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39–454 2008

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 

VIC SNYDER, Arkansas 

MICHAEL H. MICHAUD, Maine 

STEPHANIE HERSETH SANDLIN, South 

Dakota 

HARRY E. MITCHELL, Arizona 

JOHN J. HALL, New York 

PHIL HARE, Illinois 

MICHAEL F. DOYLE, Pennsylvania 

SHELLEY BERKLEY, Nevada 

JOHN T. SALAZAR, Colorado 

CIRO D. RODRIGUEZ, Texas 

JOE DONNELLY, Indiana 

JERRY MCNERNEY, California 

ZACHARY T. SPACE, Ohio 

TIMOTHY J. WALZ, Minnesota 

STEVE BUYER, Indiana, Ranking 

CLIFF STEARNS, Florida 

JERRY MORAN, Kansas 

RICHARD H. BAKER, Louisiana 

HENRY E. BROWN, JR., South Carolina 

JEFF MILLER, Florida 

JOHN BOOZMAN, Arkansas 

GINNY BROWN-WAITE, Florida 

MICHAEL R. TURNER, Ohio 

BRIAN P. BILBRAY, California 

DOUG LAMBORN, Colorado 

GUS M. BILIRAKIS, Florida 

VERN BUCHANAN, Florida 

Malcom A. Shorter, Staff Director 

SUBCOMMITTEE ON OVERSIGHT AND INVESTIGATIONS 

HARRY E. MITCHELL, Arizona, Chairman 

ZACHARY T. SPACE, Ohio 

TIMOTHY J. WALZ, Minnesota 

CIRO D. RODRIGUEZ, Texas 

GINNY BROWN-WAITE, Florida, Ranking 

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. 


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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 


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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 BrownWaite. 

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. 


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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 


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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, MinVerDate Aug 31 2005 04:26 Jul 11, 2008 Jkt 039454 PO 00000 Frm 00007 Fmt 6633 Sfmt 6633 E:\HR\OC\A454.XXX A454

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nesota; 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 activeduty 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. 


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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 


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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. 


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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. 


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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. 


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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. 


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10 

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. 


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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? 


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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. 


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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. 


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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 


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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 MultiSensory 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 


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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. 


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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. 


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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 inVerDate Aug 31 2005 04:26 Jul 11, 2008 Jkt 039454 PO 00000 Frm 00022 Fmt 6633 Sfmt 6633 E:\HR\OC\A454.XXX A454

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cluded 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. 


erowe on PROD1PC71 with REPORTS
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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 


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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. 


erowe on PROD1PC71 with REPORTS
22 

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 Ap- propriations 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. 


erowe on PROD1PC71 with REPORTS
23 

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 


erowe on PROD1PC71 with REPORTS
24 

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 


erowe on PROD1PC71 with REPORTS
25 

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.]zzzzz 


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(26) 

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 


erowe on PROD1PC71 with REPORTS
27 

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. 

f 

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 


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28 

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. 

f 

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 squaremiles) 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 fulltime equivalent employees (FTEE) and more than 1,700 volunteers. The FY 2007 


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29 

1 NBC Channel 11: ‘‘The Bay Area at 11’’, KNTV–San Francisco 02/07/2007. 

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. 


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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 


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31 

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 liaiVerDate Aug 31 2005 04:26 Jul 11, 2008 Jkt 039454 PO 00000 Frm 00035 Fmt 6604 Sfmt 6621 E:\HR\OC\A454.XXX A454

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sons 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. 

f 

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, 


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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-ofthe-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 treatVerDate Aug 31 2005 04:26 Jul 11, 2008 Jkt 039454 PO 00000 Frm 00037 Fmt 6604 Sfmt 6621 E:\HR\OC\A454.XXX A454

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ment 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, nonmedical 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 


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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. 

f 

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 


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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 


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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 

PRC 

Number 

of patients 

Number 

of new 

admissions 

Number 

of discharges 

Number 

of new 

referrals 

Number 

accepted/ 

awaiting 

transfer 

Not admitted 

Needed 

a more 

appropriate 

level 

Chose 

to go 

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 conVerDate Aug 31 2005 04:26 Jul 11, 2008 Jkt 039454 PO 00000 Frm 00041 Fmt 6604 Sfmt 6621 E:\HR\OC\A454.XXX A454

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ducting 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 Path #4 Filled 

PRC—Inpatient Speech/Lang Path #5 Filled 

PRC—Inpatient Lead Recreation Therapist (Community/Volunteer 

Coord/Family Care Coord) 

Advertised 

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 Psychologist (Psychology) Advertised 


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Program Position title Status 

PRC—Inpatient Staff Support—Clinical Psychologist (Psychology) or Social Worker (SocWk) Advertised 

PRC—Inpatient Sexuality Therapist—specializing TBI—Clinical 

Psychologist (Psychology) or Physician-Urologist 

(Surgical) 

Advertised 

OEF/OIF Program Program Manager Filled 

OEF/OIF Program Program Support Asst Advertised 

OEF/OIF Program OIF/OEF Social Work Case Manager/Outreach Duty 

station: Palo Alto 

Filled 

OEF/OIF Program OIF/OEF Social Work Case Manager/Outreach Duty 

station: San Jose/Monterey 

Advertised 

OEF/OIF Program OIF/OEF Social Work Case Manager/Outreach Duty 

station: Livermore 

Filled 

OEF/OIF Program OIF/OEF Nurse Case Manager Duty station: 

Livermore 

Advertised 

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 Path Filled 

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 


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40 

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. 


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41 

Core PRC Staffing Vacancies 

Core PRC Staff 

Type 

Target 

36 positions 

Palo Alto Minneapolis Richmond Tampa 

# vacant 

in last 

180 

days 

# mths 

vacant 

# vacant 

in last 

180 

days 

# mths 

vacant 

# vacant 

in last 

180 

days 

# mths 

vacant 

# vacant 

in last 

180 

days 

# mths 

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: 

Regional Polytrauma/TBI 

Rehab Center VISN 

Polytrauma/ 

TBI Network Site 

Polytrauma/ 

TBI Support 

Clinic Teams 

Polytrauma/ 

TBI Point of 

Contact 

Richmond VISN 1 Boston West Haven 

Togus 

White River 

Bedford 

Manchester 

Providence 

North 

Hampton 

VISN 2 Syracuse Albany 

Buffalo 

Bath 

Canandaigua 


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Regional Polytrauma/TBI 

Rehab Center VISN 

Polytrauma/ 

TBI Network Site 

Polytrauma/ 

TBI Support 

Clinic Teams 

Polytrauma/ 

TBI Point of 

Contact 

VISN 3 Bronx Hudson Valley 

HCS/ Montrose 

Hudson Valley 

HCS/Castlepoint 

NJHCS/East 

Orange 

NJHCS/Lyons 

NY Harbor 

HCS/New York 

NY Harbor 

HCS/Brooklyn 

NY Harbor 

HCS/St Albans 

Northport 

VAMC 

**All facilities 

in VISN 3 have 

appropriate 

service levels 

to be classified 

as at least a 

Polytrauma 

Support Clinic 

Team. 

VISN 4 Philadelphia Pittsburgh 

Wilmington 

Erie 

Lebanon 

Coatesville 

Altoona 

Butler 

Wilkes-Barre 

Clarksburg 

VISN 5 Washington, 

DC 

Baltimore 

Martinsburg 

**All facilities 

in VISN 5 have 

appropriate 

service levels 

to be classified 

as at least a 

Polytrauma 

Support Clinic 

Team. 

VISN 6 Richmond Hampton 

Salisbury 

Durham 

Ashville 

Beckley 

Fayetteville 

Salem 

Tampa VISN 7 Augusta Tuscaloosa 

Columbia 

Charleston 

Atlanta 

Birmingham 

Dublin 

Tuskegee 

VISN 8 Tampa 

San Juan 

Bay Pines 

Gainesville 

Miami 

West Palm 

Orlando 

VISN 9 Lexington Huntington 

Louisville 

Memphis 

TVHC–

Nashville 

TVHC–

Murfeesboro 

TVHC–

Mountain Home 

**All facilities 

in VISN 9 have 

appropriate 

service levels 

to be classified 

at least a 

Polytrauma 

Support Clinic 

Team. 

VISN 16 Houston Alexandria 

Jackson 

Central 

Arkansas-Little 

Rock 

Muskogee 

Shreveport 

Gulf Coast 

(Biloxi) 

Fayetteville, 

AR 

New Orleans 

Oklahoma City 

Waco 

VISN 17 Dallas Temple 

San Antonio 

Kerrville 


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Regional Polytrauma/TBI 

Rehab Center VISN 

Polytrauma/ 

TBI Network Site 

Polytrauma/ 

TBI Support 

Clinic Teams 

Polytrauma/ 

TBI Point of 

Contact 

Palo Alto VISN 18 Southern 

Arizona HCS 

(Tucson) 

New Mexico 

HCS– Albuquerque 

Amarillo 

West Texas 

HCS (Big 

Spring) 

El Paso 

Northern 

Arizona HCS 

(Prescott) 

Phoenix 

VISN 19 Denver Salt Lake 

Grand Junction 

Cheyenne 

Montana HCS–

Ft. Harrison 

Sheridan 

VISN 20 Seattle Portland 

Boise 

Alaska 

American Lake 

Roseburg 

Spokane 

Walla Walla 

White City 

VISN 21 Palo Alto Sacramento 

San Francisco 

Sierra Nevada 

HCS 

Honolulu 

Manila 

Central 

California HCS 

(Fresno) 

VISN 22 West LA Long Beach 

San Diego 

Loma Linda 

Southern 

Nevada HCS 

Sepulveda 

Minneapolis VISN 10 Cleveland Cincinnati 

Dayton 

Columbus 

Chillicothe 

VISN 11 Indianapolis Detroit 

Danville (Iliana) 

Ann Arbor 

Battle Creek 

NICHS–

Marion 

Saginaw 

VISN 12 Hines Milwaukee 

North Chicago 

Tomah 

Madison 

Chicago HCS 

(Jesse Brown) 

Iron Mountain 

VISN 15 St. Louis Kansas City Wichita 

Poplar Bluff 

Columbia, MO 

Eastern 

Kansas/Topeka 

Marion 

VISN 23 Minneapolis Sioux Falls 

Black Hills 

Iowa City 

Central IowaKnoxville 

Fargo 

St. Cloud 

Central IowaDes Moines 

Greater 

NebraskaGrand Island 

Greater 

NebraskaLincoln 

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 


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44 

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 


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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. 

f 

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 §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. §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. 


erowe on PROD1PC71 with REPORTS
46 

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 exVerDate Aug 31 2005 04:26 Jul 11, 2008 Jkt 039454 PO 00000 Frm 00050 Fmt 6604 Sfmt 6621 E:\HR\OC\A454.XXX A454

erowe on PROD1PC71 with REPORTS
47 

ceeding 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). 


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48 

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 funcVerDate Aug 31 2005 04:26 Jul 11, 2008 Jkt 039454 PO 00000 Frm 00052 Fmt 6604 Sfmt 6621 E:\HR\OC\A454.XXX A454

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tioning 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. 


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50 

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. 


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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] 


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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 costbased 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: 


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[[Page 1063]] 

Cost-based 

rates 

Interagency 

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 


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54 

Cost-based 

rates 

Interagency 

rates 

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 Emergency Dental) 300 282 

Emergency Dental Outpatient Visit 185 167 

D. Prescription Filled, Per Prescription 45 45 

[[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 

Æ 


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