February 4, 2010

Mr. Chairman and Members of the Subcommittee: Thank you for this opportunity to present The American Legion's views on seamless transition issues. Since 2001, the Department of Veterans Affairs (VA) Health Care system has undergone a major transformation in an attempt to accommodate the nation's veterans; to include increasing outpatient and preventive care in its growing network of outpatient clinics. Currently, there are approximately 23.4 million veterans in the United States; of that total, 7.8 million are enrolled in the VA Health Care system. VA treats 5.8 million veterans at more than 150 hospitals and 800 plus clinics.

As we examine the transition process, The American Legion, in its efforts to ensure transitioning service members receive continuous/seamless care, has determined that veterans are facing various challenges, which may irrevocably deter any chance of a successful and smooth transition back into their local communities. An example of challenges include, incomplete Post Deployment Health Reassessment (PDHRA) questionnaires, inability to fully share medical records among the Department of Defense (DoD) and VA Healthcare facilities, lack of space at VA Medical Facilities, and shortage of staff, to include nurses and physicians.

VA and DoD both play important roles in the transition process. As women and men return from Iraq and Afghanistan facing uncertainty with injuries and illnesses, The American Legion contends that closer oversight must be placed on various programs, such as the PDHRA and Federal Recovery Coordination (FRCP) programs that have been implemented to ensure no one falls through the cracks. We ask Congress to assess these roles to ascertain the appropriateness of functional tools required to accommodate the nation's veterans, their families, and the complex issues they are met with.The transition period is very important because many conditions service members are suffering from may go undiagnosed due to being in the emergent stage. The role of DoD and VA must be that of "safety net catalysts" that carefully guide service members and veterans as they transition from active duty military treatment facilities to VA Medical Centers; thereby ensuring every service member or veteran is the recipient of adequate and continuous care.

The following are some of the obligations DoD and VA have taken on to support each service member and veteran as they transition from active duty to civilian life:

Department of Defense and Seamless Transition:

To ensure that each service member's transition is successful, DoD has implemented the following:

When transitioning from active duty service to civilian life, service members must undergo final physical examinations before separation which includes: Medical screening (including eye exam); dental examination; and mental health screening.

They are offered a Medical Board Review for any unfitting conditions. This review is scheduled and performed at the request of the service member.

Post-Deployment Health Reassessment Program

The PDHRA program was established to identify and address service members' health concerns that emerge over time following deployments. To be in compliance with DoD's policy, each military service must electronically submit PDHRA questionnaires to DoD's central depository.

However, a recent audit disclosed that the central depository did not contain questionnaires for approximately 23 percent of the 319,000 (OEF/OIF) service members who returned from theater. This means approximately 72,000 service members were without questionnaires in the repository. The response to the absence of the questionnaires concluded that DoD does not have reasonable assurance that service members, to whom the PDHRA requirement applies, were given the opportunity to fill out the questionnaire and identify as well as address health concerns that could emerge over time following deployment.

The American Legion believes the administration of the PDHRA is essential to the success of the service member's transition, because the results would disclose telltale signs of debilitating illnesses, such as the disorders that plague many veterans who have gone undiagnosed at separation from active duty. These illnesses and injuries include Depression, Post Traumatic Stress Disorder (PTSD), Mood Disorders and Traumatic Brain Injuries (TBI), Spinal Cord Injuries (SCI), Blind Eye Injuries, respectively

Department of Veterans Affairs and Seamless Transition:

Upon separation from active duty service, VA informs the veteran of the following:

Eligibility to enroll for health care at any VA Medical Center or clinic within 5 years following military separation date. Upon enrollment, VA will administer health care benefits to the veteran immediately.

VA provides dental examinations and benefits to veterans with service-related dental conditions. The veteran may be eligible for one-time dental care; however, each veteran must apply for a dental exam within the first 180 days following the separation date.

Every VA Medical Center (VAMC) has a team ready to welcome Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) service members and help coordinate their care.

Federal Recovery Coordination Program:

The American Legion would also like to ensure that the FRCP is successfully assisting all recovering service members and veterans suffered from severe wounds, illnesses and injuries, as well as their families in accessing the care, services, and benefits provided through specifically, DoD and VA.

According to recent VA reports, the greatest challenge for Federal Recovery Coordinators (FRCs) is the integration of Information Technology (IT) access within VA and the Military Training Facility (MTF). Although DoD and VA state that these challenges will be overcome with the implementation of more IT integration between VA and DoD, The American Legion would like to know the status of DoD and VA full IT integration and medical records sharing. Further, The American Legion recommends a strong emphasis by this Subcommittee for expediting the effort be made.

VA Polytrauma of Care, VA Social Worker and Seamless Transition:

VA's Seamless Transition Social Worker, who is assigned to the MTF responsible for caring for the patient, makes contact with staff at the receiving Polytrauma System of Care facility. Vital clinical information is then transmitted to the Admission Case Manager at the Polytrauma Rehabilitation Center for review.

The Admission Case Manager remains in contact with the Seamless Transition Social Worker and the clinical team at the Military Treatment Facility until the patient is transferred to the receiving VA Polytrauma facility. During the service member's stay, the VA Case Manager remains in contact with the patient's military branch to keep them informed of progress and/or changes in the patient's condition.

VA and DoD, both ensure open communication and effective coordination through the following resources: phone calls, secure record transfers, and meetings. In addition, physicians in the VA Polytrauma System of Care and at Military Treatment Facilities contact each other directly through teleconferencing, videoconferencing, and through VA social workers assigned to each facility. Although the aforementioned duties are outlined and in place, VA continues to face challenges, such as screening and evaluating veterans for TBI.

More Challenges Transitioning Service Members and Veterans Face:

There have been various reports of critical challenges involving veterans who had recently departed from active duty service. These challenges, as reported by RAND, includes barriers to mental health care access in community settings. More specifically, it was discovered that:

Military service members and veterans are often reluctant to seek mental health care. The following reasons being:

Concern that admitting a mental health problem is a sign of weakness

Fear that use of mental health services will have negative career repercussions (especially among active-duty personnel, who are required to disclose treatment)

Skepticism about the effectiveness of treatment and concerns about the negative side effects of medication.

The mental health workforce has insufficient capacity. The following reasons being:

Mental health specialty care for conditions such as Post Traumatic Stress Disorder (PTSD) and Depression are not readily available in many parts of the country.

Studies also show that most mental health specialists are concentrated in urban areas.

Even where specialty care is available, limited health plan coverage may reduce access for veterans seeking care outside of the Veterans Health Administration (VHA).

The American Legion "A System Worth Saving" Site Visits:

During The American Legion's 2009 Site Visits, it was discovered that challenges were system wide when it comes to meeting the needs of OEF/OIF service members turned veterans. Lack of sufficient and appropriate staff to meet increasing workloads, a lack of support for families caring for returning severely injured veterans, and difficulty reaching new veterans who recently separated from active duty military, especially significant number that may be possibly suffering from psychological disorders are among the critical issues. According to VA, during outreach, it was reported that the battlefield mindset may be preventing veterans from seeking healthcare from the VA by admitting that there is a problem.

When women veterans' experiences include defragmentation of care, this cannot be deemed a successful transition. For example, approximately 49 percent of women veterans continue to split care between VA and the private sector. There continues to be a lack of space for a women veterans' clinic in some VA facilities. A common deterrent for women veterans include, the provision of day care for their children, and women veterans being uninformed of full service provided by VA which, at times, causes available clinics to be underutilized. Currently, an unknown number of veterans, men and women, are missing VA appointments due to childcare challenges.

The American Legion recently passed Resolution No. 29, "Improvements to Implement a Seamless Transition," which recognized gaps in services, and has consistently advocated improvements be made to the process of service members in their transition from active duty to civilian life. The American Legion continues to express that service members and their families are easily overwhelmed when dealing with the bureaucracy of multiple departments. However, a more expeditious process that explicitly focuses on moving service members from point A to point B, i.e., DoD to VA, respectively, would ensure timely and accessible care.

The American Legion believes it is extremely vital that this nation's service members, before their departure, should be placed in a comparable or full duplex capable, fully compatible, DoD/VA database with appointment reminders to ensure their transition isn't stifled by the unknown; after all, active duty service members have been conditioned to be directed to all military appointments and events.

Upon separation from service, these newly transitioned veterans may continue to have the expectation that everything will be set up for them. Both DoD and VA are working to ensure service members and veterans successfully receive information and treatment respectively. It is The American Legion's contention that the interaction between DoD and VA be heightened, most importantly, by complete shared access of the medical records of service members and veterans, as well as assessments of this relationship.

Let us remember that there is no pause button for veterans. Every moment is critical and must be treated as such. Although the World War II veterans' population is diminishing at approximately 1000 daily; other veterans, to include those from the Vietnam era to current OEF/OIF are presenting to VA with old and new issues. Complacency in communication between DoD and VA and implementation of programs can never be relative.

The American Legion hereby reiterates its position and urge careful oversight of effective communication between DoD and VA, to include, verbal and written, as well as full implementation of programs to ensure no one is left behind during the transition process.

Mr. Chairman and Members of the Subcommittee, The American Legion sincerely appreciates this opportunity to submit testimony and looks forward to working with you and your colleagues to ensure all service members are met with the best of health care upon transitioning into the community. Thank you.