Traumatic Brain Injury Among Veterans
Erin Bagalman
Analyst in Health Policy
May 5, 2011
Congressional Research Service
7-5700
www.crs.gov
R40941
CRS Report for Congress
P
repared for Members and Committees of Congress
Traumatic Brain Injury Among Veterans
Summary
Traumatic Brain Injury (TBI) has been defined as “an alteration in brain function, or other
evidence of brain pathology, caused by an external force.” In the general population, TBI results
mainly from falls, motor vehicle/traffic accidents, assaults, and other instances in which the head
is struck by or strikes against an object. In military servicemembers, TBI may also result from
improvised explosive devices, mortars, grenades, bullets, or mines.
Traumatic brain injury has become known as a “signature wound” of Operation Enduring
Freedom (OEF) and Operation Iraqi Freedom (OIF), because the incidence of TBI is higher in
these conflicts than it has been in previous conflicts. As of FY2010, 1.25 million OEF/OIF
veterans have left active duty and became eligible for Department of Veterans Affairs (VA) health
care; half of them have obtained VA health care; and 45,606 have been diagnosed with TBI-
related conditions at VA medical facilities. The total number of OEF/OIF veterans with TBI is not
known, in part because some OEF/OIF veterans have not accessed VA health care services.
The VA has engaged in outreach efforts to OEF/OIF veterans via mail, telephone, and television
advertisements. In order to make contact with servicemembers before separation and conversion
to veteran status, the VA participates in some Department of Defense (DOD) activities. Some
OEF/OIF veterans may choose not to enroll in VA health care, because they have health coverage
from other sources or because they do not perceive a need for health care. Others may experience
barriers to accessing VA care.
Servicemembers who sustain mild TBI (also known as “concussion”), which accounts for the
majority of injuries, may walk away from the event, seemingly unharmed; thus mild TBI may go
unnoticed and untreated. Accordingly, VA policy requires that all OEF/OIF veterans receiving
medical care in the VA health care system must be screened for possible TBI, and that those who
screen positive must be offered further evaluation and specialized treatment. The VA and the
DOD have jointly developed evidence-based clinical practice guidelines for treatment of mild
TBI.
Servicemembers who sustain moderate to severe TBI (i.e., recognizable injuries) require
immediate treatment, which begins at the site of the event and continues at a military treatment
facility. Once stabilized, servicemembers may remain at a military treatment facility or be
transferred to the VA Polytrauma System of Care. Transfers from DOD to VA facilities require
coordination between the two systems, and several programs have been developed to facilitate
coordination of care.
The VA’s FY2010 budget for “TBI and Other Neurotrauma” research was $22 million (rounded).
Before applying a 0.2% rescission for most non-defense items, the full-year continuing resolution
for FY2011 maintained VA’s research funding at the FY2010 level. The large number of studies
conducted by the VA and the DOD, as well as the Department of Health and Human Services
(HHS), raises questions for some about potential duplication of effort, gaps in the research,
dissemination of research findings, and translation of research into practice.
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Contents
Introduction ................................................................................................................................ 1
Traumatic Brain Injury (TBI) Overview ...................................................................................... 1
TBI Among Veterans................................................................................................................... 4
Access to Care ...................................................................................................................... 5
Identification of TBI ............................................................................................................. 7
Treatment of TBI .................................................................................................................. 8
VA Polytrauma System of Care ....................................................................................... 9
Coordination of VA and DOD Treatment ....................................................................... 10
TBI Research ...................................................................................................................... 11
Potential Issues for the 112th Congress....................................................................................... 12
Figures
Figure 1. VA Polytrauma System of Care................................................................................... 10
Figure 2. Locations of VA Liaisons Assigned to Military Treatment Facilities............................ 11
Figure B-1. Flowchart of VA Process for Identifying and Treating TBI ...................................... 17
Tables
Table 1. Classification of TBI as Mild, Moderate, or Severe ........................................................ 3
Table A-1. Number of OEF/OIF Veterans Diagnosed with TBI-Related Conditions at VA
Medical Facilities, FY2002-FY2010, by State of Residence ................................................... 16
Table C-1. Congressional Action on TBI Among Veterans, 2004-2010....................................... 18
Appendixes
Appendix A. OEF/OIF Veterans with TBI, by State ................................................................... 16
Appendix B. Flowchart of VA Process for Identifying and Treating TBI .................................... 17
Appendix C. Past Congressional Action .................................................................................... 18
Contacts
Author Contact Information ...................................................................................................... 19
Acknowledgments .................................................................................................................... 20
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Traumatic Brain Injury Among Veterans
Introduction
Traumatic brain injury (TBI) has become known as a “signature wound” of Operation Enduring
Freedom (OEF) and Operation Iraqi Freedom (OIF),1 because the incidence of TBI is higher in
these conflicts than it has been in previous conflicts. This report discusses TBI among veterans
receiving care in Department of Veterans Affairs (VA) medical facilities, with particular attention
to OEF/OIF veterans.
The VA health care system does not function in a vacuum. Individuals may sustain injuries during
military service, receive early stages of treatment from the Department of Defense (DOD), and
transfer to the VA for later stages of treatment. In this report, agencies other than the VA are
addressed only to the extent that they work in coordination with the VA.
The remainder of this report is organized in three parts. The first part provides an overview of
TBI, as background for the rest of the report. The second part focuses on TBI among veterans
receiving VA health care services,2 with sections addressing access to care, identification of TBI,
treatment of TBI, and TBI research. The third part discusses potential issues for the 112th
Congress, in the context of past congressional action related to TBI among veterans.
Several numbers are presented in this report, quantifying TBI among different populations (i.e.,
civilians, servicemembers, or veterans), measured over different periods (i.e., a single year or
multiple years), by different organizations (i.e., the Centers for Disease Control and Prevention,
DOD, or VA). Each number is independent of the others; they do not sum to a total.
Traumatic Brain Injury (TBI) Overview
To provide some context for the discussion of TBI among veterans, this part of the report
discusses TBI in general terms, including the definition, causes, and prevalence of TBI; various
ways in which traumatic brain injuries can be classified; the signs and symptoms of TBI; and
associated comorbid conditions (including both mental and physical health).
1 Operation Enduring Freedom (OEF) began on October 7, 2001, and continues today. Operation Iraqi Freedom (OIF)
began on March 20, 2003; on September 1, 2010, OIF was redesignated Operation New Dawn, which continues today.
(These operations are not defined in statute; the dates presented here are commonly accepted.) The abbreviation
OEF/OIF is used throughout this report to refer to Operation Enduring Freedom and Operation Iraqi Freedom (now
called Operation New Dawn).
2 This report focuses on TBI as a health care issue, and therefore does not address classification of TBI as a service-
connected disability for compensation purposes; for a general discussion of veterans’ disability benefits, refer to CRS
Report RL34626, Veterans’ Benefits: Benefits Available for Disabled Veterans, by Christine Scott and Carol D. Davis.
This report does not address TBI in the military health care system, except where necessary to provide context or
explain joint endeavors of the Departments of Defense and Veterans Affairs; for information about the military health
care system, refer to CRS Report RL33537, Military Medical Care: Questions and Answers, by Don J. Jansen. For
information about TBI among professional football players, refer to CRS Report R41555, NFL Players and Efforts to
Protect Them From Concussions, by L. Elaine Halchin.
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Definition, Causes, and Prevalence
In 2011, the Brain Injury Association of America adopted a definition of TBI as “an alteration in
brain function, or other evidence of brain pathology, caused by an external force.”3 In the general
population, TBI results mainly from falls, motor vehicle/traffic accidents, assaults, and other
instances in which the head is struck by or strikes against an object.4 In the United States each
year, an estimated 1.7 million people sustain TBI:
• 1.365 million are treated and released from an emergency department,
• 275,000 are hospitalized, and
• 52,000 die as a result of their injuries.
In military servicemembers, TBI may result from the events listed above, or from improvised
explosive devices, mortars, grenades, bullets, or mines.5 The DOD reports that in 2010, a total of
30,703 servicemembers sustained TBI.6
Classification
Traumatic brain injury is not a specific diagnosis; the term encompasses a range of conditions. A
TBI may be classified as focal or diffuse; open or closed; and mild, moderate, or severe. If the
injury is localized to a small area of the brain, it is a focal injury; an injury occurring over a large
area is diffuse. If the head hits, or is hit by, an object that penetrates the skull and the brain’s
protective coverings, the injury is open (also called penetrating); otherwise, the injury is closed
and can be further classified as mild, moderate, or severe.7
Many methods have been used to classify TBI as mild, moderate, or severe; three commonly used
methods are based on loss of consciousness, post-traumatic amnesia (i.e., loss of memory), or the
Glasgow Coma Scale.8 The Glasgow Coma Scale assigns points in three areas: eye opening,
verbal response, and motor response. The sum of points in the three areas ranges from 3 to 15,
with lower scores indicating greater severity of TBI.9 Table 1 summarizes the criteria for mild,
moderate, and severe TBI.
3 Brain Injury Association of America, “BIAA Adopts New TBI Definition,” press release, February 6, 2011,
http://www.biausa.org/AnnouncementRetrieve.aspx?ID=66290.
4 Mark Faul, Likang Xu, and Marlena M. Wald, et al., Traumatic Brain Injury in the United States: Emergency
Department Visits, Hospitalizations, and Deaths, Centers for Disease Control and Prevention, National Center for
Injury Prevention and Control, Atlanta, GA, March 2010, http://www.cdc.gov/traumaticbraininjury/pdf/blue_book.pdf.
5 Terri Tanielian and Lisa H. Jaycox, eds. Invisible Wounds of War: Psychological and Cognitive Injuries, Their
Consequences, and Services to Assist Recovery, RAND Corporation, 2008, p. 310, http://www.rand.org/pubs/
monographs/2008/RAND_MG720.pdf.
6 Defense and Veterans Brain Injury Center, DOD Numbers for Traumatic Brain Injury, http://www.dvbic.org/TBI-
Numbers.aspx.
7 Marcia Vital, Traumatic Brain Injury: Hope Through Research, National Institutes of Health, National Institute of
Neurological Disorders and Stroke, NIH Publication No. 02-158, Bethesda, MD, September 2002,
http://www.ninds.nih.gov/disorders/tbi/tbi_htr.pdf.
8 Michael S. Jaffee, Kathy M. Helmick, and Philip D. Girard, et al., “Acute clinical care and care coordination within
Department of Defense,” Journal of Rehabilitation Research & Development, vol. 46, no. 6 (2009), pp. 655-666.
9 Marcia Vital, Traumatic Brain Injury: Hope Through Research, National Institutes of Health, National Institute of
Neurological Disorders and Stroke, NIH Publication No. 02-158, Bethesda, MD, September 2002,
(continued...)
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Table 1. Classification of TBI as Mild, Moderate, or Severe
Mild
Moderate
Severe
Loss of consciousness
< 30 minutes
30 minutes-24 hours
> 24 hours
Post-traumatic amnesia
< 1 day
1-7 days
> 7 days
Glasgow Coma Scale score
13-15 points
9-12 points
3-8 points (coma)
Source: CRS summary of classification described by Michael S. Jaffee, Kathy M. Helmick, and Philip D. Girard, et
al., “Acute clinical care and care coordination within Department of Defense,” Journal of Rehabilitation Research &
Development, vol. 46, no. 6 (2009), pp. 655-666.
Signs and Symptoms
Mild TBI (concussion) may manifest as a range of physical, psychological, and cognitive
problems. Common physical signs and symptoms of mild TBI include headaches, fatigue,
lethargy, dizziness, and lightheadedness. Individuals with mild TBI may experience blurred
vision, eye fatigue, ringing in the ears, or a bad taste in the mouth. Psychological symptoms may
appear as behavioral or mood changes. Cognitive difficulties may include confusion and
problems with memory, attention, concentration, or thinking. Individuals with mild TBI may also
sleep more or less than usual.10
Individuals with moderate to severe TBI may experience any of the signs and symptoms listed
above, as well as repeated nausea or vomiting, a persistent or worsening headache, seizures or
convulsions, numbness or weakness in their feet or hands, and loss of coordination. They may
experience increased confusion, restlessness, or agitation. Their pupils might be dilated and their
speech might be slurred. They may be unable to awaken from sleep.11
Comorbid Conditions
Traumatic brain injury is associated with comorbid conditions that include both mental and
physical illnesses. Mental disorders associated with TBI include anxiety disorders and depressive
disorders; estimates of how often such conditions co-occur with TBI vary.12 While some studies
have found a link between TBI and increased alcohol or drug use, a report by the Institute of
Medicine (IOM) found just the opposite: limited/suggestive evidence of an association between
TBI and decreased alcohol and drug use within one to three years of the injury.13
(...continued)
http://www.ninds.nih.gov/disorders/tbi/tbi_htr.pdf.
10 Marcia Vital, Traumatic Brain Injury: Hope Through Research, National Institutes of Health, National Institute of
Neurological Disorders and Stroke, NIH Publication No. 02-158, Bethesda, MD, September 2002,
http://www.ninds.nih.gov/disorders/tbi/tbi_htr.pdf.
11 Ibid.
12 Brent E. Masel and Douglas S. DeWitt, “Traumatic Brain Injury: A Disease Process, Not an Event,” Journal of
Neurotrauma, no. 27 (August 2010), p. 1529–1540; and Terri Tanielian and Lisa H. Jaycox, eds. Invisible Wounds of
War: Psychological and Cognitive Injuries, Their Consequences, and Services to Assist Recovery, RAND Corporation,
2008, p. 310, http://www.rand.org/pubs/monographs/2008/RAND_MG720.pdf.
13 Brent E. Masel and Douglas S. DeWitt, “Traumatic Brain Injury: A Disease Process, Not an Event,” Journal of
Neurotrauma, no. 27 (August 2010), p. 1529–1540; and Institute of Medicine (IOM), Gulf War and Health, Volume 7:
Long-term Consequences of Traumatic Brain Injury (Washington, DC: The National Academies Press, 2009).
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Individuals with TBI are at increased risk of developing epilepsy and neurodegenerative diseases
such as Alzheimer’s disease, Lewy body dementia, or Parkinson’s disease. Repetitive blows to the
head can result in chronic traumatic encephalopathy (CTE); CTE may begin with loss of
concentration, attention, or memory, and may eventually progress to problems with coordination,
gait, slurred speech, and tremors. Post-traumatic hypopituitarism (PTH) is a neuroendocrine
disorder associated with TBI; chronic PTH leads to other neuroendocrine conditions, including
hypothyroidism and deficiencies in growth hormone and gonadotropin. Individuals with TBI may
also develop sleep disturbances, obstructive sleep apnea, incontinence, sexual dysfunction,
metabolic dysfunction, or musculoskeletal dysfunction.14
The next part of the report addresses TBI in the veteran population, including sections on access
to care, identification of TBI, treatment of TBI, and TBI research.
TBI Among Veterans
As stated before, traumatic brain injury has become known as a “signature wound” of OEF/OIF,
because servicemembers in these operations have experienced TBI in larger numbers than those
serving in past conflicts. Three factors contribute to the increase in TBI. First, the number of blast
injuries caused by improvised explosive devices (IED), rocket-propelled grenades, and land
mines has increased; it has been reported that the primary mechanism of injury in OIF is a blast
injury.15 Second, injuries that would have been fatal in the past may not be fatal now, thanks to
advances in protective equipment, combat medicine, and air evacuation.16 Third, health care
professionals are more alert to the possibility of TBI and may therefore be more likely to
diagnose TBI accurately.17
The total number of veterans who have experienced TBI is not known, in part because TBI is
difficult to identify,18 and in part because some veterans have not accessed VA health care
services.19 Among OEF/OIF veterans who have accessed VA health care services, the VA has
indicated that 45,606 have been diagnosed with TBI-related conditions at VA medical facilities as
of FY2010.20 The number in each state is shown in Appendix A.
This part of the report focuses on TBI among veterans receiving care provided by VA medical
facilities. The four sections address access to care, identification of TBI, treatment of TBI, and
TBI research. Because individuals may sustain injuries during military service (as noted
14 Ibid.
15 Geoffrey Ling, Faris Bandak, and Rocco Armonda, et al., “Explosive Blast Neurotrauma,” Journal of Neutrotrauma,
vol. 26 (2009), pp. 815-825.
16 Atul Gawande, “Casualties of War—Military Care for the Wounded from Iraq and Afghanistan,” New England
Journal of Medicine, vol. 351, no. 24 (2004), pp. 2471-2475.
17 Office of the Surgeon General, Center for Excellence in Medical Multimedia, Traumatic Brain Injury: The Journey
Home, http://www.traumaticbraininjuryatoz.org.
18 Terri Tanielian and Lisa H. Jaycox, eds. Invisible Wounds of War: Psychological and Cognitive Injuries, Their
Consequences, and Services to Assist Recovery, RAND Corporation, 2008, p. 47, http://www.rand.org/pubs/
monographs/2008/RAND_MG720.pdf.
19 U.S. Department of Veterans Affairs, Office of Public Health and Environmental Hazards, Analysis of VA Health
Care Utilization among Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) Veterans, Cumulative
from 1st Quarter FY2002 through 4th Quarter FY2010, December 2010.
20 Response to CRS inquiry to VA Program Office, December 23, 2010.
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previously), the DOD may have a role in each of these areas; however, as noted previously, the
focus of this report is on the VA, and other agencies are addressed only to the extent that they
work in coordination with the VA.
Access to Care
This section summarizes enrollment in VA health care and briefly describes VA outreach efforts to
increase enrollment.
Veterans generally must enroll in the VA health care system to receive medical care, as described
in the text box below.
The VA has engaged in outreach efforts to OEF/OIF veterans via mail,21 telephone,22 and
television advertisements.23 In order to make contact with servicemembers before separation and
conversion to veteran status, the VA participates in some DOD activities. VA reaches out to
OEF/OIF veterans to inform them of their benefits by
• participating in Reserve component out-processing at DOD demobilization sites;
• attending the DOD’s Yellow Ribbon Program (YRP) events;24
• partnering with the National Guard in training transition assistance advisors;
• contacting OEF/OIF veterans through the Combat Veterans Call Center;
• supporting the DOD health assessment and linking veterans with appointments;
• hosting Individual Ready Reserve musters; and
• using social media and other internet-based outreach.25
21 Department of Veterans Affairs, Letter to OEF/OIF Veterans, http://www.gibill.va.gov/documents/
CH33_veteran_outreach_letter.pdf.
22 Department of Veterans Affairs, Returning Service Members (OEF/OIF): Welcome Home and Outreach,
http://www.oefoif.va.gov/WelcomeHomeOutreach.asp.
23 Department of Veterans Affairs, Public and Intergovernmental Affairs, VA Video Outreach Message Aimed at New
Veterans, http://www1.va.gov/opa/pressrel/pressrelease.cfm?id=1981.
24 The DOD Yellow Ribbon Program, established under the National Defense Authorization Act for Fiscal Year 2008,
enacted 1/28/2008 (P.L. 110-181), is distinct from the VA Yellow Ribbon Program (which focuses on education).
25 Department of Veterans Affairs, Returning Service Members (OEF/OIF): Seven Touches of Outreach,
http://www.oefoif.va.gov/SevenTouchesOutreach.asp.
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Veterans Health Administration: Eligibility, Enrollment, and Services
The Department of Veterans Affairs (VA) provides services and benefits to eligible veterans through three major
operating units: the Veterans Health Administration (VHA), the Veterans Benefits Administration (VBA), and the
National Cemetery Administration (NCA). The VHA operates the nation’s largest integrated direct health care
delivery system. As of FY2010, the VHA health care system includes 152 hospitals (medical centers), 133 nursing
homes, 791 community-based outpatient clinics (CBOCs), and 6 independent outpatient clinics. (The VHA also
operates 300 Readjustment Counseling Centers, or Vet Centers, which provide psychosocial services, but not
medical care; Vet Centers have their own eligibility criteria.)
Under the Veterans’ Health Care Eligibility Reform Act of 1996 (P.L. 104-262), eligibility for VHA health care is based
primarily on veteran status, which is established by a period of active-duty status and an honorable discharge or
release from active military service. (A veteran with a discharge other than honorable may still retain eligibility for VA
health care benefits for disabilities incurred or aggravated during service in the military.) As a requirement to obtain
care through the VA, veterans are required to enrol in the VA health care system. Once enrol ed, veterans are
categorized into eight priority groups. Veterans with service-connected disabilities or with incomes below a means
test are designated “high priority” and are enrol ed in Priority Groups 1-6. (The term “service-connected” means,
with respect to disability, that such disability was incurred or aggravated in the line of duty in the active military, naval,
or air service.) The remaining veterans (primarily those without service-connected medical conditions and with
incomes and net worth above the means test) are enrol ed in Priority Group 7 or 8.
Under the National Defense Authorization Act for Fiscal Year 2008 (P.L. 110-181), veterans who served in a theater
of combat operations after November 11, 1998, are offered a five-year post-discharge period of enhanced enrollment
for VHA health care. Veterans who enroll during this period are provided care regardless of service-connected
disability status. Veterans who enroll in the VHA system under this extended enrollment authority continue to be
enrolled even after the five-year eligibility period ends.
In FY2010 approximately 8.4 million veterans were enrolled in the VHA health care system; this represents 36.4% of
the 23.1 million veterans living in the United States. Thus the majority of veterans (63.6%) are not enrolled in the
VHA health care system.
All enrolled veterans are offered a standard medical benefits package, which includes a full range of inpatient,
outpatient, and preventive medical services. Among these services are medical, surgical, and mental health care,
including substance abuse treatment; prescription drugs, including over-the-counter drugs, available under the VA
national formulary system; home health services and institutional respite care; noninstitutional adult day health care
and noninstitutional respite care; and periodic medical exams.
Source: Summarized from CRS Report R41343, Veterans Medical Care: FY2011 Appropriations.
Note: Some of the numbers have been updated since publication of the source report.
From FY2002 through FY2010, 1.25 million OEF/OIF veterans (including members of the
Reserve and National Guard) left active duty and became eligible for VA health care; by the end
of FY2010, half of them had obtained VA health care.26 Some veterans may choose not to enroll
in VA health care because they have health coverage from other sources (e.g., private insurance or
TRICARE27) or because they do not perceive a need for health care. Others may experience
barriers to accessing VA care; potential barriers to access are discussed under “Potential Issues for
the 112th Congress” later in this report.
26 U.S. Department of Veterans Affairs, Office of Public Health and Environmental Hazards, Analysis of VA Health
Care Utilization among Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) Veterans, Cumulative
from 1st Quarter FY2002 through 4th Quarter FY2010, December 2010.
27 TRICARE is a system of military and private health care offering benefits for active duty servicemembers, National
Guard and Reserve members, military retirees, their families, survivors, and certain former spouses. See CRS Report
RL33537, Military Medical Care: Questions and Answers, by Don J. Jansen.
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Identification of TBI
This section describes the two-step process the VA uses to identify TBI: screening for TBI and
confirming a diagnosis of TBI.
As noted previously, the initial injury may occur during military service; thus the DOD may be
responsible for identification of TBI. Moderate to severe TBI, in particular, is likely to be
recognized immediately at the time of the initial injury; however, mild TBI may go unnoticed if
an individual walks away seemingly unharmed. Despite repeated assessments by the DOD, a
veteran may enter the VA health care system with an undiagnosed TBI. In order to identify cases
of TBI that might otherwise go untreated, VA policy requires that all OEF/OIF veterans receiving
medical care in the VA health care system must be screened for possible TBI, and that those who
screen positive must be offered further evaluation and specialized treatment.28
The VA developed a screening instrument and a protocol for further evaluation of individuals who
screen positive. The screening instrument was adapted from one already used by the DOD and
was incorporated into a national clinical reminder in the computerized patient record system.29
When a provider opens a veteran’s computerized record, the clinical reminder alerts the provider
that action is required. The clinical reminder then prompts the provider to ask the veteran a series
of questions in order to complete the TBI screening instrument.
If a veteran screens negative for possible TBI, the clinical reminder is resolved and no further
action is required. If a veteran screens positive for possible TBI, the clinical reminder generates
an electronic consult for a follow-up evaluation. The protocol for completing the additional
evaluation includes a 22-item neurobehavioral symptom inventory.
The diagnosis of TBI is complicated by symptoms that overlap with posttraumatic stress disorder
(PTSD),30 such as difficulty concentrating, irritability or outbursts of anger, and memory loss.31
Because of the complexity of diagnosing TBI and differentiating symptoms of other disorders,32
specialized training is required to administer the evaluation.33
28 Department of Veterans Affairs, Veterans Health Administration, Screening and Evaluation of Possible Traumatic
Brain Injury in Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) Veterans, VHA Directive
2007-013, April 13, 2007; unless otherwise noted, all information in this subsection is drawn from this source.
29 This reminder, together with reminders for screens for PTSD, depression, alcohol abuse, and infectious diseases
endemic to Southwest Asia, constitutes the “Afghan and Iraq Post-Deployment Screen.” Veterans Health
Administration, Implementation of the National Clinical Reminder for Afghan and Iraq Post-Deployment Screening,
Department of Veterans Affairs, VHA Directive 2005-055, Washington, DC, December 1, 2005.
30 Posttraumatic stress disorder (PTSD) is an anxiety disorder that may occur following a traumatic event.
31 American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text
Revision (Arlington, VA: American Psychiatric Association, 2000), pp. 463-468.
32 The VA is studying differential diagnoses, in an effort to build objective and consistent diagnostic criteria for TBI
and PTSD. Department of Veterans Affairs, Office of Public Health and Environmental Hazards,
http://www.publichealth.va.gov/research/epidemiology.
33 Department of Veterans Affairs, Veterans Health Administration, Screening and Evaluation of Possible Traumatic
Brain Injury in Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) Veterans, VHA Directive
2007-013, April 13, 2007.
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If the follow-up evaluation finds that the veteran does not have TBI, the consult is completed and
results are reported to the referring clinician. If the follow-up evaluation finds that the veteran has
TBI, the veteran is referred for specialized treatment, as described in the next section.
As of September 2010, a total of 420,374 OEF/OIF veterans had been screened for TBI. Of those
who were screened, 102,569 either reported a prior diagnosis of TBI or screened positive for
possible TBI. A follow-up evaluation (which was not required for those who reported a prior
diagnosis of TBI) was completed for 57,995 of those who screened positive for possible TBI, and
a TBI diagnosis was confirmed in 18,280 of them.34 Note that the 18,280 represents only those
OEF/OIF veterans with a TBI diagnosis confirmed by the VA’s follow-up evaluation. It does not
include OEF/OIF veterans who reported a prior diagnosis of TBI at the screening, nor does it
include OEF/OIF veterans who do not receive VA health care.
The VA’s identification process is illustrated in Appendix B (which also illustrates the treatment
process that follows).
Treatment of TBI
This section describes treatment of veterans with TBI in the VA health care system, focusing on
treatment of veterans with moderate to severe TBI. The first subsection describes the VA
Polytrauma System of Care. The second subsection describes several programs aimed at
coordinating VA and DOD treatment.
As mentioned previously, the early stages of treatment may occur within the military health care
system, if the initial injury occurs during military service; however, this report focuses on
treatment within the VA health care system. Regardless of where treatment is provided, the type
of treatment needed depends on the severity of the injury.
Servicemembers who sustain mild TBI (which accounts for the majority of injuries35) may walk
away from the event, seemingly unharmed; thus mild TBI may go unnoticed and untreated. Most
cases of mild TBI resolve without medical attention. Education about mild TBI can effectively
“normalize symptoms and provide expectation of rapid recovery.”36 The VA and the DOD have
jointly developed evidence-based clinical practice guidelines for treatment of mild TBI.37
Servicemembers who sustain moderate to severe TBI (i.e., recognizable injuries) require
immediate treatment, which begins at the site of the event and continues at a military treatment
facility. Once stabilized, servicemembers may remain at a military treatment facility or be sent to
VA medical facilities for continuing treatment, rehabilitation, and transitional care. When
servicemembers transfer from DOD to VA facilities (regardless of whether they change to veteran
status), coordination between the two systems is necessary.
34 Response to CRS inquiry to VA Program Office, January 5, 2011.
35 Mild TBI accounted for 81% of the servicemembers sustaining TBI in 2010. Defense and Veterans Brain Injury
Center, DOD Numbers for Traumatic Brain Injury, http://www.dvbic.org/TBI-Numbers.aspx.
36 Charles W. Hoge, Dennis McGurk, and Jeffrey L. Thomas et al., “Mild Traumatic Brain Injury in US Soldiers
Returning from Iraq,” New England Journal of Medicine, vol. 358, no. 5 (2008), pp. 453-463.
37 Department of Veterans Affairs and Department of Defense, VA/DOD Clinical Practice Guideline for Management
of Concussion/mild Traumatic Brain Injury (mTBI), April 2009, http://www.healthquality.va.gov/
management_of_concussion_mtbi.asp.
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VA Polytrauma System of Care
Veterans with moderate to severe TBI (alone or in combination with other conditions) may
receive care through the VA Polytrauma System of Care (PSC).38 The PSC is designed to function
within the existing VA health care system, which is organized into geographic regions called
Veterans Integrated Service Networks (VISN). Like the larger VISN structure, the PSC is
geographically dispersed, thereby making the specialized treatment more accessible to veterans,
regardless of where they live. The PSC operates as a “hub and spoke” model with four
components, each of which is described below.
Component I of the PSC comprises four regional Polytrauma Rehabilitation Centers, which serve
as regional referral centers, the “hubs” of the PSC. Polytrauma Rehabilitation Centers provide
direct care and consultation, as well as research and education related to polytrauma and TBI.
Each Polytrauma Rehabilitation Center has a minimum of 12 dedicated comprehensive
rehabilitation beds and 10 dedicated transitional rehabilitation beds. Required staff include a
rehabilitation physician, registered nurses, social workers, speech-language pathologists, physical
therapists, occupational therapists, recreation therapists, a neuropsychologist, a counseling
psychologist, and a family therapist, among others. Construction of a fifth regional Polytrauma
Rehabilitation Center is underway.
Component II of the PSC extends the “spokes” to 22 Polytrauma Network Sites: one in each
VISN (including one at each of the Polytrauma Rehabilitation Centers) plus one in Puerto Rico.
In consultation with the Polytrauma Rehabilitation Centers, Polytrauma Network Sites provide
specialized, post-acute rehabilitation services in a setting appropriate to the needs of veterans,
servicemembers, and families. Each Polytrauma Network Site has a dedicated interdisciplinary
team with specialized training, to provide case management and identify resources both within
and outside the VA. Figure 1 shows the location of each Polytrauma Network Site, including the
Polytrauma Rehabilitation Centers.
Component III of the PSC extends care to 82 VA medical facilities that do not have Polytrauma
Rehabilitation Centers or Polytrauma Network Sites, by establishing Polytrauma Support Clinic
Teams. These local teams of providers have rehabilitation expertise and deliver follow-up
services in consultation with regional and network specialists. They provide direct care,
consultation, and telerehabilitation, as needed.
Component IV of the PSC addresses the needs of veterans at 48 VA medical facilities that lack the
necessary services to provide specialized care. Such facilities must designate a Polytrauma Point
of Contact who is responsible for coordinating the treatment of veterans at their facility. The role
of the Polytrauma Point of Contact is to ensure that veterans are referred to a facility capable of
providing the services they require.
38 Veterans Health Administration, Polytrauma-Traumatic Brain Injury (TBI) System of Care, Department of Veterans
Affairs, VHA Directive 2009-028, Washington, DC, June 9, 2009; unless otherwise noted, all information in this
subsection is drawn from this source. Polytrauma is defined therein as “two or more injuries sustained in the same
incident that affect multiple body parts or organ systems and result in physical cognitive, psychological, or
psychosocial impairments and functional disabilities.”
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Figure 1. VA Polytrauma System of Care
Location of Polytrauma Rehabilitation Centers and Polytrauma Network Sites
Source: CRS adaptation of VA map from http://www.polytrauma.va.gov/system-of-care/care-facilities.
Note: A fifth Polytrauma Rehabilitation Center is currently under construction in San Antonio, TX.
The treatment process within the VA’s PSC (excluding any treatment provided by the DOD) is
illustrated in Appendix B, which also illustrates the identification process described earlier.
Coordination of VA and DOD Treatment
As noted elsewhere in this report, injured servicemembers may transfer directly from military
treatment facilities to VA medical facilities (and may later convert to veteran status), or veterans
may access VA medical facilities after having received treatment in military facilities. Such
situations require coordination between the two agencies in caring for servicemembers or
veterans with TBI. Three VA and joint VA/DOD programs seek to address the transition from
DOD to VA health care facilities: OEF/OIF Care Management, the VA Liaison Program, and the
Federal Recovery Coordinator Program.39
Every VA Medical Center has an OEF/OIF Care Management Team, consisting of case managers
and transition patient advocates, to help coordinate care and navigate the VA system. Case
managers are either nurses or social workers. Transition patient advocates serve as personal
advocates for patients moving throughout the VA health care system. This service is available to
all OEF/OIF veterans without referral.
The VA Liaison Program places VA employees at military treatment facilities, where they provide
onsite consultation about VA resources. Liaisons coordinate referrals with the OEF/OIF Care
39 Department of Veterans Affairs, Returning Service Members (OEF/OIF), http://www.oefoif.va.gov.
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Management teams at local VA facilities; they maintain involvement until health care is arranged
and transfer is complete. Figure 2 shows the locations of military treatment facilities with VA
liaisons and the number of liaisons at each facility.
Figure 2. Locations of VA Liaisons Assigned to Military Treatment Facilities
Source: CRS adaptation of DOD map from Real Warriors Campaign, http://www.realwarriors.net/guardreserve/
reintegration/VAbenefits.php
Notes: NNMC = National Naval Medical Center; WRAMC = Walter Reed Army Medical Center.
The Federal Recovery Coordination Program (FRCP) was established via a memorandum of
understanding between the VA and the DOD, signed on October 30, 2007.40 Veterans or
servicemembers with TBI (one of several qualifying conditions) can self-refer to the FRCP or be
referred by clinicians, family members, veterans service organizations, or others. Each veteran (or
servicemember) enrolled in the FRCP is assigned a Federal Recovery Coordinator (FRC), who
coordinates services provided by the DOD, the VA, and other public and private entities; the FRC
does not provide direct services.
TBI Research
The VA’s FY2010 budget for “TBI and Other Neurotrauma” research was $22 million
(rounded).41 Before applying a 0.2% rescission for most non-defense items, the full-year
continuing resolution for FY2011 maintained VA’s research funding at the FY2010 level.42
40 U.S. Congress, House Committee on Veterans’ Affairs, Subcommittee on Oversight and Investigations, Leaving No
One Behind: Is the Federal Recovery Coordination Program Working? 111th Cong., 1st sess., April 28, 2009, Opening
Statement of Chairman Mitchell.
41 Department of Veterans Affairs, Congressional Submission: FY 2011 Funding and FY 2012 Advance Appropriations
Request, http://www.va.gov/budget/docs/summary/Fy2012_Volume_I-Summary_Volume.pdf.
42 Department of Defense and Full-Year Continuing Appropriations Act, 2011, enacted April 15, 2011 (P.L. 112-10).
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The VA Office of Research and Development has solicited research proposals on a range of topics
related to TBI, including (but not limited to)
• identifying the origins, disease pathways, and genetics of TBI;
• operationalizing the definition of mild TBI;
• developing and evaluating instruments to measure TBI;
• assessing the service needs of veterans with TBI and barriers to treatment; and
• identifying and evaluating treatments for TBI.43
Research on TBI and related conditions may also be conducted under the auspices of the VA’s
Mental Health Strategic Healthcare Group (MHSHG), which supports the research efforts
conducted at the National Center for PTSD, four Centers of Excellence (CoEs), and 10 Mental
Illness Research Education and Clinical Centers (MIRECCs).44
The VA is currently partnering with the National Institute of Disability and Rehabilitation
Research to develop the Traumatic Brain Injury Veterans Health Registry, which will facilitate
future research by providing longitudinal data on the demographics, military service data, injury
information, and treatment of all veterans with TBI.45
The Defense and Veterans Brain Injury Center (DVBIC), a component of the Defense Centers of
Excellence for Psychological Health and Traumatic Brain Injury, is a collaboration between the
VA and the DOD. Research conducted by the DVBIC includes randomized controlled trials of
treatment strategies for TBI, epidemiologic studies of military-related TBI, and translational
research involving brain imaging technology.46
Potential Issues for the 112th Congress
This part of the report focuses on ongoing issues that may be of interest to the 112th Congress, in
the context of past congressional action addressing these issues. Appendix C summarizes
provisions of public laws that address TBI among veterans, beginning with the 108th Congress
and ending with the 111th Congress. In addition to specific issues noted here, a number of
initiatives are in the planning and implementation process, providing opportunities for Congress
to exercise its oversight function while programs are implemented and research is conducted.
Ongoing Issues in Access to Care
By extending the period of enhanced eligibility for OEF/OIF veterans (as described in the text
box, “Veterans Health Administration: Eligibility, Enrollment, and Services,” above), the National
43 Department of Veterans Affairs, Office of Research and Development, Program Announcement: Traumatic Brain
Injury, June 17, 2008.
44 U.S. Department of Veterans Affairs, MIRECCs and Centers of Excellence, http://www.mirecc.va.gov/national-
mirecc-overview.asp.
45 Department of Veterans Affairs, Two VA Initiatives on Traumatic Brain Injury in Veterans, March 2010,
http://www.publichealth.va.gov/docs/epidemiology/TBI_brochure.pdf.
46 Defense and Veterans Brain Injury Center, Research, http://www.dvbic.org/Research.aspx.
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Defense Authorization Act for Fiscal Year 2008 (P.L. 110-181) facilitated access to care.
However, a veteran’s own behavior—whether intentional or not—may interfere with his or her
ability to access the VA health care system and thus be properly diagnosed. Some veterans may
choose not to disclose symptoms of TBI because they believe that being diagnosed with a TBI
would affect their ability to stay in the National Guard or Reserves, or affect other future
employment plans.47 Similarly, some servicemembers leaving war zones may not disclose mental
health symptoms, or may downplay such symptoms, in order to avoid any delay in their return
home.48 Some veterans may not be fully aware of changes in their functioning due to TBI.49
Cognitive impairments due to TBI may compromise veterans’ ability to seek care or navigate the
system.50
Ongoing Issues in Identification of TBI
In addition to facilitating access to care (as noted above), P.L. 110-181 contributed to the
identification of TBI by directing the Secretaries of the VA and DOD to propose medical codes to
indicate TBI on medical records; this law also contributed to identification of TBI by requiring
the VA Secretary to establish and maintain a TBI Veterans Health Registry. The Traumatic Brain
Injury Act of 2008 (P.L. 110-206) also contributed to identification of TBI by involving HHS in
tracking the incidence and prevalence of TBI among veterans. Ongoing issues in identification of
TBI among OEF/OIF veterans at VA medical facilities generally fall into two categories—the
screening instrument and how it is used.
Because the VA modified an existing screening instrument, the VA is responsible for establishing
its validity and reliability for use with a slightly different population (i.e., OEF/OIF veterans
receiving care from the VA, rather than servicemembers returning from OEF/OIF). Clinical
validity refers to both how well the screening instrument identifies patients with TBI (i.e.,
sensitivity) and how well it identifies patients without TBI (i.e., specificity). At least one study
has found that the screening instrument has high sensitivity and moderate specificity.51 Because a
positive screen is followed by a more thorough evaluation, sensitivity is more important than
specificity in the screening instrument.
Reliability is the ability of the screening instrument to yield the same results if administered
repeatedly to the same person. A small, preliminary study of test-retest reliability found that most
47 U.S. Government Accountability Office, Mild Traumatic Brain Injury Screening and Evaluation Implemented for
OEF/OIF Veterans, but Challenges Remain, 08-276, February 2008.
48 Terri Tanielian and Lisa H. Jaycox, eds. Invisible Wounds of War: Psychological and Cognitive Injuries, Their
Consequences, and Services to Assist Recovery, RAND Corporation, 2008, p. 7, http://www.rand.org/pubs/
monographs/2008/RAND_MG720.pdf.
49 Rodney D. Vanderploeg, Heather G. Belanger, and Jennifer D. Duchnick et al., “Awareness Problems Following
Moderate to Severe Traumatic Brain Injury: Prevalence, Assessment Methods, and Injury Correlates,” Journal of
Rehabilitation Research & Development, vol. 44, no. 7 (2007), pp. 937-950.
50 Henry L. Lew, John H. Poole, and Sylvia B. Guillory et al., “Persistent Problems after Traumatic Brain Injury: The
Need for Long-Term Follow-up and Coordinated Care,” Journal of Rehabilitation Research & Development, vol. 43
(2006), pp. vii-x.
51 K.T. Donnelly, J.P. Donnelly, and M. Dunnamm, et al., “Reliability, Sensitivity, and Specificity of the VA Traumatic
Brain Injury Screening Tool,” Journal of Head Trauma Rehabilitation, E-pub ahead of print 2011.
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items in the screening instrument do not have good reliability.52 A larger study found that the
screening instrument has high test-retest reliability.53 Another VA study is in progress.54
The VA is also responsible for ensuring that the screening instrument is used as intended, by
properly trained staff. Investigations have found that some providers used the screening
instrument before being trained,55 and that some OEF/OIF veterans were not screened or had
delayed screenings because staff were not aware of procedures.56 The VA is currently tracking
completion and timeliness of TBI screenings and follow-up evaluations at the VISN level.57
Ongoing Issues in Treatment of TBI
Several laws have addressed treatment of TBI provided by either professionals or family
caregivers. The Veterans Health Programs Improvement Act of 2004 (P.L. 108-422) resulted in
the establishment of the Polytrauma System of Care. The Caregivers and Veterans Omnibus
Health Services Act of 2010 (P.L. 111-163) built on work initiated under the National Defense
Authorization Act for Fiscal Year 2007 (P.L. 109-364) in training family caregivers for veterans;
P.L. 111-163 also enabled the VA to utilize non-VA facilities under certain circumstances.
An ongoing issue in treatment of TBI is coordination of care. Programs intended to improve
coordination of care between VA and DOD may face their own coordination challenges. A 2011
report by the GAO identified challenges the Federal Recovery Coordinator Program is facing,
including in coordination with other programs.58 Because the majority of enrollees are enrolled in
at least one other program for wounded servicemembers or veterans, the program must coordinate
not only among care providers, but also among other care coordinators. Having multiple care
coordinators increases the potential for duplication of effort, conflicting treatment goals, or failure
to address issues (if each coordinator thinks someone else is handling the issue).
Ongoing Issues in TBI Research
Congress has appropriated funds for many research projects related to TBI. For example, the
National Defense Authorization Act for Fiscal Year 2008 (P.L. 110-181) required the VA to
collaborate with the TBI rehabilitation research community, grantees of the National Institute of
52 Sarah A. Van Dyke, Bradley N. Axelrod, and Christian Schutte, “Test-Retest Reliability of the Traumatic Brain
Injury Screening Instrument,” Military Medicine, vol. 175, no. 12 (2010), pp. 947-949.
53 K.T. Donnelly, J.P. Donnelly, and M. Dunnamm, et al., “Reliability, Sensitivity, and Specificity of the VA Traumatic
Brain Injury Screening Tool,” Journal of Head Trauma Rehabilitation, Epub ahead of print 2011.
54 Department of Veterans Affairs (Babcock-Parziale, Judi - Principal Investigator), Evaluation of VA’s TBI Clinical
Reminder And Secondary Level Evaluation, ClinicalTrials.gov Identifier: NCT00852527, http://clinicaltrials.gov/ct2/
show/NCT00852527.
55 U.S. Government Accountability Office, VA Health Care: Mild Traumatic Brain Injury Screening and Evaluation
Implemented for OEF/OIF Veterans, But Challenges Remain, GAO-08-276, February 2008, http://www.gao.gov.
56 VA Office of Inspector General, Office of Audits & Evaluations, Veterans Health Administration Audit of
Community-Based Outpatient Clinic Management Oversight, VAOIG-09-02093-211, July 28, 2010,
http://www.va.gov/oig/52/reports/2010/VAOIG-09-02093-211.pdf.
57 VA Quality Enhancement Research Initiative (QUERI), Polytrauma/Blast-Related Injuries QUERI Center Strategic
Plan, December 2009, http://www.queri.research.va.gov/about/strategic_plans/ptbri.pdf.
58 U.S. Government Accountability Office, DOD and VA Health Care: Federal Recovery Coordination Program
Continues to Expand but Faces Significant Challenges, GAO-11-250, March 23, 2011.
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Disability and Rehabilitation Research (within the Department of Education), the Defense and
Veterans Brain Injury Center, and other governmental entities engaged in TBI rehabilitation.
The large number of studies conducted by the VA, DOD, and HHS (including both the Centers for
Disease Control and Prevention and the National Institutes of Health) raises questions for some
about potential duplication of effort, gaps in the research, dissemination of research findings, and
translation of research into practice. While duplication of effort may seem wasteful, replicating
studies is a normal part of the research process; ideally, the replicated studies yield the same
results as the original study and thus increase confidence in the findings. The direction of
subsequent research is often guided by identifying gaps in the existing research. Dissemination of
research findings is necessary in order for the findings to be useful, and strong findings should be
translated into practice in order to improve care.
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Appendix A. OEF/OIF Veterans with TBI, by State
Table A-1. Number of OEF/OIF Veterans Diagnosed with TBI-Related Conditions at
VA Medical Facilities, FY2002-FY2010, by State of Residence
Alabama 766
Nevada
286
Alaska 258
New
Hampshire
232
Arizona 1,049
New
Jersey 480
Arkansas 1,106
New
Mexico 292
California 5,084
New
York 1,934
Colorado 1,158
North
Carolina
1,842
Connecticut 280
North
Dakota 219
Delaware 91
Ohio
1,389
District Of Columbia
93
Oklahoma
1,203
Florida 2,383
Oregon 706
Georgia 1,725
Pennsylvania
1,350
Hawai 361
Rhode
Island
129
Idaho 244
South
Carolina
379
Illinois 1,116 South
Dakota
224
Indiana 816
Tennessee 1,017
Iowa 369
Texas 4,075
Kansas 693
Utah
221
Kentucky 1,243
Vermont
163
Louisiana 505
Virginia
1,050
Maine 185
Washington
1,645
Maryland 493
West
Virginia
256
Massachusetts 636
Wisconsin
704
Michigan 790
Wyoming 147
Minnesota 1,028
Mississippi 331
Puerto
Rico 459
Missouri 796
Other
577
Montana 363
Unknown 336
Source: Response to CRS inquiry to VA Program Office, December 23, 2010.
Notes: Status as an OEF/OIF veteran is based on OEF/OIF deployment rosters from the DOD Defense
Manpower Data Center with the last out-of-country dates through August 2010. Diagnoses were made during
outpatient visits and hospitalizations at VA medical facilities between FY2002Q1 and FY2010Q4. TBI-related
conditions are defined by VA Environmental Epidemiology System as the fol owing ICD-9-CM codes: 310.2, 800,
801, 802, 803, 804, 850, 851, 852, 853, 854, 950. Each veteran may be diagnosed in the VA medical system with
multiple TBI-related conditions, but is counted only once in the table. State of residence taken from first record
of deployment in support of OEF/OIF. Due to the duration of OEF/OIF and repeated deployments, a number of
the veterans who died in-theater may have previously accessed VA health care services and may therefore be
included in these counts.
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Appendix B. Flowchart of VA Process for
Identifying and Treating TBI
Figure B-1. Flowchart of VA Process for Identifying and Treating TBI
Source: Visual depiction of the identification and treatment processes described under the heading “TBI Among
Veterans.”
Notes: VA = Department of Veterans Affairs; TBI = Traumatic Brain Injury; PSCT = Polytrauma Support Clinic
Team.
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Appendix C. Past Congressional Action
Table C-1 summarizes provisions of public laws that address TBI among veterans, beginning
with the 108th Congress and ending with the 111th Congress. Note that many of the laws listed in
Table C-1 do not focus on the VA, but include provisions relevant to veterans. For example, the
National Defense Authorization Act for Fiscal Year 2007 (P.L. 109-364) primarily addresses the
DOD, but is included because the panel it requires the DOD Secretary to establish is responsible
for developing curricula for training family members in the provision of care and assistance to
veterans (and servicemembers) with TBI. Similarly, the Traumatic Brain Injury Act of 2008 (P.L.
110-206) primarily addresses HHS, but is included because of a requirement that the HHS
Secretary report on activities and procedures that can be implemented by the Centers for Disease
Control and Prevention (CDC) to improve the collection and dissemination of epidemiological
studies on the incidence and prevalence of TBI in veterans.
Table C-1. Congressional Action on TBI Among Veterans, 2004-2010
(Excludes provisions focused on servicemembers, rather than veterans)
Public Law
Short Title
Key Provisions Related to TBI Among Veterans
P.L. 108-422
Veterans Health Programs
Directs the VA to designate an appropriate number of cooperative
Improvement Act of 2004
centers for clinical care, consultation, research, and education
activities on polytrauma (i.e., the Polytrauma System of Care).
P.L. 109-364
John Warner National Defense
Requires the DOD Secretary to establish a Traumatic Brain Injury
Authorization Act for Fiscal Year Family Caregiver Panel to develop curricula for training family
2007
members in the provision of care and assistance to servicemembers
and veterans with TBI.
P.L. 110-161
Consolidated Appropriations
Authorizes the VA Secretary to transfer up to $5 million to the
Act, 2008
HHS Secretary for the Graduate Psychology Education Program to
support increased training of psychologists in the treatment of TBI,
PTSD, and related disorders.
[Same provision appears in P.L. 110-329 and P.L. 111-117.]
P.L. 110-181
National Defense Authorization
Extends the period of enhanced eligibility for OEF/OIF veterans.
Act for Fiscal Year 2008
Directs the VA and DOD Secretaries to propose codes for
inclusion in the ICD to ensure that veterans and servicemembers
with TBI receive a medical designation concomitant with the injury.
Requires the VA Secretary, in selecting locations for an assisted-
living services pilot program, to give special consideration to rural
areas and locations with a high concentration of TBI.
Requires the VA Secretary to establish and maintain a TBI Veterans
Health Registry, including information about each OEF/OIF veteran
who exhibits symptoms associated with TBI and applies for care or
files a claim for disability compensation from VA. The VA is to
notify veterans in the registry of significant developments in
research on health consequences of OEF/OIF service.
Requires the VA to collaborate with the TBI rehabilitation research
community, grantees of the NIDRR of the Department of
Education, the DVBIC, and other governmental entities engaged in
TBI rehabilitation.
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Public Law
Short Title
Key Provisions Related to TBI Among Veterans
P.L. 110-206
Traumatic Brain Injury Act of
Requires the HHS Secretary to report on activities and procedures
2008
that can be implemented by the CDC to improve the col ection
and dissemination of compatible epidemiological studies on the
incidence and prevalence of TBI in veterans.
P.L. 110-329
Consolidated Security, Disaster
Authorizes the VA Secretary to transfer up to $5 million to the
Assistance, and Continuing
HHS Secretary for the Graduate Psychology Education Program to
Appropriations Act, 2009
support increased training of psychologists in the treatment of TBI,
PTSD, and related disorders.
[Same provision appears in P.L. 110-161 and P.L. 111-117.]
P.L. 111-117
Consolidated Appropriations
Authorizes the VA Secretary to transfer up to $5 million to the
Act, 2010
HHS Secretary for the Graduate Psychology Education Program to
support increased training of psychologists in the treatment of TBI,
PTSD, and related disorders.
[Same provision appears in P.L. 110-161 and P.L. 110-329.]
P.L. 111-163
Caregivers and Veterans
Directs the VA Secretary to establish a program of comprehensive
Omnibus Health Services Act of
assistance for family caregivers of eligible veterans, including those
2010
with TBI. Once fully implemented, the program will include
instruction and training in personal care services; ongoing technical
support; counseling; and lodging and subsistence while
accompanying the veteran for VA medical care. The program will
also allow additional assistance for the primary personal care
provider, including mental health services, respite care, and a
monthly stipend comparable to that provided to commercial
caregivers in that geographic area.
Authorizes the VA Secretary to utilize non-VA facilities (that meet
accreditation standards) for the care and treatment of veterans
with TBI, and to contract with non-VA providers for specialized
residential care and rehabilitation services to veterans with TBI
who would otherwise require nursing home admission.
Directs the VA Secretary to establish the Committee on Care of
Veterans with TBI, to continually assess VA capabilities to meet the
treatment and rehabilitation needs of veterans with TBI.
Source: CRS analysis of data from the Legislative Information Service.
Notes: TBI = Traumatic Brain Injury; OEF/OIF = Operation Enduring Freedom and Operation Iraqi Freedom
(including Operation New Dawn); VA = Department of Veterans Affairs; DOD = Department of Defense; HHS
= Department of Health and Human Services; CDC = Centers for Disease Control and Prevention; ICD =
International Classification of Diseases; DVBIC = Defense and Veterans Brain Injury Center; NIDRR = National
Institute of Disability and Rehabilitation Research.
Author Contact Information
Erin Bagalman
Analyst in Health Policy
ebagalman@crs.loc.gov, 7-5345
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Acknowledgments
This report is an update based on the original report written by Amalia K. Corby-Edwards, Analyst in
Public Health and Epidemiology. Patricia S. McClaughry, Senior Graphics Specialist, produced the
graphics.
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