Thursday, June 04, 2009

Barack and the world's blue . . .





"Let me begin by asking you to think about what it took for each of you to get prepared for the day today," Anna Frese of Wounded Warrior Project declared. "I'm not talking about the first cup of coffee or your morning paper. I'm asking you to think about more basic activities. Raising your arm to reach for a bedside light switch. Moving a finger to wipe the sleep from your eyes. Getting out of bed, walking to the bathroom. While most of us take this for granted, severely injured service members, like my brother Eric [Edmundson], can no longer carry out these basic activities of daily living without assistance. Eric and other severely wounded warriors get the most intimate, devoted care from family members in the privacy of their homes, twenty four hours a day, seven days a week, 365 days a year."

Anna Frese was addressing the US House Veterans Affairs Subcommittee on Health this morning in a hearing entitled "Meeting the Needs of Family Caregivers of Veterans." She explained how her father and her brother are a team in his care and wellness and how "Eric relies on Dad to assist him in everything, and Dad does it with pride and great respect. But there is an unseen price. Our father, now 54 years old, is no longer employed and has used up his retirement funds and savings, no longer has health insurance and has not contributed to Social Security in almost four years. Even though his future has been drastically altered, he tells me often, 'Eric would do it for me'."

Frese was on the first panel as was Ret. Commander Rene A. Campos of Military Officers Association of America who read a letter from the father of a veteran injured in 2007 during part of her testimony, "All the army ever wanted was a soldier. The army got it. All we want is a little help. We got excellent care at the military treatment facility but we had to fight to get our son in private care and take him home. There are so many problems with the VA bureaucracy. We were lucky to know the system but so many other families are struggling."

US House Rep Michael Michaud chaired the subcommittee and noted that the hearing was a way of "exploring ways to better help the family caregivers of our veterans." Dr. Barbara Cohoon of the National Military Family Association noted that family caregivers are an integral part of the recovery.

Cohoon, Campos and Frese made up the first panel. Prepared opening statements for this hearing can be found here. (Individual links did not work in yesterday's snapshot. My apologies. So we'll just note the main page for the statements.)

Chair Mike Michaud: My first question is, we've talked about financial compensation for family caregivers so my question is, to all three, what do you think that compensation should be financially? Commander?

Rene Campos: I couldn't speak to a dollar value but, as I mentioned and as Barbara talked about, this needs to be addressed at the very beginning, at the time of injury and we have to recognize that, I don't believe, one system will fit all, that these situations are going to change over time, that the needs of families are going to change and the service member and the veteran. I -- I look at trying to get DoD and VA to work closer together, than recognizing that these families are -- are getting quite a bit of support and immediate care at the time of injury and they're pretty much in a cocoon. So when they transition into the VA system it needs to be easier for them and not try to guess all over again where to start and that's why in terms of compensation, we want to see DoD and VA work together to build a package that is -- because these folks will be going back into the DoD system and they'll be trans-trans, uhm, transitioning between the systems at several times throughout their longer term care. So I can't give you a dollar value or specifically but we should make sure that it is a package that will meet the needs of veterans, of the family, of the wounded, as they transition over their life.

Chair Mike Michaud: Doctor?

Dr. Barbara Cahoon: Our association has really proposed as far as two different types of payment -- one as far as the non-medical care and the other as far as the medical care which would be more of your hands-on. And the reason for that is that we do find caregivers are really providing two different roles and depending upon the type of injury and also the cycle of the recovery or where they are in the recovery phase kind of determines how much involvement that they're doing. If someone has a severe or a moderate TBI but, other than that, is functional as far as being able to get around then the caregiver is more involved in what you would call non-medical care -- they're making the doctors' appointments, they're making sure they are getting to where they need to go, they're actually maybe looking on their Blackberry and following a GPS to make sure they made it to Walter Reed or to Bethesda or to where ever and they're making sure that they do go home. So there's a lot of non-medical care that go on. So we're looking more at that to be kind of a range but basically a kind of an amount that's given each month. And as far as the medical care? We're looking more at what that would be as far as hands-on, similar to nursing care that would be given -- especially if someone was -- had a spinal injury and basically was from the waist down needed certain types of care, you're turning them in the bed. You're actually physically giving them medication. Those types of things. And there are systems in place now where that's actually then, you know, compensated hourly. So that's -- we're kind of looking at those two different pieces. But also too, as far as the care that they're giving, as far as providing them, they also have lost significant amount of money as far as walking away from the current job that they are. So there's two different financial impacts going on at the same time.

Chair Mike Michaud: Thank you. Ms. Frese?

Anna Frese: That's a good question. Uh -- let me work with the number that we do know. The cost per day for in-house VA nursing home care for next year is projected to rise to $887.33. Per day. We can then get an annual cost of $324,000. And while I don't want to guesstimate the cost of what enacting the caregiver legislation would be I can comfortably express with confidence that the failure to provide such support increase the risk that veterans would have to be institutionalized and those costs are clearly far in excess of the relatively modest cost of caregiver assistance would be.

Chair Mike Michaud: Thank you my next question, I know some of you have answered this in your opening statements, but if all three of you could just address if we were to pass legislation what are the -- would we put in the legislation? The three most important components of offering a caregiver program, what would the three most top priority parts be? Anna? And I know you've talked about some during your opening testimony but not knowing what we'll be able to get through the House and through the Senate, if we had to pick three, what would the three top priorities be? Ms. Frese?

Anna Frese: As we spoke about earlier, each family, each circumstance, family dynamics of each family is so drastically different. From what I hear from families and from our own experience, the health care especially for the parents who are caring and those who are not a spouse and not covered under that health care, they need some form of health care to take care of their own health so they can actually be around and continue to care for the veteran. And also it comes back to the economic support as well. The time spent worrying about how they're going to continue living and paying for their needs. You spend more time focusing on the worrying than actually -- you want to be able to focus your time, your strength and your full ability on your veteran rather than worrying. The health care piece, the income and the mental health to help sustain the long term ability of the care giver.

Rene Campos: As I mentioned, we're concerned about adding more programs or adding more layers onto already complicated bureaucracies. We go back to the need for and establishing some sort of permanent office or seamless transition agency of some kind and, again, I -- I -- if it's extending the current SOC [Joint DoD-VA Senior Oversight Committee] out or whatever, we need some good solid oversight that doesn't change when the administration changes -- So we need the continuity of the leadership and oversight of programs. So I think that's critical to whatever we do. The other thing we need to do is that we have, again, a reciprocal program for caregivers that includes both the medical and the non-medical aspects. Because, again, these families that have been on active duty, have child care, they have a lot of other family support, non-medical support services that are there. So they should have a package that they can expect that would also help transition over into the VA system. And then finally we go back to at the time of injury, they really need an advocate. They need someone that can walk them through all these different things that are going to be happening to them over, in some cases, the course of their life. So we think there needs to be an advocacy program of some kind that's set up. I think the quality of life foundation report I mentioned is a good starting point.

Dr. Barbara Cohoon: First of all this needs to start upstream, as I mentioned before, while they're still active duty if you're going to do anything as far as the caregiver. One of the conversations we recently had with Secretary [of Veterans Affairs Eric] Shinseki is that -- If the care-giver's not taken care upstream, by the time he gets them, in their veteran status, they're either burnt out or they're so frustrated with the system that they may stop being a caregiver and then everyone loses -- especially the family. So this really needs to make sure -- we want to make sure that this actually starts upstream while the service member is still active duty. The other piece is that we have to remember that the caregiver well being is directly linked to the veterans' care, well being. So if the care-giver's taken care of, we know that the veterans' taken care of and vice versa. And so ways in which we can help the caregiver is we can recognize that the role that they're playing is important and then the pieces that they are providing also need to be recognized and how we go about recognizing that can be done in lots of different ways. We talked about the compensation as far as financial, we also realize that they have walked away from a lot of different things. They lose their health care, they lose their ability as far as to maintain a retirement or even lose their retirement. We also need to make sure that they have respite care, those types of pieces. So we need to make -- we're looking at the well being of the caregiver as one of those packages you talked about. The other is the caregiver also needs to maintain a purpose in life -- not only as far as taking care of the veteran but also as far as them personally. And also remember that what surrounds them is their family. It may not be Mom or Dad, it may be their sister or brother. Or if it's Mom or Dad that's doing that, they have other children that they're taking care of or maybe a father that they're also taking care of so that the family unit itself is in a delicate balance so whatever you provide the caregiver effects everyone else.

US House Rep Henry Brown (Ranking Member) raised issues of payment and should it go to the primary care-giver. Dr. Cohoon explained why that was necessary and also addressed how more than one person in the family could be trained in the care-giving but one person would be doing it. She also noted that at some point in the process, someone steps forward and that person becomes the primary care-giver. An important point and one that does conflict with the aim to appoint a care-giver before someone is wounded -- a point she seemed not to grasp or to ignore. A service member, not injured, picking someone as their primary care-giver may fill a blank on a piece of paper but it's a lot more complicated than listing someone as a primary contact should you be injured or killed. There are people who think they can be it and then, exposed to the realities, can't. There are people who think they can do it and in injury comes when they're pregnant or some other health issue has arisen. A service member designating a primary care-giver before deploying would only fill a blank on a piece of paper, it would not really answer anything.

US House Rep Henry Brown would return to the issue of payment during the third panel where you saw government workers from the VA (administrators) pretend they worked for their tax dollars and pretend that progress was being made. How little they are doing (how slowly they are dragging their feet) would emerge slowly. But first Brown hoped he found a roll dog the Dept Under Secretary of Defense Office of Transition Policy and Care Coordination Noel Koch. But first Koch needed to know if he was being asked a question. Then Koch needed Brown to repeat the question because, Brown apparently, hadn't been paying attention. Brown actually had to repeat the question and then he had to explain it. And having to ask the question twice -- the second time at Brown's request -- it does not build confidnece in the VA that their Deputy cannot grasp the basic formulation of words into a question. After Brown explained it (after asking it twice), Koch took a stab at it.

Noel Koch: This is -- this is -- this is a somewhat complicated issue here the question of who is the receipiant of the support is -- is -- is the issue. And there's a point beyond which we can't control how families function so, in some cases, the concern is the money goes to the -- to the family and the family spends it and it's not spent on care and it's not spent on the purpose that it's been provided for. Suggestions that we provide it straight to the service member raise some of the same concerns so this is just -- it's not something -- there's a point beyond which we can't manage the way human beings conduct their lives. I mean, everybody has a sugestion and usually that suggestion is a function of some personal experience or something they're familiar with . . .

And on and on he went. Did he understand the question? If so, his simple answer was, "Different people would feel differently about payment methods." Equally true is he could have pointed to Brown that anyone wrongly using monies that resulted in a veteran not getting care would be subject to prosecution for abuse and neglect. In fairness to Koch, Brown's question may have been so confusing because the monies being discussed in the hearing were not the veterans' benefits. The hearing was about payments to care-givers for the work that care-givers do.

Brown then raised that the services were said to be hard to follow, "We've heard testimony that access to resources and information for family care-givers is highly variable and there's not any standardized and ongoing training of any formal support network. How would you respond to those concerns?" That question was directed at Dr. Madhulika Agarwal who is with the VA and is the Chief Officer of Patient Care Services. Grasp the title and prepare to be frightened. Agarwal strung a lot of words together which said nothing. She ate up time and thought she'd done a great deal of it.

Dr. Madhulika Agarwal: Um. Thank you for the question, sir. Um. [Plays with mike. The same one she was using for her opening statement just minutes prior. But it ate up a second or two of time.] We certainly are making efforts in doing better outreach about our programs. We've had an initiative known as the Combat Call Center Initiative which was instituted by Secretary [James] Peake last year which reached out to about 1600 veterans who were identified in the seriously ill category during the transition process and were given information on our current program -- particularly about the care management -- case management programs and other services and also offered services at that time. The Federal Recovery Program, again, for the seriously injured veterans . . . this resource . . . has been . . . really . . . I think amplifying in helping us with . . . navigating between the VA, the DoD as well as the private sector. They have a resource directory. Which I think is a useful resource for the care-givers and the families. We have a set of liasons in the military treatment facilities and a case management system which is very knowledgable about the programs that we offer uhm. And we are working to improve and align our outreach through the internet, intranet and MyHealth.web.

Once she mentions Peake's name, she is reading from a piece of paper in front of her, it should be noted. That's shameful. In her position, she should damn well know what the VA offers. Someone should have asked that, someone should have said, "Doctor, are you unable to answer this basic question about what the VA provides without stealing long glances at your crib sheet?" Her little cheat sheet didn't even help her. It's the "Combat Veteran Call Center" -- not the "Combat Call Center." In addition, that wasn't a test program. In May of last year, that was a program. It's supposed to be up and fully running. The VA contracted to EDS who predicted in May of 2008 that the first six months (starting May 1, 2008) would see the Combat Veteran Call Center assisting "nearly 570,000 recent war time veterans." 16,000? 17,000 was the initial focus but by month six, 570,00 veterans were supposed to be served and if they weren't, the EDS didn't do the job they promised and the VA didn't provide the oversight they were supposed to. Now she should have been asked that but Little Debbie got to close up the questions so American veterans and their families suffered. The doctor was an idiot and anyone who needs a cheat sheet and still can't get the facts right doesn't just need to be left behind a grade they need to be expelled. There is no oversight at the VA when it comes to the administrators and, until there is, there will be very little improvement for veterans and their families.

Brown seemed confused by the doctor's wordy non-answer (it was confusing) and attempted to give her the benefit of the doubt.

US House Rep Henry Brown: So you basically have a website that has these services which are available --

Dr. Madhulika Agarwal (overlapping): We're currently working on that

US House Rep Henry Brown: -- and how to get those resources?

Dr. Madhulika Agarwal: We are working on it, sir. It's in -- it's in development phase.

Well Agarwal, the Iraq War is not in the "development phase" so when does the VA plan to get off its ass and gets its act together? Hmm. A website of resources. They're developing it. They're in that phase. The obvious follow up was: "What is the timeline for this project? When is this website scheduled to be up and running?" Again, the committee passed to Little Debbie Halvorson. All the thought Little Debbie put into the day took place in the morning when selecting that very bad outfit (was the necklace a faucet?) with the plunging neckline.

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