STATEMENT OF
ANTONETTE ZEISS, PH. D.
ACTING DEPUTY CHIEF OFFICER, MENTAL HEALTH SERVICES
OFFICE OF PATIENT CARE SERVICES
VETERANS HEALTH ADMINISTRATION
U.S. DEPARTMENT OF VETERANS AFFAIRS
BEFORE THE
COMMITTEE ON VETERANS’ AFFAIRS
UNITED STATES SENATE

MAY 25, 2011

Chairman Murray, Ranking Member Burr, Members of the Senate Veterans’ Affairs Committee:  I am pleased to be here today to discuss how the Department of Veterans Affairs (VA) and the Department of Defense (DoD) are meeting the needs of returning and injured Veterans and Servicemembers.  I am accompanied today by Ms. Deborah Amdur, Chief Consultant, Care Management and Social Work, Office of Patient Care Services; Mr. Cliff Freeman, Director, VA/DoD Health Information Sharing; and Shane McNamee, M.D., Chief of Physical Medicine and Rehabilitation Service at the Hunter Holmes McGuire (Richmond) VA Medical Center.

You heard last week from Deputy Secretary Gould about many of our efforts in this area, and my testimony will re-emphasize some of the points he made while expanding on several key areas of collaboration and support such as mental health services, prosthetics and rehabilitation, electronic health records, and care coordination, per your request.

Mental Health Services
VA offers mental health services to eligible Veterans through medical facilities, community-based outpatient clinics (CBOC), and in VA’s Vet Centers.  VA has been making significant advances in its mental health services since 2005, beginning with implementation of the VA Comprehensive Mental Health Strategic Plan utilizing special purpose funds available through the Mental Health Enhancement Initiative.  In 2007 implementation of the strategic plan culminated in development of the VHA Handbook on Uniform Mental Health Services in VA Medical Centers and Clinics, which defines what mental health services should be available to all enrolled Veterans who need them, no matter where they receive care, and to sustain and extend the enhancements made up to that point.  VA is still in the process of fully implementing this Handbook, and has made extensive progress to date.  We continue to emphasize additional areas for final development.

VA’s enhanced mental health activities include outreach to help those in need to access services, a comprehensive program of treatment and rehabilitation for those with mental health conditions, and programs established specifically to care for those at high risk of suicide. 

VA ensures that treatment of mental health conditions includes attention to the benefits as well as the risks of the full range of effective interventions, with emphasis on all relevant modalities, including psychopharmacological care, evidence-based psychotherapy, peer support, vocational rehabilitation, and crisis intervention.  Making these treatments available incorporates the principle that when there is evidence for the effectiveness of a number of different treatment strategies, the choice of treatment should be based on the Veteran’s values and preferences, as well as the clinical judgment of the provider.

To reduce the stigma of seeking care and to improve access, VA has integrated mental health into primary care settings to provide much of the care that is needed for those with the most common mental health conditions, when appropriate.  Mental health services are incorporated in the evolution of VA primary care to Patient Aligned Care Teams (PACT), an interdisciplinary model to organize a site for holistic care of the Veteran in a single primary health care location.  In parallel with the implementation of these programs, VA has been modifying its specialty mental health care services to emphasize psychosocial as well as pharmacological treatments and to focus on principles of rehabilitation and recovery.  VA also has a full range of sites of care, from inpatient acute mental health units, to extended care Residential Rehabilitation Treatment Programs, to outpatient specialty mental health care (as well as care in the PACT), to mental health care in geriatrics and extended care settings, to mental health staff as a component of Home-Based Primary Care, delivering mental health services to eligible home-bound Veterans and their caregivers in their own homes.
 
VA/DoD Integrated Mental Health Strategy
The development of the VA/DoD Integrated Mental Health Strategy (IMHS) was a major focus of the Departments in fiscal year (FY) 2010 and was approved in final form in October 2010.  In October 2009, VA and DoD convened the first-ever joint Summit meeting to make recommendations for how the two Departments can more effectively work together to meet the mental health needs of America’s military personnel, Veterans and their families.  The IMHS derives from this Summit and subsequent joint efforts of subject matter experts. It was developed to address the growing population of Servicemembers and Veterans with mental health needs.  Mental health care provides unique challenges for the two organizations with separate missions in that they serve the same population, but at different times in their lives and careers.  As such, the IMHS centers on a coordinated public health model to improve the access, quality, effectiveness, and efficiency of mental health services. Recipients of these services include Active Duty Servicemembers, National Guard and Reserve Component members, Veterans, and their families. 

The IMHS identifies 28 Strategic Actions that fall under the following four strategic goals:  1) Expand access to behavioral health care in VA and DoD; 2) Ensure quality and continuity of care across the Departments for Servicemembers, Veterans, and their families; 3) Advance care through community partnership and education and reduce stigma through successful public communication and use of innovative technological approaches; and 4) Promote resilience and build better behavioral health care systems for tomorrow.  The first goal of expanding access to behavioral health care includes specific actions such as integrating mental health services into primary care settings; expanding eligibility to Vet Center services to members of the Armed Forces who served in Operations Enduring Freedom, Iraqi Freedom, or New Dawn (OEF/OIF/OND); sharing mental health staff between the Departments; and developing processes for implementing joint DoD and VA tele-mental health services.  The second goal of ensuring quality and continuous care includes specific actions such as coordinating and standardizing training in evidence-based psychotherapies; developing quality measures for mental health services based on VA-DoD Clinical Practice Guidelines; evaluating patient outcomes and using this data to support clinical decisions and improve our programs; and implementing the “inTransition” mental health coaching program.  The third goal of advancing care through community partnerships, education, and successful public communication includes specific actions such as exploring methods to help family members identify mental health needs through education and coaching; coordinating the Departments’ communications plans to improve public health messaging; facilitating access to Web-based resources; and promoting a better understanding of military culture for providers.  The final goal of promoting resilience includes specific actions such as exploring methods to distribute knowledge on suicide risk and prevention; recommending and promoting family resilience programs; building from lessons learned in DoD’s resilience programs; and translating mental health research into innovative programs.  This unprecedented level of collaboration is providing unique opportunities to coordinate our mental health efforts across the two Departments, for the benefit of all of our Servicemembers, eligible Veterans, and their eligible family members. 

Suicide Prevention / Veterans Crisis Line
The VA Suicide Prevention Program is based on the concept of ready access to high quality mental health care and other services.  All VA Suicide Prevention Program elements are shared with DoD, and a joint conference is held annually to encourage use of all strategies across both Departments, including educational products and materials.  One of the main mechanisms to access enhanced care provided to high risk patients is through the Veterans Crisis Line.  The Crisis Line is located in Canandaigua, New York and partners with the Substance Abuse and Mental Health Services Administration National Suicide Prevention Lifeline.  All calls from Veterans, Servicemembers, families and friends calling about Veterans or Servicemembers are routed to the Veterans Crisis Line.  The Call Center started in July 2007, and the Veterans Chat Service was started in July 2009.  To date the Call Center has:
• Received over 400,000 calls;
• Initiated over 15,000 rescues;
• Referred over 55,000 Veterans to local VA Suicide Prevention Coordinators for same day or next day services;
• Answered calls from over 5,000 Active Duty Service members; and
• Responded to over 16,000 chats.

Readjustment Counseling Service:  Vet Centers
Vet Centers are community-based counseling centers that provide community outreach, professional readjustment counseling for war-related readjustment problems, and case management referrals for combat Veterans.  Vet Centers also provide bereavement counseling for families of Servicemembers who died while on Active Duty.  Through March 31, 2011, Vet Centers have cumulatively provided face-to-face readjustment services to more than 525,000 OEF/OIF/OND Veterans and their families.  As outlined in Section 401 of Public Law 111-163, VA is currently drafting regulations to expand Vet Center eligibility to include members of the Active Duty Armed Forces who served in OEF/OIF/OND (includes Members of the National Guard and Reserve who are on Active Duty). 

In addition to the 300 Vet Centers that will be operational by the end of 2011, the Readjustment Counseling Service program also has 50 Mobile Vet Centers providing outreach to separating Servicemembers and Veterans in rural areas.  The Mobile Vet Centers provide outreach and direct readjustment counseling at active military, Reserve, and National Guard demobilization activities.  To better serve eligible Veterans with military-related family problems, VA is adding licensed family counselors to over 200 Vet Center sites that do not currently have a family counselor on staff.  

Other Significant VA-DoD Mental Health Collaborations
The Defense Centers of Excellence (DCoE) for Psychological Health (PH) and Traumatic Brain Injury (TBI) was created in November 2007 to assess, validate, oversee and facilitate prevention, resilience, identification, treatment outreach, rehabilitation and reintegration programs for psychological health and traumatic brain injury to ensure DoD meets the needs of Servicemembers, eligible Veterans, military families and communities.  VA personnel occupy three key leadership positions within DCoE:  Deputy Director for VA, VA Senior Liaison to DCoE for Psychological Health, and VA Senior Liaison to DCoE for TBI.  DCoE and VA also collaboratively plan and participate in multiple continuing education conferences each year, including the joint suicide prevention conference. 

Under the auspices of the VA/DoD Evidence Based Practice Guidelines Work Group, personnel from VA and DoD serve on clinical practice guidelines committees for developing, updating and deploying joint clinical practice guidelines for mental health conditions.  The VA/DoD guideline for evidence-based management of Post-Traumatic Stress was updated in 2010.  Other evidence-based clinical practice guidelines for mental health include Major Depressive Disorder, Substance Use Disorders and Bipolar Disorder.

Prosthetics and Rehabilitation
VA is vigilant in its search for new technologies that will benefit the men and women with medical needs who have served our country.  Any technology that is commercially available and medically indicated may be provided to eligible Veterans.  These devices cover every aspect of a Veteran’s life, including wheeled mobility, aids for the blind, artificial limbs and bracing, and vehicular and home adaptations.  Serving those eligible Veterans and Servicemembers with amputation is an area of extensive collaboration between VA and DoD.  We evaluate new technologies, develop joint VA/DoD patient and family education materials, and produce Clinical Practice Guidelines related to care.  VA and DoD have further partnered with the Amputee Coalition of America (ACA) to establish Peer Visitation Programs for Veterans and Servicemembers with amputation.  The principal mechanism for delivery of these services is through the new VA Amputation System of Care. 

VA’s Amputation System of Care began rollout in 2009, and is expected to be fully operational by the end of FY 2011.  This model of care provides specialized expertise in amputation rehabilitation, incorporating the latest practice in medical rehabilitation management, rehabilitation therapies, and technological advances in prosthetic componentry.  The System is comprised of four distinct tiers that mirror the hub-and-spoke model of VA’s Polytrauma System of Care.  These tiers include:
• Seven (7) Regional Amputation Centers, which provide comprehensive rehabilitation care through interdisciplinary teams and which serve as a resource across VA for tele-rehabilitation.  These Centers provide the highest level of specialized expertise in clinical care and technology and are located in the Bronx (NY), Denver (CO), Minneapolis (MN), Palo Alto (CA), Richmond (VA), Seattle (WA), and Tampa (FL).
• Fifteen (15) Polytrauma Amputation Network Sites, which provide a full range of clinical and ancillary services to eligible Veterans closer to home.
• One hundred (100) Amputation Clinic Teams, which provide outpatient amputation care and services;
• Thirty-one (31) Amputation Points of Contact, who facilitate referrals and access to services.  At least one person at these facilities is knowledgeable of the Amputation System of Care and can provide appropriate consultation, assessments and referrals based on this knowledge.

The Amputation System of Care is available to all eligible Veterans and Servicemembers and provides the appropriate level of care and expertise based on the specific rehabilitation needs of each individual.  While the System is not yet fully operational, our efforts to date have increased access for eligible Veterans in need of specialty amputation care.  We have seen a 55 percent increase in workload and a 40 percent increase in the number of Veterans served by the Regional Amputation Centers through the end of FY 2010.  Moreover, VA has served 191 percent more Veterans requiring amputation or prosthetic services through telehealth because of expansions in these programs.  VA has 65 Prosthetic Labs that are accredited by the Board for Orthotist/Prosthetist Certification or American Board for Certification in Orthotics and Prosthetics.  The Department also maintains more than 600 contracts with private prosthetics companies and two national providers of upper extremity prosthetics to ensure eligible Veterans have access to any commercially available and prescribed technologies. 

As of April 30, 2011, VA’s cohort of Veterans from OEF/OIF/OND includes a total of 1,228 Servicemembers who have sustained major limb amputations.  While these patients’ initial rehabilitation and recovery has mainly been completed within DoD medical treatment facilities, 748 of these members have transitioned to Veteran status and have received prostheses and amputation care services from VA.  Based on a mutually recognized need to better serve this new cohort of combat injured Servicemembers, VA and DoD are establishing a 3 year pilot program at the Hunter Holmes McGuire VA Medical Center in Richmond, VA, to provide residential transitional rehabilitation.  This pilot program will focus on improving the health and wellness outcomes of patients with amputations and facilitating successful transition of active duty Servicemembers to return to unrestricted military duty, or civilian vocations.

Another key area of collaboration between VA and DoD is research to identify and incorporate, the best practices and technological advancements for amputation care.  In 2003, clinicians and researchers from both departments outlined joint initiatives to further prosthetics research and improve care for military and Veteran amputees.  This meeting was held in response to the needs of an increasing number of soldiers suffering limb loss due to combat in Iraq and Afghanistan, resulting in a number of research projects that are now underway.

One such project is the Defense Advanced Research Projects Agency (DARPA) “Revolutionizing Prosthetics” research program initiated in 2005, which has culminated in development of the first prototype advanced prosthetic arms for clinical testing in VA.  The first VA research subject was studied in April 2009.  The Next-Generation DARPA Prosthetic Arm System incorporates major technological advances such as flexible socket design and innovative control features, hardware, and software that together enable enhanced functionality that promises to surpass any currently available prosthetic device.  Ongoing results of this VA clinical research are informing design efforts leading to the optimization of a revised version of the Next-Generation DARPA Prosthetic Arm System.  VA will employ a similar design to conduct usability research on the revised arm system.  The expectation is that the results of these efforts will lead to commercialization of a refined, highly usable product.  Since April 2009, 26 research subjects have been fitted with the arm during their participation in the VA research study.

Establishment of the DoD Center of Excellence on Traumatic Extremity Injuries and Amputations (CoE) will also be a key collaboration between DoD and VA to further advance amputation care and services.  A joint Memorandum of Understanding (MOU) for establishment of the Center was signed by the Assistant Secretary of Defense for Health Affairs (ASD (HA)) and Under Secretary of Health (VA) on August 18, 2010.  A primary focus of this CoE will be on research efforts aimed at saving injured extremities, avoiding amputations, and preserving and restoring function of injured extremities. 

A working group comprised of representatives from the Services, VA, and Health Affairs has developed the concept of operations for the structure, mission and goals for the Center.  Pending final approval by DoD, this plan will be sent to VA for review and concurrence prior to implementation.

Electronic Health Records
In the last 2 years, we have made major strides in sharing health and benefits data between our two Departments, and made significant progress toward our long-term goal of seamless data sharing systems.  Our objective is to ensure that appropriate health, administrative, and benefits information is visible, accessible, and understandable through secure and interoperable information technology to all appropriate users.  For the past several years, we have shared increasing amounts of health information to support clinicians involved in providing day-to-day health care for Veterans and Servicemembers.  Our clinicians can now access health information for almost four million Veterans and Servicemembers between our health information systems.  Veterans and Servicemembers are able to access increasing amounts of personal health information from home or work sites through our “Blue Button” technology, using VA and DoD secure Web sites.

For the last 2 years, we have worked together on a Virtual Lifetime Electronic Record (VLER).  This project takes a phased approach to sharing health and benefits data to a broader audience, including private health clinicians involved in Veteran/Servicemember care, benefits adjudicators, family members, care coordinators, and other caregivers.  We are in the first phase of this project, with five operational “pilot” sites where we are sharing health information between VA, DoD, and private sector health providers.  VLER will be fully developed by 2014, providing health and benefits data to all authorized users in a safe, private, secure manner, regardless of the user’s location.

More recently, Secretary Gates and Secretary Shinseki formally agreed that our two Departments would work cooperatively toward a common electronic health record.  We call this effort the “integrated Electronic Health Record,” or iEHR.  As I speak to you today, our functional and technical experts are meeting to develop and draft detailed plans on executing an overall concept of operations that the two Secretaries will utilize to determine the best approach to achieving this complex goal.  Once completed, the iEHR will be a national model for capturing, storing, and sharing electronic health information.   

Care Coordination
The two Departments continue to drive toward providing a comprehensive continuum of care to optimize the health and well being of Servicemembers, Veterans, and their eligible beneficiaries.  Our joint efforts to provide a "single system" experience of life-time services are supported by three common goals:  1) efficiencies of operations; 2) health care; and 3) benefits.  The goal of efficiencies of operations describes the Department’s efforts to reduce duplication and increase cost savings through joint planning and resource sharing.  Our health care goal is a patient-centered health care system that consistently delivers excellent quality, access, and value across the Departments.  We also strive to anticipate and address Servicemember, Veteran, and family needs through an integrated approach to delivering comprehensive benefits and services.  There are five key areas where VA and DoD are collaborating to promote better care coordination for transitioning Servicemembers and Veterans:  the Federal Recovery Coordination Program, the VA Polytrauma/Traumatic Brain Injury System of Care, VA Liaisons for Health Care, OEF/OIF/OND Care Management, and caregiver support.

Federal Recovery Coordination Program (FRCP)
The Senior Oversight Committee (SOC established FRCP, in October 2007, as a joint VA and DoD program designed to coordinate access to Federal, state, and local programs, benefits, and services for severely wounded, ill, and injured Servicemembers, Veterans, and their families.  The SOC maintains oversight of the FRCP.  The program was specifically charged with providing seamless support from the time a Servicemember arrived at the initial Medical Treatment Facility in the United States through the duration of care and rehabilitation.  Services are now provided through recovery, rehabilitation, and reintegration into the community.  Federal Recovery Coordinators (FRC) are Masters-prepared nurses and clinical social workers who provide for all aspects of care coordination, both clinical and non-clinical.  FRCs are located at both VA and DoD facilities.

FRCs work together with other programs designed to serve the wounded, ill, and injured population including clinical case managers and non-clinical care coordinators.  FRCs are unique in that they provide their clients a single point of contact regardless of where they are located, where they receive their care, and regardless of whether they remain on Active Duty or transition to Veteran status. 

FRCs assist clients in the development of a Federal Individual Recovery Plan and ensure that resources are available, as appropriate, to assist clients in achieving stated goals.  More than 1,300 clients have participated in the FRC program since its inception in 2008.  Currently, FRCP has more than 700 active clients in various stages of recovery.  There are currently 22 FRCs with an average caseload of 33 clients.  A satisfaction survey conducted in 2010 reported that 80 percent of FRCP clients were satisfied or very satisfied with the program.

VA/DoD Collaborations for Polytrauma/Traumatic Brain Injury (TBI)
VA and DoD share a longstanding integrated collaboration in the area of TBI.  Providing world-class medical and rehabilitation services for Veterans and Servicemembers with TBI and polytrauma is one of VA’s highest priorities.  Since 1992, VA and the Defense and Veterans Brain Injury Center (DVBIC) have been integrated at VA Polytrauma Rehabilitation Centers (PRC), formerly known as Lead TBI Centers, to collect and coordinate surveillance of long-term treatment outcomes for patients with TBI.  From this collaboration, VA expanded services to establish the VA Polytrauma/TBI System of Care to provide specialty rehabilitation care for complex injuries and TBI.

Today, this system of care spans more than 100 VA Medical Centers to create points of access along a continuum, and integrates comprehensive clinical rehabilitative services, including:  treatment by interdisciplinary teams of rehabilitation specialists; specialty care management; patient and family education and training; psychosocial support; and advanced rehabilitation and prosthetic technologies.  In addition to specialty services, eligible Veterans and Servicemembers recovering from TBI receive comprehensive treatment from clinical programs involved in post-combat care including:  Primary Care, Mental Health, Care Management and Social Work, Extended Care, Prosthetics, Telehealth, and others.

VA’s provision of evidence-based medical and rehabilitation care is supported through a system-wide collaboration with the Commission on Accreditation of Rehabilitation Facilities to achieve and maintain national accreditation for VA rehabilitation programs.  Collaboration with the National Institute on Disability and Rehabilitation Research TBI Model Systems Project enables VA to collect and benchmark VA rehabilitation and longitudinal outcomes with those from other national TBI Model Systems rehabilitation centers.  With clinical and research outcomes that rival those of academic, private sector, and DoD facilities, VA leads the medical and scientific communities in the area of TBI and polytrauma rehabilitation.

Since April 2007, VA has screened more than 500,000 Veterans from Operation Enduring Freedom (OEF)/Operation Iraqi Freedom/(OIF)/Operation New Dawn (OND) entering the VA health care system for possible TBI.  Patients who screen positive are referred for comprehensive evaluation by a specialty team, and are referred for appropriate care and services.  An individualized rehabilitation and community reintegration plan of care is developed for patients receiving ongoing rehabilitation treatment for TBI.  Veterans who are screened and report current symptoms are evaluated, referred, and treated as appropriate.

Additionally, 1,969 Veterans and Servicemembers with more severe TBI and extensive, multiple injuries were inpatients in one of the specialized VA Polytrauma Rehabilitation Centers between March 2003 and December 2010.  VA and DoD collaborations in the area of TBI include: developing collaborative clinical research protocols; developing and implementing best clinical practices for TBI; developing materials for families and caregivers of Veterans with TBI; developing integrated education and training curriculum on TBI for joint training of VA and DoD heath care providers; and coordinating the development of the best strategies and policies regarding TBI for implementation by VA and DoD.

Recent initiatives that have resulted from the ongoing collaboration between VA and DoD include:
• Development and deployment of joint DoD/VA clinical practice guidelines for care of mild TBI;
• A uniform training curriculum for family members in providing care and assistance to Servicemembers and Veterans with TBI (“Traumatic Brain Injury:  A Guide for Caregivers of Servicemembers and Veterans”);
• Implementing the Congressionally-mandated 5-year pilot program to assess the effectiveness of providing assisted living services to Veterans with TBI;
• Integrated TBI education and training curriculum for VA and DoD health care providers (DVBIC);
• Revisions to the International Classification of Diseases, Clinical Modification (ICD-9-CM) diagnostic codes for TBI, resulting in improvements in identification, classification, tracking, and reporting of TBI;
• Collaborative clinical research protocols investigating the efficacy of various TBI treatments; and
• Development of the protocol used by the Emerging Consciousness care path at the four PRCs to serve those Veterans with severe TBI who are slow to recover consciousness.

VA Liaisons for Health Care
VA has a system in place to transition severely ill and injured Servicemembers from DoD to VA’s system of care.  Typically, a severely injured Servicemember returns from theater and is sent to a military treatment facility (MTF) where he/she is medically stabilized.  A key component of transitioning these injured and ill Servicemembers and Veterans are the VA Liaisons for Health Care, who are either social workers or nurses strategically placed in MTFs with concentrations of recovering Servicemembers returning from Iraq and Afghanistan.  After initially having started with 1 VA Liaison at 2 MTFs, VA now has 33 VA Liaisons for Health Care stationed at 18 MTFs to transition ill and injured Servicemembers from DoD to the VA system of care.  VA Liaisons facilitate the transfer of Servicemembers and Veterans from the MTF to the VA health care facility closest to their home or the most appropriate facility that specializes in services that their medical condition requires. 

VA Liaisons are co-located with DoD Case Managers at MTFs and provide onsite consultation and collaboration regarding VA resources and treatment options.  VA Liaisons educate Servicemembers and their families about VA’s system of care, coordinate the Servicemember’s initial registration with VA, and secure outpatient appointments or inpatient transfer to a VA health care facility as appropriate.  VA Liaisons make early connections with Servicemembers and families to begin building a positive relationship with VA.  VA Liaisons coordinated 7,150 transitions for health care in FY 2010, and have facilitated more than 25,000 transitions since the program began in 2003.

VHA OEF/OIF/OND Care Management
As Servicemembers recover from their injuries and reintegrate into the community, VHA works closely with FRCs and DoD case managers and treatment teams to ensure the continuity of care.  Each VA Medical Center has an OEF/OIF/OND Care Management team in place to coordinate patient care activities and ensure that Servicemembers and Veterans are receiving patient-centered, integrated care and benefits.  Members of the OEF/OIF/OND Care Management team include:  a Program Manager, Clinical Case Managers, and a Transition Patient Advocate (TPA).  The Program Manager, who is either a nurse or social worker, has overall administrative and clinical responsibility for the team and ensures that all OEF/OIF/OND Veterans are screened for case management.  Clinical Case Managers, who are either nurses or social workers, coordinate patient care activities and ensure that all clinicians providing care to the patient are doing so in a cohesive and integrated manner.  The severely injured OEF/OIF/OND Veterans are automatically provided with a Clinical Case Manager while others may be assigned a Clinical Case Manager if determined necessary by a positive screening or upon request.  The TPA helps the Veteran and family navigate the VA system by acting as a communicator, facilitator, and problem solver.  VA Clinical Case Managers maintain regular contact with Veterans and their families to provide support and assistance to address any health care and psychosocial needs that arise. 

The OEF/OIF/OND Care Management program now serves over 54,000 Servicemembers and Veterans including over 6,300 who have been severely injured.  The current caseload each OEF/OIF/OND case manager is managing on a regular basis is 54.  In addition, they provide lifetime case management for another 70 Veterans by maintaining contact once or twice per year to assess their condition and needs.  This is a practical caseload ratio based on the acuity and population at each VA health care facility.

VA developed and implemented the Care Management Tracking and Reporting Application (CMTRA), a Web-based application designed to track all OEF/OIF/OND Servicemembers and Veterans receiving care management.  This robust tracking system allows clinical case managers to specify a case management plan for each Veteran and to coordinate with specialty case managers such as Polytrauma Case Managers, Spinal Cord Injury Case Managers, and others.  CMTRA management reports are critical in monitoring the quality of care management activities throughout VHA.

OEF/OIF/OND Care Management team members actively support outreach events in the community, and also make presentations to community partners, Veterans Service Organizations, colleges, employment agencies, and others to collaborate in providing services and connecting with returning Servicemembers and Veterans.

Caregiver Support
Caregivers are a valuable resource providing physical, emotional, and other support to seriously injured Veterans and Servicemembers, making it possible for them to remain in their homes.  Recognizing the significant sacrifices made by family caregivers of certain Veterans and Servicemembers who incurred or aggravated a serious injury in the line of duty on or after September 11, 2001, the new Caregivers and Veterans Omnibus Health Services Act of 2010, signed into law by President Obama on May 5, 2010, enhances existing services for caregivers of Veterans who are currently enrolled in VA care.  It also provides unprecedented new benefits and services to family caregivers who care for certain eligible Veterans and Servicemembers undergoing medical discharge who are in need of personal care services.  These new benefits, which are being implemented through an Interim Final Rule published earlier this month, include, for designated primary family caregivers of eligible Veterans and Servicemembers, a stipend, mental health services, and health care coverage if the primary family caregiver is not otherwise entitled to care or services under a health plan contract. 

Starting May 9, 2011, VA began accepting applications for this program; we processed more than 625 applications in the first week.  Caregiver Support Coordinators at each VA medical center are available to assist Veterans and their family caregivers with the application process, which can be done online, in person, or by telephone.  The benefits under this program are in addition to the range of benefits and services that support Veterans and their family caregivers.  These include such things as in-home care, specialized education and training, respite care, equipment and home and automobile modification, and financial assistance for eligible Veterans.  VA is enhancing its current services and developing a comprehensive National Caregiver Support Program with a prevention and wellness focus that includes the use of evidence-based training and support services for caregivers.  VA’s Caregiver Support Coordinators are the clinical experts on caregiver issues; these Coordinators are most familiar with the VA and non-VA support resources that are available to support family caregivers in successfully caring for Veterans at home.  VA has a Caregiver Support Web site (www.caregiver.va.gov) and Caregiver Support Line (1-855-260-3274) that provide a wealth of information and resources for Veterans, families, and the general public.  More than 6,000 Veterans and caregivers have received assistance from the clinical social workers staffing the Support Line since its inception on February 1, 2011.

Conclusion
VA and DoD continue to work together diligently to resolve transition issues while aggressively implementing improvements and expanding existing programs.  While we are pleased with the quality of effort and progress made to date, we fully understand our two Departments have a responsibility to continue these efforts.  We appreciate the opportunity to discuss these programs with you and to hear your recommendations.

Thank you again for your support to our wounded, ill, and injured Servicemembers, Veterans, and their families and your interest in the ongoing collaboration and cooperation between our Departments.  My colleagues and I are prepared to respond to any questions you may have.