16 National Center and on the VA's capability and capacity to provide PTSD diagnosis and treatment. 6. Require a report by September 30, 1985, on VA efforts, in both its hospice and other programs, to provide palliative care, supportive counseling, and other medical services to terminally ill veterans and supportive counseling to their family members. 7. Specify that veterans eligible for adaptive equipment for their automobiles are entitled to a maximum of two such adaptions at any one time or within a 4-year period unless, as a result of circumstances beyond the veteran's control, the veteran no longer has use of one of these two vehicles, in which case the Administrator would be authorized to provide the veteran with an adaptation for a third vehicle. 8. Expand the definition of the Vietnam era for the purposes of title 38, United States Code, to include the period beginning on February 21, 1961, and ending on August 4, 1964, in the case of those who served in Vietnam during that time. 9. Require the Administrator, not later than April 1, 1987, to assess and report on the need for readjustment colunseling among veterans and active-duty personnel who served during World War II or the Korean conflict (particularly those who were in combat), who are former prisoners of war, and who served after the end of the Vietnam era in combat or combatlike situations. 10. Require the Administrator and the Secretary of Defense to submit a joint report, within 180 days after enactment, on (A) the appropriateness and desirability of extending eligibility for VA readjustment counseling to active-duty personnel who either served during the Vietnam era or served at a later time in combat or combat-like situations, and (B) on how, if eligibility were extended to these personnel, the VA and the Department of Defense would arrange for VA services to be provided, including how the VA would be reimbursed, and how VA and DOD would publicize the availability of services. 11. Improve and clarify the VA's authority to provide security on VA property through a force of VA security officers by mandating the issuance of regulations relating to security matters, authorizing a special uniform allowance for certain VA security service officers, and authorizing the Administrator, when and to the extent necessary for recruitment and retention purposes, to adjust the rates of pay of VA security service officers on a geographical or national basis. 12. Modify the due date of a recurring report to the Congress from the Comptroller General on the compliance of the Director of the Office of Management and Budget with certain statutory requirements relating to funded personnel ceilings for VA health-care personnel. 13. Require the Administrator and the Secretaries of Defense and of Health and Human Services, within 180 days after enactment, to submit a joint report on the question of U.S. Government responsibility for providing benefits for disabilities which may be related to exposure to dioxin or to traumatic events for individuals who were present in Vietnam for at 17 least 30 days as employees of voluntary organizations and, to the extent any such responsibility is identified, on how Federal or other benefits should be provided. 14. Extend for 1 year, through fiscal year 1985, the VA's authority to provide certain contract health-care services to veterans in Puerto Rico and the Virgin Islands. 15. Require the VA to conduct a 39-month demonstration project and submit by February 1, 1987, a report on the first 2 years experience-under which the income received by veterans for their participation in VA incentive and compensated work therapy programs would not be counted as income for the purpose of VA pension programs. 16. Specify that a veteran's participation in a VA incentive or compensated work therapy program will not be considered a basis for denying or discontinuing a total disability rating for VA compensation or pension purposes. 17. Require the Administrator to submit by January 1, 1986, a report describing the results of a study of the utilization of VA health-care facilities by veterans who live in locations remote from those facilities and, by July 1, 1986, a report describing a possible experimental program through which the VA could offer health-care services, at five sites, to veterans in areas remote from existing VA facilities. DISCUSSION Coordination of Veterans' Administration-Community Referral Assistance and Services Section 2 of the Committee bill, which is derived with modifications from section 2 of S. 2514 as introduced would add a new section-section 4120, "Coordination of referral assistance and services"-to title 38, United States Code, pursuant to which the Administrator would be required to designate one organizational unit in each VA health-care facility to help coordinate referral assistance by the VA to eligible veterans and to facilitate and help coordinate the provision of non-VA care and related services when such assistance is necessary for the health of eligible veterans. Special emphasis would be placed on assisting veterans 65 years of age or older. The Committee has received information from a variety of sources, including witnesses who presented testimony at the Čommittee's June 1982 hearing on the aging veteran, concerning difficulties in organizing and managing the provision of comprehensive health-care services, particularly for elderly veterans. Such services are often fragmented due to the variety of providers, delivery sites, and payment mechanisms involved, and the multiple and complex health-care needs of the patients. With regard to such fragmentation, Dr. Ewald Bussee, Dean Emeritus, Duke University Medical School, and Chairman, Geriatrics and Gerontology Advisory Committee to the Veterans' Administration, testified as follows at the April 11 hearing in support of S. 2514 as introduced: This is a serious problem, not only within the Veterans' Administration but in our entire health care system, particularly in what we call long-term care which usually involves elderly people. I believe that the Veterans' Adminis 37-524 0-84-36 18 tration can make numerous contributions to improving the well-being of our elderly veterans as well as other disabled people and for this reason, I very strongly urge this effort be supported and expanded. Dr. Terrie Wetle of the Harvard Medical School, who also testified stated: The Veterans' Administration is certainly the nation's largest single coordinated health care system. It is a major provider of geriatric institutional based care, but has only begun to emphasize community based services. It is also recognized that elderly veterans are quite likely to have multiple entitlements and eligibilities, including VA benefits, Medicare, Medicaid, social security and services under title 3 of the Older Americans Act, and others. To ensure the availability of the broad array of services required by the elderly I think it is imperative that the VA develop and improve linkages with community based providers. Attempts to address the fragmentation problem have resulted in such solutions as problem-oriented medical records and improved discharge planning. These practices are links between patient medical care needs, recommended medical services, and treatment plans. Yet some monitoring activity still is necessary, particularly to ensure that recommended services are sought and received by the patient. On an individual patient level, the skills of a social worker often provide the cohesive element to indentify and bring together sources of a particular health-care service and the personal attention that are sometimes necessary to ensure that patients referred for specific care both seek it and receive it. Indeed, the VA, in its April 11 testimony stated that the VA's social work serv ices have seen that "part of their responsibilities and their overall patient treatment and planning, which includes discharge planning, is to develop linkages with the community that will enable the placement of patients into the community following their hospital care. The Committee believes that such linkages, which are estab lished in individual cases, may also be useful in the aggregate for a patient population at specific medical centers. The VA acknowl edged during testimony before the Committee that there is no sys tematic effort at each VA medical center to put the experiences of individual social workers or the social work service in place at the level of aggregrate or interagency planning. Further evidence in testimony received by the Committee indicated that in certain VA facilities and for certain individuals, referral information has not been collected and organized in a way that would make it available more generally and in a more understandable fashion to providers and patients with differing levels of knowledge and skills. With the growing size of the aging veteran population and exist ing statutory eligibilities, the Committee is aware that the VA may not have the capacity or resources available at each VA facility to provide all services to all otherwise eligible veterans who seek care from the VA. Thus, it is the Committee's intent that this new section would result in structured arrangements being fashioned be 19 tween VA facilities and various public and private local agencies to help ensure that referrals for non-VA care are made efficiently and effectively and that, as appropriate, VA and non-VA health and health-related services are provided in a well-coordinated and effective fashion. The Committee expects the VA, in carrying out this provision, to address both the current fragmented referral effort and the anticipated increased demand by encouraging the exercise of two coordinating responsibilities-internal, among VA staff, and external, with non-VA providers. By raising the focus for these two coordinating responsibilities above the individual patient level, the aggregate experience of all patient referral activities is expected to result in better integrated, more comprehensive referral patterns within a VA medical facility and outside of VA health-care facilities to augment VA services or to provide referral assistance to veterans who are not eligible for particular VA services. It is the Committee's intent that the internal coordinating responsibility will aid in planning and implementing appropriate discharges of VA patients by identifying for these patients all potential sources of medical and social services in their communities that might provide needed post-hospital care. The external coordinating responsibility is intended to promote greater VA-community interaction and result in an increase in the access to a number and variety of community services for veterans in need of community care. The Committee believes the more active participation by the VA in helping guide veterans to appropriate services which may not be offered by the VA, or to appropriate community-based services in the cases of veterans with limited eligibility for VA services would make an important contribution to the coordination and provision of care for these veterans. The collection and dissemination of information on sources of care should also be an aid to the provision of services for non-veterans as well. It is the Committee's intent that this provision provide an opportunity for the individual VA medical facilities and the VA as a whole to act as catalysts in addressing and resolving the problem of fragmentation of services, especially with respect to elderly veterans. The Committee emphasizes that, as provided in the Committee bill, implementation of this provision is required to be accomplished in a manner consistent (A) with the policy of the United States, set forth in section 409(a) of Public Law 97-306, that the Veterans' Administration shall maintain a comprehensive, nationwide health-care system for the direct provision of quality healthcare services to eligible veterans, (B) with the mandate of section 4101(a) of title 38, United States Code, that the VA's Department of Medicine and Surgery shall provide a complete medical and hospital service for the medical care and treatment of veterans, and (C) with the U.S. Government's historic, firm commitment and moral obligation to provide care to veterans with service-connected disabilities. Alcoholism Treatment and Rehabilitation Section 3 of the Committee bill, which is derived in part and with modifications from section 5 of S. 2269, S. 2278, and section 2 of S. 2514 as introduced would extend for 2 years, through Septem 20 ber 1987, the VA's present discretionary authority to contract with halfway houses and other community-based facilities for the treatment and rehabilitation of veterans with alcohol or drug abuse or dependence disabilities and would require the Administrator to submit to Congress fiscal years 1985 and 1986 reports on the experience under this contract authority, including such matters as the rate of successful rehabilitation of participants and costs per veteran. It would delete the references in current law to this program being a "pilot" program. It would also require the Administrator to prescribe regulations providing guidelines for VA-operated treatment and rehabilitation programs for veterans with alcohol or drug dependence or abuse disabilities to include guidance on the duration of treatment, kinds of treatment provided, use of individual treatment plans, and followup for veterans receiving care and treatment; and would require the Administrator to report to Congress on the activities of all VA alcohol and drug treatment programs. The Committee notes that the term "followup" is intended to refer to any efforts made by the VA, after the completion or termination of treatment or rehabilitation, to contact the veteran regarding his or her health status and possible need for further services. Contract Program Public Law 96-22, the Veterans' Health Care Amendments of 1979, established a 5-year pilot program for the treatment and rehabilitation of veterans with alcohol or drug dependence or abuse disabilities. Under this pilot program, the VA was provided with specific authority to contract with halfway houses, therapeutic communities, psychiatric residential treatment centers, and other community-based treatment facilities for alcohol and drug treat ment and rehabilitation for veterans. Public Law 96-22 also required the Administrator to report to Congress, by March 31, 1983, on the effectiveness of this pilot program; the due date of that report was subsequently postponed by section 6 of Public Law 97251, to March 31, 1984. Provisions in S. 2514 as introduced, S. 2269, and S. 2278 would have made this authority permanent. In connection with the Committee's April 11 hearings, Ken Schonlau, President of the Association of Halfway House alcoholism Programs of North America, Inc. (approximately 100 of the Association's 324 members had contracts with VA medical centers under this authority), submitted written testimony which strongly endorsed proposals to make the contract programs permanent. He further suggested that (1) local VA medical centers accept State facility licensing and program certification as quality assurance mechanisms, (2) the program be expanded to include social detoxification services, and (3) the duration of stay in the program remain 60 days with a discretioanary 30-day extension, if necessary. Joseph Collins, Executive Director of the California Association of Alcoholic Recovery Homes, submitted testimony to the Commit tee based on information obtained from a survey of 15 members of the Association which had contracts with the VA. He recommended:1 1. The pilot program should be made a permanent part of the VA's overall health service program. |