WASHINGTON, DC — Investigators have linked recent incidents of VA patients dying by suicide to inadequate TBI care, leaving legislators concerned that veterans with traumatic brain injuries are falling through the cracks. It also has them questioning whether filling those gaps with non-VA care would strengthen or disrupt the continuity of care for veterans with TBI.
“In January, the [VA Office of the Inspector General] released a report about a patient who died by suicide after receiving mental healthcare at a VA facility. Among the reviewed concerns, the OIG found the VA facility did not provide adequate follow-up for the patient’s TBI,” said Rep. Marionette Miller-Meeks (R-IA) at a recent House VA Health subcommittee hearing on the topic. “This veteran was a middle-aged man with a history of mental illness, migraines, chronic pain and gait disturbances with documented falls. In other words, he was the classic clinical picture of an individual with TBI. Yet somehow the patient didn’t receive follow-up specific to TBI, and his mental health declined until the end.”
An investigation of a similar incident at another facility found that staff did not submit a consultation for a TBI evaluation following a veteran’s positive TBI screening. Miller-Meeks also pointed to a third OIG report that found VA failed to properly report its spending on TBI care, which it’s obligated to do.
“Quality in patient care is the most urgent need, but quality in data is also necessary. In the past annual congressional reports have reflected outdated information and the number of inpatient beds dedicated to TBI. Reports have also omitted key spending information on the number of veterans with TBI treated annually,” Miller-Meeks said. “Wrong data takes resources away from areas of need.”
While VA leaders did not speak to those specific incidents, they did stress the complexity of TBI care and the importance of integrated services for veterans with complex injuries.
“Any veteran who served after September 11 is screened for possible TBI and then evaluated by a specialist to make sure their medical record was documented with a specific diagnosis. … [We’ve found that] veterans with TBI compared to civilian counterparts have a higher comorbidity for mental health conditions,” said Joel Scholten, MD, VA’s director of Physical Medicine and Rehabilitation.
Those comorbidities, which include PTSD, depression, physical injuries, as well as symptoms caused by toxic exposure, highlight the importance of a polytrauma system of care that follows a veteran throughout their life, Scholten added.
“TBI is a chronic condition,” he explained. “Patients don’t come to a TBI rehab clinic and have a silo of care and then move on and live the rest of their life. Instead, intensive evaluation and skilled treatment is focused on improving the veterans’ symptoms, improving functional ability, and ability to participate in community activities.”
While the hearing avoided becoming a referendum on direct care versus community care—something that has occurred at numerous recent hearings—Scholten stressed the importance of keeping veterans in the VA system.
“Each veteran has a unique presentation; therefore, their plan of care should be individually developed. Any efforts we can do to better integrate care delivery will result in greater impact on symptom reduction,” he said. “That care is obviously easier to provide when it is provided within the VA healthcare system, because we’re focused on providing wraparound services for traumatic brain injury.”
Though legislators remained relatively quiet on community care, they did use the opportunity to debate the merits of The BEACON Act. The proposed legislation would channel funds from VA into grants to private organizations conducting treatment and research, including clinical trials into mild TBI.
“[The BEACON Act] would divert funding from VA general mental healthcare programs and the Center for PTSD,” argued ranking Democrat Julia Brownley (D-CA). “The bill does not establish sufficient uses of funds or require sufficient scientific rigor to ensure the outcomes of the scientific trials are usable. VA’s existing research infrastructure is better suited to conduct these trials and already does.”
Proponents of the bill, like Dr. Russell Gore, chief medical officer at the Avalon Action Alliance, a nonprofit dedicated to helping veterans access complex care, see the legislation as something to supplement VA care, not supplant it.
“I see this as an opportunity for building partnerships, building capacity and for establishing the evidence necessary to shift what we consider to be the standard of care for traumatic brain injury,” Gore told Brownley. “The current standard of care for TBI in this country in particular mild to moderate injury is to do nothing, and that’s scary.”
