U.S. GOVERNMENT PRINTING OFFICE

WASHINGTON : 

For sale by the Superintendent of Documents, U.S. Government Printing Office,

http://bookstore.gpo.gov. For more information, contact the GPO Customer Contact Center,

U.S. Government Printing Office. Phone 202–512–1800, or 866–512–1800 (toll-free). E-mail, gpo@custhelp.com.

58–060 2011

HEALING THE PHYSICAL INJURIES OF WAR 

HEARING 

BEFORE THE

SUBCOMMITTEE ON HEALTH 

OF THE

COMMITTEE ON VETERANS’ AFFAIRS 

U.S. HOUSE OF REPRESENTATIVES 

ONE HUNDRED ELEVENTH CONGRESS 

SECOND SESSION 

JULY 22, 2010

Serial No. 111–93 

Printed for the use of the Committee on Veterans’ Affairs 

( 


ccoleman on DSK8P6SHH1PROD with HEARING
ii 

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 

DEBORAH L. HALVORSON, Illinois 

THOMAS S.P. PERRIELLO, Virginia 

HARRY TEAGUE, New Mexico 

CIRO D. RODRIGUEZ, Texas 

JOE DONNELLY, Indiana 

JERRY MCNERNEY, California 

ZACHARY T. SPACE, Ohio 

TIMOTHY J. WALZ, Minnesota 

JOHN H. ADLER, New Jersey 

ANN KIRKPATRICK, Arizona 

GLENN C. NYE, Virginia 

STEVE BUYER, Indiana, Ranking 

CLIFF STEARNS, Florida 

JERRY MORAN, Kansas 

HENRY E. BROWN, JR., South Carolina 

JEFF MILLER, Florida 

JOHN BOOZMAN, Arkansas 

BRIAN P. BILBRAY, California 

DOUG LAMBORN, Colorado 

GUS M. BILIRAKIS, Florida 

VERN BUCHANAN, Florida 

DAVID P. ROE, Tennessee 

Malcom A. Shorter, Staff Director 

SUBCOMMITTEE ON HEALTH 

MICHAEL H. MICHAUD, Maine, Chairman 

CORRINE BROWN, Florida 

VIC SNYDER, Arkansas 

HARRY TEAGUE, New Mexico 

CIRO D. RODRIGUEZ, Texas 

JOE DONNELLY, Indiana 

JERRY MCNERNEY, California 

GLENN C. NYE, Virginia 

DEBORAH L. HALVORSON, Illinois 

THOMAS S.P. PERRIELLO, Virginia 

HENRY E. BROWN, JR., South Carolina, 

Ranking 

CLIFF STEARNS, Florida 

JERRY MORAN, Kansas 

JOHN BOOZMAN, Arkansas 

GUS M. BILIRAKIS, Florida 

VERN BUCHANAN, Florida 

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. 


ccoleman on DSK8P6SHH1PROD with HEARING
iii 

C O N T E N T S 

July 22, 2010 

Page 

Healing the Physical Injuries of War ..................................................................... 1 

OPENING STATEMENTS 

Chairman Michael H. Michaud .............................................................................. 1 

Prepared statement of Chairman Michaud .................................................... 35 

Hon. Henry E. Brown, Jr., Ranking Republican Member .................................... 2 

Prepared statement of Congressman Brown .................................................. 35 

WITNESSES 

U.S. Department of Defense, Jack Smith, M.D., MMM, Acting Deputy Assistant Secretary for Clinical and Program Policy .................................................. 27 

Prepared statement of Dr. Smith .................................................................... 55 

U.S. Department of Veterans Affairs, Lucille B. Beck, Ph.D., Chief Consultant, Rehabilitation Services, Office of Patient Care Services, and Director, 

Audiology and Speech Pathology Service, Veterans Health Administration .. 29 

Prepared statement of Dr. Beck ...................................................................... 58 

American Legion, Denise A. Williams, Assistant Director for Health Policy, 

Veterans Affairs and Rehabilitation Commission ............................................. 10 

Prepared statement of Ms. Williams .............................................................. 53 

Blinded Veterans Association, Thomas Zampieri, Ph.D., Director of Government Relations ..................................................................................................... 3 

Prepared statement of Dr. Zampieri ............................................................... 36 

Disabled American Veterans, Joy J. Ilem, Deputy National Legislative Director .......................................................................................................................... 6 

Prepared statement of Ms. Ilem ...................................................................... 42 

Iraq and Afghanistan Veterans of America, Tom Tarantino, Legislative Associate ....................................................................................................................... 8 

Prepared statement of Mr. Tarantino ............................................................. 49 

Paralyzed Veterans of America, Carl Blake, National Legislative Director ....... 4 

Prepared statement of Mr. Blake .................................................................... 40 

MATERIAL SUBMITTED FOR THE RECORD 

Post-Hearing Questions and Responses for the Record: 

Hon. Michael Michaud, Chairman, Subcommittee on Health, Committee on Veterans’ Affairs to Thomas Zampieri, Ph.D., Director of 

Government Relations, Blinded Veterans Association, letter dated 

July 27, 2010, and response letter dated August 13, 2010 .................... 66 

Hon. Michael Michaud, Chairman, Subcommittee on Health, Committee on Veterans’ Affairs to Carl Blake, National Legislative Director, Paralyzed Veterans of America, letter dated July 27, 2010, and 

response letter dated August 31, 2010 .................................................... 68 

Hon. Michael Michaud, Chairman, Subcommittee on Health, Committee on Veterans’ Affairs to Joy J. Ilem, Deputy National Legislative Director, Disabled American Veterans, letter dated July 27, 

2010, and Ms. Ilem’s responses ................................................................ 71 

Hon. Michael Michaud, Chairman, Subcommittee on Health, Committee on Veterans’ Affairs to Tom Tarantino, Legislative Associate, 

Iraq and Afghanistan Veterans of America, letter dated July 27, 

2010, and Mr. Tarantino’s responses ....................................................... 75 


ccoleman on DSK8P6SHH1PROD with HEARING
Page

iv 

Post-Hearing Questions and Responses for the Record—Continued 

Hon. Michael Michaud, Chairman, Subcommittee on Health, Committee on Veterans’ Affairs to Denise A. Williams, Assistant Director 

for Health Policy, Veterans Affairs and Rehabilitation Commission, 

American Legion, letter dated July 27, 2010, and response from 

Tim Tetz, Director, National Legislative Commission, letter dated 

September 8, 2010 ..................................................................................... 77 

Hon. Michael Michaud, Chairman, Subcommittee on Health, Committee on Veterans’ Affairs to Hon. Robert M. Gates, Secretary, U.S. 

Department of Defense, letter dated July 27, 2010, and DoD’s responses ....................................................................................................... 79 

Hon. Michael Michaud, Chairman, Subcommittee on Health, Committee on Veterans’ Affairs to Hon. Eric K. Shinseki, Secretary, U.S. 

Department of Veterans Affairs, letter dated July 27, 2010, and 

VA responses ............................................................................................. 82 


ccoleman on DSK8P6SHH1PROD with HEARING
(1) 

HEALING THE PHYSICAL INJURIES OF WAR 

THURSDAY, JULY 22, 2010 

U.S. HOUSE OF REPRESENTATIVES, 

COMMITTEE ON VETERANS’ AFFAIRS, 

SUBCOMMITTEE ON HEALTH, 

Washington, DC. 

The Subcommittee met, pursuant to notice, at 9:59 a.m., in Room 

334, Cannon House Office Building, Hon. Michael H. Michaud 

[Chairman of the Subcommittee] presiding. 

Present: Representatives Michaud, Donnelly, McNerney, 

Halvorson, Perriello, Brown of South Carolina, and Bilirakis. 

OPENING STATEMENT OF CHAIRMAN MICHAUD 

Mr. MICHAUD. I will call the Subcommittee on Health to order, 

and I would like to thank everyone for coming this morning. 

The purpose of today’s hearing is to explore how we can best 

serve our veterans who have sustained severe physical wounds 

from the wars in Iraq and Afghanistan. 

Today we will closely examine the U.S. Department of Veterans 

Affairs’ (VA’s) specialized service for the severely injured, which include blind rehabilitation, spinal cord injury (SCI) centers, polytrauma centers, and prosthetic and sensory aids services. 

With advances in protective body armor and combat medicine, 

our servicemembers are surviving war wounds which otherwise 

would have resulted in casualties. Many servicemembers who are 

severely injured in Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) will require sophisticated, comprehensive, and often lifelong care. 

We know that the blast injuries from improvised explosive devices (IEDs) are the most common cause of injuries and death 

among our OEF/OIF servicemembers. Blast injuries often include 

combinations of traumatic brain injury (TBI), blindness, spinal cord 

injuries, burns, and damage to the limbs, which results in amputations. 

Today, we will examine whether VA is meeting the needs of our 

severely injured, and whether the veterans have access to the most 

current therapies for treating their physical war injuries. We will 

identify what VA is doing well and what areas they need improvement in. We will also explore how VA ensures that the quality of 

care is consistent and standardized across the VA health care system so that veterans receive the same high quality care regardless 

of which VA facility they visit. Finally, we will review VA’s current 

efforts to coordinate specialized services for the severely injured 


ccoleman on DSK8P6SHH1PROD with HEARING
2 

with the U.S. Department of Defense (DoD) and how we can 

achieve improved coordination between the two Departments. 

I look forward to hearing the panels this morning, and I would 

turn it over to my good friend Ranking Member Mr. Brown for any 

opening statement he may have. 

[The prepared statement of Chairman Michaud appears on 

p. 35.] 

OPENING STATEMENT OF HON. HENRY E. BROWN, JR. 

Mr. BROWN. Thank you, Mr. Chairman, and good morning all. 

Yesterday we reached a milestone. It was 80 years ago on July 

the 21st, 1930, that President Herbert Hoover first established 

what we now know as the Department of Veterans Affairs. Since 

that day, VA has endeavored to fulfill their mission to care for 

those who have borne the battle and for those who return carrying 

the very worst wounds of war, including spinal cord injury, traumatic brain injury, amputations, and blindness. 

The VA has developed specialized services to meet the unique rehabilitative needs of our veteran population. Providing these types 

of services to our very highest priority veterans is the backbone of 

the Department. 

Since 1996, Congress has mandated that the VA maintain capacity for these specialized rehabilitative services, and in 2004, Congress enacted legislation to provide comprehensive services for severely injured servicemembers suffering with complex injuries resulting from blast injuries. This came to be called VA’s Polytrauma 

System of Care. 

More than 2.1 million servicemembers have been deployed since 

October 2001. As of April the 3rd, 1,552 had suffered amputations 

in Iraq or Afghanistan. Countless others have suffered TBI, SCI, 

eye trauma, hearing loss, or other severe combat wounds. 

These young heroes are going to require a lifetime of rehabilitation and highly skilled medical services and support. They have 

risked life and limb in our name, and in return, it is our responsibility to provide them with the care they require and so dearly deserve. 

As the battles in Iraq and Afghanistan persist, the specialized 

caregiver in VA medical, polytrauma, spinal cord injury, and blind 

rehabilitation centers continue to take on increasing importance. 

We must diligently prioritize investments in specialized services, 

medical research, and recruitment to have all the tools necessary 

to provide all veterans, and especially our most severely wounded 

veterans, with an active and full life characterized by independence, functionality, and achievement. 

I am grateful to our panelists and audience members for being 

here this morning, and I yield back. 

Thank you, Mr. Chairman. 

[The prepared statement of Mr. Brown appears on p. 35.] 

Mr. MICHAUD. Thank you very much, Mr. Brown. 

I would like to call the first panel forward, and while they are 

coming forward I will introduce them. We first have Dr. Thomas 

Zampieri who represents the Blinded Veterans Association (BVA), 

Carl Blake, of the Paralyzed Veterans of America (PVA), Joy Ilem, 

from the Disabled American Veterans (DAV), Tom Tarantino who 


ccoleman on DSK8P6SHH1PROD with HEARING
3 

is with Iraq and Afghanistan Veterans of America (IAVA), and 

Denise Williams who is from the American Legion. 

I want to thank all of you for coming this morning and look forward to hearing your testimony today. We will start with Dr. 

Zampieri. 

STATEMENTS OF THOMAS ZAMPIERI, PH.D., DIRECTOR OF 

GOVERNMENT RELATIONS, BLINDED VETERANS ASSOCIATION; CARL BLAKE, NATIONAL LEGISLATIVE DIRECTOR, 

PARALYZED VETERANS OF AMERICA; JOY J. ILEM, DEPUTY 

NATIONAL LEGISLATIVE DIRECTOR, DISABLED AMERICAN 

VETERANS; TOM TARANTINO, LEGISLATIVE ASSOCIATE, 

IRAQ AND AFGHANISTAN VETERANS OF AMERICA; AND 

DENISE A. WILLIAMS, ASSISTANT DIRECTOR OF HEALTH 

POLICY, VETERANS AFFAIRS AND REHABILITATION COMMISSION, AMERICAN LEGION 

STATEMENT OF THOMAS ZAMPIERI, PH.D. 

Dr. ZAMPIERI. Mr. Chairman, Members of the Subcommittee, the 

Blinded Veterans Association appreciates this opportunity to 

present our testimony today, and I appreciate that the Committee 

is taking a look at the specialized programs in regards to the returning servicemembers with a variety of injuries. 

I also appreciate the fact that that you highlighted that oftentimes in this town we don’t hear a lot about the other injuries. 

Most of the research papers and scientific papers on these types of 

wounded coming back clearly demonstrate that they all have multiple injuries. It is rare you ever just have somebody that comes 

back with just quote ‘‘TBI.’’ They have a variety of injuries. Burns, 

fractures, amputations, psychosocial problems associated with the 

multi-trauma that they have sustained, and so it is just good that 

this is being done today. 

The VA, I want to start off on some good news, you know, the 

blind rehab service has expanded services throughout the system. 

Ironically back in 2004, they developed the plans for a continuum 

of care based on the idea that the aging population of veterans 

would need a lot of low-vision and blind rehabilitative services. Little, I think did they realize back then, that the plans that they 

were making to expand services would suddenly be immediately 

useful for the returning servicemembers with eye trauma and traumatic brain injuries with vision impairments associated with the 

TBIs. 

And so what we have is now the VA has expanded, they have 

had ten in-patient blind centers, which offer comprehensive rehabilitative services for those with blindness, but they also have all 

the specialized staff in those centers such as consultants with the 

general surgeons, neurologists, psychiatrists, pharmacologists, occupational therapists, physical therapists, speech pathologists. The 

list goes on and on. 

So those individuals referred into the ten blind centers get, I 

think, excellent care, but the VA has also expanded and they now 

have 55 sites where they have either low vision specialists or advanced blind rehabilitative centers, and those centers have specialized staff. They have actually hired about 250 staff, including about 


ccoleman on DSK8P6SHH1PROD with HEARING
4 

60 low-vision optometrists, and they are screening these patients 

with vision problems and visual impairments. And so that is the 

good news. 

I want to compliment the Chairman, because actually the number of blind rehabilitative outpatient specialists (BROS) that you 

helped sponsor and Congressman Brown helped support, doubled 

the number of blind rehab specialists that were in the system. 

Again, it is just good timing. So we went from about 25 blind rehabilitation specialists to 75 in the system. They are at all of the VA 

polytrauma centers. And so that is the good news this morning I 

guess. 

The other thing that I want to touch on is there is a problem. 

The BROS that are assigned to the military treatment facilities 

have a problem in getting credentialed and privileged. It is something that has been worked on by the VA and they have had meetings with DoD representatives, but the problem is DoD has never 

had the credential or privilege. Anyone who is a BROS, an orientation mobility specialist, who has a master’s degree, that category 

of occupation doesn’t exist and it is been a problem, because the 

BROS are unable to actually do the training inside the military 

treatment centers, even though they can visit the patients, explain 

the training that they need, they are restricted, and that is an 

issue that I wanted to include in my testimony today. 

Last, I want to talk about—there is problems, though, with the 

Vision Centers of Excellence. It is been slow to get it started to say 

the least. It is been slow in getting the staffing. It is been difficult 

to get any accurate budgets in the last couple years. Budget requests that come over from the Pentagon rarely have included any 

special request for funding, even though it has been identified as 

an area where there is a shortage of funding. It has taken a long 

time to get the staffing for the Vision Centers of Excellence, and 

also the electronic registry, which is important for tracking all of 

the eye injured has been not operational yet. The VA Information 

Technology (IT) Department and Department of Defense IT people 

have done a lot of work on the registry, but again, I hear stories 

about problems with finding the funding for the registry. 

With that I will try to end this by thanking you again for having 

this hearing, and be glad to answer any questions you have on my 

testimony that I have submitted. 

Thank you. 

[The prepared statement of Dr. Zampieri appears on p. 36.] 

Mr. MICHAUD. Thank you very much, Doctor. 

Mr. Blake. 

STATEMENT OF CARL BLAKE 

Mr. BLAKE. Thank you Chairman Michaud and Members of the 

Subcommittee, on behalf of Paralyzed Veterans of America I would 

like to thank you for the opportunity to be here today to present 

our views on how the Department of Veterans Affairs is doing in 

caring for severely injured veterans, including Operation Enduring 

Freedom and Operation Iraqi Freedom veterans. 

My comments will be limited primarily to veterans who have incurred spinal cord injury or dysfunction while on active duty. 


ccoleman on DSK8P6SHH1PROD with HEARING
5 

It is important to emphasize that specialized services are part of 

the core mission and responsibility of the VA. For a long time, this 

has included spinal cord injury care, blinded rehabilitation, treatment for mental health conditions, including post-traumatic stress 

disorder, and similar conditions. Today, traumatic brain injury and 

polytrauma injuries are new areas that the VA has had to focus its 

attention on as part of their specialized care programs. 

The VA’s specialized services are incomparable resources that 

often cannot be duplicated in the private sector. 

For PVA there is an ongoing issue that has not received a great 

deal of focus. Some active-duty soldiers with a new spinal cord injury or dysfunction are being transferred directly to civilian hospitals in the community and bypassing the VA health care system. 

This is particularly true of newly injured servicemembers who 

incur their spinal cord injury in places other than the combat theaters of Iraq and Afghanistan. This violates the Memorandum of 

Agreement between the VA and DoD that was effective January 1, 

2007, requiring that care management services will be provided by 

the Military Medical Support Office, the appropriate Military 

Treatment Facility, and the admitting VA Medical Center as a 

joint collaboration, and that whenever possible the VA health care 

facility closest to the active-duty member’s home of record should 

be contacted first. 

In addition, it requires that to ensure optimal care, active-duty 

patients are to go directly to a VA medical facility without passing 

through a transit military hospital, clearly indicating the critical 

nature of rapidly integrating these veterans into an SCI health 

care system. 

This is not happening. For example, PVA found that some 

servicemembers who incurred a spinal cord injury while serving in 

Afghanistan and Iraq were being transferred to Sheppard Spinal 

Center, a private facility located in Atlanta, when VA facilities are 

available in Augusta. When we raised our concerns with the VA regarding Augusta in a recent site visit report, the VA responded by 

conducting an information meeting at Sheppard to present information and increase referrals. However, reactionary measures such as 

this should not be the standard for addressing these types of concerns. 

Of additional concern to PVA it was reported that some of these 

newly injured soldiers receiving treatment in private facilities are 

being discharged to community nursing homes after a period of 

time in these private rehabilitation facilities. In fact, some of these 

men and women have received sub-optimal rehabilitation and some 

are being discharged without proper equipment. 

PVA is greatly concerned with this type of process and treatment. There is a serious need to reinforce compliance by DoD regarding the Memorandum of Agreement toward the treatment of 

soldiers with new spinal cord injury and disease (SCI/D) at VA SCI 

centers. 

Ensuring that these men and women gain quick access to VA 

care in spinal cord injury centers is critically important because it 

begins what will become a lifelong treatment process. 


ccoleman on DSK8P6SHH1PROD with HEARING
6 

SCI/D care in the VA is unique from private care for spinal cord 

injury rehabilitation because of the care coordination that the veteran receives for the remainder of his or her life. 

We ask that the Subcommittee work with your colleagues of the 

House Committee on Armed Services to ensure that our SCI/D veterans are getting the complete, proper, and appropriate care they 

have earned and deserve. 

PVA also remains concerned that the VA must maintain its capacity for the provision of SCI/D care as mandated by Public Law 

104–262, the Veterans Health Care Eligibility Reform Act of 1996. 

This law required the VA to maintain its capacity to provide for the 

special treatment and rehabilitative needs of veterans with spinal 

cord injury, blindness, amputations, and mental illness. 

The baseline of capacity for spinal cord injury was established 

based on the number of staffed beds and the number of full-time 

equivalent employees assigned to provide care on the date of enactment of the law. 

Unfortunately, the single biggest accountability measure, an annual capacity reporting requirement, expired in April 2004. This allows the VA to make changes to its SCI/D capacity in a less than 

transparent manner. 

In accordance with the recommendations of The Independent 

Budget for fiscal year 2011, PVA calls on this Subcommittee to approve legislation to reinstate this vitally important reporting requirement. 

Lastly, Mr. Chairman, the SCI/D programs of the VA face a common challenge with the larger health care system, a shortage of 

qualified nurse staffing. In order to meet this challenge head on, 

some SCI centers in the VA have offered recruitment and retention 

bonuses to enhance their nurse staffs, unfortunately, this is not a 

uniform national policy and these actions are subject to the budget 

decisions of local VA medical center and Veterans Integrated Service Network directors. 

In accordance with recommendations of The Independent Budget, 

we believe it is time for the Veterans Health Administration (VHA) 

to centralize policies and funding for systemwide recruitment and 

retention of SCI nurse staffing. 

Additionally, we believe Congress should establish a specialty 

pay provision for nurses working in the SCI service, and should 

consider extending similar provisions to the other VA specialized 

services. 

Once again, Mr. Chairman, Ranking Member Brown, I would 

like to thank you for the opportunity to testify. I would be happy 

to answer any questions that you or the Members of the Subcommittee might have. 

Thank you. 

[The prepared statement of Mr. Blake appears on p. 40.] 

Mr. MICHAUD. Thank you very much. 

Ms. Ilem. 

STATEMENT OF JOY J. ILEM 

Ms. ILEM. Thank you. Mr. Chairman and Members of the Subcommittee, thank you for inviting DAV to testify at this important 

hearing about VA specialty rehabilitation services for severely inVerDate Nov 24 2008 00:57 Jan 06, 2011 Jkt 058060 PO 00000 Frm 00010 Fmt 6633 Sfmt 6633 I:\WAYS\OUT\58060.XXX GPO1 PsN: 58060

ccoleman on DSK8P6SHH1PROD with HEARING
7 

jured Iraq and Afghanistan war veterans. My remarks are focused 

on VA’s polytrauma and traumatic brain injury system of care. 

According to VA, over the past 7 years, a total of 1,792 in-patients with severe injuries have been treated at VA’s Polytrauma 

Rehabilitation Centers, also known as PRCs. 

Early on in the wars, VA received little information about the 

treatment that wounded servicemembers had received before arriving at a VA facility; however, in late 2009, a team of VA polytrauma specialists visited the Landstuhl Army Medical Center in 

Germany to establish a regular information exchange on these 

transfer cases between the military and VA PRCs. 

We are pleased with this relatively new development and believe 

it has begun to address the gaps in care that were clearly evident 

early on in the wars. 

Recently, DAV’s National Commander visited the Tampa VA 

PRC. He met with injured patients and families and received very 

positive feedback about the level and coordination of care provided, 

and the high regard these families held for the dedicated VA and 

DoD staff. 

Also in preparing for this hearing, I had the opportunity to interview with a father of a severely brain injured servicemember now 

at the Tampa PRC. I was very pleased to learn that from the date 

of his son’s injury to present, the communication and care coordination provided between DoD and VA in his opinion was seamless. 

We acknowledge and commend the report of improved collaboration between the Departments, and we value the dedicated staffs 

that created and sustained this critical system to better coordinate 

and optimize care for the severely injured. 

According to the Institute of Medicine (IOM), VA has established 

a comprehensive system for polytrauma and severe TBI care for 

acute and chronic needs that arise in the initial months and years 

post injury, but IOM also reported that protocols and programs to 

manage the lifetime effects of these conditions are not in place and 

have not been fully studied. 

In this connection, DAV is aware of an extraordinary proposal 

called the Heroes Ranch. We understand that property is available 

for a proposed Tampa area facility to service a VA post-acute longterm residential brain injury model for the most severely injured. 

According to the proposal, a three-tiered program would include 

post-acute long-term care for patients in a vegetative state or a 

state of emerging consciousness, subacute residential rehabilitation 

in a safe environment to treat patients with neurobehavioral deficits, and an outpatient day rehabilitation services program, a specialized form of adult day health care. 

We understand this proposal is pending within VA, however, we 

are not clear if it has been approved or funded, therefore, we ask 

the Subcommittee to inquire about the status of this unique initiative. 

For the severely impaired, in many cases, VA may need to provide permanent living arrangements in an age appropriate therapeutic environment, thus we are very pleased to see at least one 

PRC is planning for these unique facilities and we urge VA to move 

forward in establishing this type residential rehab model. 


ccoleman on DSK8P6SHH1PROD with HEARING
8 

As highlighted in prior hearings, DAV also remains concerned 

about the problems that exist in the Federal Recovery Coordinator 

Program in social work case management system that are initial 

to coordinating complex components of care for polytrauma patients 

and their families. We believe these issues warrant continued oversight and evaluation by the Subcommittee. 

Mr. Chairman, although not defined in the severely injured category, we would like to bring to the Subcommittee’s attention our 

concerns about treatment and care for veterans with mild to moderate TBI residuals. 

Multiple sources indicate that in the near future VA will likely 

be confronted with a significant OEF/OIF injured population with 

these problems. We believe VA level two PRC sites may struggle 

to provide the specialized or individualized interdisciplinary care 

and support this particular population will need. 

We ask the Subcommittee to provide oversight to ensure sufficient resources and staff are available for VA to also accomplish 

this mission. 

Additionally, VA TBI specialists with whom we have consulted 

believe a new specialized dual track program is necessary to meet 

the individualized needs of veterans with mild to moderate TBI residuals accompanied by post-traumatic stress disorder. 

Mr. Chairman, for these reasons we hope VA will now turn its 

attention to the needs of thousands of veterans with less life 

threatening, but still troubling brain injuries, caused by war that 

are little understood but in need of significant attention. 

Mr. Chairman, this concludes my statement and I will be able to 

take any questions you may have. 

Thank you. 

[The prepared statement of Ms. Ilem appears on p. 42.] 

Mr. MICHAUD. Thank you very much. 

Mr. Tarantino. 

STATEMENT OF TOM TARANTINO 

Mr. TARANTINO. Thank you, Mr. Chairman, Ranking Member, 

and Members of the Subcommittee, on behalf of Iraq and Afghanistan Veterans of America’s 190,000 members and supporters, I 

would like to thank you for allowing us to testify before the Subcommittee. 

My name is Tom Tarantino and I am a Legislative Associate 

with IAVA. I proudly served in the Army for 10 years, and during 

these 10 years, my most significant and important duty was to take 

care of other soldiers. In the military, they teach us to have each 

other’s backs. And although my uniform is now a suit and tie, I am 

proud to work with Congress to continue to have the backs now 

and in the future. 

Over the past few years, the Committee has secured impressive 

improvements to the VA health care system. IAVA applauds the 

work this Committee has done and will continue to do in the 

months and years to come. 

Now we have asked our members what they thought of treatment they are receiving at the VA and we received a wide range 

of opinions, both complimentary and critical. However, several common themes appeared. Long waits for appointments, frequent 


ccoleman on DSK8P6SHH1PROD with HEARING
9 

interaction with rude administrative staff, a growing distrust of VA 

health care, and long drives to VA facilities. Fortunately, we received very few complaints about the actual quality of care at VA 

medical centers. But in addition to the concerns listed above, our 

members have expressed concern with how the VA deals with traumatic brain injury. 

To properly treat returning combat veterans with mild to severe 

TBI, the VA must completely rethink and adapt their medical rehabilitation practices. IAVA is concerned that the VA has limited or 

denied access to some veterans seeking recovery services for TBI, 

because current statute requires that the VA provide services to restore function to wounded veterans. And while full recovery should 

always be the desired outcome for rehabilitation, sustaining current function or just preventing future harm should also warrant 

access to VA services. 

And I have no doubt that Members of this Committee agree that 

the VA’s role isn’t just to help those who might get better, but also 

to help and support those who might get worse. 

IAVA recommends adjusting these statutes to embrace the realities of injuries like TBI. Veterans should be able to focus on maintenance and recovery not fighting with the VA. 

Among our members seeking services at the VA, the single most 

common complaint is how long it takes just to schedule an appointment. Despite improvements of wait times for primary care and 

specialty care, many veterans have experienced unacceptably long 

waits just to speak to someone who can get them an appointment 

that is 4 to 6 weeks away. Unfortunately, I have experienced this 

myself. After spending 45 minutes attempting to get my primary 

care team on the phone I gave up and vented by frustration on 

Twitter. Fortunately somebody at the VA follows my Twitter feed 

and I actually received a call from the Medical Director’s Office at 

DC a day later. I was able to get an appointment because of the 

magic in new media, but the point is that no veteran should wait 

45 minutes listening to a phone ring. 

In addition to the long wait times, some veterans have to drive 

almost an entire day to get to their local VA facility, and IAVA is 

concerned that the VA has yet to develop a consistent and humane 

policy for answering that age old question of how far is too far to 

make a veteran drive to the VA? 

Now we acknowledge that the VA can’t always be a short drive 

for every veteran, these veterans however should be given a choice 

to continue using VA care or access more convenient local medical 

care. 

We also believe the VA should assist veterans who need to drive 

to their appointments. They should provide a lodging stipend and 

mileage reimbursement for veterans forced to travel long distances 

for VA medical care, and it should be comparable to the stipend 

paid to VA employees when they travel. 

Now those of us in this room know that the VA provides good 

care and services; however, the reality is that some of our members 

openly fear going to the VA. Recent media reports about HIV 

(human immunodeficiency virus) and hepatitis exposure only 

served to fuel that fire. A veteran who reads about his or her battle 

buddies being exposed to infectious diseases while being treated at 


ccoleman on DSK8P6SHH1PROD with HEARING
10 

a VA medical center will likely think twice before they try to seek 

the care and services they need. 

Now whether or not those fears are actually warranted is a topic 

for another hearing, but the end result is the same, that if the VA 

and VA health has a massive public relations problem, and until 

the VA adequately addresses this issue, many combat veterans will 

be weary to seek treatment. 

IAVA believes that in order for the VA to conduct effective outreach, it must centralize its efforts and aggressively re-brand itself 

to the American people as one Department of Veterans Affairs. 

Now the VA provides great health care, it has sent generations 

of Americans to college, it is enabled millions of veterans to own 

their own home, and regularly contributes to the advancement of 

medical science. It is absolutely astounding to me that only a handful of Americans actually know that. 

In addition to re-branding itself to America. the VA has to develop a relationship with servicemembers while they are still in 

service. Like many successful college alumni associations that greet 

students at orientation and put on student programs throughout 

their entire time in college, the VA must shed its passive persona 

and start recruiting veterans and their families more aggressively 

into VA programs. 

Now overall, the VA continues to provide good care to our Nation’s veterans; however, we must continue to strive for better. In 

the military they taught us to never stop improving our fights positions and always be forever vigilant. It is this proactive ethos that 

continues to lead to victory on the battle field. And if we are to 

honor the service and sacrifice of American’s warriors, we must instill this spirit in all the services that we develop to care for them. 

I want to thank you for your time and attention and I would 

happy to answer any questions. 

[The prepared statement of Mr. Tarantino appears on p. 49.] 

Mr. MICHAUD. Thank you very much. 

Ms. Williams. 

STATEMENT OF DENISE A. WILLIAMS 

Ms. WILLIAMS. Mr. Chairman and Members of the Subcommittee, 

thank you for this opportunity to present the American Legion’s 

views on the Department of Veterans Affairs efforts to care for severely injured servicemembers from OIF and OEF. 

The United States military operations in Iraq and Afghanistan 

has produced a significant number of servicemen and women with 

amputations. According to the DoD, as of April 3rd, 2010, there has 

been a total of 1,552 members that suffered amputations. This 

unique population of younger servicemembers requires extraordinary medical care and rehabilitation. Walter Reed Army Medical 

Center, among many DoD facilities dedicated to assisting wounded 

warriors, has highly advanced programs to care for warriors with 

amputations. 

In response to the large number of veterans with prosthetics and 

rehabilitative needs, VA established the Polytrauma Rehabilitation 

Centers, however, the American Legion is concerned about VA’s 

ability to consistently meet the long-term needs of these young veterans. 


ccoleman on DSK8P6SHH1PROD with HEARING
11 

As stated by the Military Medicine Journal, rehabilitation is a 

crucial step in optimizing long-term function and quality of life 

after amputation. 

Although returning veterans with combat-related amputations 

may be getting the best in rehabilitative care and technology available, their expected long-term health care outcomes are considerably less clear. 

It is imperative that both DoD and VA clinicians seriously consider the issues associated with combat-related amputees and try 

to alleviate any foreseeable problems that OIF/OEF amputees may 

face in the future. 

The VA has made great strides in addressing the increased influx of young veterans with amputations; however, it has been reported that VA does not have the state-of-art prostheses available 

in comparison to the DoD. That is why it is of utmost importance 

that VA receives the adequate funding to ensure that all VA medical facilities are fully equipped to address these veterans’ prosthetic needs. 

This is especially vital for the veterans that reside in rural and 

highly rural areas. It would be a grave disservice to these veterans 

if they have to bear the burden of traveling hundreds of miles in 

order to receive care in addition to enduring their debilitating condition. 

The American Legion applauds VA on the establishment of the 

Prosthetics Women’s Workgroup to enhance the care of female veterans in regard to their prosthetics requirement. Despite this implementation, there are still cases where the fitting of the prostheses for women veterans has presented problems due to their 

smaller physique. 

The American Legion urges VA to increase their focus on amputation and prosthetics research programs in order to enhance and 

create innovative means to address this population of veterans’ 

health care needs. 

During our ‘‘System Worth Saving’’ site visits to the polytrauma 

centers, some facilities reported that there were staffing shortages 

in certain specialty areas such as physical medicine and rehabilitation, speech and language pathology, physical therapy, and certified rehabilitation nursing. This was attributed to the competitive 

salaries being offered for these positions in the private sector. 

Considering the complex nature of these severely wounded veterans, the American Legion finds this unacceptable. The Department of Veterans Affairs needs to step up their recruiting efforts 

in these areas so that in the future these veterans are not faced 

with the dilemma of going outside of the VA for care. 

There are currently 49,460 blind veterans enrolled in the VA 

health care system and that number is expected to increase because of the number of eye injuries in Iraq and Afghanistan. DoD 

reports that in the current conflict, eye injuries account for 13 percent of all injuries. The American Academy of Ophthalmology reports that eye injuries are a very common form of morbidity in a 

combat environment. 

DoD does not provide rehabilitation for blindness. Unlike other 

injuries where after rehabilitation warriors may be retained and 


ccoleman on DSK8P6SHH1PROD with HEARING
12 

continue service, blinded warriors are medically discharged and relegated to utilize the VA for their rehabilitative needs. 

Section 1623 of the National Defense Authorization Act of 2008 

requires DoD to establish a Center of Excellence in the prevention, 

diagnosis, treatment, and rehabilitation of eye injuries, and for 

DoD to collaborate with VA on matters pertaining to the Center. 

In addition, Section 1623 directs DoD and VA to implement a 

joint program on traumatic brain injury post-traumatic visual syndrome, including vision screening, diagnosis, rehabilitative management, and vision research. Unfortunately, the Center has yet to 

be fully established because of constant funding delays and bureaucratic hurdles. 

The American Legion calls for immediate action from the Secretary of Defense and the Secretary of VA to rectify this important 

issue. 

Mr. Chairman and Members of the Subcommittee, the American 

Legion sincerely appreciates the opportunity to submit testimony 

and looks forward to working with you and your colleagues on 

these important issues. 

This concludes my written statement and I would welcome any 

questions you may have. 

[The prepared statement of Ms. Williams appears on p. 53.] 

Mr. MICHAUD. Thank you very much, Ms. Williams. And once 

again, I would like to thank all the panelists for your testimony 

and also for the recommendations included within your testimony, 

which will be very helpful. 

This question is for all the panelists. I have heard anecdotes 

from veterans who applaud the prosthetic services that they receive 

at the Department of Defense, but are very leery of the care that 

they might receive through the VA system. Do you believe that 

DoD provides better overall prosthetic services compared to the VA, 

or do you believe that these anecdotes that I am hearing represent 

just a few, isolated cases? 

Ms. ILEM. I will go ahead and take a stab at that. 

I think early on, you know, we heard reports, I mean, I remember from hearing even with Tammy Duckworth, you know, one of 

the situations is—that is very unique is DoD and Walter Reed obviously have had, you know, the focus has been on them for really 

doing much of the prosthetics and rehab there on site. 

I know that VA, from attending their prosthetic meetings, you 

know, have integrated their people to go out there and see, you 

know, what is going on as these people start to transfer back to 

VA, but the complaints were, you know, when they return to the 

VA to have either their item serviced or to continue their rehabilitation, they ran into sort of a disconnect from, you know, anyone 

at the facility where they had been working with the prosthetist 

and had very much attention to and access to all the newest items 

and options, you know, at the DoD site. You know, it seemed very 

different within the VA. 

I think that, you know, VA’s prosthetic services tried to really 

improve that and make, you know, good strides in trying to make 

sure that they are ready to accept these veterans as they transition 

back into VA to prepare—to repair their equipment, to have—I 


ccoleman on DSK8P6SHH1PROD with HEARING
13 

know that they have access to all of the vendors that are working 

out there, and they have done this liaison work. 

I am hoping that, you know, that that perception as Tom as mentioned, you know, it lingers when you hear so much about DoD and 

then people want to return there because it is a very sensitive 

issue in terms of the people that they are working with and the 

items that they are working with, and then to have to go to a new 

system where people that haven’t seem the high-tech equipment, 

you know, you don’t have a lot of confidence. I am sure, if they are 

saying that is the first time I have seen that. But the truth is they 

are getting access to some of the most high quality equipment that 

nobody has seen. 

So I am hoping it is changing, but it still may be the case in 

some situations. 

Mr. BLAKE. Mr. Chairman, I just sort of want to piggyback a little bit on what Joy had to say and also make another comment 

first. 

Representing a membership that is probably one of the highest 

in users of prosthetic devices and equipment from the VA, I would 

say that our members generally never—I won’t say never—generally do not have problems getting the most state-of-the-art wheelchairs and other types of equipment that they need. In the occasion 

where maybe there is some difficulty getting a piece of prosthetic 

equipment or whatever it may be, it is usually just a matter of 

working with the prosthetics department through our service officers or what have you to make sure that the right steps are taken. 

But our members are not experiencing a lot of problems getting 

what they need. And believe me when it comes to state-of-the-art 

wheelchairs, you would be surprised at what is out there. 

I want to sort of tag along with what Joy had to say. I think you 

would find that DoD is not unlike VA in sort of the prosthetic 

structure, and some of the VA’s prosthetic services, not unlike the 

rest of its health care, has become adaptable to changing needs of 

this generation. Prosthetics is no exception. 

I think a lot of focus is put on the—we talk about these advanced 

prosthetics that the servicemembers are getting from DoD, but it 

really boils down to them getting them through Walter Reed, Bethesda, Brooke or some of the major military check points. But if 

they went back to a lot of home stations, I think you would find 

that a lot of these military treatment facilities, they don’t exactly 

have the capacity to meet their needs when it comes to prosthetics 

or the maintenance required for that equipment either. 

So DoD is not unlike VA in this respect. And I think VA is probably trying to address it more than DoD would in that respect. And 

we have heard time and again from Mr. Downs, who oversees the 

VA’s prosthetics, that I think he recognizes the need for them to 

become more adaptable and get it to the field so that as these men 

and women ultimately are going to come to their local facilities the 

VA can meet their needs, particularly on the maintenance of this 

high-end equipment. 

I mean, they are intimately involved in what is going on out at 

Walter Reed in particular, because that is sort of where everything 

begins when it comes to these advanced prosthetics. 


ccoleman on DSK8P6SHH1PROD with HEARING
14 

So you can beat up on the VA for it, but in fairness to the VA, 

I mean they are seeing demands on their system that they never 

could have imagined before now also. 

Mr. MICHAUD. Thank you very much. 

My last question, for all the panelists is, in talking to your membership, do you believe that specialty care within the VA system 

is provided equally among all VA facilities? 

Mr. BLAKE. I will speak to the SCI side of it. I think because of 

the model that has been established we feel pretty confident that 

it is sort of a uniform policy in the way all SCI care is provided 

across the system. That again is a function of the way the entire 

SCI service has been set up through the hub and spoke model. 

We are encouraged to see that the VA is sort of moving that way 

in the polytrauma aspect, and yet there are a lot of challenges as 

it relates to TBI that Joy raised and going forward that the VA is 

going to have to figure out how to deal with along the way. 

But I feel pretty confident that they do the right think across the 

board when it comes to SCI service in particular. 

Ms. ILEM. I would add onto that. 

Some of the complaints that we have heard from veterans contacting us about mild to moderate TBI is that, you know, their families sort of recognized they had an issue, they had been using the 

VA system for other things, went to the VA, weren’t satisfied in 

areas of the country. 

I mean, I had received calls sort of from different locations saying, you know, I ended up in the private sector with VA fee basing 

me into an outpatient program that really offered a range of things 

that I have learned so much in the last 6 months in terms of, you 

know, mild TBI, how to deal with it from my family center care addressing, you know, a range of issues and opportunities for them 

to have this wide range of outpatient care. And in those cases, you 

know, I have contacted the VA directly and tried to find out is it, 

you know, just this location that they are having this problem or 

is this a systemic problem? It is hard to say unless, you know, 

somewhere like PVA, you know, really has people on the ground 

that are doing site visits in the region. Within that specific area, 

you know, that is a concern of ours. 

We are hoping that in certain areas they have the interdisciplinary teams that are needed to provide that care and that they have 

developed a wide range of services and a good type of program for 

that, but I am not convinced of that that it is everywhere yet. 

I think at certain locations, you know, with the—obviously with 

the major polytrauma centers, but as you go further out and then 

obviously in the rural areas where those services are not available, 

you know, and they have to connect them with the nearest privatesector facilities, you know, we would like to see some continuity of 

care and make sure that care is available everywhere. 

Mr. MICHAUD. All right. 

Ms. WILLIAMS. I would like to add that during our site visit that 

was a main issue, staffing shortages as Joy just mentioned. In the 

areas where they have the polytrauma centers you will see where 

they have a lot of specialty care available, but as you go out to the 

other facilities there is definitely a shortage for specialty care, and 


ccoleman on DSK8P6SHH1PROD with HEARING
15 

we hear that from the veterans and we have also heard that from 

VA staff themselves at the facilities that there is a shortage. 

Dr. ZAMPIERI. The same thing. The major centers, both the military polytrauma centers, Walter Reed, Bethesda, Brooke Army 

Medical Center, Balboa in San Diego, or you go to any of the four 

VA polytrauma centers, it is amazing. I think everybody gets seen 

by everybody. I mean it is not unusual to have a team of 30 different specialists seeing a patient. 

And the hand off has improved dramatically from back in 2005 

when I was sitting in this room I think with a couple things. One 

is we always are concerned that, you know, everybody focuses I 

think on, you know, the famous beat up in this town is Walter 

Reed when something goes wrong, and the universe focuses there, 

but the patients who are evacuated back through Landstuhl come 

back into the United States, I think there is a misperception that 

well everybody goes through Bethesda or Walter Reed, and in actuality, some people will admit that about 30 percent of all the 

wounded and walking wounded actually go back to the original 

home platform base of deployment. 

So if you go to Fort Drum or Fort Carson, Colorado, or Fort Gordon, Georgia, or just name a base, Fort Hood, Texas, you will find 

individuals who were evacuated back through the system that 

didn’t get seen in one of these highly specialized centers, and some 

of those are the ones that we find that have a vision problem that, 

you know, they didn’t have a lot of other severe injuries so they 

were evacked back and then they sort of get lost. Somebody on one 

side doesn’t notify the VA blind rehab services or the local Visual 

Impairment Services Team (VIST) coordinator that they have 

somebody that is experiencing vision problems, and that there is 

treatment available, that there is specialized devices from prosthetics that are available to help them in their recovery and treatment. 

And so that is why the Vision Centers of Excellence is important, 

because it isn’t just the major trauma severe cases that need to be 

tracked, it is all of the types of injuries, mild, moderate, severe, as 

far as vision goes, that need to be carefully tracked and followed, 

and the providers need to be able to exchange the information between them—between the VA providers, the ophthalmologist and 

the military, their colleagues in the military treatment facilities. 

Because again, a person at Fort Drum, New York, may suddenly 

have somebody come in that was evacuated back from Landstuhl 

with injuries and that is where one of the problems is. 

Thank you. 

Mr. MICHAUD. Thank you. Mr. Bilirakis. 

Mr. BILIRAKIS. Thank you, Mr. Chairman, I appreciate it. 

Mr. Zampieri, on that point again, I understand your frustration 

with the delays in the planned construction and operation of the 

Vision Center of Excellence. How confident are you that your timeline will be met? 

Dr. ZAMPIERI. Thank you very much. 

Wow. I have been chasing the ghost of timelines for quite a 

while, and I am not sure. You know, in fact someone said that 

what was originally—you know, the Vision Centers of Excellence 

by the way is not a clinical surgical center, it is an administrative 


ccoleman on DSK8P6SHH1PROD with HEARING
16 

headquarters to coordinate and facilitate information flow of 

connectivity between all of these patients and the providers, and so 

you are not building a surgical rehab center or whatever, it is like 

4,000 square feet of office space, and here we are, the money was 

provided in the war supplemental last August and originally it was 

hoped that the construction would start this summer, then I was 

told it wouldn’t start until this fall, and now I am being told that 

instead of January, February, or March, that it won’t get done 

until next May or June. 

I mean this is really phenomenally incompetent. I mean, I don’t 

know how else to put it. You know, they open up a 72,000 square 

foot National Intrepid Center of Excellence for traumatic brain injuries and mental health, which cost $68 million, has all the stateof-the-art equipment in it, over 100 employees, those are clinicians 

and providers and counselors and therapists, and they do that and 

a grand opening, at the same time they can’t renovate 3,800 square 

feet of just office cubicles so that we can get this thing up and running and people all collocated instead of temporary office spaces 

where they have been moved like three times in the last year and 

a half? 

And so yeah, I am a little frustrated, and I don’t believe any of 

the timelines. 

And also I might as well, since you asked, there is never a budget anywhere in anybody’s testimony, and I am frankly very frustrated about that. 

Thank you. 

Mr. BILIRAKIS. Thank you. 

Mr. Blake, I appreciate your interest in reinstating what we call 

the capacity report; however, I am concerned that the requirements 

for that report need to be reevaluated and updated to ensure that 

the information contained in the report is relevant and functional. 

Would you be willing to work with us on that? 

Mr. BLAKE. Absolutely, and we have already discussed this with 

the staff. There was some discussion about why the capacity report 

even expired in the first place, and I have already talked to our 

staff at PVA as well about the willingness to try to figure out what 

would be a more useful report, what kind of information should it 

include, and how could it be used once these reports were to be 

processed again? 

So the short answer is, yes, sir, very much. 

Mr. BILIRAKIS. Thanks so much, I appreciate it. 

Ms. Ilem, I hope I didn’t mispronounce your name. In your testimony you mentioned the proposed facility in Tampa called the Heroes Ranch, which is in my Congressional district. I think this is 

a wonderful concept. I have some background here and I have 

talked to the James A. Haley VA Medical Center about this and 

I believe it could be a viable solution to the problem of how to treat 

our catastrophically wounded warriors. 

Can you tell me more? Give me your thoughts on this, and if you 

can elaborate a little bit I would really appreciate it because it is 

something that I would like to pursue. 

Ms. ILEM. Sure. As I noted in my statement our National Commander was able to visit the facility and came back and told me 

about this proposal that he had seen. 


ccoleman on DSK8P6SHH1PROD with HEARING
17 

One of the things we have been hearing from different people actually starting a couple a years ago is the concern about a number 

of patients, you know, probably not a significant number, but still 

those that may not be able to go home, they may not have someone 

to care for them at home, and it really wouldn’t be a—you know, 

a really appropriate place to put them that was within a Federal 

system to make sure that they have continued rehabilitation 

throughout, and obviously these would be the most severely impaired. 

So my understanding of the overview of the project was to really 

have this residential facility that would be for these very specific 

group of people. 

And I asked some folks there, you know, why a place away from 

a clinical setting? And they mentioned to me that, you know, when 

they have taken people out, some of the severely wounded, when 

they get them out of the clinical setting they really start to see 

some progress and a responsiveness in some of these people, and 

so it is so important to be in an environment that is not perhaps 

just a clinical, you know, the clinical setting. 

Also, you know, this would be a very highly specialized type of 

care setting and model, and so I am really hoping to hear from VA 

if they are able to comment on it. 

DAV would certainly support, as we have talked about it in The 

Independent Budget, we have talked about it in the testimony, that 

there is probably going to be a need for maybe a couple of these 

centers in the country to make sure that these people aren’t forgotten after, you know, time goes by and that we really provide them 

with the state-of-the-art care that they need, even those that perhaps aren’t going to be able to be reintegrated with their families 

or into society in any real way, but they need a setting too that 

continues the care for them. 

So we would love to collaborate with your staff and you on this 

project, and hopefully VA can shed some light on this and let us 

know what the status of the initiative may be. 

Mr. BILIRAKIS. Thank you very much. Thank you for your willingness to work with me on that. 

Mr. Chairman, I have one last question, is that okay? All right. 

Again for Ms. Ilem. 

You mention in your testimony that the Institute of Medicine 

March 2010 report said, and I quote, ‘‘Although VA has established 

a comprehensive system of rehabilitation services for polytrauma 

and severe TBI patients that addresses acute and chronic needs 

that arise in the initial months and years after injury, protocols, 

and programs to manage the devastating lifetime effects that many 

of these veterans must live with are not in place.’’ That is a real 

shame. 

Can you tell me where the VA is failing and what can we do 

about it? 

Ms. ILEM. I don’t know if I would use the word failing, because 

I mean, I was impressed that VA has developed these post-acute 

facilities, the residential facilities that are attached with the polytrauma centers that are almost apartment like that is staffed with 

clinical staff so when veterans are getting ready to discharge from 

the facility but not quite ready to go home to make sure they are 


ccoleman on DSK8P6SHH1PROD with HEARING
18 

going to be safe and really be able to care for themselves or be in 

an assisted living situation. And I think there is that component. 

And they are looking at some of these things right after the post 

acute. I mean obviously the focus has been on this, you know, the 

long period that it takes to rehabilitation. Oftentimes many surgeries, transferring back between DoD and VA. And I think VA has 

developed these programs right outside of that. 

The concern is about this lifetime of care for some of these folks 

who just may not have the support or the ability to really function 

on their own and may need, you know, continued support, as well 

as their family members who are dealing with this traumatic injury along with them. 

So I think this proposal was so exciting about the Heroes Ranch 

because it also mentioned this integration of family centered, an 

opportunity—you could see people being able to go there that were 

with the veteran and perhaps have their own track of information 

and being able to deal with this sort of a respite for them as well, 

but also learning environment of all the pressures that they deal 

with as long term caregivers. 

And so I think it is good news that we are starting to see this 

come up within the VA, because obviously we think they are going 

to be the folks that are going to have the lifetime care, you know, 

responsibility for these folks. 

And so, you know, I think that was the concern and IOM sort 

of fleshed that out to say they are doing a good job for this, you 

know, immediate time in maybe the first couple years, but after 

that what are we going to do and how are we going to follow them? 

Mr. BILIRAKIS. Great. Thank you very much, I appreciate it. Let 

us get it done together. 

Mr. MICHAUD. Mr. Perriello. 

Mr. PERRIELLO. Thank you, Mr. Chairman, just two questions. 

First, you know, the Chairman was kind enough to come down 

to my district and do a field hearing this week in Bedford, Virginia, 

and one of the things that I think was most powerful was hearing 

the story of Lynn Tucker who has three sons who are all marines 

who face different health issues, and her son Ben has had severe 

brain injury and requires 24/7 care actually from a dirt bike accident, it was not service related. 

But one of the things that she talked about most in her story was 

given that it is highly specialized care how often she is bounced between different facilities, different VA hospitals, different clinics 

without a lot of coordination and effort. 

And so I guess—and we have heard some of that today. While 

the quality of care is often very strong, once its gotten to it is the 

barrier of getting there and particularly when it may involve multiple locations over time and some use of civilian as well as VA facilities. 

So I guess the question is with some sense of urgency, what are 

the immediate steps that can be taken within the VA to help coordinate the—when it comes to specialized care, and particularly in 

rural communities? 

Dr. ZAMPIERI. I guess just one thought is, you know, it is important that the military case managers, social workers are aware— 


ccoleman on DSK8P6SHH1PROD with HEARING
19 

exactly aware of the resources there are in the VA system for specialized care. 

You know, it seems like an easy quote ‘‘thing to do,’’ but you 

know, really you are dealing with hundreds of people at hundreds 

of different sites making sure that they are aware that their counterparts in the VA system like in case of vision impaired servicemembers, that there are VIST coordinators at every VA hospital. 

You know, and so it doesn’t matter if you are in Montana or southern Virginia or up in Maine, you know, there is a VIST there, and 

that person can help facilitate getting that person all the specialized things that they need whether it is prosthetics or eye appointments or whatever. 

But if that side of the fence doesn’t have their staff aware—and 

I am sure it is the same with the other specialties with regards to 

those kind of problems. 

Mr. PERRIELLO. But your general sense is the program is working we simply don’t have enough people or that it is just given the 

complexity this is the best we are going to be able to do? 

Dr. ZAMPIERI. Communications between those people. I don’t 

know if you can—maybe in smaller facilities make the argument 

there isn’t enough staff, it is more the sense of the staff that are 

there are they informed, and also do they have the links that they 

have to communicate with the VA people that they need? 

You know, it is actually sort of scary if you go out to Walter Reed 

there are so many case managers that you actually have to figure 

out who is not a family member, you know, because they are there 

everywhere. It is whether or not, you know, somebody is picking up 

the phone and contacting the right person back at the local clinic, 

VA hospital, whatever. 

Mr. BLAKE. Well, Mr. Perriello, first let me say I had the opportunity to sit in on the field hearing in the back of the room on Monday and Ms. Tucker’s testimony was very powerful, I will say that. 

I think Tom hit on—from my perspective there were two things 

that stood out to me. One was an obvious break down in communication in her son’s particular case. She talked about going to 

Durham and Danville and Salem and all these different places, nobody ever seemed to talk to each other and nobody knew what was 

going on with her son’s case. And so I think the structures are in 

place to meet her son’s needs, but they were obviously not being 

met. 

The other thing that sort of stood out to me was I would say her 

son would probably be—would fall under the classification of polytrauma even though seemingly his biggest concern was just immediately TBI, but I think that is the area where we would sort of 

be caught in. And yet, very little did she talk about his treatment 

at Richmond where the polytrauma center actually is and the care 

coordination that should go on for her son. 

I thought that it sounded like to me she said she had a couple 

people that were her go to people, but that wasn’t care coordination, these are sort of her contacts in the VA to help her get things 

done, but that screams to me that who is the person who ultimately has responsibility for ensuring that his care is being met 

across the spectrum? 


ccoleman on DSK8P6SHH1PROD with HEARING
20 

So I think there is an obvious—maybe some evaluation needs to 

be done to go back and look at how is the VA doing care management of these individuals? And I think the rule setting is the challenge. You know, when you have individuals who are—who live 

within even 100 miles—you know, SCI veterans are a unique example, because there aren’t a lot of SCI centers around the country. I mean they are fairly well geographically placed, but there are 

some areas where it is hundreds of miles to an SCI center, and yet 

our members have sort of grown accustom to what they can get and 

where they can get it. Through the model that the SCI uses they 

go to the nearest SCI center to their acute care, but they can also 

go to local facilities where there is sort of a step down, and we sort 

of developed this hub and spoke model to ensure that they can get 

some form of care, even some degree of the specialized care at the 

local level as best as possible. And I think the TBI aspect is something that the VA is still trying to get its arms around. 

So I hate to say that is sort of the unfortunate situation she was 

in, but the things from her case in particular I think that stood out 

were care management and communication, and it is obviously important in the rural setting because of the break down that goes 

on between the VA sort of putting the word out there and what is 

available and how they can get you around to certain places. 

But the fact that that young man was taken to four or five different facilities, plus she went to a couple of private facilities, I 

mean that was just—made me cringe just thinking about it, so. 

Mr. PERRIELLO. Yeah. 

Ms. ILEM. I would just have one thing to add to that. I think that 

the Office of Rural Health, we have been somewhat disappointed 

in that program—that office getting really stood up and that could 

help with a lot of these types of situations, so. 

Mr. PERRIELLO. If I can do one more quick question just for Mr. 

Tarantino. And thank you for coming down to the hearing, Mr. 

Blake, we really appreciate that, and thank you for your service. 

One of the things you talked about was re-branding the VA. So 

going out of the weeds for a second and into kind of the big picture, 

you know, there is nothing worse in that experience than being on 

the phone, I have to deal with it with my cable company all the 

time, because you know—and I give up because it is not worth it 

to get my DVR fixed, but that really doesn’t matter at the end of 

the day. We are talking about life and death issues of people just 

getting turned off in the system. 

So one of the questions I have in terms of the branding work that 

needs to be done is how much is that a matter of this younger generation coming back, the OEF/OIF men and women, what is their 

perception of both the quality of care at the VA which you have 

spoken to and the ease of accessing it? Where do we stand right 

now in terms of what you hear on that? 

Mr. TARANTINO. Well, Congressman, I think for those who are actually able to get into the VA and receive care the quality is very 

good, and we hear that from our membership, they provide very 

good care. 

The problem is that there is this negative perception, and this 

is partly structural within the VA and it is also partly a public perception. 


ccoleman on DSK8P6SHH1PROD with HEARING
21 

You know, VA, as I don’t have to tell you, we know that the VA 

is three separate agencies that largely work independent of each 

other, but when they communicate to the American people that is 

the way that they communicate. The VHA communicates, the Veterans Benefits Administration (VBA) communicates, the National 

Cemetery Administration, you know, talks to the American people. 

But as a veteran, someone who doesn’t live in DC and is not in the 

veterans affairs world, I don’t understand that. 

When my GI Bill check is late I am not upset with the VBA. 

When I, you know, can’t get an appointment I am not upset with 

the VHA, I am upset with the VA, and that is the mind set, but 

the VA doesn’t communicate to people the way people perceive 

them. 

So I think that is something they really need to start changing. 

And I think when you are talking about just the younger generation you need to start looking at how Iraq and Afghanistan veterans communicate with the world. The VA is starting this. They 

are building up their new media strategy, but they really need to 

start breaking down those barriers. 

Every time I talk to someone at the VA to talk about outreach 

the big question they ask is, how do I reach out to veterans? Well 

first of all you have not to stop reaching out to veterans, because 

we are ten percent of the—less than ten percent of the population, 

we don’t all live in one place, we don’t all watch the same movies 

or read the same newspapers, we are everywhere. You need to 

start reaching out to America. Because quite often you are not 

going to catch the veteran. You are not going to go catch the veteran and say hey, I need to go get in services. You are going to 

catch their mother, their brother, their girlfriend, their buddies 

who are going to say hey man, you need help, go, and I know, because I see this, I can see the VA, and maybe you should go talk 

to the VA because they are there for you. 

Right now if you are not a veteran, the VA basically just ignores 

you, and that is the wrong answer. 

Mr. PERRIELLO. Thank you. 

Mr. MICHAUD. Mrs. Halvorson. 

Mrs. HALVORSON. Thank you, Mr. Chairman. And thank you all 

so much for being here. And I know we are preaching to the choir 

and vice versa, you guys are great, and I know I have more questions than I have time for, so I will probably be submitting them 

for the record and we will get some answers back. Again, I don’t 

know where to start. 

First of all, can I just start with Tom here. You do a phenomenal 

job with what you have, and I know that I don’t want to put you 

on the spot, but later on I want you to tell me who told you that 

you are not going to get your 4,000 square feet of space until next 

summer. I want to know, because that is ridiculous. 

And I also want to point out that maybe the public doesn’t know 

that you take people’s mileage that they have extra and don’t you 

help people to fly places so that you can help them? Because you 

don’t have very many centers and people don’t have very much 

money and you don’t get much help from the VA. So I want everybody to know that, you know, they can donate their mileage, right, 


ccoleman on DSK8P6SHH1PROD with HEARING
22 

to help you and the people that you help get to places, because that 

is a very important thing. 

Also somebody was talking about, you know, being understaffed, 

and I want to just piggyback on what Mr. Perriello said. This is 

about communication. I have a master’s degree in communication, 

and I don’t say that just to pat myself on the back, but I got that 

later in life, and maybe it is something a little more, but when I 

became a Congressperson I had just been through the fact that my 

husband and I had a son that was seriously injured in Afghanistan, 

and I knew that if I were lucky enough to become a 

Congressperson that I was going to make it my mission to help 

families who had gone through the same thing. My husband spent 

the night with Jay and I went back and forth on the shuttle bus 

listening to families and what they were going through. 

So when I became the Congressperson, I hired a full-time caseworker that just did veterans’ issues, because the problem is communication. We have so many people that are so busy doing all 

their different things, but everybody is trying to reinvent the 

wheel. So I have a caseworker who just does veteran case work, 

and she goes out every night doing her outreach. I hate to say it, 

but she is now the one that spends all day long doing all the things 

that maybe the VA or the different people should be doing, but that 

one person doing all the outreach can help. And if we do more communication and outreach, maybe we wouldn’t have these kind of 

problems that we have. 

So I am just trying to find out from all of you how we can do 

a better job or how the VA can do a better job on that communication between each other. 

Now the other thing that we are trying to do in our district is 

have that central location. We have a hospital that is soon to be 

empty that I am insisting on, I am not going to take no for an answer, that we change into a VA medical facility that we have all 

those different specialties at so that it is a one-stop shop, that people don’t have to drive to far. 

What I am trying to figure out is what we have been talking 

about since I became a Member of Congress that we have a seamless transition. I don’t see it. And I think it was Mr. Blake that 

said that DoD isn’t keeping track and they aren’t doing the reporting that they need to. How do we do that reporting, and is the VA 

ready to get the report that if we do are we ready for that? Mr. 

Blake. 

Mr. BLAKE. I didn’t say that comment, but I am going to try to 

address the question. 

Mrs. HALVORSON. Okay, I apologize if it wasn’t you. 

Mr. BLAKE. I think the problem is ensuring that there is the 

transition to VA from DoD and that DoD doesn’t necessarily have 

that as their top priority. 

Mrs. HALVORSON. Uh-huh. 

Mr. BLAKE. I mean they are still going to do their best to take 

care of them whether it be at Landstuhl or Walter Reed or what 

have you, but I don’t think that the first consideration in their 

mind is to immediately coordinate with the VA for their care. It depends on what type of injury I think the servicemember has incurred about. 


ccoleman on DSK8P6SHH1PROD with HEARING
23 

Also I talked about the SCI side, and the DoD generally does a 

pretty good job with that, but you know, I can’t speak for blinded 

veterans. I think you would have a much more—— 

Mrs. HALVORSON. And I think I said it wrong. What is happening, I believe, is that DoD doesn’t publicly track the data on the 

seriously injured, but if they did and then once they are out of theater is the VA ready to get at that data? Because the Department 

of Defense, when they are done with being in that budget, they are 

happily ready to get rid of them to put them in the VA budget. I 

am trying to—— 

Mr. BLAKE. I am going to try to answer for Tom here again. 

Mrs. HALVORSON. Okay. 

Mr. BLAKE. I don’t know that it is a matter of not publicly tracking the data, it is just that they’re not even necessarily tracking 

the right data. 

Mrs. HALVORSON. Okay. 

Mr. BLAKE. I think—and Tom can probably speak better to this 

for the blinded side—I think that there are a lot of folks who are 

not being captured in their evaluation for what are their problems 

that they are experiencing when they go. 

Mrs. HALVORSON. Right. 

Mr. BLAKE. So you know, in the case of blinded veterans they are 

finding all these individuals who escaped the system and were 

never identified as having a problem. 

We have seen this with TBI in particular where Joy mentioned 

the mild to moderate side. A lot of these folks are escaping—I hate 

to say escaping—they are leaving the service and then later things 

start to crop up and those things were never identified while they 

were in service. 

So a lot of things go missed when they are trying to ensure that 

these individuals are going to get the care down the road. 

Dr. ZAMPIERI. Yeah, the electronic registries are an issue. I think 

what you are getting at is that. 

You know, it is interesting bureaucracy is Ph.D. is political 

science but I spent 25 years as a clinical person. I did surgery and 

so I throw that out there because I was also an aero medical flight 

surgeon in the Army and retired as a major, so I think I know a 

little bit about the system as a medical provider. 

Mrs. HALVORSON. Sure. 

Dr. ZAMPIERI. And what happens is bureaucracies look at these 

electronic registries as repetitive duplication efforts, unnecessary 

expenses, et cetera, et cetera. What they don’t understand from a 

clinical point of view is that the registries, whether it is amputees, 

spinal cord, vision impaired, whatever the registry is, there is key 

clinical information that needs to be seen by the other providers. 

Whether it is a DoD provider that had a person that has come back 

from a VA polytrauma center or whether it is a VA provider who 

is an ophthalmologist that is at Kansas City who has a veteran 

who shows up that has had surgery in Landstuhl, surgery at Walter Reed, surgery down at Richmond, Virginia, at the polytrauma 

center and he ends up back out there. Those surgical records that 

are unique to what is important to that ophthalmologist is what is 

important in the registry. 

Also it is important for all these registries for outcomes. 


ccoleman on DSK8P6SHH1PROD with HEARING
24 

You know, a little stunning fact that I told Secretary Shinseki a 

year ago when I met with him was that we have outcome studies 

from Vietnam eye trauma cases, 50 percent of them went blind 10 

years after. Somebody ought to be worried about, you know, if 

there are several thousand serious penetrating eye injured are we 

going to have that same rate in 2020 that they had in 1978 when 

they did 10 year follow up of injured servicemembers in Vietnam 

in 1968? 

So any way, the bureaucracies love to say well, you know, we are 

going to eventually have a fully interoperable exchange of health 

care electronic records and so you don’t need all these registries. 

And I have been told that, and again from the research standpoint, 

it is important that you have those registries because of the coordination of research. If somebody starts on a research program on 

the DoD side and ends up in the VA, whether it is clinical outcomes, whether it is development of certain policies, whether it is, 

you know, just being able to answer how many are certain types 

of retinal injuries, whatever, optic nerve injuries there are. 

Any way, sorry. I am really frustrated when people say well, you know it is going to cost $8 million for that eye trauma registry, and 

that is just going to be repetitive of all these other registries. Well 

guess what, there is a reason for that. And again, you know, you 

look at the Vietnam experiences or the Korean War experiences or 

World War II experiences, you know, you want to improve things. 

Mr. MICHAUD. Mr. McNerney. 

Dr. ZAMPIERI. Thank you. 

Mr. MICHAUD. We will be called for votes shortly, so if we can 

try to finish up this panel. 

Mr. MCNERNEY. Okay, thank you, Mr. Chairman. 

Yesterday I was in here in the same room and we had a hearing 

on some of the new treatments that are available for post-traumatic stress and for traumatic brain injury, and I couldn’t help but 

think that some of the treatments and methodologies are transferable to the physical injuries that are not in the same category. And 

so I just ask that you consider coordinating your efforts. 

There is a lot going on out there. And today I have seen a tremendous transformation of American society from the 1970s to now 

when so many groups, so many individuals are reaching out and 

trying to do what they can to help veterans and to make veterans 

welcome. So it is a great feeling to see that happening out there, 

and I welcome everyone here and thank you for your hard work. 

I can see you are all dedicated to what you are trying to achieve. 

I have some specific questions. Mr. Blake, you noted that many 

servicemembers with mild traumatic brain injury leave the service 

without having the proper diagnosis and consequently that they 

are unaware that they need or should be looking for treatment. 

How do you recommend that we move forward in either preventing that from happening, making sure that we get the proper 

diagnosis before they leave or reach them when they are having 

the problems that make them aware that they need service or 

help? 

Mr. BLAKE. Well, I would say it is not as simple as just saying 

they are just being diagnosed because oftentimes it is not that 

easy, but one of the things we have put a lot of emphasis on over 


ccoleman on DSK8P6SHH1PROD with HEARING
25 

the—for many years, not just in recent past—is the need for really 

comprehensive medical examinations of these servicemembers both 

post-deployment and when they are preparing to leave the service. 

There has been a lot of grousing over the years about medical 

screening and things like that that are done to exit servicemembers 

either from theaters or from the service altogether and I am not 

sure that goes far enough. It doesn’t benefit the servicemember in 

the long run, because a lot of times this is self-reporting and that 

is not going to help them out, and you know, it has an outcome for 

them both of the benefit side and the health care side in the future. 

Ms. ILEM. I would just like to add, you know, sometimes we hear 

one step forward but then two steps back. 

We recently had heard that theater they were going, you know, 

very quick examinations following if someone was near a blast, perhaps doesn’t physically know that they have had a injury, but definitely want to measure, you know, how close they were to the 

blast, and you know, we have heard a couple of different things 

and it certainly starts right there in being able to track. 

Then we started to hear that because servicemembers wanted to 

return with their unit and didn’t want to be pulled out that they 

would try to, you know, answer the questions in a way or were familiar with, you know, how to answer them so that they wouldn’t 

be pulled out. 

But if we really don’t have an accurate tracking that, you know, 

over a period of time they have been exposed to this number of 

blasts, and then you know, be able to follow that along, you know, 

it is very difficult later on and oftentimes it is the family who are 

the first ones who recognize it that there is a change in this person, 

all be it subtle, you know, they have problems holding a job, you 

know temper issues, a variety of things. 

So again, it is a DoD, VA collaboration where you really want to 

see this great hand off, but right from the start being able to have 

accurate information so down line you can say hey, you know, this 

person was exposed to this number of blasts, let us really do a 

good, you know, cognitive assessment on this person and see if we 

have some, you know, minor or you know, mild deficit, but still, 

you know. 

Mr. MCNERNEY. I mean ultimately I think we will develop—well 

not we, but somebody is going to develop a way to diagnose this 

relatively early, but right now we have to depend on recordkeeping 

and so on to do that. 

I have two more questions, I hope I have enough time. 

Mr. Tarantino, you raised some concerns about the VA limiting 

or denying access to some veterans who need services with traumatic brain injury. Can you expand on that point a little bit and 

give some examples of the type of care that is being limited or denied? 

Mr. TARANTINO. Yes, Congressman. Basically, we have been 

hearing a lot from our members who have tried to receive care at 

local medical centers, and this is kind of a theme that has come 

up over and over where members who have sought traumatic TBI 

care are being denied because they are not—their rehabilitation 

land essentially they are not going to get consistently better, they 

are going to need to just maintain their services. 


ccoleman on DSK8P6SHH1PROD with HEARING
26 

I am actually looking for, there is actually in our written testimony we do have a story of—I am trying to find it, excuse me— 

of a vet who was denied care. She was denied services. Basically, 

they said well, you don’t qualify for the services we provide because 

you are looking for long-term maintenance and that is not what we 

are providing. 

Mr. MCNERNEY. Well, probably also because they don’t recognize 

that she has that sort of injury I am guessing, but that seems to 

be what you are getting at. 

Mr. TARANTINO. Right. I mean this is a larger issue of we need 

to start restructuring the way we look at these wounds. You know, 

we are not just looking at wounds that, you know, you are going 

to get care and you are going to recover and ultimately you will get 

better—fully better. A lot of these wounds are going to be either 

just maintaining that basic level of functioning, which is going to 

require a lot of time and money and patience, and frankly a structure that isn’t built at the VA to where we need it, but it is also 

going to be some of this can be degenerative, and we are going to 

need to double our efforts in making sure that these veterans’ quality of life can at least be maintained and that the VA is going to 

be able to provide services to them whether it be 24-hour care, 

whether it, you know, just be continual adaptive services. 

I mean this speaks to that larger issue, our entire range of 

adaptive services is horribly, horribly out of date. 

Mr. MCNERNEY. Okay, thank you. 

Ms. Williams, in your testimony you applauded the VA for efforts 

in the area of prosthetics for women veterans, and that is a great 

achievement. 

My question is, are there gender differences where the needs of 

women are not being met whether it is for blind rehabilitation, spinal cord injuries, or so on and polytrauma that are not as well met 

for women as they are for the men veterans? 

Ms. WILLIAMS. In terms of the spinal cord injury there was a 

part that I found during my research that was not included in the 

testimony, and I wanted to—I can bring that to your attention regarding women with spinal cord injuries and the difficulties that 

they face in receiving their medical care, specifically their Pap 

smear and what they have to go through in order to receive the 

care because of if they are in a wheelchair and if they have lost 

use of their legs. 

There are certain—I am having a brain cramp—but it is the debilitating condition that the females face with the spinal cord injury compared to their males having to receive their breast exam, 

what they have to go through to receive a mammogram and their 

Pap smear as a spinal cord injury. 

Mr. MCNERNEY. Okay, those are good specific topics. And if you 

could keep us informed about the progress of that sort of treatment, it would be beneficial I think for the VA. 

Ms. WILLIAMS. Sure. 

Mr. MCNERNEY. Thank you, Mr. Chairman. 

Mr. MICHAUD. Thank you. Once again, I would like to thank the 

panel for coming this morning. Your testimony has been very helpful and I look forward to working with you as we provide services 

for our veterans. Once again, thank you very much. 


ccoleman on DSK8P6SHH1PROD with HEARING
27 

We will try to get through the second panel before they actually 

call the votes, and I would ask the second panel to come forward. 

We have Dr. Jack Smith, Acting Deputy Assistant Secretary for 

Clinical and Program Policy from the Department of Defense, and 

Dr. Lucille Beck from the Veterans Administration, who is accompanied by Dr. Margaret Hammond from the VA, Deborah Amdur 

from the VA and Billie Randolph from the VA. 

I want to thank our second panel for coming forward. We do have 

your full written testimony, which will be submitted for the record, 

so if you could summarize your written testimony so we are able 

to ask questions before they call for votes, I would appreciate it. 

We will start with Dr. Smith. 

STATEMENTS OF JACK SMITH, M.D., MMM, ACTING DEPUTY 

ASSISTANT SECRETARY FOR CLINICAL AND PROGRAM POLICY, U.S. DEPARTMENT OF DEFENSE; LUCILLE B. BECK, 

PH.D., CHIEF CONSULTANT, REHABILITATION SERVICES, OFFICE OF PATIENT CARE SERVICES, AND DIRECTOR, AUDIOLOGY AND SPEECH PATHOLOGY SERVICE, VETERANS 

HEALTH ADMINISTRATION, U.S. DEPARTMENT OF VETERANS 

AFFAIRS; ACCOMPANIED BY MARGARET C. HAMMOND, M.D., 

CHIEF CONSULTANT, SPINAL CORD INJURIES AND DISORDERS SERVICES, VETERANS HEALTH ADMINISTRATION, 

U.S. DEPARTMENT OF VETERANS AFFAIRS; AND BILLIE RANDOLPH, DEPUTY CHIEF, PROSTHETICS, VETERANS HEALTH 

ADMINISTRATION, U.S. DEPARTMENT OF VETERANS AFFAIRS 

STATEMENT OF JACK SMITH, M.D., MMM 

Dr. SMITH. Well thank you, Chairman Michaud, distinguished 

Members of the Subcommittee, thank you for the opportunity to appear here to talk to you about the Department of Defense’s medical 

care for those who have suffered physical injuries in combat. 

On October 16th, 2009, Secretary of Defense Gates stated quote, 

‘‘Beyond waging the wars we are in, treatment of our wounded, 

their continuing care, and eventual reintegration into everyday life 

is my highest priority. I consider this a solemn pact between those 

who have risked and suffered and the Nation that owes them its 

eternal gratitude.’’ 

We who work in Military Health System completely agree with 

Secretary Gates and share his commitment to provide the best possible treatment for our wounded warriors. 

One of the Military Health System’s foremost sustained priorities 

is to improve the experience of care for those who are receiving 

treatment in our military treatment facilities every day, the 

wounded, ill, and injured from our current conflicts who are moving 

through the joint patient evacuation system from point of injury 

and theater of operations to the point of definitive care in the 

United States where many are recovering from at our flag ship 

military medical centers in the National Capital area and other 

clinical centers around the country. 

DoD has also long been a leader in research on improved treatments for traumatic injuries. 


ccoleman on DSK8P6SHH1PROD with HEARING
28 

The U.S. Army Institute of Surgical Research located at the 

Brooke Army Medical Center in Texas, is dedicated to laboratory, 

clinical trauma, and combat care research. Its mission is to identify 

opportunities for improvement and discover new treatments for 

combat injuries for servicemembers across the full spectrum of 

military operations. 

Severely injured servicemembers often require prolonged treatment, time to heal, and rehabilitative care before a decision can be 

made on the medical ability to remain on active duty. 

The Military Health System (MHS) is meeting this challenge by 

improving our coordination of health care for servicemembers with 

our partners in the VA. 

The MHS is committed to ensuring that servicemembers are provided outstanding clinical care and streamlined administrative 

processes to return them to duty status if possible or to assist them 

with a transition to civilian life in coordination with the VA in an 

effective and timely manner. 

To ensure a seamless transition of health services from one agency to another, the MHS and the VA are working together to ensure 

that medical providers have a full understanding of the care capabilities within both agencies and that clear communication of the 

transition plan between providers and each agency and with the 

patient and family occur. 

We are also working to ensure both timely transfer of all pertinent medical records before or at the time of transfer of the patient, and appropriate communication after the transfer between 

the medical providers and with the patient and family. 

The Department of Defense continues to improve the transition 

of health care between the agencies by working in partnership with 

the VA to establish and support Federal Recovery Coordination 

Program, the VA Liaisons for Health Care Program, and the Recovery Coordination Program. 

DoD has also established a number of specialty centers of excellence in collaboration with VA centers. Centers dedicated to wounded warrior care include the Walter Reed Army Medical Amputee 

Care Center and Gate Laboratory, the National Naval Medical 

Centers National Intrepid Center of Excellence for Traumatic 

Brain Injury and Psychological Health, the Center for the Intrepid 

in Brooke Army Medical Burn Center at Fort Sam Houston, Naval 

Medical Center San Diego Comprehensive Combat Casualty Care 

Center, the Defense Centers of Excellence for Traumatic Brain Injury and Psychological Health, and the Centers of Excellence for 

Vision, Hearing, and Traumatic Extremity Injuries and Amputations. 

We have made tremendous progress in combat, trauma, and rehabilitative care of our injured combatants over the last 9 years. 

The medical personnel of our combined services are working very 

hard to develop and implement the MHS programs necessary to return our severely injured servicemembers to duty or to a protective 

civilian life. 

Thank you for your continued support of our servicemembers and 

their families, and I would be pleased to respond to any questions. 

[The prepared statement of Dr. Smith appears on p. 55.] 

Mr. MICHAUD. Thank you. 


ccoleman on DSK8P6SHH1PROD with HEARING
29 

Dr. Beck. 

STATEMENT OF LUCILLE B. BECK, PH.D. 

Dr. BECK. Good Morning, Chairman Michaud and Members of 

the Subcommittee. Thank you for the opportunity to discuss the 

Department of Veterans Affairs’ full complement of specialty, rehabilitative services for severely injured veterans and servicemembers. 

I am accompanied today by Deborah Amdur, Chief Consultant 

for Care Management and Social Work Services, Dr. Margaret 

Hammond, Chief Consultant for Spinal Cord Injuries and Disorders, and Dr. Billie Randolph, Deputy Chief Consultant for Prosthetics and Sensory Aid Service. 

My testimony will discuss how VA supports and facilitates the 

transition and care management of Operation Enduring Freedom 

and Operation Iraqi Freedom veterans. I will highlight the specialty rehabilitation services provided by VA for severely injured 

veterans and servicemembers since 2003 for four program areas: 

Blind Rehabilitation, Spinal Cord Injury, Polytrauma Traumatic 

Brain Injury, and Amputation, Prosthetics, and Sensory Aids. 

VA and DoD partnered to create the Federal Recovery Coordination Program in order to facilitate access to VA for severely injured 

veterans and servicemembers and to assure that these veterans 

and servicemembers receive the benefits and care they need to recover. 

Currently, 556 clients are enrolled in the FRC program and another 31 individuals are being evaluated, 497 have previously received assistance. 

The VA care management and social work service coordinates 

care for 5,800 severely injured servicemembers and veterans. 

Additionally, VA has placed liaisons at military treatment facilities and developed an OEF/OIF team at each VA medical center to 

help coordinate the care for returning servicemembers and veterans. 

The first specialty rehab program I want to discuss is VA’s blind 

rehabilitation service which assesses, recommends, and trains visually-impaired veterans in the use of technology and assisted devices such as computers, personal digital assistance, and global positioning systems. 

Blind rehabilitation services are delivered at every medical center and select outpatient rehabilitation clinics and in-patient centers. These services are structured and geographically located for 

visually-impaired veterans and servicemembers to access the care 

they need. 

A total of 1,098 OEF/OIF veterans and servicemembers are 

tracked to ensure ongoing coordination. Of this total 126 servicemembers have attended in-patient blind rehabilitation centers due 

to severely disabling visual impairment. 

Second, VA’s spinal cord injury system of care is internationally 

regarded for its comprehensive and coordinated services for rehabilitation, surgical, medical, preventive, ambulatory, long-term, and 

home-based care. 

VA promotes activity based therapies at SCI centers, and recently enhanced the rehabilitation and training environments to 


ccoleman on DSK8P6SHH1PROD with HEARING
30 

offer the latest and most effective interventions for newly injured 

servicemembers and veterans. 

VA has treated 503 servicemembers in its SCI units. 

Third, the VA’s polytrauma system of care is an integrated tiered 

system that provides specialized interdisciplinary and comprehensive care, including treatment by teams of rehabilitation specialists, specialty care management, patient and family education and 

training, psychosocial support, and advanced rehabilitation and 

prosthetic technologies. 

New programs at each polytrauma rehabilitation center include 

transitional rehabilitation programs, emerging consciousness care, 

and assisted technology laboratories. 

VA has treated 1,792 patients at the PRCs: 907 servicemembers, 

and 885 veterans with severe injuries. 

Finally, VA’s Amputation and Prosthetic’s and Sensory Aid Program provides veterans with the full spectrum of commercially 

available rehabilitation and prosthetic equipment to maximize 

their independence and health. 

Prosthetics currently serves 657 OEF/OIF amputee veterans and 

servicemembers. Specialized prosthetic devices are provided to 

meet the unique needs of returning veterans, and this program has 

pioneered the use of best practices for management of prosthetic 

devices and care through its clinical management program. 

Thank you again to the opportunity to appear today and discuss 

VA’s work in providing our OEF/OIF veterans with timely access 

to the specialty care services they need. We appreciate Congress’s 

support in provides the resources we need to serve our veterans. 

My colleagues and I look forward to answering your questions. 

Thank you. 

[The prepared statement of Dr. Beck appears on p. 58.] 

Mr. MICHAUD. Thank you very much, Dr. Beck. 

Mr. Bilirakis. 

Mr. BILIRAKIS. In the interest of time I will submit my questions 

for the record. 

Mr. MICHAUD. Mrs. Halvorson. 

Mrs. HALVORSON. Thank you, Mr. Chairman, I will submit most 

of mine, but I do have a couple questions. 

First of all, Dr. Smith, could you just give me a short answer on 

what is the status on the eye trauma registry that Tom brought up 

earlier? 

Dr. SMITH. Sure. We worked very closely with the VA in establishing the clinical requirements for the registry. Those requirements have been established at this point. They were in the process of putting together a model to build for that. 

Meanwhile, we are utilizing our clinical data repository and case 

management systems to identify the patients who need care so that 

we can communicate and refer those to the VA. 

We are also working on an eye forum in our joint theater trauma 

registry, which begin to give us more visibility on patients who 

have sustained injuries in the theater. 

So there are multiple avenues we are pursuing, including the 

registry, which is going to take a little more time to build because 

of its need to draw information from the various clinical reposiVerDate Nov 24 2008 00:57 Jan 06, 2011 Jkt 058060 PO 00000 Frm 00034 Fmt 6633 Sfmt 6633 I:\WAYS\OUT\58060.XXX GPO1 PsN: 58060

ccoleman on DSK8P6SHH1PROD with HEARING
31 

tories that we talked about and our ongoing effort to establish and 

improve our electronic health record. 

Mrs. HALVORSON. And speaking of that, real quick. You know, 

you say that you are working on a seamless transition, but yet I 

hear from all my veterans that the VA can’t talk to the DoD. When 

the young service man leaves the theater, they get medical records 

that the VA can’t talk to the DoD. 

Why can’t they—when the servicemember leaves the DoD that 

they can just get a CD of all their records or you can put it on a 

USB and hand it to them and say here you go, you have your medical records all to yourself? 

Dr. SMITH. We have for patients who are being transferred to the 

polytrauma centers full copies of records go, including imageries 

and—— 

Mrs. HALVORSON. Where do they go? 

Dr. SMITH. They go to the polytrauma center. 

Mrs. HALVORSON. Which everybody loses something somewhere, 

because that is what they tell me when they come to me. 

Dr. SMITH. Yeah. Well everything is scanned at the time they are 

transferred from DoD to the VA. 

We also have the Bi-Directional Health Information Exchange 

which makes visible to VA doctors anything that is in our electronic health record, and certainly I am not going to tell you—— 

Mrs. HALVORSON. But doesn’t that servicemember own his own 

record? You can’t just give it to him? 

Dr. SMITH. Well, if he is being medically evacuated out of the 

theater—— 

Mrs. HALVORSON. No, no, no. Just when he leaves theater can’t 

he say I want my medical records, put it on a USB, a little thing 

and it is mine? 

Dr. SMITH. We don’t currently have that process. We do give an 

electronic copy of the health record to the VA at the time that people separate from the military. 

Mrs. HALVORSON. But they can’t read it. You don’t have the same 

system so it is not seamless. 

Dr. SMITH. We do have interoperability ability initiatives under 

way and the Bi-Directional Health Information Exchange I believe 

is working. 

Mrs. HALVORSON. But it is not simple. Our office works all day 

long trying the figure out the medical record issues. 

I am just saying, and I am not going to belabor the issue, we 

have to figure out the VA member—this is an issue, this is a bad 

issue, and VA—the men and women who served our country who 

worked so hard, their medical records should be something that 

they own and that we shouldn’t have this kind of problem every 

day. When they leave they should own their own records that 

they—because there is a problem with trust. And you guys give 

them to the VA or you do something with them, but they own them 

and then there is problems, and the VA can’t read them. 

So this is something that we need a whole Subcommittee on just 

that. So something better be done so the VA can read your records. 

Because I was in Landstuhl and they showed us a system that 

should be seamless. And again, I don’t want to get on my high 


ccoleman on DSK8P6SHH1PROD with HEARING
32 

horse, but I am supporting and protecting my veterans, and they 

are not happy. 

So Mr. Chairman, I yield back. 

Mr. MICHAUD. Thank you. Mr. McNerney. 

Mr. MCNERNEY. Well, thank you, Mr. Chairman. Thank you for 

your testimony, Dr. Beck and Dr. Smith. 

Dr. Beck, how would you respond to the Legioneer’s claims or 

comments that the returning soldiers get the best rehabilitative 

treatment for amputations, but the long-term prognosis is not that 

good or not that clear? In other words, they are going to get the 

best possible treatment from the DoD, but the long-term treatment 

is not as clear. 

Dr. BECK. Thank you, Congressman. 

We are working very closely with the Department of Defense 

with the three centers who are providing the primary amputation 

rehabilitation. Brooke Army Medical Center at the Center for the 

Intrepid, Navy at Balboa, and at Walter Reed. We are sharing staff 

at those centers. We have VA staff at the Center for the Intrepid. 

We now have VA staff who are at Walter Reed and at the DC VA 

Medical Center. We are working at all levels to integrate and communicate all of the services. We are training together. The military 

and the VA are training our staffs, our interdisciplinary team of 

physicians and physical therapists and occupational therapists and 

our clinical prosthetics. 

Mr. MCNERNEY. Okay. I mean there is no doubt in my mind that 

the intention is good. 

I guess what I am trying to get at is that they get out of Walter 

Reed or Bethesda, they are in pretty good physical shape, but they 

need long-term guidance—— 

Dr. BECK. Yes, sir. 

Mr. MCNERNEY [continuing]. In some way to make sure that 

they don’t fall off the cart, you know, and get into problems. 

Dr. BECK. Yes, sir. And what the VA is doing and has developed 

in the last 3 years is a refreshed amputation some of care, and in 

my written testimony we provided the information. 

We have stood up seven regional amputation centers in the VA 

around the country that are specialized centers providing the full 

compliment of medical and rehabilitative care for our amputees. 

We also have amputee specialty care at 21 of our network sites, the 

Veterans Integrated Service Network sites, and we have amputation clinic teams around the country. And the intention and the effort is to manage and care for all of VA’s amputees. We have approximately 43,000 amputees already in the VA system being 

served and are now addressing the need—their needs as well as 

the needs of our OEF/OIF traumatic amputees. 

So we are providing the latest in prosthetist equipment, artificial 

limbs, and services through our network of private prosthetist providers as well. 

Mr. MCNERNEY. Okay, thank you. 

I am going to yield back, Mr. Chairman. 

Mr. MICHAUD. Thank you very much. I have just a couple quick 

questions for Dr. Smith. 

Yesterday we had a Roundtable discussion in which we discussed 

hyperbaric therapies that I know the DoD has been using. There 


ccoleman on DSK8P6SHH1PROD with HEARING
33 

is a DoD report on hyperbaric therapy that has never been submitted. 

Could you provide the Committee with a copy of that report? 

That is my first question. 

[The DoD subsequently provided the following information:] 

To our knowledge, the DoD participants at the House Veterans’ Affairs Committee Roundtable held the day before this hearing did not reference any 

Hyperbaric Oxygen (HBO) report. The only HBO report referenced that day was 

of another panelist and the Department does not have an association with or 

knowledge of the other panelist’s report. 

However, there is a separate HBO report which may be of interest to the Committee. As requested by the Joint Explanatory Statement for H.R. 3326, the Department of Defense Appropriations Bill, 2010, DoD is currently working on a 

final report to Congress on HBO due in September 2010. 

Mr. MICHAUD. And my second question is, Congress passed legislation requiring the DoD to perform a baseline evaluation when 

soldiers go to Iraq and Afghanistan and an evaluation when they 

come back. It is my understanding that they have stopped doing 

that evaluation and that is a big concern. Is it because in the evaluation that has been done that traumatic brain injury issues are 

coming up and you don’t want to face what our soldiers are going 

through? 

I do not want another Agent Orange with our veterans in Iraq 

and Afghanistan, so please provide that report on hyperbaric therapy, or what has been done on the report if it is not completed, and 

also address in writing why the DoD is not evaluating the soldiers 

when they come back. 

[The DoD subsequently provided the following information:] 

The Department of Defense (DoD) does not perform routine, population-based, 

post-deployment neurocognitive assessments on its returning servicemembers. 

Neurocognitive assessments are focused exclusively on assessing cognition. At 

present, research does not support the use of computerized neurocognitive assessments tools such as Automated Neuropsychological Assessment Metrics 

(ANAM) for post-deployment population-based concussion screening. There are 

many reasons (e.g. sleep deprivation, depression, concussion, etc.) there could be 

changes in cognitive scores between pre- and post-deployment. 

However, DoD completes an overall screening post-deployment with the goal of 

identifying all servicemembers who may have persistent symptoms from a concussive injury obtained during deployment. DoD screens the post-deployment 

population for the entire spectrum of symptoms associated with concussion 

rather than only evaluating symptoms of cognition. Because a concussion can 

produce a variety of symptoms (with or without cognitive dysfunction) such as 

headache, dizziness, insomnia, irritability, mood and anxiety disturbances, in 

addition to isolated cognitive disturbances, the tool used for post-deployment 

screening is an adaptation of the Brief TBI Screen that was recommended by 

the Institute of Medicine for this purpose in its December 2008 report. Those 

servicemembers who screen positive for having possible symptoms associated 

with a concussion receive further medical evaluation to include assessments of 

cognition with ANAM or other formal neuropsychological assessments. 

This process works to provide the comparative information necessary for postinjury care of mild traumatic brain injury in the acute phases of injury and 

identify cases that may not have been evaluated in theater or have persistent 

symptoms. The Department continues to look for the best methods for delivering quality, evidence-based care to our servicemembers. 

Mr. MICHAUD. Also for the VA, Dr. Beck, please provide to the 

Subcommittee information on VA’s progress in implementing the 

caregivers legislation that was recently passed, including when we 

can expect it to be fully implemented. 


ccoleman on DSK8P6SHH1PROD with HEARING
34 

There will be additional questions from the Subcommittee as 

well. 

Unfortunately, the vote is open. We have 7 minutes to get over 

there to vote, so I will provide additional questions for the record 

from the rest of the Committee. 

I want to thank both Dr. Smith and Dr. Beck and those who you 

who are accompanied by, for coming today, as well as the first 

panel for your enlightened testimony. 

As you can tell from the questions both for the first panel and 

that I know we would have asked on this panel had we had the 

time, this is a very important issue that we have to deal with. And 

some of the other questions that will come forward, particularly of 

VA, as we heard from the Iraq and Afghanistan folks, is there is 

still a concern about the time frame, and about some of the concerns with VA having to put veterans on hold for 45 minutes, and 

a pubic relations problem within the veterans’ community. Hopefully we will be able to address some of those questions and we will 

be asking additional questions of this panel as well. 

So once again, I want to thank you all for coming. I really appreciate it. 

If there are no other questions, we will adjourn the hearing. 

So thank you. 

[Whereupon, at 11:41 a.m., the Subcommittee was adjourned.] 


ccoleman on DSK8P6SHH1PROD with HEARING
(35) 

A P P E N D I X 

Opening Statement of Hon. Michael H. Michaud, 

Chairman, Subcommittee on Health 

The Subcommittee on Health will now come to order. I would like to thank everyone for attending this hearing. 

The purpose of today’s hearing is to explore how we can best serve our veterans 

who have sustained severe physical wounds from the wars in Iraq and Afghanistan. 

Today, we will closely examine VA’s specialized services for the severely injured, 

which include blind rehabilitation, spinal cord injury centers, polytrauma centers, 

and prosthetics and sensory aids services. 

With advances in protective body armor and combat medicine, our servicemembers are surviving war wounds which otherwise would have resulted in casualties. Many servicemembers who are severely injured in Operation Enduring Freedom and Operation Iraqi Freedom (OEF/OIF) will require sophisticated, comprehensive, and often lifelong care. We know that blast injuries from improvised explosive 

devices are the most common causes of injury and death among our OEF and OIF 

servicemembers. Blast injuries often include combinations of TBI, blindness, spinal 

cord injuries, severe burns, and damage to the limbs which results in amputations. 

Today, we will examine whether VA is meeting the needs of the severely injured 

and whether veterans have access to the most current therapies for treating their 

physical war injuries. We will identify what VA is doing well and what areas are 

in need of improvement. We will also explore how VA ensures that the quality of 

care is consistent and standardized across the VA health care system so that veteran receive the same high quality care regardless of which VA facility they visit. 

Finally, we will review VA’s current efforts to coordinate specialized services for the 

severely injured with the DoD and how we can achieve improved coordination between the two departments. 

I look forward to hearing from our witnesses today. 

f 

Opening Statement of Hon. Henry E. Brown, Jr., 

Ranking Republican Member, Subcommittee on Health 

Thank you, Mr. Chairman, and good morning. 

Yesterday, we reached a milestone. It was eighty years ago—on July 21, 1930— 

that President Herbert Hoover first established what we now know as the Department of Veterans Affairs (VA). 

Since that day, VA has endeavored to fulfill their mission to ‘‘care for those who 

have borne the battle’’. For those who return from battle carrying the very worst 

wounds of war, including spinal cord injury (SCI), traumatic brain injury (TBI), amputation, and blindness the VA has developed specialized services to meet their 

unique rehabilitative needs. Providing these types of services to our very highest 

priority veterans is the backbone of the Department. 

Since 1996, Congress has mandated that the VA maintain capacity for these specialized rehabilitative services. And, in 2004, Congress enacted legislation to provide 

comprehensive services for severely injured servicemembers suffering with complex 

injuries resulting from blast injuries. This came to be called VA’s Polytrauma System of Care. 

More than 2.1 million servicemembers have been deployed since October 2001. As 

of April 3, one thousand five hundred and fifty two have suffered amputations in 

Iraq or Afghanistan. Countless others have suffered TBI, SCI, eye trauma, hearing 

loss, or other severe combat wounds. These young heroes are going to require a lifetime of rehabilitation and highly skilled medical services and support. They risked 

life and limb in our name and in return it is our responsibility to provide them with 

the care they require and so dearly deserve. 


ccoleman on DSK8P6SHH1PROD with HEARING
36 

As the battles in Iraq and Afghanistan persist, the specialized care given in VA 

Medical, Polytrauma, Spinal Cord Injury, and Blind Rehabilitation Centers continue 

to take on increased importance. 

We must diligently prioritize investment in specialized services, medical research, 

and recruitment to have all the tools necessary to provide all veterans and especially our most severely wounded veterans with an active and full life characterized 

by independence, functionality, and achievement. 

I’m grateful to all our panelists and audience members for being here this morning and I yield back. 

f 

Prepared Statement of Thomas Zampieri, Ph.D., Director 

of Government Relations, Blinded Veterans Association 

INTRODUCTION 

Chairman Michaud, Ranking Member Congressman Brown, and members of the 

House Veterans Affairs Subcommittee on Health, on behalf of the Blinded Veterans 

Association (BVA), thank you for this opportunity to present our testimony today 

on ‘‘Healing the Physical Injuries of War.’’ BVA is the only congressionally chartered 

Veterans Service Organization (VSO) exclusively dedicated to serving the needs of 

our Nation’s blinded veterans and their families for over 65 years. Today, as U.S. 

forces remain engaged in two wars and with the surge into Afghanistan resulting 

in more wounded returning from the battlefields, this hearing is important in reviewing the current systems specialized services and what works and does not work 

well. While the media often covers the signature injury of the wars, ‘‘Traumatic 

Brain Injuries’’ and the mental health problems like Post Traumatic Stress Disorders (PTSD) it is important to note that most wounded return with several injuries ‘‘polytrauma’’ and they should all be considered in planning for VA specialized 

care and benefits they require. 

SEAMLESS TRANSITION ISSUES 

During the past couple years, BVA has worked extensively with the members of 

the Committee and tried to get the House Armed Services Committee (HASC) to 

hold DoD more accountable for the many organizational problems associated with 

the Seamless Transition process involving the battle eye-injured and those with visual complications associated with Traumatic Brain Injury (TBI). Many severely eyeinjured OIF and OEF wounded servicemembers are not centrally tracked, making 

the implementation of the Eye Trauma Registry vital. This tracking failure negatively affects some in their access to the full continuum of VA Eye Care Service, 

Blind Rehabilitation Service (BRS), and Low-Vision outpatient programs that these 

committees helped establish. BVA again stresses that, according to DoD data compiled between March 2003 and December 2009, DoD reported 10 percent of all combat-injured casualties evacuated from OIF and OEF had associated mild, moderate, 

or severe eye injuries, considering that 38,497 U.S. servicemembers have been evacuated from being wounded or injured this is obviously a significant number. Fortunately, due to advanced combat surgery teams, and the rapid evacuation military 

aero-medical system, the severely eye injured in these wars have had their vision 

sometimes fully or partially restored, but approximately 124 blinded have required 

treatment at one of the ten VA Blind Rehabilitation Centers (BRCs) and there are 

large numbers with TBI low vision problems. There has been insufficient governance or oversight of the Vision Center Excellence (VCE) by the Joint Executive 

Council (JEC) and some failure of both agencies to provide detailed budgets, necessary for VCE joint staffing, implementing the Eye Trauma Registry has been delayed, and the planned construction renovation for 3,870 square feet of office space 

for the VCE at the National Naval Medical Center in Bethesda is not expected to 

be completed until April FY 2011. BVA requests that no further delays for the immediate operational implementation plans for the VCE in FY 2010 are acceptable 

and they should not be tolerated. 

BVA points to the frustrating fact that despite the MILCON/VA Appropriations 

including $6.8 million for FY 2009 for VA implementation of its portion of the VCE 

initiative, it was April 2010 before VA had a total of four staff appointed to the 

VCE. Members found that the funding had been reprogrammed over five years instead of utilizing the funds to urgently start the VCE operations. BVA requests that 

Congress include $9,350,000 in the Defense Appropriations FY 2011 and require 

that VHA and DoD Assistant Secretary Defense for Health Affairs (ASDHA) report 


ccoleman on DSK8P6SHH1PROD with HEARING
37 

quarterly on VCE joint staffing plans, the status of the Eye Trauma Registry, and 

expenditures of the MILCON/VA appropriations provided to HVAC and HASC. 

BVA believes that the VCE and its Eye Trauma Registry are where improved coordination to ensure availability of eye care and vision rehabilitation services, best 

outcome practices, and evidence-based clinical research measures can be developed 

and refined for the TBI-wounded who face vision dysfunction and those suffering 

penetrating eye wounds. Research coordinated with the Defense Veterans Brain Injury Centers (DVBIC) and the Defense Intrepid Center of Excellence (NICOE) for 

TBI, along with VA Polytrauma sites, can be facilitated, data-analyzed, and published to improve both acute injury care and long-term vision rehabilitation. We predict that the number of TBI-injured will continue to rise as a result of the troop 

surge into Afghanistan this year. 

VA’s Full Continuum of Care 

A very positive note is that VA continues to build on a now 62-year history of successful blind rehabilitation programs, which include 10 residential Blind Rehabilitative Centers (BRC’s) throughout the United States and construction on two new 

BRC’s is occurring now. At present, the implementation of a sweeping $40 million, 

three-year Full Continuum of Care plan has been completed that this committee 

supported. While the plan was originally initiated to serve the projected aging population of veterans with degenerative eye diseases requiring specialized services, the 

new 55 intermediate and advanced low vision blind rehabilitation outpatient programs also have specialized staffing in place to provide the full range of basic, intermediate, and advanced vision services essential to the new generation of eye injured 

veterans from OIF and OEF. In addition, VA continues to emphasize medical vision 

research and the latest advances in prosthetic adaptive equipment, with access to 

new vision technology through a coordinated team approach that is designed to benefit both low vision and blinded veterans of all eras. 

VA Blind Rehabilitative Centers 

BRCs are especially important for the returning OIF and OEF service personnel 

because they often suffer from multiple traumas that include TBI, amputations, 

other neurosensory losses, and limb injuries. One VA research study found PTSD 

in 44 percent of TBI patients, 22 percent suffer depression, 40 percent had acute 

and chronic pain management issues. Mild TBI was found in 44 percent of these 

433 patients, with 56 percent diagnosed with moderate to severe TBI with 12 percent of those had penetrating brain trauma. The Defense Veterans Brain Injury 

Center (DVBIC) reports that an analysis of the first 433 TBI wounded found 19 percent had concomitant amputation of an extremity. The VA BRC can deliver the entire array of highly specialized care needed for them to optimize their rehabilitation 

outcomes and successfully reintegrate within their families and communities. Mr. 

Chairman, we wish to strongly emphasize that private agencies may lack all of the 

highly specialized consultant services, and prosthetics expertise, that our residential 

blind centers have now developed, and they all have Commission on Accreditation 

of Rehabilitation Facilities (CARF) approval. Only the inpatient VA Blind Centers 

have all the various specialized consultant services needed such as prosthetics, orthopedics, neurology, rehabilitative medicine, surgery, ophthalmology and low vision 

optometry, and psychiatry to treat these polytrauma servicemembers. 

There is no environment of which we are aware that better facilitates the initial 

emotional adjustment to the severe problems associated with the traumatic loss of 

vision than full, comprehensive VA blind rehabilitation. One BVA recommendation 

though is that VHA BRS should have more central control over VA blind center 

staffing resources and the funding levels because BRS will be better able to track 

demand for workload across all centers, monitor waiting times, and improve the 

overall allocation of critical resources in meeting new staffing demands. 

VISUAL IMPAIRMENT SERVICES TEAMS AND BLIND REHABILITATION 

OUTPATIENT SPECIALISTS 

The mission of each Visual Impairment Service Team (VIST) program is to provide blinded veterans with the highest quality of adjustment to vision loss services 

and blind rehabilitation training. To accomplish this mission, VIST has established 

mechanisms to maximize the identification of blinded veterans and to offer a review 

of benefits and services for which they are eligible. The VIST concept was created 

in order to coordinate the delivery of comprehensive medical and rehabilitation services for blinded veterans. VIST Coordinators are in a unique position to provide 

comprehensive case management and Seamless Transition services to returning 


ccoleman on DSK8P6SHH1PROD with HEARING
38 

OIF/OEF service personnel for the remainder of their lives. They can assist not only 

the newly blinded veteran but can also provide his/her family with timely and vital 

information that facilitates psychosocial adjustment. 

The VIST system now employs 114 full-time Coordinators and 43 who work parttime. The average caseload is 375 blinded veterans. VIST Coordinators nationwide 

serve as the critical key case managers for some 49,269 blinded veterans, a number 

that is projected to increase to 52,000 within a couple of years. The VIST teams are 

able to coordinate local services when a veteran requires them and follow blinded 

veterans who attend a BRC and later require any additional training due to improvements in adaptive equipment or technology. 

BLIND REHABILITATIVE OUTPATIENT SPECIALISTS (BROS) 

VA BRS established several new Blind Rehabilitative Outpatient Specialists positions during FY 2009 in facilities throughout the system, bringing the total of BROS 

to 73 working full-time, triple the number from 2004 largely due to the efforts of 

this committee and Chairman Michaud. The creation of the positions placed VA in 

a better position to deliver accessible, cost-effective, top-quality outpatient blind rehabilitation services. 

While the BROS is a highly qualified professional who, often is dually certified; 

that is, he/she has a dual masters science degree both in Orientation and Mobility 

(living skills and manual skills) and Rehabilitation Teaching and is credentialed and 

privileged in VA medical centers there is problem within DoD medical treatment facilities (MTF). The defense health care system has never before credentialed BROS 

professionals because for sixty years blinded servicemembers were sent to VA 

BRC’s. While DoD credentials other occupations with similar master’s degrees for 

example, occupational and physical therapists, DoD has no policy for credentialing 

of VA BROS. We credit VHA and VCE director, COL Gagliano, for trying over the 

past year for DoD MTF’s to credential these VA BROS into selected MTF’s to begin 

early blind rehabilitative training skills for the severely wounded that may be pending being transferred to VA BRC.Walter Reed Med Center and Navy Medical Center 

currently have been unable to credential the local VA BROS so they can provide 

this training. Such training prepares these individuals to provide the full range of 

mobility, living, and adaptive manual skills that are essential early skills in recovery and return to the veteran’s home environment and BROs provide reassurance 

to family members that the training will lead to independence. Today in several 

DoD and VA medical centers there are wide number of clinical providers, social 

workers, and other staff working together within each department’s facilities to improve transition and clinical care. BVA would strongly recommend that the VA 

Committee working with HASC provide ‘‘NDAA report language’’ that VA 

credentialed and privileged BROS shall be granted MTF clinical privileges as VA 

clinical consultants representing VA Blind Rehabilitative Service and that DoD and 

VHA report back to the committees on the implementation of this privileging process. 

ADVANCED BLIND REHABILITATION PROGRAMS 

Pre-admission home assessments, individualized evaluations, and outpatient 

training, all of which are complemented by a post-completion home follow-up, are 

part of the new three year expansion of VA’s Advanced Outpatient Blind programs. 

These programs have been referred to historically as VISOR (Visual Impairment 

Services Outpatient Rehabilitation Program). They consist of a nine-day rehabilitation experience, offering Living Skills Training, Orientation and Mobility, and LowVision Adaptive Devices Therapy with appropriate prosthetics while staying in 

Hoptel bed at a medical center with nursing care as necessary during the stay. A 

VIST Coordinator with low-vision credentials manages the program with other key 

staff members consisting of certified BROS, Orientation and Mobility Specialists, 

Rehabilitation Teachers, Low-Vision Therapists, and Low-Vision Ophthalmologists. 

These new programs considerably improve access, provide new rehabilitation services of the highest quality, reduce waiting times, and decrease veteran travel across 

networks. 

INTERMEDIATE LOW-VISION OPTOMETRY PROGRAMS: VICTORS 

Another important model of service delivery that does not fall under VA BRS is 

the Visual Impairment Center to Optimize Remaining Sight (VICTORS), an innovative program operated by VA Optometry Service. It consists of special services to 

low-vision veterans who, although not legally blind, suffer from severe visual impairments. Veterans must usually have a visual acuity of 20/70 through 20/200 to 


ccoleman on DSK8P6SHH1PROD with HEARING
39 

be considered for this service. The program, entirely outpatient, typically lasts three 

days. Veterans undergo a comprehensive, low-vision optometric evaluation and then 

appropriate low-vision prosthetics devices are then prescribed. The Low-Vision Optometrists employed in Intermediate programs are ideal for the highly specialized 

skills necessary for the assessment, diagnosis, treatment, and coordination of services for returnees from Iraq or Afghanistan with TBI visual dysfunction and who 

also require low-vision services. These new low-vision programs assist veterans with 

some residual vision from conditions such as macular degeneration, diabetic retinopathy, glaucoma and other degenerative eye diseases in maintaining independence 

and functional status at home or work. 

PRIVATE AGENCIES AND POLY TRAUMA REHABILITATION SERVICES 

BVA objects to finding that private agencies for blind are asking for members to 

earmark various ‘centers of excellence’ and private agencies trying to initiate new 

independent programs to ‘‘manage these new OIF and OEF combat wounded,’’ adding to the confusion and negatively impacting transition between DoD and VA. Recent combat blinded servicemembers often suffer from multiple traumas that include TBI, amputations, neuro-sensory losses, PTSD, pain management, and depression. The New England Journal of Medicine’s January 31, 2008 article on the experience of mild TBI wounded found even mild cases were significantly more likely 

within three to four months after injury to develop altered mental status, depression, headaches, emotional distress in up to 30 percent of cases, again evidence that 

without neurology, neuro-psychology or psychiatry staff, the specialized treatment 

necessary for recovery will be missed. Only VA Blind Rehabilitation Centers (BRC’s) 

can deliver the entire full array of these inpatient medical-surgical and psychiatric 

specialized care often needed for veterans to fully optimize their rehabilitation outcomes and successfully reintegrate into their families and communities. They need 

the specialized VA mental health services with coordinated multidisciplinary health 

care teams that the VA medical centers are capable of providing. 

We caution that residential private agencies for the blind do not have the full specialized nursing, physical therapy, pain management, speech pathology, pharmacy 

services, and lab or radiology support services, along with subspecialty surgery specialists, to provide the clinical care necessary for the wounded. The lack of electronic 

health care records in the private agencies would make things worse when veterans 

returned into DoD or VA medical services. BVA requests that any private agencies 

should demonstrate peer reviewed quality outcome measurements that are a standard part of VHA BRS and they also must be accredited by either the National Accreditation Council for Agencies Serving the Blind and Visually Handicapped (NAC) 

or the Commission on Accreditation of Rehabilitation Facilities (CARF) and blind rehabilitation instructors must be certified by the Academy for Certification of Vision 

Rehabilitation and Education Professionals (ACVREP). They should also have the 

specialized medical staffing necessary for complex wounds. 

BVA believes that the DoD–VA Seamless Transition process for eye trauma cases 

must include the sharing of outcome studies, clinical guidelines, and joint peer reviewed research projects on vision care and vision loss prevention through the exchange of electronic medical records and clinical specialized consultation. These 

components are not present in private agencies for the blind. 

RECOMMENDATIONS 

• Congress must ensure the full establishment and budget of the Vision Center 

of Excellence VCE and Eye Trauma Registry must become operational. Joint 

DoD/VA staffing resources available now is critical for successful Seamless 

Transition of eye injured. Request DoD appropriations include $9,350,000 for 

FY 2011 for operations and staffing for the VCE. Section 1624 of NDAA FY 

2008 must be modified and specific organizational governance alignment for 

the VCE Director and VA Deputy Director shall report directly to the Assistant Secretary of Defense for Health Affairs and to the Under Secretary of 

Health (USH) in VHA. 

• BVA would strongly recommend that the VA Committee with HASC provide 

‘‘NDAA report language’’ that VA credentialed and privileged Blind Rehabilitative Outpatient Specialists (BROS) ‘shall be granted MTF clinical privileges 

as VA clinical staff’ for VA Blind Rehabilitative Service (BRS) and that DoD 

and VHA shall report back to the committees on the implementation of this 

privileging process for BROS. 

• The new, specialized VA programs for blinded and low-vision veterans Continuum of Care must be utilized by DoD and to ensure that continuing eduVerDate Nov 24 2008 00:57 Jan 06, 2011 Jkt 058060 PO 00000 Frm 00043 Fmt 6604 Sfmt 6621 I:\WAYS\OUT\58060.XXX GPO1 PsN: 58060

ccoleman on DSK8P6SHH1PROD with HEARING
40 

cation of DoD staff about this must occur along with the various VA Case 

Managers, the Federal Recovery Coordinators (FRCs) and the Vision Center 

of Excellence (VCE). Veterans and their families must know where these resources are located so that they continue to receive the high quality VA vision 

health care. 

• BVA supports the National Alliance for Eye Vision Research’s (NAEVR) position that extramural defense vision research funding through the dedicated 

Peer Reviewed Medical Research-Visionline item in the DoD’s Congressionally 

Directed Medical Research Program (PRMRP) is essential. BVA urges that 

PRMR–Vision be funded at $10 million in FY2011 defense appropriations and 

BVA also appreciates the dear colleague letter of Congressman Walz dated 

July 15, 2010 requesting members support this level of funding. 

CONCLUSION: 

Once again, Mr. Chairman, and Members of the subcommittee, BVA appreciates 

this opportunity to present our testimony on Specialized VA Health Care services 

confronting the newly injured returning from OIF and OEF. I will answer any questions you have. 

f 

Prepared Statement of Carl Blake, National 

Legislative Director, Paralyzed Veterans of America 

Chairman Michaud and Members of the Subcommittee, on behalf of Paralyzed 

Veterans of America (PVA), I would like to thank you for the opportunity to present 

PVA’s views on how the Department of Veterans Affairs (VA) is caring for the severely injured Operation Enduring Freedom (OEF) and Operation Iraqi Freedom 

(OIF) veterans. The challenges the VA has faced in delivering care to OEF/OIF veterans have been unique as this generation of servicemembers has experienced new 

and different actions in combat, such as the wide-spread use of improvised explosive 

devices (IED). And yet, the delivery of specialized health care is something that the 

VA has greatly improved upon over the years and has established itself as a world 

leader. 

The wars in Afghanistan and Iraq have now continued for an extended period of 

time. The number of casualties and new veterans being created has had a significant impact on the VA. PVA appreciates the Subcommittee’s continued efforts to 

sufficiently fund the care for this growing number of veterans. VA has done a great 

many things to provide for the care of our newest generation of veterans. The open 

enrollment of OEF/OIF veterans into the VA health care system for up to five years 

after these servicemembers leave the service, creation of multiple polytrauma centers to address the complex and severe disabilities that some servicemembers are 

experiencing as a result of their service, the expansion of mental health programs 

as well as programs targeted at women veterans, and other efforts to ensure the 

proper care of these men and women demonstrates VA’s willingness to go the extra 

distance to provide timely and sufficient care. 

It is important to emphasize that specialized services are part of the core mission 

and responsibility of the VA. For a long time, this has included spinal cord injury 

care, blind rehabilitation, treatment for mental health conditions—including posttraumatic stress disorder (PTSD)—and similar conditions. Today, traumatic brain 

injury (TBI) and polytrauma injuries are new areas that the VA has had to focus 

its attention on as part of their specialized care programs. 

Specialized services were initially developed to care for the unique health care 

needs of veterans. The VA’s specialized services are incomparable resources that 

often cannot be duplicated in the private sector. With this in mind, we believe that 

the VA must be given the opportunity to show what it is capable of doing in addressing TBI and polytrauma conditions for this newest generation of veterans. 

The provision of specialized services is vital to maintaining a viable VA health 

care system. Specialized services are part of the primary mission of the VA. The erosion of these services would lead to the degradation of the larger VA health care 

mission. With growing pressure to allow veterans to seek care outside of the VA, 

the VA faces the possibility that the critical mass of patients needed to keep all 

services viable could significantly decline. All of the primary care support services 

are critical to the broader specialized care program provided to veterans with spinal 

cord injury. If primary care services decline, then specialized care is also diminished. 


ccoleman on DSK8P6SHH1PROD with HEARING
41 

As such, we are pleased to see that the VA has applied the spinal cord injury care 

model to treatment for polytrauma and TBI. PVA believes that the hub-and-spoke 

model used in the VA’s spinal cord injury service serves as an excellent model for 

how this network of polytrauma centers can be used. Second level treatment centers 

(spokes) refer spinal cord injured veterans directly to one of the 23 spinal cord injury centers (hubs) when a broader range of specialized care is needed. 

Treatment of polytrauma and TBI can function in the same fashion. The new level 

two polytrauma centers (spokes) being established will better assist VA to raise 

awareness of the complex medical issues that severely injured servicemembers and 

veterans are facing. These increased access points will also allow VA to develop a 

system-wide screening tool for clinicians to use to assess TBI patients. When more 

comprehensive treatment is needed, a veteran can be referred to the level one polytrauma center that serves as the hub. Unfortunately, the ability of VA to provide 

this critical care has been called into question. PVA recognizes that the VA’s ability 

to provide the highest quality TBI care is still in its development stages; however, 

it continues to meet these veterans’ needs while continuing to expand its capabilities. 

While VA has gone to great lengths to provide appropriate care for OEF/OIF veterans, there have been several recent media reports indicating problems with proper 

identification and treatment of servicemembers suffering from TBI. This has occurred despite increased attention to the problem. Those with significant cases of 

TBI are being identified and well cared for. It is those with less severe cases of TBI 

that seem to be falling through the health care cracks. In most cases, this is not 

VA’s fault. Instead, the identification and treatment by Department of Defense 

(DoD) personnel on the scene or at the initial care sites are not making this identification. This is leading to a lack of continued care when those veterans who may 

suffer from mild to moderate, but undiagnosed, TBI injuries leave the service and 

seek care at VA facilities. We expect VA will continue to work closely with DoD to 

ensure TBI care is provided to all veterans who have suffered this often debilitating 

injury. 

But for PVA, there is an ongoing problem that has not received a similar level 

of appropriate media coverage. Some active duty soldiers with a new Spinal Cord 

Injury/Dysfunction (SCI/D) are being transferred directly to civilian hospitals in the 

community and bypassing the VA health care system. This is particularly true of 

newly injured servicemembers who incur their spinal cord injury in places other 

than the combat theaters of Iraq and Afghanistan. This violates a Memorandum of 

Agreement between VA and DoD that was effective January 1, 2007 requiring that 

‘‘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’’ and that ‘‘whenever possible the VA health care facility closest to the active duty member’s home of record . . . should be contacted 

first.’’ In addition, it requires that ‘‘To ensure optimal care, active duty patients are 

to go directly to a VA medical facility without passing through a transit military 

hospital,’’ clearly indicating the critical nature of rapidly integrating these veterans 

into an SCI health care system. 

This is not happening. For example, servicemembers who have experienced a spinal cord injury while serving in Afghanistan and Iraq are being transferred to 

Sheppard Spinal Center, a private facility, in Atlanta when VA facilities are available in Augusta. When we raised our concerns with the VA regarding Augusta in 

a site visit report, the VA responded by conducting an information meeting at 

Sheppard to present information and increase referrals. However, reactionary measures such as this should not be the standard for addressing these types of concerns. 

Of additional concern to PVA, it was reported that some of these newly injured 

soldiers receiving treatment in private facilities are being discharged to community 

nursing homes after a period of time in these private rehabilitation facilities. In 

fact, some of these men and women have received sub-optimal rehabilitation and 

some are being discharged without proper equipment. PVA is greatly concerned with 

this type of process and treatment. There is a serious need to reinforce compliance 

by DoD regarding the Memorandum of Agreement toward the treatment of soldiers 

with new SCI/D at VA SCI centers. 

Ensuring that these men and women gain quick access to VA care in spinal cord 

injury centers is critically important because it begins what will become a lifelong 

treatment process. SCI/D care in the VA is unique from private care for spinal cord 

injury rehabilitation because of the care coordination that the veteran receives for 

the remainder of his or her life. Care coordination begins as soon as a new injury 

enters the VA SCI service. Failure to transfer new injuries into the VA only serves 

to deny these men and women the world-class specialized care the VA will provide. 

While we understand that local VA medical centers and DoD facilities are taking 


ccoleman on DSK8P6SHH1PROD with HEARING
42 

actions to improve this process, we ask that the Subcommittee work with your colleagues of the House Committee on Armed Services to ensure our SCI/D veterans 

are getting the complete, proper and appropriate care for their sacrifices. 

VA has historically been the best provider of care for our injured veterans. They 

are familiar with the wounds of war and the physiological and psychological conditions that accompany them. It is unacceptable that DoD might move its disabled 

warriors to sub-standard care and we can only believe that this is because some individuals within the DoD health care system do not understand the complexities of 

SCI/D care and the multitude of conditions that require attention for veterans with 

spinal cord injuries. 

PVA also remains concerned that the VA must maintain its capacity for the provision of SCI/D care as mandated by P.L. 104–262, the ‘‘Veterans Health Care Eligibility Reform Act of 1996.’’ This law required the VA to maintain its capacity to provide for the special treatment and rehabilitative needs of veterans with spinal cord 

injury, blindness, amputations, and mental illness. The baseline of capacity for spinal cord injury was established based on the number of staffed beds and the number 

of full-time equivalent employees assigned to provide care on the date of enactment 

of the law. 

Ultimately, we cannot emphasize enough that any reduction in staffed beds can 

have a direct negative impact on the newest generation of veterans as well as veterans of previous generations. Unfortunately, the single biggest accountability measure—an annual capacity reporting requirement—expired in April 2004. This allows 

the VA to make changes to its SCI/D capacity in a less than transparent manner. 

In accordance with the recommendations of The Independent Budget for FY 2011, 

PVA calls on this Subcommittee to approve legislation to reinstate this vitally important reporting requirement. 

Additionally, the SCI/D programs of the VA face a common challenge with the 

larger health care system—a shortage of qualified nurse staffing. As a result, VA 

is experiencing delays in admissions and bed reductions at its SCI centers. In order 

to meet this challenge head on, some SCI centers in the VA have offered recruitment and retention bonuses to enhance their nurse staffs. Unfortunately, this is not 

a uniform national policy and these actions are subject to the budget decisions of 

local VA medical center and Veterans Integrated Service Network (VISN) directors. 

In accordance with recommendations of The Independent Budget, we believe it is 

time for the Veterans Health Administration (VHA) to centralize policies and funding for systemwide recruitment and retention of SCI nurse staffing. Additionally, we 

believe Congress should establish a specialty pay provision for nurses working in 

the SCI service, and should consider extending similar provisions to the other VA 

specialized services. 

PVA appreciates the emphasis this Subcommittee has placed on reviewing the 

care being provided to the most severely disabled servicemembers and veterans returning from OEF/OIF. It cannot be overstated that the VA is the best option for 

these men and women when it comes to provision of specialized services. And yet, 

we have only touched on a small segment of this population—SCI/D veterans—in 

our testimony today. There are many more severely injured servicemembers and 

veterans who are dealing with TBI, vision impairment, amputations, and serious 

mental illness. We would encourage the Subcommittee to review The Independent 

Budget for FY 2011. This comprehensive policy document includes significant discussion about the challenges of providing care to this generation of war-wounded 

veterans, as well as the individual issues with the different segments of specialized 

services. 

PVA would like to thank the Subcommittee once again for allowing us to provide 

testimony on these important health care issues facing OEF/OIF veterans, as well 

as other severely disabled veterans. We certainly appreciate the continued attention 

this Subcommittee has placed on these issues. I would be happy to answer any 

questions that you might have. Thank you. 

f 

Prepared Statement of Joy J. Ilem, Deputy National 

Legislative Director, Disabled American Veterans 

Mr. Chairman, Ranking Member Brown, and Members of the Subcommittee: 

Thank you for inviting the Disabled American Veterans (DAV) to testify at this 

hearing of the Subcommittee on Health, titled ‘‘Healing the Physical Injuries of 

War.’’ We appreciate the Subcommittee’s leadership in enhancing the Department 

of Veterans Affairs (VA) health care programs on which many service-connected disabled veterans must rely, and to comment on how the VA is caring for the severely 


ccoleman on DSK8P6SHH1PROD with HEARING
43 

1 R. Jesse, M.D., Ph.D., Acting Principal Deputy Under Secretary for Health, Veterans Health 

Administration, Department of Veterans Affairs; Testimony before the United States Senate 

Committee on Armed Services; June 22, 2010. 2D.X. Cifu, M.D., Acting National Director VHA PM&R Services, Chief of PM&R Richmond 

VAMC; VA Polytrauma System of Care; PowerPoint Presentation, November 3, 2009. 3 VA QUERI Fact Sheet; Polytrauma & Blast-Related Injuries; June 2010. 4 Institute of Medicine; Preliminary Assessment of Readjustment Needs of Veterans, Servicemembers, and Their Families; Ch. 5, March 31, 2010. 5Wade, Sarah, Statement before House Veterans’ Affairs Subcommittee on Oversight and Investigations, April 28, 2009. 6Lynch, Cheryl, Statement before House Veterans’ Affairs Subcommittee on Oversight and Investigations, April 28, 2009. 

injured servicemembers and veterans of Operations Enduring and Iraqi Freedom 

(OEF/OIF) through its specialty programs. We also appreciate the Subcommittee’s 

interest in identifying any gaps in care or services that may exist within these programs. We are specifically focusing our testimony on VA’s Polytrauma/Traumatic 

Brain Injury (TBI) System of Care. 

According to VA’s June 2010 Queri Fact Sheet on Polytrauma and Blast Related 

Injuries more than 37,000 OEF/OIF servicemembers have been wounded in action, 

and of those, more than 20,000 were unable to return to duty within 72 hours, presumably because of the severity of their injuries. Blasts were listed in the Fact 

Sheet as the most common cause of injury. In combat, sources of blast injury includes artillery, rocket and mortar shells, mines, booby traps, aerial bombs, improvised explosive devices (IEDs), and rocket-propelled grenades 

According to VA, from March 2003 through March 2010 a total of 1,792 inpatients 

with severe injuries have been treated at Polytrauma Rehabilitation Centers.1 Within this total group of patients, 774 were injured in OEF/OIF with the remaining injured in non-combat, non-deployed incidents.2 Blast injuries are often polytraumatic, 

meaning they affect multiple body systems or organs, resulting in physical, cognitive, psychological, and psychosocial impairments and functional disabilities.3 As 

a result of these blasts, servicemembers and veterans who are classified as polytraumatic often experience a combination of amputations, spinal card injury (SCI), 

visual and auditory impairments, brain injury, post traumatic stress disorder 

(PTSD) and other catastrophic medical conditions. Patients presenting with these 

types of injuries require a high level of provider coordination, interdisciplinary clinical support and a wide range of specialized services. 

As reported by the Army Office of the Surgeon General, from September 2001 to 

January 12, 2009, there were 1,184 amputations in personnel deployed to OIF and 

OEF, nearly three-quarters of which were major amputations. IEDs caused 55 percent of the 1,184 OEF/OIF amputations.4 Through our research we have found it 

difficult to come up with a firm number representing the total number of severely 

wounded from OEF/OIF as it appears that VA and Department of Defense (DoD) 

track veterans and servicemembers separately, with VA using only the number of 

servicemembers or veterans who have been treated in one of its Polytrauma Centers. We suggest that VA and DoD collaborate to provide an accurate accounting of 

the number of severely wounded, how they classify a person in this category, where 

they were treated, as well as their active duty or veteran status at time of accounting. 

In 2005, due to the number of polytrauma casualties from the wars in Afghanistan and Iraq, VA expanded the scope of services available at its existing VA TBI 

Centers to establish a more integrated, tiered system of specialized, interdisciplinary care for polytrauma injuries and TBI. Currently, VA operates four regional 

Polytrauma/TBI Rehabilitation Centers (PRCs) that provide specialized inpatient rehabilitation treatment and expanded clinical expertise in polytrauma. The PRCs are 

located at VA medical centers in Minneapolis, Palo Alto, Richmond, and Tampa, and 

a fifth PRC is currently being established in San Antonio. These PRCs are the hub 

of the Polytrauma/TBI System of Care, which includes four Polytrauma Transitional 

Rehabilitation Programs that are co-located within the PRCs; 22 specialized outpatient and subacute residential rehabilitation programs referred to as Polytrauma 

Network Sites (PNS) that are geographically distributed within each of the VA’s 21 

integrated service networks (VISNs) including one at the VA medical center in San 

Juan, Puerto Rico. VA has also reportedly designated Polytrauma Support Clinic 

Teams at smaller, more remote VA facilities; and has established a point of contact 

and referral at all other VA facilities.5, 6

Today’s injured military servicemembers are experiencing higher survival rates 

than in previous wars, with the overall survival rate among wounded troops being 

about 90 percent. This increase is attributed to the widespread use of body armor, 


ccoleman on DSK8P6SHH1PROD with HEARING
44 

7 Institute of Medicine; Preliminary Assessment of Readjustment Needs of Veterans, Servicemembers, and Their Families; Ch. 5, March 31, 2010. 8 Vanguard; Better Care for Wounded Warriors; Winter 2009/2010. 9 Institute of Medicine; Preliminary Assessment of Readjustment Needs of Veterans, Servicemembers, and Their Families; Ch. 5, March 31, 2010. 

improved battlefield triage procedures and expedited medical evacuation.7 For a majority of our wounded servicemembers, the first level of complex intervention on 

their journey to a VA PRC normally occurs at the Landstuhl Regional Medical Center in Germany, operated by the U.S. Army. Up until 2009, VA received little to 

no information about wounded servicemember transport, the full extent of the acute 

care process that servicemembers had undergone, or the stress that these patients 

had experienced before arriving at a VA PRC. However, in October of 2009, a team 

of two VA physicians and two nurses from VA’s Polytrauma System of Care spent 

four days at Landstuhl to gather information and put a system in place to establish 

a regular exchange of information between medical teams in the military and VA’s 

PRCs. The PRCs are now able to track patients from the beginning of their journeys 

and can identify medical complications much earlier. This system of coordination 

has established a continuum of care that is not proprietary to the DoD or VA, and 

has aided them to develop one system that benefits our wounded personnel and veterans.8 We are pleased with this relatively new development and believe it addressed one key area where gaps in care were evident for those who were treated 

before its implementation at VA PRCs. 

Recently DAV National Commander Roberto ‘‘Bobby’’ Barrera visited VA’s PRC in 

Tampa, Florida. In meeting with injured servicemembers, veterans and their families, our Commander received very positive feedback about the level and coordination of care provided to severely injured patients, and remarked on the high regard 

these families held for the dedicated medical staff caring for their loved ones. 

In preparing for this hearing, I had the opportunity to talk with the father of a 

severely disabled servicemember who was injured nearly nine months ago in Afghanistan and is now an inpatient at the Tampa PRC. I was very pleased to learn 

that his impression, from the date of his son’s injury to the present, the care provided—initially in Afghanistan, then in Landstuhl and subsequently in VA’s PRC 

in Tampa, was seamless. This father commented on the high level of coordination 

of care and expert staff, in both VA and DoD, that was necessary and existed every 

step of the way as his son was transported to the United States and from Tampa 

to Walter Reed Army Medical Center (WRAMC) for surgeries and returned to the 

Tampa PRC. 

DAV was very pleased to hear this stellar report about DoD/VA collaboration and 

coordination of care and acknowledge the dedicated staff who created this critical 

system—to optimize care coordination and transition of complex patients across the 

DoD and VA health care systems. This helps to ensure every severely injured 

servicemember and disabled veteran has the best care available, and reduces the 

burden that families must endure during these extreme circumstances post-injury 

of a loved one. I was pleased to learn that this particular veteran is now beginning 

to communicate and walk—although it was apparent that his recovery will be slow 

and he likely will require years of surgeries, comprehensive rehabilitation, family 

support—and a lifetime of attendance by VA. 

In a March 2010 report, the Institute of Medicine (IOM) suggested that more research and program development are needed to substantiate the potential usefulness and cost-effectiveness of protocols in use for the long-term management of TBI 

and polytrauma, including: 

• Prospective clinical surveillance to allow early detection and intervention for 

health complications; 

• Protocols for preventive interventions that target high-incidence or high-risk 

complications; 

• Protocols for training in self-management aimed at improving health and 

well-being; 

• Access to medical care to treat complications; and 

• Access to rehabilitation services to optimize functional abilities.9

According to the IOM, the array of potential health outcomes associated with TBI 

suggests that injured servicemembers and veterans will present long-term medical 

and psychosocial needs from the persistent physical disability as well as cognitive 

deficits and psychosocial problems that may develop in later life. Access to rehabilitation therapies are essential—including psychological, social, and vocational services. Although VA has established a comprehensive system of rehabilitation services 

for polytrauma and severe TBI patients that addresses acute and chronic needs that 


ccoleman on DSK8P6SHH1PROD with HEARING
45 

10 Ibid. 11 R. Jesse, M.D., Ph.D., Acting Principal Deputy Under Secretary for Health, Veterans Health 

Administration, Department of Veterans Affairs; Testimony before the United States Senate 

Committee on Armed Services; June 22, 2010. 12L. Beck, PhD., Chief Consultant, Office of Rehabilitation Services, Office of Patient Services, 

Veterans Health Administration, Department of Veterans Affairs; Testimony before the United 

States Senate Committee on Veterans’ Affairs; May 5, 2010. 

arise in the initial months and years after injury—protocols and programs to manage the devastating lifetime effects that many of these veterans must live with are 

not in place and have not been studied for either military or civilian populations. 

We concur with IOM that as in other chronic health conditions, long-term management of TBI may be effective in reducing mortality, morbidity, and associated costs 

of VA’s caring for this extraordinary population.10

VA testified that in 2007 it developed and implemented Transitional Rehabilitation Programs at each PRC. These facilities consist of 10-bed residential units with 

a home-like environment to facilitate community reintegration. The average stay is 

approximately 3 months in one of these rehabilitation units. Other specialized services developed by VA include the establishment of an Emerging Consciousness care 

path at the four PRCs for severe TBI patients that are slow to recover consciousness 

as well as a program to evaluate ocular health and visual function.11 According to 

VA it has also developed policies regarding comprehensive long-term care for postacute TBI rehabilitation that includes residential, community and home-based components utilizing interdisciplinary treatment teams.12 However, in some cases it 

may be difficult to find appropriate residential placement options for OEF/OIF veteran patients who are ready for discharge from acute rehabilitation but unable to 

return home. For many of these severely disabled young men and women medical 

foster care or nursing home placement is not an appropriate option. However, we 

are not aware of any age-appropriate, government sponsored facilities for this 

unique younger patient population with polytraumatic injuries and brain injury. 

These types of facilities for long-term placement only exist in the private sector, but 

again, they may not be appropriate placement options for a variety of reasons. In 

this connection, DAV National Commander Barrera heard about an extraordinary 

proposal called ‘‘Heroes Ranch’’ while on his visit to the Tampa PRC. 

We understand that 85 acres of land is available for the proposed Tampa-area Heroes Ranch—and would serve as a post-acute long-term care residential brain injury 

facility for active duty military servicemembers and veterans. The location of the 

land for the proposed Ranch is approximately 15 miles from the Tampa VA PRC. 

This cutting edge residence would serve the most severely injured—including individuals in a vegetative state, patients with neurobehavioral problems, and those 

persons that require a structured day program for ongoing recovery after completing 

acute inpatient rehabilitation. According to the proposal a three-tiered program 

would include: 

1. Post-acute long-term care for patients in a state of emerging consciousness 

who have completed twelve weeks of acute inpatient TBI rehabilitation and 

whose families are not ready, or are unavailable, to care for them at home; 

2. Sub-acute residential rehabilitation in a safe environment to treat patients 

with residual neurobehavioral issues; and 

3. Outpatient day rehabilitation in a structured environment for brain injured, 

neurologically and cognitively impaired veterans. 

To meet the long term needs of this unique population and the goal of an interdisciplinary approach, resources would be needed to staff the facility with a Medical 

Director to guide a team consisting of psychiatrists, neuropsychologists, psychologists, physical therapists, speech/cognitive therapists, recreational therapists, occupational therapists, vocational counselors, psychosocial counselors, nursing staff, 

nurse practitioners, physician assistants, living skills advisors, social workers, administrative personnel, and family therapists as well as support personnel, equipment and supplies. 

We understand this proposal is pending consideration within VA but not yet formally approved or funded. We ask that the Subcommittee inquire about this exceptional idea in order to clarify VA’s intent. Clearly, an offsite VA therapeutic residential facility of this type is needed to ensure the ongoing recovery of this uniquely 

and catastrophically disabled veteran population, and as an aid to their families. 

VA’s mission is to provide leadership excellence for therapeutic, rehabilitative, vocational, and recreational services to sick and disabled veterans, and as a nation, it 

is our duty to ensure that a proper life-time age appropriate care center is estabVerDate Nov 24 2008 00:57 Jan 06, 2011 Jkt 058060 PO 00000 Frm 00049 Fmt 6604 Sfmt 6621 I:\WAYS\OUT\58060.XXX GPO1 PsN: 58060

ccoleman on DSK8P6SHH1PROD with HEARING
46 

13 J. M. Griffin, PhD, G. Friedemann-Sa ́nchez, PhD, et al; JRRD; Families of Patients with 

Polytrauma: Understanding the Evidence and Charting a New Research Agenda; Vol. 46, No. 

6, pp 879–892, 2009. 14 Ibid. 

lished within VA for these men and women who courageously served the nation and 

nearly made the ultimate sacrifice. DAV has testified in the past before this Committee to support VA’s development and deployment of therapeutic residential care 

facilities for our newest war generation. On May 7, 2007, Adrian Atizado, DAV Assistant National Legislative Director, gave the following testimony: 

Mr. Chairman, when we think of long-term care, we assume that these programs are reserved for the oldest veterans, near the end of life. Today, however, we confront a new population of veterans in need of specialized forms of 

long-term care—a population that will need comfort and care for decades. 

These are the veterans suffering from poly-traumatic injuries and traumatic 

brain injuries as a consequence of combat in Iraq and Afghanistan. In discussion with VA officials, including facility executives and clinicians now caring 

for some of these injured veterans, it has become apparent to DAV and others 

in our community that VA still needs to adapt its existing long-term care programs to better meet the individualized needs of a truly special and unique 

population, VA’s existing programs will not be satisfactory or sufficient in the 

long run. In that regard, VA needs to plan to establish age-appropriate residential facilities, and additional programs to support these facilities, to meet 

the needs of this new population. While the numbers of veterans sustaining 

these catastrophic injuries are small, their needs are extraordinary. While 

today they are under the close supervision of the Department of Defense and 

its health agencies, their family members, and VA, as years go by VA will become a more crucial part of their care and social support system, and in many 

cases may need to provide for their permanent living arrangements in an ageappropriate therapeutic environment. 

We are very pleased to see that at least one PRC, such planning for these unique 

therapeutic residential facilities is now underway. We strongly endorse the development of the facility in Tampa as well as the establishment of similar facilities in 

other areas of the country with concentrated populations of severely injured veterans with polytrauma and TBI. 

Another issue DAV is concerned about relates to family caregiver needs and VA’s 

pending implementation of the family support provisions of Public Law 111–163, the 

Caregivers and Veterans Omnibus Health Services Act of 2010. We ask the Subcommittee to provide oversight at regular intervals to ensure VA is making progress 

to fully implement all of the provisions in this important Act, and especially to move 

forward rapidly on provisions that are uncomplicated (more flexible and expanded 

respite services, for example). Caregivers of the severely wounded have waited years 

for this important and comprehensive package of services mandated in this precedent-setting legislation. 

Likewise, although much of the knowledge DoD and VA have gained on TBI is 

likely to transfer to the care of polytrauma patients, the information needs of caregivers of patients with catastrophic injuries may be distinct from those with TBI because the context, number and severity of the injuries and the amount and type of 

medical information required to treat them are more vast and complex. Similarly, 

administrative information is complex because patients are often involved in two, 

or sometimes three, health care and benefit systems simultaneously, including DoD 

and TRICARE, VA, and private, contract hospitals or clinics in their home communities. Research is needed to assess the specific information needs of caregivers who 

face these complexities.13

Furthermore, researchers suggest that few studies have been conducted to determine the information needs of families based on severity of injury, to determine the 

best timing and approach to communicate information based on the patient’s level 

of cognitive functioning, or the best training for providers on communicating with 

families who are grieving or angry about their loved one’s conditions and oftenchanging prospects for survival and recovery—especially early on in this process. 

Family caregivers respond and adjust differently depending on family composition, 

kinship to patient and other factors. No research exists today that addresses different information needs of family members, according to caregiver gender, on polytrauma or TBI cases.14 We believe such research should be done on a priority basis. 

As required by section 1702 of Public Law 110–181, the National Defense Authorization Act of 2008, and according to VA in testimony earlier this year, VA has developed and implemented a national template to ensure that it provides every vetVerDate Nov 24 2008 00:57 Jan 06, 2011 Jkt 058060 PO 00000 Frm 00050 Fmt 6604 Sfmt 6621 I:\WAYS\OUT\58060.XXX GPO1 PsN: 58060

ccoleman on DSK8P6SHH1PROD with HEARING
47 

15L. Beck, PhD., Chief Consultant, Office of Rehabilitation Services, Office of Patient Services, 

Veterans Health Administration, Department of Veterans Affairs; Testimony before the United 

States Senate Committee on Veterans’ Affairs; May 5, 2010. 16 J. M. Griffin, PhD, G. Friedemann-Sa ́nchez, PhD, et al; JRRD; Families of Patients with 

Polytrauma: Understanding the Evidence and Charting a New Research Agenda; Vol. 46, No. 

6, pp 879–892, 2009 17 VA QUERI Fact Sheet; Polytrauma & Blast-Related Injuries; June 2010. 18 C. Hall, RN, PhD, CCDOR, Minneapolis VAMC; Second Annual Trauma Spectrums Disorders Conference; VA Polytrauma Rehabilitation Centers’ Family Care Collaborative; December 

10, 2009. 

eran receiving inpatient or outpatient treatment for TBI who requires ongoing rehabilitation, an individualized rehabilitation and community reintegration plan. VA integrates this national template into its electronic health record, and includes in the 

record results of the comprehensive assessment, measurable goals that were developed as a result of the plan, and recommendations for specific rehabilitative treatments. The patient and family participate in developing the treatment plan and are 

provided a copy of the plan. According to VA, since April 2009, in consonance with 

this mandate, 8,373 of these individualized plans have been completed and filed for 

veterans who receive ongoing rehabilitative care in VA.15

Intervention studies that test the effectiveness of communication strategies for 

families and caregivers of those with a TBI are almost entirely absent, and these 

same gaps, therefore, probably occur in cases of caregivers of patients with polytrauma. Currently, no evidence-based guidelines have been developed on best practices for communication and education to support the adaptation and adjustment of 

families of patients with polytrauma across the continuum of treatment, rehabilitation, and lifelong services.16 DAV believes these studies should be done and the results of them distributed across the Polytrauma System of Care. 

While DAV believes great strides have been made over the past two years, VA 

recently acknowledged embracing opportunities for further improvement in its Polytrauma System of Care, and states the Department’s ongoing goals as follows: 

1. Ensuring that blast-exposed veterans receive screenings and evaluation for 

high-frequency, invisible sonic wounds that may produce mild TBI, PTSD, 

and other psychiatric problems, or pain and sensory loss; 

2. Promoting identification and evaluation of potentially the best practices for 

polytrauma rehabilitation, including those that optimize care coordination 

and transition across care systems and settings such as DoD and VA; 

3. Optimizing the ability of caregivers and family members to provide supportive assistance to veterans with impairments resultant from polytrauma 

and blast-related injuries; 

4. Identifying and testing methods for improving process of care and outcomes, 

even when the evidence base is not well established; and 

5. Identifying and testing methods for measuring readiness to implement and 

sustain practice improvements in polytrauma care.17

Historically, VA has focused its health care system on individual veterans, often 

to the exclusion of the needs of their family members, even including family caregivers. Thus, family-centered care is relatively new in VA. In that regard we were 

pleased to learn that the Minneapolis PRC, located at the Minneapolis VA Medical 

Center, has participated in a six-month pilot program designed to embrace the principles of family-centered care, and to include families as partners in care delivery 

of their wounded loved ones. As a part of this pilot program, a ‘‘Family Care Map’’ 

was created. The Family Care Map is a web-based resource that helps families navigate the many layers of information, ranging from where to find temporary lodging 

to locating sources of personal counseling. Soon this Web site is expected to be migrated to the main VA Web site for the VA Polytrauma System of Care so that all 

PRC-involved families may benefit from access to consolidated information to help 

them cope with these extraordinary circumstances.18

We appreciate VA’s efforts to standardize family-centered care and improve communications for this population and urge VA to move forward quickly to make this 

important information available to these families. Overall, based on our monitoring 

of their progress and as reviewed in this testimony, we believe that in most cases 

DoD and VA PRCs are collaborating well with respect to the most severely injured 

and are providing comprehensive, coordinated care in PRCs for this relatively small 

population. However, DAV remains concerned about the gaps that exist in the Federal Recovery Coordination Program and social work case management essential to 

coordinating complex components of care for polytrauma patients and their families. 


ccoleman on DSK8P6SHH1PROD with HEARING
48 

19 R. Jesse, M.D., Ph.D., Acting Principal Deputy Under Secretary for Health, Veterans Health 

Administration, Department of Veterans Affairs; Testimony before the United States Senate 

Committee on Armed Services; June 22, 2010. 20 Ibid. 

These gaps were highlighted by disabled veterans and their families in hearings 

held by the House Veterans’ Affairs Subcommittee on Oversight and Investigation 

in 2009 and 2010 and warrant continued oversight and evaluation. 

In testimony VA, reported the development and implementation of its ‘‘TBI 

Screening and Evaluation Program’’ for all OEF/OIF veterans who receive care 

within VA. According to VA, from April 2007 through March 2010: 

• 408,474 OEF/OIF veterans were screened for possible TBI; • 56,161 who screened positive were evaluated and received follow-up care and 

services appropriate to their diagnosis and their symptoms; • 30,368 were confirmed with a diagnosis of mild TBI; and • Over 90 percent of all veterans who were screened were determined not to 

have TBI, but all who screened positive and completed a comprehensive evaluation were referred for appropriate treatment.19

In 2009, VA and DoD collaboratively developed a clinical practice guideline for 

mild TBI and deployed this methodology to health care providers in both systems, 

and provided other recommendations as well in the areas of cognitive rehabilitation, 

driver training, and the management of the comorbidities of mild TBI, 

posttraumatic stress disorder (PTSD) and pain. Also, the 2009 VA-led collaboration 

with DoD and the National Center for Health Statistics produced revisions to the 

International Classification of Diseases, Clinical Modification (ICD–9–CM) diagnostic codes for TBI, resulting in significant improvements in the identification, 

classification, tracking, and reporting of TBI and its associated symptoms.20 These 

are late-arriving, but welcome, improvements during the sunsetting of our wars 

overseas. As more and more veterans are being identified with mild to moderate 

TBI, some several years after-the-fact, VA appears to be making progress, but we 

are concerned it may still lack a robust universal system of treatment and care for 

this population. 

Although there are not definitive numbers on how many veterans may need specialized services for mild to moderate TBI in the next five years—the findings from 

initial studies, articles and reports on these conditions, including PTSD and other 

post-deployment mental health issues, and VA’s current workload based on preliminary mental health and TBI screening numbers for OEF/OIF veterans indicate that 

in the near future, VA will likely be confronted with a significant population seeking 

care. To this regard, DAV remains concerned that screening and treatment of veterans with mild-to-moderate TBI in medical centers outside the five designated VA 

PRCs may not be receiving a commensurate level of additional VA resources they 

may need to fully assess and care for these injured veterans. Based on our discussion with VA staff some non-PRC sites may struggle to provide timely access to 

care, comprehensive evaluations, treatment and support for this particular patient 

population. We ask the Subcommittee through its oversight of VA’s specialized programs to make inquiry to ensure that sufficient resources and staff to accomplish 

this mission has been provided to non-PRC sites for treatment of mild-to-moderate 

TBI cases. 

We also ask the Subcommittee to evaluate VA’s current approaches and plans to 

ensure the care for those with mild-to-moderate TBI receive commensurate attention from VA, in contrast to the overwhelming response to the severely injured being 

cared for in PRC sites. We believe the situation and potential demand warrants an 

independent evaluation of its outpatient TBI programs. VA TBI specialists with 

whom we have consulted believe a new ‘‘dual track’’ specialized program is necessary to meet the individualized needs of veterans with mild-to-moderate TBI residuals accompanied by PTSD. It is likely more resources, staffing, training, research and education will be necessary to stand up effective programs to reliably 

deliver this type of appropriate interdisciplinary care. 

Mr. Chairman, in summary, DAV has concluded that DoD and VA have done a 

commendable job in saving the lives of, and addressing the catastrophic medical, 

surgical and rehabilitative needs of a new generation of severely disabled American 

war veterans, but we note that recent progress was years in the making. We hope 

VA will now turn its attention to the unmet needs of thousands of veterans with 

less life threatening but troubling injuries to the brain caused by war that are still 

little understood but in need of appropriate attention. We also urge VA to move forward swiftly in establishing needed therapeutic residential rehabilitation facilities 

modeled on the Tampa proposal for the sustained and unique care of the most seVerDate Nov 24 2008 00:57 Jan 06, 2011 Jkt 058060 PO 00000 Frm 00052 Fmt 6604 Sfmt 6621 I:\WAYS\OUT\58060.XXX GPO1 PsN: 58060

ccoleman on DSK8P6SHH1PROD with HEARING
49 

verely injured OEF/OIF veterans who will not easily or possibly ever be able to return to their homes. 

Mr. Chairman, this concludes my statement on behalf of DAV. I would be pleased 

to address your questions, or those of other Subcommittee members. 

f 

Prepared Statement of Tom Tarantino, Legislative 

Associate, Iraq and Afghanistan Veterans of America 

Mr. Chairman, Ranking Member, and members of the subcommittee, on behalf of 

Iraq and Afghanistan Veterans of America’s one hundred and ninety thousand members and supporters, I would like to thank you for allowing us testify before your 

subcommittee on ‘‘Healing the of Physical Injuries of War.’’ 

‘‘Veterans need to know that their country will continue to take care of their 

service-related injuries. A servicemember’s body pays a heavy toll from the high 

physical demands of deployments. It’s more than just paying disability claims, 

it’s a back or knee that starts to cause problems for a middle-aged man because 

he spent four years humping with a pack and patrolling with 60 lbs of gear.’’— 

IAVA Veteran 

My name is Tom Tarantino and I am a Legislative Associate with IAVA. I proudly 

served 10 years in the Army beginning my career as an enlisted Reservist, and leaving service as an Active Duty Cavalry Officer. During these ten years, my single 

most important duty was to take care of other soldiers. In the military they teach 

us to have each other’s backs. And although my uniform is now a suit and tie, I 

am proud to work with this Congress to continue to have the backs of America’s 

servicemembers and veterans. 

Over the past few years this Committee has helped secure impressive improvements to the VA health care system. For the first time in over twenty years, the 

VA now has a timely and fully funded budget that will end the practice of rationing 

health care services. The VA is developing a virtual lifetime service record that will 

seamlessly transition a veteran’s health record from DoD to the VA, ensuring a 

higher quality of care. Female veterans can now receive postnatal care for their 

newborn babies, and family caregivers of severely wounded veterans will have the 

training and assistance they need to support their loved ones. Thank you for all the 

work this Committee has done and will continue to do in the months and years to 

come. 

Specifically, we look forward to the work this Committee will do to continue to 

improve VA health care. The VA is the largest health care provider in the nation, 

and overall, it provides much higher quality of care than the nation’s private sector 

hospitals. The pressing problem with the VA health care system is not the quality 

of care, but a lack of access to the system. In order to continue to improve on both 

the quality of care and access to the system, IAVA fully supports all of the recommendations contained in this year’s Independent Budget that address issues related to specialized services, access to care, invisible wounds, prosthetics, long termcare, finance and administration. IAVA would like to focus our testimony on just 

few of those key issues as they relate to Iraq and Afghanistan veterans seeking 

treatment for combat injuries, especially Traumatic Brain Injury. 

We asked our members what they thought of the treatment they were receiving 

at the VA and we received a wide range of opinions, both complimentary and critical. However, several common themes appeared: 1) Long waits for quality appointments 2) Rude administrative staff 3) Growing distrust of VA health care 4) Long 

drives to VA facilities. We received only a few complaints about the actual quality 

of care at the VA. 

I. Rethink and adapt the VA’s rehabilitation practices for wounds of the 

wars in Iraq and Afghanistan 

Traumatic Brain Injury (TBI) is the signature wound of the wars in Iraq and Afghanistan. To properly treat these returning combat veterans with mild to severe 

TBI, the VA must completely rethink and adapt their medical rehabilitation practices just as the DoD has had to adapt to fight an unconventional war against insurgents. 

‘‘I suffered a TBI in Iraq and now have PTSD. Due to my symptoms, I lost my 

job, my family, my self-respect and for a time, my freedom! I have had to swallow my pride and accept Government assistance. I would rather work but the 

jobs I might be able to hold for a short time pay so little I would not be able 


ccoleman on DSK8P6SHH1PROD with HEARING
50 

1 ‘‘such professional, counseling, and guidance services and treatment programs as are necessary to restore, to the maximum extent possible, the physical, mental, and psychological functioning of an ill or disabled person.’’ 38 U.S.C. 1701(8). 2 VA Performance and Accountability Report, FY 2009, p. II- 145. 

to visit and take care of my sons. At times I feel like a complete failure.’’—IAVA 

Veteran 

As our friends over at Wounded Warrior Project (WWP) have stated, any successful rehabilitation of a veteran suffering from TBI ‘‘must be veteran-centered.’’ This 

means ensuring that all TBI patients are given a thoughtful individualized rehabilitation plan that is thorough and honest about what the VA can and cannot provide. 

Any rehabilitation plan must include the veteran’s family as a core component to 

rehabilitation. 

‘‘After my wife straightened out the VA doctors and fired a few, I finally got 

a doctor that truly listens and does what needs to be done to make sure I have 

what I need. She spends time talking with me and my wife. Some of the doctors 

have a problem talking with my wife, but I have a TBI and I don’t understand 

things well and she explains them to me and makes sure I do as I am suppose 

to. She is my caregiver and my best friend. She advocates for me and does 

whatever she has to, to make the doctor understand me, and vice versa.’’—IAVA 

Veteran 

IAVA is concerned that the VA has limited or denied access to some veterans 

seeking recovery services for Traumatic Brain Injury. Current statute requires that 

the VA provide services to ‘‘restore’’ function to wounded veterans.1 Full recovery 

should always be the desired outcome for a rehabilitation plan. However, sustaining 

current functions or preventing future harm should also warrant access to VA services. I have no doubt that the members of this committee agree that the VA’s role 

isn’t just to help those who might get better, but it also to help those who might 

get worse. IAVA recommends adjusting these statutes to embrace the realities of injuries like TBI. Veterans should be able to focus more on recovery then fighting with 

the VA. 

‘‘I have a possible traumatic brain injury or it could be PTSD but whatever it is, 

there is no way I could sit there and try and read through 10 pages of legal speak. 

Believe me I tried. Even if I read through all of it, I have no idea what I am reading 

cause I can’t focus on anything.’’—IAVA Veteran 

II. I have to wait how long to see a VA doctor? 

Among IAVA members seeking services at the VA, the single most common complaint is how long it takes to schedule an appointment. 

‘‘I did visit the VA, but will not again. Sorry to say, but the process to get an 

appointment is impossible. I had to get an appointment to get an appointment. 

What I mean is this—It took 3 weeks to get an appointment to see a nurse who 

assessed my injury, then she made an appointment to for me to see a doctor 

about my injury for 3 weeks later. By the time I was able to see a doctor, it 

was over 6 weeks. I lost 2 days of work. It seems like the process is set up to 

discourage patient care.’’—IAVA Veteran 

When veterans began returning home from Iraq and Afghanistan, the VA was 

caught unprepared, with a serious shortage of staff and an exceedingly inadequate 

budget. Wait times varied regionally, but for some patients, lasted six months or 

more. The problems weren’t limited to primary care along; the backlog was especially severe for veterans seeking mental health treatment. In recent years, wait 

times for primary and specialty care at the VA have improved, but approximately 

8 percent of patients—or more than 450,000 veterans—are still waiting more than 

30 days for their desired appointments, according to the VA.2 Moreover, the VA’s 

Inspector General suggests that wait may be even longer than the VA admits. And 

there are still some veterans who have ‘‘to wait on the phone for 2+ hours to speak 

with someone to set an appointment with [a] primary care physician that ends up 

being 4–6 weeks away from the date of my call.’’ Even when veterans are able to 

schedule an appointment, many times they still have to sit around the hospital for 

hours once they arrive because the VA ‘‘booked 20 patients during a 2 hour window.’’ 

For veterans, long wait times mean that they may have to suffer for months until 

their next appointment or opt for not receiving the care they need at all. 


ccoleman on DSK8P6SHH1PROD with HEARING
51 

3 U.S. Department of Veterans Affairs, ‘‘About Rural Veterans: Common Challenges Faced by 

Rural Veterans,’’ January 6, 2010: http://www.ruralhealth.va.gov/RURALHEALTH/ 

About_Rural_Veterans.asp. 4GAO–03–756T, ‘‘Department of Veterans Affairs: Key Management Challenges in Health and 

Disability Programs,’’ May 8, 2003, p. 6: http://www.gao.gov/new. items/d03756t.pdf. 

‘‘Ortho is a nightmare. I had to schedule a cortisone shot 2 1⁄2 months in advance, even though my shoulder was in pain now.’’—IAVA Veteran 

Just as the VA is working to address the VA disability backlog, the VA must continue attacking the issue of long appointment wait times. As recommended in the 

Independent Budget, the solution involves improved tracking, a completely revamped scheduling IT system and an increase in the number of medical providers 

in critical areas. To this end, IAVA supports the following recommendations from 

the Independent Budget: 

• The Veterans Health Administration should make external comparisons to 

measure its performance in providing timely access to care. • The VHA should fully implement complementary aspects of the Institute for 

Health care Improvement’s Advanced Clinic Access principles and measures 

for primary and specialty care to maximize productivity of clinical care resources by identifying additional high-volume clinics that could benefit. • VA should consider implementing complementary recommendations contained 

in the Booz Allen Hamilton report Patient Scheduling and Waiting Times 

Measurement Improvement Study. • The VHA should certify the validity and quality of waiting time data from 

its 50 high-volume clinics to measure the performance of networks and facilities. • The VHA should complete implementation of the eight recommendations for 

corrective action identified in the July 8, 2005 report by the VA Office of Inspector General. • VA must ensure that schedulers receive adequate annual training on scheduling policies and practices in accordance with the OIG’s recommendations. 

III. How far is too far to drive? 

Some veterans have to drive for an ‘‘entire day to get to their local VA facility’’ 

and IAVA is concerned that the VA has yet to develop a consistent and humane policy for answering an age old question, ‘‘How far is too far to make a veteran drive 

to the VA?’’ About 3 million veterans, or 37.8 percent of veterans enrolled in the 

VA system, reside in rural areas,3 and as of 2003, ‘‘more than 25 percent of veterans 

enrolled in VA health care—over 1.7 million— live over 60 minutes driving time 

from a VA hospital.’’ 4

‘‘I have an obvious service related injury that I receive a prescription for 

(Celebrex for a knee that was injured by IED) . . . rather than give me a referral to a local orthopedist in town, they wanted me to drive 5.5 hours to Tucson, 

which I could not do because of a busy work schedule. The whole process is very 

slow and cumbersome.’’—IAVA Veteran 

IAVA acknowledges that the VA can’t always be a short drive from every veteran. 

However, we believe that the VA should issue clear guidelines for when a veteran 

lives too far from a local VA facility. These veterans should be given the choice to 

continue using the VA or access more convenient local medical care. 

‘‘My main concern with the VA health care system is distance. We only have 

an outpatient clinic here and if I need anything more than a flu shot, I have 

to drive 125 miles to the nearest VA hospital.’’—IAVA Veteran 

IAVA also believes that the VA should assist veterans who need to drive to their 

appointment or need a ride. IAVA recommends that that the VA should (1) Promote, 

oversee, and evaluate a pilot program that provides a network of drivers for veterans struggling to find transportation to the nearest VA hospital and (2) Provide 

a lodging stipend and mileage reimbursement for veterans forced to travel long distances for VA medical care, comparable to the stipend paid to VA employees when 

they travel. 

‘‘For anything dental or surgical I have to travel 2 hours and often times for 

appointments that don’t last 30 minutes. Additionally, because I don’t qualify 

for travel pay, I often have to ask social workers for gas cards. The SWs appear 

to be annoyed by me whenever I ask for their assistance in obtaining gas 

cards.’’—IAVA Veteran 


ccoleman on DSK8P6SHH1PROD with HEARING
52 

IV. ‘‘I hear the VA is a nightmare.’’ 

Some of our members openly fear the VA. Recent media reports about HIV and 

Hepatitis exposure have only served to fuel that fire. A veteran returning home 

from Afghanistan who reads about his or her battle buddies being exposed to infectious diseases while being treated at the local VA will likely think twice before seeking the care s/he needs. 

‘‘As a Navy Hospital Corpsman who has worked in a VA hospital I am nervous 

about care provided by the VA.’’—IAVA Veteran 

Whether or not these fears are warranted is a topic for another hearing, but the 

end result is still the same, VA health care has a public relations problem. Until 

the VA adequately addresses this issue many combat veterans will be weary to seek 

treatment. IAVA believes that the VA must address this issue head on by owning 

the mistake, doing everything in their power to take care of those affected and then 

redoubling efforts to make sure proper medical procedures are followed at other facilities. 

What we don’t want to see are stories like the saga of Judy Yarzebinski. After 

being treated at a local VA she was notified that she had been exposed to dirty 

equipment. Sadly she tested positive for hepatitis C and due to other medical issues 

cannot be treated for it. Judy will now have to live with fevers, headaches, fatigue, 

loss of appetite, nausea, vomiting, and diarrhea for the rest of her life. To make 

matters worse the VA now denies having caused the exposure in the first place. 

Public battles such as this are exactly what make weary veterans reluctant to seek 

out VA care. 

IAVA believes that in order for the VA to conduct effective outreach, it must centralize its efforts between VHA, VBA, and NCA and aggressively re-brand itself as 

one Department of Veterans Affairs. The average veteran (and the average American for that matter) does not understand the difference between the VHA and the 

VBA. When I wait an entire semester for my GI Bill check to come, I’m upset with 

the VA, not the VBA. When I wait 2 months for a medical appointment, I’m upset 

with the VA, not the VHA. If the VA wants to effectively improve communications, 

it must speak to the veteran population clearly, and re-brand itself to the American 

people. 

The Department of Veterans Affairs must develop a relationship with servicemembers while they are still in the service. Like many successful college alumni associations that greet students at orientation and put on student programs throughout their time in college, the VA must shed its passive persona and start recruiting 

veterans and their families more aggressively into VA programs. Once a veteran 

leaves the military, the VA should create a regular means of communicating with 

veterans about events, benefits, programs and opportunities. IAVA is encouraged by 

the development of the Veterans Relationship Manager. Leveraging modern technology to develop a single means of communication between all sectors of the VA 

and a veteran is a step in the right direction. If a veteran received half as many 

letters and emails from the VA, as college grads do from their alumni association, 

we would be getting somewhere. 

To assist in building this relationship IAVA recommends automatically enrolling 

all troops leaving active-duty service, whether from the active or reserve component, 

in VA health care. 

‘‘Getting a VA card AND being vested (and what vested means) is a great way 

to prepare, even for those who work and have their own insurance, in case of 

lay off or other emergency.’’—IAVA Veteran 

In addition to providing a more seamless transition for separating combat veterans, automatic enrollment will cement the relationship between the VA and veterans. 

Overall the VA continues to provide good care to our nation’s veterans. However, 

we must continue to strive for better. In the military, they teach us to never stop 

improving our fighting position and be forever vigilant. It is this proactive ethos 

that continues to lead to victory on the battlefield. If we are to honor the service 

and sacrifice of America’s warriors, we must instill this spirit in all of the services 

that we develop to care for them. No one program or piece of technology will solve 

these problems, but together we can ensure that the citizens of this country have 

a system of care that honors the freedoms that we enjoy and care for those who 

have sacrificed blood and limb on our behalf. 

f 


ccoleman on DSK8P6SHH1PROD with HEARING
53 

Prepared Statement of Denise A. Williams, Assistant 

Director for Health Policy, Veterans Affairs and 

Rehabilitation Commission, American Legion 

Mr. Chairman and Members of the Subcommittee: 

Thank you for this opportunity to present The American Legion’s views on the Department of Veterans Affairs (VA) efforts in caring for the severely injured servicemembers from Operation Enduring Freedom (OEF) and Operation Iraqi Freedom 

(OIF). 

The current Global War on Terror (GWOT) has introduced more sophisticated 

forms of weaponry than in previous conflicts. As a result, our servicemembers are 

sustaining severe and unique wounds. The Department of Defense (DoD), reports 

that as of April 3, 2010, a total of 8,810 servicemembers have been wounded in action during OIF and 2,038 have been wounded in action during OEF. Servicemembers are surviving their wounds in considerably higher numbers because of advancements in body armor, helmets, and improved battlefield medical care. Currently the survival rate for wounded servicemembers is about 90 percent due to 

these improvements in equipment and the timely and effective application of emergency medical treatment. The improvised explosive device (IED) is the weapon of 

choice for our enemy, and is insidious in its utilization and often even more devastating in its long-term effects than gunshots due to the multiple and terrible 

wounds and burns it produces. These devices have resulted in amputations, Traumatic Brain Injuries (TBI), spinal cord injuries, and blindness. 

Amputation: Prosthetics and Sensory Aids 

The United States military operations in Iraq and Afghanistan have produced a 

significant number of service men and women with amputations. According to the 

DoD as of April 3, 2010, there has been a total of 1552 servicemembers that suffered 

amputations. This unique population of younger servicemembers requires extraordinary medical care and rehabilitation. Walter Reed Army Medical Center 

(WRAMC), among many DoD facilities dedicated to assisting wounded warriors, has 

highly advanced programs to care for warriors with amputations. In addition, there 

is an array of specialty physicians, rehabilitation, psychological support groups, 

recreation sports group, and vocational counselors. Once these servicemembers transition from the military to the civilian world, their care is essentially in the hands 

of the Veterans Health Administration (VHA). In response to the large number of 

veterans with prosthetics and rehabilitative needs, VA established Polytrauma Rehabilitation Centers (PRC). The VA Polytrauma Rehabilitation Centers provide 

treatment through multi-disciplinary medical teams including Cardiologists, Internal Medicine, Physical Therapist, social work and Transition Patient Case managers 

and much more specialty medical service areas, to help treat the multiple injuries. 

Currently, VA maintains four VA Polytrauma Rehabilitation Centers in Richmond, 

VA; Minneapolis, MN; Palo Alto, CA and Tampa, FL. 

However, the American Legion is concerned about VA’s ability to consistently 

meet the long term needs of these young veterans. As stated by the Military Medicine Journal, rehabilitation is a crucial step in optimizing long-term function and 

quality of life after amputation. Although returning veterans with combat-related 

amputations may be getting the best in rehabilitative care and technology available, 

their expected long term health outcomes are considerably less clear. It is imperative that both DoD and VA clinicians seriously consider the issues associated with 

combat-related amputees and try to alleviate any foreseeable problems that these 

OIF/OEF amputees may face in the future. The Military Medicine Journal further 

cautioned that research findings indicate that traumatic lower-limb amputees, particularly bilateral transfemoral amputees, are vulnerable to a number of health 

risks including Cardio Vascular Disease (CVD) and Ischemic Heart Disease (IHD). 

Considering these facts, The American Legion recommends that VA conducts further research on this matter to stay ahead of the curve and counter any long-term 

issues these veterans may encounter as they get older. 

The VA has made great strides in addressing the increased influx of young veterans with amputations. However, it has been reported that VA does not have the 

state-of-the art prostheses available in comparison to the Department of Defense. 

That is why it is of utmost importance that VA receives the adequate funding to 

ensure that all VA medical centers are fully equipped to address these veterans’ 

prosthetic needs. This is especially vital for the veterans that reside in rural and 

highly rural areas. It would be a grave disservice to these veterans if they have to 

bear the burden of travelling hundreds of miles in order to receive health care in 

addition to enduring their debilitating condition. The American Legion applauds VA 


ccoleman on DSK8P6SHH1PROD with HEARING
54 

on the establishment of the Prosthetics Women’s Workgroup to enhance the care of 

female veterans in regard to their prosthetics requirements. Despite this implementation, there are still cases where the fitting of the prostheses for women veterans 

has presented problems due to their smaller physique. The American Legion urges 

VA to increase their focus on amputation and prosthetics research programs in 

order to enhance and create innovative means to address this population of veterans’ health care needs. 

Polytrauma Centers 

The VA has designated five VA Medical Centers as Polytrauma Rehabilitation 

Centers (PRC). These centers provide specialized care for returning servicemembers 

and veterans who suffer from multiple and severe injuries. They also provide specialized rehabilitation to help injured servicemembers or veterans optimize their 

level of independence and functionality. In addition to the four centers mentioned 

above, there is a fifth center currently under construction in San Antonio, TX. In 

addition to the five designated sites, VA has established 18 Polytrauma Network 

Sites (PNS); one in each Veterans Integrated Service Network (VISNs); and approximately 81 Polytrauma Support Clinic Teams to augment the care of those with severe/multiple injuries. 

The Veterans Health Administration defines polytrauma as two or more injuries 

sustained in the same incident that affect multiple body parts or organ systems and 

result in physical, cognitive, psychological, or psychosocial impairments and functional disabilities. 

During our ‘‘System Worth Saving’’ site visits to the Polytrauma centers some facilities reported that there were staffing shortages in certain specialty areas such 

as: physical medicine and rehabilitation, speech and language pathology, physical 

therapy, and certified rehabilitation nursing. This was attributed to the competitive 

salaries being offered for these positions in the private sector. Considering the complex nature of these severely wounded veterans The American Legion finds this unacceptable. The Department of Veterans Affairs needs to step up their recruiting efforts in these areas so that in the future these veterans are not faced with the dilemma of going outside of the VA for care. 

Blind Rehabilitation 

There are currently 49,460 blind veterans enrolled in the VA health care system 

and that number is expected to increase because of the number of eye injuries in 

Iraq and Afghanistan. The Department of Defense reports that in the current conflict, eye injuries account for 13 percent of all injuries. The American Academy of 

Ophthalmology reports that eye injuries are a very common form of morbidity in a 

combat environment. Although effective counter measures have been developed to 

protect some parts of the human body against the effects of IEDs, such as body 

armor to protect the chest and abdomen, and helmets which protect the brain, there 

are no proven counter measures effective for protection of the eyes which will not 

impair visual requirements. Consequently, many warriors who survive blasts now 

face a future with terrible burns, amputations, and blindness. 

The Department of Defense does not provide rehabilitation for blindness. Unlike 

other injuries where after rehabilitation warriors may be retained and continue 

service, blinded warriors are medically discharged and are relegated to utilizing the 

VA for their rehabilitative needs. Currently VA employs about 155 Visual Impairment Service Team (VIST) Coordinators and 73 Blind Rehabilitation Outpatient 

Specialists (BROS). Given the prediction that the number of blinded veterans is expected to increase over the next several years, The American Legion urges VA to 

recruit more specialists to fill this gap. In addition, VA has a long history of providing inpatient and outpatient care for blind veterans. However, this has been for 

the older veteran population with visual impairment or blindness due to their age. 

Mr. Chairman, The American Legion would like to encourage VA to continue to 

modernize their overall rehabilitation programs and approach in order to help these 

newly blinded and younger veterans meet and overcome the challenges of visual impairment. 

Section 1623 of the National Defense Authorization Act of 2008 requires DoD to 

establish a Center of Excellence (COE) in the prevention, diagnosis, treatment, and 

rehabilitation of eye injuries and for DoD to collaborate with VA on all matters pertaining to the center. In addition, Section 1623 directs DoD and VA to implement 

a joint program on traumatic brain injury post traumatic visual syndrome, including 

vision screening, diagnosis, rehabilitative management, and vision research. Unfortunately, the center has yet to be fully established because of constant funding 


ccoleman on DSK8P6SHH1PROD with HEARING
55 

delays and bureaucratic hurdles. The American Legion calls for immediate action 

from the Secretary of Defense and the Secretary of VA to rectify this important 

issue. 

Spinal Cord Injury Centers 

As with most serious injuries, spinal cord injury is a life-altering and chronic condition that can affect an individual’s independence, sense of self worth, and create 

additional health problems. The Veterans Health Administration reported that since 

Fiscal Year 2003, they have treated a total of 503 active duty servicemembers at 

their Spinal Cord Injury (SCI) Centers and of that number 162 sustained their injury in combat. The Veterans Health Administration is the largest health care system to care for spinal cord injuries. VA has a total of 24 SCI centers throughout 

the country and they serve about 14,000 veterans annually. The Journal of Women’s 

Health reports that spinal cord injury patients are at a greater risk of having chronic conditions, especially as they get older. It is important that VA receives sufficient 

funding to ensure adequate staffing at these facilities to provide the necessary longterm care to these veterans. 

Mr. Chairman and Members of the Subcommittee, the American Legion sincerely 

appreciates the opportunity to submit testimony and looks forward to working with 

you and your colleagues on these important issues. 

That concludes my written statement and I would welcome any questions you 

may have. 

f 

Prepared Statement of Jack Smith, M.D., MMM, Acting Deputy 

Assistant Secretary for Clinical and Program Policy, 

U.S. Department of Defense 

Introduction 

Chairman Michaud, Congressman Brown, distinguished Members of the Subcommittee, thank you for the opportunity to appear here to talk to you about the 

Department of Defense’s (DoD) medical care for physical injuries in combat. On behalf of DoD, I want to take this opportunity to thank you for your continued support 

and demonstrated commitment to our servicemembers, veterans, and their families. 

Today, I will describe some of the aspects of DoD medical care for severely injured 

servicemembers who have returned from Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF). 

On October 16, 2009, Secretary of Defense Gates stated ‘‘Beyond waging the wars 

we are in, treatment of our wounded, their continuing care, and eventual reintegration into everyday life is my highest priority. I consider this a solemn pact between 

those who have risked and suffered and the nation that owes them its eternal gratitude.’’ We who work in military medicine completely agree with Secretary Gates. 

Prevalence of Injuries in OIF and OEF 

Over the last nine years, a new era of combat has emerged in which our servicemembers are constantly challenged by the demands of a high operational tempo. 

More than 2.1 million servicemembers have deployed to OEF and OIF from October 

2001 to May 30, 2010. Of those, 31,882 were wounded in action in OIF, and 6,773 

were wounded in action in OEF. A total of 61,874 servicemembers have been transported out of Iraq and Afghanistan to receive medical care. Of those who were 

transported, 18 percent were for battle injuries, 21 percent were for non-battle injuries (such as motor vehicle injuries), and 61 percent were for diseases. 

DoD Care for Polytrauma 

Severely injured servicemembers often require prolonged and intensive medical 

treatment and rehabilitative care. DoD has addressed this challenge by establishing 

specialty centers of excellence. DoD also has strengthened its partnership with the 

Department of Veterans Affairs, including with the four Polytrauma Rehabilitation 

Centers. Servicemembers who sustain severe injuries require complex, well-integrated care from a variety of medical specialties, which DoD provides at centers that 

specialize in providing care for combat trauma. 

Key components of DoD health care for severely injured servicemembers include 

three DoD amputee care centers, the Brooke Army Medical Center Burn Center, 

and the Defense and Veterans Brain Injury Center. DoD has established three 


ccoleman on DSK8P6SHH1PROD with HEARING
56 

major centers that specialize in the treatment and rehabilitation of combat injuries. 

The Military Advanced Training Center at Walter Reed Army Medical Center 

opened in 2007 to provide optimal amputation care and prosthetics. The Center for 

the Intrepid at Brooke Army Medical Center opened in January 2007 in San Antonio to provide state-of-the-art rehabilitation for servicemembers with amputations 

or severe burns. The Comprehensive Combat and Complex Casualty Care Center at 

the Naval Medical Center San Diego has a similar mission; and its mission and infrastructure were expanded in 2007. Each of these three trauma care centers provides orthopedic surgery, reconstructive plastic surgery, amputee care and prosthetics, and care for traumatic brain injuries (TBI) and post-traumatic stress disorder. 

DoD has long been a leader in research on improved treatments for traumatic injuries. The U.S. Army Institute of Surgical Research (USAISR) is located at the 

Brooke Army Medical Center in Texas. USAISR is dedicated to both laboratory and 

clinical trauma research. Its mission is to discover new treatments for combat casualty care for injured servicemembers across the full spectrum of military operations. In addition, USAISR is involved in providing state-of-the-art trauma, burn, 

and critical care to servicemembers around the world and to civilians in the local 

community. Brooke Army Medical Center has a world class burn care center, and 

it is considered one of the world’s leaders in burn care research. 

The Defense and Veterans Brain Injury Center (DVBIC) was established in 1992 

to provide state-of-the-art care for servicemembers who were diagnosed with traumatic brain injuries (TBIs). TBI is often part of the spectrum of polytrauma, which 

includes spinal cord injuries, amputations, and visual and hearing impairment. 

DVBIC serves servicemembers and veterans with TBI and their families, through 

state-of-the-art medical care, and through innovative clinical research and educational programs. DVBIC has established several specialized centers, including 

centers at the Walter Reed Army Medical Center, Naval Medical Center San Diego, 

and San Antonio Military Medical Center. For polytrauma patients who have sustained a TBI, DVBIC is part of the comprehensive medical team, coordinating and 

contributing to multidisciplinary treatment. Through a network of TBI Regional 

Care Coordinators, DVBIC also assists in coordinating servicemember transitions as 

they move among different systems of care, including between military medical 

treatment facilities, Department of Veterans Affairs (VA) Polytrauma Centers, and 

local community care. 

DoD has established three Centers of Excellence focused on hearing impairment, 

vision impairment, and extremity injuries and amputations. These centers collaborate to the maximum extent practicable with VA, institutions of higher education, 

and other appropriate public and private entities (U.S. and international) to carry 

out their responsibilities. In addition, they are working together to create registries 

that will enable them to document injuries and follow treatments of servicemembers 

suffering eye, ear, or extremity injuries. These centers augment the work of the Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury 

(DCoE), which was established in 2007. The DCoE offers a central coordinating 

point for activities related to traumatic brain injuries and psychological health. 

DCoE focuses on the full continuum of medical care and prevention to enhance coordination among the Services, Federal agencies, and civilian medical organizations. 

DoD Extremity and Amputation Center of Excellence 

The DoD Extremity and Amputation Center of Excellence (EACE) was approved 

for establishment in May 2010 pending final agreements with VA, but it has been 

working since early 2009 to serve as the lead organization for identifying policy 

issues, providing direction and oversight of a multidisciplinary network for care, and 

research on traumatic amputations and extremity injuries. The EACE will promote 

excellence in the research, diagnosis, treatment, and rehabilitation of traumatic injuries; and its vision is to assist servicemembers as they return to the highest possible levels of physical and psychological functioning. The EACE will oversee medical care from the time of injury through definitive care and rehabilitation to reduce 

disability and optimize the quality of life of servicemembers and veterans. EACE 

services will include rehabilitation, in collaboration with the VA. EACE will include 

several affiliated regional centers, including the three DoD amputee centers, and the 

VA Polytrauma Rehabilitation Centers. 

DoD Vision Center of Excellence 

The DoD Vision Center of Excellence (VCE) was formally established in May 2010 

with the Navy as the Lead Component, but it has been working since 2008 to proVerDate Nov 24 2008 00:57 Jan 06, 2011 Jkt 058060 PO 00000 Frm 00060 Fmt 6604 Sfmt 6621 I:\WAYS\OUT\58060.XXX GPO1 PsN: 58060

ccoleman on DSK8P6SHH1PROD with HEARING
57 

vide leadership in the prevention, diagnosis, treatment, and rehabilitation of eye injuries. 

VA has provided the deputy director for this center. The VCE will provide clinical 

support for the full scope of military eye care, treatment, and research; and it will 

provide clinical education programs on eye injuries in servicemembers for both the 

DoD and VA. Servicemembers can experience vision problems through a variety of 

mechanisms: trauma from explosions and projectiles, vision abnormalities secondary 

to TBI, and eye injuries from chemical hazards, biological hazards, or extreme environmental conditions. The VCE is working with VA to coordinate transition of medical care. For example, a collaborative process has been developed at Walter Reed 

Army Medical Center for servicemembers to receive blind rehabilitation care from 

VA while they are still receiving DoD care. The VCE is involved in several innovative research projects, including evaluating treatments for blast and burn injuries 

to eye structures and treatments for TBI-associated visual problems. The VCE is 

planning to establish four Regional Clinical Centers for Ocular Disease and Trauma 

at military medical centers that have ophthalmology residency training programs. 

The VCE recently added two VA staff members with expertise in Blind Rehabilitation and Low Vision Research; they will work closely with the VA Blind Rehabilitation Centers and Polytrauma Centers in tracking and caring for patients with eye 

and vision injuries across the DoD and VA continuum of care. In addition, there are 

several research centers in DoD and VA that are collaborating with the VCE. 

DoD Hearing Center of Excellence 

The Hearing Center of Excellence (HCE) also was established in May 2010, but 

has been working since early 2009 to promote excellence in the prevention, diagnosis, treatment, and rehabilitation of hearing loss and injuries of the vestibular 

system in servicemembers and veterans. The Air Force is the Lead Component for 

this center. The scope of the HCE includes hearing loss, tinnitus, and problems with 

balance and equilibrium, which could be due to injuries from blasts, blunt trauma, 

barotrauma, and high noise levels. Hearing loss is very frequent in veterans, and 

hearing loss and tinnitus are the top two diseases in terms of VA disability compensation. In addition, vertigo and dizziness are common symptoms in patients with 

TBI. There is close collaboration with affiliated Regional Centers for Otologic Disease and Trauma at several military and VA hospitals, including Walter Reed Army 

Medical Center, Naval Medical Center San Diego, and Madigan Army Medical Center in Tacoma, WA. In addition, there are several research centers in DoD and VA 

that are collaborating with the HCE. 

DoD Program on Spinal Cord Injuries 

DoD is conducting a robust research program on spinal cord injuries that includes 

laboratory research on repair and regeneration of damaged spinal cords and clinical 

research to improve rehabilitation therapies. The program focuses on innovative 

projects that have the potential to make a significant impact on improving the function, wellness, and overall quality of life for servicemembers. The scientific areas include neuroprotection and repair, and rehabilitation and complications of chronic 

spinal cord injuries. 

DoD Support Programs for Severely Injured Servicemembers and Their 

Families 

DoD has developed many support resources to assist injured servicemembers, veterans, and their families. One important resource is the Recovery Coordination Program, which was established in 2008, to ensure that wounded, ill, or injured servicemembers receive the non-medical support they need to successfully navigate the 

road to recovery. A servicemember who has a serious injury would be eligible for 

a Recovery Care Coordinator (RCC), if the servicemember would not return to duty 

within a specified time determined by the Military Wounded Warrior Program or 

if the servicemember might be medically separated. The RCC works for one of the 

programs in any of the four Services, including the Army Reserve, as well as the 

Special Operations Command Care Coalition. The RCC develops a recovery plan, 

evaluates its effectiveness, and adjusts it as transitions occur. The RCC makes sure 

the plan meets the servicemember’s and the family’s goals, and works with the individual’s Commander to coordinate the services included in the plan. Currently, 

there are 130 RCCs in 55 locations nationwide. 

DoD provides outreach to servicemembers and families to promote awareness of 

the available resources. We conduct outreach to encourage servicemembers and families to seek help from these programs, when needed, and to ensure the most comVerDate Nov 24 2008 00:57 Jan 06, 2011 Jkt 058060 PO 00000 Frm 00061 Fmt 6604 Sfmt 6621 I:\WAYS\OUT\58060.XXX GPO1 PsN: 58060

ccoleman on DSK8P6SHH1PROD with HEARING
58 

plete recovery possible. One of the most important support resources is Military One 

Source, which provides assistance to servicemembers and their families to evaluate 

their needs, and coordinate referrals to other programs to provide the appropriate 

services. Military One Source is a central coordination point to ensure accessibility 

to the many available resources for servicemembers and their families. 

Four service-specific programs provide assistance: the Army Wounded Warrior 

Program, Marine Wounded Warrior Regiment, Air Force Wounded Warrior, and 

Navy Safe Harbor. The wounded warrior programs assist and advocate for severely 

wounded, ill, and injured servicemembers, veterans, and their families, wherever 

they are located. The four Service-specific programs provide counseling, employment 

assistance, family support, and other services needed to transition to home and the 

community. These services are provided as long as severely injured servicemembers 

and their families require support. 

Transition from DoD Care to VA Care for Severely Injured Servicemembers 

DoD and VA are working together to improve their coordination of medical care 

for servicemembers and veterans, including those who were severely injured in OIF 

and OEF. The key objectives of our coordinated transition efforts include: ensuring 

continuity of medical care from DoD to VA health care providers; and providing 

clear and comprehensive information about available support programs to servicemembers and their families. 

DoD takes advantage of the four VA Polytrauma Rehabilitation Centers (Tampa, 

Minneapolis, Richmond, and Palo Alto) to meet the needs of active-duty servicemembers who have experienced multiple, severe injuries, including TBI. DoD has 

a longstanding relationship with VA to ensure continuity of care, and DoD refers 

injured servicemembers to VA for long-term rehabilitation. From March 2003 to 

June 2010, more than 500 active-duty servicemembers who were injured in theater 

were treated in the four VA Polytrauma Rehabilitation Centers. In addition, 21 VA 

Polytrauma Network Sites nationwide provide continuing long-term care to these injured veterans 

In August 2003, DoD incorporated a VA Liaison Program at Walter Reed Army 

Medical Center to provide case management for combat veterans. When severely injured servicemembers need long-term medical care, VA liaison personnel work with 

them to coordinate VA services. This joint program has expanded to 12 more military hospitals. At these 13 hospitals, 27 VA nurses and social workers provide the 

linkage to follow-up care at VA facilities near the servicemembers’ homes. As of 

June 2010, this program had made more than 10,000 patient referrals to VA to ensure continuity of care. 

Conclusion 

DoD is providing comprehensive, state-of-the-art care for severely injured servicemembers in collaboration with our partners at VA. We are committed to continued 

and more expansive collaboration and coordination with VA because we believe it 

is essential to our ability to provide servicemembers, veterans, and their families 

with consistently superior medical care and support services as well as continuity 

of care in the most comprehensive way. 

Thank you for the opportunity to address this vital issue. I will be pleased to respond to any questions you may have and to participate in an ongoing dialogue to 

better serve our current and former servicemembers. 

f 

Prepared Statement of Lucille B. Beck, Ph.D. Chief Consultant, 

Rehabilitation Services, Office of Patient Care Services, and Director, 

Audiology and Speech Pathology Service, Veterans Health Administration, 

U.S. Department of Veterans Affairs 

Good Morning, Chairman Michaud, Ranking Member Brown, and Members of the 

Subcommittee. Thank you for the opportunity to appear to discuss the Department 

of Veterans Affairs’ (VA) work in caring for severely injured Operation Enduring 

Freedom (OEF) and Operation Iraqi Freedom (OIF) Veterans and Servicemembers 

through our full complement of specialty, rehabilitative services. VA’s mission includes ensuring we have appropriately staffed facilities that provide timely, accessible, coordinated, high quality specialty care for our severely injured Veterans. We 

appreciate Congress’ support in providing VA the resources necessary to meet the 

needs of our Veterans. 


ccoleman on DSK8P6SHH1PROD with HEARING
59 

VA is committed to helping Servicemembers transition from active duty to Veteran status as smoothly as possible. The Veterans Health Administration (VHA) is 

well-known for its integrated system of health care and its expertise in treating spinal cord injuries and disorders (SCI/D), traumatic brain injury (TBI), and blindness 

and visual impairment. Our provision of quality rehabilitation care is supported 

through a system-wide, long-term collaboration with the Commission on Accreditation of Rehabilitation Facilities (CARF) to achieve and maintain national accreditation for all appropriate VHA rehabilitation programs. VA continues to increase collaborations with private sector facilities to successfully meet the individualized 

needs of Veterans and complement VA care and services. This ensures that quality 

rehabilitation programs are offered in a timely manner that meet the unique needs 

of severely injured Veterans and provide a catalyst for improving their quality of 

life. 

Our severely injured Veterans returning from OEF/OIF rightfully expect us to 

provide the latest in treatment, technology, and rehabilitation services. VA has established policies and supports its facilities to ensure that specialty services are 

structured appropriately, fully staffed, and effectively coordinated. We understand 

and appreciate the specialized skills required to deliver the care our Veterans need 

and deserve, and to that end VA has created numerous education and training opportunities for our clinical providers. 

Facility capacity and bed occupancy rates are routinely monitored at the local 

level and are reported to the national program offices at least monthly to ensure 

our OEF/OIF Veterans have open access to our care and services. Any surge in demand for services are addressed with corrective actions such as temporarily increased staffing, use of additional existing authorized beds at the Polytrauma Rehabilitation Centers (PRCs), careful planning of elective admissions, and transfers 

within the Polytrauma System of Care (PSC) of non-traumatically disabled Veterans 

to ensure that the first priority for admissions remains allocated to Servicemembers 

and Veterans with severe injuries. Flexibility is available to provide additional resources at specific locations, if necessary. 

My testimony will begin by explaining how VA supports and facilitates the transition and care management of severely injured OEF/OIF Veterans into specialty rehabilitation programs, then provide a detailed review of four major rehabilitation 

areas: VA’s Blind Rehabilitation Service, its Spinal Cord Injury/Disorders program 

(SCI/D), the Polytrauma and TBI System of Care, and the Amputation System of 

Care and Prosthetics and Sensory Aids Service. 

Transition and Care Management of OEF/OIF Veterans 

VA recognizes that severely injured Servicemembers face a significant transition 

when returning home and becoming Veterans. In addition to treating Veterans with 

blindness, SCI&D, polytrauma/TBI, and amputations, VA and Department of Defense (DoD) have worked together through a Memorandum of Agreement for almost 

30 years to deliver rehabilitation services to active duty Veterans and Servicemembers with such injuries. 

As soon as the pre-requisites for medical stability are met, the DoD physician and 

the VA admitting physician at one of VA’s specialty centers begin discussion on the 

patient’s medical status and arrange for appropriate transportation and admission 

to the VA facility closest to the Veteran’s or Servicemember’s home. Each patient 

receives a customized rehabilitation plan designed to achieve patient-centered goals 

and maximal functional independence. Rehabilitation serves to improve any bodily 

functions affected by the injury, teach compensatory functions using remaining intact body systems, anticipate and prevent medical complications, alter the environment as needed, and educate the person to promote autonomy and to achieve their 

full potential and quality of life. 

In order to make VA easier to access for those most in need, we have responded 

by partnering with DoD to create the Federal Recovery Coordination Program, and 

creating a Care Management and Social Work Service responsible for developing 

policies and deploying staff to VA and DoD facilities. 

VA’s Care Management and Social Work Service 

In October 2007, VA established the Care Management and Social Work Service 

to address the needs of wounded and ill Veterans and Servicemembers. VA’s Military Liaisons for Health care are social workers or nurses who serve as essential 

resources for transitioning injured and ill OEF/OIF Veterans and Servicemembers. 

VA now has 33 VA Military Liaisons for Health care stationed at 18 military medical treatment facilities (MTFs) to transition ill and injured Servicemembers from 


ccoleman on DSK8P6SHH1PROD with HEARING
60 

DoD to a VA more appropriate for the specialized services their medical condition 

requires, or closer to home. 

VA Military Liaisons are co-located with DoD Case Managers at MTFs and provide onsite consultation and collaboration regarding VA resources and treatment options. They educate Servicemembers and their families about VA’s system of care, 

coordinate the Servicemember’s initial registration with VA, and secure outpatient 

appointments or inpatient transfer to a VA health care facility as appropriate. VA 

Military Liaisons make early connections with Servicemembers and families to 

begin building a positive relationship with VA. Our Liaisons coordinated 5,000 referrals for health care and over 20,000 professional consultations in fiscal year (FY) 

2010 through June. 

Each VA medical center has an OEF/OIF Care Management team in place to coordinate patient care activities and ensure that Servicemembers and Veterans are 

receiving patient-centered, integrated care and benefits. Members of the OEF/OIF 

Care Management team include: a Program Manager, Clinical Case Managers, Veterans Benefits Administration (VBA) Service Representatives, and a Transition Patient Advocate. The Program Manager, a nurse or social worker, has overall administrative and clinical responsibility for the team and ensures that all OEF/OIF Veterans are screened for case management. Severely injured OEF/OIF Veterans are 

provided a case manager, and any other OEF/OIF Veteran may be assigned a case 

manager based upon initial assessment or upon request. Clinical Case Managers coordinate patient care activities and ensure that all clinicians providing care to the 

patient are doing so in a cohesive and integrated manner. 

VBA team members assist Veterans by educating them about VA benefits and assisting with the benefit application process. The Transition Patient Advocate helps 

the Veteran and family navigate VA’s system by acting as a communicator, 

facilitator and problem-solver. Since many returning OEF/OIF Veterans connect to 

more than one specialty case manager, VA introduced a new concept of a ‘‘lead’’ case 

manager. The lead case manager now serves as a central communication point for 

the patient and his or her family. Case managers maintain regular contact with 

Veterans and their families to provide support and assistance to address any health 

care and psychosocial needs that may arise. The OEF/OIF Care Management program now serves over 44,000 Servicemembers and Veterans, including 5,800 who 

are severely injured. 

OEF/OIF Care Management team members actively support outreach events in 

the community, such as annual ‘Welcome Home’ events. OEF/OIF team members 

also participate in the demobilization process, the Yellow Ribbon Reintegration Program, Post-Deployment Health Reassessment events, and Individual Ready Reserve 

musters. OEF/OIF staff regularly make presentations to community partners, Veterans Service Organizations, colleges, employment agencies and others to collaborate in providing services and connecting with returning Servicemembers and Veterans. VHA and VBA officials coordinate on the full range of services and benefits 

to Veterans and their families to support their transition back to civilian life. 

Federal Recovery Coordination Program 

The needs of severely injured Servicemembers and Veterans are also met through 

the services provided by the Federal Recovery Coordination (FRC) Program. FRCs 

serve to ensure that severely injured Veterans and Servicemembers receive access 

to the benefits and care they need to recover. Since its creation in 2008, the FRC 

Program has helped Servicemembers and Veterans access Federal, state and local 

programs, benefits and services, while supporting the families of these heroes 

through their recovery, rehabilitation, and reintegration into the community. Currently, 556 clients are enrolled and another 31 individuals are being evaluated for 

enrollment; an additional 497 have received assistance through FRC. 

Blind Rehabilitation 

The VA Blind Rehabilitation Service (BRS) provides world-class comprehensive 

evaluation, planning, and rehabilitation treatment for OEF/OIF Veterans and 

Servicemembers with any level of visual impairment. BRS assesses, recommends 

and trains Veterans in the use of technology and assistive devices with enlarged 

print, Braille or speech output such as computers, personal digital assistants and 

global positioning systems. BRS, together with VA eye care practitioners, incorporates the latest in optical enhancing devices into rehabilitation care. This technology serves to enhance independence, social functioning, employment, and education. 


ccoleman on DSK8P6SHH1PROD with HEARING
61 

Blind Rehabilitation Services are delivered at every VA medical center, with 157 

Visual Impairment Service Team Coordinators who provide care management, and 

77 Blind Rehabilitation Outpatient Specialists who provide in-home and in-community service. Additionally, VA has 55 outpatient blind and vision rehabilitation clinics, and 10 inpatient Blind Rehabilitation Centers; three additional inpatient centers will open in FY 2011 in Cleveland, OH, Biloxi, MS, and Long Beach, CA. VA 

blind rehabilitation services are structured and geographically located for visually 

impaired Veterans and Servicemembers to access the care they need. 

The BRS database tracks OEF/OIF Veterans with visual impairment to ensure 

ongoing coordination of care for these patients. As of June 2010, Blind Rehabilitation Service is tracking 1,098 OEF/OIF Veterans and Servicemembers who have received blind and vision rehabilitation care, or who have been referred for screening 

to rule out possible visual consequences associated with TBI. Of this total, 126 active duty Servicemembers have attended inpatient blind rehabilitation centers due 

to severely disabling visual impairment. VA has also held several national training 

conferences on the visual consequences of TBI to educate our providers, and has 

added specific medical codes to document the visual consequences of TBI in VA’s 

clinical patient record system. We have placed Blind Rehabilitation Outpatient Specialists at Walter Reed Army and National Naval Medical Centers, as well as at locations in VA’s Polytrauma System of Care. Results indicate that patients completing VA’s inpatient blind rehabilitation programs have better functional outcomes 

than patients from blind rehabilitation programs in the private sector. 

Spinal Cord Injury 

VA’s Spinal Cord Injury Program is the largest single network of care and rehabilitation in the Nation for the treatment of persons with spinal cord injury (SCI). 

VA facilities nationwide in 2009 provided a full range of services to 27,067 Veterans 

with SCI/D; 13,398 of these Veterans received specialized care within the 24 Spinal 

Cord Injury Centers or SCI Support Clinics. For Veterans with SCI, VA provides 

health care and rehabilitation services, maintains medical equipment and supplies, 

and offers education and preventive health services. Since 2003, 503 Servicemembers have been treated in VA SCI units, and of those Servicemembers, 162 incurred a spinal cord injury in an OEF/OIF theater of operations. 

VA’s SCI system of care is internationally regarded for its comprehensive and coordinated services for rehabilitation, surgical, medical, preventive, ambulatory, long 

term, and home-based care. Interdisciplinary teams of professionals with highly specialized knowledge and experience deliver rehabilitation care, SCI specialty care, 

and broadly based medical services. VA is a world leader in best practices providing 

outstanding clinical care, customized wheelchairs, adaptive equipment, technological 

interventions, therapies, teaching, and training so Veterans with SCI can be as 

healthy and independent as possible in their homes and communities. 

VA promotes activity-based therapies at its SCI Centers to improve mobility, recovery of walking and hand function. Recently, VA enhanced the rehabilitation and 

training environments to offer the latest and most effective interventions to fully 

utilize sensory patterned feedback, re-training of central pattern generators, use of 

body weight support, and electrical stimulation for newly injured Servicemembers 

and Veterans in all VA Spinal Cord Injury Centers. These services include: early 

standing and weight-bearing; body weight support and treadmill training; over 

ground training for walking; and electrical stimulation for weak and paralyzed muscles in the lower limbs for ambulation and upper limbs for hand function. There is 

currently a growing and integrated system of telehealth services for Veterans with 

SCI, and recent funding has provided telehealth systems in every SCI Center and 

to more than 90 percent of the SCI support and primary care teams. 

VA’s SCI System of Care prevents and treats co-morbid problems related to the 

original spinal cord injury. For example, pressure ulcers (bed sores) are a common 

and costly complication resulting in high rates of illness and death. Data from FY 

2008–2010 demonstrate that our new prevention efforts are successful and have reduced the rate of developing a new hospital-acquired pressure ulcer to an extremely 

low level. The data reflects that 95 percent of patients with SCI were screened for 

pressure ulcer risk within twenty four hours of admission, 96 percent of at-risk patients had a documented plan of skin care within 48 hours of admission, and only 

1.3 percent of patients with SCI who were hospitalized in FY 2009 developed pressure ulcers. 


ccoleman on DSK8P6SHH1PROD with HEARING
62 

Polytrauma/Traumatic Brain Injury 

VA also offers rehabilitation services for returning OEF/OIF Veterans and 

Servicemembers with polytrauma and traumatic brain injuries. ‘‘Polytrauma’’ is a 

new word in the medical lexicon that was termed by VA to describe the injuries to 

multiple body parts and organs occurring as a result of exposure to explosive devices 

or blasts to those serving in OEF/OIF. Polytrauma is defined as two or more injuries 

to physical regions or organ systems, one of which may be life threatening, resulting 

in physical, cognitive, psychological, or psychosocial impairments and functional disability. Traumatic brain injury (TBI) frequently occurs in polytrauma in combination with other disabling conditions such as amputation, auditory and visual impairments, spinal cord injury, post-traumatic stress disorder (PTSD), and other medical 

problems. Due to the severity and complexity of their injuries, Servicemembers and 

Veterans with polytrauma require an extraordinary level of coordination and integration of clinical and other support services. 

VA has developed and implemented numerous programs that ensure the provision 

of world-class rehabilitation services for Veterans and active duty Servicemembers 

with TBI. Since 1992, VA has had four lead TBI Centers designated as part of the 

Defense and Veterans Brain Injury Center (DVBIC) collaboration to provide comprehensive rehabilitation for Veterans and active duty Servicemembers. In 1997, VA 

designated a TBI Network of Care to support care coordination and access to services across VA’s system. 

Beginning in 2005, VA expanded the scope of services at existing VA TBI Centers 

to implement an integrated nationwide Polytrauma System of Care (PSC) that provides world-class rehabilitation services, and ensures that Veterans and Servicemembers with TBI and polytrauma transition seamlessly from DoD and VA and 

back into their home communities. Today, the VA Polytrauma System of Care is an 

integrated, tiered system that provides specialized, interdisciplinary care for polytrauma injuries and TBI across four levels of facilities, including: 4 Polytrauma Rehabilitation Centers, 22 Polytrauma Network Sites, 82 Polytrauma Support Clinic 

Teams, and 48 Polytrauma Points of Contact. The System offers comprehensive clinical rehabilitative services including: treatment by interdisciplinary teams of rehabilitation specialists; specialty care management; patient and family education and 

training; psychosocial support; and advanced rehabilitation and prosthetic technologies. 

Polytrauma Rehabilitation Centers (PRCs) serve as regional referral centers for 

the most intensive specialized care and comprehensive rehabilitation care for Veterans and Servicemembers with complex and severe polytrauma. PRCs maintain a 

full staff of dedicated rehabilitation professionals and consultants from other specialties to support these patients. Each PRC is accredited for Brain Injury Rehabilitation by the Commission on Accreditation of Rehabilitation Facilities (CARF), and 

each serves as a resource to develop educational programs and best practice models 

for other facilities across the system. The four regional Centers are located in Richmond, VA; Tampa, FL; Minneapolis, MN; and Palo Alto, CA. A fifth Center is currently under construction in San Antonio, TX, and is expected to open in 2011. 

The next three levels of the Polytrauma System of Care provide specialized rehabilitation services and coordinate care at locations closer to the Veterans’ home communities. Polytrauma Network Sites (PNS) provide inpatient and outpatient rehabilitation care and coordinate TBI and polytrauma services throughout the Veterans 

Integrated Service Network (VISN). The inpatient rehabilitation units at the PNS 

maintain CARF accreditation for Comprehensive Inpatient Medical Rehabilitation. 

Polytrauma Support Clinic Teams conduct comprehensive evaluations of patients 

with positive TBI screens and develop and implement rehabilitation and community 

reintegration plans for Veterans and Servicemembers in their catchment areas. 

Polytrauma Points of Contact ensure that Veterans and Servicemembers needing 

specialized rehabilitation services are referred to the appropriate level of care within 

or outside of VA, if necessary. VA appreciates Congress’ work in passing the Caregivers and Veterans Omnibus Health Services Act of 2010 (Public Law 111–163), 

which will allow VA to provide specialized residential care for TBI patients and rehabilitation services for Veterans with TBI at non-Department facilities. 

VA continually enhances the scope of specialized rehabilitation services available 

through the Polytrauma System of Care. New programs and initiatives include: 

• In 2007, VA developed and implemented Transitional Rehabilitation Programs at each PRC. These 10-bed residential units provide rehabilitation in 

a home-like environment to facilitate community reintegration for Veterans 

and their families. Through December 2009, 188 Veterans and Servicemembers have participated in this program spending, on average, about 3 


ccoleman on DSK8P6SHH1PROD with HEARING
63 

months in transitional rehabilitation. Almost 90 percent of these individuals 

return to active duty or transition to independent living. • Beginning in 2007, VA implemented a specialized Emerging Consciousness 

care path at the four PRCs to serve those Veterans with severe TBI who are 

slow to recover consciousness. To meet the challenges of caring for these individuals, VA collaboratively developed this care path with subject matter experts from Defense and Veterans Brain Injury Center (DVBIC) and the private sector. From January 2007 through December 2009, 87 Veterans and 

Servicemembers have been admitted into VA’s Emerging Consciousness program. Approximately 70 percent of these patients emerge to consciousness before leaving inpatient rehabilitation. • In April 2009, VA began an advanced technology initiative to establish Assistive Technology laboratories at the four PRCs to provide the most advanced 

technologies related to cognitive-communication, sensory and motor impairments. This initiative allowed VA to enter into a contractual agreement with 

the University of Pittsburgh to develop state-of-the-art Assistive Technology 

(AT) labs. The goal of this initiative is to develop extensive banks of AT devices for equipment trials, a method for evaluating new AT technology, standardized evaluation procedures, and an outcomes data collection tool. AT can 

contribute to enhancing an individual’s ability to function in their environment and achieve the highest level of independence possible for persons with 

disabilities. 

Since March 2003, an average of 130 Servicemembers with severe polytraumatic 

injuries have been referred annually for acute medical, surgical, and rehabilitative 

care at the four PRCs, ranging from 99 (FY 2003) to 330 (FY 2008), for a total of 

907 Servicemembers. Of the total 907 Servicemembers served, 754 were injured in 

OEF/OIF areas of operations. Thus far in FY 2010, a total of 110 Servicemembers 

have been treated at the PRCs. Additionally, a total of 885 Veterans with severe 

injuries have been admitted to the PRCs since 2003. In FY 2009, 49,207 patients 

were seen across VA for inpatient or outpatient services related to TBI; 46,990 patients were treated in outpatient clinics for a total of 83,794 visits. This represents 

a 30 percent increase over FY 2008. 

VA has developed and implemented the TBI Screening and Evaluation Program 

for all OEF/OIF Veterans who receive care within VA. From April 2007 through 

April 2010, VA has screened 418,109 OEF/OIF Veterans for possible TBI; of these, 

57,569 Veterans who screened positive have been evaluated and have received follow-up care and services appropriate for their diagnosis and their symptoms. A total 

of 31,480 Veterans have been confirmed with a diagnosis of having incurred a mild 

TBI. Over 90 percent of all Veterans who are screened are determined not to have 

TBI, but the 10 percent who screen positive and complete the comprehensive evaluation are referred for appropriate treatment. Completion of the TBI screening and 

evaluation for each OEF/OIF Veteran allows VA to continually assess resources and 

access to care. 

VA has sufficient resources to meet the needs of Veterans with TBI, and TBI is 

a Select Program in VA budget submissions. In FY 2010, $231.9 million has been 

programmed for TBI care for all Veterans and $58.2 million is programmed for 

OEF/OIF Veterans. 

Amputation/Prosthetics and Sensory Aid Programs 

A closely related Program is the Amputation System of Care and VA’s Prosthetics 

and Sensory Aid Services. These two efforts complement each other in providing 

quality, accessible care to Veterans across the country. 

Amputation System of Care 

VA has an extensive program for amputation rehabilitation. In 2007, VA’s Offices 

of Rehabilitation and the Prosthetics and Sensory Aids Service collaborated to develop an Amputation System of Care (ASC) designed to standardize care delivery, 

reduce variance, and increase access to state-of-the-science rehabilitation techniques 

and prosthetic technology. VA began deploying this System in 2009, enhancing 

structures within VA to create tiered levels of expertise and accessibility across four 

distinct components of care. Today there are 7 Regional Amputation Centers, 15 

Polytrauma/Amputation Network Sites, 101 Amputation Clinic Teams, and 31 Amputation Points of Contact across the ASC. Collectively, this system delivers specialized expertise in amputation rehabilitation incorporating the latest practice in medical rehabilitation management, rehabilitation therapies, and technological advances 

in prosthetic components. 


ccoleman on DSK8P6SHH1PROD with HEARING
64 

Regional Amputation Centers provide the highest level of specialized expertise in 

clinical care, technology, and rehabilitation for Veterans with the most severe extremity injuries and amputations. These Centers have clinical expertise in state-ofthe-science medical and rehabilitation techniques and prosthetic components and 

design. These Centers provide comprehensive, holistic rehabilitation care through 

an interdisciplinary team that includes physiatrists, physical therapists, occupational therapists, prosthetists, social workers, case managers, nurses, psychologists 

and recreation therapists. These Centers also serve as a resource for other facilities 

in the System through the development of tele-rehabilitation for consultation, models of care, best practices, educational programs, and the evaluation of new technology. 

Polytrauma/Amputation Network Sites also provide inpatient and outpatient amputation rehabilitation as well as prosthetic labs closer to the Veteran’s home. These 

Sites provide care to Veterans with multiple impairments, including amputation, 

and addressing the long-term care needs and coordinating access to specialized services either directly or via consultation. These Sites also provide interdisciplinary 

care, with the clinical teams at these facilities well-trained in evaluation techniques, 

rehabilitation methods, and prescription of prostheses. In addition to providing the 

full range of clinical and ancillary services, the Sites serve as a resource and consultant for complex management issues to other facilities within their network. 

Amputation Clinic Teams are designated at facilities with limited resources that 

may not provide a full scope of services, but still offer an interdisciplinary amputation care team. Facilities at this level may or may not have an in-house Prosthetic/ 

Orthotic Laboratory or an inpatient rehabilitation bed program. Any sites without 

such services are augmented as necessary either through a contract, referral to a 

Polytrauma/Amputation Network Site, or through fee-based referral to an accredited 

facility in the private sector community. Finally, Amputation Points of Contact are 

located at smaller VA facilities and ensure that Veterans and Servicemembers needing specialized rehabilitation and prosthetic services are referred to appropriate 

level of care or to other non-VA services. 

VA provides care to more than 43,000 amputees, many of whom are older Veterans who require amputations as a result of medical problems such as dysvascular 

disease or diabetes. A growing number of OEF/OIF Veterans with traumatic amputations also come to VA for services. As of June 1, 2010 there were 1,011 OEF/OIF 

Veterans or Servicemembers with major amputations, of which 657 (or 65 percent) 

have sought care in VA. Much of this care has been in the area of prosthetics where 

new prosthetic limbs and limb repair is provided. All Veterans with amputation 

seen within VA, including OEF/OIF Veterans who account for 1.67 percent of these 

patients, require specialty care for the rest of their lifetime. VA’s Amputation System of Care will ensure that VA is able to meet their needs. 

The VA Amputation System of Care works collaboratively with the Department 

of Defense’s Amputation Centers at Walter Reed Army Medical Center, the Center 

for the Intrepid in San Antonio at Brooke Army Medical Center, and the Amputation Center at the Balboa Navy Medical Center to coordinate transition services, 

train interdisciplinary amputee teams, and develop best practices. 

VA and the Amputee Coalition of America (ACA) have partnered to establish a 

Peer Visitation Program within VA. The ACA has trained 20 VA instructors across 

the Nation who can now train Veterans to be peer visitors. VA currently has over 

30 Veterans certified as peer visitors, and expects to double this number in 2011. 

This program has been extremely successful at Walter Reed Army Medical Center 

and was identified by Servicemembers as the most important factor supporting their 

rehabilitation, second only to physical therapy with amputations. VA and ACA are 

currently exploring establishing a peer visitation program for caregivers of amputees. 

VA and DoD partnered to develop the Amputation Rehabilitation Clinical Practice 

Guideline, which represents the first attempt to provide an evidence-based structure 

for rehabilitation in lower limb amputation. This will further assist in identifying 

priorities for new research efforts and allocation of resources to incorporate new 

technology as rehabilitation practices emerge. VA and DoD also partnered to develop the Amputation Patient Education Handbook ‘‘The Next Step.’’ This publication has received extensive positive feedback from Veterans, Servicemembers, and 

clinicians in its pre-release, and will be available for distribution across VA and 

DoD by the end of July 2010. 

Lastly, VA is developing a Telehealth Amputation Program to improve access to 

specialty amputation care closer to the Veteran’s home. Telehealth will be used to 

connect all four levels of the ASC, and amputation specialty care to community 

based outpatient clinics. 


ccoleman on DSK8P6SHH1PROD with HEARING
65 

Prosthetics and Sensory Aids 

VA’s Prosthetic and Sensory Aids Service (PSAS) provides Veterans with the prescribed equipment they require to maximize their independence and health. PSAS 

exceeds other health care organizations in providing the variety and array of equipment and services. PSAS provides everything from state-of-the-science bionic limbs, 

to custom wheeled mobility and seating solutions, to home and vehicle adaptations. 

PSAS has a national evaluation process for reviewing and approving the purchase 

of new or experimental technology and services that are medically prescribed by the 

Veterans VA health care provider. This process allows for the provision of devices 

that are not typically provided by DoD, Medicare, or any private health care provider. 

Female Veterans particularly find the personal attention required for their specific needs through PSAS. Prosthetic devices such as breast prostheses or breast 

pumps, or a prosthetic style designed for women instead of men, are provided by 

PSAS to meet the unique needs of this Veteran population. In FY 2009, PSAS provided items and services to 116,000 female Veterans at a cost of over $61 million. 

Over 40,000 female Veterans received eyeglasses through VA with timely, accurate 

service, and an eyeglass style with which they are comfortable. Our interdisciplinary 

Prosthetic Women’s Workgroup provides guidance regarding new items that are 

available to this special population, and is assisting with developing a brochure that 

targets female Veterans to inform them about PSAS services. PSAS provides the 

personal service to ensure that every female Veteran receives the equipment and 

services—in the preferred style unique to women—to maximize her independence 

and quality of life. 

Although not exclusive to the OEF/OIF Veteran, this population has helped bring 

to the forefront a wide range of technologies to keep this population active and engaged in their community. VA provides computers for blind as well as physically disabled Veterans to assist them in managing their lives and retaining their independence. VA also provides global positioning systems (GPS), smartphones, and the most 

advanced wheeled-mobility and seating solutions available. VA was the first in the 

U.S. to provide a microprocessor knee over ten years ago, and we have remained 

at the cutting edge of technology in the realm of prosthetic limbs. We are currently 

optimizing the DEKA arm in hopes of getting it to the market place soon so that 

all Americans with upper extremity amputations might benefit. VA is also receiving 

several of the new X–2 knees developed through a public-private endeavor to build 

a knee that can navigate stairs, water, and even enable the user to walk backwards. 

PSAS is a pioneer in the area of standardizing care through its Prosthetic Clinical 

Management Program. PSAS developed national contracts that not only saved VA 

$400 million over the past few years, but also elevated the level of care for all Veterans by awarding national contracts to companies that provide only the highest 

quality products. Interdisciplinary teams of clinical, patient safety and engineering 

experts rigorously review each offer to ensure only the best products are procured 

for our Veterans. This Program has also led the development of more than 35 clinical practice recommendations that provide guidance to clinicians for prescribing 

prosthetic devices. The result has been the successful elevation of the quality of devices and evaluations for Veterans. 

Care to Women Veterans 

The conflicts in Iraq and Afghanistan have introduced a new generation of Veterans into VA with specialized needs. One segment of this new generation is Women 

Veterans. Of the 1.1 million OEF/OIF Veterans, 128,397 are women Veterans; approximately 50 percent of these women Veterans utilized VA health care between 

FY 2002 and the first quarter of FY 2010. Our women Veterans have unique health 

care needs compared with the larger male Veteran population. On average, women 

Veterans are younger than male Veterans with over two-thirds of OEF/OIF women 

Veterans being in reproductive age groups. VA again thanks Congress for its work 

on Public Law 111–163, which has given VA the authority to provide newborn care 

for women Veterans. VA has enhanced its current system to transition from a disease model to a wellness model of care that assures equal access for all Veterans, 

and continues to deliver world-class health care for our Veterans who have served. 

Conclusion 

Thank you again for this opportunity to speak about VA’s role in providing timely, 

coordinated care to our severely injured OEF/OIF servicemembers and veterans. I 

am prepared to answer any questions the subcommittee might have. 


ccoleman on DSK8P6SHH1PROD with HEARING
66 

MATERIAL SUBMITTED FOR THE RECORD 

Committee on Veterans’ Affairs 

Subcommittee on Health 

Washington, DC. 

July 27, 2010 

Thomas Zampieri, Ph.D. 

Director of Government Relations 

Blinded Veterans Association 

477 H Street, NW 

Washington, DC 20001 

Dear Dr. Zampieri: 

Thank you for your testimony at the U.S. House of Representatives Committee 

on Veterans’ Affairs Subcommittee on Health oversight hearing on ‘‘Healing the 

Physical Injuries of War’’, which took place on July 22, 2010. 

Please provide answers to the following questions by Tuesday, September 7, 2010, 

to Jeff Burdette, Legislative Assistant to the Subcommittee on Health. 

1. Do you believe that VA is meeting the needs of our servicemembers and veterans who are severely injured from the war in Iraq and Afghanistan? What 

is VA doing well and what areas are in need of improvement. 

2. Is VA properly staffed to care for severely injured veterans and do our veterans have access to the most current therapies? 

3. How would you rate the coordination between DoD and VA in providing medical care for severely injured OEF/OIF veterans? What are your recommendations for enhancing coordination efforts between VA and DoD? 

4. Of the total number of veterans who are blind or have low vision, do you 

have a sense of how many of these veterans are accessing care at VA? 

Thank you again for taking the time to answer these questions. The Committee 

looks forward to receiving your answers by September 7, 2010. 

Sincerely, 

MICHAEL H. MICHAUD 

Chairman 

Blinded Veterans Association 

Washington, DC. 

August 13, 2010 

The Honorable Michael Michaud 

Chairman, House VA Subcommittee Health 

United States Congress 

335 Cannon House Office Building 

Washington, DC 20515 

Dear Chairman Michaud, 

The Blinded Veterans Association (BVA), is the only congressionally chartered 

veterans service organization exclusively dedicated to serving the needs of our nation’s blinded veterans and their families and we appreciated the invitation to provide testimony before committee on July 21, and chance to respond to the questions. 

BVA is concerned that the Vision Center of Excellence established in the NDAA FY 

2008 section 1623 has not had the full staffing, funding, and operational support 

necessary to meet the needs of ensuring that the combat eye injured have seamless 

transition of eye care, from DoD and VA medical treatment centers. These eye 

wounded require the coordination of vision services during these transitions. Visually impaired must be provided contacts with VA Visual Impairment Service Team 

(VIST) Coordinators and the Blind Rehabilitative Outpatient Specialists (BROS) 

they need. The claim that the Office of the Assistant Secretary Defense for Health 

Affairs (ASDHA) does not have enough operational funds to establish the VCE since 

January 2008 is completely absurd. The small amount spent of less than $ 2.5 million is reflective of bureaucratic indifference and lack of governance for the eye 

wounded and BVA requests the VA Committee request a GAO investigation into the 

implementation of the VCE. 

Regarding the questions you have submitted this is our responses: 


ccoleman on DSK8P6SHH1PROD with HEARING
67 

1. BVA has seen tremendous effort and resources devoted to improving the outpatient services for blinded and low vision veterans in the establishment of 

55 new specialized programs and addition of 276 staff since January 2007 

with the Continuum of Care that VHA approved. As VA expanded the staffing, and improved access to specialized rehabilitation services for vision loss 

from injuries the problem has been communications between DoD medical 

treatment facilities eye care professionals, case managers, and transition coordinators to VA staff for those with either combat eye injuries or Traumatic 

Brain Injury with vision functional impairments know where these services 

are located. 

2. BVA would request that the issue of Blind Rehabilitative Outpatient Specialists (BROS) who are employed by the VA and assigned to MTF’s but are not 

being credentialed and privileged within DoD MTF’s is significant problem. 

While new combat wounded are awaiting transfer into a VA Blind Center the 

wounded and families benefit from the training the VA BROS can provide. 

However, because DoD has never employed BROS as allied health occupation 

they have no mechanism to credential them to provide rehabilitation to 

servicemembers within MTF’s. For two years no progress has been made on 

this problem despite meetings and outreach from VA. We recommend that 

the HVAC work with the HASC on language in NDAA that would resolve 

this problem with out further delays. 

3. The Vision Center of Excellence is required to have joint Eye Trauma Registry to track eye injured or TBI visually impaired servicemembers with vital 

eye care consultant reports, surgery records, diagnostic testing results, and 

share this with VA eye care providers. The work on this registry started in 

FY 2007 and CONOPS were approved in August 2009. Defense Veterans Eye 

Injury and Vision Registry (DVEIVR) was tested from March 15–24, 2010 

and successfully but still is not being funded with the $ 6 million to implement the sharing of data elements between DoD and VA clinicians. 

4. The VA witness during the hearing stated VA Blind Rehabilitative Services 

(BRS) has provided inpatient blind rehabilitative training to 126 OIF and 

OEF veterans. VA BRS is also following an additional 1,089 with low vision 

impairments, from TBI injuries mostly and we believe that there are others 

that have entered the system without being identified as having visual injuries that must all be screened. TBI’s rarely result in legal blindness, but reports find rising numbers with vision problems diagnosed with variety visual 

impairments. The VA Polytrauma Centers report that 80 percent of all TBI 

patients have complained of visual symptoms from there blast exposure. VA 

research has further revealed that approximately 65 percent of those with 

diagnosis of visual dysfunction have at least one, and often three of the following associated visual disorders including diplopia, convergence disorder, 

photophobia, ocular-motor dysfunction, visual field loss, color blindness, and 

an inability to interpret print. One research study that examined 25 TBI veterans found none of the following visual complications during the normal 

medical evacuation process were diagnosed early; corneal damage 20 percent, 

cataracts 28 percent, angle recession glaucoma 32 percent, retinal injury 22 

percent, these all would place these individuals at high risk of progressive 

visual impairments if not diagnosed and treated early. With 1,200 diagnosed 

with optic nerve damage this is a significant population of wounded requiring specialized VA services and they must be entered into the (DVEIVR) so 

both DoD and VA can ensure high quality care and avoid unnecessary complications and coordinate new research protocols for vision impairments. 

BVA also included in our testimony concern that some private agencies are trying 

to get earmarks to provide specialized services for blinded veterans without having 

the same staffing and accreditation standards that VA provides within its specialized rehabilitation centers. We strongly object and would request that language be 

supported in the MILCON VA appropriations report clarifying that any private 

agency should demonstrate peer reviewed quality outcome measurements that are 

standard part of VHA BRS, and should it ever be necessary to refer a visually impaired or blinded veteran to a non VA BRC, they should be accredited by National 

Accreditation Council for Agencies Serving the Blind and Visually Handicapped 

(NAC) and/or the Commission For Accreditation of Rehabilitation Facilities (CARF), 

and that the employed Blind Instructors or Specialists be Certified by the Academy 

for Certification of Vision Rehabilitation and Education Professionals (ACVREP). 

Private agencies without nursing, medical, and psychology staffing on site should 

not be allowed to provide services to acute polytrauma new injured servicemembers. 


ccoleman on DSK8P6SHH1PROD with HEARING
68 

BVA appreciates your strong leadership on this important veteran’s health care 

issue for those suffering eye injuries from the current wars and TBI visual complications, and we request that both DoD and senior VA JEC management report back 

to your subcommittee and move the Vision Center of Excellence quickly into full operations. 

Sincerely, 

Thomas Zampieri Ph.D. 

f 

Director Government Relations 

Committee on Veterans’ Affairs 

Subcommittee on Health 

Washington, DC. 

July 27, 2010 

Mr. Carl Blake 

National Legislative Director 

Paralyzed Veterans of America 

801 18th Street NW 

Washington, DC 20006 

Dear Mr. Blake: 

Thank you for your testimony at the U.S. House of Representatives Committee 

on Veterans’ Affairs Subcommittee on Health oversight hearing on ‘‘Healing the 

Physical Injuries of War’’, which took place on July 22, 2010. 

Please provide answers to the following questions by Tuesday, September 7, 2010, 

to Jeff Burdette, Legislative Assistant to the Subcommittee on Health. 

1. Do you believe that VA is meeting the needs of our servicemembers and veterans who are severely injured from the war in Iraq and Afghanistan? What 

is VA doing well and what areas are in need of improvement. 

2. Is VA properly staffed to care for severely injured veterans and do our veterans have access to the most current therapies? 

3. How would you rate the coordination between DoD and VA in providing medical care for severely injured OEF/OIF veterans? What are your recommendations for enhancing coordination efforts between VA and DoD? 

4. You noted that the growing pressure of allowing veterans to seek care outside of VA threatens the VA health care system because VA would lose the 

critical mass of patients that are needed to maintain specialized services at 

VA. What do you propose for our severely injured veterans in rural communities who do not live near VA facilities? 

5. You discussed the coordination issues presented by DoD’s transfer of SCI patients to a civil hospital, rather than to the VA. Do you have further information on the prevalence of this practice or the rationale for it? 

6. Your testimony addressed the important of VA maintaining the SCI capacity 

mandated by P.L. 104–262. Given that the capacity levels set by this legislation were established prior to the current conflicts, do you believe the mandated capacity remains sufficient? 

Thank you again for taking the time to answer these questions. The Committee 

looks forward to receiving your answers by September 7, 2010. 

Sincerely, 

Michael H. Michaud 

Chairman 


ccoleman on DSK8P6SHH1PROD with HEARING
69 

Paralyzed Veterans of America 

Washington, DC. 

August 31, 2010 

Honorable Michael Michaud 

Chairman 

House Committee on Veterans’ Affairs 

Subcommittee on Health 

338 Cannon House Office Building 

Washington, DC 20515 

Dear Chairman Michaud: 

On behalf of Paralyzed Veterans of America (PVA), I would like to thank you for 

the opportunity to present our views on ‘‘Healing the Physical Injuries of War.’’ We 

also appreciate the opportunity to address what the Department of Veterans Affairs 

(VA) is doing in caring for severely injured veterans, in particular, veterans of Operation Enduring Freedom and Operation Iraqi Freedom (OEF/OIF). 

As we testified, specialized services are part of the core mission and responsibility 

of the VA, including spinal cord injury care, blinded rehabilitation, and mental 

health treatment, including traumatic brain injury. The VA’s specialized health care 

programs are unmatched by private health care facilities. We appreciate the Subcommittee’s interest in ensuring that these veterans receive the absolute best care 

available. 

Attached are responses to each of the questions presented in your July 27, 2010 

follow-up questions. Thank you. 

Sincerely, 

Carl Blake 

National Legislative Director 

Question 1: Do you believe that VA is meeting the needs of our servicemembers 

and veterans who are severely injured from the war in Iraq and Afghanistan? What 

is VA doing well and what areas are in need of improvement? 

Answer: VA continues to provide exceptional care for severely injured veterans 

of the wars in Iraq and Afghanistan. The law that allows for a veteran to receive 

care for up to five years following his or her return from a combat theater has been 

a tremendous benefit to these veterans. It has ensured that if they suffer from any 

health problems, including mental health issues such as PTSD, they have a place 

with knowledgeable professionals to seek treatment. 

However, we believe that there is still an ongoing need to ensure proper delivery 

of care to veterans living in rural communities. Deployment of National Guard and 

Reserve servicemembers, a large percentage who generally come from more rural 

communities, has created a growing demand for health services from those same 

rural areas. However, we believe that VA has the infrastructure in place to provide 

the vast majority of care needed for these men and women through its extensive 

network of Community-Based Outpatient Clinics (CBOCs) and its hospital system. 

Additionally, the hub-and-spoke delivery system used for spinal cord injury care has 

allowed the VA to address the demands of the most severely disabled veterans it 

cares for. This same model can be applied to other specialized health care concerns. 

Question 2: Is VA properly staffed to care for severely injured veterans and do 

our veterans have access to the most current therapies? 

Answer: Based on a recent staffing survey (July 2010) of the Spinal Cord Injury 

(SCI) service, the VA is clearly understaffed in some critical areas. As expressed in 

our testimony, the most notable shortage is in the number of nurse staff. As of the 

July survey, the VA SCI service faced a total nurse deficit of approximately 134 

nurses. This is particularly troublesome because these are the individuals who provide the majority of bedside care to SCI veterans. Additionally, while the survey is 

specific to SCI staffing, it may be applicable to other specialized care services. 

PVA believes it is critical that a uniform national policy be established for nurse 

staffing and VHA should centralize policies for funding a systemwide recruitment 

and retention plan for SCI nurses. Additionally, as we recommended in our testimony, we believe it is time for the VA to consider a nurse specialty pay for those 

nurse staff working in SCI centers. 

In the meantime, the VA SCI service also faces shortages in doctor, social worker, 

psychologist, and therapist staffing. While our veterans do have access to the most 


ccoleman on DSK8P6SHH1PROD with HEARING
70 

current treatments and therapies, these staff shortages can have a severe impact 

on their ability to receive this critical care in a timely manner. 

It is important, however, to point out that not all VA SCI centers are understaffed. In fact, several currently meet the fully staffed bed requirements that have 

been established. Likewise, the staffed levels of facilities are constantly changing 

due to the changing acuity levels of the patients that come and go from the various 

facilities. However, the fact remains that across the system the VA SCI service still 

faces shortages in all of its critical health professional areas. 

Question 3: How would you rate the coordination between DoD and VA in providing medical care for severely injured OEF/OIF veterans? What are your recommendations for enhancing coordination efforts between VA and DoD? 

Answer: The coordination between the Department of Defense (DoD) and the VA 

to provide care for severely injured veterans is generally good, particularly for veterans of Operation Enduring Freedom and Operation Iraqi Freedom (OEF/OIF). The 

transfer of patients from the primary DoD health care centers, such as Walter Reed 

Army Medical Center, Bethesda Naval Hospital, Brooke Army Hospital, and Balboa 

Naval Hospital, generally works well, particularly when trying to move spinal cord 

injured servicemembers from those facilities to VA SCI centers. 

However, as mentioned in our testimony, we have seen some complications in this 

transfer when it comes to servicemembers who were not injured in the combat theater, but instead at their home installations. In order to improve and enhance this 

coordination, we believe that continued education, particularly in DoD facilities, is 

critical to ensuring that the DoD facilities are aware of their responsibilities in expeditiously transferring severely injured servicemembers, particularly those with 

SCI and other polytrauma, to the appropriate VA medical center. Additionally, we 

think continued congressional oversight is necessary to ensure that DoD and VA are 

both fulfilling their responsibilities to care for these men and women. 

Question 4: You noted that the growing pressure of allowing veterans to seek 

care outside of VA threatens the VA health care system because VA would lose the 

critical mass of patients that are needed to maintain specialized services at VA. 

What do you propose for our severely injured veterans in rural communities who 

do not live near VA facilities? 

Answer: PVA’s points regarding the growing pressure of outside care dealt with 

the challenges of maintaining capacity in the VA system. This can only be done if 

sufficient patients are treated at a facility, otherwise the costs per patient can rise 

significantly. PVA believes VA’s hub-and-spoke model of Medical Centers supporting 

Community-Based Outpatient Clinics (CBOC) is an excellent method to maintain a 

critical mass of patients in an area while providing for veterans living at ever greater distances from VA hospitals. 

This is perhaps most important in rural communities. We recognize the fact that 

veterans in rural communities have greater challenges getting care from VA facilities. But this is not only a problem for veterans. Rural communities are bereft of 

specialty care facilities, not only for veterans, but for all members of the community. 

While general care may be available, the specialized care needed by those with any 

type of catastrophic injury may be hundreds of miles away. PVA has worked to educate our members that due to the limited availability of some forms of specialized 

care, there will sometimes be the need to travel some distance to receive this care 

at a VA facility. Moreover, our members have come to realize that in order to receive the absolute best specialized care, they sometimes must travel significant distances to a VA facility because comparable care is simply not available in their local 

communities. 

The success of CBOCs only confirms the need for greater expansion of these valuable resources further into the rural community. This will create a wider net of care 

facilities, providing ever increasing services to rural veterans. PVA strongly supports this method of providing for our severely injured veterans in rural communities. 

Question 5: You discussed the coordination issues presented by DoD’s transfer 

of SCI patients to a civilian hospital, rather than to the VA. Do you have further 

information on the prevalence of this practice or the rationale for it? 

Answer: We cannot provide specific data on the prevalence of this occurrence. 

However, as we mentioned in our testimony, this coordination and transfer issue 

tends to be more prevalent when it involves a servicemember who was injured 

somewhere other than in the combat theaters of Iraq and Afghanistan, such as at 

their home installations. We find this particularly troublesome as it suggests a lesser priority is placed on getting these men and women to the appropriate care in the 


ccoleman on DSK8P6SHH1PROD with HEARING
71 

VA as opposed to those injured in Iraq and Afghanistan. We also believe it reflects 

the fact that the Memorandum of Agreement that the VA has with DoD to transfer 

spinal cord injured servicemembers is not well-publicized beyond the major intake 

centers such as Walter Reed and Bethesda, and that some of the local DoD health 

care facilities are unaware of this responsibility. 

Question 6: Your testimony addressed the important of VA maintaining the SCI 

capacity mandated by P.L. 104–262. Given that the capacity levels set by this legislation were established prior to the current conflicts, do you believe the mandated 

capacity remains sufficient? 

Answer: With the length of the wars in Afghanistan and Iraq and the anticipation that the current conflicts may continue well into the future, PVA believes in 

is necessary for VA to reevaluate its mandated capacity levels to reflect changes 

since 9/11. It is PVA’s experience that VA is generally meeting the needs of veterans 

with Spinal Cord Injury (SCI). However, capacity is a function of available beds and 

staff. Staffing challenges, particularly nursing shortages, continue to plague VA. 

In addition, the demographics of the veteran population have changed with the 

increased numbers of National Guard and Reserves serving, a military population 

generally older than regular Active Duty forces. With approximately 160 new combat injured SCI veterans and hundreds more non-combat related injuries since the 

beginning of the war, and the possibility of increasing numbers as the weapons used 

increase in destructive power and availability, there is a real possibility of even 

higher rates of catastrophic disabilities. Considering these conditions and the fact 

that the nature of health care delivery has changed since enactment of P.L. 104– 

262, it would make sense for VA to look forward and anticipate these effects on future capacity. 

f 

Committee on Veterans’ Affairs 

Subcommittee on Health 

Washington, DC. 

July 27, 2010 

Ms. Joy J. Ilem 

Deputy National Legislative Director 

Disabled American Veterans 

807 Maine Avenue, SW 

Washington, DC 20024 

Dear Ms. Ilem: 

Thank you for your testimony at the U.S. House of Representatives Committee 

on Veterans’ Affairs Subcommittee on Health oversight hearing on ‘‘Healing the 

Physical Injuries of War’’, which took place on July 22, 2010. 

Please provide answers to the following questions by Tuesday, September 7, 2010, 

to Jeff Burdette, Legislative Assistant to the Subcommittee on Health. 

1. Do you believe that VA is meeting the needs of our servicemembers and veterans who are severely injured from the war in Iraq and Afghanistan? What 

is VA doing well and what areas are in need of improvement. 

2. Is VA properly staffed to care for severely injured veterans and do our veterans have access to the most current therapies? 

3. How would you rate the coordination between DoD and VA in providing medical care for severely injured OEF/OIF veterans? What are your recommendations for enhancing coordination efforts between VA and DoD? 

4. You raised concerns about the gaps that exist in the Federal Recovery Coordination Program. What are these gaps, why do you think they exist, and 

what can we do to eliminate them? 

Thank you again for taking the time to answer these questions. The Committee 

looks forward to receiving your answers by September 7, 2010. 

Sincerely, 

Michael H. Michaud 

Chairman 


ccoleman on DSK8P6SHH1PROD with HEARING
72 

1 VA QUERI Fact Sheet; Polytrauma & Blast-Related Injuries; June 2010. 

POST–HEARING QUESTIONS FOR JOY J. ILEM, DEPUTY 

NATIONAL LEGISLATIVE DIRECTOR OF THE DISABLED AMERICAN 

VETERANS, FROM THE COMMITTEE ON VETERANS’ AFFAIRS, 

SUBCOMMITTEE ON HEALTH, HEARING, HEALING THE PHYSICAL 

INJURIES OF WAR, JULY 22, 2010 

Question 1: Do you believe that VA is meeting the needs of our servicemembers 

and veterans who are severely injured from the war in Iraq and Afghanistan? What 

is VA doing well and what areas are in need of improvement? 

Answer: It appears to DAV that the Department of Veterans Affairs (VA) four 

regional Polytrauma/TBI Rehabilitation Centers (PRCs), designed to provide specialized inpatient rehabilitation treatment and expanded clinical expertise in polytrauma, are meeting the needs of severely injured servicemembers from Iraq and 

Afghanistan. These PRCs are the ‘‘hub’’ of the VA’s Polytrauma/TBI System of Care, 

which includes four Polytrauma Transitional Rehabilitation Programs that are colocated within the PRCs—established to help patients transition from the acute 

post-injury phase into a rehabilitation mode aimed at restoring as much independence and functional capacity as possible so they can return home. The reports DAV 

has received from veterans and their families during these initial stages of care and 

recovery have for the most part been positive, including high regard for VA staff 

and satisfaction with their coordination of care. 

As the Subcommittee is aware, the VA has also established a specialized outpatient and sub-acute residential rehabilitation program, referred to as a Polytrauma Network Site (PNS) within each of the VA’s 21 integrated service networks 

(VISNs), plus one at the VA Medical Center in San Juan, Puerto Rico. VA has also 

reportedly designated Polytrauma Support Clinic Teams at smaller, more remote 

VA facilities; and has established a point of contact for polytrauma referrals at all 

other VA facilities.1, 2

DAV has expressed concern about these secondary sites of specialty care, noting 

that we are less confident that VA has attuned their available services to achieve 

consistency of polytrauma care throughout the system nationwide. Although we believe at the national program level appropriate directives and policies have established that consistency, it is not clear if these mandates are actually being carried 

out in all sites of care. We have received continued reports from veterans seeking 

VA care for what they believe is a mild TBI—but not being satisfied with the limited cognitive testing and seemingly fragmented services offered by VA at those 

sites. Two veterans who contacted DAV recently expressed concern that VA staff did 

not offer a well-rounded comprehensive program to initially educate patients about 

TBI and cohesively treat symptoms such as memory deficit, anger control issues, 

and depression or provide family education, marital or mental health counseling. In 

one case the veteran requested and was authorized care in the private sector at VA 

expense and was very impressed with the holistic ‘‘TBI program’’ and services that 

were available at a local facility specializing in head injuries. He further commented 

that he received care at VA for his other service-related conditions, was satisfied 

with that care and could not understand why VA (in his opinion) was unable to 

properly screen, diagnose and treat him for his mild TBI condition, a condition that 

had greatly impacted his job, family and his own self-esteem. 

Additionally, these veterans appeared to be labeled as ‘‘difficult patients’’ and reported having had trouble getting the services they needed from VA. Having worked 

with TBI patients in the private sector before I joined DAV, I can attest that issues 

related to mood, behavioral problems and difficulty managing anger are common 

symptoms and behaviors associated with TBI patients. We believe appropriate VA 

medical personnel should be trained and equipped to handle these challenges to ensure patients are treated properly for the symptoms that are associated with head 

injuries—regardless if they are mild, moderate or severe. In such cases we have contacted VA staff at VA’s Central Office or the local facility involved and asked that 

the various specialty coordinators reach out to these veterans and help resolve their 

issues. 

DAV believes these types of reports warrant investigation and oversight of VA’s 

secondary system of TBI care, and recommends an independent review by GAO or 

another qualified entity to determine the effectiveness of these services and patient 

satisfaction levels. 

Question 2: Is VA properly staffed to care for severely injured veterans and do 

our veterans have access to the most current therapies? 


ccoleman on DSK8P6SHH1PROD with HEARING
73 

2L. Beck, PhD., Chief Consultant, Office of Rehabilitation Services, Office of Patient Services, 

Veterans Health Administration, Department of Veterans Affairs; Testimony before the United 

States Senate Committee on Veterans’ Affairs; May 5, 2010. 

Answer: As noted above, DAV remains concerned about veterans’ access to current therapies at all secondary VA TBI/Polytrauma Network Sites of care. Likewise, 

we are concerned about sufficient staffing levels and availability of specialists and 

other resources at all VA Polytrauma primary and secondary sites. We recommend 

the Subcommittee survey the four regional sites to address this issue, as well as a 

sample from the secondary sites. Because of the medical complexity and severity of 

these patients’ injuries these positions are often associated with a high level of 

stress, staff burn-out and elevated turnover rates. 

Access to current therapies remains important to TBI patients. Several veterans 

have expressed their desire to be able to access more holistic, comprehensive programs to treat TBI symptoms to include education for themselves and family members about brain injuries, access to mental health and marital counseling, and to 

be seen by specialists who work as a team to address all of these patients’ issues 

and most of all compassionate medical personal that understand the associated behaviors and challenges TBI patients face. In addition, as we noted in our testimony 

during the hearing, we strongly believe that a gap exists between VA’s acute polytrauma and TBI programs and a severely injured veteran’s optimal long-term rehabilitation and stabilization. Today, VA is able to offer limited options, primarily 

nursing home placements. The ‘‘Heroes Ranch’’ concept being developed at the 

Tampa VA PRC is one that we embrace and that we believe offers a good model 

of age-appropriate therapeutic residential care that could begin to fill that gap. 

As noted in our testimony, VA has developed and implemented a national template to ensure that it provides every veteran receiving inpatient or outpatient 

treatment for TBI who requires ongoing rehabilitation, an individualized rehabilitation and community reintegration plan. VA integrates this national template into 

its electronic health record, and includes in the record results of the comprehensive 

assessment, measurable goals that were developed as a result of the plan, and recommendations for specific rehabilitative treatments. The patient and family participate in developing the treatment plan and are provided a copy of the plan. These 

are all positive steps; however, we encourage VA to periodically survey patients and 

family members in these programs about their experiences in care and treatment 

programs and settings to gauge if there are any improvements that can be made 

and to ensure consistency and effectiveness of treatments. 

Finally, as noted in our statement, while DAV believes great strides have been 

made over the past two years, VA recently acknowledged embracing opportunities 

for further improvement in its Polytrauma System of Care, and states the Department’s ongoing goals as follows: 

1. Ensuring that blast-exposed veterans receive screenings and evaluation for 

high-frequency, invisible sonic wounds that may produce mild TBI, PTSD, 

and other psychiatric problems, or pain and sensory loss; 

2. Promoting identification and evaluation of potentially the best practices for 

polytrauma rehabilitation, including those that optimize care coordination 

and transition across care systems and settings such as DoD and VA; 

3. Optimizing the ability of caregivers and family members to provide supportive assistance to veterans with impairments resultant from polytrauma 

and blast-related injuries; 

4. Identifying and testing methods for improving process of care and outcomes, 

even when the evidence base is not well established; and 

5. Identifying and testing methods for measuring readiness to implement and 

sustain practice improvements in polytrauma care.3

DAV fully supports VA’s goals, and we ask the Subcommittee, through oversight, 

to monitor VA’s progress in achieving them for this deserving population with the 

most severe physical wounds of war. 

Question 3: How would you rate the coordination between DoD and VA in providing medical care for severely injured OEF/OIF veterans? What are your recommendations for enhancing coordination efforts between VA and DoD? 

Answer: As noted in our testimony DAV gives VA high marks for coordination 

of care between the two Departments at VA’s four regional PRCs and associated 

military treatment facilities. VA has made new inroads to improve communication 

between the agencies’ medical systems to ensure polytrauma patient care is truly 


ccoleman on DSK8P6SHH1PROD with HEARING
74 

4 Brogan, Mark A. (Capt., USA, Ret.), Statement before House Veterans’ Affairs Subcommittee 

on Oversight and Investigations, April 28, 2009. 5Wade, Sarah, Statement before House Veterans’ Affairs Subcommittee on Oversight and Investigations, April 28, 2009. 

seamless from the time of injury throughout all stages of transition and care. From 

what we have read, seen and heard—there have been significant improvements over 

the years in this regard; however, we encourage VA and DoD to continue to collaborate and improve on this very complex network of highly specialized care. We do 

understand that compatibility of IT systems and access to electronic health records 

between the Departments is a continuing challenge and needs significant additional 

improvement. In that connection, we were pleased that VA announced on August 

23, 2010, the establishment of a very progressive pilot program of interactive electronic health record portability among VA, DoD and private facilities in the Richmond-Tidewater area of Virginia (but also involving the San Diego, California area 

facilities as well). We hope the Subcommittee will closely monitor this effort because 

we believe, if it is successful, it may serve as a model of responsive IT interactivity, 

not only for polytrauma patients, but for all forms of VA health care for sick and 

disabled veterans. 

Question 4: You raised concerns about the gaps that exist in the Federal Recovery Coordination Program. What are these gaps, why do you think they exist, and 

what can we do to eliminate them? 

Answer: As noted in our testimony, DAV remains concerned about the gaps that 

exist in the Federal Recovery Coordination Program and social work case management essential to coordinating complex components of care for polytrauma patients 

and their families. These gaps were highlighted by disabled veterans and their caregivers in hearings held by the House Veterans’ Affairs Subcommittee on Oversight 

and Investigation in April 2009 and January 2010 and warrant continued oversight 

and evaluation by the full Committee and its Subcommittees. 

Prior to the establishment of the Federal Recovery Coordination (FRC) Program, 

veterans and their families reported a complex and frustrating bureaucracy requiring them to try to navigate the DoD and VA systems ‘‘on their own.’’ One witness 

described it as, ‘‘. . . a journey of blind exploration.’’ There were complaints of a 

lack of continuity, coordination of care and communication between DoD and VA 

during a servicemember’s transition from active duty, the return home, veteran status and VA health and benefits systems. Likewise, families complained they felt 

they were carrying the burden of a servicemember’s recovery and reintegration back 

into civilian life and had little guidance or support from VA or DoD. One witness 

at the hearing noted that lost paperwork, confusing processes and lack of information were common occurrences. This witness also reported that he had had a total 

of 13 social work representatives within VA and DoD—but none of them communicated regularly with each other to make sure everything was covered in his case.4

Another witness, the spouse of a severely disabled veteran, reported a similar experience prior to the establishment of the FRC program but noted that, once the 

program was up and running, things began to go more smoothly until a new FRC 

was assigned to their case—after only four months—requiring them to start all over 

again. High personnel turnover rates appeared to be a trend early on in the program for other families as well—and hope for a single point of contact that was fully 

knowledgeable about her husband’s injuries and case as well as a complete understanding of all their benefits and a comprehensive ‘‘life plan’’ were dashed.5

One witness said it best when referring to the life-altering nature and responsibility of caring for a brain injured veteran—‘‘The responsibility is daunting, the 

stress is never ending, and we need a lifeline.’’ Although the hearing witnesses all 

agreed that the FRC program was needed and had the potential to be beneficial, 

there still seems to be a number of issues that need to be addressed including better 

communicating, educating, promoting visibility of the program and streamlining the 

referral process. It appears some family members are not aware they have an option 

to request an FRC and are sometimes confused about the roles of the multitude of 

advocates, program managers, and DoD and VA social workers and case managers 

to their wounded loved ones. The FRC’s level of knowledge about catastrophic injuries and their impact on patients and families—as well as being knowledgeable 

about DoD and VA health and benefits systems and community services are of vital 

importance to family members and caregivers alike. They also want to be able to 

rely on the FRC to help address the need of lifelong care and caregiving for their 

injured loved ones should these veterans outlive their parents, spouses or other 


ccoleman on DSK8P6SHH1PROD with HEARING
75 

6Lynch, Cheryl, Statement before House Veterans’ Affairs Subcommittee on Oversight and Investigations, April 28, 2009. 7Guice, Karen, M.D., MPP, Executive Director, Federal Recovery Coordination Program, Department of Veterans Affairs, Statement before House Veterans’ Affairs Subcommittee on Oversight and Investigations, April 28, 2009 

caregivers, or in cases where their caregivers become unable to continuously care 

for these veterans.6

The Executive Director of the FRC Program, Dr. Karen Guice, acknowledged 

there are ongoing challenges for the program and that there have been many lessons learned and adjustments in the program to improve its overall effectiveness. 

For these reasons, we again urge continued Congressional oversight of this extremely important program and recommend the FRC program be continually monitored and that families and veterans be surveyed periodically to make needed adjustments and improvements to the program.

f 

7

Committee on Veterans’ Affairs 

Subcommittee on Health 

Washington, DC. 

July 27, 2010 

Mr. Tom Tarantino 

Legislative Associate 

Iraq and Afghanistan Veterans of America 

308 Massachusetts Avenue, NE 

Washington, DC 20002 

Dear Mr. Tarantino: 

Thank you for your testimony at the U.S. House of Representatives Committee 

on Veterans’ Affairs Subcommittee on Health oversight hearing on ‘‘Healing the 

Physical Injuries of War,’’ which took place on July 22, 2010. 

Please provide answers to the following questions by Tuesday, September 7, 2010, 

to Jeff Burdette, Legislative Assistant to the Subcommittee on Health. 

1. Do you believe that VA is meeting the needs of our servicemembers and veterans who are severely injured from the war in Iraq and Afghanistan? What 

is VA doing well and what areas are in need of improvement. 

2. Is VA properly staffed to care for severely injured veterans and do our veterans have access to the most current therapies? 

3. How would you rate the coordination between DoD and VA in providing medical care for severely injured OEF/OIF veterans? What are your recommendations for enhancing coordination efforts between VA and DoD? 

4. You noted that you ‘‘received only a few complaints about the actual quality 

of care at VA.’’ This may be the case for the veterans enrolled in VHA, but 

do you believe that there is a perception problem out there for our OEF and 

OIF veterans who view VA health care as substandard care, and therefore 

not even enroll in VHA? 

5. You raised some concerns about VA limiting or denying access to some veterans who seek recovery services for TBI. Can you expand on this point and 

give us some examples of the types of care that VA is limiting or denying? 

6. In your testimony you discussed the often lengthy drive times faced by veterans seeking VA care. Have you found this issue to be of particular relevance to veterans seeking specialty care, and especially for those with particularly severe injuries? 

Thank you again for taking the time to answer these questions. The Committee 

looks forward to receiving your answers by September 7, 2010. 

Sincerely, 

Michael H. Michaud 

Chairman 


ccoleman on DSK8P6SHH1PROD with HEARING
76 

House Veterans’ Affairs Subcommittee on Health, ‘‘Healing 

the Physical Injuries of War.’’ Questions for the Record for 

Tom Tarantino, Iraq and Afghanistan Veterans of America (IAVA) 

Question 1: Do you believe that VA is meeting the needs of our servicemembers 

and veterans who are severely injured from the war in Iraq and Afghanistan? What 

is VA doing well and what areas are in need of improvement? 

Response: The VA is meeting many of the needs of servicemembers and veterans 

who are severely injured, however there is much left to be desired. VA has some 

of the brightest Doctors and best protocols for handling combat injuries, but access 

to that level of care can be limited at best. 

Question 2: Is VA properly staffed to care for severely injured veterans and do 

our veterans have access to the most current therapies? 

Response: The VA is still understaffed across the board, hence the long wait 

times for appointments. We’ve heard numerous complaints from veterans who have 

not been able to see a physical therapist for months at a time, nor come in for routine check-ups on past VA care. 

Question 3: How would you rate the coordination between DoD and VA in providing medical care for severely injured OEF/OEF veterans? What are your recommendations for enhancing coordination efforts between VA and DoD? 

Response: We would rate the coordination as significantly improved, but nowhere near seamless. Seamless transition will be when a veteran walks into the VA 

and doesn’t have to prove that they served in the military and their military medical records are available immediately to both the health care and benefits staff. 

Question 4: You noted that you ‘‘received only a few complaints about the actual 

quality of car at VA.’’ This may be the case for veterans enrolled in VHA, but do 

you believe that there is a perception program out there for our OEF and OIF veterans who view the VA health care as substandard care and therefore not even enroll in VHA? 

Response: As we stated in our testimony the VA has a huge perception issue 

among returning veterans. Many veterans think of the VA as a health care of last 

resort and avoid the VA altogether. One particular quote Questions for the Record, 

HVAC Health Tom Tarantino, IAVA ‘‘Healing the Physical Injuries of War’’ 2 of 2 

from our members sticks out in my mind, ‘‘You get what you pay for.’’ The implication is that the service at VA is substandard because it is supposedly free. The truth 

of the matter is that many veterans pay a hefty price to earn access to VA health 

care. We believe that VA must do a better job showing veterans why VA health care 

is safe, accessible and high quality. 

Question 5: You raised concerns about VA limiting or denying access to some veterans who seek recovery services for TBI. Can you expand on this point and give 

us some examples of the types of care that VA is limiting or denying? 

Response: As we put together our testimony for this hearing we consulted with 

several other veterans groups on what they felt needed to be discussed. This particular issue regarding TBI was brought up by the Wounded Warrior Project in a 

Senate Hearing on May 5th, 2010. They listed a number of examples including a 

veteran suffering from TBI in Tampa where the VA ‘‘refused [the wife’s] requests 

for further therapy to prevent reversal in the gains he had made.’’ The end result 

was the veteran seeking help through Medicare and being discharged from the VA. 

The veteran then ‘‘moved into his own apartment, but—without structure and supervision, and with a condition marked by impulsivity and lack of insight—he spun 

out of control, and has struggled since then with PTSD, depression, and substance— 

use complicating his TBI problems.’’ Only after being admitted at Navy Bethesda 

Hospital and receiving a thorough and helpful care plan was this veteran put back 

on the right track and the Tampa VAMC finally acquiesced. . 

Question 6: In your testimony you discussed the often—lengthy drive times faced 

by veterans seeking VA care. Have you found this issue to be of particular relevance 

to veterans seeking specialty care, and especially for those with particularly severe 

injuries? 

Response: Long wait times and longer drives to get to VA care has been continually relayed to us by our members. The issue of lengthy drives seemed to apply 

to both general and specialty care. 

f 


ccoleman on DSK8P6SHH1PROD with HEARING
77 

Committee on Veterans’ Affairs 

Subcommittee on Health 

Washington, DC. 

July 27, 2010 

Ms. Denise A. Williams 

Assistant Director for Health Policy 

Veterans Affairs and Rehabilitation Commission 

The American Legion 

1608 K Street, NW 

Washington, DC 20006 

Dear Ms. Williams: 

Thank you for your testimony at the U.S. House of Representatives Committee 

on Veterans’ Affairs Subcommittee on Health oversight hearing on ‘‘Healing the 

Physical Injuries of War’’, which took place on July 22, 2010. 

Please provide answers to the following questions by Tuesday, September 7, 2010, 

to Jeff Burdette, Legislative Assistant to the Subcommittee on Health. 

1. Do you believe that VA is meeting the needs of our servicemembers and veterans who are severely injured from the war in Iraq and Afghanistan? What 

is VA doing well and what areas are in need of improvement. 

2. Is VA properly staffed to care for severely injured veterans and do our veterans have access to the most current therapies? 

3. How would you rate the coordination between DoD and VA in providing medical care for severely injured OEF/OIF veterans? What are your recommendations for enhancing coordination efforts between VA and DoD? 

Thank you again for taking the time to answer these questions. The Committee 

looks forward to receiving your answers by September 7, 2010. 

Sincerely, 

Michael H. Michaud 

Chairman 

American Legion 

Washington, DC. 

September 8, 2010 

Honorable Michael H. Michaud, Chairman 

Subcommittee on Health 

Committee on Veterans’ Affairs 

335 Cannon House Office Building 

Washington, D.C. 20515 

Dear Chairman Michaud, 

The American Legion appreciates the opportunity to submit responses in reference to your July 27 letter from the ‘‘Healing the Physical Injuries of War.’’ testimony held on July 22, 2010. 

1. Do you believe that VA is meeting the needs of our servicemembers 

and veterans who are severely injured from the war in Iraq and Afghanistan? 

The American Legion has noted improvements in recent years by both the Department of Defense (DoD) and Department of Veterans Affairs (VA) in the treatment 

of severely injured and transitioning servicemembers but gaps still exist. 

Some of the positive steps DoD and VA undertook included implementation of the 

Federal Recovery Coordinators, VA Polytrauma Rehabilitation System of Care, VA 

Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) case management teams and establishing directives for Traumatic Brain Injury (TBI) screening, clinical reminders and a new symptom and diagnostic code for TBI. The American Legion believes most of the visible wounds of Iraq and Afghanistan are adequately being addressed by VA’s interdisciplinary medical team at the VA Polytrauma Rehabilitation Centers. However, some of the concerns we have include: 

shortages of specialty medical providers and the influx of the two million returning 

troops overburdening the capabilities of access and quality of care. 


ccoleman on DSK8P6SHH1PROD with HEARING
78 

In addition, The American Legion continues to be concerned about prevention, 

screening, diagnosis and treatment and combat-related research for the invisible 

wounds of war such as TBI and Post Traumatic Stress. The American Legion believes TBI and PTS are interrelated and DoD and VA are treating the symptoms 

of these injuries and not the diagnosis. During an Improved Explosive Device (IED) 

explosion, a servicemember can experience a penetrating woundor have an undetected mild, moderate or severe case of TBI. From this experience, it is very likely 

that the veteran may develop PTS leading to substance abuse, depression and regrettably, suicide. 

2. Is VA properly staffed to care for the severely injured veterans and 

do our veterans have access to the most current therapies? 

The American Legion believes VA health care is the ‘‘best care anywhere,’’ and 

is the model for the national health care. The VA Health care system is a system 

designed to meet unique and complex needs of our nation’s veterans. In order to ensure quality of care for veterans, The American Legion developed a System Worth 

Saving program in 2003 to report on best practices and challenges in the delivery 

of VA Health Care as well as to obtain feedback from veterans on their level of care. 

In the 2010 System Worth Saving site visits, it was noted that there is a shortage 

of specialty providers across the country in areas such as Psychiatrists, Gastrointestinal (GI), Cardiology physicians, Radiation and Hematology Oncologists and 

Anesthesiologists, Audio and Speech Pathology, Dietetics, Social Work, Rehabilitation Medicine, Physical Therapists, Nurses, Pharmacists and many other critical 

areas. As a result of shortages in these critical staffing areas and rural location challenges, VA’s Fee-Basis or Purchased Care costs have doubled in the last four years. 

In FY 2005, approximately 496,885 veterans were fee-based into the community for 

their health care needs at an expense of $1.6 Billion and in FY 2009, 920,404 veterans were fee-based into the community at a cost of $3.8 Billion. In most of the 

facilities visited, their Fee-Basis budget was between 15–25 percent of their hospital 

operating budget which significantly impacts the medical center’s ability to 

prioritize other medical center needs and projects. 

The American Legion recommends Congress designate specific funding to address 

recruitment and retention and rural health incentives. In addition, The American 

Legion was pleased that the House Veterans Affairs Committee recently held a 

hearing on Innovative Treatments for TBI and PTS to discuss new technologies, research and treatment for these injuries. The American Legion has continued to recommend that Congress exercise oversight and appropriate the necessary funding for 

DoD and VA to fully explore and fund research and studies to prevent, diagnose and 

treat these complex injuries. 

3. How would you rate the coordination between DoD and VA in providing medical care for severely injured OEF/OIF Veterans? What 

are your recommendations for enhancing coordination efforts between VA and DoD? 

The American Legion would rate the coordination between DoD and VA as improved but gaps still remain. As highlighted in our testimony, DoD reported that 

as of April 3, 2010, there were a total of 8,810 servicemembers wounded in action 

during Operation Iraqi Freedom (OIF) and 2,038 have been wounded in action during Operation Enduring Freedom (OEF). Of the two million servicemembers currently deployed, The American Legion is concerned that VA does not have a capacity 

and number of specialty providers necessary to accommodate for an increase in demand of these returning soldiers. Due to medical advances on the battlefield in the 

current conflicts in Iraq and Afghanistan, our nation’s heroes are surviving life 

threatening injuries at a higher rate but will require significant lifelong care in the 

VA. 

VA’s Seamless Transition process targets the severely injured servicemembers 

and the Military Treatment Facilities (MTFs) have VA Nurse Liaisons and VA Social Workers on site to ensure a warm handoff into one of the four lead Polytrauma 

Rehabilitation Centers. In addition, VA established Polytrauma Network sites at 

each of their 22 Veteran Integrated Service Networks (VISNs), 82 Polytrauma Support Clinic Teams and 48 Polytrauma Points of Contact to provide case management 

close to the transitioning servicemember’s home. 

While the case management process has improved, a major impediment still needing to be resolved is the bilateral record exchange between DoD and VA. Both agencies will never truly have seamless transition if their medical records are not interoperable. The American Legion has fully supported the Lifetime Electronic Medical 

Record Initiative which will create a bilateral record exchange from DoD into VA. 


ccoleman on DSK8P6SHH1PROD with HEARING
79 

Since 2007, The American Legion has continued to advocate for this improvement 

because every day without a bilateral record, a potential veteran can fall through 

the cracks and need access their needed medical care. 

The American Legion was pleased to see passage of the Caregiver and Veterans 

Omnibus Health Services Act which will train and pay a stipend to a family member caregiver in the homes of our severely wounded soldiers. The American Legion’s 

only concern with the Caregiver law is that only OEF/OIF caregivers will receive 

a stipend when many other veterans from previous conflicts do not receive this benefit and are taken care of by a family member in their homes for many injuries or 

illnesses. 

The American Legion recommends that Congress exercise its oversight to ensure 

VA provides an annual Mental Health Strategic Report, to make transparent, the 

agency’s efforts in appropriations and where these funds are spent, as well as services provided through research, screening and treatment for all Mental Health illnesses. 

Once again, The American Legion appreciates the opportunity to provide recommendations to improve DoD and VA’s efforts to ensure both agencies are prepared to meet the long-term and complex health care needs of our nation’s veterans. 

Thank you for your continued commitment to America’s veterans and their families. 

Sincerely, 

Tim Tetz 

f 

Director, National Legislative Commission 

Committee on Veterans’ Affairs 

Subcommittee on Health 

Washington, DC. 

July 27, 2010 

Honorable Robert M. Gates 

Secretary 

U.S Department of Defense 

1400 Defense Pentagon 

Washington, DC 20301 

Dear Secretary Gates: 

Thank you for the testimony of Dr. Jack Smith, Acting Deputy Assistant Secretary for Clinical and Program Policy at the U.S. House of Representatives Committee on Veterans’ Affairs Subcommittee on Health oversight hearing on ‘‘Healing 

the Physical Wounds of War’’, which took place on July 22, 2010. 

Please provide answers to the following questions by Tuesday, September 7, 2010, 

to Jeff Burdette, Legislative Assistant to the Subcommittee on Health. 

1. How does DoD define severely injured servicemembers? How does DoD track 

the number of and the types of severe injuries? Do you share this data with 

VA, and is it made available to the public? 

2. Does DoD offer the same types of specialized services as VA? Are there certain specialized services that DoD offers, but which VA does not? 

3. Where is DoD headed in terms of further enhancing coordination efforts with 

VA in caring for the severely injured? 

4. Why is it that VA’s Blind Rehabilitation Outpatient Specialists do not have 

clinical privileges at military treatment facilities? 

5. In PVA’s testimony, they expressed concern that some mild TBI cases are 

falling through the cracks because of DoD’s failure to diagnose and treat 

mild TBI? What can DoD do to improve on this front? 

6. During their testimony, PVA raised concerns about some active duty soldiers 

with spinal cord injury and dysfunction bypassing the VA health care system 

and being transferred directly to civilian hospitals in the community. Why 

is this happening? What is DoD’s rationale for bypassing the VA health care 

system? 


ccoleman on DSK8P6SHH1PROD with HEARING
80 

Thank you again for taking the time to answer these questions. The Committee 

looks forward to receiving your answers by September 7, 2010. 

Sincerely, 

Michael H. Michaud 

Chairman 

Hearing Date: July 22, 2010 

Committee: HVA 

Member: Congressman Michaud 

Witness: Dr. Smith 

Question 1: How does DoD define severely injured servicemembers? How does 

DoD track the number of and the types of severe injuries? Do you share this data 

with VA, and is it made available to the public? 

Answer: The Department uses the following definitions: 

• Seriously Ill or Injured—The casualty status of a person who has an injury; 

a physiological or psychological disease or condition; or a mental disorder that 

requires medical attention and medical authority declares that the condition 

is life-threatening or life-altering, and/or that death is possible, but not likely 

within 72 hours. This may include post-traumatic stress disorder and associated conditions. NOTE: A casualty status is assigned at a specific point in 

time and can be changed. 

• Very Seriously Ill or Injured—The casualty status of a person whose illness 

or injury is such that a medical authority declares it more likely than not 

that death will occur within 72 hours. 

The Department of Defense tracks the number of medically evacuated patients 

and the reason for evacuation using TRANSCOM data; collects and evaluates trauma care using the Joint Trauma Registry; collects and evaluates disease and injury 

trends using the Theater Medical Data System records; and collects and reports theater morbidity and mortality counts and reasons using personnel data sent to the 

Defense Manpower Data Center (DMDC), Data, Analysis and Programs Division. 

Direct individual medical information is available to the Department of Veterans 

Affairs (VA) via data sharing (i.e., Bilateral Health Information Exchange and Federal Health Information Exchange). Inpatient medical records for severely injured 

members being transferred to VA poly-trauma centers are also scanned and forwarded to the VA. Medical information on individuals is not publicly available. 

However, military casualty information is publicly available on the DMDC Analysis 

and Programs Division Web site at http://siadapp.dmdc.osd.mil/personnel/ 

MMIDHOME.HTM. 

Question 2: Does DoD offer the same types of specialized services as VA? Are 

there certain specialized services that DoD offers, but which VA does not? 

Answer: DoD does offer specialized services, as does VA. The two Departments 

have many MOAs regarding the sharing of specialty care. These agreements center 

on the core competencies of each Department in meeting the special needs of their 

beneficiaries. For example, there is a long standing Memorandum of Agreement 

(MOA) between the Department of Veterans Affairs (VA) and the Department of Defense (DoD) associated with specialized care for Active Duty Servicemembers 

(ADSMs) sustaining spinal cord injuries, traumatic brain injuries, blindness, or a 

combination of injuries (polytrauma). The Veterans Health Administration is known 

for its integrated system of health care for these conditions and the VA/DoD Health 

Executive Council identified the need for procedures governing the treatment of 

ADSM inpatients, outpatients, and other related comprehensive services at VA facilities. 

Question 3: Where is DoD headed in terms of further enhancing coordination efforts with VA in caring for the severely injured? 

Answer: Currently, we are sustaining the momentum of DoD and VA collaboration by improving upon the existing programs as lessons are learned as well as 

striving to identify new opportunities for collaborative and cooperative activities 

with the VA. At all levels within DoD, program managers and directors are working 

closely with their VA counterparts to improve access, quality, and efficiency as the 

keys to maintaining and improving upon the firm foundation for coordinated health 


ccoleman on DSK8P6SHH1PROD with HEARING
81 

care services and benefits. These efforts have been and will continue to be future 

high priorities for the DoD. 

Question 4: Why is it that VA’s Blind Rehabilitation Outpatient Specialists do 

not have clinical privileges at military treatment facilities? 

Answer: The Veterans Health Administration (VHA) is the only medical organization that credentials blind rehabilitation specialists (BRS) and blind rehabilitation 

outpatient specialists (BROS) as an occupational series, which is a subgroup of an 

occupational group or a job family that includes all classes of positions at various 

skill levels in a type of work. The VHA developed an occupational series to organize, 

identify, and credential these professionals after World War II, when the first VHA 

inpatient blind rehabilitation center opened. When Medicare was deployed in the 

1950’s, a decision was made not to include rehabilitation for visual impairment because age-related visual impairment was not the health issue at that time that it 

is today. Therefore, other third party medical insurers do not currently recognize 

these professionals. 

There has not been a similar credentialing system in place in the Department of 

Defense (DoD). The DoD has not provided blind rehabilitation training to Servicemembers since transferring that care from DoD to the Department of Veterans Affairs (VA) following World War II. In 1947, President Truman transferred blind rehabilitation training programs at Valley Forge General Hospital (Valley Forge, PA), 

Dibble General Hospital (Menlo Park, CA), and Old Farms Convalescent Hospital 

(Avon, CT) to the VA via Presidential Order. 

Although they are not credentialed rehabilitation providers in the DoD at this 

time, BRS and BROS as additional occupational series’ may be considered by DoD 

in the future. We are conducting an analysis of the requirements and courses of action for credentialing rehabilitation providers in the DoD. Currently, VA BROSs can 

and do support DoD credentialed providers such as optometrists, occupational therapists, and physical therapists in establishment of rehabilitation care plans for 

Servicemembers. DoD military treatment facilities refer to VA health care facilities 

and blind rehabilitation providers as needed to provide equal access to care. 

Question 5: In PVA’s testimony, they expressed concern that some mild TBI 

cases are falling through the cracks because of DoD’s failure to diagnose and treat 

mild TBI? What can DoD do to improve on this front? 

Answer: The Deputy Secretary of Defense recently signed a policy whereby mandatory medical evaluations occur in the presence of clearly defined inciting events. 

In addition to these mandatory medical evaluations for early detection and treatment of concussion, there are also line commander reporting requirements to ensure 

those who are exposed to possible concussive events undergo an evaluation. 

All Servicemembers take the Post-Deployment Health Assessment and the PostDeployment Health Reassessment at the end of their deployment cycle. Embedded 

within these assessments are TBI related screening questions to further identify 

those who may have sustained a TBI with current symptoms who may require further evaluation. 

The Department of Defense (DoD) is committed to providing optimal health care 

to all Servicemembers. This includes all who sustain any severity of traumatic brain 

injury (TBI). While more severe levels of TBI are obvious and easier to diagnose 

than mild TBI, the DoD will continue to take steps to ensure that Servicemembers 

with a potential concussive injury are fully evaluated and promptly treated. 

*Note: The question refers to the testimony of Mr. Carl Blake, National Legislative Director, Paralyzed Veterans of America (PVA). 

Question 6: During their testimony, PVA raised concerns about some active duty 

soldiers with spinal cord injury and dysfunction bypassing the VA health care system and being transferred directly to civilian hospitals in the community. Why is 

this happening? What is DoD’s rationale for bypassing the VA health care system? 

Answer: Patient preference as to the location of their long term treatment is the 

individual’s prerogative. The responsible military treatment facility (MTF) obtains 

the preference of the active duty Servicemember (or their guardian, conservator, or 

designee) for those individuals being considered for treatment under the spinal cord 

injury, traumatic brain injury, blindness, or polytrauma injury Memorandum of 

Agreement. The MTF will identify to the Servicemember or their designee the appropriate participating VA facility and make all transfer arrangements. Should the 

Servicemember or their designee request transfer to a TRICARE network provider 

or other civilian facility, the MTF will honor that request. 

*Note: The question refers to the testimony of Mr. Carl Blake, National Legislative Director, Paralyzed Veterans of America (PVA). 

f 


ccoleman on DSK8P6SHH1PROD with HEARING
82 

Committee on Veterans’ Affairs 

Subcommittee on Health 

Washington, DC. 

July 27, 2010 

Honorable Eric K. Shinseki 

Secretary 

U.S. Department of Veterans Affairs 

810 Vermont Avenue NW 

Washington, DC 20240 

Dear Secretary Shinseki: 

Thank you for the testimony of Dr. Lucille B. Beck, Chief Consultant, Rehabilitation Services, Office of Patient Care Services in the Veterans Health Administration 

at the U.S. House of Representatives Committee on Veterans’ Affairs Subcommittee 

on Health oversight hearing on ‘‘Healing the Physical Injuries of War’’, which took 

place on July 22, 2010. 

Please provide answers to the following questions by Tuesday, September 7, 2010, 

to Jeff Burdette, Legislative Assistant to the Subcommittee on Health. 

1. Does VA track veterans by the number and types of severe injuries? 

2. While OEF/OIF veterans may currently comprise a small proportion of the 

total number of veterans who use specialized services at VA, this is likely 

to change as our veterans return from Iraq and Afghanistan in increasing 

numbers. Given this, does VA have a good sense of the future demand for 

specialized services among our OEF/OIF veterans population? What is VA 

doing to prepare for the pending increase in demand for specialized services? 

3. Dr. Beck’s testimony emphasized VA’s efforts in the area of prosthetics for 

women veterans. Are there gender differences where the needs of women veterans differ from their male counterparts for other specialized services such 

as blind rehabilitation, spinal cord injury centers, and polytrauma? If such 

difference exist, what is VA doing in these other areas to provide gender-specific care that meets the unique needs of women veterans? 

4. Does VA offer the same types of specialized services as that of DoD? Are 

there certain specialized services that VA offers but which DoD does not 

offer? 

5. How does VA know that they are providing the right kinds of specialized 

services? Also, how does VA know that they are serving severely injured 

OEF/OIF veterans on a timely basis at their current capacity? Can VA quickly ramp-up or ramp-down services to accommodate changes in the severely 

wounded veteran population? 

6. How does VA ensure high quality of care for severely injured OEF/OIF veterans? In other words, how does VA know that care is consistent, standardized, and measurable across the VA health care system? 

7. In their testimony, DAV brought to the Subcommittee’s attention the proposed Tampa area Heroes Ranch, which would serve as a post-acute longterm care residential brain injury facility for active duty military servicemembers and veterans. Where is the VA in reviewing this proposal? When 

can we expect a formal decision from VA? 

8. Where is VA in implementing the caregiver family support provisions of public law 111–163? When will caregivers have access to the supportive services 

provided in the recently enacted caregiver legislation? 

Thank you again for taking the time to answer these questions. The Committee 

looks forward to receiving your answers by September 7, 2010. 

Sincerely, 

Michael H. Michaud 

Chairman 


ccoleman on DSK8P6SHH1PROD with HEARING
83 

Committee on Veterans’ Affairs, U.S. House of Representatives, 

Post-Hearing Questions for Lucille Beck, Ph.D., Chief Consultant 

for Rehabilitation Services, U.S. Department of Veterans Affairs 

from the Honorable Michael H. Michaud, ‘‘Healing the Physical 

Wounds of War,’’ Oversight Hearing Subcommittee on Health, July 22, 2010 

Question 1: Does VA track Veterans by the number and types of severe injuries? 

Response: Yes. Veterans are identified and tracked through a database appropriate for their injuries and the type of rehabilitation centers where they receive 

specialized services; e.g., Polytrauma Rehabilitation Centers (PRC), Blind Rehabilitation Centers, Spinal Cord Injury Centers. Additionally, VA established the Care 

Management Tracking and Reporting Application (CMTRA) to track Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) Veterans and to ensure appropriate care management of severely injured Veterans. Six categories of severe injuries are tracked, including: amputations, blindness/severe visual impairment, major 

burns, severe mental health, spinal cord injury (SCI), and severe traumatic brain 

injury (TBI). 

Question 2: While OEF/OIF Veterans may currently comprise a small proportion 

of the total number of Veterans who use specialized services at VA, this is likely 

to change as our Veterans return from Iraq and Afghanistan in increasing numbers. 

Given this, does VA have a good sense of future demand for specialized services 

among our OEF/OIF veterans population? What is VA doing to prepare for the 

pending increase in demand for specialized services? 

Response: VA projects demand for VA health care services by OEF/OIF Veterans 

for the next 20 years using a force-deployment scenario developed by the Congressional Budget Office. This allows VA to project enrollment and demand for VA 

health care services for OEF/OIF Veterans who will separate from the military in 

the future. The OEF/OIF health care utilization projections, including VA specialized services, reflect their unique morbidity and reliance on VA health care. Further, because this is a very dynamic population, VA studies evolving trends each 

year and makes adjustments to the projections as necessary. 

There are many actions undertaken by VA to provide and plan for specialized rehabilitation services in the future, including: 

• Chartered the Polytrauma Rehabilitation and Extended Care Task Force to 

address the long-term rehabilitative care needs of seriously injured OEF/OIF 

Veterans, and develop approaches to meet such needs through enhancements 

to current VA programs and services. 

• Developed and implemented the VHA Strategic Plan for TBI, and established 

TBI as a select program in VA budget submissions. 

• Developed and implemented the Polytrauma/TBI System of Care that provides specialized rehabilitation services within every Veteran Integrated Service Network, nationwide. This system of care consists of four levels of facilities, including 4 Polytrauma Rehabilitation Centers, 22 Polytrauma Network 

Sites, and 82 Polytrauma Support Clinic Teams with interdisciplinary teams 

of rehabilitation specialists, specialty care management, psychosocial support, 

and advanced rehabilitation and prosthetic technologies. 

• Developed and implemented the Blind Rehabilitation Continuum of Care establishing 55 new low vision and blind rehabilitation clinics that provide the 

full spectrum of vision services through this one-of-a-kind National model of 

care for outpatient blind rehabilitation services. 

• Developed and established the VA Amputation System of Care; a four component system of care that mirrors the model utilized by the Polytrauma System of Care, to provide services and expertise for Veterans with amputations. 

• Developed and implemented the TBI Screening and Evaluation Program for 

all OEF/OIF Veterans receiving care within VA. Veterans who screen positive 

are referred for comprehensive evaluation and receive follow-up care and 

services as appropriate for their diagnosis and symptoms. 

• Increase initiatives to use telehealth technology to enhance access to specialty 

care, coordination of care and case management, and therapeutic interventions. 

• Sustain the continued development of VA’s future workforce. Recruiting actions and innovative educational and academic training programs are being 

established to attract the best and brightest specialty providers, and to prepare these professionals to meet the specialty needs of Veterans. Maintaining 

the appropriate number of specialty rehabilitation providers is necessary to 


ccoleman on DSK8P6SHH1PROD with HEARING
84 

support timely evaluation and services for the wide range of symptoms commonly seen following TBI and polytraumatic injuries. 

Question 3: Dr. Beck’s testimony emphasized VA’s efforts in the area of prosthetics for Women Veterans. Are there gender differences where the needs of 

Women Veterans differ from their male counterparts for other specialized services 

such as blind rehabilitation, spinal cord injury centers, and polytrauma? If such differences exist, what is VA doing in these other areas to provide gender-specific care 

that meets the unique needs of women Veterans? 

Response: VA Rehabilitation Services and Women’s Health Care Services within 

each medical facility partner to accommodate the individual needs of women Veterans participating in rehabilitation with a range of disabilities including amputation, polytrauma, and spinal cord injury. Accommodation is made in fitting of prosthetic components, spinal orthoses, and adaptive equipment needed for the treatment and care of women Veterans. Certified mastectomy fitters and female 

Orthotists/Prosthetists are available for the specialized fitting of prostheses and 

orthoses. Spinal Cord Injury (SCI) primary care providers arrange for timely women’s health care and gender specific screenings during the Veteran’s annual evaluation, or earlier when a need arises. These services are provided by trained SCI staff 

in coordination with Women’s Health clinical staff. 

VA Prosthetic and Sensory Aids Service also formed a Prosthetics Women’s 

Workgroup to address the unique needs of female Veterans. This Workgroup, comprised entirely of Women Veterans, developed a list of gender-specific items that are 

routinely available for the health and well-being of Women Veterans. Any specialized, medically indicated item can also be procured. 

While the number of severely injured women who require specialized rehabilitation services is relatively small, women Veterans are an increasingly important population that VA serves; nine percent of the 1.1 million OEF/OIF Veterans who are 

eligible for VA care are women. To address the unique needs of this growing Veteran community, VA has implemented tools to evaluate and expand care for all 

Women Veterans at every site. There are now full-time Women Veteran Program 

Managers at our 144 medical health systems, and VHA is implementing comprehensive primary care for women at all facilities, with a completion date of 2013. In 

order to accomplish this, VA has provided mini-residency training to over 500 providers in women’s health. 

Special accommodations are further made for women inpatients to ensure privacy 

and safety, including: private hospital rooms, grouping female patients together in 

adjacent rooms with private shower facilities, and providing support for visiting 

families with small children. VA Women’s Health Program continues to address the 

unique, gender-specific needs of all Women Veterans. 

Question 4: Does VA offer the same set of specialized services as that of DoD? 

Are there certain services that VA offers but which DoD does not offer? 

Response: VA offers the same set of rehabilitation services as DoD, and further 

provides more advanced, specialized services that are not available within DoD. 

DoD health care focuses primarily on short-term rehabilitation for Servicemembers 

with less severe injuries, and return to full military duty. VA provides the most 

comprehensive Rehabilitation Services for patients with more complex severe injuries and long-term consequences. Because of VA’s capabilities in this area, a Memorandum of Agreement has existed between DoD and VA since 1981 for VA to provide specialized rehabilitation services for active duty Servicemembers with Spinal 

Cord Injury, TBI/Polytrauma, and Blindness. VA also provides the full range of rehabilitation services for patients requiring general rehabilitation. 

Question 5: How does VA know that they are providing the right kinds of specialized services? Also, how does VA know that they are serving severely injured 

OEF/OIF Veterans on a timely basis at their current capacity? Can VA quickly 

ramp-up or ramp-down services to accommodate changes in the severely wounded 

Veteran population? 

Response: VA utilizes state-of-the-science care that is evidence-based, and translates this into best practices that are defined in clinical practice guidelines and deployed to VA health care providers for use. Performance measures are established 

that monitor program and treatment outcomes. As examples: 

• For 876 former patients with severe injuries treated at Polytrauma Rehabilitation Centers (PRCs): 

• 781 (89 percent) are living in a private residence; 

• 642 (73 percent) live alone or independently; 


ccoleman on DSK8P6SHH1PROD with HEARING
85 

• 413 (47 percent) report they are retired (age, disability, other reasons); • 206 (24 percent) are employed; • 90 (10 percent) are in school part-time or full-time; • 59 (7 percent) are looking for a job or performing volunteer work. 

• VA implemented a specialized Emerging Consciousness care path at the PRCs 

to serve those Veterans with severe TBI who are slow to recover consciousness. Approximately 70 percent of the 87 Veterans and Servicemembers admitted in VA Emerging Consciousness care emerge to consciousness before 

leaving inpatient rehabilitation. • For patients treated in Spinal Cord Injury Centers, new prevention efforts 

have successfully reduced the rate of developing a hospital-acquired pressure 

ulcer (which is a serious health risk for SCI patients). Only 1.3 percent of patients with SCI who were hospitalized in FY 2009 developed new pressure ulcers. 

With regard to monitoring VA capacity, at no time during the wars in Iraq or Afghanistan has VA been unable to accommodate receipt of severely injured Servicemembers upon request from DoD because of capacity. Specialty units (Polytrauma 

Rehabilitation Centers, Blind Rehabilitation Centers, Spinal Cord Injury Centers) 

regularly monitor and report capacity, remaining ready and responsive in their capacity to serve patients who are severely injured, and accommodate surges in patient volume. 

VA also partners with DoD to monitor and transition patients from DoD to VA 

health care. VA Military Liaisons are co-located with DoD Case Managers at military treatment facilities to provide onsite consultation and collaboration regarding 

VA resources and treatment options. They educate Servicemembers and their families about VA’s system of care, and facilitate inpatient transfer to a VA health care 

facility as appropriate. 

Question 6: How does VA ensure high quality of care for severely injured OEF/ 

OIF Veterans? In other words, how does VA know that care is consistent, standardized, and measurable across the VA health care system? 

Response: VA employs a systems approach to ensure that that VA specialty rehabilitation care programs adhere to the highest professional standards of service 

and effectiveness. This includes: 

• Accreditation. VA specialty rehabilitation care programs are accredited by the 

Joint Commission, and by the Commission on Accreditation of Rehabilitation 

Facilities (CARF). CARF is the internationally recognized standard of excellence for rehabilitation programs. CARF accreditation is mandatory for all VA 

inpatient rehabilitation programs and for all levels of rehabilitation programming at the specialty centers. • Outcomes Measurement. VA collects and analyzes rehabilitation outcomes 

using the Functional Independence Measure (FIM), the most widely accepted 

functional assessment measure in use in the rehabilitation community. FIM 

data is collected and analyzed by the Uniform Data System for Medical Rehabilitation, which allows VA to benchmark outcomes against those of other 

non-VA entities. The Functional Status and Outcomes Database (FSOD) is 

used to track patient outcomes across the full continuum of rehabilitative care 

from onset of disease or injury to completion of the patient’s rehabilitation 

goals without respect to the venue in which services are provided. VA also 

recently established a collaborative relationship with the National Institute 

for Disability and Rehabilitation Research to participate in the TBI outcome 

data management project with 16 TBI Model Systems centers from the private sector. 

• Translational Research. The VA Quality Enhancement Research Initiative 

(QUERI) utilizes clinical practice needs to inform VA’s research agenda, that 

in turn translates research results to identify interventions that improve the 

quality of patient care. Spinal cord injury (SCI), polytrauma and blast-related 

injuries are conditions that are part of the QUERI effort, promoting the successful rehabilitation, psychological adjustment and community re-integration 

of individuals who have sustained these injuries. 

In order to standardize consistent delivery of quality services across VA health 

care system, VA Central Office provides guidance to the field regarding the structure of the specialty care services and systems, resource requirements, and the processes and procedures involved in the delivery and coordination of services. Directives, handbooks, and guidance have been issued that set policies and describe procedures for the Polytrauma System of Care, Spinal Cord Injury and Disorders, Blind 


ccoleman on DSK8P6SHH1PROD with HEARING
86 

Rehabilitation Services, other specialty rehabilitation services and care management. 

VA has created and provided numerous educational and training opportunities for 

clinical providers, and other VA staff to become familiar with the diagnosis and 

treatment of TBI, the continuum of rehabilitation services available through the 

Polytrauma System of Care, and managing other impairments associated with TBI 

(pain and mental health issues). Over 25 national conferences and satellite broadcasts, each with 50 to 1,200 participants, have been offered though VA Employee 

Education System in the last three years. Speakers have included internationally 

recognized experts in TBI. Prior to the implementation of the mandatory TBI 

screening in 2007, over 60,000 VA providers completed a mandatory four hour TBI 

education course. 

Educational and training initiatives are also established and ongoing for VA specialty providers who work with Spinal Cord Injury and Disorders, Blind Rehabilitation Services, and Amputation System of Care (e.g., physiatrists, neurologists, 

orthopedists, rehabilitation nurses, rehabilitation therapists, mental health providers, social workers, care managers, etc). 

Question 7: In their testimony, DAV brought to the Subcommittee’s attention the 

proposed Tampa area Heroes Ranch, which would serve as a post-acute long-term 

care residential brain injury facility for active duty military Servicemembers and 

Veterans. Where is the VA in reviewing this proposal? When can we expect a formal 

decision from VA? 

Response: VISN 8 has submitted a proposal to pilot a post-acute, long term, comprehensive care facility for active duty Servicemembers and Veterans with TBI and/ 

or polytrauma. This pilot project would be an outpatient treatment facility that 

would serve the most severe injuries, including those warriors in a vegetative and 

semi-conscious state, those patients with neurobehavioral problems, and those persons that require a structured day program for ongoing recovery after completing 

acute inpatient rehabilitation. The proposal is currently under review by the Deputy 

Under Secretary for Health for Operations and Management (DUSHOM). VA is anticipating a formal decision regarding Heroes Ranch in the first quarter of FY 2011. 

Question 8: Where is VA in implementing the caregiver family support provisions of Public Law 111–163? When will caregivers have access to the supportive 

services provided in the recently enacted caregiver legislation? 

Response: The Office of Care Management and Social Work in the Office of Patient Care Services, in collaboration with the Chief Business Office, has primary responsibility for implementing the caregiver programs required by title I of Public 

Law 111–163. VA has developed a Steering Committee to direct the implementation 

process. VA is working with the Gallup Organization to hold focus groups with Veterans who may be eligible for the program and their family caregivers; Veterans 

Service Organizations; and National Organizations that specialize in providing assistance to individuals with disabilities or family caregivers; the law requires that 

VA consult with these groups, and DoD, in developing the family caregiver program 

implementation plan. VA believes stakeholder feedback is critical as it moves forward with plans for implementation. DoD is providing direct input on the Steering 

Committee. VA is developing the plan for implementation and will begin offering the 

services and benefits as soon as possible. 

In addition, VA has established four national Workgroups, comprised of more 

than 50 subject matter experts from around the country, to work on specific components of the law, including: eligibility, caregiver benefits, clinical requirements, and 

information technology. These Workgroups held face-to-face meetings in Washington 

the week of July 19 to develop recommendations for implementing key components 

of the law. As of the beginning of August, the Workgroups are reporting their recommendations to the Steering Committee. 

This is a very complex program and will require time and regulations to implement it fully. The timeline for regulations is difficult to define specifically, but portions of the program, such as training and other supportive services, are already 

available for Veterans and their caregivers. VA routinely offers in-person educational support for caregivers of Veterans undergoing discharge from an inpatient 

stay at a VA facility and teaches techniques, strategies, and skills for caring for a 

disabled Veteran. Counseling for family members under 38 United States Code 

(U.S.C.) 1782 may also be available, and VA’s respite care program has benefited 

Veterans for a number of years. Each VA medical center has designated a Caregiver 

Support Point of Contact to coordinate caregiver activities and serve as a resource 

expert for Veterans, their families and VA providers to assist them in locating and 

accessing non-VA resources. 


ccoleman on DSK8P6SHH1PROD with HEARING
87 

VA clinical experts are working on developing core competencies for primary caregivers and developing a comprehensive training and support program for caregivers. 

Training and support services will also be integrated into a comprehensive caregiver 

Web site. VA will ensure public awareness of the new benefits and services, as well 

as the related application process through public service announcements and other 

forms of outreach. 

VA plans to submit its implementation plan to Congress within the required 180 

days. 

Æ 


ccoleman on DSK8P6SHH1PROD with HEARING