The Independent Budget
Veterans Agenda for the 116th Congress

Health Care

Timely and Comprehensive Mental Health Services

Background and Justification

Suicide among the nation’s veterans continues to be a top priority for both VA and DOD. This is why VA, in cooperation with other government agencies, now releases annual data regarding veteran suicide. In September 2018, VA released its most recent analysis of veteran suicide with data from 2016. The data found suicide has remained fairly consistent within the veteran community over recent years. An average of 20 veterans and service members die by suicide every day. While this number must be eradicated, it is worth noting that as the number of veteran suicides has remained consistent in recent years, non-veteran suicides have continued to increase.

One death by suicide is one too many. Congress must ensure sufficient resources are available for effective VA suicide prevention efforts, including to identify those at higher risk of suicide, to deploy new interventions, and to effectively treat those with previous suicide attempts. Programs such as the Veterans Crisis Line (VCL); the placement of suicide prevention coordinators at all Veterans Affairs Medical Centers (VAMCs) and large outpatient facilities; integration of behavioral health into primary care settings, and joint campaigns between DOD and VA should be continued to aid in anti-stigma efforts and to promote suicide prevention efforts.

Timely access to mental health care is a critical aspect of health care quality. Over the past decade, the VA Office of Mental Health Services has developed a comprehensive set of services while seeing a significant increase in the number of veterans receiving care. VA provided specialty mental health services to 1.6 million veterans in fiscal year (FY) 2015. In 2016, the MyVA Access initiative was announced to address urgent health needs of veterans, with a plan to make same-day primary care and mental health services available at all VAMCs. From the beginning of FY 2016 through June 2017, VA had completed over one million same-day appointments for more than 500,000 unique patients through the primary care- mental health integration or regular mental health clinics. In 2017, VA began providing access to care for veterans with OTH discharges who were in a mental health crisis.

The Government Accountability Office (GAO) has identified several key barriers that deter veterans from seeking mental health care. These include stigma, lack of understanding or awareness of the potential for improvement, lack of child care or transportation, and work or family commitments. Early intervention and timely access to mental health care can greatly improve quality of life, promote recovery, prevent suicide, obviate long- term health consequences, and minimize the disabling effects of mental illness.

Since 2012, VA has increased staffing of new mental health providers, made efforts to improve wait times for mental health services, and addressed numerous barriers to care. Despite the increased need and improved outcomes of these services, according to an annual Office of Inspector General (OIG) report determining VHA staffing shortages, FY 2018 saw the most frequent staffing shortage in psychiatry and the fourth most frequent in psychology. Out of 141 facilities surveyed, 98 had a shortage for psychiatrists and 58 had a shortage for psychologists. By not adequately staffing VHA, the capacity to serve veterans and provide the necessary access to mental health care needed by so many veterans will continue to be limited.

Veterans who served in Iraq and Afghanistan make up only a small percentage of VA’s patient population, yet they require a significant proportion of VA specialized mental health services. There are nearly 3.5 million veterans who served after September 11, 2001. Without an end date for the Global War on Terror, this cohort will continue to grow, as will the need for specialized mental health services.

Alarmingly, VA’s annual report on suicide data has continuously shown that veterans ages 18-34 have the highest rates of suicide. These numbers have continuously risen over the past three years, which is particularly worrisome as 54 percent of post- 9/11 veterans fall into this age range. Studies show post-9/11 veterans who leave the military are also at increased risk of suicide during their first three years after service.

With this in mind, Executive Order 13822 established a requirement for VA, DOD, and Department of Homeland Security to coordinate an interagency plan. The Joint Access Plan (JAP) that was developed must provide seamless access to mental health treatment and suicide prevention resources for service members transitioning out of the military during their first year of separation.

Additional framework was also built into the JAP to provide more support for veterans identified as being at increased risk for suicide. This includes using current algorithms already implemented to identify veterans within VHA who are among the highest risk of suicide. The overall goals of the JAP, which are still being implemented, include better assurance that all new veterans know how to access VA services.

There are also provisions in the plan that call for increasing partnerships between VA and private sector providers. The IBVSOs understand that sometimes there is a need for care to be supplemented from within the community, but also firmly believe these non-VA providers must be held to an equally high standard of care. It is imperative that veterans recently leaving their military service are able to access knowledgeable, evidence-based care through VA. Current reports show the care provided by non-VA providers is of lower quality, and these providers prescribe veterans opioids at higher rates.

Another population at increased risk of suicide are veterans who received OTH discharges. Veterans with this particular discharge have rapidly increased in recent years, and mostly received these discharges for administrative purposes without any due process, rendering them without access to VHA. With the goal of eliminating veteran suicide in mind, VA expanded access to emergency mental health care for veterans who received an OTH discharge in July 2017. At the end of FY 2018, just over 100 veterans had utilized this care.

Surveys conducted by IBVSOs show veterans prefer using VA for reasons such as continuum-of-care and cultural competency. VA must continue expanding ways veterans may access mental health care. VA must continue expanding telehealth options for veterans seeking mental health who are in rural areas and may struggle to access any form of health care. It is also crucial VA provide telemental health for women, lesbian, gay, bisexual, and transgender (LGBT) and racial/ethnic minorities who face unique barriers such as travel difficulties, lack of access to childcare, or increased concerns of stigmas. VA must also expand mental health programs beyond trauma. Veterans need access to these appointments for struggles related to families and lifestyles, as well as gender-specific needs such as post-partum struggles or during menopause.

Along with TBI, PTSD is closely associated with post-9/11 veterans. PTSD is the psychological impact of experiencing or witnessing something traumatic. Like TBI, the effects of PTSD can be of an acute nature where veterans spontaneously recover, or they can be chronic, resulting in symptoms that veterans may experience for the rest of their lives without effective treatment. Unfortunately, multiple deployments with intense exposure to warfare have put many veterans of recent deployments at high risk for developing chronic PTSD.

Lessons learned from the Vietnam War better informed VA’s deployment of resources to address PTSD in the wake of the Global War on Terror. Early on, VA was able to screen for veterans’ exposure to events associated with the development of chronic PTSD and use existing protocols to assess symptoms associated with the disorder. VA and DOD developed post-deployment screenings that identify appropriate candidates for more comprehensive assessments. VA also integrated behavioral health into the primary care setting, which allows individuals who screen positive for PTSD or mental health issues to be assessed almost immediately.

VA has trained thousands of clinicians in the evidence-based protocols shown to be most effective in addressing PTSD — cognitive processing and prolonged exposure therapies. Yet, treatment becomes more difficult as more veterans come to VA struggling with co-morbidities. Common co- morbidities include PTSD, MST, or TBI with SUD and chronic pain. Symptoms of PTSD, MST, and TBI can all resemble one another, and often times patients who survived sexual trauma do have PTSD. Many affected individuals experience high levels of anxiety or depression and exhibit difficulty with self-regulation, judgment, and concentration due to preoccupation with the memories of traumatic events. Diagnosis is further complicated by the fact that veterans often may have coexisting conditions of TBI and PTSD. Symptoms of PTSD may significantly impair veterans’ ability to re-engage with their community and put them at higher risk for developing SUD or death by suicide.

Unfortunately, many veterans have more than one mental health disorder. Patients with more than one diagnosis are often among the most difficult to treat. While estimates of the prevalence of coexisting PTSD and SUD vary, most findings suggest significant portions of the population with PTSD also have SUD. Researchers from the VA National Center on PTSD cite a large epidemiologic study, finding almost half of those in the general population with lifetime PTSD also suffer from SUD. This is why it is incredibly important for VA providers to take the proper steps in preventing at- risk veterans from self-medicating, while also being responsible for handling patients with chronic pain and their necessary treatments.

VA has also taken steps to ensure it appropriately uses pharmaceutical treatments. Under the Opioid Safety Initiative (OSI), VA has reduced the number of veterans for whom it prescribes opioids by over 22 percent. Prescribed use of opioids for chronic pain management has unfortunately led to addiction to these drugs for many veterans as well as for many other Americans. VA uses evidence- based clinical guidelines to manage pharmacological treatment of PTSD and SUD to ensure better health outcomes. IBVSOs have been disheartened to hear from so many veterans who were abruptly taken off their opioids used for pain management, without receiving warning or a fair treatment plan. Often times, this leaves veterans desperate to self- medicate.

Research on mental health issues associated with combat or sexual trauma, such as PTSD and TBI, has allowed providers and researchers to better understand and diagnose mental health disorders in ways that have never before been possible. This can be advanced by continuing genomic research on biomarkers for varying risk factors. To aid in this ongoing and important research, VA must complete recruitment of the Post-Deployment Afghanistan/ Iraq Trauma Related Inventory of Traits study, which will provide a pool of 20,000 veterans of Iraq and Afghanistan to identify possible genetic variations that may influence risk of PTSD and TBI.

VA developed the polytrauma system to address TBI and other frequently co-occurring injuries (including wounds requiring amputation, sight, or hearing impairment, spinal cord injury, pain, and mental illnesses such as depression and PTSD), using a highly integrated and coordinated approach to address the complex needs for medical, rehabilitation, and supportive services. The system integrates VA and DOD care delivery and works closely with the grantees from the National Institute on Disability, Independent Living, and Rehabilitation Research TBI Model Systems to share data and best practices. Much more research, including research into assistive technologies that may assist veterans with reintegration into the community, is necessary.

To meet the emerging needs of veterans with TBI, VA uses polytrauma rehabilitation centers (PRCs). PRCs serve as the hubs of the nationwide system VA has in place at 148 medical facilities today, which include five PRCs in addition to network sites, pol- ytrauma clinics, and polytrauma care teams (embeded in some primary ambulatory care teams).

Veterans with the most chronic and severe brain injuries and their families often require a lifetime of care and support. VA has a case-management system in place designed to follow these patients into at least the first two years of recovery in the community. An individualized rehabilitation and community reintegration plan is developed with an interdisciplinary care team, including the veteran or their family caregiver, prior to the veteran’s discharge from a PRC facility. The successful implementation of the plan is highly dependent upon the family’s ability to adequately support the veteran at home, the patient’s distance from needed care, and the PRC case manager’s ability to provide the necessary resources to execute the discharge plan. For exam- ple, the PRC may prescribe speech therapy for a discharged veteran, yet the VAMC that is nearest to the veteran’s home responsible for delivering the care may not deem the veteran an appropriate candidate for treatment. VAMCs also significantly vary the amount of care (such as physical, speech, and occu- pational therapy) they are willing to reimburse or provide, often halting such services once it deems a maximum level of benefit has been reached. Unfor- tunately, without these services, veterans may regress and even develop secondary conditions that require more intensive medical treatment.

MST continues to be a problem within DOD for all active, reserve, and guard components. The defi- nition of MST under federal law (Title 38, USC, section 1720D), is defined as psychological trauma, which in the judgment of a VA mental health pro- fessional resulted from a physical assault of a sexual nature, battery of a sexual nature, or sexual harass- ment that occurred while the veteran was serving on active duty, active duty for training, or inactive duty training.

MST affects service members and veterans of all backgrounds without regard to age or race. Most survivors of sexual trauma during their time in the military are males, but women are disproportionately affected.

While DOD continues to increase its efforts to reduce or eliminate sexual trauma within the mili- tary service, the number of service members affected by MST is slow to decline. Congress must ensure DOD and VA improve their collaborative effort in awareness, reporting, prevention, and response among both service members and veterans. The identification of service members transitioning from military service having been affected by MST is a vital step in ensuring the veteran receives all of the appropriate care he or she needs.

VA’s national screening program screens all patients enrolled in VHA for MST. National data from this program reveals about one in four women and one in 100 men respond affirmatively to having experienced MST. All veterans who screen positive are offered a referral for free MST-related treatment, which notably does not trigger the VBA disability claims process. Previous years of VA data show growing numbers exceeding 100,000 veterans receive care for MST related treatment.

In FY 2017, 3,681 men and 8,080 women submitted claims to VBA for health problems related to MST. Of those claims, 55 percent of men’s and 42 percent of women’s claims were denied. This is why IBVSOs encourage Congress to hold oversight hearings on VA care related to MST and VBA’s process of handling MST claims.

It can take many years for survivors to even acknowledge a trauma occurred, and sharing details with advocates and care providers can be extremely difficult. Survivors of sexual assault often report they feel re-traumatized when they have to recount their experiences to disability compensation examiners. Therefore, we encourage VBA to employ the clinical and counseling expertise of sexual trauma experts within VHA or other specialized providers during the compensation examination phase.

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Improvements Needed in the Program of Comprehensive Assistance for Family Caregivers (PCAFC) of Severely Injured Veterans

Background and Justification

VA provides essential health care services to severely disabled veterans. It is their caregivers, however, that provide the day-to-day services and support needed to sustain a veteran’s well-being. Caregivers are the most important component of rehabilitation and maintenance for veterans with catastrophic injuries. Their welfare directly impacts the quality of care veterans receive. The VA’s PCAFC is unique in the United States. It is the only integrated program that is required to provide health care, a stipend, travel expenses, mental health care, respite care, and injury-specific training. Without these support services, the quality of care provided by the caregiver is likely to be compromised and the veteran is more likely to experience frequent medical complications and require long-term institutional care. Veterans who access PCAFC are medically stable enough to live within their community but lack the functionality to care for themselves on an ongoing basis.

Title I of Public Law 111-163, the Caregivers and Veterans Omnibus Health Services Act of 2010, required VA to create a caregiver-support program for those veterans catastrophically injured as a result of their service. When the program started in 2011, it was estimated 4,000 veterans would apply. Instead, more than 45,000 applied, demonstrating a critical and unmet need. There are currently 19,926 participants – a precipitous drop from a high of just under 27,000 in FY 2016. Given the unique nature of the program and the larger than anticipated demand, VA has encountered several complications including staff shortages, unclear procedures, and an antiquated IT system. After a comprehensive review in 2017 and the issuance of VHA Directive 1152(1), Caregiver Support Program, the IBVSOs believe VHA has made consistent improvements. Overwhelmingly, veterans in the program have reported positively on their experience. Their caregivers are better equipped to serve and they experience fewer financial and emotional stresses because of the availability of respite, mental health care, and a monthly stipend.

As of January 2019, to be eligible, a veteran must have been catastrophically injured in service on or after September 11, 2001. Expanded access to veterans of earlier eras is expected to begin in 2020, further raising demand for PCAFC’s services. The veteran’s injuries must require the assistance of a caregiver in order to complete one or more Activ- ities of Daily Living (ADLs) or require supervi- sion due to a neurological injury. Veterans may be discharged from the program for noncompliance or if their condition improves. The program is run by caregiver support coordinators (CSCs) across 140 medical centers. Every 90 days, VHA evaluates participants’ wellbeing and every year they conduct in-home assessments to confirm or adjust the families’ level of care and support.

Most recent data indicates 19,926 primary care- givers were receiving needed supports and services through this program at the end of 2018. VA’s fami- ly caregiver website (caregiver.va.gov) averages 2,241 hits a day. The Caregiver Support Line (1-855-260- 3274) averages 230 calls a day.

The Law’s Inequity for Caregivers and Veterans

While Title I of Public Law 111-163 created a program to address the adverse impact of caregiving, the law turned a blind eye to those caring for veterans that became ill because of their service. Family caregivers of veterans suffering from a severe service-connected illness, such as amyotrophic lateral sclerosis (ALS) or multiple sclerosis (MS), provide enormous amounts of care and support. They are, however, currently excluded from primary caregiver supports for no other reason than congressional concerns regarding cost.

The IBVSOs challenge the cost concerns, contending there are savings to be had by delaying a veteran’s entry into an institutional setting. According to the Congressional Budget Office (CBO), to participate in PCAFC is about $19,000 per year compared to the annual federal cost of nursing home care of over $60,000 in state veterans homes (matched by equal or greater state funding), $100,000 in community nursing homes, and about $400,000 in VA nursing homes.

If caregivers can no longer afford to meet family members’ needs, or become ill themselves, veterans likely have no other option but to be institutionalized. VA is obligated to pay the full cost of nursing home services for veterans needing care due to a service-connected disability, including illness. Yet, VA is not allowed to delay such an admission by supporting their caregiver.

It is unconscionable that the needs of one group of veterans and the work of their caregivers be recognized and supported, while another group continues to labor in the shadows, unacknowledged and with no reprieve. The largest cohort of veterans that will be applying to participate in PCAFC is from the Vietnam era. As they age, it is preferred – from both a financial and quality of life perspective – that every effort be made to let these veterans age in place opposed to in an institution. As Vietnam era veterans age, the demand for long- term care resources will grow significantly. Seriously ill veterans will require the most intensive and expensive institutional care. By providing their caregivers the means to keep them at home with family, they will live healthier lives, and delay higher costs.

Program Leadership and Operations

VHA operated the caregiver support program for more than five years under interim guidance. A final VHA Directive 1152, Caregiver Support Program, was not issued until June 14, 2017. This overdue directive was distributed in the midst of a temporary suspension initiated in April 2017 of discharging or revoking caregivers’ eligibility for the Caregiver Support Program and to conduct an internal review to evaluate the consistency of the program nationwide. Upon completion of its review, VA reinstated full operation of the program in July 2018, making significant changes to the program to affect policy and execution moving forward. This change includes mandatory VA staff training on the new directive, standardizing program information, a Frequently Asked Questions webpage for the program, and a document outlining the roles, responsibilities, and requirements for caregiver support coordinators, family caregivers, and veterans participating in the Caregiver Support Program.

Despite these enhancements, reports from 2014 and 2018 by GAO and VA Office of the Inspector General (OIG) describe specific and prevalent weak- nesses. Because VHA’s Caregiver Support Program office does not have the tools, resources, or support to properly manage, evaluate, and improve the program, caregivers and veterans are being adversely affected. Currently, only one person acts as both the director and deputy director of the Caregiver Support Program. The program and the caregivers of severely injured veterans this individual serves are therefore not being effectively represented in higher organizational policy discussions.

The IBVSOs appreciate VHA leadership support toward the hiring of a program analyst. Unlike other clinical programs under VHA’s current organizational structure, however, its Caregiver Support Program office has no corresponding clinical operations office to work collaboratively with its policy office and support field operations.

Variable application of eligibility and unclear roles across facilities continue to plague the program participants and applicants. VA must give consistent and transparent information to veterans regarding eligibility and tier reduction. Without reasonable support and reliable data, the IBVSOs are concerned about VA’s ability to properly analyze and project the number of resources needed to address the backlog of pending applications, while supporting and preparing for the impending number of caregivers expected to come into the program over the next five years.

Future Income Security for Primary Caregivers

Caregivers of severely injured and ill veterans often withdraw from school and/or give up time from work and forgo pay in order to spend many hours per week supporting, attending, and advocating for their injured veterans. Under PCAFC, predominantly spouses — but also some parents, relatives, and friends — receive a tax-free stipend based on the amount of hourly assistance the veteran requires. Over 4,800 caregivers are assigned to Tier 3 (the highest level, for providing a maximum of 40 hours of care per week) for their stipend payments. This “living stipend,” a term used by Congress, has been interpreted by VA to be “exempt from taxation under 38 U.S.C. 5301(a) (1)” based on the language contained in the law that states, “[N]othing in this section shall be construed to create . . . an employment relationship between the Secretary and an individual in receipt of assistance or support under this section.”

Because of the relative youth of the veteran when they become injured, many primary caregivers face a lifetime of supporting their veterans. Due to stipend payments’ tax-free nature, primary caregivers cannot claim them as income, and stipends are not considered wages or earnings creditable for the purposes of Social Security, which places the caregivers’ future income security at risk. There have been bills introduced in this and past Congresses, and likely will be introduced in the 116th Congress as well, to give up to five years of caregiving credit under Social Security. Some bills have been written in a way that would disadvantage veteran caregivers by the way they define “compensation.” While not a VA issue, Congress should be cautioned not to inadvertently harm veteran caregivers in this manner.

Enhancements Needed in Caregiver Services and Support

The IBVSOs often hear from primary caregivers that the training and education component of the program is basically an orientation. While the education and training component is required by law, the content is wholly within VA’s discretion. VA should amend such education and training to account for the primary caregiver’s experience and meet specific caregiving needs. This will be particularly pertinent as longtime caregivers from earlier eras join the program.

Caregivers report the unreliable availability of respite. Currently, the program includes many caregivers who are young spouses, many with young children in the home, creating barriers to respite services if childcare is not equally available. The caregiver is unable to truly experience respite if his or her caregiving responsibilities shift from the veteran to the children. Caregivers may also not be using this critical benefit due to unavailability of the service in their community and because they are concerned about entrusting the health and well- being of their veteran to a stranger. It is imperative VA identify local barriers to receiving respite care in the most convenient setting for the caregiver and veteran. IBVSOs support VA’s current efforts to use every means available, such as innovating an existing program, the Veteran-Directed Home and Community Based Services (VD-HCBS) to address this unmet need.

To date, VA evaluations of both the PCAFC and the Caregiver Support Program indicates increased use of health care services by veterans participating in PCAFC, though it is unclear if this increase in health care use is improving health status, health outcomes, and quality of life for veterans. Equally important, the evaluations suggest caregivers in PCAFC are more confident and better prepared in their role and that the stipend is reducing the financial strain of caregiving. The IBVSOs urge VA to continue program evaluations while addressing the existing limitations to better guide the current program and policy, and to inform policymakers overseeing the program.

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Long-Term Care

Background and Justification

LTSS encompasses a broad range of assistance to veterans who have physical or mental impairments and have lost the ability to function independently. LTSS includes help with performing self-care activities and household tasks, habilitation and rehabilitation, adult day services, case management, social services, assistive technology, home modification, medical care, and services to help disabled veterans remain an active member of their community. LTSS are provided to veterans who require help with activities and instrumental activities of daily living in a variety of settings, including in the home, assisted living and other supportive housing settings, and nursing homes.

Veterans Who Will Need Long-Term Services and Supports

According to the VHA, the projected total number of veterans most likely to require geriatric services in the coming decade — predominantly those ages 85 and older, and those of any age with significant disabilities due to chronic diseases or severe injuries — will remain well over one million strong. Nearly 40 percent of veterans who served on or after September 11, 2001 have a severe disability, which is higher than any other veteran cohort of earlier war eras. Population data show the number of veterans enrolled in the VA healthcare system who exhibit limitations in one or more activities of daily living will remain more than 1.2 million. VA can expect that as these veterans with functional limitations age, they will need LTSS and the VA’s LTSS workload concurrently.

Women veterans age 65 and older in the national veteran population will increase by 73 percent between 2019 and 2029 to over 617,000, despite the fact that the total veteran population older than 65 will decline by 16 percent to 7.6 million. The higher rate of young female veteran enrollment and health-care utilization, combined with longer life expectancy for women, suggests there will be a rising demand in VA geriatric and extended-care settings for gynecological care and management of chronic disorders more prevalent among older women, such as osteoporosis and breast cancer

The IBVSOs additionally believe that there are differences in culture, needs, and expectations in the newest generation of the severely ill and injured veteran patient population that require LTSS compared to the needs of elderly veterans. In most instances, the expectation is that these younger, severely disabled veterans will not want to reside in a nursing home, but rather receive appropriate support for safe and independent living in their community of choice. Gaps in VA’s LTSS package and in the geographic availability of LTSS is beginning to describe the limitations of VA’s current LTSS model of care.

Rebalancing of Long-Term Services and Supports

With the exception of nursing home care, the majority of LTSS is part of VA’s uniform health benefits package and these services are available to all enrolled veterans as outlined in Public Law 104-262, Veterans’ Health Care Eligibility Reform Act of 1996, and Public Law 106-117, Veterans Millennium Health Care and Benefits Act of 1999 (Millennium Act). In response to VA’s largely nursing home-based system of LTSS, the Millennium Act directed VA to expand non- institutional HCBS while maintaining the “level and staffing of extended-care services” that existed in 1998.

Since these laws were enacted, VA has been attempting to balance its LTSS system substituting nursing home services with more cost-effective and veteran preferred HCBS, which can reduce costs and improve the veteran’s quality of life. Over the last decade, VA has helped veterans move out of, and has diverted them from nursing homes. VA adopted a performance measure to increase access to HCBS using 2006 as the baseline fiscal year. In 2008, the VHA added two new HCBS programs with its Medical Foster Home (MFH) and Veteran- Directed Home and Community-Based Services, in partnership with the Department of Health and Human Services. From FYs 2008 to 2017, the proportion of VA’s LTSS budget being spent on HCBS has risen from 15 to 36 percent.

VA should be commended for such a tremendous shift in spending to balance its LTSS system. However, according to the Medicaid and Children’s Health Insurance Program Payment and Access Commission, for the fourth consecutive year in 2016, more than half of Medicaid spending for LTSS was HCBS rather than institutional care. This shift is the result of a variety of factors, including efforts by federal and state policymakers to balance Medicaid LTSS spending towards HCBS in order to curb spending growth and meet beneficiary preferences to live in the community. Clearly, VA has much more to do.

Last Congress, the IBVSOs made recommendations directed at the leadership of the VA, VHA, and VAMCs to sustain the commitment of balancing the Department’s LTSS. There must be an open commitment by VA leadership, a performance metric to measure and guide regional balancing at the Veterans Integrated Service Networks (VISN) level, and an evidence-based assessment instrument to be adopted and utilized by all local VA facilities, to help determine the level of HCBS services needed for veterans and their caregivers that would enable them to remain active participants in their community

These recommendations were made in light of institutional inertia supported by conflicting authorities. Current law requires VA to provide nursing home care services based on medical need to a subpopulation of veterans enrolled in VA health care. In contrast, VA policy makes HCBS available to all veterans in need who are enrolled. Not until recently has there been serious attempts made to address these conflicting authorities; not in law, but within the parameters of national handbooks and directives.

As a result, in 2017, VA formalized these efforts and announced its Choose Home initiative designed to allow veterans to remain in their homes instead of institutional settings. It is to employ evidence- based policy and action to improve the experience of veterans and their families. VA has indicated it will continue to capture LTSS expenditures and workload to align services provided with veterans’ needs. Finally, guidance has been issued to VA facilities to adopt an evidence-based assessment instrument.

If VA is to successfully execute its Choose Home initiative, VA must identify gaps, weaknesses, strengths, and unmet needs of the aging and younger complex patient population. Unlike previous budget requests, VA’s request for FY 2019 and 2020 did not include LTSS workload data in a non-institutional setting. This data was included in response to inadequate oversight and monitoring to ensure veterans were receiving needed home care services. To address this gap, VA should resume public reporting of LTSS workload data in its budget requests. Furthermore, the required assessment instrument utilized for the Choose Home initiative should allow the collection and reporting of validated data and other information to support local and national policy decisions, as well as justify future budget requests.

While VA is continuing to balance its LTSS system, all VAMCs should be able to meet the requirement to provide the full array of HCBS to veterans in its assigned service area. We continue to hear of waiting lists for in-home support, which is not publicly reported, and of reductions of in-home services, without clinical justification or time allotted for veterans and their families to adjust to the reduction of services.

Another area in need of attention are the innovations and advances in VA’s LTSS, which have been slow to proliferate. For example, VA’s Veteran-Directed Home and Community-Based Services (VD-HCBS) program, initiated in 2008, is serving over 2,100 younger and aging veterans with catastrophic disabilities whose individual needs have not been satisfied with VA’s traditional LTSS. Yet, VD-HCBS is only offered at 79 out of 170 VAMCs.

To enhance its LTSS benefit package while addressing its mounting nursing home spending, VA piloted the Medical Foster Home (MFH) program in 2000. It allows veterans in need of nursing home care to receive such care at a private home in which a trained caregiver provides round-the-clock care — including room and board, assistance with activities of daily living, medication management, and recreational and social support — to a small group of veterans. Veterans residing in MFHs also receive care through VA’s Home Based Primary Care program. MFHs have successfully served over 4,000 veterans with more than 1,000 residing in MFHs today. The program costs approximately $1,500 to $3,000 per month, while traditional nursing home care costs approximately $7,000 per month.

Currently, VA has no authority to pay for care in a MFH, and veterans — even those who VA is required by law to pay for needed nursing home care — must pay out-of-pocket to reside in a MFH. As a result, “VA pays more than twice as much for the long-term nursing home care for many veterans than it would if VA was granted…authority to pay for care in a MFH.”

Slow progress to provide more cost-effective and veteran-centric LTSS must be addressed by the Administration in its budget requests, and by Congress in providing the authorities and resources necessary for VA to meet the current and projected demand for LTSS. In doing so, however, the IBVSOs will oppose any proposal to eliminate the minimum bed capacity for VA Community Living Centers (CLCs). We strongly recommend that Congress enforce its average daily bed census mandate for VA to provide institutional care, and provide adequate funding to allow VA to expand HCBS to meet current and future demand.

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Women Veterans

Background and Justification

Women’s representation within the Armed Forces (16 percent), Military Reserves, and National Guard (20 percent each) is growing, composing an increasingly large share of the military and veterans’ populations. Women veterans now comprise about 10 percent of the total veteran population, and more than 7 percent of the veterans using VA health care services. In the next decade, women are projected to make up more than 10 percent of VA’s users. The diverse population of women veterans using VA care require knowledgeable providers in women’s health to deliver comprehensive primary care services, including mental health, gender-specific care, and referrals for reproductive health care needs.

VA has had difficulty in keeping pace with the rapidly growing numbers of women seeking care and benefits from VA — a population that is diverse, including both younger and older women with different health care needs. Women veterans using VA often have complex health care needs that require specialty care for service-connected conditions such as post-deployment readjustment challenges, PTSD due to war-related trauma and sexual trauma, mental health care, and substance use disorders — services which, on average, they use at higher rates and more often than male veterans.

Women veterans, on average, use significantly more contract care as men in VHA, in part because VA cannot always accommodate their gender-specific care needs due to lack of providers with expertise in women’s health, and VA’s inability to provide safe maternity care and obstetric services due to low volume. Despite these limitations, IBVSOs believe that VA is the best system to provide comprehensive primary care, mental health, and specialty services for women veterans and strongly support the Department’s decision to include women’s health care as a foundational service in VA. VA’s programs feature preventative services, behavioral health integration, care coordination, and wraparound specialty and social services that best meet the needs of this complex patient population. Assisting women veterans in overcoming known barriers to care by offering access to childcare, transportation, or beneficiary travel services is often necessary to ensure that they have access to critical services.

Women veterans using VA health care require care coordination to ensure they receive the same quality of care in the community that they would receive at VA, and access to VA specialty care services. Care coordination duties within VA can be time- consuming and often these are collateral duty assignments. As such, VA must allow enough time for women’s health program managers and other coordinators to perform these essential duties.

VA should ensure all of its health care and benefits programs are collecting data on gender and race to ensure equity in benefits, access, and health outcomes for all veterans. Likewise, VAMC directors should be responsible for ensuring that environment of care standards are met in all clinical spaces seeing women, and that identified deficiencies are quickly resolved.

Finally, institutional cultural change from the top down is necessary to ensure women’s contributions to military service are recognized and appreciated so that women veterans feel welcome at VA and receive quality care at all VA facilities.

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Prosthetics

The VA has a reputation in the United States and around the world of providing the best possible prosthetic care to its disabled veterans. This was not true after WWII, but steady progress by Congress, veterans service organizations (VSOs), and VA employees has made it so. America’s disabled veterans, present and future, depend on VA maintaining its global leadership in prosthetics care and service.

The recommendations for this section of the IB have evolved from lessons learned and experiences of all those involved in the development of the VA prosthetics program. Constant oversight and attention are necessary in order to manage the program and monitor the performance to maintain the highest quality and service to provide the best prosthetic care in the world. The recommendations are warning flags of what must be done for the VA to continue the provision of high-quality prosthetics to America’s disabled veterans.

Continuation of Centralized Prosthetic Funding

Congress must ensure that appropriations are sufficient to meet the prosthetic needs of all enrolled veterans —including the latest advances in technology —so that funding shortfalls do not compromise other programs. VA must continue to protect all funding for prosthetics and sensory aids. VHA leadership should continue to hold field managers accountable for ensuring that data is properly entered into the National Prosthetic Patient Database (NPPD). The national director of the PSAS should closely monitor prosthetic budgets at the facilities.

Protection of PSAS funding has had a positive impact on meeting the specialized needs of disabled veterans. Prior to the implementation of centralized funding, many VAMCs reduced budgets by withholding dollars for prosthetics. Such actions delayed provision of wheelchairs, artificial limbs, and other prosthetic devices. Once centralized funding was implemented, the Veterans Affairs Central Office (VACO) could better account for the national prosthetic budget and medical spending related to specialized services, including veterans with spinal cord injury and disorders (SCI/D), TBI, or amputations.

The IBVSOs strongly encourage VA to maintain a dedicated, centralized funding prosthetic budget to ensure the continuation of timely delivery of quality prosthetic services to the millions of veterans who rely on prosthetic and sensory aids’ devices and services to recover and maintain a reasonable quality of life.

FY 18 Cost and FY 19 Projected Expenditure
Category	FY 18	FY 19 (Budgeted)
Surgical Implants	$700,451,662.23	$810,662,182.25
Medical Equipment	$525,010,598.73	$607,616,857.26
Sensori-Neuro Aids	$482,630,056.62	$558,568,072.59
Oxygen And Respiratory	$282,808,628.40	$327,306,325.64
Wheelchairs/Accessories	$280,532,741.24	$324,672,345.67
Shoes/Orthotics	$112,327,118.31	$130,000,900.50
Orthosis/Orthotics	$101,632,045.72	$117,623,042.98
Biological Implants	$92,161,912.01	$106,662,858.75
All Other Supplies & Equipment	$83,664,449.74	$96,828,388.11
Artificial Legs	$80,495,085.47	$93,160,349.47
Home Improvements and Structural Alterations (HISA)	$39,814,268.20	$46,078,727.89
Misc	$16,656,728.04	$19,277,532.25
Restorations	$9,224,975.60	$10,676,452.43
Artificial Arms/Terminal Dev	$6,893,355.17	$7,977,969.99
Home Dialysis Program	$4,406,132.24	$5,099,402.24
Repair	$501,066,714.03	$579,905,591.98
Total	$3,319,776,471.74	$3,842,117,000.00

Continuous Training of Prosthetic Staff in the Field

The process of prescribing prosthetics and the procedures to be followed in selecting, purchasing, delivering, and training in the use of prosthetics is an involved, complex, bureaucratic ordeal. The skills and training required to manage and implement the prosthetic policies and procedures in a standard, consistent manner uniformly at the facility level is the key to successfully providing prosthetics to disabled veterans, and also the root cause of problems if employees are not properly trained. Training should be conducted on a continual basis through conference calls, webinars, face-to-face meetings, and other tools. An annual training plan for all levels of employees should be developed and implemented. This would help the prosthetic employees who are most likely to be the disabled veterans’ first point of contact. VA should provide a plan and funding to ensure training is conducted.

Timely Delivery of Prosthetic Devices

Prosthetics are as personal to an individual as the original body part or function. The purpose of prosthetics is to replace or support a body function in order for the individual to regain mobility and independence, which contributes to the individual’s dignity as a human being. Delays in providing prosthetics are unacceptable. A person without a wheelchair or legs is immobile. A person without arms is not independent. A person without glasses cannot read. A person with a disability cannot function without the tools to do so. The reduction of delays to a minimum is a priority that can be solved through training and expediting the purchase process. Currently, the procurement process is also a major source of delays that are caused by an overloaded system and a lack of training. The increase of the micro-purchase threshold to allow prosthetic staff to make purchases up to $10,000 was a major positive step to reduce delays and speed up the provision of prosthetics to the disabled veteran. As a result, the procurement workload in prosthetics has increased which requires VA to address the shortage of staffing in prosthetics’ services, training, and updated administrative tools to do their job.

Consistent Oversight and Management of the Prosthetic Program

The PSAS spends over three billion dollars annually to purchase and repair prosthetics and services. This is accomplished through a myriad of directives written by the policy program leader and staff in VACO. The effectiveness of how well those policies are carried out can only be accomplished by oversight at the VA facility, Veterans Integrated Services Networks (VISN), and VACO levels. The burden of carrying out these processes lies directly with the service chief and staff level. They are the ones who receive the consult, process the consult, and deliver the product to the veteran. How well they do their job can be measured in the data generated and recorded. To be useful, the data must be monitored daily at the facility level and up the chain of command in the operational side and by the program managers in the VACO.

Ensuring quality and accuracy of prosthetic prescriptions is imperative to patient care.

The clinician must prescribe the highest quality prosthetic that will accomplish the objective of improved mobility and independence for the patient, regardless of cost. If cost is the only determining factor, then excellent health care will become mediocre. Training for the prescriber, the clinical staff, and the administrative staff will help them all decide the benefits of a product based not on cost but on outcomes. This is yet another reason why prosthetic centralized funding is so important to maintaining high quality prosthetic care —the clinician does not have to worry about the subtle pressure to hold down costs.

Importance of Prosthetics to Women Veterans

Women veterans constitute a higher percentage of the veteran population than ever before. Despite the increase in the number of women who serve, the realization of what differentiates women veterans from male veterans has been lagging far behind the actions required to improve women’s prosthetic services. The VA must assure prosthetists and administrators at every level understand women’s prosthetic needs. VA must include women in the development of processes necessary to match women’s prosthetic needs, to ensure their outcomes and satisfaction is equal to men in using prosthetic aids. All VA facility leaders must be accountable for meeting women veterans’ standard of care for quality, privacy, safety, and dignity. Research and Development service should ensure that VA researchers lead and fund cooperative studies. VA must include academic affiliates, other federal agencies, and for-profit industry in order to advance understanding and application of prostheses for women.

Inclusion of Stakeholders in the Development of Rules, Policies, and Directives

VA’s proposed prosthetic rule would modify regulations governing prosthetic and rehabilitative items and services. IBVSOs are concerned that the regulations as written will lead to the denial of critical prosthetics and services to our members and other disabled veterans. We strongly urge VA to make changes before finalizing these regulations.

These items and services are critical to our members’ overall health and well-being, their quality of life, their independence and reintegration into regular activities, and their participation in the community through sports and other activities. A veteran whose mental, emotional, and overall health deteriorates because he or she cannot access needed prosthetic or rehabilitation devices is of significant concern. We therefore request: 1) VA’s specific reassurance that this proposed rule will not result in any reduction of devices, items, equipment, or services currently available to qualifying veterans, and 2) VA amend the prosthetic regulation before finalizing it.

With respect to amending the proposed regulations, the IBVSOs request language changes in two specific ways. While we understand that VA is moving to update and reorganize its regulations by creating a new subchapter to cover prosthetics and rehabilitation, we believe the “promote, preserve, or restore” language in the current § 17.38(b) should be maintained in the new § 17.3230. Removing this language could result in significantly reducing services to veterans. Congress has not enacted any law requiring such a change, and if the agency intends to continue current practices under the new regulations, there is no reason to delete this language.

Given how long the current regulations have been in effect, the proposed changes will be difficult to implement. We urge VA to include VSO stakeholders in drafting any handbooks, directives, or other guidance that will be used to implement any new regulations that are promulgated. We welcome the opportunity to work with the agency in drafting or reviewing any material.

Prosthetics Provided in the Community Care Model to Maintain Quality, Service, and Oversight

Changes in America’s health care delivery and payment systems will affect all aspects of VA care, including purchasing prosthetics and sensory aids. VA must have a plan to safeguard the viability and quality of its current prosthetics program. Medicare and Medicaid payment systems are now dictating the standards for durable medical equipment and other aids that lead to a proliferation of “lowest common denominator” devices and discourage innovation and early adoption of new technology that may improve veterans’ satisfaction and health care outcomes. The private sector is totally unaware of how encompassing VA prosthetic care is for disabled veterans. They are, however, very aware of the stringent limits of Medicare and Medicaid payment schedules, and that is the current model they use in prescribing prosthetics to disabled veterans. Consequently, VA must have a robust plan to implement prosthetic care in the community, aggressive training of VA and private care staff, and must increase their oversight of the community care model in the provision of prosthetics. A data system must be able to capture and track prosthetics such as is done with the National Prosthetic Patient Database. It is also imperative that the VSOs be included in this process.

Keep Directives Updated

The complexity of the prosthetic program requires clear guidelines and instructions of the process to effectively and efficiently permit staff at the facility level to do their job. As directives age, administrations change, technology improves, and overall change occurs, the paper processes must evolve to address those changes so that the disabled veteran is served in a quality, timely manner. Currently, the majority of directives and guidelines are years out of date and are a constant source of misunderstanding and confusion for VA staff, veterans, and VSOs. Stakeholders need to be included in the development of directives and guidelines to improvement management of the program. Working together will also help VA and the VSOs develop renewed trust.

Continued Improvement of the Prosthetic and Sensory Aids Website

Veterans coming out of their service have received the best in technical training and are experts in using technology in all aspects of their career, at every level in every Military Occupational Specialty (MOS). When they exit the service, they expect the VA to be on a par with their experience and training. Applying for benefits, health care, education, housing, clothing allowance, Home Improvements and Structural Alterations (HISA), automobiles, and grants should be a seamless effort.

Questions veterans have about prosthetics and sensory aids should be easily accessible through the internet with links to specific areas. In turn, those sites should include links to the directives describing the processes that VA staff use to provide prosthetics to the disabled veteran. VA must devote IT resources to develop these much needed internet resources, and maintain and update the sites on a continual basis.

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Electronic Health Record Modernization (EHRM)

Background and Justification

VA’s health IT and EHR system — the VistA — is an innovative, enterprise-wide clinical and business information system that enhances care for veterans. VistA’s veteran-centric focus represents the clinical workflow processes that both supports and measures VA’s holistic models of care delivering the best quality medical care to veterans. It also supports a myriad of clinical, administrative, and financial functions that are not normally found in private sector health care EHR systems.

At a time when patient records were not readily available electronically, VistA allowed VA to significantly reduce duplicative tests, medical errors, and costs. Harvard Business School awarded VA the coveted Innovations in American Government Award in 2006 for VistA as a model EHR. However, in response to congressional mandate stemming from administrative disorganization, failed IT initiatives, and security breaches, all of VA’s administration and management of IT were centralized into a single organization that same year. Since then, VA has struggled to comprehensively maintain, adapt, and innovate its once dynamic VistA system, which has led to security, maintenance, and development challenges. Additionally, VA continues to experience interoperability issues between itself, DOD, and community health care providers.

With the rise of commercial health IT solutions, the stagnant modernization of VistA, and the publicly announced 2017 decision for VA to no longer develop its own health IT platform, then VA Secretary David Shulkin awarded Cerner Corporation the task of replacing VistA with a new VA EHRM solution over the next 10 years in June 2017. The contract itself was signed nearly a year later in May 2018. Certainly, bi-directional exchange of information resulting in meaningful use of such information with a closed/proprietary system presents distinct challenges that VA must overcome in its contract, but collaborating with DOD offers potential cost savings and opportunities for VA such as capitalizing on challenges DOD encounters deploying its own Cerner solution, applying lessons learned to anticipate and mitigate issues, and identifying potential efficiencies for faster and successful deployment.

Customization to Support VA

According to the announcement of VA pilot site’s assessment in the Pacific Northwest, the new EHRM system from Cerner will be identical to the one currently in the pilot phase at DOD. The roots of commercial EHRs were targeted to support commercial healthcare systems and their revenue concerns. Whether commercial or DOD, neither health system delivers the same breadth and depth of services or benefits that VA provides veterans. Moreover, the manner by which these services and benefits are delivered is markedly different. While the decision for VA to no longer develop software appears to be settled, the IBVSOs are concerned that VA is not acknowledging the reality that successful adoption and long-term sustainability of an EHRM will likely require considerable modification and customization.

Of immediate concern to the IBVSOs is the notion, according to the Office of Electronic Health Record Modernization, that the incoming “EHRM program is not simply a technical solution or software replacement. VA is redesigning the way it delivers health care, with a future state that is patient-focused and efficient with an effective delivery system—one that offers veterans and their families the best health care available.” [1] The VA health care system has moved beyond patient- focused care to providing veteran-centric holistic care that touches every domain of a veteran’s life where health care is but only one important aspect. Congress and the Administration must ensure that the incoming EHRM, at a minimum, does not diminish from VA’s world-renowned health care system. Additionally, the product must have the capability to support and nurture future VA innovations.

Over its lifetime, VistA and the graphic user interface Computerized Patient Record System, has been highly customized to support VA and its comprehensive approach to wellness throughout the continuum of care during a veteran’s life. The multitude of applications in VistA, the uniqueness of benefits and services delivered, and the robustness of VA’s health care delivery makes satisfaction of all users — veterans, their family caregivers, and clinicians, administration, and financial managers alike — paramount. Medscape EHR reports for 2014 and 2016 rank the VA’s computerized record system as the Overall Top Rated EHR with physicians, placing it in the top three for ease of use, overall satisfaction, connectivity, and usefulness as a clinical tool. For VA clinicians, workflows that are unique to VA and to the needs of veterans that improves patient care and outcomes, promotes safety and best practices, enhances communication between veterans and multiple providers, and reduces the risk of error, must remain. In other words, the EHRM must support VA’s healthcare delivery model, not the reverse.

EHR is the core but not the entirety of VistA. VA does not just treat physical injuries and mental health, but includes the delivery of other VA benefits and services not generally offered in other health care systems such as a full complement of long-term services and supports, home adaptation, and travel assistance. VistA also supports veterans through various means including web portals such as My HealthEVet, mobile applications, kiosks, and call centers.

For veterans, the patient portal must be secure, user friendly, and facilitate engagement in their own care. Medical information important to veterans and their caregivers such as their treatment plans, prescriptions, and lab results must be easily viewed. Communicating asynchronously with their clinical team, requesting refills, and updating their medical history and status must be simple. My HealthEVet provides a suite of online tools to help veterans engage in and manage their health. They are able to enter and track personal health information, receive wellness reminders, conduct transactions with the VA health care system, communicate asynchronously with their VA health care team members, and access content from the VistA EHR. There are about 4.2 million registered users and 2.5 million identity-validated users of My HealthEVet who have requested more than 114 million refills, exchanged over 57 million secure messages, and downloaded over 27 million Blue Button files.

My HealthEVet also has the potential for telemental health, computerized therapies, online peer support groups, and other successful therapies. Despite its success, VA has yet to engage the veteran community on whether or when My HealthEVet will be replaced in this modernization effort and if additional patient facing transactional features will be added.

VA’s Office of Electronic Health Record Modernization (OEHRM) will play a central role in both selecting and implementing the new EHMR system as well as communicating its benefits to the veterans VA serves. This office is to manage the preparation, deployment, and maintenance of VA’s new electronic healthcare record system and the health information technology tools dependent upon it. In the preparatory phase, OEHRM is charged with configuring and designing a system focused on quality, safety, and patient outcomes, which will encourage IT innovations to be used across the entire VA healthcare system. Primarily, it is critical VA ensures OEHRM has the resources, knowledgeable and experienced staff, and the authority to effectively discharge its responsibilities.

As it convenes clinical councils, OEHRM must not forget that the most important part of VA’s clinical team in delivering patient-centered care — the veteran and their family caregivers. The integration of patient and family caregivers into the VA health care system holds tremendous promise for improving the well-being of veterans, while having the potential to reduce costs associated with hospital readmissions and nursing home care.

Governance

GAO’s September 2018 report found the VA-DOD IPO has been involved in various approaches, since 2008, to increase health information interoperability. Its mission is to lead and coordinate the adoption of, and contribution to, national health data standards to ensure interoperability across the DOD, VA, and private sector healthcare providers. However, the IPO must be more than a convening body.

Congress must ensure the IPO is effectively positioned to function as the single point of accountability with resources and staffing control, authority to develop interagency processes, as well as decision making authority for both departments’ EHR system interoperability efforts. Congress must reinforce its original intent in creating the IPO and enable the office to fulfill its management responsibilities while guaranteeing issues will be resolved at the lowest level.

VA’s EHR modernization efforts require collaboration with the VA Office of Information Technology (OIT) which, unfortunately, has degraded over the last decade resulting in uncoordinated execution of VHA’s IT strategy and restricted development of new and improved capabilities for VistA and the Computerized Patient Record System (CPRS). The IBVSOs recommend adding a VHA Chief Information Officer with a direct line to the VA CIO to identify and advocate for health IT needs and priorities.

Continued Development and Sustainability of VistA

Cost of full integration of the Cerner EHR is projected at $16 billion over the next 10 years, with $5.8 billion of those funds set aside to manage and support the current VistA infrastructure. VA has indicated VistA will remain throughout the implementation phase, but has not fully described timelines, projected implementation of the new system, draw-down dates for the old system, and what the maintenance schedule will be for all or part of the system.

A 10-year EHRM deployment presents challenges to VA facilities and may impact the care veterans receive, especially those on the East Coast where EHRM will be deployed last, while the rest of the VA health care system has EHRM, and in snowbird destinations where veterans will be traveling from a northeastern VA facility using VistA to another in the southwest using EHRM. In January 2018, VA had reviewed and mapped all VistA modules and indicated that it planned to stop adding new capabilities to VistA modules that VA will eventually retire. The IBVSOs believe this approach raises potential patient safety issues since state-of-the- art medicine and telehealth changes almost daily. We recommend VA’s strategy be clear on targeted investments to maintain the state-of-the-art nature of VistA.

The incoming VA CIO pledged to maintain VistA during the 10-year process to implement the new Cerner EHR, yet concerns continue to be raised based on past performance and about the reduction in spending for development and maintenance of VistA. For example, during the past decade, VistA and CPRS development has been reactionary and confined to addressing concerns with minor enhancements and point solutions. Additionally, VA’s research program is one of the Department’s four main missions. Despite it being a priority, the FY 2019 budget for this program requested no funding for new technology solutions or for existing solutions undergoing development, modernization, or enhancement.

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Non-VA Emergency Care

Background and Justification

In order for VA to pay for emergency services provided to veterans by non-VA providers, VA must apply three disparate statutory authorities with varying eligibility requirements. This difference in criteria has led to some non-VA emergency care claims being inaccurately and improperly processed, resulting in waste for the agency and extraneous out-of-pocket expenses for veterans.

According to VA, approximately 30 percent of the 2.9 million non-VA emergency claims for payment or reimbursement filed with the VA in FY 2014 were denied. Between the start of FY 2014 and August 2015, approximately 89,000 claims were denied because they did not meet the timely filing requirement; 140,000 claims were denied because a VA facility was determined to have been available; 320,000 claims were denied because the veteran was determined to have other health insurance that should have paid for the care; and 98,000 claims were denied because the condition was determined not to be an emergency. In all of these instances, a veteran was in need of care and shouldn’t have had to shoulder a disproportionate financial burden because of administrative errors.

Erroneous denials of non-VA emergency care claims make veterans financially liable for care that VA should have covered. Because the financial liability is often large and credit ratings are negatively affected, veterans choose to delay or avoid going to non-VA emergency rooms or go to a VA facility instead.

Additionally, the Court of Appeals for Veterans Claims ruled unanimously on April 8, 2016, that VA wrongly denied claims for reimbursement when the Department ignored a 2010 statute meant to protect certain veterans from out-of-pocket costs when forced to use non-VA emergency care. From this ruling that held VA’s regulation as inconsistent with the statute and invalid, it is estimated more than two million claims submitted since 2010 could be eligible for reimbursement, and that over the next decade nearly 69 million claims could be submitted, which could cost as much as $10 billion.

The IBVSOs recommend VA issue an interim final rule to remedy the inconsistency between current non-VA emergency care reimbursement regulations and statute. In January 2018, VA issued such a rule yet veterans who filed claims before April 8, 2016, would see no reimbursement from VA. Without legislative relief, these veterans will have to pay emergency care bills that Congress had intended the VA pay.

Moreover, current law prescribing non-VA emergency care benefits are convoluted and burdensome for veterans to interpret, and for VA staff to administer. The risk of being liable for such high costs can keep veterans from going to the emergency room. A 2010 study in the Journal of the American Medical Association found that almost half of uninsured patients or patients with financial concerns waited six hours or more to seek care, while those without financial concerns were more likely to seek emergency care within two hours. Veterans should not be forced into weighing choices between impoverishment or risking chronic disability or death in using their non-VA emergency care benefit. VA must review and synchronize its policy guidance to ensure both VA administrators and veteran patients are aware of when it is appropriate to seek and fund emergency care.

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Strategies for Ending Veteran Homelessness

Background and Justification

The Annual Homeless Assessment Report (AHAR) point-in-time census for 2018 once again shows promise in eliminating homelessness among veterans. Homeless veterans are now estimated to number fewer than 40,000. The count dropped by 5.4 percent over the past year and reversed a slight uptick in the AHAR count from 2017. In the last decade, VA has made remarkable progress in decreasing homelessness in the veteran population by nearly half – reducing it from 74,087 individuals in 2010. For the first time since 2010, in 2017, the number of homeless veterans increased since VA began its targeted initiative.

Trends were most pronounced in major cities including Los Angeles and New York City, among women veterans, (seven percent increase for women compared to a one percent increase for men), and among unsheltered veterans, which increased by 18 percent. The number of veterans with families who experienced homelessness continued to decrease.[1] The 2018 count shows corrections in homelessness among women veterans dropping by 10 percent over the past year. There was also a smaller decrease among the unsheltered veterans population, which decreased by almost 5 percent between 2017 and 2018.

Research indicates there are a number of risk factors that can contribute to a veteran becoming homeless including a history of sexual abuse, unemployment, single parenthood, mental health or substance use issues, family dissolution, and lack of social support.[2] VA identified that veterans who experience homelessness are more than five times as likely as other veterans to attempt suicide, and about 50 percent of those veterans identified as high risk for suicide had contact with VA’s homeless programs.[3] Veterans with mental health issues and traumatic brain injuries diagnosed at separation are also more likely to experience homelessness. Women veterans are twice as likely as women in the general population to become homeless, and in 2017, were becoming homeless at a rate that is seven times the rate of male veterans (see increases in 2017 AHAR counts for women and men veterans discussed above). Among homeless women veterans, 30 percent have children living with them, and 45 percent of women veterans who were unstably housed had custody of children.[4]

VA recognizes homelessness among the veteran population is a multi-dimensional problem that requires a multifaceted approach. In collaboration with other federal, state, and local agencies, VA has deployed a range of programs and complementary services that help coordinate outreach to identify veterans who are homeless or at risk of becoming homeless, connect veterans with resources for housing, and provide access to health services, vocational training, and employment services. Key programs include: the Homeless Providers Grant and Per Diem Program (GPD)[5]; HUD-VASH[6]; SSVF Program[7], and Health Care For Homeless Veterans (HCHV) Program[8]. According toVA, in FY 2017, over 600,000 veterans and their family members were prevented from falling into homelessness, were rapidly re-housed, or permanently housed.

VA’s homeless programs are comprehensive including medical, dental, and mental health services, as well as specialized programs for post- traumatic stress disorder, sexual trauma, substance use disorder (SUD), and vocational rehabilitation. VA adopted a model of housing veterans first — rather than requiring them to be in recovery or treatment for mental health or SUDs prior to receiving housing assistance. Homeless prevention coordinators and peer mentors are essential to the success of the program and helps veterans navigate the system and get the services they need. VA should consider increasing the use of peer specialists, particularly those who are in recovery from SUDs and/or have experienced homelessness. Peers who have had similar experiences are often able to connect on a more personal level and can help homeless veterans overcome challenges, actively engage in treatment, and maintain healthy, sober lifestyles.

While VA’s comprehensive services, efforts, and approach to ending homelessness among veterans is effective overall, the National Coalition for Homeless Veterans recommends increased funding for the SSVF program — the only program targeted at those at risk of losing housing. This would allow VA to maintain these prevention efforts, expand the program to new communities, and focus on innovative approaches to preventing more veterans from becoming homeless. The IBVSOs recommend VA address unique risks associated with subpopulations of homeless veterans, particularly women, minorities, those with serious, chronic mental illness or traumatic brain injuries, and aging veterans. VA should also continue to develop relationships with community providers that supplement current services and ensure its programs remain effective, and flexible to provide the services these veterans need to successfully transition into stable housing. The IBVSOs commend VA and HUD for establishing a new pilot program to provide grants to make housing more accessible for low-income veterans with physical disabilities.

The IBVSOs further recommend that VA continue the growth of its EUL program, and work in partnership with HUD on project-based HUD- VASH vouchers, in order to spur the construction of critically needed affordable housing for homeless veterans with the highest needs.

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Spinal Cord Injury and Disorder (SCI/D) Care

Background and Justification

SCI/D System of Care

VA’s SCI/D System of Care is provided using a “Hub and Spokes” model. This model has been shown to work very well as long as all patients are seen by qualified SCI/D trained staff. Because of staff turnover and a general lack of education and training in outlying “spokes” facilities, not all SCI/D patients have the advantage of referrals, consults, and comprehensive annual evaluations in a SCI/D center.

This is further complicated by confusion as to where to treat spinal cord diseases, such as multiple sclerosis (MS) and amyotrophic lateral sclerosis (ALS). Some SCI/D centers treat these patients while others deny admission. In December 2009, VA developed and published the VHA Handbook 1011.06: Multiple Sclerosis System of Care Procedures, which identifies a model of care and health care protocols for meeting the individual treatment needs of SCI/D veterans. Additionally, the VHA ALS Handbook 1101.07 (2014) speaks to the importance of coordinating care with SCI/D services (e.g. bowel and bladder care), encouraging ALS clinics to be located within SCI/D centers, and incorporating SCI/D staff into the ALS interdisciplinary care team. More of a national effort must be taken to integrate the ALS and MS Systems of Care with SCI/D, instead of deferring to the local level. In the meantime, MS clinics should be encouraged to engage in efforts to have SCI/D centers provide certain services on a consultative basis necessary for MS veterans.

Nursing Staff

Historical data has shown that SCI/D units are the most difficult places to recruit and retain nursing staff. Caring for a SCI/D veteran is physically, mentally, and emotionally demanding. SCI/D nursing staff provides hands-on care that involves frequent bending and heavy lifting. Repetitive movements and heavy lifting associated with caring for SCI/D patients often lead to work- related injuries and high turnover. Occupational injuries correlate with a shortage of nursing staff. Veterans with SCI/D often have psychosocial conditions such as PTSD, depression, and paranoia as a result of their injury/disorder. Special skills, knowledge, and dedication are required in order for nursing staff to care for SCI/D veterans.

Facilities are faced with local budget challenges when considering a recruitment or incentive specialty pay in the area of SCI/D. The funding necessary to support this effort is taken from local facility budgets, thus detracting from other needed medical programs. A consistent national policy of salary enhancement for specialty services should be implemented across the country to ensure qualified staff is recruited and retained.

Funding to support this initiative should be made available to the medical facilities from the Veterans Integrated Service Networks (VISN) or Veterans Affairs Central Office (VACO) to supplement their operating budgets.

Unfortunately, the significant nurse shortage has resulted in VA facilities restricting admissions to SCI/D centers. Reports of bed closures have been received and are attributed to nursing shortages. When veterans are denied admission to SCI/D centers, leadership is not able to capture or report accurate data for the average daily census. The average daily census is not only important for adequate staffing to meet the medical needs of veterans, but is also a vital component of ensuring that SCI/D centers receive adequate funding. Since SCI/D centers are funded based on utilization, refusing care to veterans does not accurately depict the growing needs of SCI/D veterans and stymies VA’s ability to address the needs of new incoming and returning veterans. Such situations severely compromise patient safety and serve as evidence for the need to enhance nurse recruitment and retention programs.

SCI/D Long-Term Care

As the veteran population ages, VA must assess and prepare for veterans’ long-term care (LTC)/extended care needs. Of particular concern is the availability of VA LTC services for the vastly growing aging SCI/D veteran population. VA is not devoting sufficient resources to meet the demands associated with onset of secondary illnesses and complications associated with aging.

Nationwide, VA operates only six designated extended care facilities for SCI/D veterans, with a total of 160 staffed beds. Often, the existing centers cannot accommodate new veterans needing long- term care services due to lack of beds. Furthermore, only three of these extended care SCI/D centers accept ventilator-dependent patients. These facilities manage long waiting lists for admission, and veterans remain underserved, bearing long-term costs that remain invisible to decision makers who focus on short-term gains at the expense of long- term care for veterans in need.

Although the majority of SCI/D veterans in LTC reside in community living centers (CLCs), these facilities do not have the same rigorous staffing requirements as extended care SCI/D units. Additionally, their staff is likely not trained in caring for SCI/D LTC patients.

While VA has identified a need to provide additional SCI/D extended care centers and has included these additional centers in ongoing renovation plans, many of these plans have been languishing for years. Therefore, the IBVSOs strongly recommend that VA and Congress work together to ensure that the SCI/D System of Care has adequate resources to staff existing LTC centers, as well as to increase the number of centers throughout the VA system.

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Access to Specialty Care

Background and Recommendations

Veterans who have incurred a spinal cord injury or disorder are entitled to health care through VA’s Spinal Cord Injury/Disorder (SCI/D) System of Care. When veterans with a SCI/D are in need of care for recurrent problems and/or have complex issues at times requiring surgery that needs specialized knowledge, it is essential that they have access to the comprehensive health care services that can only be provided by a VA SCI/D center.

VA policy identifies transportation as a major component in ensuring veterans with SCI/D receive a comprehensive annual health exam at the SCI/D hub facilities. Two years ago, the VA implemented the extension of travel reimbursement for catastrophically disabled non-service connected veterans seeking SCI/D annual examinations. However, there are many cases where veterans do not receive travel reimbursements for appointments related to their SCI/D annual examination.

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Amyotrophic Lateral Sclerosis (ALS)

Background and Justification

ALS is a degenerative neurological disease that destroys nerve cells in the body that allow for voluntary muscle control. Research shows that the risk of ALS is increased among veterans. It leads to the gradual loss of brain and spinal cord cells that facilitate motor skills such as walking or running, eventually eliminating one’s ability to move voluntarily.[1] ALS is fatal and usually progresses at a fast rate after diagnosis. Therefore, it is of great importance for veterans to receive timely care and for the VA to be able to provide the clinical expertise that is needed to meet veterans’ medical needs.

VA issued VHA Handbook 1101.07: ALS System of Care Procedures in July 2014. It describes the essential components and procedures to ensure that all enrolled veterans have access to ALS care and that the veteran and the veteran’s family and caregivers are given necessary clinical care and support provided by a comprehensive, professional ALS interdisciplinary care team. The major focus of clinical care is to provide the highest quality of life through the management of symptoms and emotional and physical suffering.

Though there is no cure for ALS, certain actions can be taken to optimize remaining function, maintain functional mobility, and maximize the veteran’s quality of life. Exercise programs may be physiologically and psychologically beneficial for veterans with ALS, particularly before there is a great deal of muscle wasting.

Care integration is also an essential aspect in the ALS System of Care. It is vital that VA utilize the established programs within other systems of care to help inform veterans of treatment modalities and support services that are available. The ALS handbook encourages having ALS clinics within SCI/D centers, and states that on SCI/D units the social worker, the advanced practice registered nurse, or the registered nurse case manager would be the best points of contact for veterans and their caregivers. However, more must be done to integrate the two services.

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Improving VA’s National System of Care for Multiple Sclerosis (MS)

Background and Justification

The VA has averaged 18,000 unique MS patients per year. MS is an extremely complex and chronic neurological disease that results in cognitive deficits such as short-term memory loss and physical impairment; afflicted veterans often lose employment and their independence. VA must increase access to quality care for veterans with multiple sclerosis by ensuring adequate staffing, coordinating care across disciplines, and enforcing VHA Handbook 1011.06.

Despite the establishment of the Multiple Sclerosis Centers of Excellence (MSCoEs) and the VHA Handbook 1011.06 in 2009, veterans still do not have consistent access to timely care for MS within VA. Issues such as the shortage of appropriate medical staff or the lack of care coordination are still precluding veterans from receiving care.

VHA Handbook 1011.06 states that VA must have “at least two MSCoEs, and at least one MS Regional Program in each Veterans Integrated Service Network (VISN)… Any VA Medical Center caring for Veterans with MS and not designated as an MS Regional Program must have a MS Support Program, spoke sites for MS care.” The VHA Handbook 1011.06 is not being enforced. Consequently, veterans do not have adequate access to MS care due to the lack of resources in local and regional facilities.

Local facilities are not adequately funded and therefore are not able to recruit and retain medical professionals with this specific experience to meet necessary staffing requirements. VA must provide local facilities with the necessary resources and funding to provide the appropriate health care services and cognitive rehabilitation that veterans with MS need. Equally important is the need for adequate funding for respite care, long-term care, and home care services for this population. Quality care can only be provided if all of the medical needs of veterans are being addressed and all individuals involved are informed.

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Reproductive and Sexual Health

Background and Justification

As a result of the recent conflicts in Afghanistan and Iraq, many service members have incurred injuries that have made them unable to conceive a child naturally. Since 2010, DOD has provided IVF to active duty and retired service members. In late 2016, Congress enabled VA to offer the same services to veterans with a service-connected reproductive injury.[1] As of this publication, over 500 veterans have been referred to IVF services. The overwhelming feedback IBVSOs receive is frustration with the VA contracting process with fertility clinics – a process that can last nearly a year. As the process is inherently time sensitive, Congress must enable VA to provide IVF services quickly to both the veteran and spouse. An estimated 3,000 veterans with spinal cord injuries and urogenital injuries are likely to avail themselves of this service in the years to come.

For over 20 years, veterans have not had access to fertility advancements because of a 1992 act of Congress prohibiting VA from providing IVF.[2] Despite the initial and recent reauthorization lifting the ban for a two-year period, the uncertainty of the service weighs heavily on veterans and their families. The permanent availability of procreative services through VA will ensure veterans and their spouses are able to have a full quality of life, one that would otherwise be denied to them as a result of their service.

Some women veterans with a catastrophic injury may be able to conceive but be unable to carry a pregnancy to term due to their injury. In such instances, implantation of a surrogate may be their only option. VA is not authorized to provide IVF services with a veteran’s surrogate. As such, the needs of women veterans with a catastrophic reproductive injury go unmet.

For veterans who have sustained a blast injury or a toxic exposure that has destroyed their genetic material, a third-party donation may be the only option. VA is not authorized to use any genetic material in IVF service that does not belong to the veteran and his or her spouse. Again, the needs of these veterans; those who have an injury due to their service, are unmet as they are not able to receive the corresponding medical treatment to address it.

There is a growing body of evidence linking post- deployment problems such as depression or post- traumatic stress disorder to sexual health problems. One study found almost 18 percent of veterans screened positive for sexual dysfunction.[4] Healthy sexual functioning and satisfaction with one’s sex life are predictors of general well-being and overall health. VA providers must work to navigate sometimes awkward questioning to ensure veterans are able to voice concerns or problems about their sexual health that undoubtedly will impact their overall health and quality of life.

The Affordable Care Act (ACA) prevents individuals with insurance from being charged pharmaceutical co-payments for all 11 categories of preventive medicine as determined by the U.S. Preventive Task Force and Centers for Disease Control and Prevention. Yet, with VA being exempt from the ACA, Section 1722A(a)(3) requires VA to charge for these categories with exemptions provided by the Secretary for immunizations and smoking cessation. Veterans are experiencing a disparity in co-payment requirements for the remaining nine categories including contraceptives women veterans receive from the pharmacy. This is an undue and unjust barrier to accessing birth control that only women veterans and the uninsured must face.

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Homeland Security and Funding for the Fourth Mission

Background and Justification

VA has four critical health care missions, the first of which is to provide health care to veterans. Its second mission is to educate and train health care professionals who work with veteran populations. The VA’s third mission is to conduct medical research. Its fourth mission is to serve civilians — both domestic and foreign — in times of national emergency.

Whether the emergency is precipitated by a natural disaster, a terrorist act, or a public health contagion, the federal preparedness plan for such events — known as the National Response Framework (NRF) — involves multiple agencies. As the largest integrated health care system in the country, with medical facilities in cities and communities all across the nation, VA is uniquely situated to provide emergency medical assistance and plays an indispensable role in our national emergency preparedness strategy.

Multiple laws authorize VA’s fourth mission. Public Law 100-707 created the NRF under the Stafford Act for federal agency involvement in natural and man-made disasters. The NRF is comprised of 15 emergency support functions for which one federal agency serves as lead. The Federal Emergency Management Agency (FEMA) is assigned about half of the emergency support functions.

The VA is tasked with a variety of public health and medical responsibilities under Emergency Support Function 8 (ESF 8) of the NRF, yet the Department of Health and Human Services (HHS) is the lead agency for that function. The typical process that is followed in a disaster involves the state/territory going to FEMA for assistance. FEMA determines if the support involves medical and public health needs and requires the engagement of HHS, which then determines the best approach to address those needs.

According to officials with the VA Office of Emergency Management (formerly the Emergency Management Strategic Health Care Group) under the Stafford Act, if the VA is activated to help with ESF 8, the agency can seek reimbursement for expenses incurred due to participation in the National Disaster Medical System (NDMS). Situations may arise in which the care provided by the VA under a Stafford Act declaration is not reimbursed by another federal department or agency.

VA’s role in homeland security and response to domestic emergencies was amplified further by Public Law 107-188, the Public Health Security and Bioterrorism Preparedness Response Act of 2002. That law reorganized the NDMS to combine federal and non-federal resources into a unified response and as an interagency partnership between HHS, the Department of Homeland Security, DOD, and VA. Through NDMS, VA serves as the principal medical care backup for DOD during and immediately following a period of war or a period of national emergency. Public Law 107-188 also requires VA to coordinate with HHS to maintain a stockpile of drugs, vaccines, medical devices, and other biological products and emergency supplies. To accomplish this part of its fourth mission, VA has established emergency pharmaceutical and medical supplies’ caches at 141 VAMCs. These stockpiles are intended to supply medications for several thousand casualties for up to two days. Unfortunately, a 2018 audit by the VA OIG found expired, missing, or excess drugs, or a combination thereof, at all 141 emergency caches. The OIG found that as a result “of ineffective management, the mission ready status of the caches was impaired.”

Also in 2002, Congress enacted Public Law 107- 287, the Department of Veterans Affairs Emergency Preparedness Act. This law directed VA to establish four emergency preparedness centers. These centers were intended to be responsible for research toward developing methods of detection, diagnosis, prevention, and treatment regarding the use of chemical, biological, or radiological threats to public health and safety. Although authorized by law at a funding level of $100 million, these centers did not receive funding and were never established.

Additionally, 2017’s hurricane season revealed a number of problems within the VA’s own emergency response protocols, as well as gaps in coordination between the VA and the rest of the Department of Homeland Security’s emergency preparedness and response system. VA resources and supplies were re-directed to the wider community response needs which stretched the VA’s capacity to serve both veterans and civilians. Failure by the VA to alert local pharmacies to its emergency prescription program led to confusion and inconsistent information given to veterans seeking to obtain needed medications. Incomplete address records held by the VA made locating veterans a challenge. Emergency shelters and intake processes failed to identify veterans so that those individuals could receive appropriate services from the VA. Many veterans with physical disabilities were unable to use emergency shelters because the structures did not comport with requirements for barrier free design.

The IBVSOs believe that the Administration must request, and Congress must appropriate, sufficient funds to ensure VA can meet its responsibilities as called for in Public Law 100-707, Public Law 107-188, and Public Law 107-287. Additionally, the IBVSOs continue to believe that these funds must be provided outside the medical services appropriation. VA has invested considerable resources to ensure it can support other government agencies when disasters occur. However, it is unclear whether the VA has received all necessary funding to fulfill its fourth mission. VA makes every effort to perform the duties assigned to it as part of the national emergency response system, but if dedicated funding is not provided, VA will be required to divert from the already strained resources it needs for direct health care programs.

Lastly, the IBVSOs also believe that Congress should undertake appropriate oversight to ensure that veterans and their families are taken into consideration within the context of the nation’s emergency management processes.

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American Indian and Alaska Native Veterans

Background and Justification

American Indians and Alaska Natives serve in the U.S. military at higher rates than any other race. While only making up 1 percent of the overall population, AI/AN make up 2 percent of the active duty personnel and 1.5 percent of the total veteran population. AI/AN veterans are more likely to have a service-connected disability and the highest unmet healthcare needs.[1] AI/AN veterans are the least likely to access their earned benefits and services through VA.

Despite the trust responsibility of the federal government to provide recognized tribal members’ health care, AI/AN experience the greatest health disparities in the United States.[2] For AI/AN veterans living in Indian country — reservations or tribal communities — they often face barriers to care that are unlike those faced by non-native veterans. AI/AN veterans are more likely to have an average household income of less than $10,000 — twice the rate of veterans in the general population living at this income level. Nearly 60 percent are unemployed.[3] Of the 27,500 miles of reservation road owned by the Department of Interior, only 7,100 is paved. These are some of the most unsafe road networks in the nation.[4] Only 25 percent of households on reservations have a vehicle. In many communities, there is limited, if any, access to the internet.[5] Without reliable means to travel to health care appointments or even access telehealth, AI/AN veterans continue to go without care.

For AI/AN veterans who are dually eligible for IHS and VA, confusion at the facility level regarding payment is a significant barrier. According to congressional testimony and media reports, AI/AN veterans have trouble accessing either IHS and VA and are often turned away by both. [6] For those who have accessed care but do not return, a negative experience —a culturally insensitive provider or lack of appropriate services — [7] is often the cause. In 2010, VA and IHS expanded upon a 2003 memorandum of understanding (MOU) to improve Native American veterans’ access to VA. Since 2010, VA has worked to build trusting relationships with tribes, expand telehealth services, and provide cultural competence training at VA. The VA Office of Tribal Government Relations (OTGR), established in 2011, is charged with overseeing tribal consultations and ensuring that VA understands the government-to-government relationships with tribes. The implementation of the MOU has been led by the VA Office of Rural Health, OTGR, and the IHS chief medical officer. As of 2018, AI/AN veterans have seen an increase in outreach from VA, improved quality, and coordination between the two federal health systems and tribal governments.

In 2012, VHA and IHS signed a reimbursement agreement allowing VA to reimburse for direct care services provided to eligible native veterans at all IHS sites across the country. Tribal health Programs (THP) enter into local reimbursement agreements with nearby VA medical centers. As of 2018, there are 104 signed local reimbursement agreements with IHS/THPs serving 9,253 veterans. VA has reimbursed IHS/THPs a total of $64 million for direct services provided to eligible AI/AN veterans. [8]

A difficult history between tribes and the federal government impacts VA’s legitimacy in tribal communities. VA must continue to work to build trust in these communities that have long been ignored.

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LGBT Veterans

Background and Justification

According to VHA’s Offices of Patient Care Services and Health Equity, an estimated one million LGBT veterans face unique challenges to accessing the quality health care they have earned through their service. As a result, LGBT veterans experience overall lower health statuses. LGBT individuals also experience mental health problems and death by suicide at a higher rate than their heterosexual counterparts. Other high- risk conditions for LGBT veterans include certain cancers, heart disease for gay and bisexual men, as well as intimate partner violence, obesity, and early death from cancer for lesbian and bisexual women. Older LGBT veterans are less likely to receive care from adult children and may experience discrimination in nursing homes or community living centers, or live in fear of such scenarios if their sexual orientation or gender identity is not publicly known. These health disparities also change and worsen for LGBT veterans who are also racial or ethnic minorities. Transgender veterans who are black have increased rates of alcohol abuse, congestive heart failure, HIV, serious mental illness, end-stage renal disease, and other illnesses when compared to white transgender veterans. Just as post-9/11 veterans face different health care challenges than those who served in the Korean War, and just as women veterans face different health care challenges than their male counterparts, LGBT veterans have specific, medically necessary needs that must be met.

Since VHA’s first directive for transgender veterans in 2011, the number of veterans enrolling in VHA who identify as transgender has been steadily increasing. To assure providers are able to deliver the highest quality of care to transgender veterans, VHA’s current Health Equity Action Plan (HEAP) was established in 2016 to undertake, advance, and achieve equitable health for all veterans who use VHA. The action plan has five key implementation focus areas which consist of (1) awareness, (2) leadership, (3) health system and life experience, (4) cultural and linguistic competency, and (5) data, research, and evaluation. Implementation focus areas (4) and (5) are the most important for IBVSOs in the 116th Congress.

To improve cultural competency, VHA must improve the diversity of its health-related workforce. While this recommendation was made in 2016 as part of HEAP, there is no current data available regarding VHA’s LGBT staffing numbers to note any areas of improvement in diversifying staff. The remaining recommendations are supportive of interactive learning, the inclusion of educational curriculum in training, and partnerships that yield the inclusion of cultural competency into training and activities. Yet, these recommendations have not been addressed in internal directives, such as VHA’s Directive 1341, Providing Health Care for Transgender and Intersex Veterans, which was established in 2018 and requires no formal training for VHA medical staff.

Some efforts to train staff have been made, and have resulted in minor improvements. For example, the employee education system, VHA TRAIN (Training Finder Real-time Affiliate-Integrated Network), has courses on the introduction to transgender veteran health care and mental health services available for them. Yet, there is little evidence that staff have availed themselves of these courses since 2016. In the meantime, the IBVSOs still hear from veterans using VHA about confusion surrounding questions of protocols for transgender veterans. While these courses are accredited and provide both certificates and credits for medical staff who complete them, more requirements, encouragement, and incentives must be provided.

As directed in VHA Directive 1341, VHA must assure the National LGBT Health Program positions are staffed. This includes the national program director position at the VA Central Office, every LGBT Veterans Integrated Service Networks (VISN) lead, and all LGBT veteran care coordinators.

VHA’s HEAP also calls for improving data availability and coordination, utilization, and diffusion of research and evaluation outcomes. Yet, the only National Veteran Health Equity report published in 2016 details VHA care for veterans receiving care in FY 2013. This is the most recent data available based on race/ethnicity, gender, age, geography, and mental health status. Having such minimal and outdated data makes identifying health inequities and systematic failures difficult for LGBT veterans who deserve and are entitled to the same quality of care that all veterans have earned through their service.

One area with timely data is VA pharmacies. Since 2012, when the U.S. Food and Drug Administration approved the first drug to reduce the risk of HIV infection in uninfected individuals who are at high risk of HIV infection, VA has annually increased the number of PrEP prescription rates. In FY 2018, VA pharmacies filled 84,425 30-day equivalent prescriptions at a cost of $76.1 million. While these prescription rates seem high, they are not nearly high enough for the current population estimates of LGBT veterans. This is why VA must work to conduct a strategic outreach campaign to educate LGBT veterans that PrEP is available at VA pharmacies.

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Rural Veterans’ Health Care

Background and Justification

Rural populations have difficulty accessing high- quality health care, but for veterans requiring specialized treatment for service-incurred disabilities or conditions, receiving needed care may be even more challenging. Rural populations are generally poorer, older, less likely to have health insurance, and more likely to describe their health status as worse than urban peers. More rural veterans (56 percent) are enrolled in the VA health care system compared to urban veterans (36 percent). Only a quarter of all veterans live in rural America, yet rural veterans constitute a third of all VA enrollees.

Health care providers cannot sustain operations in many rural areas of the country where the individual’s need may be great but the combined population does not have enough need for services to fully engage a health care clinic or provider. Rural populations often rely upon safety net providers — federally qualified health centers (FQHCs), rural health clinics, critical access hospitals, or other community resources — to address the needs of all community members. Indian Health Service and military treatment facilities also help fill rural health needs but follow stricter eligibility guidelines.

VA has 21 hospitals or medical centers located in rural areas. Community Based Outpatient Centers add another 350 points of access in rural settings. Still, access to health care for rural veterans is a problem, particularly as veterans age, become more disabled, or lose family caregivers. Transportation is one of the most pressing issues for rural veterans. Beneficiary travel funds reimburse eligible veterans for part of their travel expenses, but the reimbursement depends upon the veteran finding an able and available driver and vehicle. Some veterans are able to tap into VSO community resources for the aged and disabled to meet transportation needs but may require assistance in coordinating these services. The White River Junction VA Medical Center in Vermont may offer a model for meeting transportation needs. It has a transportation program that allows veterans to schedule van rides for medical appointments at VA facilities or care paid for by VA in the community. It uses vans with wheelchair lifts and employs drivers living in different parts of its catchment area to improve coverage. The program takes calls from about 200 veterans daily, demonstrating the tremendous need for such a program.

VA has used telehealth initiatives to reach rural populations, particularly for providing mental health care. Unfortunately, more than a third (36 percent) of rural veterans lack access to the internet at home, which further constrains VA’s ability to meet their needs. The web-based technologies that VA routinely uses to monitor and educate so many veterans cannot be used for them in their homes.

VHA’s Office of Rural Health (ORH) is charged with developing innovative approaches to addressing veterans’ needs and produces a national rural needs assessment. It also develops and funds rural promising practices to offer new models of rural care and provides training to rural health providers. ORH additionally collaborates with other VA programs and federal agencies to develop options for expanding veterans’ access to high-quality health care in rural communities.

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Black, Hispanic, or Latino, Asian, and Multiracial Veterans

Background and Justification

According to VA’s Office of Research and Development, health care is distributed unevenly in the United States. Minority populations often receive less care or care of lesser quality compared to their Caucasian peers.

The minority veteran population makes up 22 percent of all veterans and accounts for over 34 percent of the women veteran population. As the veteran population declines to an estimated 12.9 million by 2040, the minority veteran population is expected to increase from 23 to 24 percent during this time. Some of the health disparities faced by racial and ethnic minorities consist of chronic illnesses such as diabetes and high blood pressure, the highest rates of cancer, and increased diagnosis of mental illness.

There are no simple answers to these disparities. These disparities are prevalent across the entire American healthcare ecosystem and are still demonstrated within VHA, where many financial barriers to receiving care are minimized. With this in mind, VA and Congress are committed to providing veterans with high-quality care in an equitable manner. To do this, research must be conducted and analyzed on how to eliminate racial and ethnic disparities. Recent research found health disparities amongst racial and ethnic minority veterans for arthritis and pain management, cancer treatment, cardiovascular disease, diabetes, HIV and Hepatitis C, mental health and substance abuse, rehabilitative and palliative care, dental procedures, use of new medical technology, preventive and ambulatory care, and more.VA must also be able to conduct outreach to those who are not actively trying to obtain health care so they can be brought into the system for care. The need is evident as studies published by the American Journal of Public Health have found mortality rates are higher for black veterans.

Solving these health disparities will not come with a straightforward or simple solution. While access to health care is certainly a major piece of this puzzle, other factors – including income, life experiences, education, support, and social context are all components of why these disparities exist. VA will not be able to address racial and ethnic health disparities without a holistic approach.

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Veterans Justice Outreach Program

Background and Justification

VTCs were established in 2009 to offer eligible justice-involved veterans an alternative path diverted from incarceration, and into treatment. The program is modeled on adult drug courts. These have been found to be successful in diverting offenders from the judicial system into treatment, was designed to reduce recidivism, homelessness, and unemployment while helping veterans successfully integrate back into their communities. While these courts operate independently of VA, they are supported by the VAt’s VJO program. VJO specialists, primarily social workers, work directly with the courts and veteran enrollees to help to coordinate treatment for issues associated with their military service that may have contributed to their involvement with the justice system such as traumatic brain injury, mental health disorders, and/or substance abuse. VJO specialists also help veterans link to supportive services such as transportation, peer mentoring, specialized programs for combat and sexual trauma, and other federal benefits and services for which they may be eligible.

GAO issued a report (GAO 16-393) on VA’s VJO program. The report identified 261 full-time employee VJO specialists working within the Department in 2015 — with each medical center having at least one program specialist. The report noted the significant growth in the program over a three-year period, with VJO specialists providing services to about 46,500 veterans in FY 2015 —a 72 percent increase from FY 2012. Congress recently addressed the need for increased staffing for the programs by funding 50 new VJO specialists under Public Law 115-240, the Veterans Treatment Court Improvement Act of 2018. The law also requires a GAO study of VA’s court program effectiveness.

While VTCs may be effective, each case requires VJO specialists to monitor and report to the courts about the veteran’s progress with treatment over a 12-24 month period. Preliminary evidence suggests that getting justice-involved veterans into treatment can lead to positive outcomes for veteran participants.[1] To determine the overall success of the program, VA should work with the Department of Justice, Homeless Veterans Re- entry Programs, and veterans to establish specific objectives and performance measures that support the VJO programs’ broad strategic goals, and measure long-term outcomes for veterans. It would also be beneficial to identify best practices to ensure consistency and effectiveness of the VJO program at all VA sites.

The IBVSOs also recommend VA track the VJO program participants by gender and race to ensure that they are meeting the needs of all veterans. While women are a minority of justice-involved veterans compared to male veterans in the program, they are generally younger, more likely to have a service-connected disability, mental health needs, and are at higher risk of becoming homeless.[2] Women veterans frequently report histories of abusive relationships and military sexual trauma which may place them at a higher risk of post- traumatic stress disorder. Without data on gender, it is difficult to assess unique challenges or any potential differences in program access or outcomes for women veterans. The IBVSOs urge VA to collect program data and assess veteran outcomes by gender to ensure women veterans have equal access to this exceptional program and to determine if any adjustments in the program are necessary to effectively serve women veterans.

VJO specialists serve as the facilitator for veterans’ entry into VA’s Justice Outreach Treatment programs. They have little control over appropriate staffing levels and availability of treatment programs for VTC-eligible veterans, especially for placement in residential substance use disorder treatment facilities and securing housing for sexual offenders. Existing wait times for mental health care, particularly more intensive evidence-based treatment services at some VA facilities, indicate high demand for these specialized services. Growing demand for services and existing program challenges warrant increased resources to establish appropriate staffing levels that reflect demand for services and comfort with the ability of VJO specialists to carry out all their program duties.

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Eye Injuries Among OIF/OEF/OND Veterans

Background and Justification

Vision is a critical sense for optimal military performance in combat and support positions and is vulnerable to acute and chronic injury in those environments. One consequence of today’s battlefield conditions is that 14.9 percent of those who are evacuated due to wounds resulting from an improvised explosive device (IED) blast forces have penetrating eye injuries and traumatic brain injury (TBI)-related visual system dysfunction. Upwards of 75 percent of all TBI patients experience short- or long-term visual disorders (double vision, light sensitivity, inability to read print, and other cognitive impairments). With the continued presence of the U.S. in Afghanistan, as well as other global threats, such eye injuries will continue to be a challenge.[1] The VHA Office of Public Health has reported that for the period of October 2001 through June 30, 2015, the total number of Operation Iraqi Freedom (OIF)/Operation Enduring Freedom (OEF) veterans enrolled in VA with visual conditions was 211,350; including 21,513 retinal and choroid hemorrhage injuries (including retinal detachment); 5,293 optic nerve pathway disorders; 12,717 corneal conditions; and 27,880 with traumatic cataracts. The VA continues to see increased enrollment of this generation with various eye and vision disorders resulting from complications from frequent blast related injuries. [2]

VHA data also reveals rising numbers of OEF/OIF/ Operation New Dawn (OND)-era veterans with TBI Visually Impaired ICD-10 Codes enrolled in VHA for vision care. In FY 2013, the total number was reported to be 39,908. By FY 2015, that number increased to 66,968 with symptoms of visual disturbances enrolled for care. [3] With an increased number of service members in Iraq, Turkey, Afghanistan, and the war region, we expect this trend to continue. VHA Blind Rehabilitation Services (BRS) also provided BVA with information indicating that as of August 2, 2016, a total of 17,014 OEF/OIF/OND-era veterans have ICD- 10 diagnoses (Impairment codes) associated with visual impairment, low vision, or blindness. [4] VA peer-reviewed research also notes that among OEF/OIF/OND veterans diagnosed with eye conditions, upward of 75 percent of all TBI patients experienced short- or long-term visual dysfunction, including double vision, sensitivity to light, and inability to read print, among other cognitive problems. [5]

DOD’s Vision Research Program at Fort Detrick, Maryland, has studied the diagnosis, treatment, and mitigation of visual dysfunction associated with TBI in defense-related vision research, and has identified gaps in the ability to diagnose and treat visual impairments from blasts, along with inadequate treatments for eye-penetrating injuries, vision restoration, epidemiological studies on sight-injured patients, ocular diagnostics, vision rehabilitation strategies, computational models of combat-related ocular injuries, and vision care education and training.

The IBVSOs believe that the DOD Vision Research Program (VRP), existing within the Congressionally Directed Medical Research Programs (CDMRP), must be funded at $20 million in FY 2020 in order to meet the challenges presented by deployment- related eye injuries. We point out that in addition to the long-term implications such injuries have for vision health, productivity, and quality of life for veterans and their families, they also have a high financial impact on society. VRP funds two types of awards: (1) hypothesis-generating, which investigates the mechanisms of corneal and retinal protection, corneal healing, and visual dysfunction resulting from TBI, and (2) translational research, which facilitates development of critical diagnostics, treatments, and therapies that can be employed on the battlefield to save vision.

In 2012, the National Alliance for Eye and Vision Research released its first-ever Cost of Military Eye Injury and Blindness study. Based on published data from 2000–10 and recognizing a range of injuries from superficial to bilateral blindness, as well as visual dysfunction from TBI, it stated that the annual incident cost has been $2.3 billion, yielding a total cost to the economy over this time frame of $25.1 billion — a large portion of which is the present value of future costs such as VA and Social Security benefits, lost wages, vocational rehabilitation, and caregiver and family care benefits. Recently, John Hopkins University reviewed and updated this study to include all worldwide eye injuries and TBI vision disorders up through FY 2016. They found the total cost to the economy to be $40 billion, and also noted that the number of eye injuries and instances of TBI vision dysfunction are increasing.

The DOD/VA Vision Center of Excellence (VCE) officially transitioned to the Defense Health Agency from Navy BUMED on August 6, 2018. The transition had been planned for the better part of a year and involved both BUMED and DHA. The VCE was transferred whole, without a change in staff makeup (12 DOD and five VHA personnel) or positions. Col. Mark Reynolds, the director of Army Public Health and an Army ophthalmologist with a history of two combat deployments, was selected to lead the VCE and began August 6, 2018. He brings a strong background in ophthalmology, battlefield surgery, and epidemiology to the VCE. The IBVSOs are concerned about the continued level of operational funding and personnel assigned to the VCE under DHA, and we request congressional oversight by the Armed Services and Veterans’ Affairs committees. The Defense Veterans Eye Injury Vision Registry (DVEIVR) started in 2011 and now has 30,000 identified service members’ eye injury records. However, the DVEIVR has had challenges over the years related to the transfer of vital eye injury clinical records from VHA to the DVEIVR by VHA contractors. With the decision to implement the joint Cerner Electronic Health Record for DOD and VHA, the IBVSOs are concerned about the ability of not only the DVEIVR but all war related registries to have bidirectional ability to continue to operate during this transition period.

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Sections 504 and 508 of the Rehabilitation Act of 1973

Background and Justification

There are more than a million veterans in the U.S. who have diagnosed visual disabilities. Additionally, hundreds of VA employees and contractors who deliver programs and services to our nation’s veterans also have visual disabilities. Both groups must rely upon the VA’s IT infrastructure to make it possible for them to communicate with the VA. Section 508 of the Rehabilitation Act of 1973 directs federal agencies to insure that all electronic and information technologies developed, procured, maintained, or used in the federal environment provide equal access for federal employees and members of the public who have disabilities. VA employees and contractors, as well as veterans who have visual and other print reading disabilities, continue to face daunting challenges when attempting to utilize VA information technologies. The following compliance issues are areas of specific and ongoing concern:

• Inaccessible kiosks at VA Medical Centers, the use of which is required to check in for scheduled appointments.
• Inaccessible telehealth tools, namely the Health Buddy home monitoring station.
• VBA web pages containing eBenefits information that is presented in a manner that is not compatible with assistive technologies, such as screen readers, used by people with visual disabilities.
• The continuing accessibility barriers faced by VA employees with visual disabilities who are forced to use legacy systems that are largely incompatible with adaptive software to do their jobs.
• Inadequate staffing of the VA Office of Section 508 Compliance, to provide VA capacity to address internal and external accessibility issues in a timely manner.

The items listed above are representative of the barriers encountered by both internal and public users of VA’s information technologies. We believe that as VA’s effort to modernize its IT infrastructure moves forward, accessibility must be a consideration from inception through execution of all IT projects. Both financial and human capital resources are in short supply. The VA cannot afford to squander its resources by continuing the traditional agency practice of implementing inaccessible systems, then retrofitting later in order to make them accessible to intended users. We urge the House and Senate Committees on Veterans’ Affairs to conduct robust oversight of VA’s compliance with Section 508 of the Rehabilitation Act of 1973 as a key element of any assessment of the sustainability of VA’s IT infrastructure.

Furthermore, the IBVSOs urge the members of the Veterans’ Affairs Committees to hold VA accountable for adequately staffing their accessibility efforts. We urge VA to dedicate full-time employees to the Section 508 Compliance Office to insure its ability to provide timely responses to the agency’s accessibility requirements.

Section 504 of the Rehabilitation Act of 1973 also directs federal agencies to modify their activities, programs, and services to insure they communicate effectively with persons who have disabilities. The VA currently provides a vast amount of information to its employees and to the veterans served by the VA in non-electronic, hard copy print format. In many cases, this print material is intended for and distributed to individuals whom the VA knows cannot and will not be able to read it, because the recipient has a documented visual disability that is known to the VA and which prevents the individual from reading printed material. To date, the VA has made virtually no progress toward building its capacity to communicate effectively with individuals who have such print reading disabilities. This failure can be life threatening to a veteran who is given discharge instructions by VA medical personnel that he or she cannot read. Likewise, VA employees provided with memoranda in a format they cannot read may face consequences that seriously impact not only their own job performance, but the lives of the veterans the employee is supposed to serve.

As efforts get under way to re-design VA’s databases and other information collection and sharing technologies, we urge the VA to build into these upgrades the capability to provide information to visually impaired veterans, as well as employees who have visual disabilities, in alternate formats such as large print, audio recording, email, braille, or other formats, so that the information can be accessed independently by the individual who receives it.

IBVSOs believe there is no better time to establish policies and practices that would increase VA’s capacity to engage in effective, accessible communications with individuals who have print reading disabilities. We urge Congress to conduct robust oversight of the VA’s efforts to address this vital issue and hold VA accountable for the effectiveness of their communications with veterans, as well as the members of the VA workforce who have print reading disabilities that preclude their use of documents in standard print format.

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Health Care Endnotes

Timely and Comprehensive Mental Health Services

1. https://www.va.gov/oig/pubs/VAOIG-17-01846-316.pdf
2. https://www.vfw.org/media-and-events/latest-releases/archives/2015/9/vfw-report-veterans-prefer-va-care

Electronic Health Record Modernization (EHRM)

1. https://www.ehrm.va.gov/library/files/factsheets/EHRMFactsheet.pdf

Strategies for Ending Veteran Homelessness

1. https://www.hudexchange.info/resources/dpcuments/2017-AHAR-Part-1.pdf
2. Disabled American Veterans (2014). Women Veterans: The Long Journey Home.
3. https://www.blogs.va.gov/VAntage/53117/va-homless-programs-training-strengthen-efforts-lower-veterans-suicide-rate
4. Tsai, J., Rosenheck, R.A., Kasprow, W.J., Kane, V. (2015). Characteristics and use of Services Among Literally Homeless and Unstably Housed U.S. Veterans with Custody of Minor Children. Psychiatr. Serv. 66(10): 1083-1090.
5. The GPD program funds community agencies providing services to homeless veterans through grants that organizations may use to build or rehabilitate facilities for transitional housing and service centers, while the per-diem funds supportive services for homeless veterans.
6. The HUD-VASH program is a collaborative program whereby HUD provides rental assistance through public housing authorities in the form of vouchers for privately owned housing, while VA provides case management services to homeless veterans.
7. The SSVF program is a VA program that provides grants to community based programs to provide supportive services to very low-income veterans’ families who are at risk of losing stable housing or are transitioning to permanent housing.
8. The Health Care for Homeless Veterans (HCHV) program connects homeless veterans with VA health care and other needed services. This program also provides outreach and case management for special populations such as chronically homeless veterans with serious mental health and SUDs.

Spinal Cord Injury and Disorder (SCI/D) Care

1. VA, VHA, Spinal Cord Injury and Disorders System of Care, VHA Handbook 1176.01, February 2011, 36, http://www.va.gov/ vhapublications/ViewPublication.asp?pub_ID=2365.

Amyotrophic Lateral Sclerosis (ALS)

1. VA, Agent Orange Review 25, no.1 (July 2010), www.publichealth.va.gov/exposures/agentorange.

Reproductive and Sexual Health

1. PL 114-223, Sec. 260, www.congress.gov/bill/114th-congress/house-bill/5325/text.
2. 38 CFR 17.38(c)(2), https://www.law.cornell.edu/cfr/text/38/17.38.
3. 1074(c)(4)(A), Title 10, USC, “Policy for Assisted Reproductive Services for the Benefit of Seriously or Severely Ill/Injured (Category II or III) Active Duty Service Members,” April 3, 2012.
4. Beaulieu, G. R., Latini, D. M., Helmer, D. A., Powers-James, C., Houlette, C. and Kauth, M. R. (2015), “An Exploration of Returning Veterans’ Sexual Health Issues Using a Brief Self-Report Measure.” Sexual Medicine, 3: 287–294. doi:10.1002/ sm2.92.

American Indian and Alaska Native Veterans

1. U.S. Census Bureau, American Community Survey, Public Use Microdata Sample, 2010. Prepared by the National Center for Veterans Analysis and Statistics.
2. Indian Health Service Fact Sheet, https://www.ihs.gov/newsroom/factsheets/disparities/
3. National Congress of American Indians, November, 2013, http://files.ncai.org/broadcasts/2013/November/bb%20-%20 Veterans.pdf
4. Ibid.
5. Broken Promises: Evaluating the Native American Health Care System, U.S. Commission on Civil Rights (September 2004): 77-80; and Frequently Asked Questions about the Native Domain, Veterans Health Administration: Office of Rural Health, http://www.ruralhealth.va.gov/native/faqs.asp, accessed June 2, 2014.
6. VA and IHS: Further Action Needed to Collaborate on Providing Health Care to Native American Veterans, GAO-13-354 (Washington, D.C.: Apr. 26, 2013). Health Care Access: Improved Oversight, Accountability, and Prioritization Can Improve Access for Native American Veterans, GAO-14-489 (Washington, D.C.: June, 2014).
7. 20 percent of AI/AN people speak English as a second language. As AI/AN veterans age they often lose their English. VA providers are unlikely to have native language translators.
8. Department of Veterans Affairs, Office of Tribal Government Relations, 2017 Executive Summary Report

Black, Hispanic, or Latino, Asian, and Multiracial Veterans

1. https://www.ncbi.nlm.nih.gov/books/NBK49219/
2. https://www.healthaffairs.org/doi/10.1377/hlthaff.2017.0029
3. https://www.research.va.gov/programs/research-health-disparities.cfm
4. https://ajph.aphapublications.org/doi/full/10.2105/AJPH.2017.304246

Veterans Justice Outreach Program

1. Knudsen, K.J. and Wingenfeld, S. (2015). A Specialized Treatment Court for Veterans with Trauma Exposure: Implications for the Field. Community Mental Health Journal. Online. 15 February 2015.
2. Blue-Howells, J., Dunn, A., Caplan, J. Working with Justice Involved Female Veterans. July 10, 2017.

Eye Injuries Among OIF/OEF/OND Veterans

1. JRRD, Development of a Mild Traumatic Brain Injury-Specific Vision Screening Protocol; Volume 50, Number 6, pp. 757- 768 (2013).
2. VHA Data Source: VSSC OEF/OIF/OND Inpt & Outpt Encounters Cube.
3. VHA Data Source: VSSC OEF/OIF/OND Inpt & Outpt Encounters Cube.
4. VHA Data Source: VSSC OEF/OIF/OND Inpt & Outpt Encounters Cube.
5. JRRD, Development of a Mild Traumatic Brain Injury-Specific Vision Screening Protocol; Volume 50, Number 6, pp. 757- 768 (2013).

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