PREPARED STATEMENT
OF
DR. JO ANN ROONEY
ACTING UNDER SECRETARY OF DEFENSE
PERSONNEL & READINESS

BEFORE THE

SENATE COMMITTEE ON VETERANS AFFAIRS

HEARING ON

WASHINGTON’S VETERANS:  HELPING THE NEWEST GENERATION TRANSITION HOME
TACOMA, WA

April 4, 2012

 
Chairwoman Murray, Ranking Member Burr, and members of the Committee, thank you for inviting me to testify before you on the care and transition of our recovering Servicemembers from the Department of Defense to the Department of Veterans Affairs (VA).  Taking care of our wounded, ill, and injured Servicemembers is one of the highest priorities of the Department, the Service Secretaries, and the Service Chiefs.  The 2007 revelations regarding Walter Reed Army Medical Center were a stark wakeup call for us all.  During the past five years, the Department has worked in tandem with VA to improve policies, procedures, and legislation that impacts the care of our wounded warriors.

The efforts by both Departments have reached important milestones in improving care for our recovering Servicemembers.  These milestones include a new disability evaluation system and improved case management, result of a programmatic cohesion with VA that is better than ever before.  Today, separating Servicemembers are afforded comprehensive mental and physical care; greater opportunity for education; and a deeper societal commitment to ensure their welfare. 

Both Departments’ leaders continue to work to achieve the highest level of care and management and to standardize care among the Military Services and with other Federal agencies, while maintaining focus on the individual.

Transition Assistance Program (TAP)
 Today’s Veterans face a number of challenges in making the transition to civilian life, and among these is embarking on a productive post-military career.  For the many success stories of Veterans who have turned skills developed in the military into success in the civilian workplace, there are, as President Obama has said, some stories of Veterans who come home and “struggle to find a job worthy of their experience and worthy of their talent.”  We see these struggles most clearly in high unemployment rates for Veterans. Making this situation more urgent is that, as we draw down from the wars in Iraq and Afghanistan and we make difficult decisions about our future force structure in light of the fiscal challenges the Nation faces, the number of Servicemembers—particularly young Servicemembers—departing the military over the next several years will likely increase.

In August 2011, the President called for the creation of a Task Force led by the Department of Defense (DoD) and VA with other agencies including the Department of Labor (DoL), Department of Education (ED), Small Business Administration (SBA), and the Office of Personnel Management (OPM), to develop proposals to maximize the career readiness of all Servicemembers.  In coordination with these partners, the Department’s role involves implementing and sustaining a comprehensive plan to ensure all transitioning Servicemembers have the support they need and deserve when leaving the military.  This includes working with other agencies in developing a clear path to civilian employment; admission into and success in an academic or technical training program; or successful start-up of an independent business entity or non-profit organization.  The effort is fully aligned with the “VOW to Hire Heroes Act of 2011” and is consistent with the Department’s commitment for keeping faith with all our military members and their families.  It provides them a comprehensive set of transition tools and support mechanisms as they complete their service to our Nation.

Veterans Employment Initiative
The Department is also participating with the Office of Personnel Management (OPM) on the initiative to increase hiring of veterans in all federal agencies.  On November 9, 2009, President Obama signed Executive Order (E.O.) 13518, Employment of Veterans in the Federal Government, making hiring Veterans a top priority and directing all Executive Agencies to aggressively enhance recruitment strategies and promote employment opportunities for Veterans.  The Department is the largest federal employer of Veterans and currently employs Veterans in more than 47 percent of civilian appropriated fund positions. In FY 2011, 34,062 (or 42%) of new hires were Veterans, of which 11,736 (or 14%) were disabled Veterans, which exceeded our projected hiring goals.

As a requirement of the E.O., the Department developed and implemented a Veterans Recruitment and Employment Operational Plan.  We established a Veterans Employment Program Office (VEPO) to facilitate and drive communication, coordination, and collaboration among Department stakeholders.  VEPO provides career guidance on job search processes, information about Department vacancies and assistance with completing applications via a Toll-free number (including TTY), web-based communication, and interaction via email.  The Department also manages a Hiring Heroes Program, providing specialized, high-touch transition assistance by organizing and conducting 8-10 Hiring Heroes Career Fairs at or near major medical treatment facilities throughout the world.  The career fairs are hosted for wounded, ill, and injured and transitioning Servicemembers, Veterans, and their family members to assist them in their search for employment.  Since April 2005, 48 Hiring Heroes Career Fairs have been conducted with over 2,600 employers from the Department, other Federal agencies, and the private sector.  Over 1,500 on-the-spot job offers were made at these events.  The 2012 career fairs are underway, with an event scheduled to be held at Joint Base Lewis-McChord on August 8, 2012.  In addition, new Veterans employment initiatives include:
• Virtual Career Fairs – The Department has expanded outreach and recruitment efforts to include virtual career fairs which promote civilian opportunities for Veterans and transitioning Servicemembers, with special emphasis on members of the National Guard and the Reserves. One recent event was organized specifically to assist National Guard and Reserve members in Kuwait as they prepare to transition back to civilian careers.
• The Department is also participating in hiring fairs conducted by VA.  The VA also offers services to Veterans for resume writing, interviewing skills, and informational sessions on Veterans hiring authorities and other helpful employment-related assistance. 
• The www.DoDVets.com website provides Veterans and transitioning Servicemembers with information on employment opportunities, Questions and Answers (Q&As), and web links to information about Veteran Hiring Authorities, Reasonable Accommodations, and other related topics. The website is also a source of information for Federal hiring managers on Veterans preference and Veterans hiring authorities.

Yellow Ribbon Reintegration Program (YRRP)
The YRRP is a Congressionally-mandated program whereby the Services provide Reserve Component (RC) service members and their families with critical support, information, services, and referrals throughout the entire deployment cycle focused primarily on local community resources to maximize successful Service member reintegration back into their civilian lives. During the past three years, the YRRP has evolved into a successful, forward-leaning program providing essential readiness and resiliency training and resources to over 800,000 service members and designees. In FY11, Congress appropriated $16M to the YRRP for enhanced outreach and reintegration employment activities which allowed the Department to support various State-led initiatives. YRRP’s FY12 funding is entirely dedicated to supporting its legislatively mandated core activities. To support the use of the Operational Reserve in the future, we will ensure funding for Service YRRPs is moved to their base line budgets.

Hero2Hired Program
This past December 2011, the Department launched a comprehensive, multi-faceted program called “Hero2Hired”, better known as H2H, using lessons learned from efforts this past year and from the United States Army Reserve Employer Partnership of the Armed Forces program, H2H was developed to address the gap in employment assistance services and support for RC Service members who are not considered veterans in law and so are ineligible for VA employment programs.  H2H focuses on helping RC Servicemembers connect to and find jobs with military-friendly companies that seek employees with specific training and skills.  H2H is a powerful, comprehensive employment program with a powerful job search site (www.H2H.jobs) and online community that is made available at no cost to service members and employers.  It contains all the tools a job seeker needs to find a job:  job listings, career exploration tools, education and training resources, advice and tips, hiring events, virtual career fairs, mobile phone app, and networking opportunities.  In 2012, H2H is sponsoring and participating with the U.S. Chamber of Commerce in 40 job fairs in high RC unemployment areas.  H2H booths will be available and staffed by H2H, YRRP and Employer Support to the Guard and Reserve (ESGR) State Committee volunteers.

Disability Evaluation System/Integrated Disability Evaluation System
The genesis of the Disability Evaluation System (DES) was the Career Compensation Act of 1949, and it remained relatively unchanged until November of 2007.  As a result of public concern and Congressional interest, the joint DoD and VA Senior Oversight Committee (SOC) chartered a DES pilot designed to create a "Servicemember-centric" seamless and transparent DES.  The DES pilot implemented many of the changes recommended by groups like the Veterans’ Disability Benefits Commission and the President's Commission on Care for America's Returning Wounded Warriors to the degree allowed within current law. 

The pilot launched at three major military medical treatment facilities (Walter Reed Army Medical Center, National Naval Medical Center, Bethesda, and Malcolm Grow Air Force Medical Center) in the National Capital Region on November 21, 2007, and successfully created an integrated process that delivers the Department benefits to wounded, ill, and injured Servicemembers and VA benefits to Veterans as soon as possible following release from duty.  We found the DES Pilot to be a faster, fairer and more efficient system.  As a result, in July 2010, the Deputy Secretaries of Defense and Veterans Affairs directed worldwide implementation to begin in October 2010, and to be complete in September 2011.  On December 31, 2010, the pilot officially ended and the first Integrated Disability Evaluation System (IDES) site became operational.

The IDES, similar to the pilot, streamlines the DES process so that the Servicemember receives a single set of physical disability examinations conducted according to VA examination protocols, proposed disability ratings prepared by VA that both the Department and VA can use, and processing by both Departments to ensure the earliest possible delivery of disability benefits. Both Departments use the VA protocols for disability examination and use the proposed VA disability rating to make their respective determinations, unless the Servicemember’s condition changes prior to discharge.  Under Title 10 authority, the Department determines fitness for duty and compensates for unfitting conditions incurred in the line of duty, while under Title 38 authority, VA compensates for all disabilities resulting from disease or injury incurred or aggravated in line of duty during active military, naval, or air service for which a disability rating of 10 percent or higher is awarded, and also determines eligibility for other VA benefits and services.  The IDES permits both Departments to provide disability benefits at the earliest point allowed under both titles.  It is important to point out that Servicemembers who separate or retire (non-disability) may still apply to VA for service-connected disability compensation.

The National Defense Authorization Act (NDAA) for FY 2008, Public Law 110-181, also required the Department to utilize the VA Schedule for Rating Disabilities (VASRD).  The Department and VA are currently developing a memorandum of understanding that will be in accord with the current statutory authority of the Secretary of Veterans Affairs, to adopt a schedule of ratings of reductions in earning capacity from specific injuries or combination of injuries, while allowing for more developmental input from the Department.  This input is critical given the direct connection between the VASRD ratings and the decision to place Servicemembers on the medical retirement list with annuities, benefits and healthcare.  This MOU would codify and formalize the Department’s active input in the future development and modernization of the VASRD, including continued participation in VA's future VA public meetings.

In summary, the IDES features a Servicemember-centric design, a simplified process, more consistent evaluations and compensation, a single medical exam and disability rating, ease of transition to Veteran status, case management advocacy, and establishment of a Servicemember relationship with VA prior to separation.  It also provides increased transparency through better information flow to Servicemembers and their families and a reduced gap between separation/retirement from service to receipt of VA benefits.

As of early this month, IDES enrollment is 25,876 Servicemembers (66 percent Army, 13 percent Marines, 10 percent Navy, and 11 percent Air Force).  Since November 2007, cumulative enrollment has been 46,385, with 15,047 completing the process and receiving benefits.  Including Servicemembers who are returned to duty by the process, active component Servicemember IDES completion time averages 364 days as of March 2012, Reserve Component members averaged 363 days, and Guard members averaged 386 days. 

This past year, the Department partnered closely with VA to implement the IDES at all 139 DES sites worldwide; however, we recognize the need to do better in the area of timeliness to complete the process.  This year our focus will be on such timeliness improvements.  We have made significant policy adjustments to remove impediments, implemented procedural improvements, enhanced oversight and assistance to the Military Departments, and added resources that should improve Military Department performance in this area, including increasing legal support to advise and counsel Servicemembers undergoing disability evaluation. We will continue to enhance our emphasis on leadership, resourcing and execution of the IDES to handle increased volume while decreasing the time spent in the process.

The Departments are looking closely at the stages of the system that are outside of timeliness tolerances and are developing other options to bring these stages within the FY12 goal of 60 percent of Active Component Servicemembers to complete the IDES within 295 days and 60 percent of the Reserve Component Servicemembers to complete the IDES within 305 days, by the end of December 2012, as the Secretaries of Defense and Veterans Affairs have directed.  The Department is fully committed to working closely with Congress to explore new initiatives to further advance the efficiency and effectiveness of the disability evaluation process.

Recovery Coordination Program
The Recovery Coordination Program (RCP) was established by the FY08 NDAA, and was further defined by the Department of Defense Instruction (DoDI) 1300.24, entitled “Recovery Coordination Program.”  The Department has implemented many of the changes recommended by the President's Commission on Care for America's Returning Wounded Warriors to the degree allowed within current law.  The NDAA for FY 2008 and the DoDI 1300.24 together provide a comprehensive policy on care and management of recovering Servicemembers, including the assignment of a Recovery Care Coordinator (RCC).  These RCCs will help wounded, ill, and injured Servicemembers and families through the phases of recovery, rehabilitation, and reintegration utilizing a Comprehensive Recovery Plan (CRP) developed in coordination with the Recovery Team.  The policy also provides for standardized training and a caseload ratio of no more than 40 recovering Servicemembers per RCC.   

Currently, there are 171 RCCs in 84 locations worldwide, placed within the Army, Navy, Marine Corps, Air Force, United States Special Operations Command, and Army Reserve Wounded Warrior Programs.  More than 3,800 Servicemembers and families have the assistance of an RCC, whose responsibilities include ensuring the Servicemember’s non-medical needs are met, and assisting in the development and implementation of the CRP.  An automated solution was developed to increase efficiency of RCCs to be able to maximize their time and service provision to our Servicemembers and their families.  Each RCC receives Department-sponsored standardized training, including information on roles and responsibilities and concepts for developing the CRP.  After the October 2011 training, 90 percent of students rated the instruction and course materials as “excellent.”  Additionally, we are now beginning to train Army “Advocates” in order to bring their program into compliance with the legislative mandate that every recovering Servicemember be provided a Department-trained RCC.  This training is continually enhanced based on feedback from participants.  The Department is committed to ensuring redundancies are mitigated with other agencies. 

Over the past five years, the Department has increased the numbers of RCCs available to provide care coordination to our recovering Servicemembers, and looking ahead, each Military Service will continue to identify and resource their requirements for additional RCCs.  Following are descriptions of three priorities that play important parts in recovering members’ recovery process.  The Recovery Care Program has expanded to include several other portfolios, many of them identified as key priorities for the non-medical care management of recovering Servicemembers during a Wounded Warrior Care Coordination Summit held in March 2011.

The Wounded Warrior Education and Employment Initiative (E2I) operates on a regional basis and engages recovering Servicemembers early in the recovery process to identify their skills, career opportunities that match those skills, and any additional skills they may need for success as they recover and prepare to leave service.  The E2I process relies on collaboration with the Service Wounded Warrior Programs and VA, operating under a Memorandum of Understanding to provide VA’s vocational rehabilitation services earlier in the recovery process than ever before.

The Operation Warfighter program (OWF) works to place wounded, ill, and injured Servicemembers in non-paid Federal internship opportunities that positively impact their rehabilitation and augment career readiness by building resumes, exploring employment interests, obtaining formal on-the-job training, and gaining valuable Federal government work experience.  There are currently more than 500 OWF interns working in approximately 75 Federal agencies and sub-components around the country, with a total of more than 2,500 placements in 105 agencies and sub-components since the inception of the program.  Going forward, the Regional Coordinators will continue to focus on local and regional outreach to strengthen relationships with Federal agencies.

The Military Adaptive Sports Program engages wounded, ill, and injured Servicemembers early in individualized physical activities outside of traditional therapy settings, inspiring recovery and encouraging new opportunities for growth and achievement.  This new initiative is being implemented throughout the Department, in partnership with the Services and the United States Olympic Committee.  The goals of the program include increasing awareness and participation in adaptive sports and recreation at the Service-level, preparing athletes for participation in competitive events such as the Warrior Games, and providing a seamless transition of participation from this program into VA’s National Veteran’s Sports program.

These measures when taken together, substantially and materially affect the life experience of our wounded warriors and the families who support them.  Our work to improve the care of recovering Servicemembers, especially as they transition from the Department to VA, is the core of our efforts to provide those who have sacrificed with the care and benefits they deserve.  Despite the significant achievements, we should not underestimate what remains to be done as we care for a new generation of Veterans who have served under very difficult circumstances for long periods.  We will continue to work with our colleagues at VA and throughout the government to provide our Servicemembers with the highest quality care and treatment. 

Special Compensation for Assistance with Activities of Daily Living
We recognize the strength of military families and caregivers of recovering Servicemembers.  If a Servicemember returns home wounded, ill, or injured, the military family and caregiver are critical to a Servicemember’s recovery and transition.  On August 31, 2011, the Department established policy, authorized by Public Law 111-84, to compensate all catastrophically wounded, ill, or injured Servicemembers with line of duty-related medical conditions, who need caregiver assistance to live outside a resident medical facility or who require supervision to prevent harm to themselves or others.  This policy, enacted through DoDI 1341.12, Special Compensation for Assistance in Activities of Daily Living (SCAADL), gives qualified Servicemembers monthly compensation to help offset the economic burden borne by their primary caregivers providing non-medical care, support, and assistance.  As of February 29, 2012, 505 Servicemembers have received the SCAADL compensation.

Interagency Electronic Health Data
The collaborative Federal partnership between the Department and VA has resulted in increased integration of healthcare services to Servicemembers and Veterans.  The Department and VA spearhead numerous interagency electronic health data sharing activities and are delivering IT solutions that significantly improve the secure sharing of appropriate electronic health information. 

Today’s interagency health information exchange (HIE) capabilities leverage the existing electronic health records (EHRs) of each Department.  As both Departments are currently addressing the need to modernize their EHRs, the Departments are working together to synchronize planning activities and identify a joint approach to modernization.

Current HIE sharing capabilities support data sharing between the Department and VA.  The Federal Health Information Exchange (FHIE), Bidirectional Health Information Exchange (BHIE), and the Clinical Data Repository/Health Data Repository (CHDR) support continuity of care for millions of Servicemembers and Veterans by facilitating the sharing of health care data as beneficiaries move beyond the Department direct care system to the VA.  The data shared includes information from the inpatient documentation system which is in use in the Department’s inpatient military treatment facilities.  The health data shared assists in continuity of care and influences decision making at the point of care. 

Transmission of Data from Point of Separation:  At separation, FHIE provides for the one-way electronic exchange of historic healthcare information from the Department to VA for Servicemembers who have separated since 2001.  On a monthly basis the Department sends:  inpatient and outpatient laboratory results; radiology reports; outpatient pharmacy data; allergy information; discharge summaries; consult reports; admission/discharge/transfer information; standard ambulatory data records; demographic data; pre- and post-deployment health assessments (PPDHAs); and post-deployment health reassessments (PDHRAs).  To date, the Department has transmitted health data on more than 5.8 million retired or separated Servicemembers to VA.  Of those, approximately 2.3 million have presented to VA for care, treatment, or claims determination.  This number grows constantly as health information on recently separated Servicemembers is extracted and transferred to VA.

Access to Data on Shared Patients:  For shared patients being treated by both the Department and VA, the Departments maintain the jointly developed Bidirectional Health Information Exchange (BHIE) system implemented in 2004.  Unlike FHIE, which provides a one-way transfer of information to VA, the two-way BHIE interface allows clinicians in both Departments to view, in real-time, health data (in text form) from the Departments’ existing health information systems.  Accessible data types include allergy, outpatient pharmacy, inpatient and outpatient laboratory and radiology reports, demographic data, diagnoses, vital signs, problem lists, family, social, and other history, questionnaires and Theater clinical data, including inpatient notes, outpatient encounters and ancillary clinical data, such as pharmacy data, allergies, laboratory results and radiology reports. 

Use of BHIE continues to increase.  As of January 2012, there is data available on more than 4.3 million shared patients, including over 293,340 Theater patients, available through BHIE. 

To increase the availability of clinical information on a shared patient population, VA and the Department collaborated to further leverage BHIE functionality to allow bidirectional access to inpatient discharge summaries from the Department’s inpatient documentation system.  Use of this inpatient documentation system at Landstuhl Regional Medical Center plays a critical role in ensuring continuity of care, beginning in theater, supporting the capture and transfer of inpatient records of care for recovering Servicemembers.  Information from these records including inpatient consultations, operative reports, history and physical reports, transfer summary notes, initial evaluation notes, procedure notes, evaluation management notes, pre-operative evaluation notes, and post-operative evaluation and management notes are accessible stateside to DoD providers caring for injured Servicemembers and to VA providers caring for injured Servicemembers and Veterans.    DoD’s inpatient documentation system is now operational at all 59 DoD inpatient sites; ensuring documentation is available from all DoD inpatient beds.

Recent improvements to BHIE include the completion of hardware, operating system, architecture, and security upgrades supporting the BHIE framework and its production environment.  This technology refresh, completed in January 2011, resulted in improved system performance, and reliability.

Exchange of Pharmacy and Allergy Data:  The Clinical Data Repository (CDR)/Health Data Repository (HDR) interface (called “CHDR”) supports interoperability between AHLTA’s CDR and VA’s HDR, enabling bidirectional sharing of standardized, computable outpatient pharmacy and medication allergy data.  Since 2006, VA and the Department have been sharing computable outpatient pharmacy and medication allergy data through the CHDR interface.  Exchanging standardized pharmacy and medication allergy data on patients supports improved patient care and safety through the ability to conduct drug-drug and drug-allergy interaction checks using data from both systems.

The Departments have exchanged computable outpatient pharmacy and medication allergy data on over 1.4 million patients who receive healthcare from both systems. 

Wounded Warrior Image Transfer:  To support our most severely wounded and injured Servicemembers transferring to VA Polytrauma Rehabilitation Centers (PRCs) for care, the Department sends radiology images and scanned paper medical records electronically.  Walter Reed National Military Medical Center and Brooke Army Medical Center are providing scanned records and radiology images electronically for patients transferring to VA PRCs in Tampa, Richmond, Palo Alto, Minneapolis, and San Antonio.  From 2007, to the present, images for more than 480 patients and scanned records for more than 585 severely wounded warriors have been sent from the Department to VA at the time of referral.

Virtual Lifetime Electronic Record:  The Departments are firmly focused on enhancing our electronic health data sharing and expanding capabilities to share information with the private sector through Nationwide Health Information Network (NwHIN) and the Virtual Lifetime Electronic Record (VLER).  NwHIN will enable the Departments to view a beneficiary’s healthcare information not only from the Department and VA, but also from other NwHIN participants.  To create a virtual healthcare record—and achieve the VLER vision—data will be pulled from EHRs and exchanged using data sharing standards and standard document formats.  A standards based approach will not only improve the long-term viability of how information is shared, but also enable the meaningful exchange of information with other government providers and with civilian providers, both account for a significant portion of care delivered to the Departments’ beneficiaries. 

VLER is being implemented iteratively through an operational pilot using incremental sets of functionality.  The VLER pilot sites are demonstrations of exchanges of electronic health information between VA, the Department, and participating private sector providers.  The pilot continues to provide evidence of the power and effectiveness of coordinated development between the Departments for increasing the secure sharing of electronic health information while leveraging existing EHR capabilities.  The Department’s VLER Health pilot is underway in San Diego, California; Tidewater, Virginia; Puget Sound, and Spokane, Washington.  In addition, VA is participating in seven other pilots with the private sector to expand the VLER capability. 

The Integrated Electronic Health Record (iEHR):  In 2011, DoD and VA committed to establishing and refining an integrated electronic health record (iEHR).  The iEHR will enable DoD and VA to align resources and investments with business needs and programs.  Going forward, a joint, common EHR platform will be implemented.  Maintenance of AHLTA and VistA throughout the deployment lifecycle of the iEHR will ensure continuity of operations. 
DoD and VA will purchase commercially available components for joint use when possible and cost effective. 

The Departments anticipate that iEHR capabilities will evolve from existing service oriented architecture (SOA) compliant capabilities, commercial off-the-shelf (COTS), open source, and custom systems.  The use of agile development for the iEHR will allow the Departments to deliver capabilities to customers at a more rapid pace.  The DoD/VA Interagency Program Office (IPO) serves as a single point of accountability and execution for the iEHR and VLER Health initiatives to help ensure synchronization of these efforts. 
World-Class Medical Care in the National Capital Region

The Department completed its largest and most complex Base Realignment and Closure (BRAC) projects in history on time last Fall in the National Capital Region (NCR).   These BRAC projects closed and transitioned Walter Reed Army Medical Center and inpatient capabilities at Joint Base Andrews to expanded facilities at Bethesda, establishing the Walter Reed National Military Medical Center (WRNMMC), and a replacement hospital at Fort Belvoir (FBCH).  Today, wounded, ill, and injured Servicemembers and their families receive care in 3 million square feet of world-class new and renovated facilities, with 160,000 new equipment items and the latest medical technologies available.

These BRAC projects were one part of the larger transformation of Military Medicine in the NCR.  The NCR has the largest concentration of healthcare assets in the Military Health System.  It contains a mix of nearly 40 Army, Navy, and Air Force Medical Treatment Facilities (MTFs), has 550,000 eligible beneficiaries and 12,000 staff, and runs on an annual operating budget of almost $1.5 billion.  Its primary medical mission is care for wounded, ill, and injured Servicemembers, and it receives over 70% of the critical care air transports returning from theater.  In order to reduce redundancies inherent in operating three separate Service systems and increase effectiveness and efficiency, the Department directed the establishment of an Integrated Healthcare Delivery System (IDS) in the NCR to be managed by the Joint Task Force National Capital Region Medical (JTF CapMed). 

JTF CapMed has command authority over NCR MTFs.  The presence of command authority provides a singular authority to drive the transformational change necessary to control unnecessary duplication among the Services and to increase interoperability. This improves responsiveness to our patients by aligning authority, responsibility, and accountability to a single entity that can make changes necessary to improve care.  As an example, JTF CapMed has consolidated and co-located appointment and referral processes in the NCR to standardize appointment and referral processes.  This has improved services by eliminating the confusion of multiple appointment processes at different MTFs in the NCR and has increased the access to care by offering appointments at any MTF in the NCR in order to meet patient needs.  The JTF’s efforts have saved the Department $109 million through contract execution and $114 million in cost avoidance through equipment re-use program.  Consolidation of the workforces at WRNMMC and FBCH and authorities sufficient to implement shared services will enable further efficiencies and economies of scale that will ultimately result in contractor and civilian personnel savings of approximately $60 million per year in fiscal year 2011 dollars.
 
The NCR also has a specific congressional mandate to provide world-class healthcare through the NCR IDS.  As discussed in the Comprehensive Master Plan provided to Congress, JTF CapMed is implementing the NCR IDS to provide more effective and efficient healthcare in the NCR and is overseeing projects at Bethesda required to achieve the world-class facility standards mandated by the NDAA for FY 2010.  The President has fully funded these efforts in his Budget Request for FY 2013.

Post-Traumatic Stress and Traumatic Brain Injury
The VA-DoD Integrated Mental Health Strategy focuses on developing community organization collaboration and partnerships, such as with the National Institutes of Health and the American Psychological Association.  Part of this work involves the creation of a network of experts on mental health issues, to include PTSD, so that there are coordinated efforts to improve access, quality, effectiveness, and efficiency of services for Servicemembers, veterans, and their families by sharing information and resources that enable partners to stay current with the changing science base and recommended best practices.

The Substance Abuse and Mental Health Services Administration (SAMHSA) in the Department of Health and Human Services maintains strong partnerships with VA and the Department to prepare community behavioral health care systems to provide trauma informed services that reflect an understanding of military culture, Servicemembers’ experiences, the range of post-trauma effects, and the effects of traumatic brain and other physical injuries. This is primarily accomplished through SAMHSA’s Servicemembers, Veterans, and their Families Policy Academies, through which SAMHSA has provided—and continues to provide—intensive technical assistance to 23 States, two Territories, and the District of Columbia to help them enhance their behavioral health systems.

Additionally, SAMHSA’s National Child Traumatic Stress Network (NCTSN) has developed training materials for behavioral health providers who encounter veterans or Servicemembers with traumatic brain injury. These materials were developed in collaboration with the VA Palo Alto Health Care Polytrauma Program.  This program is a two-hour comprehensive training is available through the NCTSN’s Learning Center Military Families.

In addition, to establish a network of public and private sector expertise in TBI, the Department has fostered collaboration with inter-Service working groups (Army, Navy, Marine Corps, and Air Force) together with other Department centers to include the Defense Centers of Excellence for PH and TBI, the Defense and Veterans Brain Injury Center (DVBIC), and the National Intrepid Center of Excellence (NICoE), VA.  In addition, other federal agencies such as the CDC and NIH have been collaborating partners to further the field of TBI and leverage expertise held within each agency.  The working groups have further included public sector expertise through consensus conferences.  The collaborative working group and consensus conference process has worked to define best practices for diagnosis and treatment of co-occurring disorders following TBI with focus on mild TBI.  The collaborative working group has developed clinical recommendations for vestibular disturbances, vision disturbances, and endocrine dysfunction following TBI.  These recommendations are intended to provide guidance to primary care providers in the MHS regarding the consideration and referral process for Servicemembers with co-occurring disorders following mild TBI.  The collaborative network efforts also addressed needs in the deployed setting with the revision of clinical practice recommendations/ algorithms for concussion management in the deployed setting.  Finally, collaborations with professional sports organizations have been developed to help further common goals of addressing barriers to seeking care for TBI related issues.

The development of a TBI repository of information for and by various federal agencies via the Federal Interagency Committee has recently been established.  This will include the following: mild TBI Translation (mTBI) Grand Rounds (research to clinical practice) through collaboration with Johns Hopkins Institutes; development of DoD centric common outcome measures and/or common data elements in partnership with US Navy and Marine Corps EpiData Center and the Health Analysis Department.

The Department and VA have also produced a suite of co-branded education materials and curricula to train clinicians regarding the effective use of VA/DoD clinical support tools based on clinical practice guidelines for disorders such as Major Depressive Disorders, mild TBI, Co-Occurring Conditions, and Substance Use Disorder.  Additionally, the Department has conducted a needs assessment survey for Behavioral Health and TBI providers as well as provided guidelines for training providers in evidence-based best practices for PTSD.

The Department produced materials for insertion into Joint Professional Military Education based on the Chairman Joint Chief of Staff’s Special Areas of Emphasis.  These materials will be used to provide line leadership with core components for a myriad of topics including PH and TBI.  DoD has added a 60-minute overview of PH and TBI in the Department briefing into the DoD APEX Senior Executive Service Orientation, a two-week requirement for all new executives to the Department. 

The Department and VA have partnered on the Integrated Mental Health Strategy, specifically by releasing the Operation Enduring Families curriculum, information, and support for Afghanistan and Iraq veterans and their families.  The curriculum resides online at VA and Military OneSource websites.  This guide was designed to assist parents, other family members and health care providers in addressing the mental and emotional health needs of military children through topic-specific, age-related, public-domain literature.  Additionally, since its rollout in July 2010, 711 providers have been trained on the Defense and Veterans Brain Injury Center (DVBIC) family caregiver curriculum, a congressionally mandated guide that serves as a roadmap for those caregivers of patients with severe and penetrating brain injury.

In response to the DoD Mental Health Task Force recommendation to address continuity of care, the Department developed the inTransition program.  This program provides Servicemembers experiencing a transition (location change, change in status or health care system) with a coach to motivate them to remain in treatment.  Available 24/7, these coaches are master’s level clinical staff trained in deployment and readjustment- related issues.  Between February 2011, and February 2012, the number of inTransition cases increased from 392 to 1,660, an increase of over 300%.  Of the Servicemembers referred to the program, 95% accepted the referral and 100% of those who completed a program survey reported the assistance received from the inTransition Program increased the likelihood they would continue treatment.

Capabilities regarding transitions of warriors with mental health conditions continue to be emphasized.  Last week, the Department signed and promulgated a DoD Instruction 6490.10, titled “Continuity of Behavioral Care for Transitioning and transferring Servicemembers” which directs clinicians to personally ensure appropriate transfer of care occurs at the time of transitioning out of military service.  Review of the Department’s practices led to our mandate to the Department’s mental health providers to:

“Contact, as applicable, a privileged Health Care Provider at the gaining facility to directly communicate the patient’s history, current status, needs during the transition period, and to establish a follow-up appointment to ensure continuity of care.”

Separating Servicemembers have 180 days of TRICARE coverage to assist them with their transition (for those who have a mental health problem that arise following separation but before getting established with a new provider), and we believe fostering an already strong culture of ownership in the patient-physician relationship will accrue to the benefit of our warriors with mental health issues transitioning into VA medical system. 

The Center for Deployment Psychology (CDP), a Uniformed Services University center, has conducted workshops for civilian providers throughout the United States.  To date over 2,300 civilian providers have attended these weeklong workshops.  These workshops include information on the identification, diagnosis, and treatment of PTSD and other frequently occurring psychological health issues such as depression, substance use disorders, and suicide.  An additional 1,200 civilian providers have attended shorter workshops that train evidence-based treatments for treating PTSD.  TBI is also a topic presented to address these challenges in Servicemembers and Veterans. 

Lastly, VA and the Department jointly develop Clinical Practice Guidelines (CPGs) to serve as one means of communicating the state of the evidence to clinical providers in the field.  VA/DoD CPGs are publically available through either Army Medical Command Quality Management Division’s website (https://www.qmo.amedd.army.mil/pguide.htm) or the VA’s Office of Quality and Safety website (http://www.healthquality.va.gov/).  An expert multidisciplinary panel of VA and Department providers developed the VA/DoD CPGs recommendations by conducting a comprehensive and rigorous review of the currently available studies on psychotherapy and medication.  Since the passage of the NDAA for FY 2008, VA and the Department have jointly developed or revised CPGs for Depression, PTSD, mTBI, Opioid Therapy for Chronic Pain, Substance Use Disorder, and Bipolar Disorder.

The dissemination of existing TBI clinical guidelines and recommendations to various involved providers are conducted in various formats.  The most powerful dissemination modality is through the Service TBI program managers who are leading the 56 Army TBI programs, six Navy TBI programs, and Air Force TBI teleconsultations and joint programs.  Ongoing resources are provided in the form of a national level resource fact sheet for military case managers as well as information and educational opportunities via the Military TBI Case Management Quarterly Newsletter to promote and advance access to care.  The nationwide dissemination of the Case Management of Concussion/mild TBI Guidance Document was conducted across the MHS.  Technology is widely utilized to disseminate TBI information as well.  The release of the Mild TBI Pocket Guide mobile application for the iPhone and Android smartphones and the Co-occurring Conditions Toolkit: Mild TBI Psychological Health mobile application for the iPhone and Android smartphones disseminated this information to a new market of users.  Additionally six mTBI web-based case studies via MHS Learn for the Department, the VA Employee Education System, and civilian healthcare professionals have been released.  The web-based case studies use patient vignettes as a way in which to educate healthcare professionals about the clinical recommendations contained within the VA/DoD mild TBI/concussion clinical practice guideline.  The technology-based efforts reported more than 4,700 downloads of the Mild TBI Pocket Guide mobile application and more than 500 downloads of the Co-occurring Conditions Toolkit mobile application.  To improve future efforts of dissemination the Department utilized the Interactive Customer Service Evaluation to obtain user feedback.

Conclusion
While we are pleased with the level of effort and progress made, we fully acknowledge there is much more to do. We have positioned ourselves to implement improvements and continue progress in providing world-class support to our Servicemembers and Veterans while allowing our two Departments to focus on our respective core missions. Our dedicated Servicemembers, Veterans, and their families deserve the very best. We pledge to give our best efforts to supporting their recovery, rehabilitation, and return to their communities.