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The other highly specialized outpatient program
offered by BRS is the Blind Rehabilitation Outpatient Specialist
(BROS) program. This is a relatively new approach to the delivery
of blind rehabilitation services to those blinded veterans who
cannot or will not attend a residential blind rehabilitation program.
A major shortcoming of the VA Blind Rehab in the past was the
lack of follow-up for veterans having completed the residential
program. VA BRS did not possess the workforce to carry out effective
follow-up, which would assess how effectively the veteran had
transferred the newly learned skills to his or her home environment.
Thanks to Congress earmarking $5,000,000 for BRS in the FY1995
VA Appropriation, BRS was able to establish 14 new BROS positions
in 14 different facilities around the system. Following that time,
four or more positions have been established. Although this is
a comparatively small number of professionals, it provides VA
with an excellent opportunity to evaluate the effectiveness of
the rehabilitation approach and with what segment of the overall
blinded veteran population it is most effective.
The BROS is a highly qualified professional
who, ideally, is dually certified: that is, he or she has a dual
Masters Degree both in Orientation and Mobility as well as Rehabilitation
Teaching. In the absence of such dually credentialed professionals,
Masters level blind rehab specialists selected for these positions
undergo extensive cross training at one of the BRCs. This prepares
these individuals to provide the full range of rehab services
in the veteran's home environment. The delivery of such outpatient
rehabilitative service may prove to be cost efficient for those
veterans who have rehabilitation needs but are unable to attend
the residential program. Many of these individuals may be at risk
and must not be denied essential rehabilitative services. Additionally,
the highly skilled professionals conduct comprehensive assessments
of the newly identified blinded veteran's needs to determine if
referral to a residential BRC is indicated. If this proves to
be the case, they may also provide some initial training before
admission, thus potentially reducing the length of stay in the
BRC. VA BRS is currently in the process of collecting functional
outcome data through the Outcomes Project for this new program.
Once sufficient data has been collected, decisions regarding the
effectiveness of this method of service delivery can be more appropriately
evaluated. Given that there are relatively few active BROS, sufficient
data does not currently exist to unequivocally validate this treatment
approach. Clearly, given the rapidly aging veteran population
and the increased prevalence of blindness associated with aging,
there will certainly be an increasing number of severely visually
impaired and blinded veterans who will be at risk but unable or
unwilling to attend a residential BRC. Field managers, however,
seem determined to accomplish all blind rehab services using this
model, in effect fully dismantling the residential programs.
Like the full-time VIST Coordinator positions,
two Visual Impairment Service Networks (VISNs) have failed to
fill vacancies in two of these BROS position. One VISN took more
than 14 months to make the decision to fill the vacancy. That
was only after BVA elevated the problem to Acting Secretary Gober
as previous attempts to have the problem fixed within VHA were
unsuccessful. The other network had frozen the vacant BROS position
and it remained vacant for more than one year. This comes after
the network director, in a letter to BVA, indicated that the position
would be filled once approval was sought by the facility. These
blatant abuses argue strongly for centralized management authority
for all elements of BRS. We appreciate the severe fiscal constraints
the networks and facilities are operating under. Nevertheless,
just one FTEE makes a bold difference in service delivery for
blinded veterans.
Mr. Chairman, the outcome measures gradually
being implemented and continually refined by VA BRS will eventually
provide a wealth of extremely valuable data about VA Blind Rehab
Services. There is hope that this data will not only validate
the efficiency of these services but also provide VA with a profile
to determine just what method of rehab intervention is most effective
with each type of blinded veteran. Here again, VA BRS is engaged
in a pioneering effort as this type of data or data collection
is unavailable anywhere in the field of blind services. Having
a relatively complete profile outlining the rehabilitative needs
of blinded veterans and what training model would be most beneficial
in addressing those needs would be an extremely valuable tool
for VIST Coordinators as they assess the needs of a given blinded
veteran. Such a profile should facilitate making the most appropriate
referral. Provided the outcome data validates the outpatient delivery
model, this could result in substantial cost savings. We caution
however, that outcome measures must be fully implemented with
sufficient data collection and analysis before programmatic decisions
are made.
While we understand the urgency, many network
and facility directors feel to complete the transformation of
the VA health care system and achieve substantial cost savings,
we firmly believe these decisions must be based on solid data.
In the case of the special disability programs, those decisions
must await sufficient data collection.
Currently VA provides only two options in
terms of rehabilitative service delivery, residential blind rehabilitation,
and the BROS. The latter is a little more than three years old
and is still under development. Furthermore, 16 positions clearly
do not provide equity of access to this model of service delivery.
I am pleased to report, however, that VA has
initiated a new approach combining the features of a residential
program with those of outpatient service delivery. The VAMC Lebanon,
Pennsylvania established the Visual Impairment Service Outpatient
Rehabilitation (VISOR) program. This approach employs the use
of hospital beds for veterans to stay for ten days while attending
a regular blind rehab training program. The beds do not enjoy
24-hour nursing coverage and, for all intents-and-purposes is
similar to staying in a hotel. The VISOR program is providing
functional outcome data to the Outcomes Project, and will afford
the opportunity to compare functional outcomes derived from this
approach to the more traditional residential BRC or the BROS.
There may be other models of service delivery not yet developed
and further research in this area must be encouraged. VA should
not abandon its leadership role in the field of blind rehabilitation
services. They must continue to explore additional alternatives
to addressing the needs of blinded veterans. Hasty decisions to
move to new untested or unproven models must be strongly resisted.
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