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Lincoln T. Smith

Lincoln T. Smith, Altarum Institute, Ann Arbor, MI, President and Chief Executive Officer

Good morning, Chairman Michaud, Ranking Member Brown, and Members of the Subcommittee.

Thank you for inviting Altarum Institute to testify on how the Department of Veterans Affairs can utilize new and innovative wireless technologies to expand access to care for veterans.  In our testimony,we will address a unique research study that we have successfully implemented at the Pathway Home, a residential veterans treatment center for returning warriors afflicted with mild traumatic brain injury and post-traumatic stress disorder.  We will also share how we have been able to integrate clinical treatment, technology, and research to enhance the recovery of service members who have served this country so valiantly. 

Altarum Institute is a nonprofit health systems research and consulting organization serving government and private-sector clients.  We provide objective research and tailored consulting services that assist our clients in understanding and solving the complex systems problems that impact health and health care.  Our unique model combines the analytical rigor of a research institution with the business acumen of a traditional consultancy to deliver comprehensive, systems-based solutions that meet unique needs.

Altarum has a very strong commitment to serving the needs of our nation’s service members and veterans.  For over 30 years, Altarum and our predecessor organizations have worked to improve military and veterans health care serving such diverse clients as the TRICARE Management Activity, the Army, Navy, and Air Force medical services, and the Department of Veterans Affairs.  Our commitment to our nation’s current and former service members does not stop with our client-based work.  Starting in 2008, we launched our $7 million Mission Projects Initiative, which includes the multiyear Veterans Community Action Teams project which we have discussed with this subcommittee in the past.  Recently, we committed to continuing the use of our own funds to benefit service members when we initiated our Veterans Transition to Community Project, which my testimony today will focus on.

Altarum’s Veterans Transition to Community Project was initiated to address one of the most critical issues affecting the almost two million Americans who have directly served or supported Operation Enduring Freedom and Operation Iraqi Freedom.  As in previous conflicts, many service members were subjected to blast-related injuries.  Estimates of 12–20 percent[1] of them were close enough in proximity to a concussive event while deployed to screen positive for mild traumatic brain injury (mTBI).  Many recover fully; however, others recover only partially and have their injuries revisit, and sometimes debilitate, them without warning.

Treatment teams have always struggled to develop comprehensive treatment plans from bits and pieces of information.  Problems such as post-traumatic stress disorder (PTSD), substance use disorders (SUD), major depressive disorders (MDD) and/or mild traumatic brain injury all result in some level of short-term memory loss.  The science of treatment is too often limited because of an incomplete picture of what is going on in the service members’ lives.  To complicate things further, a large number of our warriors are Reserve or National Guard members who, because of the nature of their service obligations, did not stay on a post following mobilization, but instead dispersed after their release from duty to every corner of the nation, making follow-up treatment and observation much harder.   

An unfortunate reality is that many of our returning service members simply do not receive treatment to address these serious health issues.  TBI is estimated to have occurred in 12–20 percent of Iraq and Afghanistan veterans.  Only 7 percent of veterans presenting for treatment through the VA have received treatment for their brain injury.  The remaining 3–13 percent of the almost 2 million veterans have not received treatment at this time.[2]  It has been projected these numbers could be as high as 300,000 troops.[3] The number of military treatment facilities, VA facilities, and contracted facilities that have the requisite skills, knowledge, and training to address theses psychological health needs is simply insufficient to meet this demand.  New techniques are required. 

Through our Veterans Transition to Community Project, Altarum has implemented a novel but elegant solution that has significant potential to dramatically impact the lives of service members and ease the burden on providers.  Our solution not only facilitates health and wellness for returning service members and their families, but it also leverages the time and resources of existing clinical and treatment staff.   The Veterans Transition to Community Project is exploring methods and technologies to connect service members to the care they need using technology that is already owned by virtually all returning service members—a cell phone.  This technology builds on skills and knowledge that warriors already possess.  The criteria are simple.  Can you e-mail?  Can you text?  Do you like pictures?  How about music?  Can you answer questions with a scale of 1–9?  This reduces training and implementation time to almost zero and also reduces participation resistance.

Our project addresses treatment in all phases of care.  During the initial treatment phase, we make use of a simple Palm PDA to begin collecting information on mental well-being.  We use the PDA to collect multiple ecological momentary assessments (EMA) from service members diagnosed with PTSD, SUD, MDD, and/or mTBI.  EMAs are short multiple choice questions that document items such as stress, rejection, fear, craving, pain, and coping several times daily over a period of months.  Data are collected and analyzed to create a composite picture of the service member or veteran—not at the single instance of treatment, but across time and daily activity.  These data improve the accuracy and applicability of treatment.

Once the service member or veteran begins the transition to home, we implement an innovative application of mobile phone technology to extend treatment and maintain contact with the patient.  EMA data collected from the individual are compared with information gathered during the clinical treatment phases.  Data are then used to tailor individualized two-way interactions with the service member or veteran customized to their strengths, needs, and recovery resources.  Altarum uses EMA data, clinical observations, and patient input to offset patient-specific triggers while augmenting motivators and support system contacts.  Reminders, supportive messages, pictures of pleasurable memories, inspirational music, and an interactive pain-scale support the service members and veterans to avert crises that may affect them in their transition from the therapeutic environment to work and community life.

Altarum’s Veterans Transition to Community Project extends treatment beyond the walls of any facility.  All that is necessary is a cell phone connection.  Our original test cohort continues to receive support and, when necessary, treatment as they disperse across the country.  Because the core of the system depends on automation, time zones and work schedules do not affect service delivery.  This intervention is driven by the demands of the service member, not the availability of clinical treatment staffs.

The advantages of our method of supporting treatment through this flexible yet common technology are manifold.

First, in a time of increasingly tight budgets, the incremental cost of maintaining a service member in this program is negligible.  A month of effective contact can be maintained with service members for far less than the cost of a single office visit.  Altarum’s project uses the veteran’s existing cell phone.  Once implemented, the secure Web-based treatment interface can be accessed from anywhere and updated in real-time by existing clinical or support staffs.  No servers, computers, hardware, software, or expensive equipment are required. 

Second, our technique is flexible and adaptable to the individual needs of each service member.  Our armed forces are a composite of American society, and one size does not and cannot fit all.  The Veterans Transition to Community Project is designed to be adapted to each participant with minimum of effort.  Altarum developed the core technology and processes, but the service member works with a treatment team to develop personalized interventions that best suit his or her needs.  Using the unique Life:WIRE Web-based interface, treatment is customized to the needs, language, and preferences of each client.  Our solution even allows each warrior to develop a personal support group which can be automatically prompted to text, e-mail, call, or call for help in later stages of treatment as the situation dictates. 

Third, our method creates a stream of data—data that can be evaluated against multiple criteria to help inform treatment, diagnoses, and progress.  Often the data provide insight into related factors affecting recovery that were not readily apparent and can have tremendous benefits not only to the individual patient, but to the wider needs of the research and treatment community.  Through our partnership with Chesapeake Research and Review, Inc., we have developed a model that protects human subjects and addresses all areas of federal privacy rights and regulations.  Secure, de-identified data can be extracted to isolate potential factors affecting recovery.  EMA data can be extracted and compared to original assessment instruments to validate the predictability of current assessment technologies.  With sufficient cross-site implementation to justify statistical validity, substrates of these data can be analyzed to identify potential differences in recovery by theater of conflict, service, gender, age, etc.

Altarum has provided the research design, funding, and analytical support of all periodic and outcomes data and is the originator and managing partner for the Veterans Transition to Community Project.  But we could not conduct this project on our own.  Altarum has partnered with three organizations whose expertise has been critical in the development and application of our techniques.  The Pathway Home, a veterans’ treatment center in Napa Valley, California, specializing in PTSD, is our research and implementation site.  BrainPCheckers® provides an electronic PDA-based assessment tool for PTSD.  Daily assessments are collected using an automated survey system.  Our cell phone interaction, support, and messaging is provided by Life:WIRE.  Each partner provides an integral piece of the project. 

Altarum has learned many critical lessons as we work through the successful implementation of this research study.  One size does not fit all.  An early participant explained that, “he didn’t feel like he could answer a question if he didn’t know what all of the words were really asking.”  Every part of treatment must be adapted to the context of the person being served.  Service members and veterans are more likely to stay involved in their continued treatment when they feel the treatment was made for them and not a generic regimen.  Clients are even more likely to stay involved when they feel they have input in adapting their treatment as they recover and their needs change.  Finally, we learned that when the treatment meets the needs of those it serves, the clients will monitor and encourage one another.  Peer support continues to proportionately increase utilization for every person involved in our research study.

The ultimate measure of success, for Altarum, is improving and protecting the lives of veterans.  The following words relayed from one of Altarum’s research staff members tells it all:

During our weekly status call, the director of our research partner, the Pathway Home, reported that our cell phone follow-up had made a big difference in the well-being, perhaps even the future, of one of the veterans.  This warrior wasn’t one of our study participants, but one of the graduates of the Pathway Home working with us to fine-tune the delivery system.  He had completed his therapy.  He is living at home in another state with his wife and family and has begun normal work.  Last weekend he used his phone to trigger a crisis response.  But, this crisis wasn’t a test—it was his.  His response immediately text messaged his clinician who was able to call the veteran and de-escalate a serious episode.  The episode resolved with a short visit to an emergency room rather than what seemed to be another extended relapse into a mental institution.  This father is back at home with his family.

Altarum’s Veterans Transition to Community Project has already changed lives.  Our solution has the advantages of low cost, rapid deployment, facility for remote distribution, and adaptability to the needs and environment of those it serves.  This makes it ideal for implementation across multiple systems—particularly for those suffering from mTBI, PTSD, SUDs, and MDDs.  We are pleased to be able to brief this committee on the measurable success available to our returning service members through this innovative program.  Thank you for this opportunity.

Mr. Chairman, this concludes my statement.

Thank you.


[1] Ramchand et al. (2010, February). Disparate prevalence estimates of PTSD among service members who served in Iraq and Afghanistan: Possible explanations. Journal of Traumatic Stress, 23, 59-68.

[2] Carlson et al. (2010, February). Psychiatric diagnoses among Iraq and Afghanistan war veterans screened for deployment-related traumatic brain injury. Journal of Traumatic Stress, 23, 117-24.

[3] Kehle et al. (2010, February). Early mental health treatment-seeking among U.W. national guard soldiers deployed to Iraq. Journal of Traumatic Stress, 23, 33-40.