```

[House Hearing, 110 Congress]
[From the U.S. Government Publishing Office]

 
                  U.S. DEPARTMENT OF VETERANS AFFAIRS
                   POLYTRAUMA REHABILITATION CENTERS:
                           MANAGEMENT ISSUES

=======================================================================

                                HEARING

                               before the

              SUBCOMMITTEE ON OVERSIGHT AND INVESTIGATIONS

                                 of the

                     COMMITTEE ON VETERANS' AFFAIRS
                     U.S. HOUSE OF REPRESENTATIVES

                       ONE HUNDRED TENTH CONGRESS

                             FIRST SESSION

                               __________

                           SEPTEMBER 25, 2007

                               __________

                           Serial No. 110-45

                               __________

       Printed for the use of the Committee on Veterans' Affairs

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                     COMMITTEE ON VETERANS' AFFAIRS

                    BOB FILNER, California, Chairman

CORRINE BROWN, Florida               STEVE BUYER, Indiana, Ranking
VIC SNYDER, Arkansas                 CLIFF STEARNS, Florida
MICHAEL H. MICHAUD, Maine            JERRY MORAN, Kansas
STEPHANIE HERSETH SANDLIN, South     RICHARD H. BAKER, Louisiana
Dakota                               HENRY E. BROWN, Jr., South 
HARRY E. MITCHELL, Arizona           Carolina
JOHN J. HALL, New York               JEFF MILLER, Florida
PHIL HARE, Illinois                  JOHN BOOZMAN, Arkansas
MICHAEL F. DOYLE, Pennsylvania       GINNY BROWN-WAITE, Florida
SHELLEY BERKLEY, Nevada              MICHAEL R. TURNER, Ohio
JOHN T. SALAZAR, Colorado            BRIAN P. BILBRAY, California
CIRO D. RODRIGUEZ, Texas             DOUG LAMBORN, Colorado
JOE DONNELLY, Indiana                GUS M. BILIRAKIS, Florida
JERRY McNERNEY, California           VERN BUCHANAN, Florida
ZACHARY T. SPACE, Ohio
TIMOTHY J. WALZ, Minnesota

                   Malcom A. Shorter, Staff Director

              SUBCOMMITTEE ON OVERSIGHT AND INVESTIGATIONS

                  HARRY E. MITCHELL, Arizona, Chairman

ZACHARY T. SPACE, Ohio               GINNY BROWN-WAITE, Florida, 
TIMOTHY J. WALZ, Minnesota           Ranking
CIRO D. RODRIGUEZ, Texas             CLIFF STEARNS, Florida
                                     BRIAN P. BILBRAY, California

Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public 
hearing records of the Committee on Veterans' Affairs are also 
published in electronic form. The printed hearing record remains the 
official version. Because electronic submissions are used to prepare 
both printed and electronic versions of the hearing record, the process 
of converting between various electronic formats may introduce 
unintentional errors or omissions. Such occurrences are inherent in the 
current publication process and should diminish as the process is 
further refined.

                            C O N T E N T S

                               __________

                           September 25, 2007

                                                                   Page
U.S. Department of Veterans Affairs Polytrauma Rehabilitation 
  Centers: Management Issues.....................................     1

                           OPENING STATEMENTS

Chairman Harry E. Mitchell.......................................     1
    Prepared statement of Chairman Mitchell......................    26
Hon. Ginny Brown-Waite, Ranking Republican Member................     3
    Prepared statement of Congresswoman Brown-Waite..............    27
Hon. Timothy J. Walz.............................................     5
Hon. Ciro D. Rodriguez...........................................    17

                               WITNESSES

U.S. Department of Veterans Affairs:
Elizabeth Joyce Freeman, Director, Veterans Affairs Palo Alto 
  Health Care System, Veterans Health Administration.............     7
    Prepared statement of Ms. Freeman............................    28
William F. Feeley, Deputy Under Secretary for Health for 
  Operations and Management, Veterans Health Administration......    18
    Prepared statement of Mr. Feeley.............................    32

                   MATERIAL SUBMITTED FOR THE RECORD

Post Hearing Questions and Responses for the Record:
Hon. Harry E. Mitchell, Chairman, and Hon. Ginny Brown-Waite, 
  Ranking Republican Member, Subcommittee on Oversight and 
  Investigations, Committee on Veterans' Affairs, to Hon. Gordon 
  H. Mansfield, Acting Secretary, U.S. Department of Veterans 
  Affairs, letter dated October 24, 2007.........................    35

                  U.S. DEPARTMENT OF VETERANS AFFAIRS
                   POLYTRAUMA REHABILITATION CENTERS:
                           MANAGEMENT ISSUES

                              ----------                              

                      TUESDAY, SEPTEMBER 25, 2007

            U. S. House of Representatives,
      Subcommittee on Oversight and Investigations,
                            Committee on Veterans' Affairs,
                                                    Washington, DC.

    The Subcommittee met, pursuant to notice at 10:06 a.m., in 
Room 334, Cannon House Office Building, Hon. Harry E. Mitchell 
[Chairman of the Subcommittee] presiding.
    Present: Representatives Mitchell, Walz, Rodriguez, and 
Brown-Waite.

             OPENING STATEMENT OF CHAIRMAN MITCHELL

    Mr. Mitchell. This hearing will come to order. I would like 
to welcome everyone to the Subcommittee on Oversight and 
Investigations. This hearing is on the U.S. Department of 
Veterans Affairs (VA) Polytrauma Rehabilitation Centers.
    I want to thank all of you for coming today. I am pleased 
that so many folks could attend this oversight hearing on the 
VA Polytrauma Rehabilitation Centers.
    The VA polytrauma centers help reintegrate into society 
servicemembers who have suffered among the worst that war can 
inflict. The most severely injured servicemembers serving in 
Iraq and Afghanistan were medivaced out of theater through 
Germany to Walter Reed, Bethesda Naval Hospital and, when 
ready, are sent to one of the four polytrauma centers which are 
located in Richmond, Tampa, Minneapolis, and Palo Alto.
    Most polytrauma patients have suffered traumatic brain 
injury (TBI) in addition to a variety of other serious injuries 
which must necessitate amputation. The soldiers, sailors, 
airmen, and marines who are treated at the polytrauma centers 
have paid a very high price for their service to their country 
as have their families, both of whom face a long and difficult 
path to recovery and sometimes a lifetime of care.
    The Nation owes these servicemembers and their families 
everything that a Nation as rich as ours can provide. The 
Nation has many who need and deserve what we can give.
    Survival rates for servicemembers injured in combat are 
extremely high compared to previous conflicts, partly because 
of greatly improved protective equipment, but also because the 
military has moved surgical medical care practically to the 
front lines. A soldier injured in an improvised explosive 
device (IED) blast can be in surgery within 30 to 45 minutes or 
even less.
    With these advances, however, comes the need to treat 
injuries that would have been fatal in the past. Injuries like 
traumatic brain injury and post traumatic stress disorder 
require medical treatment and long-term care of a new kind. The 
VA polytrauma centers are an essential part of that care.
    Congress has provided sufficient resources and is providing 
more that have enabled the VA to establish and expand 
polytrauma care. It must be said that the VA has stepped up to 
the plate to meet this need.
    In addition to the four polytrauma centers, the VA has 
created a network of subacute polytrauma care centers in each 
of the Veterans Integrated Service Networks and outreach 
programs throughout the country. This is not to say that 
everything is as it should be. We would not be having this 
hearing if that were the case.
    Polytrauma care is not perfect. There is also the sharing 
of electronic medical information and other issues that have 
been highlighted by Senator Dole and Secretary Shalala that the 
Subcommittee and full Committee will be addressing in the near 
future.
    But there should be no misunderstanding. We are not here to 
criticize the VA's care providers or to suggest that the 
quality of care to the Nation's most severely injured 
servicemembers is anything less than exemplary. The 
Subcommittee has found some management issues that need to be 
addressed and that is why the title of this hearing is what it 
is. The Subcommittee's oversight is intended to ensure the 
superb care the VA provides is provided to those who deserve 
it.
    Data provided by the VA shows that the Palo Alto VA's 
Polytrauma Center from the beginning of this year through July 
filled only 60 percent of its available beds while the three 
other polytrauma centers combined have been running at 98 
percent capacity. We have found no good reason why that should 
be.
    The VA's Palo Alto Hospital has a beautiful facility and 
even more beautiful Fisher House where family members can stay 
and is practically married to the Stanford Medical School. Palo 
Alto has all the resources it needs to provide the care for all 
the polytrauma patients it can take.
    The Subcommittee has also found the Palo Alto Polytrauma 
Center would not accept minimally responsive brain-injured 
patients while the other polytrauma centers did so until the VA 
created a treatment protocol for those patients in December of 
2006 and effectively forced Palo Alto to accept these patients.
    This past spring, the VA's Office of Medical Investigations 
found disarray, morale problems, insufficient programs for 
families, and lack of leadership. All of these raise obvious 
issues not just about local management but also about VA's 
Central Office. Why, for example, did the fact that Palo Alto's 
failure to fill the beds while the other polytrauma centers 
were at full capacity not raise a red flag at Headquarters?
    We begin today by hearing from the senior management of the 
Palo Alto Health Care System headed by its Director, Elizabeth 
Freeman. Subcommittee staff has spent much time with Ms. 
Freeman and her team, and they are to be commended for their 
willingness to meet with and provide information to the 
Subcommittee.
    We hope, indeed expect, that their testimony will describe 
sufficient progress in addressing the concerns of the Office of 
Medical Investigations (OMI) and the Subcommittee.
    The second panel is headed by William Feeley, Deputy Under 
Secretary for Health and Operations and Management. The 
Subcommittee extends its thanks to Mr. Feeley and the VA 
witnesses with him for their efforts to provide the best care 
possible to our injured servicemembers and appreciates their 
cooperation to the Subcommittee in meeting with and providing 
information to us.
    We in no way doubt their good will and dedication, but 
there are obvious management issues for the Central Office that 
are raised by the fact that there were empty beds in Palo Alto, 
and these witnesses will be asked to address these issues.
    Dr. Barbara Sigford, Dr. Shane McNamee, both of whom are 
personally involved in running polytrauma centers, are at the 
witness table as well. We look forward to hearing from them 
about the good things that are going on for those who have made 
great sacrifices for our country.
    On Sunday night, the Public Broadcasting System (PBS) began 
a 15-hour presentation of Ken Burns' documentary on World War 
II. America achieved great things in that war, but the 
documentary reminds us, or perhaps more realistically teaches 
us, of the terrible cost of war.
    We, as a Nation, owe a debt that can never be repaid to 
those who serve, an obligation that must be met to those, who 
were injured in that service. We are here today to do our part 
in making sure this happens. No one can doubt the dedication of 
the men and women in the military and the VA who provide care 
for our servicemembers.
    [The prepared statement of Chairman Mitchell appears on
p. 26.]
    Mr. Mitchell. Before I recognize the Ranking Republican 
Member for her remarks, I would like to swear in our witnesses. 
I ask that all witnesses stand and raise their right hand from 
both panels, if they would, please.
    [Witnesses sworn.]
    Mr. Mitchell. Thank you.
    Now I would like to recognize Ms. Brown-Waite for her 
opening remarks.

          OPENING STATEMENT OF HON. GINNY BROWN-WAITE

    Ms. Brown-Waite. I thank the Chairman very much, and I also 
thank him for holding this hearing.
    I believe that the title of this hearing is very 
appropriate and I am rather disappointed. I do not know if 
there are any members of the media, but normally the room is 
filled because this is a very, very important issue as we talk 
about our wounded warriors from the Global War on Terrorism. 
Obviously the quest for excellence should be of the utmost 
important.
    Our Subcommittee staff recently visited several polytrauma 
rehabilitation centers located in Richmond, Virginia; 
Minneapolis, Minnesota; and the subject center, Palo Alto, 
California. They did this to provide insight on the level of 
care being provided to our wounded servicemembers at those 
units.
    Last Congress, while serving as the Chairman of this 
Committee, Ranking Member Buyer followed injured servicemembers 
from a combat support hospital in Iraq through the Landstuhl 
Army Medical Center in Germany, and on to Walter Reed and 
Bethesda. Mr. Buyer has also visited the Minneapolis VA Medical 
Center's Polytrauma Rehabilitation Center (PRC) to evaluate 
care and services received by our most critically injured 
servicemembers.
    What I still see today is of great concern. The tracking of 
medical records still includes the paperwork and hard copies of 
medical records accompanying the servicemembers as they 
transfer stateside and ultimately to the VA.
    We know that that is U.S. Department of Defense's (DoD's) 
fault, but it is still ongoing, Mr. Chairman, and I did not 
know if you were aware of that. As much as this Committee has 
said, ``Let us move on and have electronic records,'' they are 
still doing the old paper records going with the veteran to the 
veteran facilities.
    The Committee hears that not all the critical medical 
information is being forwarded to the polytrauma units by the 
DoD and many of the VA facilities are not using or have not 
heard of the Joint Patient Tracking Application (JPTA) and the 
Veterans Tracking Application (VTA) systems.
    At the PRC in Palo Alto, our staff found several issues 
relating to lack of staffing and resources. This same concern 
was detailed in the draft OMI report obtained by our staff 
prior to their visit to Palo Alto.
    I would like to have the witnesses address this deficiency 
in care to the servicemembers and veterans who are being 
treated at this facility and I am also interested in learning 
how widespread this problem is.
    During the staff visit to the PRC unit in Minneapolis, the 
Committee learned about the unusually high turnover rate of 
active-duty military liaison officers. I am concerned about how 
this turnover rate affects continuity of care for our severely 
injured servicemembers.
    PRC staff told us that there were also no electronic 
transfer of records between DoD and PRC in Minneapolis. I am 
interested in learning what is being done to address this 
issue.
    I know that some of our PRCs are doing a great job while it 
seems others are still having great difficulties.
    How are the best practices being shared between PRCs, the 
good PRCs to provide the best possible care for our severely 
wounded servicemembers?
    Let me give you one example. The district that I represent 
is north of Tampa. And when I was down at the Haley Hospital 
reviewing the polytrauma unit there, which, by the way, is 
excellent, I met some families from the west coast, not the 
west coast of Florida, but the west coast, Washington State.
    They chose to have their wounded warrior go to Tampa to the 
polytrauma unit there. When I asked why they did not choose to 
go Palo Alto, their response was because they wanted the best 
care available.
    It is a shame that veterans and their families do not feel 
that the best care available is not also the closest care that 
would be available, namely at the Palo Alto center.
    Mr. Chairman, we need to be concerned about the care our 
wounded servicemembers are receiving as they move from the 
battlefield through the line of care to our VA facilities.
    Congress' responsibility to these men and women in uniform 
does not end with their care at the PRC units. As the Oversight 
Subcommittee, we must also ensure that they have a seamless 
transition from active duty to civilian-veteran status.
    I cannot stress enough the importance of working toward a 
standard Benefits Delivery at Discharge or (BDD) documentation. 
A standard BDD would include one physical to be shared between 
the two departments, DoD and the VA, providing servicemembers 
with documentation as to the benefits for which they may be 
eligible.
    With the use of a shared BDD, we could conceivably have the 
claims backlog at the VA caught up in a few years. This program 
was successfully tested between DoD and VA from 1995 to 1997. 
It is also a strong recommendation coming from the President's 
Dole-Shalala Commission report.
    Again, Mr. Chairman, I thank you for calling for this 
hearing and I look forward to learning from our witnesses how 
the VA is working with the DoD to improve the care for our 
Nation's heroes and how we can better share some of the best 
practices from the superior polytrauma units to the remaining 
polytrauma units.
    Thank you, Mr. Chairman.
    [The prepared statement of Congresswoman Brown-Waite 
appears on p. 27.]
    Mr. Mitchell. Thank you.
    I understand Mr. Walz has to leave early today. So at this 
time, if there are no objections, I would like to recognize him 
for his brief opening statement.

           OPENING STATEMENT OF HON. TIMOTHY J. WALZ

    Mr. Walz. Thank you, Mr. Chairman and Ranking Member.
    Thank you to each of you for being here today. Thank you 
for making the choice to serve in the VA, to put your expertise 
and your careers in service to our veterans and it is truly a 
noble cause, and for those members from the VA here.
    I say it every time we are here that our job is to be 
partners with you in this. Our job is to help provide the 
funding and the oversight and the guidance necessary to help 
you do your jobs. And for what you do, I am truly appreciative 
of that.
    My State of Minnesota is fortunate to have a polytrauma 
center in Minneapolis and it is one that I have been to many 
times and am incredibly proud of what has been done.
    All of us know that what we are doing, one soldier or one 
Marine or one airmen or one seaman who does not get the care 
that they need is one too many, and we are always dealing with 
a very, very high expectation. But I do think it is important 
to note how often we do things right and how often you are 
serving that care.
    We are fortunate to have Dr. Sigford. She is here 
representing today in her position as National Program 
Director, but she is based in Minneapolis, and for that, I am 
very thankful because I have been there many times and I have 
seen that care. I am looking forward to this discussion.
    The one thing that I am encouraged about by the Palo Alto 
experience is we appear to have the ability to be able to 
correct and we appear to be making changes in the right 
direction. And too often in this Committee, we identify issues, 
we identify what we need to fix, and then it just takes so long 
to see any changes that the frustration level grows.
    And while we are not claiming that we have everything under 
control, while we are not claiming we are doing things 
perfectly, we are claiming that, I think, that the 
communication that is happening between those of us who sat 
here in our responsibility to provide you the resources and the 
guidance and those delivering that care is starting to get 
there. So I thank you for that.
    All of us know that our ultimate responsibility, and I 
always like to quote, I represent the district that the Mayo 
Clinic is in, and their single charge on the wall everywhere 
is, ``what is best for the patient is what is best.'' And that 
comes from Dr. Will Mayo and those quotes and the way they do 
everything is dependent on that.
    And I said when I am up on the floor and the one thing I 
can tell you that sticks in my mind, my last visit out to the 
Minneapolis center, I met with a mother. She was from Michigan 
and she was there with her son who was a double amputee and a 
TBI patient. And the strain of the care was showing on her and 
she said the only thing that gets her through is, she said the 
floor that she was on with her son is staffed by angels.
    And that care that she receives up there from those people 
is absolutely heartwarming. We need to make sure we keep them 
there. We need to make sure that the turnover rate is lowered. 
We need to make sure that our nursing staff is adequate and the 
resources are there. And that is why this oversight of this is 
so important.
    So I thank you all. I am sorry I am going to have to leave 
a little early for a conflicting meeting. But we do have your 
written testimony, and to know that this Committee takes very 
seriously the work you are doing and appreciates it.
    I yield back.
    Mr. Mitchell. Thank you.
    Mr. Rodriguez.
    Mr. Rodriguez. I will yield until the second panel.
    Mr. Mitchell. Thank you.
    At this time, I would like to ask unanimous consent that 
all Members have 5 legislative days to submit a statement for 
the record. If there are no objections, so ordered.
    We will now proceed to panel one. Ms. Elizabeth J. Freeman 
is the Director of the VA Palo Alto Health Care System. Ms. 
Freeman has been the Director of Palo Alto since 2001 and has 
been with the VA since 1983.
    We would like to thank you, Ms. Freeman, for being here and 
for the many years of service to our veterans.
    After you introduce your panel members, you will have 5 
minutes then to make your presentation. Thank you.

   STATEMENT OF ELIZABETH JOYCE FREEMAN, DIRECTOR, VETERANS 
     AFFAIRS PALO ALTO HEALTH CARE SYSTEM, VETERANS HEALTH 
     ADMINISTRATION, U.S. DEPARTMENT OF VETERANS AFFAIRS; 
    ACCOMPANIED BY LAWRENCE L. LEUNG, M.D., CHIEF OF STAFF, 
VETERANS AFFAIRS PALO ALTO HEALTH CARE SYSTEM, VETERANS HEALTH 
   ADMINISTRATION, U.S. DEPARTMENT OF VETERANS AFFAIRS; AND 
  STEPHEN EZEJI-OKOYE, M.D., DEPUTY CHIEF OF STAFF, VETERANS 
     AFFAIRS PALO ALTO HEALTH CARE SYSTEM, VETERANS HEALTH 
      ADMINISTRATION, U.S. DEPARTMENT OF VETERANS AFFAIRS

    Ms. Freeman. Thank you. Good morning.
    I would like to introduce Dr. Larry Leung, who is our Chief 
of Staff, and a name that is very difficult to pronounce, Dr. 
Stephen Ezeji-Okoye, who is our Deputy Chief of Staff, to my 
left.
    And I will go ahead and read my oral statement.
    Good morning, Mr. Chairman and other Members of the 
Subcommittee. Thank you for the opportunity to appear before 
you today to discuss the polytrauma rehabilitation center or 
PRC located at the Department of Veterans Affairs, Palo Alto 
Health Care System.
    It is a privilege to be on Capitol Hill to speak and answer 
questions about this vital program and other issues that are 
important to veterans who have bravely served in Operation 
Iraqi Freedom and Operation Enduring Freedom.
    I would like to submit my written statement for the record.
    The core of the PRC at the VA Palo Alto Health Care System 
is a 12-bed ward located on the Palo Alto Division Campus. The 
PRC is frequently the subject of interest by oversight bodies, 
veterans' advocates, Department of Defense personnel, media, 
and elected officials.
    Nearly every week, we have the honor of hosting visits by 
distinguished guests. The vast majority of these visits are 
very positive and generate considerable praise for the PRC and 
its dedicated staff.
    The PRC is also subjected to the oversight of the Veterans 
Health Administration or VHA. Earlier this year, the VHA Office 
of the Medical Inspector or OMI came to Palo Alto and assessed 
the PRC. The OMI reviewed allegations related to a delay in 
accreditation, inappropriate declinations of referrals, and 
lack of effective leadership at the program level.
    I will comment briefly on these three areas.
    Regarding accreditation, Palo Alto has been and continues 
to be fully accredited. Palo Alto was due for its triennial 
Commission on Accreditation of Rehabilitation Facilities or 
CARF survey of rehabilitation programs in February of 2007. 
Based on internal and external assessments, I determined we 
needed additional time to prepare for the survey. Consequently, 
I asked and received approval from CARF to delay its survey for 
a few months.
    I am pleased to report to the Subcommittee that the CARF 
survey occurred July 19th and 20th, 2007, and resulted in full 
accreditation for another maximum 3-year period. I would like 
to emphasize that at no time did our accreditation with CARF 
lapse.
    Regarding referrals, I would like to note that the OMI did 
not substantiate the allegation that the PRC was 
inappropriately declining or otherwise cherry picking patients 
to produce favorable outcomes. Nonetheless, I have instituted 
changes that will make it easier for referring sites to send us 
patients.
    There is now a single point of contact for referrals to the 
PRC and a clearly defined physician to accept them. The 
acceptance decision will be promptly communicated to the 
referring site, patient, and family. If, for any reason, the 
referring site disagrees with a decision, the referring site 
will be encouraged to appeal the decision to the Palo Alto 
Chief of Staff.
    We have improved our process for tracking the disposition 
of all referrals to the PRC and will report results monthly to 
the Veterans Integrated Service Network 21 Office and to VA's 
Central Office.
    I have instructed my staff to look for every possible way 
to accept as many patients as possible in either the PRC or a 
more appropriate setting. I have also intensified our 
communication with and outreach to potential referring sites.
    Just yesterday, I went to National Naval Medical Center in 
Bethesda, Maryland, and met with senior medical and social work 
staff. I was pleased to learn that the VHA Polytrauma System 
are including the PRC at Palo Alto as their first choice for 
referrals.
    I will followup on this productive meeting by sending a 
clinical team from my PRC to this and other referring sites to 
foster collaboration and eliminate any impediments to 
referrals. I will also invite and encourage referring sites to 
send a clinical team from their facilities to Palo Alto.
    Regarding leadership at the program level, the OMI 
expressed concerns about the leadership and communication in 
the PRC. I have addressed leadership challenges in both the 
short-term and long-term horizons. I have established an 
Associate Chief of Staff for Polytrauma. The Associate Chief of 
Staff for Polytrauma will provide clear and stable leadership 
and the Associate Chief of Staff designation will signal its 
organizational importance.
    I have already started recruitment for the Associate Chief 
of Staff for Polytrauma and established a Search Committee. I 
am pleased to report that Stanford University will participate 
in the recruitment and offer a faculty position to the 
successful candidate.
    In the interim, I have appointed a physician to serve as 
the PRC Program Director and to be responsible for day-to-day 
operations in the PRC including the disposition of referrals. 
This individual has the necessary leadership, team building and 
interpersonal skills to achieve outstanding clinical results 
and to meet the expectations of families. The PRC Program 
Director has already generated widespread support from the PRC 
staff.
    In closing, I would like to emphasize the quality of care 
provided at the PRC has been and continues to be outstanding. 
As the referrals and needs of our patients change, the PRC 
evolves.
    My staff and I have developed a forward-looking plan to 
significantly increase the intensity of services and associated 
staffing. We have also received funding for significant 
equipment purchases and infrastructure improvement.
    My staff and I are fully committed to making any 
improvements necessary to meet the needs and exceed the 
expectations of our Nation's heroes and their families.
    Again, thank you, Mr. Chairman, for the opportunity to 
testify at this hearing. I and the staff who accompanied me 
would be delighted to address any questions.
    [The prepared statement of Ms. Freeman appears on p. 28.]
    Mr. Mitchell. Thank you, Ms. Freeman. And I appreciate you 
being here today. I appreciate it very much.
    And we appreciate the good work that all of your colleagues 
at Palo Alto are doing to provide the care to our veterans. And 
we are particularly appreciative of the care that Palo Alto's 
Polytrauma Unit has provided to our most seriously injured Iraq 
and Afghanistan veterans.
    As I said in the opening statement, we are not here to 
question you or your colleagues' dedication or suggest that the 
care at Palo Alto's Polytrauma Unit provides anything short of 
what is the best.
    That said, however, we cannot ignore the fact that Palo 
Alto has a history of empty beds in sharp contrast to the full 
beds at the other polytrauma centers.
    The Office of Medical Investigations may have concluded 
that Palo Alto has not been cherry picking patients, but that 
just begs the question of why Palo Alto had empty beds.
    I appreciate very much that Palo Alto currently has more 
than its allocation of polytrauma patients, but I am 
disappointed that it took the scrutiny of this Subcommittee to 
make that happen.
    I can assure you that the scrutiny that you are getting now 
will continue and that our staff will be visiting Palo Alto 
again soon.
    What we need and what our servicemembers giving their all 
to this war need is not only your assurance that Palo Alto will 
never again have empty beds, but also how your specific plans 
for operating the polytrauma center will ensure those results. 
And I heard you outline your plan and what you plan to do 
hopefully.
    When the Subcommittee staff visits you again in a few 
months, what can we expect them to find?
    Ms. Freeman. Thank you. Thank you for the question.
    We have been aware that our average daily census has been 
less than 12 and we have 12 beds on the Polytrauma Unit. And 
the number of beds that are occupied, that average daily census 
or ADC is dependent on the number of patients we accept and 
that is dependent on the number of patients that are referred.
    And we are now aware of this perception that we had been 
receiving less referrals. And so the outreach efforts that we 
have made in order to increase the number of referrals and thus 
increase the number of admissions is the outreach that I 
described in my oral statement and by personally reaching out 
to those at other military treatment facilities beginning with 
the case managers in trying to identify any difficulties there.
    I will follow that up with sending my clinical team to 
Walter Reed, Bethesda, Madigan, and other referring centers. I 
will also invite the clinical teams from those centers to come 
to Palo Alto and to be assured that the quality of care that we 
provide is excellent.
    Mr. Mitchell. Thank you.
    Ms. Brown-Waite.
    Ms. Brown-Waite. I thank the Chairman very much.
    I am going to have to leave the Subcommittee to go to a 
markup, so I will be leaving in a few minutes. But before 
leave, I had a few questions.
    Ms. Freeman, I understand that the Under Secretary for 
Health asked VHA National Center of Organizational Development 
to visit all four polytrauma centers and assess current 
structure and staff.
    Would you share with us the findings and recommendations of 
this visit?
    My second question--actually, if you would answer them in 
reverse--I understand that last February, you asked for a delay 
in the scheduled triennial accreditation.
    Knowing this important accreditation process was upcoming, 
what were the reasons for the requested delay? And I also 
understand that you just recently successfully passed the 
accreditation.
    Would you elaborate what specific steps were taken between 
February and July to mitigate your concerns about passing the 
accreditation?
    Ms. Freeman. Certainly. Thank you for that question, and I 
will go ahead and answer the question about accreditation 
first.
    First of all, I just want to assure the Subcommittee that 
our accreditation, as I said in my statement, it never lapsed 
and we remain fully accredited.
    We had performed some internal and external assessments. We 
had an external consultant help us prepare for CARF and she 
commented that the quality of the care was outstanding, but she 
thought there were some structural components that needed to be 
put in place.
    So my reason in asking for the delay was to give us time to 
get the paperwork and other processes in place to be able to 
demonstrate to CARF that we should continue our accreditation.
    And as I reported, when they did visit on July 19th through 
20th, we did successfully pass that survey. And they were very, 
very complimentary.
    I would also comment that requesting that sort of delay is 
something I would do in any other area where we are preparing 
for an external survey. If I had similar information, I would 
make the same decision.
    Regarding your question on the National Center for 
Organizational Development (NCOD), we very much appreciated the 
Under Secretary asking them to come and visit us and the other 
four polytrauma centers. I think it was terrific for the staff 
morale. They very much enjoyed it. I believe we had 48 staff on 
the unit and 43 of them interviewed with the NCOD staff.
    And as far as their recommendations, the areas that the 
staff identified that were of concern to them were most focused 
on building and maintaining appropriate boundaries between the 
care team and the families. There were also issues about 
referral patterns and the discharge process and also concerns 
about training.
    And so we have taken all of those recommendations. We have 
an internal team that is going to develop action plans on those 
recommendations. And we are making progress as we speak.
    Ms. Brown-Waite. And if I may follow-up. Could you 
elaborate a little bit more on the review that you had where it 
was suggested that there be a change in structural components? 
Could you elaborate a little bit more on that?
    Ms. Freeman. Sure. Thank you for that question.
    Some of the structures that we need to put in place were 
data management and evaluation of data and quality improvement 
processes. So not that those were not occurring, but the 
documentation of them and making it easy for a surveyor to 
identify and recognize and give us credit for.
    Ms. Brown-Waite. Are you aware of family reluctance to have 
the polytrauma veteran treated at Palo Alto?
    Ms. Freeman. I am not aware of any individual case where a 
family expressed concern about Palo Alto, but I would be very 
happy to follow-up with you, if I may, after the hearing about 
that family situation.
    Ms. Brown-Waite. So no one has ever said, I am not going to 
go to the polytrauma unit closest to my home city, my home 
state, but rather travel across the country to another one? You 
have never heard this? This is the first time you have heard 
this?
    Ms. Freeman. I cannot speak for what a family member 
expressed to a referral coordinator as to their reason as to 
why they would select one polytrauma center over another.
    Ms. Brown-Waite. Would you not want that information?
    Ms. Freeman. I would be very happy to get that information 
and act on that information and understand what that family's 
concerns were and correct them.
    Ms. Brown-Waite. Well, Mr. Chairman, Ms. Freeman, with all 
due respect, I would think that that would be a primary focus 
which might help to determine what some of the problems are at 
Palo Alto.
    Well over a year ago, because I have the polytrauma unit so 
close to me, I began to look at, okay, why are there so few 
there and there is a waiting list at some of the other 
facilities. And so this is nothing new to me nor any of the 
Members who have been on the Committee for a while. So I would 
think in your position, you would want to know this.
    Ms. Freeman. Again, I am not aware of any particular family 
stating that they did not want to be referred to Palo Alto. And 
if that information was conveyed to me, I would promptly act 
upon it.
    Mr. Mitchell. Excuse me.
    Ms. Brown-Waite. I yield back the balance of my time.
    Mr. Mitchell. Thank you.
    I would like to just kind of follow-up. Do you know of any 
other patients that were denied access to Palo Alto but ended 
up at either Richmond, Tampa, or Minneapolis?
    Ms. Freeman. One of the programs that we had not initiated 
that the other four polytrauma centers initiated was in the 
area of emerging consciousness, so there could have been 
patients that might have been referred to Palo Alto that were 
referred to those other programs before we instituted our 
program.
    Mr. Mitchell. What does that mean?
    Ms. Freeman. Emerging consciousness?
    Mr. Mitchell. The question was, were there people who were 
rejected at Palo Alto?
    Ms. Brown-Waite. Or rejected Palo Alto.
    Mr. Mitchell. Well, yes. You asked that.
    But I am saying who you did not accept, did they end up at 
any of the other polytrauma centers?
    Ms. Freeman. We have received 173 referrals from the time 
we became a polytrauma center in February of 2005. And we have 
accepted 143 or about 81 percent of those patients.
    And while I do not recall every instance of the 30 some who 
were not accepted at our polytrauma center, in general, the 
reason would be that they might have had--there might have been 
a more threatening, life-threatening condition that needed to 
be addressed first before they were referred into the 
polytrauma unit such as substance abuse or post traumatic 
stress disorder.
    Mr. Mitchell. Let me follow-up. Excuse me for taking this 
privilege here.
    Would they have been released from Bethesda or Walter Reed 
under those conditions and sent out to you if they did not feel 
that they should be in the center?
    Ms. Freeman. I am sorry. Could you repeat the question?
    Mr. Mitchell. I think the patients that you receive or are 
referred to you are referred from Walter Reed, Bethesda.
    Ms. Freeman. Walter Reed, Bethesda, Madigan----
    Mr. Mitchell. Okay.
    Ms. Freeman [continuing]. Other--of the 173 referrals----
    Mr. Mitchell. Right.
    Ms. Freeman [continuing]. I described, it is many 
locations, not just Walter Reed and----
    Mr. Mitchell. And you are saying that some of those 
referred from those particular hospitals probably should not 
have been referred? They should have stayed in those hospitals? 
Why would--just one example--why would Walter Reed refer 
someone to a polytrauma center that they did not feel was ready 
to be referred?
    Ms. Freeman. Some of the referrals that I am speaking of 
with the other symptoms or other disease states that needed to 
be treated, they might not have been from Walter Reed or 
Bethesda. They could have been from another place.
    Mr. Mitchell. Okay. Any of them, any number of them. Are 
you saying that some of those people would be referred when 
they should not have been?
    Ms. Freeman. I am going to ask Dr. Ezeji-Okoye to help me 
because I am not doing a good job of explaining this to you. 
But there could be other reasons that I am not explaining.
    Mr. Mitchell. Let me ask this question. The people that you 
get are referred; is that correct?
    Ms. Freeman. Yes.
    Mr. Mitchell. And what you are saying is some that are 
referred, I get the impression, should not have been referred 
because they were not ready to be referred to this next level 
of treatment; is that right?
    Ms. Freeman. Could you help me?
    Dr. Ezeji-Okoye. Sure.
    Thank you, Congressman.
    The VA operates a polytrauma system of care and that system 
of care encompasses multiple areas as well as multiple 
disciplines. Patients are referred in for evaluation and 
appropriate placement into the correct area within the 
polytrauma system of care.
    Patients who initially may be referred from an outpatient 
setting, for example, may have conditions, as Ms. Freeman 
mentioned, such as substance abuse which would interfere or 
prevent them from being able to fully benefit from the acute 
inpatient rehabilitation on a PRC and so they are directed to 
the most appropriate setting either within Palo Alto or within 
another health care system within VA.
    Mr. Mitchell. So what you are saying is that those 
hospitals that are doing the referring are not really doing the 
job they should when they referred them to the next level of 
treatment; is that correct?
    Dr. Ezeji-Okoye. No, sir. That is not what I was meaning to 
imply. The centers when they refer in some cases such as many 
of the cases we get from Walter Reed and Bethesda, it is clear 
that the patient is suffering from polytrauma and that is the 
major and overwhelming issue. And they are accepted.
    Other sites refer to the polytrauma network or the 
polytrauma system of care because they want assistance in 
evaluating what are the deficiencies and deficits that the 
veteran may be suffering from and help in assessing what the 
correct placement for that patient may be.
    The polytrauma system of care may take that initial 
admission information and then in reviewing the documentation 
and discussing with the team make a determination that the most 
appropriate setting is actually not the PRC but perhaps a 
substance abuse center or post traumatic stress disorder 
center, and then after completion of that treatment would then 
come to the PRC.
    Mr. Mitchell. Would you say that you have a higher level of 
rejection of those referred than the other centers?
    Dr. Ezeji-Okoye. I do not know the information, sir, on the 
acceptance and rejection rate of other centers. We have tried 
to accept every----
    Mr. Mitchell. Excuse me. It seems to me it is kind of 
obvious when you have 60 percent of the beds filled, the others 
have in the 90s, that you must be rejecting more or they are 
just not referring more to you to begin with, one or the other.
    Dr. Ezeji-Okoye. We have not been denying patients. We have 
been trying to find the most appropriate setting for each of 
those patients. As Ms. Freeman mentioned, we have been 
concerned of this recent information about the perception that 
we were not accepting or were difficult to refer to. And then 
that is why we have been doing the outreach to the other 
centers to make sure that perception is not continued.
    Mr. Mitchell. Well, it must be a perception because either 
one or the other. Either you are rejecting more than everybody 
else or you are getting less referrals, one or the other.
    Thank you.
    Mr. Rodriguez.
    Mr. Rodriguez. Thank you very much.
    And let me say that, first of all, I guess, to the next 
panel, thank you very much. We are looking forward to being the 
fifth polytrauma center in San Antonio, so we look forward to 
working with our soldiers that are in need.
    Let me just, I guess, from a political perspective, I have 
always judged politicians based on those that get elected 
because they want to be there and those that want to make 
something happen and actually do the work.
    One of the biggest problems we find is veterans going and 
feeling like they are being neglected or not wanted there. And 
that attitude of, I guess, maybe also that reflects on the work 
ethic of the people that are there in terms of not wanting to 
deliver the work.
    And that would be, you know, the biggest concerns that I 
would have. Not only you say there is a perception, but there 
is a reality also that you have only had 60 percent.
    Do you communicate at all with the other four centers? Do 
you meet at all and discuss, you know?
    Ms. Freeman. Yes, sir. There are conference calls between 
our leadership at our PRC and Headquarters that all of the 
polytrauma sites are participating in.
    Mr. Rodriguez. You get to see what the others are doing and 
not doing?
    Ms. Freeman. Yes, sir.
    Mr. Rodriguez. One of the things that I would be concerned 
in terms of your staffing there is in terms of their attitudes 
and, you know, how aggressive they might be or the lack of 
aggressiveness in terms of responding as to why they are there. 
And that is to work and work for our veterans.
    And so I would be concerned in terms of no matter what you 
do, if that attitude is not there and it is not brought up from 
the leadership perspective and if you are just there to be 
there for the sake of having a job, you know, I tell the staff 
that I have, and, again, the only analogy I can give you of my 
own, and that is that when staff comes to me, they are only on 
board as long as I am there, which is only 2 years at a time, 
and I expect them to have that aggressive attitude in terms of 
trying to make things happen versus just being there and biding 
their time while they are being employed.
    And so I would hope that your attitude there is also in 
terms of service to our constituents and service to our 
veterans that are out there. And that requires--I do not know 
how you can change that attitude, but it has to come from the 
leadership.
    Ms. Freeman. Yes, sir. And I want to assure you that our 
staff are highly motivated to accept as many patients as 
possible. They are extremely, extremely committed to providing 
outstanding care to those patients. I would invite you to come 
and visit our unit and see for yourself the close connection 
between our case managers and the families and the patients 
that they care for, the close connection among the therapy 
staff, the physician staff, and the patients and families that 
we have the honor to serve.
    Mr. Rodriguez. Yeah, because nothing worse than an attitude 
of you do not want to go there, I want to go somewhere else, 
and/or with the occupancy rates. That also says that if you 
have the same workload, you know, and the others are carrying 
much more of a workload, there is something wrong with that 
picture also, especially when the need is there.
    And I can tell you in San Antonio, we have a large number 
of veterans at Brooke Army Medical Center and both out there at 
Wilford Hall and the other trauma centers as well as the Audie 
Murphy veteran needs in terms of services.
    And so we look forward to doing that. So I would, you know, 
hope that as you move forward, you know, there continues dialog 
with the others and seeing what they are doing or not doing or 
whether a shift in staff needs to occur in order to make that 
happen in terms of the type of clientele.
    Now, you mentioned some connection in terms of the type of 
clients that are being referred and why the others might be at 
a higher rate and you are not. And you mentioned, was that some 
type of designation?
    Ms. Freeman. Emerging consciousness.
    Mr. Rodriguez. Yes. Tell me about that.
    Ms. Freeman. I am going to let Dr. Ezeji-Okoye describe 
emerging consciousness patients.
    Dr. Ezeji-Okoye. Thank you.
    Thank you, Congressman.
    The Emerging Consciousness Program is a program that was 
developed through VA that encompasses family support, the care 
of the injured patient through programs such as Multi-Sensory 
Stimulation as well as other rehabilitation efforts.
    Palo Alto offered many components or most components of the 
Emerging Consciousness Program, but we did not offer the Multi-
Sensory Stimulation Program. At that time, it was the opinion 
of our clinical leadership that the evidence was not sufficient 
to support that program. However, over time and with discussion 
with the other VA centers, it was agreed that the situation had 
evolved and that we thought it would be beneficial to also 
include this service at Palo Alto. And so in the fall of 2006, 
we began to put in place our own Multi-Sensory Stimulation 
Program and accepted our first emerging consciousness patient 
in November of that year.
    Mr. Rodriguez. Thank you. I think I have run out of time. 
Thank you.
    Mr. Mitchell. Thank you.
    Ms. Brown-Waite.
    Ms. Brown-Waite. Thank you.
    You may have said this and I missed it. We are supposed to 
have a vote and I am trying to find out when I have to leave 
for the other Committee. But how many current inpatients are 
there in the polytrauma unit?
    Ms. Freeman. Actually, as of last night, there were 17. We 
have 12 beds designated for polytrauma. There are 17 
inpatients. We have three polytrauma patients on our spinal 
cord injury unit and one patient in our intensive care unit.
    Ms. Brown-Waite. And how many are outpatients? Do you have 
outpatients in the polytrauma unit?
    Ms. Freeman. We have a transitional program, and bear with 
me for just one moment. Within our transitional program, we 
have 12 beds in the transitional program and I believe--I can 
check with you for the record the exact number as of yesterday, 
but we had five participants who were using our lodger beds and 
I believe there are others who are using that program but 
reside in the community.
    Ms. Brown-Waite. One of the other questions is, I believe I 
heard you say that you have conferences regularly with the 
other polytrauma units. I understand that is a weekly 
teleconference; is that correct?
    Ms. Freeman. Yes.
    Ms. Brown-Waite. At some point, do you discuss the patient 
count, the utilization rate, and has this come up in your 
conversation with other polytrauma units about the difference 
in the number of patients that you treat versus the other 
facilities?
    Ms. Freeman. Thank you.
    I do not personally participate in those conferences. The 
Program Director and Medical Director participate in the 
conferences. And so to my knowledge, I have not been personally 
aware of the difference between the ADC for our center and the 
other centers until Mr. Bestor brought it up on his visit.
    And I do not know if Dr. Ezeji-Okoye wants to comment on 
that.
    Dr. Ezeji-Okoye. I participated in some of the conference 
calls and the conference calls have generally focused on making 
sure that we are developing quality programs across all of the 
polytrauma centers. And that has been the primary focus of the 
calls that I have been on.
    Ms. Brown-Waite. So are best practices shared during these 
conference calls?
    Dr. Ezeji-Okoye. Part of the conference call has been 
focusing on each polytrauma site taking a leadership role in 
developing what would be best practices within the polytrauma 
sites overall and then sharing those. We have been charged with 
looking at some of the educational and training portions of the 
polytrauma system of care and developing those.
    Ms. Brown-Waite. Thank you.
    I yield back, Mr. Chairman.
    Mr. Mitchell. Does anyone have any other questions they 
would like to ask?
    [No response.]
    Mr. Mitchell. Thank you, and thank you very much for being 
here.
    And I do want you to know that, as I mentioned in my 
opening statement, that members of this Subcommittee staff will 
probably be out to visit again.
    Very good. Thank you.
    Ms. Freeman. Thank you.
    Dr. Ezeji-Okoye. Thank you very much.
    Mr. Mitchell. At this time, I would like to welcome the 
second panel to the witness table.
    Mr. William Feeley is the Deputy Under Secretary for Health 
of Operations and Management at the VA and the Chief Operations 
Officer for the VHA. Deputy Under Secretary Feeley has over 30 
years as a career civil servant, spending the majority of that 
time in the VA.
    And I want to thank you, Mr. Feeley, for your commitment to 
help our Nation's veterans and welcome you.
    And before we start your 5-minute presentation, would you 
please introduce the staff that you brought with you.
    Mr. Feeley. Thank you, Mr. Chairman.
    I have Dr. Ed Huycke from the----
    Ms. Brown-Waite. You might want to turn your microphone on, 
sir.
    Mr. Feeley. Sorry. I have Dr. Ed Huycke to my right from 
the Office of Seamless Transition; Dr. Shane McNamee, Medical 
Director at the Richmond Polytrauma Center. I've got Lu Beck, 
Chief Consultant of Rehabilitation Services in Headquarters and 
Dr. Barbara Sigford, National Program Director for Physical 
Medicine and Rehabilitation.
    Mr. Mitchell. Thank you.
    Before you begin, I would like to recognize Mr. Rodriguez, 
if it is all right.

          OPENING STATEMENT OF HON. CIRO D. RODRIGUEZ

    Mr. Rodriguez. Thank you, Mr. Chairman. Thank you for 
allowing me to make some opening comments that I did not make 
initially. I just first want to thank you.
    And I think it was the right thing for San Antonio to be 
selected as the next site for the fifth polytrauma center as 
they announced recently, you know, the fifth one.
    But first off, I also want to express my extreme 
disappointment with the fact that I, and the Committee, were 
not informed about the new polytrauma center in San Antonio, 
only after the media inquiry asked me to comment on it. And I 
think that the VA could have been more courteous to the Members 
of the Committee especially to letting us know in terms of the 
selection process.
    And since the designation, my office has been in touch with 
the VA staff. And from what I have been told, the VA has little 
information in terms of the new facility. And so I am glad 
today that I will have the opportunity to be able to ask you 
some questions and be able to dialog with you and work with you 
to make that happen because there is no doubt that there is a 
tremendous need out there and we are hoping to fill that need.
    So thank you very much for allowing me to make those 
opening comments. Thank you, Mr. Chairman.
    Mr. Mitchell. Thank you.
    Mr. Feeley.

  TESTIMONY OF WILLIAM F. FEELEY, DEPUTY UNDER SECRETARY FOR 
     HEALTH FOR OPERATIONS AND MANAGEMENT, VETERANS HEALTH 
     ADMINISTRATION, U.S. DEPARTMENT OF VETERANS AFFAIRS; 
ACCOMPANIED BY EDWARD HUYCKE, M.D., CHIEF DEPARTMENT OF DEFENSE 
  COORDINATION OFFICER, VETERANS HEALTH ADMINISTRATION, U.S. 
 DEPARTMENT OF VETERANS AFFAIRS; LUCILLE B. BECK, PH.D., CHIEF 
    CONSULTANT, REHABILITATION STRATEGIC HEALTH CARE GROUP, 
  VETERANS HEALTH ADMINISTRATION, U.S. DEPARTMENT OF VETERANS 
    AFFAIRS; BARBARA SIGFORD, M.D., PH.D., NATIONAL PROGRAM 
  DIRECTOR, PHYSICAL MEDICINE AND REHABILITATION, MINNEAPOLIS 
       POLYTRAUMA REHABILITATION CENTER, VETERANS HEALTH 
ADMINISTRATION, U.S. DEPARTMENT OF VETERANS AFFAIRS; AND SHANE 
     McNAMEE, M.D., MEDICAL DIRECTOR, RICHMOND POLYTRAUMA 
REHABILITATION CENTER, HUNTER HOLMES McGUIRE, VETERANS AFFAIRS 
MEDICAL CENTER, VETERANS HEALTH ADMINISTRATION, U.S. DEPARTMENT 
                      OF VETERANS AFFAIRS

    Mr. Feeley. Good morning, Chairman and Members of the 
Subcommittee. I want to thank you for the opportunity to 
discuss the Veterans Health Administration's ongoing efforts to 
improve the quality of care that we provide to veterans 
suffering from traumatic brain injury and complex multiple 
trauma.
    The focus of my testimony today will be on treatment and 
rehabilitation provided by VA to veterans recovering from TBI 
and complex multiple trauma and the current initiatives to 
further enhance these services to our veterans within the 
system of care.
    The mission of the VA Polytrauma System of care is to 
provide the highest quality of medical rehabilitation and 
support services for veterans and active-duty servicemembers 
injured in service to our country.
    This integrated, nationwide system of care has been 
designed to produce access for life-long rehabilitation care 
for veterans and active-duty servicemembers recovering from 
polytrauma and TBI.
    The four VHA polytrauma centers located in Minneapolis, 
Palo Alto, Richmond, and Tampa and soon to be San Antonio are 
the flagship facilities of the polytrauma system of care. These 
centers serve as hubs for acute medical and rehabilitation 
care, research and education related to polytrauma and TBI.
    During fiscal year 2007, the four PRCs added transitional 
rehabilitation programs at these sites. These programs serve 
veterans and active-duty servicemembers with polytrauma and/or 
TBI who have physical, cognitive, or behavioral difficulties 
that persist after the acute phase of rehabilitation and 
prevent them from effectively reintegrating into community or 
returning to active duty.
    Transitional residential rehabilitation offers a 
progressive return to independent living through a structured 
program focused on restoring psychosocial and vocational skills 
in a controlled therapeutic setting.
    All remaining VHA medical centers provide an aspect of the 
continuum of polytrauma system of care based on the levels of 
intervention available at the site. The definition of these 
levels was included in my written testimony and in the interest 
of time, I will not elaborate on those definitions now.
    The coordination of transition of care is critical. Care 
management across the entire continuum is a critical function 
in the polytrauma system of care to ensure lifelong 
coordination of services for patients recovering from 
polytrauma and TBI.
    At the direction of the Secretary, 100 transitional patient 
advocates (TPAs) have been recruited nationwide. The TPAs 
contact the patient and family while in the military treatment 
facility. One of their responsibilities is to ensure that all 
questions concerning VA are answered and each case is expedited 
through the VA benefits process.
    If necessary, the transitional patient advocate will travel 
with the family and veteran from the military treatment 
facility to their home and provide transportation to all VHA 
appointments.
    Psychosocial support for families of injured servicemembers 
is paramount as decisions are made to transition from the acute 
medical setting of a military treatment facility to a 
rehabilitation setting.
    VA social workers or nurse liaisons are located at the ten 
military treatment facilities including our most frequent 
referral sources, Walter Reed Army Medical Center and Bethesda 
National Naval Medical Center. These individuals provide 
necessary psychosocial support to families during the 
transition process, advising the families through the process.
    The admissions case manager from the polytrauma 
rehabilitation center maintains personal contact with the 
family prior to transfer and to provide additional support and 
further information about the expected care plan.
    Upon admission to the VHA PRC, the senior leadership of the 
facility personally meets with the family and servicemember to 
ensure that they feel welcomed and that their needs are being 
met.
    A care manager is also assigned to each patient. The care 
manager coordinates services and addresses emerging needs as 
the patient engages the various levels and types of VHA 
services necessary to support their rehabilitation. The care 
manager will also coordinate the ultimate transition to home.
    Mr. Mitchell. Mr. Feeley, I hate to cut you off, but we are 
going to be voting pretty soon and I would like to get some 
questions in. And we have your written testimony, if you do not 
mind----
    Mr. Feeley. I would be glad to end now and let you ask any 
questions you might like to ask.
    Mr. Mitchell. Thank you.
    Mr. Feeley. Thank you.
    [The prepared statement of Mr. Feeley appears on p. 32.]
    Mr. Mitchell. And I have a couple questions. And I 
appreciate you being here as well and thanks for your testimony 
regarding the polytrauma system.
    The description you have given is very interesting, very 
valuable. We have your written testimony.
    But the data provided by your staff shows that Palo Alto 
has been leaving beds empty while other polytrauma centers have 
been offering full capacity. And this data is not just about 
last week. It goes all the way back to 2005.
    In 2007, Palo Alto had filled 60 percent of its beds while 
the other polytrauma centers were at full capacity. And you 
have the data. You understand all this.
    And the question is, why wasn't anything done about it?
    Mr. Feeley. I will tell you that my concentration has been 
on opening up the transitional rehabilitation beds, on making 
sure that additional resources were added to the polytrauma 
center, and to assure all the infrastructure and space needs 
were where they needed to be.
    I would indicate that your point is very well taken related 
to monitoring the number of referrals and the type of referrals 
and the disposition of referrals.
    And starting with this fiscal year 2008, I have asked Dr. 
Beck to create a monthly report that will show the utilization 
in each site, the number of referred and the dispositions.
    I have looked at the data related to October 1, 2005, to 
July of 2007, and note the point you are making, so this is a 
lesson learned for us on a headquarters' level.
    Mr. Mitchell. Is there any legitimate reason why Palo Alto 
should have been different from any of the other polytrauma 
centers?
    Mr. Feeley. I really do not have any explanation for why 
that is the case. I think that your point earlier with the 
previous panel, it is either the number of referrals in or the 
outreach may not have been as aggressive. But I am very 
comfortable that Palo Alto has a very strong leadership team 
and they have the message. The census today is at 12 beds. The 
outreach to Bethesda yesterday will be followed by many other 
outreach efforts to ensure a maximum utilization of bed 
capacity.
    Mr. Mitchell. And what I heard you say, I thought earlier, 
was that the reason you really did not do much about this is 
you were busy doing something else, getting the actual 
facilities in place, so you were not really looking at----
    Mr. Feeley. What I would say to you, this data did not come 
to my attention until very recently and there was not a 
capacity issue with all beds being full throughout the system. 
We have 48 beds and there was not a complaint coming up through 
any of our data systems. And it is my understanding there are 
no waiting lists to get into the program, at least right now.
    So what I was trying to convey that my primary interest was 
developing transitional rehabilitation housing for veterans who 
had been through acute rehab and needed an additional runway. 
Palo Alto was one of the first facilities that had the 
transitional housing put in place because they had one of the 
first day hospital programs for TBI injured patients.
    Mr. Mitchell. And are you telling us that there will be 
people looking at this data from now on and that, you know----
    Mr. Feeley. Absolutely correct.
    Mr. Mitchell. Obviously you said you did not get the data, 
so either no one gave it to you or you just did not look at it, 
one or the other.
    Mr. Feeley. The data was not coming forward, but it will be 
starting October 1st on a monthly basis by facility, so I will 
know what the average daily census is, what the utilization 
rate is. We will know who needs to outreach and we will also 
know what type of dispositions we are challenged with and we 
may need to beef up our resources to meet those needs.
    Mr. Mitchell. Thank you.
    Ms. Brown-Waite.
    Ms. Brown-Waite. Thank you very much.
    Mr. Feeley, I just talked to another Member of Congress 
about a clinic that was opening up in their district that the 
VA never even attempted to cooperate with that Member's 
schedule. I am embarrassed that you never informed the Member 
of Congress and Mr. Rodriguez who I served with before on this 
Committee. I am glad that he is back.
    You should not do that. You need to be involved whether it 
is a Republican or a Democrat. You need to let the Members of 
Congress know what is going on so they do not hear it from the 
press. Please take that away and share it with other executives 
in the VA.
    Mr. Feeley. I understand the lesson learned.
    Ms. Brown-Waite. Maybe I just instill the fear of God or 
Ginny Brown-Waite in the people in Florida, but they would 
never ever do that. Please just do not ever let that happen 
again.
    This question is for Dr. McNamee and/or Dr. Huycke. I 
understand that our staff paid you a visit a couple of weeks 
ago and that it went pretty well.
    Would you care to touch upon the ability for your staff to 
receive complete and critical medical information about our 
wounded warriors transferring to your polytrauma center?
    Dr. McNamee. Thank you for the question, ma'am.
    I did have the opportunity to meet with Mr. Bestor and Mr. 
Wu about a week ago and sat them down and went through the 
transfer of medical records with them and specifically the 
pieces of medical record that we are indeed receiving.
    The item that we use most frequently now which is a 
complete medical record potentially from what Mr. Bestor told 
me and with the exception of some psychological data that I had 
not been able to verify on our end yet, but is a complete 
medical record that is scanned at both Bethesda and Walter Reed 
into a PDF file and is loaded into our medical record system at 
the VA. It can be sorted. It can be searched to some degree and 
also printed off.
    This is direct documentation of medical care at the 
military treatment facility before they are discharged to us. 
These documents range anywhere from 500 to I have seen 2,500 
pages that come down through. This also is accompanied by full 
imaging, so all imaging from Bilad and battlefield up through 
the military treatment facilities are also loaded into our 
computer system which we use on a very frequent basis which Mr. 
Bestor and Mr. Wu also had the opportunity to see.
    Ms. Brown-Waite. One other question. Do you know why DoD 
installed their server in your facility? Does any other 
polytrauma center have the same setup to receive medical 
information from DoD facilities?
    Dr. McNamee. I can answer what happens in our facility 
specifically, ma'am. I would direct your question otherwise for 
that.
    Ms. Brown-Waite. So the answer is you do not know why they 
chose your facility?
    Dr. McNamee. I know that they chose our facility because we 
are receiving these individuals. My answer is, is I do not know 
what specifically the setup is at the other four polytrauma 
centers. I would assume that they have the same setup that we 
do, but I cannot verify that.
    Ms. Brown-Waite. Mr. Feeley, can you?
    Mr. Feeley. I do not know the answer, but I do not know if 
any other panel member does.
    Dr. Sigford. Yes. Is my microphone--there you go. I am 
sorry. I thought the green light was on.
    Yes. All four of the polytrauma rehabilitation centers have 
the same capacity to receive that scanned PDF file and load it 
in their electronic record.
    Ms. Brown-Waite. What about the images? Are they also----
    Dr. Sigford. Yes.
    Ms. Brown-Waite [continuing]. Available?
    Dr. Sigford. Yes.
    Ms. Brown-Waite. So it comes from DoD?
    Dr. Sigford. Yes.
    Ms. Brown-Waite. You can get them though?
    Dr. Sigford. Yes.
    Ms. Brown-Waite. Okay. I think this question is for Mr. 
Feeley. What exactly is the timeline in preparing the newly 
announced facility in San Antonio? When will patients begin 
being received there?
    Mr. Feeley. I will be hopeful that I think the dollar 
amount is $67 to $70 million and hopefully we would be seeing 
patients the beginning of fiscal year 2011. It is about a 36-
month runway. Now, we were pressed to do this sooner. That 
would be the far-out date.
    Ms. Brown-Waite. And thank you.
    I am going to yield back the balance of my time.
    Mr. Mitchell. Thank you.
    Mr. Rodriguez.
    Mr. Rodriguez. Thank you, Ms. Brown-Waite, for those 
questions and those comments.
    Congressman Chet Edwards on Appropriations, and I sit on 
Appropriations also, worked and we put $30 million initially to 
get going on the Supplemental.
    Do you have those resources in hand to start up the San 
Antonio facility?
    Mr. Feeley. I believe those dollars and resources are in 
hand to get launched.
    Mr. Rodriguez. Okay. You should have them in hand. And you 
are saying it is going to be until 2011?
    Mr. Feeley. It is a huge project with major renovation. So 
it could be done in 24 months, but I would rather give you the 
outside number of 36. I think that is more accurate.
    Mr. Rodriguez. Okay.
    Mr. Feeley. This is a huge renovation.
    Mr. Rodriguez. Is it a priority for the VA in terms of 
making this happen as quickly as possible?
    Mr. Feeley. Absolutely.
    Mr. Rodriguez. Okay. And the priority means at the most, 36 
months----
    Mr. Feeley. Correct.
    Mr. Rodriguez [continuing]. Less, 24? In spite of the fact 
that you already have half of that in hand or you should have?
    Mr. Feeley. The half that we have in hand was received----
    Mr. Rodriguez. In the Supplemental.
    Mr. Feeley [continuing]. Almost 8 weeks ago. It is not 
exactly like it arrived 10 months ago.
    Mr. Rodriguez. Yeah. The Supplemental.
    Mr. Feeley. But we will accelerate as aggressively as we 
can to get it done realizing we have the Intrepid Brook and 
major needs there.
    Mr. Rodriguez. Are you putting the next 36 as part of the 
existing 2008 or 2009 budget?
    Mr. Feeley. That I do not know the answer to, but I can get 
back to you on that.
    [The information was provided in the response to Question 7 
in the post-hearing questions for the record, which appears on 
p. 40.]
    Mr. Rodriguez. Okay, because we will have another 
Supplemental. We will see what we can work out, but I would be 
glad if you can maybe look at using some of those resources 
there since you already have the first $30 million.
    Mr. Feeley. We also have an excellent Network Director in 
Mr. Shay, who was the former Director at San Antonio, who is 
very committed to this initiative, so----
    Mr. Rodriguez. No. He is a great guy. You have some good 
people there trying to make that happen. So I know they are 
looking forward to making that a reality. And so I want to 
thank you for that.
    And overall, I know I tell my veterans that there is a new 
day at the VA and for those that have been shunned in the past 
to go back, especially a lot of our Vietnam veterans that have 
had a rough time getting access and, you know, and for a good 
reason. We also, you know, did not fund it appropriately. But I 
am hoping that we can start making some inroads to these 
veterans that are coming out of both Afghanistan and Iraq.
    So the indication is hopefully by 2011 or before then. Do 
you know when we might start breaking ground?
    Mr. Feeley. There is actually a ceremony, I believe, this 
Friday, the 28th down in San Antonio to make this announcement. 
But I do not know when the ground breaking would actually 
occur.
    Mr. Rodriguez. Yeah. Again, I would really appreciate if 
you would let me know when those ceremonies are occurring, you 
know, since I am on the Committee. So I would appreciate it. 
And I know that the Secretary, I think, informed the Chairman, 
I think afterward, but I did not get that until much later.
    Mr. Feeley. I understand how sensitive it is. Thank you.
    Mr. Rodriguez. Okay. I would appreciate it. And I would 
also appreciate if you have any areas of problems, you know, to 
let us know what we can do because there is nothing worse than 
for us to find out that in terms of utilization rates that are 
out there because at those rates, the Capital Asset Realignment 
for Enhanced Services (CARES) Commission was going around the 
country, you know, and closing facilities that were at 50 and 
60 percent utilization.
    And so if that is the case, then, you know, you got to be 
looking at that real closely because I remember those 
recommendations from the CARES Commission that if it was only 
60 percent, you know, they were going to get recommended to get 
closed.
    Mr. Feeley. The Congress has been very benevolent with 
resources. We have the money to do the job right. We are adding 
additional staff to all of these programs including Palo Alto. 
And I understand the need to get capacity up.
    Mr. Rodriguez. Yeah. And the fact that, you know, you 
construct this one in terms of--is 12 beds sufficient?
    Mr. Feeley. I think we are going to go with 12 beds. By 
history, the same as the other sites, with 12 transitional 
beds, that will give us, I guess I will describe an accordion 
capacity to grow if we need to.
    In addition, we are going to put additional resources in to 
be able to treat moderate brain injury that has a need for a 
lot of psychological support and cognitive work on an 
outpatient basis. So this is something that is very exciting 
that is going to happen at San Antonio.
    Mr. Rodriguez. Okay. We are looking forward to it and 
looking forward to working with you. Thank you.
    Mr. Mitchell. Thank you, Mr. Rodriguez.
    We have one last question from Ms. Brown-Waite and that 
will conclude this hearing.
    Ms. Brown-Waite. As you can tell, we have votes, so we will 
be leaving for that.
    Mr. Feeley, our staff has informed me that not all 
facilities are using, or not even aware of the use and 
availability of JPTA and VTA programs to track incoming 
patients from DoD.
    How widely would you say has VA educated the outlying 
medical centers and outpatient clinics on this patient tracking 
application? And for the polytrauma units, which obviously this 
information is very important, how much data is transferred 
from DoD using this application when a servicemember is 
transferred between the two organizations?
    Mr. Feeley. Thank you. I am going to let Dr. Huycke comment 
on that.
    Dr. Huycke. Ma'am, thank you for the question because I 
think the JPTA/VTA initiative in the VA has truly been one of a 
good news story.
    Right now in the VA, we have 49 individuals at 15 VA 
medical centers who have access to the joint patient tracking 
application. Of course, that is the DoD version. And on top of 
that, we have more than 1,200 individuals in the VA system 
spread throughout the country who have access to the veterans 
tracking application. As you know, the veterans tracking 
application is the VA image of the joint patient tracking 
application.
    We have prioritized the rolling of this capability out to 
the polytrauma units because of the acuity and the necessity of 
getting it out to those folks first. And so that is where the 
priority has been and continues to be. And all of the 
polytrauma units have more than a single individual with access 
to the joint patient tracking application and to VTA.
    So on top of that, there have been, for instance, at the 
last national call, Mr. Feeley's last national call, we put out 
the information on the veterans tracking application. So 
although we are probably not where we would like to be with 
VTA, we believe that to be a very good news story between the 
collaboration of DoD and VA.
    Mr. Mitchell. Just one follow-up. My understanding is that 
Palo Alto as well as--who is the other--Minneapolis, have not 
even heard of these programs. So I do not know if fault lies 
with them or with you, but I would think that there ought to be 
better coordination of all of these.
    And with that, I want to thank all of you for what you are 
doing because, you know, our veterans deserve nothing but the 
very finest from what this country has to offer. And there may 
be more questions that will be asked by the staff that we did 
not get to ask today, so it may be in writing, but I want you 
to know that we are very concerned about this. And so expect 
some follow-up from both of our staffs.
    Thank you, and this meeting is adjourned.
    [Whereupon, at 11:22 a.m., the Subcommittee was 
adjourned.]

                            A P P E N D I X

                              ----------                              

             Prepared Statement of Hon. Harry E. Mitchell,
         Chairman, Subcommittee on Oversight and Investigations

    This hearing will come to order.
    Thank you all for coming today. I am pleased that so many folks 
could attend this oversight hearing on VA Polytrauma Rehabilitation 
Centers. The VA polytrauma centers help mend and reintegrate into 
society servicemembers who have suffered among the worst that war can 
inflict. The most severely injured servicemembers serving in Iraq and 
Afghanistan are medevac-ed out of theater through Germany to Walter 
Reed and Bethesda Naval Hospitals and, when they are ready, are sent to 
one of the four polytrauma centers, which are located in Richmond, 
Tampa, Minneapolis, and Palo Alto. Most polytrauma patients have 
suffered traumatic brain injury in addition to a variety of other 
serious injuries, some which necessitate amputation. The soldiers, 
sailors, airmen, and Marines who are treated at the polytrauma centers 
have paid a very high price for their service to their country, as have 
their families, both of whom face a long and difficult path to recovery 
and sometimes a lifetime of care. The Nation owes these servicemembers 
and their families everything that a Nation as rich as ours can 
provide.
    The Nation has many who need and deserve what we can give. Survival 
rates for servicemembers injured in combat are extremely high compared 
to previous conflicts, partly because of greatly improved protective 
equipment, but also because the military has moved surgical medical 
care practically to the front lines. A soldier injured in an IED blast 
can be in surgery within 30 to 45 minutes or even less. With these 
advances, however, comes the need to treat injuries that would have 
been fatal in the past. Injuries like traumatic brain injury and post-
traumatic stress disorder require medical treatment and long-term care 
of a new kind. The VA polytrauma centers are an essential part of that 
care.
    Congress has provided significant resources, and is providing more, 
that have enabled the VA to establish and expand polytrauma care. It 
must be said that the VA has stepped up to the plate to meet this need. 
In addition to the four polytrauma centers, the VA has created a 
network of sub-acute polytrauma care centers in each of the Veterans 
Integrated Services Networks and outreach programs throughout the 
country. This is not to say that everything is as it should be--we 
would not be having this hearing if that were the case. Polytrauma care 
is not perfect. There is also the sharing of electronic medical 
information and other issues that have been highlighted by Senator Dole 
and Secretary Shalala that the Subcommittee and the Full Committee will 
be addressing in the near future. But there should be no 
misunderstanding--we are not here to criticize the VA's care providers 
or to suggest that the quality of care that the Nation's most severely 
injured servicemembers is anything less than exemplary. The 
Subcommittee has found some management issues that need to be 
addressed--that is why the title of this hearing is what it is. The 
Subcommittee's oversight is intended to ensure that the superb care the 
VA provides is provided to those who deserve to receive it.
    Data provided by the VA shows that the Palo Alto VA's polytrauma 
center, from the beginning of this year through July, filled only 60 
percent of its available beds, while the three other polytrauma centers 
combined have been running at 98 percent of capacity. We have found no 
good reason why that should be. The VA's Palo Alto hospital has a 
beautiful facility, an even more beautiful Fisher House where family 
members can stay, and is practically married to the Stanford Medical 
School. Palo Alto has all the resources it could need to provide care 
for all the polytrauma patients it can take. The Subcommittee has also 
found that the Palo Alto polytrauma center would not accept minimally 
responsive brain injured patients while the other polytrauma centers 
did so, until the VA created a treatment protocol for those patients in 
December 2006 and effectively forced Palo Alto to accept these 
patients. This past spring, the VA's Office of Medical Investigations 
found disarray, morale problems, insufficient programs for families, 
and lack of leadership. All of this raises obvious issues not just 
about local management but also about VA's central office. Why, for 
example, did the fact that Palo Alto's failure to fill its beds while 
the other polytrauma centers were at full capacity not raise a red flag 
at headquarters?
    We begin today by hearing from the senior management of the Palo 
Alto Health Care system, headed by its Director, Lisa Freeman. 
Subcommittee staff has spent much time with Ms. Freeman and her team 
and they are to be commended for their willingness to meet with and 
provide information to the Subcommittee. We hope, indeed expect, that 
their testimony will describe significant progress in addressing the 
concerns of the Office of Medical Investigations and this Subcommittee.
    The second panel is headed by William Feeley, Deputy Under 
Secretary for Health for Operations and Management. The Subcommittee 
extends its thanks to Mr. Feeley and the VA witnesses with him for 
their efforts to provide the best care possible to our injured 
servicemembers and appreciates their cooperation with the Subcommittee 
in meeting with and providing information to us. We in no way doubt 
their good will and dedication. But there are obvious management issues 
for the central office that are raised by the fact that there were 
empty beds in Palo Alto and these witnesses will be asked to address 
these issues. Dr. Barbara Sigford and Dr. Shane McNamee, both of whom 
are personally involved in running polytrauma centers, are at the 
witness table as well. We look forward to hearing from them about the 
good things they are doing for those who have made great sacrifices for 
their country.
    On Sunday night, the Public Broadcasting System began a 15 hour 
presentation of Ken Burns' documentary on World War Two. America 
achieved great things in that war, but the documentary reminds us, or, 
perhaps, more realistically, teaches us of the terrible cost of war. We 
as a Nation owe a debt that can never be repaid to those who serve, and 
an obligation that must be met to meet the needs of those injured in 
that service. We are here today to do our part in making sure that this 
happens.
    No one can doubt the dedication of the men and women in the 
military and the VA who provide care for our servicemembers.

                                 
             Prepared Statement of Hon. Ginny Brown-Waite,
                       Ranking Republican Member

    Thank you, Mr. Chairman, for yielding.
    Mr. Chairman, I believe the title of this hearing is very 
appropriate. When we talk about our wounded warriors from the Global 
War on Terrorism, the quest for excellence should be of utmost 
importance.
    Our Committee staff recently visited several Polytrauma 
Rehabilitation Centers located in Richmond, Virginia, Minneapolis, 
Minnesota, and Palo Alto, California. They did this to provide 
oversight on the level of care being provided to our wounded 
servicemembers at those units. Last Congress, while serving as Chairman 
of this Committee, Ranking Member Buyer followed injured servicemembers 
from a combat support hospital in Iraq through Landstuhl Army Medical 
Center in Germany, and on to Walter Reed and Bethesda. Mr. Buyer has 
also visited the Minneapolis PRC to evaluate care and services received 
by our most critically injured servicemembers.
    What I still see today is of great concern. The tracking of medical 
records still includes the paperwork and hard copies of medical records 
accompanying the servicemembers as they transfer stateside and 
ultimately to the VA. The Committee hears that not all the critical 
medical information is being forwarded to the Polytrauma units by the 
Department of Defense, and many of the VA facilities are not using or 
have never heard of the Joint Patient Tracking Application and the 
Veteran Tracking Application systems.
    At the PRC unit in Palo Alto, our staff found several issues 
relating to lack of staffing and resources. This same concern was 
detailed in the draft OMI report obtained by our staff prior to their 
visit to Palo Alto. I would like to have the witnesses address this 
deficiency in care to the servicemembers and veterans who are being 
treated in this facility, and am interested in learning how widespread 
this problem is.
    During the staff visit to the PRC unit in Minneapolis, the 
Committee learned about the unusually high turnover rate of the active 
duty officers' military liaison. I am concerned about how this turnover 
rate affects the continuity of care for our severely injured 
servicemembers. PRC staff told us that there were also no electronic 
transfer of records between the DoD and the PRC in Minneapolis. I am 
interested in learning what is being done to address this situation. I 
know that some of our PRCs are doing a great job, while it seems that 
others are still having great difficulties. How are best practices 
being shared between PRCs to provide the best possible care for our 
severely wounded servicemembers and veterans?
    Mr. Chairman, I am quite concerned about the care our wounded 
servicemembers are receiving as they move from the battlefield through 
the line of care to our VA facilities. As I have stated in the past, 
the hand-off between DoD and VA should be seamless and transparent to 
the servicemembers and their families receiving care and treatment . . 
. not a fumble. Repeatedly, the Committee has heard that many of these 
transfers require multiple phone calls, emails, faxes, and 
videoconferencing. Our veterans must have this seamless transition to 
maintain a continuum of care between the two departments. Committee 
Members have been fighting this recurring battle on the home front for 
our servicemembers and veterans.
    Mr. Chairman, Congress' responsibility to these men and women in 
uniform does not end with their care at the PRC units. As the Oversight 
Committee, we must also ensure that they have a seamless transition 
from active duty to civilian/veteran status.
    I cannot stress enough the importance of working toward a standard 
Benefits Delivery upon Discharge (BDD) documentation. A standard BDD 
would include one physical to be shared between the DoD and the VA, 
providing servicemembers with documentation as to the benefits for 
which they may be eligible. With the use of a standard shared BDD, we 
could conceivably have the claims backlog at the VA caught up in just a 
few years. This program was successfully tested between DoD and VA from 
1995-1997. It is also a strong recommendation for the President's Dole-
Shalala Commission report.
    Again, Mr. Chairman, thank you for calling this hearing, and I look 
forward to hearing from our witnesses about how VA is working with the 
DoD to improve care for our Nation's heroes.

                                 
        Prepared Statement of Elizabeth Joyce Freeman, Director,
             Veterans Affairs Palo Alto Health Care System,
  Veterans Health Administration, U.S. Department of Veterans Affairs

    Mr. Chairman and Members of the Committee, thank you for the 
opportunity to appear before you today to discuss the Polytrauma 
Rehabilitation Center (PRC) located at the Department of Veterans 
Affairs Palo Alto Health Care System (VAPAHCS). It is a privilege to be 
on Capitol Hill to speak and answer questions about this vital program 
and other issues that are important to veterans who have bravely served 
in Operation Enduring Freedom and Operation Iraqi Freedom (OEF/OIF).
    Mr. Chairman, I would also like to thank you and your Committee for 
your advocacy on behalf of our Nation's veterans. The Committee and its 
staff have been actively involved in many issues affecting veterans 
this year. Several weeks ago, I had the pleasure of hosting a visit by 
senior staff from the Committee, including Mr. Geoffrey Bestor and Mr. 
Art Wu. They toured VAPAHCS and interviewed several patients, family 
members and staff. I appreciated their interest, insights and 
suggestions.
    Today, I will provide a brief overview of VAPAHCS and the PRC. I 
will present some of our successes, challenges and upcoming 
enhancements at the PRC. I will also specifically discuss areas of 
particular interest and recent scrutiny, including accreditation, 
referral process, emerging consciousness program, family support and 
programmatic leadership.
VA Palo Alto Health Care System (VAPAHCS)
    VAPAHCS is one of the largest and most complex health care systems 
in the Veterans Health Administration (VHA). It provides primary, 
secondary and tertiary care services across a large geographic area 
(i.e., 10 counties over 13,500 square-miles) in the South San Francisco 
Bay area. VAPAHCS operates facilities at three inpatient divisions 
(i.e., Palo Alto, Menlo Park and Livermore) and six outpatient clinics 
(i.e., Capitola, Modesto, Monterey, San Jose, Sonora and Stockton). 
VAPAHCS offers most of the highly specialized services in VHA, 
including traumatic brain injury (TBI), blind rehabilitation, hospice, 
palliative care, spinal cord injury (SCI), post-traumatic stress 
disorder (PTSD), gero-psychiatric inpatient care, war-related illness 
and injuries, domiciliary care and organ transplantation.
    In fiscal year (FY) 2006, VAPAHCS had enrolled more than 85,000 
veterans and provided care to 53,000 unique veterans. VAPAHCS staff 
includes nearly 3,000 full-time equivalent employees (FTEE) and more 
than 1,700 volunteers. The FY 2007 operating budget for VAPAHCS is 
approximately $600 million. VAPAHCS has particularly strong academic 
programs, including the third most highly funded research program in 
VHA. VAPAHCS and the veterans it proudly serves benefit from a balanced 
relationship with Stanford University School of Medicine and 
affiliations with more than 100 other academic institutions.
Polytrauma Rehabilitation Center (PRC)
    VA established the Polytrauma System of Care (PSC) in 2005 to 
address the biopsychosocial needs of the most severely injured OEF/OIF 
veterans. The PSC consists of PRCs, Polytrauma Network Sites (PNSs), 
Polytrauma Support Clinic Teams (PSCTs) and Polytrauma Points of 
Contact (PPOCs). PRCs serve as a regional referral center for acute 
medical and rehabilitative care for patients with polytrauma (defined 
as two or more injuries, one of which might be life threatening, 
resulting in significant physical, cognitive, psychological or social 
impairments and functional disability) and TBI. PRCs maintain a full 
team of dedicated rehabilitation specialists and experts from other 
specialties related to polytrauma. PRCs also serve as consultants to 
other facilities across the PSC.
    The PRC at VAPAHCS is one of four PRCs in VHA (the other three are 
located in Minneapolis, MN; Richmond, VA; and Tampa, FL). A fifth 
polytrauma site was just recently announced for San Antonio, TX. The 
PRC offers a continuum of acute rehabilitative services in a variety of 
venues, including inpatient wards, outpatient clinics and residential 
transitional settings. Clinical care is provided by a dedicated 
interdisciplinary team with specific expertise in physiatry, 
rehabilitation nursing, neuro-psychology, psychology, speech-language 
pathology, occupational therapy, physical therapy, social work, 
therapeutic recreation therapy, prosthetics, SCI, blind rehabilitation 
and PTSD.
    The core of the PRC at VAPAHCS is a 12-bed ward located in Building 
7D on the campus of the Palo Alto Division. The PRC building also has 
four general rehabilitation beds that are available to polytrauma 
patients on a priority basis, plus two additional beds for residential 
rehabilitation and/or women veterans. Since its inception (i.e., from 
February 2005 through early September 2007), the PRC has accepted 143 
patients. The average daily census (ADC) has steadily increased since 
FY 2005. Through the third quarter of FY 2007, the PRC ADC has been 7.9 
for an occupancy rate of 65 percent.
    Another important component of the PRC is the Polytrauma 
Residential Transitional Rehabilitation Program (PRTRP). PRTRP is 
designed for veterans and active duty servicemembers who have completed 
their acute rehabilitation but have lingering impairments that prevent 
them from safely re-integrating into their community or returning to 
active duty. PRTRP has the goal of establishing independent living 
through a structured program that focuses on restoring home, community, 
leisure, psychological and vocational skills in a controlled, 
therapeutic setting. Services typically provided include individual and 
group therapies, case management, care coordination and vocational 
rehabilitation. Through the third quarter of FY 2007, the ADC in the 
PRTRP has been 4.7 and therefore the combined ADC for both the PRC and 
PRTRP is 12.6.
    In part due to the ongoing war in southwest Asia and our country's 
deep concern for injured veterans, the PRC at VAPAHCS has received 
considerable attention from domestic and international media outlets. 
Since the establishment of the PRC in 2005, more than 200 print and 
broadcast stories have been disseminated about the PRC, its patients 
and its staff. Stories from respected organizations such as Associated 
Press, New York Times, Jim Lehrer NewsHour, National Public Radio, NBC 
Nightly News and British Broadcasting Company, have all portrayed the 
quality of the care at the PRC as outstanding.
    One poignant example is the story of Marine Corps Corporal (Cpl.) 
Jason Poole. Cpl. Poole was on his third tour in Iraq in 2004, 10 days 
shy of coming home, when his patrol was hit by a roadside bomb. The 
explosion and resulting injuries (e.g., shrapnel went into his left ear 
and out his left eye) left him in coma for two months. When he arrived 
at VAPAHCS, he was unable to walk, talk or breathe without a tube in 
place. Two years and seven reconstructive surgeries later, he was 
interviewed by the local NBC news affiliate. ``I've been treated 
amazingly here,'' he said. ``These people [staff at the PRC at VAPAHCS] 
gave me my life. They are everything to me. I would not be where I am 
today without their help.'' \1\ The accomplishments of Cpl. Poole and 
so many other courageous men and women at the PRC are extraordinarily 
gratifying to me.
---------------------------------------------------------------------------
    \1\ NBC Channel 11: ``The Bay Area at 11'', KNTV-San Francisco 02/
07/2007.
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Challenges and Improvements
    While the PRC at VAPAHCS has enjoyed considerable success, it has 
experienced and continues to face challenges. Staffing is a major area 
of concern. VAPAHCS expends considerable effort to attract and retain 
the ``best and the brightest.'' The health care labor market in the 
greater San Francisco Bay Area is highly competitive and compounded by 
an exceedingly high cost of living. In part due to our affiliations 
with prestigious academic partners such as Stanford University School 
of Medicine, Washington State University and the University of 
California San Francisco School of Medicine; VAPAHCS generally has been 
successful in recruitment. However, recruitment for some positions 
(e.g., physiatry) has been especially problematic.
    While work on the PRC is fulfilling, it is also inherently 
demanding. Knowledgeable and well-intended individuals can have 
different opinions and these differences can be exaggerated in the PRC 
environment. Consequently, the VHA Under Secretary for Health (USH) 
recently asked the VHA National Center of Organizational Development 
(NCOD) to visit all four PRCs to assess current structure and staff. 
NCOD came to VAPAHCS and met with senior leadership and front line 
staff. The initial visit was beneficial and we look forward to 
continuing our partnership with NCOD.
    Also, as noted earlier, the PRC is a highly visible endeavor. The 
PRC is frequently the subject of scrutiny by oversight bodies, 
veterans' advocates, Department of Defense (DoD) personnel, media and 
elected officials. Nearly every week, VAPAHCS has the honor of hosting 
visits by interested parties. The vast majority of these visits are 
very positive and generate considerable praise and compliments for PRC 
staff and leadership.
    However, earlier this year, the VHA Office of the Medical Inspector 
(OMI) received a letter from the Senate Committee on Veterans' Affairs 
expressing concern about the delivery of care at the PRC at VAPAHCS. 
OMI was asked to look into several allegations, including delays in 
accreditation, inappropriate declinations of referrals and lack of 
effective leadership at the program level. As a result, OMI came to 
VAPAHCS in March 2007 and assessed the PRC. Some of the allegations 
were validated (e.g., delay in accreditation survey), while others were 
not substantiated (e.g., OMI concluded VAPAHCS did not ``cherry pick'' 
referrals). I will discuss these and other issues in the following 
sections.

    Accreditation. One of the concerns expressed in the OMI report was 
the delay in the accreditation survey by the Commission on 
Accreditation of Rehabilitation Facilities (CARF). CARF confers up to 
(i.e., a maximum) 3-year accreditation status to rehabilitation 
facilities that undergo a successful survey. VAPAHCS was due for its 
triennial CARF survey of rehabilitation programs (including the PRC) in 
February 2007. Based on internal and external assessments (e.g., a 
``mock survey'' by a contracted private health care organization), I 
determined we needed additional time to prepare for the survey. 
Consequently, I asked CARF to delay its survey for a few months.
    I am pleased to report to the Committee that the CARF survey 
occurred July 19-20, 2007, and resulted in full accreditation for the 
maximum 3-years for all of the four programs surveyed (i.e., 
outpatient, inpatient and residential brain injury rehabilitation, as 
well as inpatient rehabilitation). As noted in the August 24, 2007, 
notification letter from CARF, ``This achievement is an indication of 
your organization's dedication and commitment to improving the quality 
of the lives of the persons served. Services, personnel, and 
documentation clearly indicate an established pattern of practice 
excellence.'' I am especially pleased that areas that were previously 
considered weaknesses (e.g., program leadership, staff education), are 
now cited by CARF to be organizational strengths.

    Referrals. I and my staff at VAPAHCS consider our selection as a 
PRC site to be a distinct privilege. We are fully committed to having 
an active, vibrant and highly effective rehabilitation program. We 
recognize that the historical level of activity at the PRC has been 
below capacity and we have evaluated the circumstances associated with 
this situation.
    I would like to emphasize that we are highly motivated to receive 
referrals to our PRC and we make every effort to accept them. Since the 
PRC began operations in 2005 (through September 14, 2007), VAPAHCS has 
received a total of 177 referrals to its PRC and accepted 143 patients 
(81 percent). The PRC declined or redirected 25 patients (14 percent) 
and the referring site withdrew 9 referrals (5 percent). The most 
common reasons for the PRC not accepting referrals have been another 
form of treatment was needed (e.g., care for PTSD, substance abuse 
treatment), another venue was more appropriate (e.g., Polytrauma 
Network Site, different PRC for geographic reasons) or the desired 
service was not available at the time (e.g., coma stimulation). I would 
like to emphasize that the OMI reviewed this issue earlier this year 
and concluded that the disposition of referrals was appropriate. And, 
while the acceptance of some referrals was delayed due to concerns 
regarding medical stability (in the context of long flights from the 
East Coast), OMI did not substantiate the allegation that VAPAHCS was 
``cherry picking'' referrals to achieve good outcomes.
    Currently, recent changes I have initiated will make it easier for 
referring sites to send us patients. There is now a single point of 
contact for all PRC referrals at VAPAHCS who has the requisite customer 
service skills. This individual collects all of the relevant 
information and presents it to an interdisciplinary team of polytrauma 
experts. The team makes a recommendation to the PRC Program Director 
and the PRC Program Director makes a decision within 2 business days 
from the time of the referral (i.e., when the needed medical 
information is available). I have instructed my staff to look for every 
possible way to accept all patients to VAPAHCS, either at the PRC or 
another program (e.g., PRTRP, National Center for PTSD). The decision 
will be promptly communicated to the referring site. If for any reason 
the referring site disagrees with the decision, the referring site will 
be encouraged to appeal the decision to the Chief of Staff, VAPAHCS. We 
will fully document the disposition for each referral and will report 
the outcomes to the Veterans Integrated Service Network (VISN) 21 
Office and VA Central Office (VACO) monthly.

    Emerging consciousness program. VHA formally introduced the 
Emerging Consciousness (EC) following its polytrauma conference in 
December 2006. EC is a program developed by VHA to optimize the long-
term functional outcomes of brain-injured patients by attempting to 
improve responsiveness, return to consciousness and advance to the next 
level of rehabilitation care. EC is intended for patients who range 
from fully comatoese to minimally conscious. EC utilizes appropriate 
medical and nursing rehabilitation services, individualized 
multisensory stimulation and prevention of complications related to 
immobilization. EC also emphasizes support to families and caregivers. 
Some patients in the EC program, even with the most optimal care may 
not regain consciousness or advance to the next level of care.
    The PRC at VAPAHCS has been providing many components of the EC 
program since its inception (e.g., rehabilitation services, prevention 
of complications and family support). However, the PRC at VAPAHCS did 
not initially offer the multisensory component. In the summer of 2006, 
VAPAHCS noted anecdotal reports of the success of multisensory 
stimulation and reassessed its potential value. VAPAHCS began offering 
this service in November 2006 and fully instituted the EC program 
following the polytrauma conference in December 2006. The PRC has 
accepted 12 patients into its EC program since November 2006, including 
a patient declined by private rehabilitation sites. At the time of this 
testimony, VAPAHCS had a census of six EC patients with five in the PRC 
and one in the intensive care unit.

    Family support. VAPAHCS recognizes that the presence and support of 
family members are critical components of the successful rehabilitation 
of injured patients. VA has inherent constraints on its ability to 
provide certain services to non-veteran family members. Fortunately, 
since the PRC began operations, VAPAHCS has developed innovative 
programs to support families of PRC patients.
    A wonderful example is the construction and opening of a Fisher 
HouseTM directly across from the PRC on the VAPAHCS campus. 
Fisher HousesTM are ``comfort homes'' with individual rooms 
for families of patients receiving medical care at major military and 
VA medical centers. Prior to the opening of the Fisher 
HouseTM in April 2006, many families complained of the 
inability to find affordable accommodations near VAPAHCS. Thanks to the 
generosity of donors and the Fisher House Foundation, families of OEF/
OIF patients now have access to a stunning 21-suite Fisher 
HouseTM. There is no charge to guests and families of OEF/
OIF patients are given priority admission. The Fisher 
HouseTM is filled to capacity nearly every night.
    We have also been able to provide limited monetary support from 
donations to our General Post Fund. The donations come from individuals 
and organizations such as Rotary Club. We have established a Fisher 
HouseTM Fund and an OEF/OIF Fund. These funds are used to 
pay for lodging, groceries, rental cars, day care for children and 
other incidentals.
    As part of our ongoing reorganization and staffing enhancements, we 
are increasing the support and services to families who are with their 
loved ones in the PRC. We are enhancing access to the Internet (e.g., 
to check e-mails, communicate with other family members), offering 
caregiver education and training, providing a ``quiet room,'' offering 
family counseling, spiritual support (e.g., chaplain services) and 
assistance with recreational activities. Another important benefit to 
families has been the placement of Department of Defense (DoD) liaisons 
in the PRC. The DoD liaisons are able to assist active duty patients 
and their families with myriad questions and services important to 
them.

    Organization and leadership. In response to recommendations by both 
internal and external entities (OMI, CARF) we continue to evaluate 
services and shape our service delivery to meet the needs of our 
patient population.
    In closing, Mr. Chairman, I would like to note that it is an 
incredible honor to host one of the four (soon to be five) PRCs in VHA. 
I am very proud of the talented and dedicated staff at VAPAHCS who 
provide outstanding and compassionate care to our Nation's heroes. They 
do incredible work in challenging circumstances. I believe we have made 
a positive difference in the lives of so many veterans and their 
families. I acknowledge that we are not perfect. In VHA, when mistakes 
occur we ``own them'' and make the requisite system changes. This same 
philosophy holds true in the PRC at VAPAHCS and our investment of 
resources, service enhancements and organizational changes are evidence 
of that approach.
    Again, Mr. Chairman, thank you for the opportunity to testify at 
this hearing. I and the staff who accompany me would be delighted to 
address any questions you might have for us.

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

    Good morning Mr. Chairman and Members of the Committee.
    Thank you for this opportunity to discuss the Veterans Health 
Administration's (VHA) ongoing efforts to improve the quality of care 
that we provide to veterans suffering from traumatic brain injury (TBI) 
and complex multiple trauma. Joining me today is Dr. Edward Huycke, 
Chief Officer for VA's Office of Seamless Transition, Dr. Lucille Beck, 
VA's Chief Consultant for Rehabilitation Services, and Dr. Barbara 
Sigford, National Program Director for Physical Medicine and 
Rehabilitation.
    VA offers comprehensive primary and specialty health care to our 
veterans and active duty servicemembers, and is an acknowledged 
national leader in providing specialty care in the treatment and 
rehabilitation of TBI and polytrauma. Since 1992, VA has maintained 
four specialized TBI Centers that have served as the primary VHA 
receiving facilities for military treatment facilities seeking 
specialized care for brain injuries and complex polytrauma. In 2005, VA 
established its Polytrauma System of Care, leveraging and enhancing the 
existing expertise at these TBI centers to meet the needs of seriously 
injured veterans and active duty servicemembers from operations in,, 
and elsewhere. This new era of combat and the resulting casualties have 
required adaptations in our approaches to care that we provide for this 
brave new generation of veterans. We readily accept the challenge and 
opportunity to adapt VA's existing integrated system to provide the 
best available continuum of care. The focus of my testimony today will 
be on treatment and rehabilitation provided by VA for veterans 
recovering from TBI and complex multiple trauma, and the current 
initiatives to further enhance these services to our veterans within 
this system of care.

                       Polytrauma System of Care

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

    Component 1--Regional. Currently the four Polytrauma/TBI 
Rehabilitation Centers (PRC)--located in Minneapolis, MN; Palo Alto, 
CA; Richmond, VA; and Tampa, FL--are the flagship facilities of the 
Polytrauma System of Care. A fifth polytrauma site was just recently 
announced for San Antonio, TX. These centers serve as hubs for acute 
medical and rehabilitation care, research, and education related to 
polytrauma and TBI. The specialized services provided at each PRC 
include: comprehensive acute rehabilitation care for complex and severe 
polytraumatic injuries, emerging consciousness programs, outpatient 
programs, and residential transitional rehabilitation programs. 
Clinical care is provided by a dedicated staff of rehabilitation 
specialists and medical consultants with expertise in the treatment of 
the physical, mental and psychosocial problems that accompany 
polytrauma and TBI. This team includes specialists in physiatry, 
rehabilitation nursing, neuropsychology, psychology, speech-language 
pathology, occupational therapy, physical therapy, social work, 
therapeutic recreation, prosthetics, and blind rehabilitation.
    One of the newest programs within the PRCs is the treatment program 
for patients with severe disorders of consciousness. Provision of 
rehabilitation services for patients who are minimally conscious or 
minimally responsive is currently based on expert opinion rather than 
scientific evidence. Cornerstones of treatment for patients with severe 
disorders of consciousness include: aggressive medical care to treat 
potential reversible causes of impaired consciousness (infection, 
sedation, etc.); prevention of complications (contracture, pressure 
sores, malnutrition); family support and education. Additional 
interventions often include structured sensory stimulation, and trials 
with medications to increase responsiveness. Programs providing 
specialized care for severe disorders of consciousness must also have a 
mechanism for monitoring response to treatment. A commonly used 
instrument for this purpose is the Disorders of Consciousness Scale 
(DOCS). VA developed its program through a process of reviewing the 
experience and expertise developed at those VA sites that had an 
established protocol, reviewing the literature, and consulting with 
private expert professionals providing these services. Development of 
the formalized program culminated with a face-to-face working 
conference in December 2006, at which time the protocol was established 
that is currently being utilized, and the requirement was set that all 
Polytrauma Rehabilitation Centers would participate. The workgroup for 
this new program continues to meet monthly.
    In 2007, staffing for the PRC teams was increased at each center in 
response to increased demands of patient workload, coordination of 
care, and support for family caregivers. The PRCs have affiliations and 
collaborative relationships with academic medical centers. A 
significant number of PRC clinical providers share VA and affiliated 
positions in training and medical rehabilitation. The inpatient 
rehabilitation programs at the PRCs maintain accreditation by the 
Commission on Accreditation of Rehabilitation Facilities (CARF) for 
both Traumatic Brain Injury and Comprehensive Rehabilitation.

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

    Components 3 and 4--Facility. The Polytrauma System of Care network 
was expanded in March, 2007, to include two new components of care: 
Polytrauma Support Clinic Teams (PSCT) and Polytrauma Points of Contact 
(PPOC). With their geographical distribution across the VA, the 75 
Polytrauma Support Clinic Teams facilitate access to specialized 
rehabilitation services for veterans and active duty servicemembers at 
locations closer to their home communities. These interdisciplinary 
teams of rehabilitation specialists are responsible for managing the 
care of patients with stable treatment plans, providing regular follow-
up visits, and responding to new medical and psychosocial problems as 
they emerge. The PSCT consults with their affiliated Polytrauma Network 
Site or Polytrauma Rehabilitation Center when more specialized services 
are required.
    The remaining 54 VA medical centers have an identified Polytrauma 
Point of Contact who is responsible for managing consultations for 
patients with polytrauma and TBI, and assisting with referrals of these 
patients to programs capable of providing the appropriate level of 
services.
    The Polytrauma Rehabilitation Centers and the Polytrauma Network 
Sites are linked through the Polytrauma Telehealth Network (PTN) that 
provides state-of-the-art multipoint videoconferencing capabilities. 
This Network ensures that polytrauma and TBI expertise are available 
throughout the system of care, and that care is provided at a location 
and time that is most accessible to the patient. This Network further 
provides such clinical activities that include remote consultations and 
evaluations of patients, and education for providers and families.

                  Coordination and Transition of Care

    Care management across the entire continuum is a critical function 
in the Polytrauma System of Care to ensure lifelong coordination of 
services for patients recovering from polytrauma and TBI. Consistent, 
comprehensive procedures and processes have been put in place to ensure 
transition of patients from military treatment facilities to VA care at 
the appropriate time, and under optimal conditions of safety and 
convenience for the patients and their families.
    At the direction of the Secretary, 100 Transition Patient Advocates 
(TPAs) have been recruited nationwide. The TPAs contact the patient and 
family while in the Military Treatment Facility. One of their 
responsibilities is to ensure that all questions concerning VA are 
answered and the case is expedited through the VA benefits process. If 
necessary, the TPA will travel with the family and veteran from the MTF 
to their home, and provide transportation to all VHA appointments.
    The VA assigns a care manager to every patient admitted within the 
VA Polytrauma System of Care. This care manager maintains scheduled 
contacts with veterans and their families to coordinate services and to 
address emerging needs. As an individual moves from one level of care 
to another, the care manager at the referring facility is responsible 
for a ``warm hand off'' to the care manager at the receiving facility 
closer to the veteran's home. The assigned care manager functions as 
the point of contact for emerging medical, psychosocial, or 
rehabilitation coordination of care, and provides patient and family 
advocacy.
    To facilitate continuity of medical care, the Polytrauma 
Rehabilitation Center receives advanced notice of potential admissions 
to their sites. Upon notification, the PRC team initiates a pre-
transfer review and follows the clinical progress until the patient is 
ready for transfer. PRC clinicians are able to complete pre-transfer 
review of the military treatment facility medical record, including up 
to date information about medications, laboratory studies, and daily 
progress notes. In addition to record review, clinician-to-clinician 
communication occurs to allow additional transfer of information and 
resolution of any outstanding questions.
    DoD and VA also have made significant progress sharing available 
electronic health information to further coordinate care of these 
patients. DoD and VA are now supporting the electronic transfer of DoD 
inpatient data to VA clinicians at polytrauma centers. DoD is currently 
transferring DoD medical digital images and electronically scanned 
inpatient health records to the VA polytrauma centers from Walter Reed 
Army Medical Center, National Naval Medical Center Bethesda and Brooke 
Army Medical Center. This effort provides VA clinicians receiving these 
combat veterans with immediate access to critical components of their 
inpatient care at DoD military treatment facilities. In the future, VA 
hopes to add the capability to provide this data bidirectionally to 
support any patients returning to DoD for further care. Additionally, 
VA and DoD are supporting the secure direct connection of authorized 
providers at VA polytrauma centers into the health information systems 
at Walter Reed Army Medical Center and National Naval Medical Center. 
This direct connection provides the most timely access to much needed 
DoD clinical information in support of care of critically injured 
patients coming from combat theaters.
    Psychosocial support for families of injured servicemembers is 
paramount as decisions are made to transition from the acute medical, 
life and death, setting of a military treatment facility to a 
rehabilitation setting. This encompasses psychological support, 
education about rehabilitation and the next setting of care, and 
information about benefits and military processes and procedures. VA 
social worker or nurse liaisons are located at 10 military treatment 
facilities, including our most frequent referral sources, Walter Reed 
Army Medical Center and National Naval Medical Center. These 
individuals provide necessary psychosocial support to families during 
the transition process, advising the families through the process. In 
addition, VA has a Certified Rehabilitation Registered Nurse assigned 
at Walter Reed Army Medical Center to provide education to the family 
on TBI, the rehabilitation process, and the PRCs. The Admission Case 
Manager from the PRC maintains personal contact with the family prior 
to transfer to provide additional support and further information about 
the expected care plan. VA also has Benefit liaisons located at the 
commonly referring military treatment facilities to provide an early 
briefing on the full array of VA services and benefits to the patients 
and families.
    Upon admission to the PRC, the senior leadership of the facility 
personally meets the family and servicemember to ensure that they feel 
welcome and that their needs are being met. Additionally, a uniformed 
active duty servicemember is located at each PRC. The Army Liaison 
Officers support military personnel and their families from all Service 
branches by addressing a broad array of issues, such as travel, non-
medical attendant orders which pay for family members to stay at the 
bedside, housing, military pay, and movement of household goods. They 
are also able to advise on Medical Boards and assist with necessary 
paperwork.
    The transition from the PRC to the home community is of critical 
importance to ensure that the treatment plan, including continued 
rehabilitation and medical care, psychosocial and logistical support is 
maintained. Records for VA medical care are readily available through 
remote access across the VA system. Follow up appointments are made 
prior to discharge, and the transferring practitioners are readily 
available for personal contact with the receiving provider to ensure 
full and complete communication. Care managers at the Polytrauma 
Network Site and the home VA medical center provide for ongoing support 
and problem resolution in the home community, while continually 
assessing for new and emerging issues. Finally, each PRC team carefully 
assesses the expected needs at discharge for transportation, equipment, 
home modifications, and other such needs and makes arrangements for 
assessed needs.
Conclusion
    The VA Polytrauma System of Care is a recognized leader in health 
care for its expertise in treating combat-related injuries, and 
managing the overlapping effects of combat stress response. Today, an 
expanded system of care is available to provide more services and to 
develop new, innovative approaches to these potentially debilitating 
conditions. Our clinicians and researchers strive to provide the 
highest standard of rehabilitation care for those recovering from 
polytrauma and TBI, while concurrently evaluating ways to enhance 
services. The VA continually assesses the unique needs of all 
polytrauma patients, and has responded decisively to the increased 
demand for services with this new generation of combat-injured 
veterans. The VA is committed to providing the necessary level of 
resources and scope of services that ensure a continuum of world-class, 
lifelong care extending from acute rehabilitation to vocational and 
transitional community rehabilitation programs for veterans at 
locations closer to their home communities.
    Thank you for your time and attention. I will be glad to respond to 
any questions that you or other Members of the Committee may have.

                                 

                                     Committee on Veterans' Affairs
                       Subcommittee on Oversight and Investigations
                                                    Washington, DC.
                                                   October 24, 2007

Honorable Gordon H. Mansfield
Acting Secretary
U.S. Department of Veterans Affairs
810 Vermont Avenue, NW
Washington, DC 20420

Dear Secretary Mansfield:

    On Tuesday, September 25, 2007, the Subcommittee on Oversight and 
Investigations of the House Committee on Veterans' Affairs held a 
hearing on VA's Polytrauma Rehabilitation Centers: Management Issues.
    During the hearing, the Subcommittee heard testimony from William 
F. Feeley, Deputy Under Secretary for Operations and Management; and 
Elizabeth J. Freeman, Director of the Palo Alto Health Care System 
(PAHCS). Mr. Feeley was accompanied by Dr. Edward Huycke, Chief 
Department of Defense Coordination Officer for VHA; Dr. Lucille B. 
Beck, the Chief Consultant for Rehabilitation Services; Dr. Barbara 
Sigford, National Program Director for Physical Medicine and 
Rehabilitation; and Dr. Shane McNamee, Medical Director of the Richmond 
Polytrauma Rehabilitation Center. Ms. Freeman was accompanied by Dr. 
Lawrence Leung, Chief of Staff for the PAHCS; and Dr. Stephan Ezeji-
Okoye, Deputy Chief of Staff for the PAHCS. As a follow-up to that 
hearing, the Subcommittee is requesting that the following questions be 
answered for the record:

     1.  Prior to the hearing, VA provided Subcommittee staff with a 
spreadsheet showing referrals to the PAHCS Polytrauma Rehabilitation 
Center (PRC). The spreadsheet included, along with other information, a 
column entitled ``Referral Decision (Accepted or Declined)'' and 
another entitled ``Admission Date and Location.'' For patients listed 
in rows numbered 1, 3, 4, 12, 20, 34, 43, 47, 50, 57, 59, 70, 82, 91, 
98, 102, 111, 121, 126, 127, 132, 137, 149, 150, 125, and 154, please 
provide information about the medical treatment of the patient 
subsequent to PAHCS PRC's decision to decline acceptance, including 
whether the patient was referred to/accepted by another medical 
facility and the outcome of any subsequent treatment.
     2.  Mr. Feeley testified at the hearing that, beginning with FY08, 
he will be receiving a report on the utilization of and disposition of 
referrals to each of the PRCs. Please provide the Subcommittee with a 
copy of the first two reports.
     3.  Please provide the Subcommittee with an update on the hiring 
of the Associate Chief of Staff for PAHCS's Polytrauma System of Care. 
In the event that PAHCS has not yet hired someone for this position, 
please provide the Subcommittee periodic updates (not less than once 
every 2 months) on the hiring process.
     4.  Prior to the hearing, VA provided Subcommittee staff with 
PAHCS's list of polytrauma staffing requests, which included the ACOS 
for the overall program, the Polytrauma Medical Director, social 
workers, therapists, and others (a total of 38 FTEs). Please provide 
the status (e.g., approved or not; advertised; position filled) for 
each one of these positions.
     5.  Each PRC currently has 12 beds. Given the continued operations 
in OIF/OEF. Is this a sufficient number of PRC beds?
     6.  In Secretary Nicholson's letter to House Committee on 
Veterans' Affairs Chairman Bob Filner informing the Chairman of the 
designation of San Antonio for the next Polytrauma Rehabilitation 
Center site, the Secretary stated that Audie Murphy VA Medical Center 
would be the host for the new PRC. Will the new PRC be located adjacent 
to the hospital or is it possible that the PRC will be placed at a 
location outside of the medical campus?
     7.  One of the major obstacles in funding of any project is how 
the administration prioritizes its proposed budget to Congress. The VA 
recently received $30 million toward the new San Antonio PRC as part of 
the Iraq supplemental bill enacted earlier this year. From what funding 
source does the Administration intend to request the additional $67 
million needed to build the PRC?
     8.  When does the VA expect the new PRC to be operational? Is 
there any way, for example, by accelerating funding, to complete the 
project earlier?
     9.  In Dr. Feeley's testimony, it was mentioned that each 
Polytrauma Center has a physiatrist on staff. Are all centers staffed 
accordingly? What are critical staff vacancies at any of the PRCs that 
need to be filled? What is the process for hiring staff at such 
centers? What criteria are used to base the hiring decisions on for 
these positions? Please list all vacant positions during the last 180 
days, and length of vacancies.
    10.  Please provide the Committee with a listing of the locations 
of the Polytrauma Support Clinic Teams (PSCT) and Polytrauma Points of 
Contact (PPOC).
    11.  On average how many patients are assigned to each care 
manager? Are the care managers able to handle their current caseloads, 
or does VHA need additional funding to increase the number of care 
managers at the VAMCs, particularly those with the Polytrauma units?
    12.  What is the relationship of the Palo Alto VAMC with the 
Department of Defense, and please provide the sharing agreement that is 
in place.
    13.  Does the PRC in Palo Alto use VTA/JPTA to track the patients 
being transferred from DoD?
    14.  When Subcommittee staff traveled to Palo Alto in August, one 
of the issues discussed was the transportation of patients from the 
East Coast Washington, DC Metro Area (Bethesda/Walter Reed) to the PRC, 
they were told much of this transport went through Travis Air Force 
Base. Please provide some specifics on how the transfer of patients 
occurs, e.g., how the transfer works, who coordinates the transfer to 
VA, and patient medical care during travel. What problems have arisen 
during transfer of patients from the East Coast to the West Coast, and 
have there been problems with continuity of care en route? Furthermore, 
how well does the handoff from the Department of Defense work?

    We request you provide responses to the Subcommittee no later than 
close of business, Monday, November 26, 2007.
    If you have any questions concerning these questions, please 
contact Subcommittee on Oversight and Investigations Staff Director, 
Geoffrey Bestor, Esq., at (202) 225-3569 or the Subcommittee Republican 
Staff Director, Arthur Wu, at (202) 225-3527.

            Sincerely,
                                                  HARRY E. MITCHELL
                                                           Chairman

                                                  GINNY BROWN-WAITE
                                          Ranking Republican Member

                               __________

                        Questions for the Record
      Hon. Harry E. Mitchell Chairman and Hon. Ginny Brown-Waite,
                       Ranking Republican Member
             Subcommittee on Oversight and Investigations,
                  House Committee on Veterans' Affairs
                           September 25, 2007

       VA's Polytrauma Rehabilitation Centers: Management Issues

    Question 1: Prior to the hearing, VA provided Subcommittee staff 
with a spreadsheet showing referrals to the PAHCS Polytrauma 
Rehabilitation Center (PRC). The spreadsheet included, along with other 
information, a column entitled ``Referral Decision (Accepted or 
Declined)'' and another entitled ``Admission Date and Location.'' For 
patients listed in rows numbered 1, 3, 4, 12, 20, 34, 43, 47, 50, 57, 
59, 70, 82, 91, 98, 102, 111, 121, 126, 127, 132, 137, 149, 150, 152, 
and 154, please provide information about the medical treatment of the 
patient subsequent to PAHCS PRC's decision to decline acceptance, 
including whether the patient was referred to/accepted by another 
medical facility and the outcome of any subsequent treatment.

    Response: The information requested includes personally 
identifiable information that is protected under the Privacy Act. 
Accordingly, this information will be provided to Chairman under 
separate cover.

    Question 2: Mr. Feeley testified at the hearing that, beginning 
with FY08, he will bereceiving a report on the utilization of and 
disposition of referrals to each of the PRCs. Please provide the 
Subcommittee with a copy of the first two reports.

    Response: Each polytrauma rehabilitation center (PRC) tracks bed 
census and submits a monthly report. The following is the summary 
report per site for the month of October 2007:

                                     Average Weekly Bed Census--October 2007
----------------------------------------------------------------------------------------------------------------
                                                                                               Not admitted
                                                                                Number   -----------------------
                               Number of   Number of   Number of   Number of   accepted/    Needed a
             PRC               patients       new     discharges      new      awaiting       more      Chose to
                                          admissions               referrals   transfer   appropriate      go
                                                                                             level     elsewhere
----------------------------------------------------------------------------------------------------------------
Richmond                          11.5          2.5         1.5         5.5         3.0         2.0          .5
----------------------------------------------------------------------------------------------------------------
Tampa                             16.0          1.5         1.0         6.0        5.25         0.5        0.75
----------------------------------------------------------------------------------------------------------------
Minneapolis                         7.5        1.25        1.75        2.75         2.0        0.75        0.75
----------------------------------------------------------------------------------------------------------------
Palo Alto                          8.25        0.25         0.5         1.0        1.75           0         0.5
----------------------------------------------------------------------------------------------------------------

    Question 3: Please provide the Subcommittee with an update on the 
hiring of the Associate Chief of Staff (ACOS) for PAHCS's Polytrauma 
System of Care. In the event that PAHCS has not yet hired someone for 
this position, please provide the Subcommittee periodic updates (not 
less than once every 2 months) on the hiring process.

    Response: Dr. Jerome Yesavage, Chief of Psychiatry at the VA Palo 
Alto Health Care System (PAHCS), is serving as the Chair of the Search 
Committee for the ACOS for Polytrauma and Operation Enduring Freedom/
Operation Iraqi Freedom (OEF/OIF) Program. The search Committee met for 
the first time on October 11, 2007, to review the general guidelines 
associated with the recruitment and interview process, and to establish 
the role of committee members. Additionally, Committee members reviewed 
the functional statement associated with the position, the vacancy 
announcements and advertisements, and performance based interview (PBI) 
questions.
    Dr. Lawrence Leung, Chief of Staff at the VA PAHCS, stated in the 
October 11, 2007, search committee meeting that filling this position 
is of the highest priority. The search committee is conducting a 
national search and has advertised in several relevant journals.
    The search committee's next meeting was held on Wednesday, December 
12, 2007, at 10:00 a.m. At this meeting, search committee members 
prioritized the applications that have been received and ranked. The 
search committee plans on conducting in-person interviews with the best 
qualified candidates the week of January 7, 2008.

    Question 4: Prior to the hearing, VA provided Subcommittee staff 
with PAHCS's list of polytrauma staffing requests, which included the 
ACOS for the overall program, the Polytrauma Medical Director, social 
workers, therapists, and others (a total of 38 FTE's). Please provide 
the status (e.g., approved or not; advertised; position filled) for 
each one of these positions.

    Response: All 38 positions are approved.

----------------------------------------------------------------------------------------------------------------
                   Program                                       Position title                        Status
----------------------------------------------------------------------------------------------------------------
Polytrauma System of Care (PSC)/OEF/OIF                ACOS for Polytrauma System of Care/OIF/OEF   Advertised,
                                                                                                       national
                                                                                                         search
                                                                                                       underway
----------------------------------------------------------------------------------------------------------------
PSC/OEF/OIF                                                                Administrative Officer        Filled
----------------------------------------------------------------------------------------------------------------
PSC/OEF/OIF                                            Health Sys Specialist/Research Coordinator       On hold
                                                                                                     until ACOS
                                                                                                      search is
                                                                                                       complete
----------------------------------------------------------------------------------------------------------------
PRC--Inpatient                                                                     Nurse Educator    Advertised
----------------------------------------------------------------------------------------------------------------
PRC--Inpatient                                                          Clinical Nurse Specialist    Advertised
----------------------------------------------------------------------------------------------------------------
PRC--Inpatient                                                  Staff Physician (Pain Management)        Filled
----------------------------------------------------------------------------------------------------------------
PRC--Inpatient                                        Staff Physician (ENT Vestibular Specialist)        Filled
----------------------------------------------------------------------------------------------------------------
PRC--Inpatient                                                      Staff Physician (Orthopedics)        Filled
----------------------------------------------------------------------------------------------------------------
PRC--Inpatient                                                              Physical Therapist #4    Advertised
----------------------------------------------------------------------------------------------------------------
PRC--Inpatient                                            Physical Therapist #5 (evening/weekend)   Filled with
                                                                                                       contract
                                                                                                          staff
----------------------------------------------------------------------------------------------------------------
PRC--Inpatient                                            Physical Therapist #6 (evening/weekend)   Filled with
                                                                                                       contract
                                                                                                          staff
----------------------------------------------------------------------------------------------------------------
PRC--Inpatient                                                              Physical Therapy Aide    Advertised
----------------------------------------------------------------------------------------------------------------
Polytrauma Unit                                                        Physical Therapy Assistant    Advertised
----------------------------------------------------------------------------------------------------------------
PRC--Inpatient                                                                            Speech/Lang PatFilled
----------------------------------------------------------------------------------------------------------------
PRC--Inpatient                                                                            Speech/Lang PatFilled
----------------------------------------------------------------------------------------------------------------
PRC--Inpatient                                                                                   LeadAdvertisedn Therapist (Community/Volunteer Coord/
                                                                               Family Care Coord)
----------------------------------------------------------------------------------------------------------------
PRC--Inpatient                                                          Occupational Therapist #4    Advertised
----------------------------------------------------------------------------------------------------------------
PRC--Inpatient                                        Occupational Therapist #5 (evening/weekend)    Advertised
----------------------------------------------------------------------------------------------------------------
PRC--Inpatient                                               Massage Therapist--Health Technician   Filled with
                                                                                                       contract
                                                                                                          staff
----------------------------------------------------------------------------------------------------------------
PRC--Inpatient                                               Recreation Therapist #1 (Supervisor)    Advertised
----------------------------------------------------------------------------------------------------------------
PRC--Inpatient                                                            Recreation Therapist #4    Advertised
----------------------------------------------------------------------------------------------------------------
PRC--Inpatient                                                 Rec Therapist #5 (evening/weekend)    Advertised
----------------------------------------------------------------------------------------------------------------
PRC--Inpatient                                Family Therapist--Social Worker (SocWk) or Clinical    Advertised
                                                                        Psychologist (Psychology)
----------------------------------------------------------------------------------------------------------------
PRC--Inpatient                                Staff Support--Clinical Psychologist (Psychology) or   Advertised
                                                                            Social Worker (SocWk)
----------------------------------------------------------------------------------------------------------------
PRC--Inpatient                                    Sexuality Therapist--specializing TBI--Clinical    Advertised
                                                 Psychologist (Psychology) or Physician-Urologist
                                                                                       (Surgical)
----------------------------------------------------------------------------------------------------------------
OEF/OIF Program                                                                   Program Manager        Filled
----------------------------------------------------------------------------------------------------------------
OEF/OIF Program                                                              Program Support Asst    Advertised
----------------------------------------------------------------------------------------------------------------
OEF/OIF Program                                    OIF/OEF Social Work Case Manager/Outreach Duty        Filled
                                                                               station: Palo Alto
----------------------------------------------------------------------------------------------------------------
OEF/OIF Program                                    OIF/OEF Social Work Case Manager/Outreach Duty    Advertised
                                                                       station: San Jose/Monterey
----------------------------------------------------------------------------------------------------------------
OEF/OIF Program                                    OIF/OEF Social Work Case Manager/Outreach Duty        Filled
                                                                                        station: Livermore
----------------------------------------------------------------------------------------------------------------
OEF/OIF Program                                         OIF/OEF Nurse Case Manager Duty station: LiveAdvertised
----------------------------------------------------------------------------------------------------------------
Polytrauma Network Site (PNS)--Outpatient                            Physiatrist: Increase to 1.0    Advertised
----------------------------------------------------------------------------------------------------------------
PNS--Outpatient                                                           Social Worker--Case Mgr        Filled
----------------------------------------------------------------------------------------------------------------
PNS--Outpatient                                                              Psychologist (Neuro)        Filled
----------------------------------------------------------------------------------------------------------------
PNS--Outpatient                                                            Occupational Therapist        Filled
----------------------------------------------------------------------------------------------------------------
PNS--Outpatient                                                                Physical Therapist        Filled
----------------------------------------------------------------------------------------------------------------
PNS--Outpatient                                                                           Speech/Lang PatFilled
----------------------------------------------------------------------------------------------------------------
PNS--Outpatient                                                              Program Support Asst    Advertised
----------------------------------------------------------------------------------------------------------------
PNS--Outpatient                                                                   RN Case Manager    Advertised
----------------------------------------------------------------------------------------------------------------
PNS--Outpatient                                                              Recreation Therapist    Advertised
----------------------------------------------------------------------------------------------------------------
PNS--Outpatient                                                                     Social Worker    Advertised
----------------------------------------------------------------------------------------------------------------
PSC                                                             Supr. Orthotist Prosthetist (PAD)        Filled
----------------------------------------------------------------------------------------------------------------
                                              This represents a total of 38 FTE, as some positions
                                                                                will be part time
----------------------------------------------------------------------------------------------------------------
Total 38
----------------------------------------------------------------------------------------------------------------

    Question 5: Each PRC currently has 12 beds. Given the continued 
operations in OEF/OIF, is this a sufficient number of PRC beds?

    Response: Yes. Currently, there is a sufficient number of PRC beds, 
and bed capacity is increased as necessary. The PRCs at Minneapolis, 
Palo Alto and Richmond currently operate 12 beds. Tampa PRC increased 
capacity and began operating 18 beds on November 5, 2007. Average 
occupancy rate at the PRCs is 81.6 percent (range 62.5 percent-95.8 
percent). Occupancy rate for October, 2007 is generally consistent with 
the trend observed during the last two quarters of fiscal year (FY) 
2007. All four existing PRCs have the flexibility of using some of its 
comprehensive inpatient rehabilitation beds for patients with 
polytrauma/traumatic brain injury (TBI), if needed.
    In addition to the four existing PRCs, construction of a new PRC in 
San Antonio is expected to be complete in December 2010.

    Question 6: In Secretary Nicholson's letter to House Committee on 
Veterans' Affairs Chairman Bob Filner informing the Chairman of the 
designation of San Antonio for the next Polytrauma Rehabilitation 
Center site, the Secretary stated that Audie Murphy VA Medical Center 
would be the host for the new PRC. Will the new PRC be located adjacent 
to the hospital or is it possible that the PRC will be placed at a 
location outside of the medical campus?

    Response: The new PRC will be located on the medical center 
grounds.

    Question 7: One of the major obstacles in funding of any project is 
how the administration prioritizes its proposed budget to Congress. The 
VA recently received $30 million toward the new San Antonio PRC as part 
of the Iraq supplemental bill enacted earlier this year. From what 
funding source does the Administration intend to request the additional 
$67 million to build the PRC?

    Response: The new PRC in San Antonio will require $66 million in 
major construction funding. VA does not intend to request additional 
construction funds for the new PRC because section 230 of Div. I of the 
Consolidated Appropriations Act, 2008, rescinded $66 million from the 
Medical Services account appropriated by Public Law 110-28 and re-
appropriated the $66 million to the Construction, Major Projects 
account.

    Question 8: When does the VA expect the new PRC to be operational? 
Is there any way, for example, by accelerating funding, to complete the 
project earlier?

    Response: Construction of the new PRC is expected to be completed 
in December 2010. The project will not likely be completed earlier, 
even with accelerated funding, due to time required to comply with 
government regulations and procedures, and to design, develop and build 
the PRC. The current project schedule is as follows:

------------------------------------------------------------------------
                      Activity                               Date
------------------------------------------------------------------------
Architect & Engineer (AlE) Advertisement (completed)              10/07
------------------------------------------------------------------------
Select AE Team                                                     2/08
------------------------------------------------------------------------
Award AlE Contract                                                 4/08
------------------------------------------------------------------------
Begin Schematic Design                                             4/08
------------------------------------------------------------------------
Complete Schematic Design                                          8/08
------------------------------------------------------------------------
Begin Design Development                                           8/08
------------------------------------------------------------------------
Complete Design Development                                       12/08
------------------------------------------------------------------------
Begin Construction Documents                                      12/08
------------------------------------------------------------------------
Complete Construction Documents                                    4/09
------------------------------------------------------------------------
Award Construction Contract                                        6/09
------------------------------------------------------------------------
Complete Construction*                                            12/10
------------------------------------------------------------------------
*18 month anticipated construction contract

    Question 9: In Mr. Feeley's testimony, it was mentioned that each 
Polytrauma Center has a physiatrist on staff. Are all centers staffed 
accordingly? What are critical staff vacancies at any of the PRCs that 
need to be filled? What is the process for hiring staff at such 
centers? What criteria are used to base the hiring decisions on for 
these positions? Please list all vacant positions during the last 180 
days, and length of vacancies.

    Response: The four PRCs have a full time physiatrist, who leads the 
interdisciplinary rehabilitation team. Veterans Health Administration 
(VHA) Directive 2005-024 Polytrauma Rehabilitation Centers recommends a 
staffing model with 36 dedicated positions representing all 
rehabilitation specialty areas. The PRCs have had stable dedicated 
teams, with occasional vacancies as listed in the table below.

                                                               Core PRC Staffing Vacancies
--------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                               Palo Alto          Minneapolis          Richmond              Tampa
                                                                         -------------------------------------------------------------------------------
                     Core PRC Staff Type                       Target 36  # vacant            # vacant            # vacant            # vacant
                                                               positions   in last   # mths    in last   # mths    in last   # mths    in last   # mths
                                                                          180 days   vacant   180 days   vacant   180 days   vacant   180 days   vacant
--------------------------------------------------------------------------------------------------------------------------------------------------------
Physiatrist                                                           1         0         0         0         0         0         0         0         0
--------------------------------------------------------------------------------------------------------------------------------------------------------
RN's                                                                 11         0         0         0         0         0         0         0         0
--------------------------------------------------------------------------------------------------------------------------------------------------------
LPN's/CNA's                                                           8         0         0         0         0         0         0         0         0
--------------------------------------------------------------------------------------------------------------------------------------------------------
Admission & F/U CRRN Case Manager                                     1         1         1         0         0         0         0         1         4
--------------------------------------------------------------------------------------------------------------------------------------------------------
Counseling Psychologist                                               1         1         5         0         0         0         0         0         0
--------------------------------------------------------------------------------------------------------------------------------------------------------
Neuropsychologist                                                     3         0         0         0         0         0         0         0         0
--------------------------------------------------------------------------------------------------------------------------------------------------------
SW Case Manager                                                       3         1         6         0         0         0         0         0         0
--------------------------------------------------------------------------------------------------------------------------------------------------------
Physical Therapist                                                  2.5         1         3         1         4         0         0         0         0
--------------------------------------------------------------------------------------------------------------------------------------------------------
Occupational Therapist                                              2.5         2         3       0.5         1         0         0         0         0
--------------------------------------------------------------------------------------------------------------------------------------------------------
Speech Therapist                                                      2         0         0         0         0         0         0         0         0
--------------------------------------------------------------------------------------------------------------------------------------------------------
Recreation Therapist                                                  2         2         0         0         0         0         0         0         0
--------------------------------------------------------------------------------------------------------------------------------------------------------
BROS                                                                  1         0         0         0         0         1         3         0         0
--------------------------------------------------------------------------------------------------------------------------------------------------------
Total                                                                36         8                 1.5                   1                   1
--------------------------------------------------------------------------------------------------------------------------------------------------------

    Hiring actions for PRCs follow guidelines established by the Office 
of Human Resource Management, and hiring is based on the applicants' 
qualifications and specialized experience. Recruiting efforts typically 
include internal and external job postings, specialized advertising in 
trade publications, and local newspaper advertising that feature 
information about the rewarding work of the PRCs.

    Question 10: Please provide the Committee with a listing of the 
locations of the Polytrauma Support Clinic Teams (PSCT) and Polytrauma 
Points of Contact (PPOC).

    Response:

----------------------------------------------------------------------------------------------------------------
                                                                               Polytrauma/TBI
     Regional Polytrauma/TBI Rehab Center          VISN      Polytrauma/TBI    Support Clinic    Polytrauma/TBI
                                                              Network Site         Teams        Point of Contact
----------------------------------------------------------------------------------------------------------------
Richmond                                           VISN 1           Boston         West Haven           Bedford
                                                                                        Togus        Manchester
                                                                                  White River        Providence
                                                                                                  North Hampton
----------------------------------------------------------------------------------------------------------------
                                                   VISN 2         Syracuse             Albany
                                                                                      Buffalo
                                                                                         Bath
                                                                                             Canandaigua
----------------------------------------------------------------------------------------------------------------
                                                   VISN 3            Bronx    Hudson Valley HCS/**All facilities
                                                                                     Montrose    in VISN 3 have
                                                                              Hudson Valley HCS/    appropriate
                                                                                             Castservice levels
                                                                                          NJHCS/to be classified
                                                                                          NJHCS/Lyas at least a
                                                                                  NY Harbor HCS/New  Polytrauma
                                                                                         York          Support Clinic
                                                                                  NY Harbor HCS/          Team.
                                                                                     Brooklyn
                                                                                  NY Harbor HCS/St
                                                                                       Albans
                                                                                Northport VAMC
----------------------------------------------------------------------------------------------------------------
                                                   VISN 4     Philadelphia         Pittsburgh                  Clarksburg
                                                                                   Wilmington
                                                                                         Erie
                                                                                      Lebanon
                                                                                             Coatesville
                                                                                      Altoona
                                                                                       Butler
                                                                                 Wilkes-Barre
----------------------------------------------------------------------------------------------------------------
                                                   VISN 5    Washington, DC         Baltimore   **All facilities
                                                                                  Martinsburg    in VISN 5 have
                                                                                                    appropriate
                                                                                                 service levels
                                                                                                to be classified
                                                                                                  as at least a
                                                                                                     Polytrauma
                                                                                                       Support Clinic
                                                                                                          Team.
----------------------------------------------------------------------------------------------------------------
                                                   VISN 6         Richmond            Hampton          Ashville
                                                                                    Salisbury           Beckley
                                                                                       Durham      Fayetteville
                                                                                                          Salem
----------------------------------------------------------------------------------------------------------------
Tampa                                              VISN 7          Augusta         Tuscaloosa            Dublin
                                                                                             Columbia  Tuskegee
                                                                                             Charleston
                                                                                      Atlanta
                                                                                   Birmingham
----------------------------------------------------------------------------------------------------------------
                                                   VISN 8            Tampa          Bay Pines           Orlando
                                                                  San Juan        Gainesville
                                                                                        Miami
                                                                                    West Palm
----------------------------------------------------------------------------------------------------------------
                                                   VISN 9        Lexington         Huntington   **All facilities
                                                                                   Louisville    in VISN 9 have
                                                                                      Memphis       appropriate
                                                                                          TVHC-Naservice levels
                                                                                          TVHC-Mto be classified
                                                                                          TVHC-Mountaat least a
                                                                                         Home        Polytrauma
                                                                                                       Support Clinic
                                                                                                          Team.
----------------------------------------------------------------------------------------------------------------
                                                  VISN 16          Houston         Alexandria             Gulf Coast
                                                                                      Jackson          (Biloxi)
                                                                                             CenFayetteville, AR
                                                                                  Little Rock       New Orleans
                                                                                     Muskogee         Oklahoma City
                                                                                   Shreveport              Waco
----------------------------------------------------------------------------------------------------------------
                                                  VISN 17           Dallas             Temple         Kerrville
                                                                                  San Antonio
----------------------------------------------------------------------------------------------------------------
Palo Alto                                         VISN 18         Southern       New Mexico HCS-       Amarillo
                                                                 Arizona HCS      Albuquerque      West Texas HCS
                                                                  (Tucson)                         (Big Spring)
                                                                                                        El Paso
                                                                                                Northern Arizona
                                                                                                              HCS (Prescott)
                                                                                                        Phoenix
----------------------------------------------------------------------------------------------------------------
                                                  VISN 19           Denver          Salt Lake                  Cheyenne
                                                                               Grand Junction         Montana HCS-Ft.
                                                                                                       Harrison
                                                                                                       Sheridan
----------------------------------------------------------------------------------------------------------------
                                                  VISN 20          Seattle           Portland            Alaska
                                                                                        Boise     American Lake
                                                                                                       Roseburg
                                                                                                        Spokane
                                                                                                    Walla Walla
                                                                                                         White City
----------------------------------------------------------------------------------------------------------------
                                                  VISN 21        Palo Alto         Sacramento     Sierra Nevada
                                                                                San Francisco                 HCS
                                                                                                       Honolulu
                                                                                                         Manila
                                                                                                               Central
                                                                                                               California HCS
                                                                                                       (Fresno)
----------------------------------------------------------------------------------------------------------------
                                                  VISN 22          West LA         Long Beach   Southern Nevada
                                                                                    San Diego                 HCS
                                                                                   Loma Linda         Sepulveda
----------------------------------------------------------------------------------------------------------------
Minneapolis                                       VISN 10                 Cleveland          Cincinnati        Columbus
                                                                                       Dayton                  Chillicothe
----------------------------------------------------------------------------------------------------------------
                                                  VISN 11     Indianapolis            Detroit           Battle Creek
                                                                             Danville (Iliana)               NICHS-Marion
                                                                                    Ann Arbor           Saginaw
----------------------------------------------------------------------------------------------------------------
                                                  VISN 12            Hines          Milwaukee     Iron Mountain
                                                                                       North Chicago
                                                                                        Tomah
                                                                                      Madison
                                                                                             Chicago HCS
                                                                                (Jesse Brown)
----------------------------------------------------------------------------------------------------------------
                                                  VISN 15        St. Louis            Kansas City       Wichita
                                                                                                   Poplar Bluff
                                                                                                               Columbia, MO
                                                                                                Eastern Kansas/
                                                                                                         Topeka
                                                                                                         Marion
----------------------------------------------------------------------------------------------------------------
                                                  VISN 23      Minneapolis        Sioux Falls             Fargo
                                                                                  Black Hills              St. Cloud
                                                                                        Iowa City              Central Iowa-Des
                                                                                             Central IowaMoines
                                                                                    Knoxville   Greater Nebraska-
                                                                                                   Grand Island
                                                                                                Greater Nebraska-
                                                                                                        Lincoln
                                                                                                          Omaha
----------------------------------------------------------------------------------------------------------------

    Question 11: On average how many patients are assigned to each care 
manager? Are the care managers able to handle their current caseloads, 
or does VHA need additional funding to increase the number of care 
managers at the VAMCs, particularly those with the Polytrauma units?

    Response: A ratio of one social worker care manager to six 
polytrauma inpatients is the established standard determined to be 
sufficient to ensure appropriate care management of OEF/OIF inpatients 
(VHA Directive 2006-043 Social work case management in VHA Polytrauma 
Centers). The PRC staffing model is consistent with this recommended 
ratio, and the social worker case manager to patient ratio at the PRCs 
ranged from 1:3 to 1:6 in October 2007.

    Question 12: What is the relationship of the Palo Alto VAMC with 
the Department of Defense, and please provide the sharing agreement 
that is in place.

    Response: VA Palo Alto Health Care System (PAHCS) has a 
longstanding relationship with the Department of Defense (DoD). VA 
PAHCS has served as one of four lead traumatic brain injury (TBI) 
centers and as a Defense and Veterans Brain Injury Center (DVBIC) site 
since 1992. The mission of DVBIC is to serve active duty military, 
their dependents and veterans with TBI through state-of-the-art medical 
care, innovative clinical research initiatives and educational 
programs. In 2005, VA PAHCS was designated as a PRC and has continued 
to build a relationship with DoD. VA liaisons, located at each military 
treatment facility (MTF), play a central role in facilitating referrals 
to the PRC as well as participating in a pre-transfer video 
teleconferences for patients, families, and the treatment teams to 
discuss pertinent clinical or psychosocial challenges. The Palo Alto 
PRC program director continues to build relationships with MTF 
referring physicians. The Walter Reed Army Medical Center (WRAMC) 
Physical Medicine and Rehabilitation Director works directly with the 
PRC program director to ensure a smooth transition during patient 
transfers. VA's PAHCS PRC program director and chief of neurosurgery 
are in direct and frequent communication with the neurosurgeon at 
National Naval Medical Center (NNMC), regarding patients transferring 
between the two medical centers. The Palo Alto PRC program director 
visited NNMC and WRAMC on November 7 to continue to enhance the working 
relationships with the referring physicians.
The Memorandum of Agreement is attached (see Attachment 1 at the end).
    Question 13: Does the PRC in Palo Alto use VTA/JPTA to track the 
patients being transferred from DoD?

    Response: The PRC receives an e-mail notification from the VA 
liaison to access veterans tracking application (VTA) for severely 
injured servicemembers for admission to the PRC. These patients are 
contacted and assigned a PRC case manager within 7 days. Through the 
joint patient tracking application (JPTA), the PRC military liaison can 
view the servicemember's status, location (operating room/emergency 
room/intensive care unit), date of status, facility location (combat 
support hospital, medical brigade, Landstuhl Regional Medical Center 
(LRMC), WRAMC) and view the dates of the evacuation transport 
itinerary. The PRC military liaison uses VTA in much the same way to 
view notes annotating the servicemember's record through their 
transition (combat support hospital, medical brigade, LRMC, etc.).

    Question 14: When Subcommittee staff traveled to Palo Alto in 
August, one of the issues discussed was the transportation of patients 
from the East Coast Washington, DC Metro Area (Bethesda/Walter Reed) to 
the PRC, they were told much of this transport went through Travis Air 
Force Base. Please provide some specifics on how the transfer of 
patients occurs, e.g., how the transfer works, who coordinates the 
transfer to VA, and patient medical care during travel. What problems 
have arisen during transfer of patients from the East Coast to the West 
Coast, and have there been problems with continuity of care en route? 
Furthermore, how well does the handoff from the Department of Defense 
work?

    Response: Transfers from WRAMC and NNMC to the Palo Alto's VA PRC 
are coordinated by DoD Military staff through the Med Evac system at 
the MTF. The VA liaison at the MTF communicates with the MTF treatment 
team when servicemembers/veterans are accepted for admission to Palo 
Alto. DoD coordinates the transportation through military staff and 
information such as the accepting VA physician's name and contact 
number, receiving ward and contact number as well as a 24 hour travel 
number at the receiving PRC is provided at the time of coordination.
    The point of contact at the accepting PRC or the transportation 
coordinator arranges for transportation from the Air Force Bases (AFB) 
to the PRC. For example, once the flight arrives at Travis AFB, 
patients are often kept overnight to assess how the patient tolerated 
the flight and to allow the patient to rest as it is approximately a 3 
hour drive to the Palo Alto PRC. To further enhance the transportation 
process from the East Coast MTFs to Palo Alto PRC, both WRAMC and NNMC 
have recently made arrangements to include staff from Travis AFB on the 
video teleconferences that take place with the PRC prior to the 
patient's transfer. Palo Alto PRC does not report any problems with 
continuity of care in between DoD and VA. The major challenge is pain 
management due to the length of the trip.
    VA defers to DoD for more specific details regarding procedures and 
processes associated with their Med Evac system.

                                 
                              ATTACHMENT 1
                        MEMORANDUM OF AGREEMENT
Department of Veterans Affairs (VA) and Department of Defense (DoD) 
        Memorandum of Agreement (MOA) 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
    1.  PURPOSE: This document establishes procedures regarding active 
duty military personnel with spinal cord injury (SCI), traumatic brain 
injury (TBI), or blindness treated at VA medical facilities under 
direct resource sharing agreements under the authorities noted in 
paragraph 2. Active duty military personnel will receive timely and 
high quality specialty care within a continuum of health care dedicated 
to the needs of persons with SCI, TBI, and blindness. Note: This MOA 
does not pertain to the transfer of active duty military personnel to 
VA facilities for care or treatment related to alcohol or drug abuse or 
dependence in accordance with Title 38 U.S.C Sec. 620A(d)(l). This MOA 
pertains to direct resource sharing agreements only, and not to 
agreements between the VA and TRICARE Managed Care Support Contractors 
(MCSCs).

    2.  AUTHORITIES:

       a.  Department of Veterans Affairs (VA) and Department of 
Defense (000) Health Resources Sharing and Emergency Operations Act (38 
U.S.C. Sec. 8111)
       b.  Section 3-105 of the VA/DoD Health Care Resource Sharing 
Guidelines of July 29, 1983.

    3.  BACKGROUND: There has been a longstanding MOA between VA and 
DoD associated with specialized care for active duty sustaining BCI, 
TBI, and blindness. VA is known for its integrated system of health 
care for these conditions. The VA/DoD Health Executive Council has 
identified the need for referral procedures governing the transfer of 
active duty military inpatients from military or civilian hospitals to 
VA medical facilities, and the treatment of active duty military 
patients at such facilities. This MOA supersedes all previous VA/DoD 
MOAs relating to active duty military referrals to VA health care 
facilities for TBI, SCI, and blindness.

    4.  DoD RESPONSIBILITIES:

       a.  Care management services will be provided by the Military 
Medical Support Office (MMSO), the appropriate Military Treatment 
Facility (MTF), and the admitting VAMC as a joint collaboration as 
appropriate to each individual servicemember's case. The referring MTF 
and the VA health care facility shall notify MMSO when a member is 
referred for care under this agreement. MMSO will provide any required 
care authorizations relating to care provided under this MOA once the 
member is admitted to a VA facility.
       b.  The referring MTF will identify and contact the VA TBI 
(Appendix A), SCI (Appendix B), or Blind Rehabilitation Center 
(Appendix C) as soon as possible to begin the referral process, to 
present the case, and to gain admission approval. The medical and 
administrative personnel of the MTF must establish immediate contact 
with their counterparts at the designated VA health' care facility to 
discuss and make specific arrangements. Whenever possible the VA health 
care facility closest to the active duty member's home of record or 
location selected by the active duty member, guardian, conservator, or 
designee should be contacted first. The servicemember's command 
ordinarily determines whether the servicemembers injury and/or 
condition occurred while in the line of duty and not due to own 
misconduct which may affect eligibility for VA health care according to 
provisions of Title 38 U.S.C. Chapter 17.
       c.   The referring MTF will provide a copy of all pertinent 
patient medical record documentation requested by the VA health care 
facility needed to make a medical decision. This includes the patient's 
history and physical, diagnostics, laboratory findings, hospital 
course, daily documentation of progress, etc. When the VA facility 
accepts a patient, the referring DoD/MTF case manager will provide the 
VA case manager with current clinical information along with the case 
management plan of care and discharge plan.
       d.  Pre-requisites for transfer, in addition to identifying an 
accepting staff physician at the VA health care facility, are 
stabilization of the patient's injuries and, the acute management of 
the medical and physiological conditions associated with the Sel, TBI, 
or blindness. Stabilization is an attempt to prevent additional 
impairments while focusing on prevention of complications. The criteria 
for the transfer of patients with SeI, TBI, or blindness require:
          1.  Attention to ailWay and adequate oxygenation;
          2.  Treatment of hemorrhage, no evidence of active bleeding;
          3.  Adequate fluid replacement;
          4.  Maintenance of systolic blood pressures (>90 mm mercury 
hydrargyrum (Hg));
          5.  Foley catheter placement, when appropriate, with adequate 
urine output;
          6.  Use of an asogastric tube, if paralytic ileus develops;
          7.  Maintenance of spinal alignment by immobilization of the 
spine, or adequate stabilization to prevent further neurologic injury 
(traction, tongs and traction, halo-vest, hard cervical collar, body 
jacket, etc.); and
          8.  Approval by the SCI Center Chief, TBI Center Medical 
Director or Designee, or Blind Rehabilitation Chief in consultation 
with other appropriate VA specialty care teams.
       e.   The referring MTF must notify the VA health care facility 
of any changes in medical status. Patients are not to be transferred if 
there is:
          1.  Deteriorating neurologic function; incomplete;
          2.  An inability to stabilize the spine, especially if the 
neurologic injury is
          3.  Bradyarrhythmias are present;
          4.  An inability to maintain systolic blood pressure >90 mm 
Hg;
          5.  Acute respiratory failure is present; or
          6.  New onset of fever, infection and/or change in medical 
status (e.g., deteriorating physiological status).
       f.   Following the VA health care facility's agreement to accept 
the patient, the MTF commander or designee is responsible for arranging 
transportation to the VA facility in accordance with governing policies 
for movement of patients. This normally will include notifying and 
submitting a patient movement request to the Global Patient Movement 
Requirements Center (GPMRC), or when overseas, to the Theater Patient 
Movement Requirement Center (TPMRC), without regard to weekend or 
holiday, to schedule the transport of the patient from either an MTF or 
a civilian hospital. If the patient is moved by other than an Air Force 
aircraft or is an emergency patient, information reported to GPMRC will 
be the minimum required to allow GPMRC to develop referral patterns. 
This notification may be made after the fact for emergency patients.
       g.   The MTF commander and GPMRC are responsible for 
coordination with the receiving VA facility for ground transportation 
from the airfield to the VA facility. Whenever possible, the 
originating MTF should arrange with any MTF within a reasonable 
distance to provide needed transportation. If that is not possible, the 
receiving VA health care facility shall obtain appropriate local 
transportation. NOTE: DoD will be responsible for payment of any costs 
incurred by VA for the transport of active duty personnel.
       h.   To ensure optimal care, active duty patients are to go 
directly to a VA medical facility without passing through a transit 
military hospital.
       i.   In emergencies, GPMRC will expedite transfers from MTFs or 
civilian hospitals to VA facilities through telephone communications. 
MTFs will report directly to the GPMRC for CONUS transfers, but MTFs 
will report to the TPMRC at Ramstein Air Base, or to the TPMRC at 
Yokota Air Base for a-CONUS transfers. The TPMRC will then coordinate 
with the GPMRC for transportation. An after-the-fact report will be 
made to GPMRC within 48 hours.
       j.    DoD will ensure meeting the goal of transfer within 3 days 
(4 days from overseas), whenever the patient's medical condition 
permits, but not exceeding 12 days. The ability to complete medical 
review board processing is not a prerequisite for transfer to a VA 
medical facility.
       k.   DoD will assure that each Surgeon General's office or her/
his designee provides necessary assistance to VA facilities in the 
preparation and transmittal of the patient's medical boards or as a 
point of contact should problems arise.
       l.   DoD will assure that the appropriate Service provide 
telephone and written notification to VA facilities when active duty 
members are discharged or released from active duty. This notification 
shall be made before the separation date and will include the date, 
type of separation, and the periods of active duty served. The DD214 
will be provided to VA in a timely manner.

    5.  VA RESPONSIBILITIES:

       a.  The Rehabilitation Services Chief Consultant and the Spinal 
Cord Injury and Disorders Chief Consultant will provide annually to 
DoD, a list of VA Spinal Cord Injury Centers, Traumatic Brain Injury 
Lead Centers, and Blind Rehabilitation Centers including their 
telephone numbers and points of contact. These lists will be updated if 
changes occur.
       b.  The Veterans Integrated Service Network (VISN) Directors 
will adhere to policies in this MOA.
       c.   The designated VA facility with an SCI Center, TBI Center, 
or Blind Rehabilitation Center will assist military authorities in the 
following manner:
           1.  Respond (following receipt of necessary medical records) 
to requests for admission from military medical authorities or their 
designees without regard to weekends or holidays. NOTE: Concurrent 
notification of the GPMRC will be provided.
           2.  Accept appropriate active-duty patients without regard 
to hour of the day, day of the week, or holidays. NOTE: The acceptance 
of local transfers from MTFs to VA facilities should be mutually agreed 
upon. At MTF's where VA staff are assigned, the VA/DoD Social Worker 
liaison will assist with the transfer.
           3.  Coordinate the transfer of active duty patients to VA 
health care facilities with the MTFs and GPMRC. NOTE: Concurrent 
notification of the GPMRC will be provided.
           4.  Coordinate with civilian hospitals and GPMRC so that 
active duty patients, who are ready for transfer to a VA specialty care 
center are transported directly from a civilian hospital to the 
appropriate VA facility.
           5.  Assist the MTF in identifying the most appropriate VA 
SCI, TBI, or Blind Rehabilitation Center. Active duty patients need to 
be referred to the designated VA medical facility closest to the active 
duty member's home of record or location selected by the active duty 
member, guardian, conservator, or designee, subject to availability of 
beds. If the preferred Center is unable to accept the patient, that VA 
medical facility will assist in locating an appropriate placement. 
NOTE: The Chief Consultant, Rehabilitation Services, or Chief 
Consultant, SCI&D Services, VA Central Office, 810 Vermont Avenue, NW, 
Washington, DC 20420, will assist when necessary.
           6.  The accepting VA staff physician will review military 
transportation arrangements and make recommendations if it is believed 
that the patient's care will be compromised due to delays or other 
clinical considerations. VA will assist referring military authorities 
and GPMRC in coordinating the medically indicated mode of 
transportation and arranging local ground transportation to VA 
facilities, such as from local airfields.
           7.  Provide immediate notification to the appropriate MTF 
Case Manager and MMSO, when an active duty member is admitted. The VA 
will assign a case manager responsible for coordinating care through a 
continuum of health care services for each member admitted. The VA case 
manager will provide the DoD/MTF case manager periodic updates, no less 
than once a month depending on the acuity or complexity of the case, 
until the medical determination or the medical board process is 
complete. This continued coordination is necessary to aid in 
communication to the DoD, primary care manager, command, other program 
managers, and medical board personnel.
           8.  Coordinate the hospital discharge of an active duty 
member with the appropriate MTF and the Military Medical Support Office 
(MMSO).
           9.  Assist with medical boards when requested by the 
military authority having cognizance over the member.
          10.  Notify DoD of the active duty member's absences, medical 
discharge, and change of location.
          11.  Prior to discharge, the VAMC where the patient is being 
treated will facilitate the patient appropriately enrolling to TRICARE 
in the region of his/her final destination.

    6.  PROGRAM DESCRIPTIONS:

       a.  Spinal Cord Injury and Disorders: The mission of the Spinal 
Cord Injury and Disorders Program within VA is to promote the health, 
independence, quality of life, and productivity of individuals with 
spinal cord injury and disorders. There are twenty SCI Centers 
available throughout VA to provide acute rehabilitative services to 
persons with new onset SCI (see Appendix B). VA offers a unique system 
of care through SCI Centers, which includes a full range of health care 
for eligible persons who have sustained injury to their spinal cord or 
who have other spinal cord lesions. Persons served in these centers 
include those with: stable neurological deficit due to spinal cord 
injury, intraspinal, nonmalignant neoplasms, vascular insult, cauda 
equina syndrome, inflammatory disease, spinal cord or cauda equina 
resulting in nonprogressive neurologic deficit, demyelinating disease 
limited to the spinal cord and of a stable nature, and degenerative 
spine disease.
       b.  Traumatic Brain Injury: VA offers a full range of traumatic 
brain injury rehabilitation to ensure that military and veteran 
personnel with brain injuries receive coordinated, comprehensive care. 
The goal is to return the brain injury survivor to the highest level of 
function and to educate family and caregivers in the long-term needs of 
the patient. VA has four lead Traumatic Brain Injury Centers (see 
Appendix A). These facilities provide comprehensive assessment, medical 
care, TBI specific acute rehabilitation, access to state of the art 
treatment, clinical trials, and leadership for a nationwide system of 
TBI care through case management. Each participating medical center has 
a designated TBI case manager who facilitates patient participation in 
the program and expedites facility transfers and community placement. 
Persons served in these Centers and covered under this MOA include 
individuals sustaining a brain injury caused by an external physical 
force resulting in open and closed injuries, and damage to the central 
nervous system resulting from anoxic/hypoxic episodes, related to 
trauma or exposure to chemical or environmental toxins that result in 
brain damage. This MOA does not include brain injuries/insult related 
to chronic illnesses (i.e., hypertension, tumors, diabetes, etc.). 
Patients with other acquired brain injury due to chronic disease or 
infectious processes are not covered under this MOA, but are eligible 
for care in these centers.
       c.   Blind Rehabilitation: Blind Rehabilitation Service offers a 
coordinated educational training and health care service delivery 
system that provides a continuum of care for veterans with blindness 
that extends from their home environment, to the local VA facility, to 
the appropriate rehabilitation setting. These services include 
adjustment to blindness counseling, patient and family education, 
benefits analysis, assistive technology, outpatient programs, and 
residential inpatient training. There are ten residential, inpatient VA 
Blind Rehabilitation Centers (BRCs) (see Appendix C). The mission of 
each BRC program is to educate each veteran on all aspects of Blind 
Rehabilitation and address the expressed needs of each veteran with 
blindness so they may successfully reintegrate back into their 
community and family environment. To accomplish this mission, BRCs 
offer a comprehensive, individualized adjustment-training program along 
with those services deemed necessary for a person to achieve a 
realistic level of independence. BRCs offer a variety of skill courses 
including: orientation and mobility, communication skills, activities 
of daily living, manual skills, visual skills, leisure skills, and 
computer access training. The veteran is also assisted in making an 
emotional and behavioral adjustment to blindness through individual 
counseling sessions and group therapy meetings. Each VA medical center 
has a Visual Impairment Services Team Coordinator who has major 
responsibility for the coordination of all services for visually 
impaired veterans and their families. Duties include arranging for the 
provision of appropriate treatment modalities (e.g. referrals to Blind 
Rehabilitation Centers and/or Blind Rehabilitation Outpatient 
Specialists) and being a resource for all local service delivery 
systems in order to enhance the functioning level of veterans with 
blindness. Referrals can be directed to the Program Analyst in the 
Blind Rehabilitation Program Office in the VA Central Office at 202-
273-8482.

    7.  DURATION:

       a.  This MOA will remain in force unless terminated at the 
request of either party after thirty (30) days written notice. In event 
this MOA is terminated, DoD shall be liable only for payment in 
accordance with provisions of this agreement for care provided before 
the effective termination date.
       b.  This agreement supersedes all local resource sharing 
agreements.

    8.  REIMBURSEMENT:

       a.  DoD will reimburse CHAMPUS Maximum Allowable Charge (CMAC) 
rates less 10 percent (CMAC-I 0%) for outpatient and professional care. 
Inpatient care will be reimbursed using the VA interagency rates 
approved by the Office of Management and Budget, which is periodically 
updated. Updates are provided via a Federal Register Notice. Although 
the Federal Register Notice indicates that the interagency billing 
rates do not apply to sharing agreements between VA and DoD, it has 
been determined that these rates are appropriate for care provided 
under this MOA. VAMCs will provide all documentation required for 
billing medical claims. At a minimum, this will include an itemized 
bill for each member on Form CMS 1500 for outpatient/professional 
services and Form DB 92 for inpatient services. Transportation, 
prosthetics, durable medical equipment, orthotics, dental services, 
home care, personal care attendants and extended care/nursing home care 
will be billed at the interagency rate if one exists, or at actual cost 
as appropriate.
       b.  VA facilities providing care to active duty servicemembers 
in accordance with this agreement will be paid by the TRICARE Managed 
Care Support Contractors (MCSCs). Claims should be forwarded to the 
MCSC for the TRICARE Region to which the member is enrolled in TRICARE 
Prime. If the member is not enrolled, the claim will be paid by the 
regional MCSC where the member resides. Prior to paying a claim, MCSCs 
will verify that the care is payable through MMSO. MMSO can be reached 
at 888-647-6676, P.O. Box 88699, Great Lakes, IL 60088-6999.
       c.   The VAMC will obtain authorization for non-network care 
from MMSO for the billing to go to the VAMC and be forwarded to the 
MCSC for payment. This is particularly applicable if there are no 
TRICARE providers, MTFs, or VAMCs/clinics capable of providing the 
needed services in the destination area.
       d.  VA facilities should send claims for payment to:
            North Region: North Region Claims, PGBA, P.O. Box 
870140, Surfside Beach, SC 29587-9740.
            South Region: TRICARE South Region, Claims 
Department, P.O. Box 7031, Camden, SC 29020-7031.
            West Region: WPS/West Region Claims, P.O. Box 
77028, Madison, WI 53707-7028.

    9.  EFFECTIVE DATE: This MOA is effective 1 January 2007.

William Wikenwerder, Jr., M.D.
Assistant Secretary for Health Affairs
Department of Defense
Date: 27 November 2006

Michael J. Kussman, MD, MS, MACP
Acting Under Secretary for Health
Department of Veterans Affairs
Date: 13 December 2006

                               __________

                         VA-DoD MOA Appendix A
 TRAUMATIC BRAIN INJURY (TBI) CENTERS ACCEPTING DEPARTMENT OF DEFENSE 
                               REFERRALS

     1.  Minneapolis VA Medical Center (117), One Veterans Drive, 
Minneapolis, MN 55417, Telephone 612-467-3562.
     2.  VA Palo Alto HCS (117), 3801 Miranda Avenue, Palo Alto, CA 
94304, Telephone 650-447-7114.
     3.  HH McGuire VA Medical Center (117), 1201 Broad Rock Boulevard, 
Richmond, VA 23249, Telephone 804-675-5332.
     4.  James A. Haley VA Medical Center (117), 13000 Bruce B. Downs 
Blvd., Tampa, FL 33612-4798, Telephone 813-972-7668 or 1-866-659-2156.

                               __________
                         VA-DoD MOA Appendix B
   SPINAL CORD INJURY (SCI) CENTERS ACCEPTING DEPARTMENT OF DEFENSE 
                               REFERRALS
     1.  Department of Veterans Affairs (VA) New Mexico Health Care 
System (HCS) (128), 1501 San Pedro Southeast, Albuquerque, NM 87108, 
Telephone 505-256-2849.
     2.  Augusta VA Medical Center (128), One Freedom Way, Augusta, GA 
30904-6285, Telephone 706-823-2216.
     3.  VA Boston HCS (128), 1400 VFW Parkway, West Roxbury, MA 02132, 
Telephone 617-323-7700 Extension 5128.
     4.  VA Medical Center (128), 130 West Kingsbridge Road, Bronx, NY 
10468.
     5.  Louis Stokes VA Medical Center (128W), 10701 East Boulevard, 
Cleveland, OR 44106.
     6.  VA North Texas HCS (128), 4500 South Lancaster Road, Dallas, 
TX 75216.
     7.  Edward Hines, Jr. VA Medical Center (128), Fifth Avenue and 
Roosevelt Road, Hines, IL.
     8.  Houston VA Medical Center (128), 2002 Holcombe Boulevard, 
Houston, TX 77030-4298.
     9.  VA Long Beach RCS (128), 5901 East 7th Street, Long Beach, CA 
90822.
    10.  VA Medical Center (128), 1030 Jefferson Avenue, Memphis, TN 
38104.
    11.  VA Medical Center (128), 1201 Northwest 16th Street, Miami, FL 
33125.
    12.  Clement J. Zablocki VA Medical Center (128),5000 West National 
Avenue, Milwaukee, WI 53295, Telephone 414-384-2000 Extension 41230.
    13.  VA Palo Alto HCS (128), 3801 Miranda Avenue, Palo Alto, CA 
94304, Telephone 650-493-5000 Extension 65870.
    14.  HH McGuire VA Medical Center (128), 1201 Broad Rock Boulevard, 
Richmond, VA, Telephone 804-675-5282.
    15.  South Texas Veterans HCS (128), 7400 Meront Minter Blvd., San 
Antonio, TX 78284, Telephone 210-617-5257.
    16.  VA San Diego HCS (128), 3350 La Jolla Village Drive, San 
Diego, CA 92161, Telephone 858-642-3117.
    17.  VA Medical Center (128), 10 Casia Street, San Juan, PR 00921-
3201, Telephone 787-641-7582 Extension 14130.
    18.  VA Puget Sound RCS (128), 1660 South Columbian Way, Seattle, 
WA 98108-1597, Telephone 206-764-2332.
    19.  Saint Louis VA Medical Center (128JB), One Jefferson Barracks 
Drive, St. Louis, MO 63125, Telephone 314-894-6677.
    20.  James A. Haley VA Medical Center (128), 13000 Bruce B. Downs 
Blvd., Tampa, FL 33612-4798, Telephone 813-972-7517.

                               __________
                         VA-DoD MOA Appendix C
  BLIND REHABILITATION CENTERS (BRC) ACCEPTING DEPARTMENT OF DEFENSE 
                               REFERRALS

     1.  Augusta VA Medical Center (324), One Freedom Way, Augusta, GA 
30904-6285, Telephone 706-733-0188 Extension 6660.
     2.  Birmingham VA Medical Center (124), 700 South 19th Street, 
Birmingham, AL 35233, Telephone 205-933-8 101.
     3.  Edward Hines, Jr. VA Medical Center (124), Fifth Avenue and 
Roosevelt Road, Hines, IL 60141-5000, Telephone 708-202-8387 Extension 
22112.
     4.  Central Texas VA Health Care System, 1901 Veterans Memorial 
Drive, Temple, TX 76504, Telephone 254-297-3755. Blind Rehabilitation 
Center, 4800 Memorial Drive, Waco, TX 76711. Telephone 254-297-3755.
     5.  San Juan VA Medical Center (124), 10 Casia Street, San Juan, 
PR 00921-3201, Telephone 787-641-8325.
     6.  Southern Arizona VA Health Care System (3-124),3601 South 6th 
Avenue, Tucson, AZ 85723, Telephone 520-629-4643.
     7.  VA Connecticut Health Care System (124), West Haven Campus, 
950 Campbell Avenue, West Haven, CT 06516, Telephone 203-932-5711 
Extension 2247.
     8.  VA Palo Alto RCS (124), 3801 Miranda Avenue, Palo Alto, CA 
94304, Telephone 650-493-5000 Extension 64218.
     9.  VA Puget Sound RCS (124), 1660 South Columbian Way, Seattle, 
WA 98108-1597, Telephone 253-583-1203. (A-l12-BRC), American Lake 
Division, 9600 Veterans Drive, Tacoma, WA 98493, Telephone: 253-983-
1299.
    10.  West Palm Beach VA Medical Center (124), 7305 North Military 
Trail, West Palm Beach, FL 33410-6400, Telephone 561-422-8425.

                               __________
  [Federal Register: January 7, 2004 (Volume 69, Number 4)] [Notices]
[Page 1062-1064]

[Page 1062]
OFFICE OF MANAGEMENT AND BUDGET
    Charges to Tortiously Liable Third Parties for Hospital, Medical, 
Surgical, and Dental Care and Treatment Furnished by the United States 
(Department of Veterans Affairs)

    AGENCY: Office of Management and Budget, Executive Office of the 
President.

    ACTION: Notification of charges to tortiously liable third parties 
for hospital, medical, surgical, and dental care and treatment 
furnished by the Department of Veterans Affairs.

    SUMMARY: By virtue of the authority vested in the President by 
section 2(a) of the Federal Medical Care Recovery Act, Public Law 87-
693 (76 Stat. 593; 42 U.S.C. 2652), and delegated to the Director of 
the Office of Management and Budget by Executive Order No. 11541 of 
July 1, 1970 (35 FR 10737), the charges to tortiously liable third 
parties for hospital, medical, surgical, and dental care and treatment 
(including prostheses and medical appliances) furnished by the 
Department of Veterans Affairs are the ``reasonable charges'' generated 
by the methodology set forth in 38 CFR 17.101 and published from time 
to time in the Federal Register, most recently on April 29, 2003 (68 FR 
22774). These charges are for use in connection with the recovery from 
tortiously liable third persons of the reasonable value of hospital, 
medical, surgical, and dental care and treatment furnished by the 
United States through the Department of Veterans Affairs (28 CFR 43.1-
43.4). These charges have been established in accordance with the 
requirements of OMB Circular A-25, which requires charges that are at 
least as great as the full cost of the services provided.
    There are two basic reasons for this change. First, VA's community-
based ``reasonable charges'' more accurately reflect the reasonable 
value of the medical care and treatment furnished by VA to the injured 
person, consistent with 42 U.S.C. 2651 and 2652, than do VA's cost-
based per-diem tort rates.
    Second, VA's present dual-rate billing system (tort feasor and 
health plan), using significantly different charges, is confusing and 
difficult to justify. VA claims, for example, may be made both against 
the tort feasor who caused the injury, using the current FMCRA per-diem 
rates, and against the veteran's health plan, using the significantly 
higher reasonable charges, for the same VA medical care. This not only 
is confusing to VA billing officials and makes settling claims more 
difficult, but such dual billing also may disadvantage veterans by 
providing a per-diem rate bill to assert against the tort feasor while 
exposing veterans to subrogation claims from their health plans who 
paid at the higher reasonable charges rates. Making the charges billed 
to all liable parties in FMCRA cases uniform will eliminate confusion 
and remove an impediment to allowing injured veterans to assert the 
higher reasonable charges rates for their causally related health care 
as a necessary and proper element of damages in their cases against the 
responsible tort feasors.
    Beginning on January 7, 2004, the charges prescribed herein 
supercede those established by the Director of the Office of Management 
and Budget for the Department of Veterans Affairs on November 1, 1999 
(64 FR 58862).
    Joshua B. Bolten, Director.
    [FR Doc. 04-317 Filed 1-6-04; 8:45 am]
    BILLING CODE 3110-01-P

                               __________
                    OFFICE OF MANAGEMENT AND BUDGET
                     DEPARTMENT OF VETERANS AFFAIRS
Cost-Based and Interagency Billing Rates for Medical Care or Services 
        Provided by the Department of Veterans Affairs
    AGENCIES: Office of Management and Budget, Executive Office of the 
President and the Department of Veterans Affairs.

    ACTION: Notice.

    SUMMARY: This document provides cost-based and interagency billing 
rates for medical care or services provided by the Department of 
Veterans Affairs (VA):

    (a) In error or on tentative eligibility;
    (b) In a medical emergency;
    (c) To pensioners of allied Nations;
    (d) For research purposes in circumstances under which VA medical 
care appropriation is to be reimbursed by VA research appropriation; 
and
    (e) To beneficiaries of the Department of Defense or other Federal 
agencies, when the care or service provided is not covered by an 
applicable sharing agreement.

    In addition, until such time as charges for outpatient dental care 
and prescription drugs are implemented under the provisions of 38 CFR 
17.101, the applicable cost-based billing rates provided in this notice 
will be used for collection or recovery by VA for outpatient dental 
care and prescription drugs provided under circumstances covered by 
that section. This notice is issued jointly by the Office of Management 
and Budget and the Department of Veterans Affairs.

    EFFECTIVE DATE: The rates set forth herein are effective January 7, 
2004, and until further notice.

    FOR FURTHER INFORMATION CONTACT: David Cleaver, Chief Business 
Office (168), Veterans Health Administration, Department of Veterans 
Affairs, 810 Vermont Avenue, NW., Washington, DC 20420, (202) 254-0361. 
(This is not a toll free number.)

    SUPPLEMENTARY INFORMATION: VA's medical regulations at 38 CFR 
17.102(h) set forth a methodology for computing rates for medical care 
or services provided by VA:

    (a) In error or on tentative eligibility;
    (b) In a medical emergency;
    (c) To pensioners of allied Nations;
    (d) For research purposes in circumstances under which VA medical 
care appropriation is to be reimbursed by VA research appropriation; 
and
    (e) To beneficiaries of the Department of Defense or other Federal 
agencies, when the care or service provided is not covered by an 
applicable sharing agreement.

    Two sets of rates are obtained via application of this methodology: 
Cost-Based Rates, for use for purposes (a) through (d), above, and 
Interagency Rates, for use for purpose (e), above. Government employee 
retirement benefits and return on fixed assets are not included in the 
Interagency Rates, and the Interagency Rates are not broken down into 
three components (Physician; Ancillary; and Nursing, Room, and Board), 
but in all other respects the Interagency Rates are the same as the 
Cost-Based Rates.
    When medical care or service is obtained at the expense of the 
Department of Veterans Affairs from a non-VA source under circumstances 
in which the Cost-Based or Interagency Rates would apply if the care or 
service had been provided by VA, then the charge for such care or 
service will be the actual amount paid by VA for that care or service.
    Inpatient charges will be at the per diem rates shown for the type 
of bed section or discrete treatment unit providing the care. 
Prescription Filled charge in lieu of the Outpatient Visit rate will be 
charged when the patient receives no service other than the Pharmacy 
outpatient service. This charge applies whether the patient receives 
the prescription in person or by mail.
    Current rates obtained via the above methodology are as follows:

[[Page 1063]]

------------------------------------------------------------------------
                                           Cost-based      Interagency
                                             rates            rates
------------------------------------------------------------------------
A. Hospital Care, Rates Per Inpatient
 Day
------------------------------------------------------------------------
General Medicine:
------------------------------------------------------------------------
    All Inclusive Rate                          $1,815           $1,668
------------------------------------------------------------------------
    Physician                                      217
------------------------------------------------------------------------
    Ancillary                                      473
------------------------------------------------------------------------
    Nursing, Room and Board                      1,125
------------------------------------------------------------------------
Neurology:
------------------------------------------------------------------------
    All Inclusive Rate                           2,289            2,098
------------------------------------------------------------------------
    Physician                                      335
------------------------------------------------------------------------
    Ancillary                                      604
------------------------------------------------------------------------
    Nursing, Room, and Board                     1,350
------------------------------------------------------------------------
Rehabilitation Medicine:
------------------------------------------------------------------------
    All Inclusive Rate                           1,723            1,574
------------------------------------------------------------------------
    Physician                                      196
------------------------------------------------------------------------
    Ancillary                                      526
------------------------------------------------------------------------
    Nursing, Room, and Board                     1,001
------------------------------------------------------------------------
Blind Rehabilitation:
------------------------------------------------------------------------
    All Inclusive Rate                           1,254            1,162
------------------------------------------------------------------------
    Physician                                      101
------------------------------------------------------------------------
    Ancillary                                      623
------------------------------------------------------------------------
    Nursing, Room, and Board                       530
------------------------------------------------------------------------
Spinal Cord Injury:
------------------------------------------------------------------------
    All Inclusive Rate                           1,237            1,136
------------------------------------------------------------------------
    Physician                                      153
------------------------------------------------------------------------
    Ancillary                                      311
------------------------------------------------------------------------
    Nursing, Room, and Board                       773
------------------------------------------------------------------------
Surgery:
------------------------------------------------------------------------
    All Inclusive Rate                           3,513            3,255
------------------------------------------------------------------------
    Physician                                      387
------------------------------------------------------------------------
    Ancillary                                    1,065
------------------------------------------------------------------------
    Nursing, Room, and Board                     2,061
------------------------------------------------------------------------
General Psychiatry:
------------------------------------------------------------------------
    All Inclusive Rate                             971              888
------------------------------------------------------------------------
    Physician                                       92
------------------------------------------------------------------------
    Ancillary                                      153
------------------------------------------------------------------------
    Nursing, Room, and Board                       726
------------------------------------------------------------------------
Substance Abuse (Alcohol and Drug
 Treatment):
------------------------------------------------------------------------
    All Inclusive Rate                           1,206            1,106
------------------------------------------------------------------------
    Physician                                      115
------------------------------------------------------------------------
    Ancillary                                      279
------------------------------------------------------------------------
    Nursing, Room, and Board                       812
------------------------------------------------------------------------
Psychosocial Residential
 Rehabilitation Treatment Programs:
------------------------------------------------------------------------
    All Inclusive Rate                             276              252
------------------------------------------------------------------------
    Physician                                       17
------------------------------------------------------------------------
    Ancillary                                       29
------------------------------------------------------------------------
    Nursing, Room, and Board                       230
------------------------------------------------------------------------
Intermediate Medicine:
------------------------------------------------------------------------
    All Inclusive Rate                             801              733
------------------------------------------------------------------------
    Physician                                       39
------------------------------------------------------------------------
    Ancillary                                      118
------------------------------------------------------------------------
    Nursing, Room, and Board                       644
------------------------------------------------------------------------
B. Nursing Home Care, Rates Per Day
------------------------------------------------------------------------
    All Inclusive Rate                             451              411
------------------------------------------------------------------------
    Physician                                       14
------------------------------------------------------------------------
    Ancillary                                       61
------------------------------------------------------------------------
    Nursing, Room, and Board                       376
------------------------------------------------------------------------
C. Outpatient Medical and Dental
 Treatment
------------------------------------------------------------------------
    Outpatient Visit (other than                   300              282
 Emergency Dental)
------------------------------------------------------------------------
    Emergency Dental Outpatient Visit              185              167
------------------------------------------------------------------------
D. Prescription Filled, Per                         45               45
 Prescription
------------------------------------------------------------------------

[[Page 1064]]
    Beginning on the effective date indicated herein, these rates 
supercede those established for the Department of Veterans Affairs by 
the Director of the Office of Management and Budget on November 1, 1999 
(64 FR 58862).
    Approved: September 17, 2003.
    Anthony J. Principi, Secretary, Department of Veterans Affairs. 
Approved: December 30, 2003.
    Joshua B. Bolten, Director, Office of Management and Budget.
[FR Doc. 04-318 Filed 1-6-04; 8:45 am]
BILLING CODE 3110-01-P

                                  
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