Veterans Affairs Committee on March 27th, 2012

[The Chair, Conservative, Greg Kerr]

The members of the official opposition are still involved in a ceremony for the outgoing acting leader of the NDP and they'll be here at some point shortly.

Given that we have four witnesses to hear from....

Oh, here they come. That's good.

I was just trying to stall here while you guys were coming.

We're ready to go.

I'd like to also point out that next Tuesday, after the RCMP do their presentation and we have the questions, we're going to take some time in the day to deal with some committee business. Please make note of that. It will come out in the notice as well.

There will be no meeting on the 5th because Thursday becomes Friday and there's no committee time available on Thursday. Those are in the House orders.

I'm delighted to continue with our study on the front-line health and well-being services for Canadian veterans.

I'm very pleased to have witnesses with us all the way from Washington.

You don't look that far away, folks. It's good to see you. Thank you very much for joining us from the United States Department of Veterans Affairs.

If you don't mind, I'm just going to read the names and titles.

First I have Margarita Cocker, deputy director, Vocational Rehabilitation and Employment Service, Veterans Benefits Administration.

We have Michael Fisher, program analyst, Readjustment Counseling Service, at the Vet Center.

We have Cheryl Flohr, acting deputy director, pre-discharge and retired pay programs, Veterans Benefits Administration.

And we have Joel Scholten, associate chief of staff, rehabilitation services, Washington D.C. Veterans Affairs Medical Center.

Thank you all for joining us. I know it took a little time to get it hooked up here, but we appreciate you taking the time today.

I understand that each of you has a separate presentation.

I know you've been talking to our clerk, who had indicated to you that we like to keep that within the 10-minute parameter if we can, and then we go to committee members for questions.

Since we're starting just a few minutes late, we're going to move right into that.

Whichever one of you wants to go first can, or did you have another sense of order?

[Cheryl Flohr, Acting Deputy Director, Pre-Discharge and Retired Pay Programs, Veterans Benefits Administration, United States Department of Veterans Affairs]

I think I'll go first, if that's all right.

[The Chair, Conservative, Greg Kerr]

It's your choice.

[Cheryl Flohr]

Mine kind of leads into the next one.

[The Chair, Conservative, Greg Kerr]

Okay.

Cheryl Flohr, acting deputy director, thank you for being here. Please commence.

[Cheryl Flohr]

It's my pleasure.

Good afternoon. I'm going to talk about our integrated disability evaluation system and give you a bit of an overview.

Prior to 2007, if a service member became wounded, ill, or injured during the course of active duty, the United States military would perform its own disability evaluation prior to the service member's separation from service. Subsequent to discharge from active duty, VA would accept the claim from the now veteran and basically re-adjudicate the disability. The veteran would have to undergo a new set of medical evaluations and a new disability rating by VA. It was a sequential process.

In 2007 we partnered with the defence department to integrate those two disability evaluation processes. It was a pilot in 2007, with three medical treatment facilities in the Washington, D.C., region. Based on the results of the pilot, we began expansion to all military treatment facilities during the course of 2011. As of the end of last fiscal year, September 2011, we have expanded this integrated disability evaluation system to 139 treatment facilities worldwide, and that covers 100% of the wounded, ill, and injured service member population. We anticipate an annual caseload of approximately 27,000 service members a year.

On the benefits of the combined or integrated program, as I mentioned, we combine a single disability examination process that is used by both the Department of Defence and VA. It's used by the Department of Defence to determine the service member's fitness for continued active duty, and it's used by VA to assign a disability rating percentage for all disabilities determined to be related to active military service.

The legacy sequential processes on average took about 540 days to complete. Our goal under the integrated process is to complete the process within 295 days. We are currently averaging 396 days on the integrated process.

In addition to combining the two disability evaluation processes, we offer other non-medical support to the wounded, ill, and injured service members. VA has military service coordinators assigned to the service members to help them with their transition from military to civilian life. We have vocational rehabilitation unemployment counsellors, which Margarita will discuss in more detail. We have Vet Center readjustment counsellors, which will also be discussed shortly.

We also have OIF/OEF case managers, who put injured service members and veterans in touch with other community resources; they research and provide access to other federal, local, and state programs that are available. These VA personnel work in coordination with other case managers assigned by the Department of Defense. VA also has a federal recovery care coordination program, and that assigns specialists to the most severely injured, wounded, and ill to provide one-on-one support to the service members and their families during transition, and after transition from military to civilian life.

Another benefit of the integrated process is that it introduces the active duty service member to the health care services available by VA prior to them actually becoming a veteran. They can establish primary care and register to be enrolled in the VA health care system while on active duty.

Finally, we have a transition assistance program that is available to every service member who is transitioning from military to civilian status. Transition assistance program, or TAP, is a partnership between the Departments of Defense, Labor, Homeland Security, and VA. Through TAP, we provide pre-separation counselling, VA benefits briefings, employment workshops, and medical support for those with disabilities.

For those service members with disabilities, we also have a disabled transition assistance program, or D-TAP, which is more focused on the vocational rehabilitation and employment services.

Pending your questions, that is all I have prepared in advance.

[The Chair, Conservative, Greg Kerr]

Thank you very much, Ms. Flohr.

We're going to hear from all four of you, and then we're going to go to the questions.

Would I be guessing right, if we're going in order, that Ms. Cocker would be next?

[Margarita Cocker, Deputy Director, Vocational Rehabilitation and Employment Service, Veterans Benefits Administration, United States Department of Veterans Affairs]

Yes, I am. Thank you.

Good afternoon. I'll be talking to you more about the vocational rehabilitation and employment program. The mission of our program is to provide the services needed to help service members and veterans with service-connected disabilities return to the workforce, or, if unable to return to the workforce, to help them become as independent as possible in their daily activities.

We provide this service through masters-level rehabilitation counsellors and employment coordinators who work in our field offices.

We have 57 regional offices and over 100 outbased offices, so that we have professional counsellors and employment coordinators in the communities where the veterans live.

I would like to go over four programs of services that our program administers, and then I'll go into more detail on one of them. The first of the four programs we administer is the chapter 31 program, which is vocational rehabilitation for individuals with service-connected disabilities. We also have a chapter 35 program, which is educational counselling for children and widows or spouses of veterans who have a permanent and total service-connected disability. We also have a chapter 36 program that we administer, which is educational and vocational counselling services for service members who are transitioning out of the military and for veterans who are eligible for an educational program. Then there is a chapter 18 program, which is vocational training and rehabilitation for children with spina bifida born to certain veterans who served in Vietnam or Korea.

I'm going to focus on what we call the chapter 31 program, which is the vocational rehabilitation employment program for veterans with disabilities and service members with disabilities.

First I'd like to talk about our coming home support program, which is our outreach program. There are multiple ways in which we perform outreach to ensure that our service members and veterans are aware of our program. We have a presence at medical hold facilities.

We are, as Ms. Flohr informed you earlier, going to be at the IDES locations, so we can be performing evaluations for group rehabilitation at the same time that the service members are going through their medical evaluation.

We also have OEF/OIF coordinators, who expedite services for the service members who are severely injured and exiting out of the military.

We also have a VetSuccess on campus program, which helps us talk about...[Technical difficulty—Editor]...positions of rehab counsellor at currently eight universities and colleges. They provide support to all veteran students who happen to be at those colleges, regardless of their eligibility for any VA benefits.

[The Chair, Conservative, Greg Kerr]

Excuse me for a second.

[Wladyslaw Lizon, Conservative, Mississauga East—Cooksville, ON]

Mr. Chair, I don't know if it's just me experiencing it, but it's quite distorted. I changed my earpiece. I don't know if this is only me or if other committee members are finding—

[The Chair, Conservative, Greg Kerr]

Is anybody else having trouble hearing?

No? Do you want to try a different—

[Wladyslaw Lizon, Conservative, Mississauga East—Cooksville, ON]

I actually did. I'll maybe switch this again. Okay.

[The Chair, Conservative, Greg Kerr]

Are we okay to proceed, then?

Sorry about that. I think we're having trouble with a couple of the earpieces here. Please, continue.

[Margarita Cocker]

Another way in which we perform outreach occurs when veterans are notified they have been awarded a service-connected disability rating by the VA. That notification is accompanied by an application for a vocational rehabilitation program, so veterans are immediately made aware of their eligibility for the program.

To be eligible for the program, active duty service members are expected to have a disability rated at 20% or higher and veterans are to have a disability already rated at 10% or higher. The entitlement for services extends up to 48 months and must be used within 12 years of the date of eligibility, but both of those can be extended and waived if the veteran or service member has a serious employment handicap or significant barriers to employment that must be overcome.

The process of benefits delivery includes the veteran or service member submitting an application, eligibility is determined, and then the veteran meets with a vocational rehabilitation counsellor to assess his or her vocational needs. That assessment includes testing of their interests, aptitudes, and abilities, and then looking at their vocational and educational history and determining their disability-related needs. Veterans who are not entitled to the program are referred to other community resources, such as state vocational rehabilitation organizations or Department of Labor programs.

We have five tracks to employment that can be provided and services within each track, depending on the veteran's unique needs.

The re-employment track is designed to help veterans who return from guard and reserves and are unable to return to their former employment. We help them to regain that previous employment, either with the same employer or with an alternate employer, and help to provide accommodation if they have disabilities.

The rapid access to employment track is for veterans who have the training and skills they need for employment but need help in bridging the gap from becoming a veteran to becoming an employed civilian. That includes assistance with developing a good resumé, transferring their military skills to civilian skills, learning interviewing skills, and helping to connect the veterans with employment opportunities.

The self-employment track is for individual veterans for whom self-employment is the most appropriate option, based on their disabilities, or who wish to pursue self-employment after completing a program of training with vocational rehabilitation employment.

The employment through the long-term services track, which is the most frequently used track, is for veterans with disabilities who can no longer perform the duties of occupations they used to be able to perform, so they need retraining in a new occupational category or a new skill to compete for employment that would be consistent with their disabilities, their interests, and their aptitudes. Through the long-term services track, we provide retraining at colleges, universities, on-the-job training locations, apprenticeship programs, and other such programs to enable the veteran to compete for employment.

The independent living program is for those veterans whose disabilities are so severe that they are unable to return to work at this time but need assistance to become more independent in their daily activities. We provide services to help them access the community, have complete access to their home, and have access to recreational activities or other daily living activities that they cannot access or cannot conduct because of the limitations of their disability; this prevents them from having to depend on others, such as family members, to conduct those daily living activities.

At the end of the program, when the veteran becomes employed in a suitable occupation, meaning that it's consistent with their interests, aptitudes, and abilities, the voc-rehab counsellor and employment coordinator ensure the stability of that employment for at least 60 days, but up to 18 months if necessary, to ensure they no longer need our services to continue that stable employment.

I will add some information about the types of results that our program produces. Most of the occupations that veterans are rehabilitated in are in the professional, technical, and managerial occupations, which speaks to the fact that they come to us a lot with managerial and leadership skills from their military occupations. We also have a smaller percentage that are in clerical services, machine trades, and structural trades.

Primarily, though, because our program is a career-focused program and not just about entry-level employment, most of the occupations are in the professional, managerial, or technical trades.

We rehabilitate approximately 10,000 veterans per year. At any given time, we have over 100,000 veterans who are at any stage in the process, including those who are in the applicant phase awaiting an eligibility determination.

That concludes my prepared statement. I'll take any questions.

[The Chair, Conservative, Greg Kerr]

Thank you very much, Ms. Cocker. We appreciate that.

Moving along, I assume you'll be next, Mr. Fisher.

[Michael Fisher, Program Analyst, Readjustment Counseling Service, Vet Center, United States Department of Veterans Affairs]

Thank you for allowing us to present.

My name is Mike Fisher, and I'm going to talk about the Vet Center program.

The Vet Center program is a community-based program within the Veterans Health Administration of VA. It provides readjustment counselling to anyone who's served in a combat zone and anyone who's experienced a military sexual trauma or harassment, as well as bereavement counselling.

Our program actually started in the late seventies, early eighties, as a place for the Vietnam combat veteran to go to speak with their fellow combat veterans. We've actually blossomed: today we have more formalized counselling, with social workers, psychologists, etc., providing readjustment counselling. But we've always held true to the veteran-to-veteran connection that we started from. A majority of our staff are combat veterans as well as veterans of other eras.

Our program is a little different from most programs within the VA in that, as I said before, we're community-based. There are approximately now 300 Vet Center locations across the country. We're in all 50 states, the District of Columbia, Puerto Rico, and Guam.

The other difference in our program is that family members—that's really whoever the veteran decides their family to be—can come and use our services. We do individual, group, marriage, and family counselling. Many of our locations have employment representatives, whether from the state or other community partners, to come in and help out with employment issues. We also have veterans service officers or other individuals within the VBA to come in and help out with benefit-related issues.

So it really becomes a one-stop shop for the veteran to come in and deal with whatever they want to talk about.

I mentioned before that we also do military sexual trauma, and we also have a bereavement program. Our bereavement program is for the family members of anyone who has experienced an active duty death. That can be in a war zone or in training; it doesn't matter where the death happens, just as long as the individual was on active duty.

We have a couple of niches within our program. Since 2003 the Secretary of VA authorized 100 outreach workers to go out and proactively provide information and referral to their fellow combat veterans. These are Iraq or Afghanistan outreach workers. We go out to federal, state, or locally sponsored veterans events and really provide information and early access to Vet Center services as well as VA services.

In the packet that you have been provided with, you'll see a couple of pages with pictures of our outreach workers. The great part about our outreach program is that many of the people who come into the outreach program come in, start doing their job, enjoy the work, and actually end up going back for their advanced degree.

One of the individuals here, Hector Delgado, is actually working on his master's in social work. He's going to become a next-generation counsellor at the Vet Center program, opening up that outreach spot where we can bring in a new combat veteran and then continue the process.

Another initiative we have just started is our combat call centre. The number is 877-WAR-VETS. This is a 24/7 call centre that's actually based out of Denver, Colorado. It allows combat veterans and their families to call in and talk about their military experience or transition from military to civilian life. The call centre is actually staffed by combat veterans of all eras as well as family members of combat veterans. It's really a safe and confidential space for them to come in and just talk with somebody.

We do have a mobile Vet Center program, and we've just increased the fleet to 70 vehicles. These vehicles are really designed to take Vet Center services and outreach to wherever the veterans or service members are. Their primary missions are to provide early access to returning service members and their families at demobilization events and going to military bases. We also provide outreach and Vet Center services to those who are geographically distant from existing services. There's also an emergency service component to that.

The vehicles themselves are large motor vehicles. They actually have space inside for confidential counselling. We have two sizes. A large vehicle has two counselling rooms; our more streamlined size has one counselling space in there. That space can actually be reconfigured to bring in litters so that when a national disaster happens, we can provide services through that.

The vehicles also have encrypted satellite technology, where we can access, in the encrypted environment, all VA systems of records. When we go on outreach events, we actually like to bring all the VA with us, whether it's representatives from VBA or the medical centres, and we can do active enrollments; we can have people access their medical records through our encrypted system.

I'd like to leave with one last point, which is in regard to our confidentiality. The Vet Center program actually maintains a separate system of records, different from the VA medical centre records as well as the VBA records. Access into those record systems is really only through the informed consent or a signed release of information from the veteran, unless it's in situations to avoid a crisis, where the individual has the potential to harm themselves or somebody else. It is really giving controlled ownership of the counselling record of the Vet Center to the veteran.

Once again, thank you for your time. We will be available to answer any questions.

[The Chair, Conservative, Greg Kerr]

Thank you very much, Mr. Fisher. I'm sure there will be lots of questions coming.

Last, but certainly not least, we will turn to Mr. Scholten for his presentation.

[Dr. Joel Scholten, Associate Chief of Staff, Rehabilitation Services, Washington DC Veterans Affairs Medical Center, United States Department of Veterans Affairs]

Good afternoon. Thank you for inviting us today.

I am here to represent the medical centre side of the house. I'm a physiatrist, or a rehabilitation physician, at the Washington DC VA Medical Center. I will be talking briefly about some of our rehabilitation outreach efforts, our mental health services, and some of the transition services through the OEF/OIF/OND program.

To start with our rehabilitation system of care, following the onset of the wars in Afghanistan and Iraq, we started to see severely injured service members entering our system with severe traumatic brain injuries and multiple other injuries. The term “polytrauma” was coined to define these new, unique, complex patterns of injuries. Typically, with polytrauma, a service member has experienced a traumatic brain injury, which really drives or defines how the rehabilitation care is provided. Within our system, the VA is able to offer rehabilitative care for injured active duty service members through a memorandum of agreement with the Department of Defense. That has been in place since 1988. This was put in place specifically to provide traumatic brain injuries, spinal cord injury, and rehabilitation care for blinded service members.

That referral system was in place, and the system of care has matured as the conflicts have continued. It has now expanded to involve more outpatient care. The polytrauma system of care now includes over 100 specialized rehabilitation sites and teams across the country. The hallmark of our rehabilitation programs is that of an individualized, interdisciplinary plan of care for each veteran and active duty service member, and then to provide advanced rehab practices and equipment by linking specialized centres with centres and clinics throughout the country.

Our polytrauma system of care is a four-tiered system of care. The polytrauma rehab centres provide the acute in-patient rehabilitation care for the most seriously injured. We have polytrauma network sites at every one of the VA's regional organizations—our veterans integrated service networks—that provide both post-acute rehabilitation as well as outpatient rehabilitation. We have an additional 86 designated polytrauma support clinic teams that provide care throughout the system. This totals over 109 designated teams throughout the VA system of care. At every medical centre that does not have a fully designated team, there is an identified point of contact so that service members and veterans in need of care can be linked to the most appropriate and the closest area for care.

There is a map of the United States in my handout that shows all the locations for care. You can see this mirrors the population of the United States, so there is a higher concentration along with the higher density of population on the east coast.

We have a full continuum of specialized rehabilitation programs, including transitional rehab programs for those individuals who are independent with their activities of daily living but still need some assistance with wholly reintegrating back into the community. We have a defined emerging consciousness program for those individuals with severe traumatic brain injury who are either in a coma or vegetative state. We have a telehealth network that links all of our TBI teams across the country. We have an assisted technology program that provides specialized expertise that can assist in the rehab of severely injured individuals. We have driver's training programs. We have an entire amputation system of care that mirrors the polytrauma system of care. In addition, we have a blind rehab system of care. Finally, we have a mild TBI screening and evaluation program, which was put in place in April 2007.

Every service member who has left the Department of Defense with a separation date after September 11, 2001, is triggered for a traumatic brain injury screen and the electronic medical record. This is a four-question screen. If they answer yes to all of the questions, they are considered to have a possible traumatic brain injury, and then they are referred for a comprehensive in-person evaluation.

Since April 2007 we have screened more than 600,000 veterans. Approximately 20% will screen positive, and of those who complete an evaluation, about half will be diagnosed with having sustained a mild traumatic brain injury or a concussion. That equates to about 7.8% of the entire population that's screened. This is not a true epidemiologic study, but we have about 7.8% who wind up with a diagnosis of traumatic brain injury. Those who do receive a diagnosis are then referred to a team and receive an individualized interdisciplinary plan of care to meet their rehab needs.

Next I'd like to talk a bit about care management and our OEF/OIF/OND program. The goals of that program are to connect early with our newest veterans and to support reintegration into the home and community. As was mentioned before, this program tries to link individuals not only with VA services that are available but also with local resources in the community. They assist in identifying and addressing risk factors. Again, in our electronic medical record there's automated screening that is put in place: questions regarding high-risk psychosocial issues; questions about post-traumatic stress disorder, depression, and alcohol abuse; traumatic brain injury screening, as I mentioned before; and all veterans are also screened for military sexual trauma.

This care management team helps with the transition from DOD to VA. The partnership began in August 2003 and is present at all medical centres across the system. In addition, the VA has 33 liaisons who are either social workers or nurses who are embedded at military treatment facilities across the country.

There is additional care management and coordination between the Department of Defense and the VA. The VA has a new caregiver support program looking at the needs of the caregivers and families of wounded and seriously injured veterans. This program provides education on the caregiver support program and the role of our caregiver support coordinators. They help to collaborate with military case managers to identify potentially eligible service members and caregivers and then assist them with the application process.

Now I'd like to briefly cover some of the VA's mental health services. You can see that this table shows some data from 2005 to 2011. The total number of users of VA health care has increased over time, and so has the percentage of that population accessing VA for care who have received specialized mental health services. In fiscal year 2011, 25% of service users received specialized mental health services in the VA care.

We have multiple programs to promote access to mental health care. Those programs with a special mental health focus include our inTransition program that's run in tandem with the Department of Defense. We have VA's national awareness mental health campaign, which is called Make the Connection. We have a suicide prevention national awareness campaign, and we have a post-traumatic stress disorder coach mobile application that's available for Apple and Android phones. In addition, we have extensive automatic screening for various mental health issues: PTSD, depression, problems with alcohol use, and military sexual trauma.

There are multiple areas of specialty mental health services within the VA, including specialty outpatient clinics for PTSD care teams and substance use disorder teams. The VA has multiple residential rehabilitation treatment programs to help that population that has extensive comorbid diagnoses that expand across the mental health spectrum. We also have in-patient mental health care for those who are at risk to themselves or to others, and the hallmark of that care includes interdisciplinary team care as well.

Mental health is integrated at various sites throughout the VA. The most important is probably at the level of the primary care team, with primary care and behavioural health embedded within our patient-aligned care teams.

Within the rehabilitation spectrum of care, there are mental health professionals embedded on the polytrauma units, on our spinal cord injury units, and in our blindness rehabilitation centres of care.

This concludes my prepared remarks. I think we'll all be happy to move to questions right now.

[The Chair, Conservative, Greg Kerr]

Thank you very much, Mr. Scholten.

I want to thank you all. That's a lot of information.

In our process here, each of the questioners whom you'll hear from has five minutes for questions and answers. We start with the official opposition, then go to the government, and then go to the other party.

At this point we're going to start with a five-minute round.

It's nice to see you again, Mr. Stoffer.

[Peter Stoffer, NDP, Sackville—Eastern Shore, NS]

Ladies and gentlemen, thank you very much for appearing before us today.

Margarita, if may I call you by your first name—I think it's a great first name, by the way—you indicated that a 20% disability is what you need to achieve some sort of benefit.

Who determines the 20% level?

[Margarita Cocker]

That is determined by the disability evaluation in the compensation service department of the Veterans Benefits Administration, which Cheryl Flohr was speaking about.

[Peter Stoffer, NDP, Sackville—Eastern Shore, NS]

If a veteran disagrees—say they were only evaluated at 10% or 15%—is there an appeal process they can go through?

[Cheryl Flohr]

There is. A veteran can appeal any decision rendered by the Veterans Benefits Administration. They have one year in which to do so.

[Peter Stoffer, NDP, Sackville—Eastern Shore, NS]

How long does that appeal process normally take?

[Cheryl Flohr]

I don't have the data at present. I know it takes in excess of 600 days to revolve.