VA Testimony of Madhulika Agarwal before Congress on January 21, 2010

United States Department of Veterans Affairs

HOUSE COMMITTEE ON VETERANS’ AFFAIRS
SUBCOMMITTEE ON OVERSIGHT AND INVESTIGATIONS
JANUARY 21, 2010
STATEMENT OF MADHULIKA AGARWAL, M.D., MPH
CHIEF OFFICER, OFFICE OF PATIENT CARE SERVICES,
VETERANS HEALTH ADMINISTRATION, U.S. DEPARTMENT OF VETERANS AFFAIRS

January 21, 2010

Good morning, Mr. Chairman and Members of the Subcommittee. Thank you for the opportunity to discuss the Department of Veterans Affairs’ (VA) efforts to help returning service members transition back to civilian life. I am accompanied today by Dr. Karen Guice, Executive Director of the Federal Recovery Coordination Program, and Mr. Paul Hutter, Chief Officer, Office of Legislative, Regulatory and Intergovernmental Affairs.

VA’s primary mission is to care for those who have borne the battle. As science and technology have advanced, more and more of our brave heroes survive what would have been fatal wounds in previous conflicts. However, survival is only the immediate goal—our job is to restore Veterans to the greatest level of health, independence and quality of life that is medically possible. To facilitate a smooth transition from the Department of Defense (DoD), VA has stationed 33 health care liaisons at 18 Military Treatment Facilities to facilitate the transfer of care to VA facilities. This program grew considerably during 2009 with six additional liaisons at five new sites. Altogether these liaisons have assisted more than 20,000 service members in transitioning from DoD to VA since 2004. We continue to work with DoD to identify additional sites that have increasing numbers of wounded warriors who may benefit from these services.

My testimony today will describe the advances made in VA’s Polytrauma System of Care, which provides coordinated inpatient, transitional, and outpatient rehabilitation services; our care management system, which coordinates complex components of care for ill and injured service members, Veterans and their families, as well as the education services VA provides to dependents and family members of injured Veterans; the Federal Recovery Coordination Program; and VA’s outreach efforts to returning service members and Veterans.

Polytrauma System of Care and Specialty Care

Polytrauma refers to complex, multiple injuries occurring as a result of the same event. Some examples of polytrauma injuries include traumatic brain injury (TBI), amputations, severe musculoskeletal injuries, burns, hearing loss or tinnitus, memory loss, visual impairment, cognitive impairment, pain, fatigue, or mental health conditions such as post-traumatic stress disorder (PTSD). Individuals with polytrauma require extraordinary levels of integrated and coordinated medical, rehabilitation and support services. To respond to these unique patient needs, VA developed a comprehensive model of care that includes interdisciplinary teams of health care providers that coordinate care as the patient moves from a Military Treatment Facility to a VA Polytrauma Rehabilitation Center, a local VA hospital, and re-integration into the Veteran’s or service member’s home community.

Since the designation of VA’s TBI Centers as Polytrauma Rehabilitation Centers in 2005, VA has continued to expand its Polytrauma System of Care by adding new specialized rehabilitation programs and teams of rehabilitation specialists at sites across the country. The VA Polytrauma System of Care has four levels of facilities: Polytrauma Rehabilitation Centers, Polytrauma Network Sites, Polytrauma Support Clinic Teams, and Polytrauma Points of Contact.

The four Rehabilitation Centers (located in Minneapolis, MN; Tampa, FL; Richmond, VA; and Palo Alto, CA) provide comprehensive medical and rehabilitation services on both an inpatient and outpatient basis for Veterans and service members with the most complex and severe injuries. These facilities typically have between 12 and 18 inpatient beds staffed by specialty rehabilitation teams that provide acute interdisciplinary evaluation, medical management and rehabilitation services. A fifth Rehabilitation Center is currently under construction in San Antonio, Texas and is expected to be completed in 2011.

Occupancy rates at these centers fluctuate over time and location. The average length of stay is 30 days, but for the most severely injured the average is 67 days. Upon discharge from a VA Polytrauma Rehabilitation Center, patients may be transferred to another facility, although more than 70 percent are discharged to their home. From March 2003 through fiscal year (FY) 2009, the Centers have treated approximately 1,500 inpatients with severe injuries; approximately 56 percent of these patients have been active duty service members. Slightly more than half of the patients treated in the Polytrauma Rehabilitation Centers were injured in non-combat, non-deployed incidents.

Recent new specialized rehabilitation initiatives at the Polytrauma Rehabilitation Centers include:

In July 2007, 10 bed residential Transitional Rehabilitation Programs were established at the four Centers to provide rehabilitation in a home-like environment to facilitate community reintegration for Veterans and their families.
Beginning in 2007, VA implemented a specialized Emerging Consciousness care path at each of the four Polytrauma Rehabilitation Centers to serve those with severe TBI who are slow to recover consciousness. These patients require complex and intensive medical services and resources to improve their level of responsiveness and reduce medical complications. VA collaboratively developed this care path with subject matter experts from the Defense and Veterans Brain Injury Center (DVBIC) and the private sector. VA and DVBIC continue to collaborate on research in this area, and our models of care continue to be updated in response to scientific advances.
In October 2008, all inpatients with TBI at VA Polytrauma Rehabilitation Centers began receiving special ocular health and visual function examinations. To date, 649 inpatients have received these examinations.
In April 2009, VA began an advanced technology initiative to establish assistive technology laboratories at the four Polytrauma Rehabilitation Centers. These facilities will serve as a resource for VA health care and provide the most advanced technologies to Veterans and service members with ongoing needs related to cognitive impairment, sensory impairment, computer access, communication deficits, wheeled mobility, self care, and home telehealth.
VA continues to optimize its Polytrauma Telehealth Network to facilitate provider-to-provider and provider-to-family coordination, as well as consultation from Polytrauma Rehabilitation Centers and Network Sites to other providers and facilities. Currently, about 30 to 40 videoconference calls are made monthly across the Network Sites to VA and DoD facilities. New Polytrauma Telehealth Network initiatives in development include home buddy systems to maintain contact with patients with mild TBI or amputation, and remote delivery of speech therapy services to Veterans in rural areas.
The Polytrauma Rehabilitation Centers have been renovated to optimize healing in an environment respectful of military service. Military liaisons located at the Centers support active duty patients and coordinate interdepartmental issues for patients and their families. Working with the Fisher House Foundation, we are also able to provide housing and other logistical support for family members staying with a Veteran or service member during his or her recovery at one of our facilities.
The remaining components of the VA Polytrauma System of Care include 22 Polytrauma Network Sites, 82 Polytrauma Support Clinic Teams, and 48 Polytrauma Points of Contact. The Polytrauma Network Sites are available in each Veterans Integrated Service Network (VISN), as well as San Juan, Puerto Rico. These sites develop and support a patient’s rehabilitation plan through comprehensive, interdisciplinary, specialized teams; provide both inpatient and outpatient care; and coordinate services for Veterans with TBI and polytrauma throughout the VISN.

In 2008, the Polytrauma Support Clinic Teams expanded to 82 VA facilities. These interdisciplinary teams of rehabilitation specialists provide dedicated outpatient services closer to home and manage the long-term or changing rehabilitation needs of Veterans. These teams coordinate clinical and support services for patients and their families. They also conduct comprehensive evaluations of patients with positive TBI screens, and develop and implement rehabilitation and community reintegration plans.

VA Polytrauma Points of Contact are available at 48 VA medical centers without specialized rehabilitation teams. These Points of Contact, established in 2007, are knowledgeable about the VA Polytrauma System of Care and coordinate case management and referrals throughout the system.

In addition to enhancements to its Polytrauma System of Care, VA has implemented several other recent initiatives to improve care for Veterans and service members with TBI:

In 2009, VA developed clinical practice guidelines for mild TBI in collaboration with DoD and deployed them to VA health care providers. VA also developed recommendations in the areas of cognitive rehabilitation, drivers’ training, and managing the co-occurrence of TBI, PTSD and pain.
In 2009, VA began collaborating with the National Institute on Disability and Rehabilitation Research TBI Model Systems to collect rehabilitation outcomes data and establish a TBI Veterans Health Registry.
Since April 2009, VA has developed an individualized rehabilitation and community reintegration plan for every outpatient Veteran with TBI who requires ongoing rehabilitation care. This national template is integrated into the electronic medical record and includes the results of a comprehensive assessment, measurable goals, and recommendations for specific rehabilitative treatments. The patient and family participate in crafting the treatment plan and receive a copy of the plan.
VA regularly collaborates with private sector facilities to successfully meet the individualized needs of Veterans and complement VA care in cases when VA is not readily able to provide the needed services or the required care in geographically inaccessible areas. VA medical facilities have identified private sector resources within their catchment area that have expertise in neurobehavioral rehabilitation and recovery programs for TBI. In FY 2009, 3,708 Veterans with TBI received inpatient and outpatient hospital care and medical services from public and private entities, with a total disbursement of over $21 million.
Several educational materials for patients and families are in the final stages of being developed and distributed nationally including: TBI Family Education Manual, TBI Information Brochure, TBI Screening Brochure, and the Family Care Map. VA and DVBIC also collaborated to develop a training curriculum for family members in providing care and assistance to Service Members and Veterans with TBI.
VA has also established an Amputation System of Care and the Blind Rehabilitation System of Care to provide specialty care for Veterans and service members. The Amputation System of Care is composed of 7 Regional Amputation Centers, 15 Polytrauma Amputation Network Sites, 100 Amputation Clinic Teams, and 30 Amputation Points of Contact. These resources have been dedicated to reduce variance and improve access across VA to amputation rehabilitation care. More than 43,000 Veterans have major limb amputations, of which about 950 are Operation Enduring Freedom or Operation Iraqi Freedom (OEF/OIF) Veterans.

Blind Rehabilitation Outpatient Specialists are assigned to Polytrauma Rehabilitation Centers and Network Sites, and patients with severe visual impairments receive further comprehensive services at any of our 10 inpatient Blind Rehabilitation Centers. In addition to these Centers, VA has 77 Blind Rehabilitation Outpatient Specialists and 137 Visual Impairment Services Coordinators. VA has also assigned Blind Rehabilitation Outpatient Specialists to Walter Reed Army and Bethesda Naval Medical Centers to serve visually impaired service members.

VA works closely with DoD to support high quality integrated care for severely injured service members and Veterans. The two Departments recently developed revisions to clinical codes to improve identification and tracking of TBI. In 2009, a 5 year pilot project to provide assisted living services for Veterans with severe TBI was initiated in collaboration with the DVBIC. We have placed three Veterans in Virginia, Florida and Wisconsin, and enrollment is pending for two Veterans in Texas and Kentucky.

VA Care Management and Education Services

Care management refers to a patient- and family-centered approach to care by an interdisciplinary team of professionals with specialized knowledge in the management of patients with complex care needs. VA has developed a robust care management system for OEF/OIF Veterans. Each VA medical center has an OEF/OIF Program Manager, OEF/OIF Case Managers, and Transition Patient Advocates. The Program Manager coordinates clinical care and oversees the transition and care for this population. The Program Manager also serves as the primary point of contact for all referrals from the VA Liaisons for Health Care. OEF/OIF Case Managers coordinate patient care activities and ensure that all clinicians providing care to the patient are doing so in a cohesive and integrated manner. Transition Patient Advocates help Veterans navigate the VA system and Veterans Benefits Administration (VBA) team members assist Veterans with the benefit application process and education about VA benefits.

All severely ill and injured OEF/OIF service members and Veterans receiving care at VA facilities are provided a case manager. All others are screened for case management needs and, based upon the results of the assessment; a case manager may be assigned as indicated. In addition, OEF/OIF service members and Veterans with special needs, including polytrauma, spinal cord injury, and blindness, are served by a specialty case manager. The patient and family serve as integral partners in the assessment and treatment care plan. Since many of the returning OEF/OIF Veterans connect to more than one specialty case manager, VA introduced a new concept of a “lead” case manager. The lead case manager serves as a central communication point for the patient and his or her family. Our case managers maintain regular contact with Veterans and their families to provide support and assistance to address any health care and psychosocial needs that may arise. As of December 31, 2009, 2,484 OEF/OIF severely ill and injured service members and Veterans were receiving on-going case management services, an increase of 49 percent in 2009. Case managers collaborate with VA, DoD and community resources to address the needs of OEF/OIF Veterans.

VA is training its staff and developing new models to support better care for severely injured and ill service members and Veterans. We have implemented Web-based training to disseminate best practices and guidelines, and a mentoring program for OEF/OIF Program Managers to share expertise. VA updated policies for transitioning and care managing OEF/OIF Veterans and service members with new handbooks published in October and November 2009. We will continue to integrate these services with our Post-Deployment Integrated Care Clinics and other specialty care such as mental health and polytrauma.

VA has adopted the Care Management Tracking and Reporting Application (CMTRA), a Web-based tracking system that includes a care management schedule for each Veteran, identifies a lead case manager, produces management reports and creates data to assist VA in measuring performance. While CMTRA initially focused on the severely ill and injured, CMTRA has now been extended to track case management of non-severely ill or injured OEF/OIF service members and Veterans.

VA works with family members and Veterans prior to discharge to train and educate them on specific health care needs and issues. For example, prior to discharge from a Polytrauma Rehabilitation Center, family members may be scheduled to stay with the Veteran in a family training apartment or the Veteran may participate in the Transitional Rehabilitation Program. This allows the family member to experience what the return home will be like for their loved one while still having rehabilitation staff and nursing staff available to answer questions, address unexpected problems, and provide the emotional support a family may need as they prepare for the next phase of rehabilitation.

VA case managers are actively involved in assisting ill and injured Veteran’s with re-integration into their home communities. VA provides skilled home care, homemaker/home health aide services, and a variety of respite care options to support Veterans and their families who require additional assistance at home. In FY 2009, VA Home-Based Primary Care interdisciplinary teams provided comprehensive primary care in the homes of 431 OEF/OIF Veterans. VA provides home modification grants and special adaptive equipment as needed to ensure a safe home environment. For OEF/OIF ill and injured Veterans who are unable to remain in their own homes, VA has developed an in-home alternative to nursing home care, the Medical Foster Home. VA is rapidly expanding its Medical Foster Home initiative, also known as "Support at Home: Where Heroes Meet Angels," across the nation. There are several OEF/OIF Veterans who would otherwise have required nursing home placement that have been served in the Medical Foster Home program this year.

VA recognizes the significant sacrifices made by family caregivers of severely ill and injured OEF/OIF Veterans. With support from Congress, VA was able to conduct eight caregiver support pilot programs at 39 VA medical centers across the country. The lessons learned from these pilot programs have provided us with the foundation to develop a comprehensive caregiver support program that will enhance caregiver education and training while providing a flexible menu of respite care options to reduce caregiver burden and improve the quality of life of Veterans and their caregivers.

Federal Recovery Coordination Program

The Federal Recovery Coordination Program (FRCP), a joint VA/DoD program, helps coordinate and access federal, state and local programs, benefits and services for seriously wounded, ill and injured service members, Veterans, and their families through recovery, rehabilitation, and reintegration into the community. As of January 11, 2010, 15 Federal Recovery Coordinators (FRCs) were coordinating care for 425 severely wounded, ill or injured service members and Veterans; another 38 individuals were being evaluated for program enrollment. Five (5) new FRCs completed their orientation in early January, bringing the total number of FRCs to 20. FRCs are located at Walter Reed Army Medical Center, National Naval Medical Center, Naval Medical Center San Diego, Camp Pendleton Naval Hospital, San Antonio Military Medical Center, Eisenhower Army Medical Center, Houston VA Medical Center, and Providence VA Medical Center.

Recovering service members and Veterans are referred to the FRCP from a variety of sources, including from the service member’s command, members of the multidisciplinary treatment team, case managers, families already in the program, Veterans Service Organizations and non-governmental organizations. Generally, those individuals whose recovery is likely to require a complex array of specialists, transfers to multiple facilities, and long periods of rehabilitation are referred to FRCP. After referral, an FRC conducts an evaluation that serves as the basis for problem identification and determination of needed services. After enrollment in FRCP, clients develop a Federal Individual Recovery Plan (FIRP) with their FRC.

FRCs have the delegated authority for oversight and coordination of the clinical and non-clinical care identified in each client’s FIRP. Working with a variety of case managers, FRCs assist their clients in reaching their goals as identified and tracked in the FIRP. The FRC and the relevant case manager determine responsibility and timeline for implementing the steps necessary to reach a goal. The FRC then monitors progress with the case manager and the client, providing support and additional resources to both, until the goal is reached. FRCs frequently organize meetings with providers, case managers and clients to make sure objectives and expectations are clear. The plan and goals change as a client progresses through the stages of recovery, rehabilitation and reintegration. The FRC provides a single, consistent point of coordination through this progression.

Outreach

VA is continuously looking for ways to improve and achieve a smooth and seamless transition for service members and their families. VA conducts numerous outreach activities to support this seamless transition. In FY 2009, VA conducted over 8,500 Transition Assistance Program and Disabled Transition Assistance Program briefings attended by over 356,800 service members and their families. VA launched a pre-discharge program home page (http://www.vba.va.gov/predischarge/ ) on June 9, 2009 to complement its Benefits Delivery at Discharge and Quick Start programs. In addition, VA launched the eBenefits portal on October 22, 2009 to streamline information to service members, Veterans and families (www.ebenefits.va.gov/ebenefits-portal/ ).

VA also conducts outreach to returning Reserve Component service members through different approaches and settings, including: 61 demobilization sites; the Yellow Ribbon Reintegration Program events at 30, 60, and 90 days post-demobilization; Post-Deployment Health Reassessments, including those conducted at VA facilities; partnerships with the National Guard; Individual Ready Reserve musters, through the Combat Veteran Call Center Initiative; and for all service members, the VA OEF/OIF Web site (http://www.oefoif.va.gov/ ).

Additionally, VA establishes contact and provides assistance through annual focus groups held at VA medical centers, annual Welcome Home events held by each medical center, and community partnerships with providers, colleges and universities, job fairs, and other activities.

Our outreach efforts have provided Veterans with knowledge and access to VA services and benefits. Of the 1,100,000 Veterans who have separated since 2002, 48 percent have used VA health care services. Between 2005 and September 2009, more than 86,000 referrals to VA were made through DoD’s Post-Deployment Health Reassessment, and since 2008, more than 70,000 Veterans have enrolled in VA health care prior to leaving a demobilization site. We also are reaching and conversing with Veterans through social media, including Facebook, Twitter, YouTube, Flickr, and blogs. Currently, VA has the fastest growing Facebook page among cabinet-level agencies with over 11,000 fans, most of whom have been gained since Veterans Day (over 1,000 fans per week). VA participation on Facebook is expanding. Each Administration has its own page for topic-specific conversations, as do a dozen VA medical centers. VA has plans to launch a Facebook page for every VA medical center.

VA now has four separate official Twitter feeds for the Department and each of the Administrations. In the past two months, VA’s primary Twitter feed has added followers at a higher growth rate than any other cabinet-level agency: nearly 2,000 have joined in that time. Half a dozen VA medical centers have active Twitter feeds. As with Facebook, VA plans to expand Twitter feeds to all medical centers beginning in 2010. VA just launched the first official Twitter feed for a VA principal in January, with Assistant Secretary Tammy Duckworth now engaging regularly with the public via her own VA Twitter account.

VA also has embraced video- and photo-sharing media with the use of YouTube (videos) and Flickr (photos). VA began posting each segment from its news magazine program The American Veteran on YouTube, while showcasing a selection of them on the VA homepage. At the same time, VA has a separate health care-related YouTube channel (administered by VHA) which has posted more than 90 videos, has 1,300 subscribers and more than 58,000 views.

In terms of blogging, VA has thus far been spreading its message via other sites—with pieces published at the White House Blog, and others with messages posed by Secretary Shinseki and Assistant Secretary Duckworth at outlets like Military.com.

VA’s main Web site has also been rebuilt to make it more user-friendly for Veterans. Up-to-date information about benefits and services is added daily. Reaching returning Veterans through their expected and familiar modes of communication is a priority. The OEF/OIF generation expects a communication style that allows conversation and engagement, and these resources help VA enhance information sharing with this group of Veterans, as well as other stakeholders.

Conclusion

VA is focusing its resources and attention to meet the needs of Veterans and their families and to ensure that as service members return home, they receive the care and support they have earned.

Thank you again for the opportunity to speak about VA’s efforts to support transitioning service members and Veterans. My colleagues and I are prepared to answer your questions at this time.