STATEMENT OF
DANIEL L. COOPER
UNDER SECRETARY FOR BENEFITS
DEPARTMENT OF VETERANS AFFAIRS
JOINT HEARING BEFORE THE
SENATE COMMITTEE ON VETERANS' AFFAIRS
AND
THE SENATE COMMITTEE ON ARMED SERVICES

April 12, 2007

Chairman Akaka, Senator Craig, and members of the Veterans Affairs Committee; Chairman Levin, Senator McCain, and members of the Armed Services Committee.  It is my pleasure to be here today to discuss the transition of servicemembers from the Department of Defense (DoD) to the Department of Veterans Affairs (VA) and the DoD and VA rating systems.  I am also pleased to be accompanied today by Dr. Gerald Cross, Acting Principal Deputy Under Secretary for Health. 

The focus of my remarks will be the seamless transition program, especially as it relates to the care of seriously injured veterans of service in Operations Iraqi and Enduring Freedom (OIF/OEF).  I will also discuss our joint efforts with DoD in the area of electronic records transfer and data and information sharing, as well as the disability rating systems used by DoD and VA.

Seamless Transition

Seamless Transition is a jointly sponsored VA and DoD initiative that provides transition assistance to seriously injured servicemembers.  In partnership with DoD, VA has implemented a number of strategies to provide timely, appropriate, and seamless transition services to the most seriously injured OIF/OEF active duty servicemembers and veterans.  Our highest priority is to ensure that those returning from the Global War on Terror transition seamlessly from DoD military treatment facilities (MTFs) to VA Medical Centers (VAMCs), continue to receive the best possible care available anywhere, and receive all the benefits they have earned through their service and sacrifice in a timely manner.  Toward that end, we continually strive to improve the delivery of our care and benefits.

Veterans Health Administration (VHA) social worker liaisons and Veterans Benefits Administration (VBA) counselors are located at ten military treatment facilities (MTFs) that receive the most severely wounded patients, including Walter Reed Army Medical Center.  These social workers and counselors are a critical part of the seamless transition process, assisting active duty servicemembers in their transition to VA medical facilities and the VA benefits system. 

The counselors and social workers assigned to the MTFs are usually the first VA representatives to meet with servicemembers and their families.  They provide information about the full range of VA benefits and services, which include:  health care and readjustment programs, disability compensation and related benefits, the traumatic injury benefit provided under the Servicemembers Group Life Insurance Program, as well as educational and housing benefits. 

VBA benefits counselors assist servicemembers in completing benefits claims and in gathering supporting evidence.  While servicemembers are hospitalized, they are kept informed of the status of their pending claims and given their counselor's name and contact information should they have questions or concerns. 

VHA social worker liaisons play a very crucial role in the seamless transition of seriously injured servicemembers from MTFs to VA medical centers, where they receive the best possible care.  Our social workers assist these servicemembers and their families in coordinating the future course of treatment for their injuries after they return home.
VA's Seamless Transition Program also includes two Outreach Coordinators-a peer-support volunteer and a veteran of the Vietnam War-who regularly visit seriously injured servicemembers at Walter Reed and Bethesda National Navy Medical Center.  Their visits enable them to establish a personal and trusted connection with patients and their families.  They encourage patients to consider participating in VA's National Rehabilitation Special Events or to attend weekly dinners held in Washington, DC, for injured OIF/OEF returnees.  In short, they are key to enhancing and advancing the successful transition of our servicemembers.
VA has coordinated the transfer of over 6,800 OIF/OEF severely injured or ill active duty servicemembers and veterans from DoD to VA care and services.  Since September 2006, a VA Certified Rehabilitation Registered Nurse (CRRN) has been assigned to Walter Reed to assess and provide regular updates to our Polytrauma Rehabilitation Centers (PRC) regarding the medical condition of incoming patients.  The CRRN advises and assists families and prepares active duty servicemembers for transition to VA and the rehabilitation phase of their recovery.
VA's social worker liaisons and the CRRN strive to fully coordinate care and information prior to a patient's transfer to our Department.  Social worker liaisons meet with patients and their families to advise and "talk them through" the transition process.  They register servicemembers or enroll recently discharged veterans in the VA health care system, and coordinate their transfer to the most appropriate VA facility for the medical services needed, or to the facility closest to their home.
In transferring seriously injured patients, both the CCRN and the social worker liaison are an integral part of the MTF treatment team.  They simultaneously provide input into the VA health care treatment plan and collaborate with both the patient and his or her family throughout the entire health care transition process.  Video teleconference calls are routinely conducted between DoD MTF treatment teams and receiving VA polytrauma center teams.  When feasible, the patient and family attend these video teleconferences to participate in discussions and to ‘meet' the VA PRC team.
As servicemembers are transferred from the MTFs to other DoD treatment facilities or VA care, the VBA benefits counselors notify the appropriate regional office of the servicemember's transfer.  All VA regional offices have established points of contact with all military hospitals and VA medical centers in their jurisdiction to ensure prompt notification of arrival, transfer, and discharge of seriously injured servicemembers.  In addition to the established points of contact for medical facilities within their jurisdiction, all regional offices have designated OIF/OEF coordinators and case managers who maintain regular contact with injured veterans to ensure their needs are being met. 

Servicemembers are given VA contact information for their regional office OIF/OEF coordinator and case manager when they are being transferred to another medical facility, released to home, or awaiting discharge/retirement orders. 

Each claim from a seriously disabled OIF/OEF veteran is case-managed to ensure seamless and expeditious processing.  All claims are immediately placed under computer control in VBA's benefits delivery system and carefully tracked through all stages of processing.  The regional office directors immediately call returning seriously disabled servicemembers and veterans when they first arrive in their jurisdiction to welcome them home and advise them that the OEF/OIF coordinator or a case manager will contact them and assist them through the claims process.  The director ensures a case manager is assigned for each compensation claim received from a seriously disabled OIF/OEF veteran.  The case manager becomes the primary VBA point of contact for the veteran.

OIF/OEF case managers maintain a case history on each injured veteran throughout the claims process.  All regional offices are also required to update a spreadsheet used to identify and track services provided to seriously injured OIF/OEF veterans on a national basis and monitored by VBA's Office of Field Operations. 

Transition Patient Advocates

Secretary Nicholson recently announced that VHA is hiring 100 new transition patient advocates who will serve as ombudsmen for severely injured OEF/OIF sevicemembers and veterans.  These transition patient advocates will initiate contact with assigned servicemembers and their families while the servicemembers are still at the MTF.  They will assist servicemembers and their families with any concerns, help resolve problems and work with case managers as well.  The transition patient advocates travel to the MTF for the initial meeting with patients and their families.

VA and DoD Information Sharing

VA and DoD have made significant progress in the development of interoperable health technologies that support seamless transition from active duty to veteran status.  Advances include the successful one-way and two-way transmission of electronic medical records between DoD and VA, and the adoption and implementation of data standards that support interoperability. 
One important aspect of coordination between DoD and VA prior to a patient's transfer to VA is access to clinical information, including a pre-transfer review of electronic medical information via remote access.  The VA polytrauma centers have been granted direct access into inpatient clinical information systems at Walter Reed and Bethesda.  This remote inpatient access is in addition to the existing bidirectional data sharing of pertinent outpatient data.  VA and DoD are working together to ensure that appropriate users are adequately trained and connectivity exists for all four polytrauma centers. 
As stated above, in addition to sharing inpatient data, VA and DoD share outpatient data through the Bidirectional Health Information Exchange (BHIE).  BHIE allows VA and DoD clinicians to share text-based outpatient clinical data between VA and select DoD military treatment facilities, including Walter Reed and Bethesda, and 18 hospitals, and more than 190 outlying clinics. 
VA and DoD information sharing successes have resulted directly from implementation of the DoD/VA Joint Electronic Health Records Interoperability (JEHRI) Plan.  JEHRI is a comprehensive strategy to develop collaborative technologies and interoperable data repositories, as well as adoption of common data standards.  VA and DoD have made significant progress with the implementation of JEHRI.  Most recently, the departments have agreed to enhance sharing through JEHRI to collaborate on the feasibility, identification and development of a common inpatient electronic health record.  Initial work on this project will begin this fiscal year. 

Additionally, a new application very near deployment will provide VA with the ability to track servicemembers from the battlefield through Landstuhl, Germany, the MTFs, and on to the VA medical facility.  The new application, known as the Veterans Tracking Application (VTA), is a modified version of DoD's Joint Patient Tracking Application - a web-based patient tracking and management tool that collects, manages, and reports on patients arriving at MTFs from forward-deployed locations.

The VTA web-based system allows approved VA users to access this real-time information about the servicemembers we serve and track injured active duty servicemembers while they transition to veteran status.  VTA will have all medically evaluated OIF/OEF servicemembers in the database as necessary to provide VA care and benefit claims support.  This application was developed for VA to coordinate care from an MTF to a VAMC to ensure that VA will know where the servicemember is currently located, where the patient came from, and who has seen the patient.  The application is also designed to identify where servicemembers filed claims and which VBA counselor assisted the servicemember in the claims process.  The application has an historic record feature to ensure we preserve all status changes.  Deployment in VBA is underway.  Full deployment in both VBA and VHA is scheduled to be completed by the end of April.  

The two Departments are also working to expand VA access to DoD inpatient documentation, particularly for severely wounded and injured servicemembers being transferred to VA for care.  An early version of this electronic capability is currently in use between Madigan Army Medical Center and the VA Puget Sound Health Care System, where inpatient discharge summaries are exchanged.  Tripler Army Medical Center, Womack Army Medical Center, and Brooke Army Medical Center have also implemented this capability.

VA and DoD Disability Rating Systems

Disability ratings and evaluations completed by VA are in accordance with Title 38 Code of Federal Regulations, Parts 3 and 4. 

Part 4, the VA Schedule for Rating Disabilities, is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of, or incident to, military service.  The percentage ratings represent, as far as can practicably be determined, the average impairment in earning capacity resulting from such diseases and injuries and their residual conditions in civil occupations.
 
The military service branches also use the VA Schedule for Rating Disabilities in determining disability ratings, although they have instituted an appendix that differs from the VA schedule. 

Although both VA and DoD use the VA Schedule for Rating Disabilities as the primary tool in the evaluation of disability resulting from disease or injury, there are a number of reasons why the resulting ratings might vary. 

The evaluation of disability is a process that involves the objective standards listed in the VA Schedule for Rating Disabilities, but also involves the evaluation of evidence.  This is important from two perspectives.  First, the medical evidence generated for the evaluation is derived differently by the two agencies.  In VA, the compensation and pension disability examination process is highly structured with examination worksheets that ensure that all elements of the rating schedule dealing with a specific disability are addressed.  Further, most VA examinations are performed solely to support the disability evaluation process.  In DoD, we understand that treating physicians produce the medical evidence.  Second, disability raters evaluate a unique fact pattern for each servicemember or veteran.  This uniquely human analytical process will produce some variability within and across organizations, which is why both agencies employ appeals processes to ensure the claimant receives the most accurate rating.

Currently, servicemembers who apply for disability compensation benefits under the Benefits Delivery at Discharge (BDD) program undergo a medical examination while still on active duty that is adequate for VA purposes.  The BDD Program is a jointly sponsored VA and DoD initiative to provide transition assistance to separating servicemembers who have disabilities related to their military service. 

The BDD Program helps servicemembers file for VA service-connected disability compensation and related benefits prior to separation from service, so that payment of benefits can begin as soon as possible after discharge.  Timely decisions on servicemembers' disability compensation claims also help to ensure continuity of medical care for their service-connected disabilities.

Under the BDD Program, servicemembers can complete an application for VA disability compensation benefits up to 180 days prior to separation.  VA and DoD have agreed to a cooperative separation examination process for servicemembers filing a VA claim for benefits.  Servicemembers attend one physical examination, instead of both a separation exam for the military and a VA exam for the disability claim.  VA fully develops the claim, and the single VA/DoD medical examination meets the military's needs for a separation physical and also fulfills VA's examination requirements for processing the disability claim. 

Claims Processing Accuracy and Consistency

 To increase the accuracy and consistency of our benefit decisions, we have established an aggressive and comprehensive program of quality assurance and oversight to assess compliance with VBA claims processing policy and procedures and assure consistent application. 

 The Systematic Technical Accuracy Review (STAR) program includes review of work in three areas:  rating accuracy, authorization accuracy, and fiduciary program accuracy.  Overall station accuracy averages for these three areas are included in the regional office director's performance standard and the station's performance measures.  STAR results are readily available to facilitate analysis and to allow for the delivery of targeted training at the regional office level.  The Compensation and Pension (C&P) Service conducts satellite broadcast training sessions based on an analysis of national STAR error trends.  Over the last four years, our rating decision quality has risen significantly from 81 percent to 89 percent.

 In addition to the STAR program, the C&P Service is identifying unusual patterns of variance in claims adjudication by diagnostic code, and then reviewing selected disabilities to assess the level of decision consistency among and between regional offices.  These studies will be used to identify where additional guidance and training are needed to improve consistency and accuracy, as well as to drive procedural or regulatory changes. 

 Site surveys of regional offices address compliance with procedures, both from a management perspective in the operation of the service center and from a program administration perspective, with particular emphasis on current consistency issues.  Training is provided, when appropriate, to address gaps identified as part of the site survey. 

 It is critical that our employees receive the essential guidance, materials, and tools to meet the ever-changing and increasingly complex demands of their decision-making responsibilities.  To that end VBA has deployed new training tools and centralized training programs that support accurate and consistent decision-making. 

 New hires receive comprehensive training and a consistent foundation in claims processing principles through a national centralized training program called "Challenge."  After the initial centralized training, employees follow a national standardized training curriculum (full lesson plans, handouts, student guides, instructor guides, and slides for classroom instruction) available to all regional offices.  Standardized computer-based tools have been developed for training decision-makers (69 modules completed and an additional eight in development).  Training letters and satellite broadcasts on the proper approach to rating complex issues are provided to the field stations.  In addition, a mandatory cycle of training for all Veterans Service Center employees has been developed consisting of an 80-hour annual curriculum.

VA has worked hard to improve the transition process for our deserving service men and women.  Yet, we are not satisfied that we have achieved all that is possible.  As you know, a Presidential Interagency Task Force and other Commissions are working to improve the services provided to our returning wounded Global War on Terror military personnel and veterans.  VA is committed to assisting their work in a collaborative effort to ensure all is being done for those who so admirably serve our Nation.

Mr. Chairman, this concludes my testimony.  I would be pleased to answer any questions you may have.