VA Testimony of Nancy Strohm before Congress on July 22, 2004

United States Department of Veterans Affairs

STATEMENT OF
NANCY J. STROHM, LCSW, CLVT
VISUAL IMPAIRMENT SERVICES TEAM COORDINATOR
VA MEDICAL CENTER, LEBANON, PA
BEFORE THE
COMMITTEE ON VETERANS' AFFAIRS
U.S.HOUSE OF REPRESENTATIVES

July 22, 2004

Mr. Chairman and Members of the Committee:

I am a licensed clinical social worker with a certification in Low Vision Rehabilitation. I have worked in the field of blind rehabilitation since 1995, when I was selected to implement the full time Visual Impairment Services Team (VIST) Program at the VA Medical Center, Lebanon, PA.

Vision loss is a condition that affects every aspect of a person’s life. A VIST Coordinator is tasked with identifying veterans who are visually impaired, assessing their needs, providing education, developing a plan for rehabilitation, implementing the plan through referral to an agency that provides direct services, and following up with the veteran yearly to determine if there are new needs. Within VISN 4, veterans with needs that can best be met at a thorough and intensive rehabilitation program, and are willing to participate, are referred to the Eastern Blind Rehabilitation Center at the VA Connecticut Health Care System, West Haven. During the nine years that I have been VIST Coordinator, I have witnessed veterans discharged to their families, homes and communities to reclaim roles that they had abandoned when blindness became unnecessarily debilitating. Among the veterans whom I referred, they were well satisfied.

However, approximately six years ago, I noticed that fewer veterans, many of them in advanced life stages, were not willing to participate in inpatient blind rehabilitation. Most of these veterans were suffering from age related maculopathy, commonly known as macular degeneration, a progressive eye disease that affects use of central vision. Despite my best presentation of the positive trade-offs of a VA rehabilitation program, they did not perceive themselves as “bad enough” to warrant this type of treatment. Common reasons for resistance included family caregiver roles, length of stay, and fear of traveling alone. Yet they still wanted to read and write, resume hobbies, take care of their daily needs, and travel safely within their communities. Their needs could not be met locally by the VIST program or through community or state agencies in a timely manner.

In the late summer of 1998, the leadership of the Blinded Veterans Association (BVA) of PA, Inc. contacted me. For nearly a decade, these veterans had been interested in expanded services for visually impaired veterans in the Lebanon area. They specifically requested an inpatient center like the one in West Haven. I referred them to the CEO at Lebanon, who listened to their concerns and then asked me to write a proposal. I was subsequently asked to develop an outpatient program that would meet the needs of veterans who were unable or unwilling to participate in a traditional inpatient program.

I reviewed services provided by community and private agencies via the internet and contacted the Carroll Center in Boston, MA, to learn more about their day program for senior citizens. A blind rehabilitation therapist from the Maine Commission for the Blind as well as faculty at the Pennsylvania College of Optometry acted as consultants. Within a short period of time, the BVA of PA, Inc., the Pennsylvania State Veterans Commission, and the VISN leadership supported the Visual Impairment Services Outpatient Rehabilitation Program, better known as VISOR.

The VISOR Program is the treatment component of the VIST Program at the Lebanon VA Medical Center. Because every veteran has unique needs and circumstances, there are three separate treatment modalities within the VISOR Program that serve veterans who are legally blind or visually impaired. They include the VISOR Outpatient Clinic, the VISOR Home Care Program, and the VISOR HOPTEL Program, a residential ten-day outpatient program for veterans who are legally blind.

The VISOR Team consists of five professionally trained blind rehabilitation specialists in the core areas of low vision, rehabilitation teaching (independent activities of daily living/communications/manual skills), and orientation and mobility. Some members of the VISOR Team are competent in the fields of recreation and social work as well. Trained staff addresses special needs for using adaptive equipment to manage diabetes and overcoming the emotional turmoil related to sight loss for both veteran and family.

The three-part VISOR model ensures that veterans receive the right care, at the right time, in the right place. The type of care each veteran receives is dependent upon an individualized treatment plan using input from the VISOR team, optometrists in the low vision clinic, the veteran, and the veteran’s family. Training with optical and non-optical aids issued through Prosthetics Service to help veterans overcome difficulties with everyday activities such as reading newsprint, writing, financial management, traveling safely in the home or community, grocery shopping, home maintenance, and participating in leisure time activities can all be accomplished on an as needed basis at a pace that is right for each veteran.

The VISOR Outpatient Clinic has thus far served 333 veterans during this fiscal year. When warranted, the therapist can provide services in the home as well. One hundred home care visits have been provided this fiscal year. The outpatient clinic and the home care program complement the VISOR HOPTEL Program (described below), and are available between VISOR HOPTEL Programs, which is in session for ten days, ten times per year.

Veterans must be legally blind and capable of self-care to participate in the VISOR HOPTEL Program. Other factors considered for participation in the program include stamina, ability to learn in a fast paced group environment, and the feasibility to leave the home environment. The VISOR HOPTEL Program begins on Monday at noon, with family involvement, and ends on Wednesday of the following week with a half-day family program. During the ten-day VISOR HOPTEL Program, rehabilitation takes place throughout the weekend in order to ensure that skills learned are continuously reinforced. Additionally, veterans are provided with the opportunity to worship and visit with family during this time.

The goal of the VISOR HOPTEL Program is to help the veteran and family return to activities that they enjoyed prior to visual impairment. A typical day begins with group therapy and ends at approximately 4:30 p.m. with adaptive leisure activities. In between, veterans are provided with education and skill training in core blind rehabilitation areas. A combination of group activities, one-to-one instructions, and independent assignments to build confidence are included in the VISOR HOPTEL curriculum. A VIST support group, held on the ninth day of the VISOR HOPTEL Program, allows current participants to access support from previous graduates and helps them transition to an ongoing support group. A family support group is run simultaneously.

Assessments by the VISOR team are completed in the VISOR Outpatient Clinic prior to the onset of the program. Education and training begins in the VISOR Outpatient Clinic during the veteran’s first contact with the VISOR Team. Veterans who are referred by other VIST Coordinators throughout the VISN are assessed at their respective medical centers. A low vision exam by a VA optometrist is an essential part of treatment planning. Approval to participate, based on physical findings, is provided by primary care. A home assessment by a member of the VISOR team provides valuable insight into the veteran’s ability to function in his/her home and neighborhood. A field visit within two weeks of the conclusion of the program ensures that skills taught at the VISOR HOPTEL Program transfer back to the home environment.

A typical veteran who participates in the VISOR HOPTEL Program has been diagnosed with age-related macular degeneration and sometimes other age related diseases such as diabetic retinopathy, glaucoma and cataracts. Since July 2000, the VISOR HOPTEL Program has rehabilitated 170 veterans, nine of whom are female. The median age during the past four years was 74. Two-thirds of the veterans ranged from that age to age 90.

The VISOR Team has provided data to the Blind Rehabilitation Services (BRS) Outcomes Project in order to compare functional outcomes of this model to the more traditional VA Blind Rehabilitation Centers. Data collected from the third quarter of FY 2001 through FY 2003 suggest that the VISOR HOPTEL Program is an efficacious model for the veterans whom we serve. We are proud of the large percentage of veterans who are able to read a magazine or newspaper article, pay their own bills, assemble or measure something, communicate in writing, and orient themselves to a familiar environment following rehabilitation via the VISOR HOPTEL model.

Patient satisfaction has been measured for the VISOR HOPTEL portion of the VISOR Program and has been 100% both on the internal satisfaction survey and on the BRS Outcomes Project survey. On the BRS survey, 100% of all veterans indicated that they would recommend this program to other veterans. These reports are congruent with the comments made by veterans and families through letters sent to our medical center. Comments include:

“This program gave us all new hope.”

“Thank you for giving me back ‘a life’.”

“It gave us a sense of security and mobility.”

“I have been able to do jobs (home repairs) that I wouldn’t think of doing before.”

“The staff and their program uplifted my spirits and gave me confidence that I could still do some of the things if I only tried.”

“Thank you for giving our father back to us.”

“Your program has helped in so many little ways to help Dad maintain some of his independence.”

Mr. Chairman and members of the committee, I have attempted to provide you with an understanding of the VISOR Program and the variety of interventions on the continuum of care that are necessary for veterans who are visually impaired to achieve independence, restore confidence, resume roles, and lead a quality life. I would be pleased to answer questions that you may have. Thank you.