VA Testimony of Robert H. Roswell, MD before Congress on October 16, 2003

United States Department of Veterans Affairs

STATEMENT OF
ROBERT H. ROSWELL, M.D.
UNDER SECRETARY FOR HEALTH
DEPARTMENT OF VETERANS AFFAIRS
BEFORE THE COMMITTEE ON VETERANS' AFFAIRS
U. S. HOUSE OF REPRESENTATIVES
HEARING ON THE TRANSITION OF RETURNING SERVICE MEMBERS

October 16, 2003

Mr. Chairman and Members of the Committee, I appreciate the opportunity to appear before you today to discuss the Department of Veterans Affairs' ( VA) efforts toward a seamless transition for returning service members.

We have been working hard both internally and with the Department of Defense ( DoD) to improve coordination to identify the men and women returning from combat theaters and provide those discharged or needing VA services while on active duty with world-class VA service. Anyone who has been wounded or injured or has become ill in defense of our country deserves the best and most timely service possible from their Government.

Recent media attention focused on some returning service members whose interactions with VA were not acceptable. We have developed processes to try to prevent these types of situations from recurring, and, in addition, we have implemented a number of longer-term strategies, policies, and procedures to provide timely, appropriate services to our returning service members.

Seamless Transition Taskforce

In August, the Under Secretary for Benefits and I charged a new VA Taskforce for the Seamless Transition of Returning Service Members to intensify and continue efforts to assure world class services are provided to our military and veterans. This taskforce, composed of VA senior leadership from key program offices as well as the VA/ DoD Executive Council structure, is initially focusing on internal coordination efforts to ensure that VA approaches this mission in a comprehensive manner. An additional goal is improving dialogue and collaboration with DoD at all levels between our two Departments, including the Military Services, Personnel and Readiness, Health Affairs, and Reserve Affairs. As an early focus, we are working closely with DoD to enhance our ability to identify and serve all returning service members that sustained injuries or illnesses while serving our country.

Thanks to the leadership of Dr. David Chu and Dr. Bill Winkenwerder, I am pleased to report that DoD transferred to VHA a roster of military personnel who recently served in theaters of combat in Afghanistan and Iraq and subsequently separated from active duty. Our records indicate that of approximately 17,000 veterans listed in this initial roster, to date, about 2,000 (12%) have sought health care from VA for a wide variety of health problems. Of this group, most have been seen as outpatients.

To ensure that our commitment is understood and shared at every level of the Department of Veterans Affairs, the Taskforce has developed a number of training materials for staff including a script and video for front line staff to ensure that they can identify veterans who have served in a theater of combat operations and take the steps necessary to ensure they receive appropriate care. Through the Taskforce, each VHA facility and each VA regional office has identified a point of contact to coordinate activities locally and to work as a team to assure that the needs of these service members or veterans are met and that contact is made should the veteran relocate. Case management guidance has been produced and was recently distributed to VHA and VBA field staff to ensure that these processes and expectations are communicated. We are committed to reducing red tape and streamlining access to health care services and VA benefits programs for these veterans.

Additional Supports for Seamless Transition

Working in collaboration with the military Surgeons General, who have been enthusiastic about improving coordination of care, the Veterans Benefits Administration ( VBA) has detailed two full-time benefits counselors and the Veterans Health Administration ( VHA) has detailed a full-time social worker to the Walter Reed Army Medical Center, the Military Treatment Facility ( MTF) receiving the largest numbers of casualties. Beginning in late August, VHA social workers and VBA Veterans Service Representatives have also been assigned as VA/ DoD Liaisons to the Brooke, Eisenhower, and Madigan Army Medical Centers; the National Naval Medical Center at Bethesda; and other MTFs receiving casualties. They work closely with military medical providers and social workers to assure that returning service members receive information and counseling about VA benefits and programs and to arrange for appropriate transfer of health care to VA facilities. Through this new collaboration, we have improved our ability to identify and serve returning service members that sustained serious injuries or illnesses while serving our country.

The VA social workers augment the clinical coordination through discharge planning activities at these MTFs. They are tracking these patients as they transfer to VA care, with the assistance of identified points of contact at every VA facility. Prior to discharge from the MTFs, the social workers enroll those transferring to VA care in order to expedite the transfer. By having representatives on site at military treatment facilities, we have also been able to assist those from recent deployments who have come into the medical center on their own. Utilizing the new case management and coordination strategies developed with the military services at the 5 MTFs, since August 25 we have met with more than 150 patients, transferred over 30 and have over 30 patients pending transfer from these MTFs to VA. We are working to expand these efforts and have partnered with the Army Disabled Solder Liaison Team to draft an agreement to standardize information transfer processes to sustain our progress. We believe these coordination and collaborative efforts have greatly improved and streamlined the transition for those seeking care through VA.

Further, we are working to improve our collaboration with DoD to enhance outreach to returning members of the Reserves and National Guard. Too often Reservists and National Guard personnel have not received timely information about the benefits and access to health care they have earned. To address this problem, working with DoD Health Affairs and DoD Reserve Affairs, we have jointly developed and distributed a new brochure summarizing the benefits available to this special population of veterans upon their return to civilian life. We have printed a million copies of this brochure to ensure the widest possible dissemination through DoD channels. It is also available on line at http://www.va.gov/environagents/docs/SVABENEFITS.pdf .

We are also actively working to ensure successful implementation of Public Law 105-368, authorizing VHA to provide health care for a two-year period to veterans who serve on active duty in a theater of combat operations during a period of war after the Gulf War, or in combat against a hostile force during a period of hostilities after November 1, 1998. Consequently those who have served or are now serving in Afghanistan and Iraq, will have a two-year period of access to free VA health care for conditions possibly related to their combat service. We are aggressively reaching out to this group of current and former service members, including those who served in the National Guard and Reserves.

Veterans Outreach and Educational Activities

Earlier this year, VA's Vet Centers began to serve veterans returning from the current conflicts in Afghanistan and Iraq. As the community-based outreach arm of VHA, the Vet Centers have initiated outreach to area military installations and are closely coordinating their efforts with military family support services on the various military bases. In addition to community outreach to new veterans, the Vet Centers provide trauma counseling, family counseling, employment services and a range of social services to assist veterans in readjusting from war-time military service to civilian life. To date the Vet Centers have seen approximately 1,400 veterans from the conflicts in Iraq and Afghanistan. The Vet Centers also function as community points of access for many returning veterans, providing them with information and referrals to VA medical facilities for health care and VA regional offices for benefits issues.

Each VBA Regional Office assigns a point of contact to offer information on VA benefits and answer questions relating to benefits to wounded or injured veterans and their families. Case managers are assigned to process expeditiously claims for compensation or other benefits, ideally within 30 days of receipt.

VBA's Transition Assistance Program ( TAP) disseminates information about VA benefits and services to separating and retiring service members. VBA military service coordinators have conducted several thousand briefings this fiscal year to service members, local Reserve Commands, and National Guard Units. VBA recently conducted a series of TAP briefings aboard the USS Constellation on its return to Honolulu from the Persian Gulf and will continue to support requests from the Department of Defense. Each separating or retiring service member also receives information from VA through the Veterans Assistance at Discharge System (VADS) when his or her DD 214, Discharge Certificate, is received by VA's Austin Automation Center directly from the military service departments. The initial "Welcome Home" letter includes a copy of VA Pamphlet 21-00-1, A Summary of VA Benefits; VA Form 21-0501, Veterans Timetable; and information on life insurance and education benefits, as applicable.

Surviving spouses, dependent children, and parents of military personnel, Reservists, and National Guard members killed on active duty are provided specialized outreach services through our Casualty Assistance Program. Through this program, VBA works with military casualty assistance officers to schedule outreach visits with families. In addition, the Secretary recently authorized the VHA Readjustment Counseling Service to provide bereavement counseling to family members of active duty military personnel who are killed in the line of duty. Bereavement counseling is a natural extension of the core components of the Vet Center readjustment counseling service mission, which includes a welcoming consumer-oriented environment; recognition of veterans' service and sacrifice to country; ease of access via 206 conveniently located community-based facilities; maximum sensitivity to the need for confidentiality; and expertise in providing psychological trauma counseling to veterans' families.

In-service death claims for Dependency and Indemnity Compensation are generally processed within 48 hours of receipt. At the time of the initial outreach visit, family members are in an acute stage of grief and are not always able to absorb and understand the full range of benefits available to them. Accordingly, VBA initiates a 6-month follow up letter to surviving spouses and dependent children outlining benefits and services, which they may be ready to discuss in further detail at that later time. If requested, a second outreach visit is made.

VHA is also partnering to conduct outreach by actively participating in discharge planning and orientation sessions for returning service members. Social Work Service, Readjustment Counseling Service, and other offices within VHA are involved in outreach activities. Posters, flyers, and information brochures are being produced to be distributed as well as posted in prominent places at VA medical centers and other VA offices explaining VA services to returning service members and "our newest veterans." As service members are discharged from the military, and VHA is made aware, staff is making contact with the individuals to explain local services available and welcome them home.

Mr. Chairman, we testified before the Oversight and Investigations Subcommittee in early July on the longer- term strategies involving outreach that VA is pursuing to assure the best possible care is provided to returning Iraqi Freedom and Afghanistan Enduring Freedom service members. Many of these efforts are coordinated with DoD under the umbrella of the Health Executive Council.

Any health or exposure data that DoD collects regarding the deployment of service members potentially will be useful to VA. Through the Deployment Health Work Group, we are actively engaged with DoD in obtaining as much deployment health and exposure information as possible. Members of the Work Group are charged with reviewing appropriate coordination of data on troop locations and the data collected as part of pre- and post-deployment health screening implemented by DoD in their Recruit Assessment Program. Further we are actively working with DoD to develop separation physical examinations that thoroughly document a veteran's health status at the time of separation from military service and that also meet the requirements of the physical examination needed by VA in connection with a veteran's claim for compensation benefits. We are optimistic that as a result of the improved collaboration between VA and DoD in these programs, we will be better positioned to evaluate health problems among service members and veterans after they leave military service, to address post-deployment health questions, and to document changes in health status for disability determination.

A critical outreach activity to veterans and families concerns the potential health effects of hazardous military deployments. In addition to VA's outreach efforts discussed above, VHA has produced a brochure that addresses the main health concerns for military service in Afghanistan, another brochure for the current conflict in the Gulf region and one recently distributed on health care for women veterans returning from the Gulf region. These brochures answer health-related questions that veterans, their families, and health care providers have about these hazardous military deployments. They also describe relevant medical care programs that VA has developed in anticipation of the health needs of veterans returning from combat and peacekeeping missions abroad. These are widely distributed to military contacts, veterans service representatives and are on VA's website.

Another challenge for outreach is to address the specific concerns of veterans and their families over the potential health impact of environmental exposures during deployment. Veterans also have questions about their symptoms and illnesses following deployment. These concerns are addressed through newsletters and fact-sheets to veterans covering health and compensation issues, including environmental health issues; regular briefings of veterans service organizations; organization of national meetings on health and research issues; media interviews; other educational material and websites with information, like www.va.gov/environagents.

Other Long-Term Strategies

In addition to the outreach activities discussed above, our strategy to assist returning service members and veterans includes the following:

In 2002, VA established two national centers for the study of war-related illness and post-deployment health issues in East Orange New Jersey, and Washington, DC, to provide specialized health care for veterans from all combat and peace-keeping missions who suffer difficult to diagnose but disabling conditions. These centers are available to eligible veterans from all eras, including the war in Afghanistan and Iraq. These centers also provide research and education programs for our health care providers.
A screening instrument in the form of a clinical reminder triggered by the veteran's separation date is being implemented for returning Iraqi Freedom and Afghanistan veterans that present for care in VA. This assessment tool will prompt the provider with specific data requirements to assure that veterans are screened for medical and psychological conditions that may be related to recent combat deployment.
VA has developed evidence based clinical approaches for treating veterans following deployment. These clinical practice guidelines ( CPGs) give health care providers the needed structure, clinical tools, and educational resources that allow them to diagnose and manage patients with deployment-related health concerns. Two post-deployment CPGs have been developed in collaboration with DoD, a general purpose post-deployment CPG and a CPG for unexplained fatigue and pain. Our goal is that all veterans will find their VA doctors well informed about specific deployments and related health hazards. The VA website contains these CPGs as well as information about unique deployment health risks and new treatments.
VA and DoD will soon release a new CPG on the management of traumatic stress. This guideline pools DoD and VA expertise to help build a joint assessment and treatment infrastructure between the two systems in order to coordinate primary care and mental health care for the purpose of managing, and, if possible, preventing acute and chronic Post Traumatic Stress Disorder (PTSD).
The Veterans Health Initiative ( VHI) is a program designed to increase recognition of the connection between military service and certain health effects; better document veterans' military and exposure histories; improve patient care; and establish a database for further study. The education component of VHI prepares VA healthcare providers to better serve their patients. A module was created on "Treating War Wounded," adapted from VHA satellite broadcasts in April 2003 and designed to assist VA clinicians in managing the clinical needs of returning wounded from the war in Iraq. Modules on spinal cord injury, cold injury, traumatic amputation, Agent Orange, the Gulf War, PTSD, POW, blindness/visual impairment and hearing loss, and radiation are available. We are developing additional modules on infectious disease health risks in Southwest Asia, military sexual trauma, traumatic brain injury, pulmonary diseases of military occupational significance, and Weapons of Mass Destruction Experiments and Exposures involving US veterans. Further, VA's National Center for PTSD has developed the Iraq War Clinician's Guide for use across VA. The website version, which can be found at WWW.NCPTSD.ORG, contains the latest fact sheets and medical literature available and is updated regularly. These important tools are integrated with other VA educational efforts to enable VA practitioners to arrive at a diagnosis more quickly and accurately and to provide more effective treatment.
Section 110 of Public Law 98-528, as amended by section 206 of Public Law 106-117, established the Under Secretary for Health's Special Committee on PTSD. This group, composed of PTSD experts from across VA, is charged with reviewing VA's capacity to provide assessment and treatment for PTSD and guiding VA's educational, research, and benefits activities concerning PTSD. The Special Committee, which is currently meeting in Washington to develop the last of its four mandated annual reports, has provided specific, prioritized, proactive recommendations designed to build, integrate, and maintain the continuum of PTSD services needed by veterans, present and future.
VA and DoD are closely collaborating to develop the ability to share medical information electronically. Since June 2002, the Departments have successfully been sharing electronic medical information. Key initiatives in the Electronic Health Records Plan are the Federal Health Information Exchange ( FHIE) and HealthePeople (Federal). FHIE provides historical data on separated and retired military personnel from the DOD's Composite Health Care System to the FHIE Data Repository for use in VA clinical encounters and potential future use in aggregate analysis. Patient data on laboratory results, radiology reports, outpatient pharmacy information, and patient demographics are now being sent from DoD to VA via secure messaging. This second phase of FHIE has been deployed and is operational at VA medical centers nationwide. It includes admission, discharge, transfer data, discharge summaries, allergies, and consult tracking.

Summary

A service member separating from military service and seeking health care through VA today will have the benefit of VA's decade-long experience with Gulf War health issues as well as the President's commitment to improving VA/ DoD collaboration. VA has successfully adapted many existing programs, improved outreach, improved clinical care through practice guidelines and educational efforts, and improved VA health provider's access to DoD health records. Secretary Principi re-emphasized VA's commitment to returning combat veterans in a letter to all employees last August, in which he reminded us that every VA employee has an obligation to ensure that every veteran who is wounded, injured, or ill from training for, preparing for, or fighting for our war on terror receives priority service. In his words, "We will have failed to meet our very reason to exist as a Department if a veteran is poorly served." I agree with that, Mr. Chairman, and VA will continue to improve services and coordination to ensure that the needs of these service members are met.

This concludes my statement. My colleagues and I will be happy to respond to any questions that you or other members of the Subcommittee might have.