic of brain trauma are rated under a hyphenated
diagnostic code, 8045-9304 with a maximum rating of 10 percent,
according to instructions contained in diagnostic code 8045. We are
currently in the process of reviewing and potentially revising the
entire neurology section of the rating schedule. We plan to address all
types of headaches, including headaches due to trauma.
We are preparing additional training material for adjudicators on
evaluating the residuals of traumatic brain injury. This will include a
discussion of post-traumatic headaches.
[Note: The following is a summary of the VA/DOD seamless transition
study conducted by the Government Accountability Office.]
DOD and VA Health Care: Challenges Encountered by Injured
Servicemembers During Their Recovery Process*
what gao found
Despite coordinated efforts, DOD and VA have had problems sharing
medical records for servicemembers transferred from DOD to VA medical
facilities. GAO reported in 2006 that two VA facilities lacked real-
time access to electronic medical records at DOD facilities. To obtain
additional medical information, facilities exchanged information by
means of a time-consuming process resulting in multiple faxes and phone
calls.
In 2005, GAO reported that VA and DOD collaboration is important
for providing early intervention for rehabilitation. VA has taken steps
to initiate early intervention efforts, which could facilitate
servicemembers' return to duty or to a civilian occupation if the
servicemembers were unable to remain in the military. However,
according to DOD, VA's outreach process may overlap with DOD's process
for evaluating servicemembers for a possible return to duty. DOD was
also concerned that VA's efforts may conflict with the military's
retention goals. In this regard, DOD and VA face both a challenge and
an opportunity to collaborate to provide better outcomes for seriously
injured servicemembers.
DOD screens servicemembers for PTSD but, as GAO reported in 2006,
it cannot ensure that further mental health evaluations occur. DOD
health care providers review questionnaires, interview servicemembers,
and use clinical judgment in determining the need for further mental
health evaluations. However, GAO found that 22 percent of the OEF/OIF
servicemembers in GAO's review who may have been at risk for developing
PTSD were referred by DOD health care providers for further
evaluations. According to DOD officials, not all of the servicemembers
at risk will need referrals. However, at the time of GAO's review DOD
had not identified the factors its health care providers used to
determine which OEF/OIF servicemembers needed referrals. Although OEF/
OIF servicemembers may obtain mental health evaluations or treatment
for PTSD through VA, VA may face a challenge in meeting the demand for
PTSD services. VA officials estimated that follow-up appointments for
veterans receiving care for PTSD may be delayed up to 90 days.
GAO's 2006 testimony pointed out problems related to military pay
have resulted in debt and other hardships for hundreds of sick and
injured servicemembers. Some servicemembers were pursued for repayment
of military debts through no fault of their own. As a result,
servicemembers have been reported to credit bureaus and private
collections agencies, been prevented from getting loans, gone months
without paychecks, and sent into financial crisis. In a 2005 testimony
GAO reported that poorly defined requirements and processes for
extending the active duty of injured and ill reserve component
servicemembers have caused them to be inappropriately dropped from
active duty, leading to significant gaps in pay and health insurance
for some servicemembers and their families.
______
[Note: The following is a summary of the VA/DOD seamless transition
study conducted by the VA Office of Inspector General.]
Health Status of and Services for OEF/OIF Veterans
After Traumatic Brain Injury Rehabilitation *
executive summary
In response to the influx of servicemembers returning from recent
conflicts in Afghanistan and Iraq, the Office of Inspector General,
Office of Healthcare Inspections undertook an assessment of selected
aspects of the health care and other services provided for these
patients by the Department of Veterans Affairs. This review addresses
the care of individuals with traumatic brain injury (TBI), focusing on
their status approximately 1 year following inpatient rehabilitation.
We interviewed a group of these patients to directly ascertain their
overall well-being, functional status, and social integration, and to
measure their perceptions of VA health care and services. In order to
gauge the effectiveness of VA rehabilitation efforts, we also compared
outcomes with those of TBI patients in the largest national civilian
database. Finally, we visited Veterans Health Administration (VHA)
facilities, met with TBI program leaders, and surveyed those
responsible for coordination of care for TBI patients.
Our inspection found that many of the 52 patients we interviewed
continued to suffer some degree of cognitive or behavioral impairment
approximately 16 months after injury. These patients had very similar
outcomes when compared with a matched group of TBI patients from the
private sector.
VHA has enhanced case management for TBI patients, but long-term
case management needs further improvement. In addition, improvement is
needed in coordination of care, so that patients are able to make a
smoother transition between Department of Defense (DOD) and VA care. A
recent VHA Directive, published after data collection for this report,
defines roles for staff at all VHA facilities to ensure a seamless
transition of care for servicemembers and veterans from DOD to the VA
health care system.
We found that families often provide heroic support for injured
servicemembers, but we also found that they frequently do so with
limited assistance. To adequately meet the needs of its TBI patients,
VHA needs to provide additional help for the family members and other
caregivers so vital to the well-being of these patients in the long-
term.
We recommended that the Under Secretary for Health should: (a)
improve case management for TBI patients to ensure lifelong
coordination of care, (b) work with DOD to establish collaborative
policies and procedures to ensure that TBI patients receive necessary
continuing care regardless of their active duty status and that
appropriate medical records are transmitted, (c) develop new
initiatives to support families caring for TBI patients, and (d) work
with DOD to ensure that rehabilitation for TBI patients is initiated
when clinically indicated.
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