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  • Tricare provider


    Some Tricare beneficiaries still have problems trying to get medical care, and officials have taken actions to try to improve the performance of contractors, said Navy Vice Adm. Raquel Bono, director of the Defense Health Agency.

    Officials are closely monitoring the performance of the two U.S. Tricare contractors, Humana Military in the East region, and Health Net Federal Services in the West region, said Bono, speaking at a family forum Monday at the 2018 AUSA annual meeting.

    She said she recently was impressing upon some senior spouses that “it’s extremely important to me that we get the type of performance we need” from the contractors.

    And, she told them, “While I may not look like it, I can be a bad ass.”

    Defense health officials have issued several corrective action plans to the contractors, among other things. Through August, the contractors were meeting contract requirements at a level of about 80 percent.

    She said there are still challenges with the accuracy of the contractors' provider directories. Defense health officials have issued corrective action plans to both contractors regarding these issues. Families have had trouble finding area doctors and other medical providers who are in the Tricare network.

    Officials also issued a corrective action plan to Health Net regarding its customer call centers. Humana has corrective action plans regarding claims processing, correspondence, autism care/Applied Behavior Analysis therapy.

    Tricare underwent massive changes in January, as three regions were reduced to two, and Tricare Select replaced Tricare Standard and Extra. There have also been increases in some co-pays and some pharmacy costs.

    Help spread the word

    Bono asked for the help of those in the audience – which included many military spouses – in getting the word out about important changes coming up.

    There are new requirements for those who are retiring. To keep Tricare with no break in coverage, the service member must re-enroll within 90 days of retirement.

    There are new open enrollment seasons affecting three benefits, all of which will be held Nov. 12 to Dec. 10:

    • Those in Tricare Prime or Select who like their plan don’t need to do anything. But anyone wishing to switch from Prime to Select, or vice versa, must do so during that open season. Until now, families could switch at any time. But once the open season is over, a switch can be made only for a qualifying life event. A few examples of those are moving, retiring, separating from active duty, getting married, having children, and getting divorced. (
    • The Tricare Retiree Dental Program ends Dec. 31. To have dental coverage for themselves and their family members through the government in 2019, retirees must enroll in the FEDVIP plan during that open enrollment season which starts Nov. 12. (
    • Retirees and their family members and active duty family members (not active duty) will also have access to new vision coverage under the FEDVIP, during that open enrollment season which starts Nov. 12. (


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  • Charities Honored


    A new charity that pays for and helps organize reunions for combat Veterans has received a $50,000 grant, the highest honor in this year’s Newman’s Own Awards competition.

    “The prevailing narrative about my Veteran generation is wrong. We are not broken, we don’t need to be fixed, we don’t need over-engineered solutions. We just need each other,” said Marine Corps Veteran James Ferguson, founder of the Warrior Reunion Foundation of Cockeysville, Maryland, in accepting the award at the Pentagon Friday.

    In just over a year, the foundation has provided seven reunions to soldiers who deployed to combat together. The eighth reunion is scheduled for November.

    While the reunions so far have involved units in the post-9/11 conflicts, their eligibility spans all generations of Veterans — soldiers in any unit who served together in any combat zone during any armed conflict.

    This marks the 19th year of the awards, sponsored by Newman’s Own, the Fisher House Foundation, and Military Times. Since the program was launched in 1999, Newman’s Own and Fisher House Foundation have contributed $1.9 million to 179 organizations for their innovative programs to improve quality of life in the military community.

    Five organizations were awarded a combined total of $200,000 in a ceremony Friday at the Pentagon.

    The organizations’ work “transcends the 50 people, 1,000 people, 100 people” they touch in their work, said Joint Chiefs Chairman Marine Gen. Joseph Dunford. “It’s sending a message that you value our Veterans,” he said.

    And this message has an impact on retention and on recruiting, as Veterans in the community encourage younger generations to serve, he said.

    The ability of the United States to sustain the high quality all-volunteer force “is really about the loud and clear message that we respect, value and appreciate the service of those in uniform,” he said.

    “Your service is inspiring and your example is humbling,” said Dave Coker, president of Fisher House Foundation told the organizations. “Your efforts to improve the quality of life in the military community is what we’re celebrating today.”

    Newman’s Own, founded by Navy Veteran and actor Paul Newman in 1982, has donated more than $530 million to thousands of charities, donating all the profits and royalties from the sale of its food products.

    “Our giving is at its best when we meet organizations like those here today that address the needs that fall in between the pillars of what’s already in the establishment,” said Jeffrey Smith, vice president of operations for Newman’s Own, Inc. “In many ways, our giving and your doing has the connective tissue” that enables solutions to come together, he said.

    Andrew Tilghman, executive editor of Military Times, noted that over the years, the Newman’s Own award winners have provided a snapshot in time of what service members and Veterans need most — such as groups sending care packages overseas, and providing funding for phone calls, and providing various forms of support for families of deployed service members in the early 2000s. Today, the groups are focusing more on the long-term transition of Veterans.

    While the all-volunteer force has been an historic success, he said, sometimes it’s taken for granted.

    “This extraordinary American institution needs support, but the Defense Department can’t do it all alone," he said. “It’s organizations like these honored here today that are helping to do just that, by contributing to and strengthening the social contract between the American people and the service members and Veterans who volunteered to protect them.”

    Ferguson said his organization is helping to support those long-term needs by helping combat comrades easily reconnect, sharing experiences only those in the same unit may understand. They pay for the reunions and help guide unit members through the planning process.

    The warrior reunions are often held outdoors, in environments more similar to a field environment, with the Veterans sleeping in cots under tents. They share stories around bonfires and during activities; they hear from experts from support organizations serving a variety of needs; they do service projects; and they hold memorial services for the fallen in their unit. Often, some of their Gold Star families attend.

    The reunions are modeled after the first one Ferguson organized for his Marine unit in 2015, which he started because he needed to spend time with his fellow Marines.

    Judges in the competition are Dunford’s wife Ellyn, Tammy Fisher, Suzie Schwartz and Lynn Pace, all trustees of the Fisher House Foundation, and Smith from Newman’s Own.

    Those receiving awards of $37,500 are:

    • Code Platoon,Chicago,Illinois. Provides software coding training to help local Veterans and military spouses pursue careers as professional software developers. Students can use their GI Bill benefits or apply for scholarships. Classes of eight to 12 students spend 60 to 80 hours a week for 14 weeks. The course is a mix of lectures, advanced coding training in Python and Ruby on Rails and team projects.
    • West Virginia Health Right, Inc.,Charleston,West Virginia. Provides free dental care to low income West Virginia Veterans without dental coverage, through their Veteran’s Dental Program. The care includes cleanings, exams, fillings, extractions and dentures. This grant will be used to help fund a program that will use a mobile dental clinic traveling to six rural counties and the onsite dental clinic at their main office, treating 500 Veterans in need.
    • Healing Warriors Program,Boulder,Colorado. A nonprofit clinic that provides non-narcotic Integrative Care therapies to treat pain and symptoms of post-traumatic stress in Veterans, active duty members and their families throughout the Colorado Front Range and southern Wyoming. Their mission is to advance the well-being through these evidence-based Integrative Care services and education.
    • Vets on Track Foundation, Inc.,Garrisonville,Virginia. Furnishes homes for Veterans who have been placed into permanent housing after living on the streets or in a shelter. This “Fresh Start” program volunteers turn these houses into warm, loving homes with everything from sofas, beds, dining room tables and chairs, dishes and silverware, to pictures, pillows and blankets.


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  • Jeff Dettbarn

    IOWA CITY, Iowa – Radiology technologist Jeff Dettbarn said he knew something was wrong at the Department of Veterans Affairs hospital in Iowa City, Iowa, when a patient arrived in February 2017 for a CT scan, but the doctor’s order for it had been canceled.

    “To have a patient show up for a scan and not have an order – you’re like, ‘What the heck is going on?’ ” he told USA TODAY in an interview.

    Dettbarn started collecting cancellation notices for diagnostic procedures such as CT scans, MRIs and ultrasounds.

    “I knew something was not right,” he said. “Because none of them were canceled by a physician.”

    Cancellations of more than 250,000 radiology orders at VA hospitals across the country since 2016 have raised questions about whether – in a rush to clear out outdated and duplicate diagnostic orders – some facilities failed to follow correct procedures. At issue is a concern over whether some medically necessary orders for CT scans and other imaging tests were canceled improperly.

    The VA inspector general is auditing mass cancellations at eight VA medical centers “to determine whether VA processed radiology requests in a timely manner and appropriately managed canceled requests,” VA Inspector General Michael Missal said.

    Those hospitals are in Tampa and Bay Pines, Florida; Salisbury, North Carolina; Cleveland; Dallas; Denver; Las Vegas; and Los Angeles.

    After receiving inquiries from USA TODAY, a ninth was added – Iowa City.

    In Iowa City, Dettbarn alerted the hospital’s compliance officer about his concerns. He is now facing disciplinary proceedings and contends they are an effort to retaliate against him.

    The VA declined to comment on disciplinary proceedings without Dettbarn’s written consent to discuss personnel matters, which he did not provide.

    This much is clear: in sworn testimony in the disciplinary proceedings against Dettbarn, Iowa City administrative staffer Lisa Bickford saidshe and other employees were told by the hospital’s chief radiologist that they needed to “clean” up a backlog of incomplete diagnostic orders, some dating back years.

    The staff responded by “annihilating” thousands of orders in a matter of weeks, Bickford said.

    Bryan Clark, a spokesman for the Iowa City hospital, acknowledged the facility failed to follow national VA guidelines for diagnostic order cancellations but said that happened in only a “small number of instances” and “anything closed improperly was reviewed” and actions were taken to try to ensure Veterans received any needed exams. He said the process was intended to “ensure the quality and safety of the care delivered to Veteran patients.”

    The VA said many of the orders were outdated or duplicated. The agency said it welcomes the oversight and is working with the inspector general to improve cancellation guidelines. VA officials said efforts to close the loop on test orders with physicians and Veterans surpass private-sector practices.

    Laurence Meyer, the chief doctor overseeing specialty care for the national VA, told USA TODAY he didn’t want to comment on how individual VA hospitals handled cancellations, but he acknowledged “we’ve received word that a few places haven’t been following the directive as intended.”

    “We’ve sent out teams and have reviewed and are aggressively working to fix that,” he said.

    The VA’s guidelines on order cancellations have undergone revisions in the past few years.

    In 2016, hospitals were told to try contacting patients multiple times before cancellations. Last year, the rules required review by a radiologist or the ordering provider before canceling. If the tests were still needed, patients should be contacted to schedule them. Since last year, hospitals have been required to establish a fail-safe "triage" process, such as written verification of review by providers.

    Concerns about diagnostic test order cancellations have also been raised at the VA hospital in Tampa. Employees estimated they canceled thousands of radiology orders without checking first with doctors or patients, according to depositions in a discrimination lawsuit brought by four ultrasound technicians.

    Those technicians told USA TODAY they worry Veterans may have gone months, if not a year or longer, before they or their doctors realized tests weren’t performed – if they realized at all. Technologist Erin Tonkyro noted that risk factors for many Veterans are higher than for other patients.

    “Cancer grows very quickly, and our patients are not like those patients on the outside – it doesn’t mean that cancer doesn’t happen in private practice. But our Veterans have been exposed to such a large amount of toxic environments like Agent Orange; now we’re talking about the burn pits that have happened overseas,” Tonkyro said.

    ‘We knew it was bad’

    At the Tampa facility, radiology managers began tackling outstanding orders in fall 2016.

    As many as 10 people were tasked with the job, one administrative staffer testified in a deposition in the technicians’ lawsuit. Multiple employees testified they canceled orders by date and did not consult any doctors before doing so, nor was there patient contact.

    They disabled office printers because of the volume of cancellations – one employee estimated they canceled thousands of radiology orders, according to testimony.

    “That’s when we really started getting worried,” said Tonkyro, who attended the depositions with her co-plaintiffs, ultrasound technologists Yenny Hernandez, Kara Mitchell-Davis and Dana Strauser. “We knew it was bad, but we had no idea the magnitude of how bad it was.”

    Strauser told USA TODAY that administrators went beyond past orders and canceled future ones. Those could have been follow-up scans for Veterans who might have been at risk of developing medical conditions, such as cancer recurrence.

    “Doctors will put an order in for six months in advance and sometimes even a year in advance, and we were getting cancellations of those future orders,” she said.

    In a statement issued by VA spokesman Curt Cashour, the VA declined to comment on what happened in Tampa, citing the litigation. “However, we are confident the James A. Haley Veterans’ Hospital has processes and procedures in place to provide the best care possible for our patients,” the statement said.

    The Tampa Bay Times first reported the technicians’ concerns in July, and the hospital’s chief of staff, Colleen Jakey, wrote to providers the following month asking them to review canceled orders, according to a copy of the correspondence obtained by USA TODAY.

    “We believe appropriate action was taken,” Jakey wrote, adding that a review of a random sample of cancellations did not turn up any cases of harm to Veterans. “This is a second-level review of these orders to confirm that each of these patients received the appropriate care and/or follow up.”

    The technicians told USA TODAY some doctors have since reordered canceled exams but won’t know whether Veteran patients suffered any harm from the delays until they are performed and assessed.

    ‘An important patient safety issue’

    VA hospitals came under increasing pressure to address outstanding diagnostic orders after a conference call that national officials convened with radiology managers across the country in January 2017. More than 325,000 orders for scans of Veteran patients had not been completed nationwide.

    The VA’s top radiologist, Robert Sherrier, called it “an important patient safety issue” in a presentation for the call.

    “Ordered studies are not being performed on Veterans, and providers may not be aware that the ordered study has not been completed,” he said.

    In a dozen states, there were VA medical centers with more than 5,000 outstanding orders, his presentation said. The numbers reached 29,000 in Columbia, S.C.; 21,000 in Cleveland; and 12,000 in Washington.

    Radiology Orders

    Some dated back to the 1980s, but others were only months old. VA officials said that in some cases, staff may not have been able to contact Veterans to schedule exams. In other cases, Veterans may not have shown up, possibly because their ailments had gone away. Some orders may have been duplicates ordered by two different doctors.

    Others may have been tests that were still needed – to monitor tumors or follow up on emergency room visits, for example.

    A panel of medical and ethics specialists conducted thousands of chart reviews, Meyer said, and determined orders for exams due to be performed before June 2015 could be canceled outright without jeopardizing Veteran health.

    Orders due after that date required further steps to ensure patient safety.

    The national call to action triggered a dramatic reduction in pending exam orders overdue by two months or longer. As of last month, the VA said, there were 31,000 nationwide.  

    ‘We look terrible’

    At the Iowa City VA hospital, Bickford said the chief of radiology – who also was the top radiology official in the Midwest for the VA – told her after the conference call in January 2017 that the facility had more outstanding orders than any other VA in the region.  

    “He came to (us) and said, ‘We’ve got to get this cleaned up now. I mean, we look terrible,’ ” Bickford said. So she and other staff “went through and started annihilating orders,” she testified in the disciplinary proceeding against Dettbarn.

    Any radiology orders more than 60 days past due were considered “invalid” and “expired,” Bickford testified. That is at odds with VA guidelines at the time requiring doctor reviews.

    Cancellation records reviewed by USA TODAY show that in some instances, she and other staff canceled future orders.

    In one case, a nurse practitioner ordered an ultrasound for September 2017 as a six-month follow-up for a Veteran with a history of kidney stones. An X-ray technician canceled it in June 2017, calling it an “expired” order.

    That same month, records indicate, Bickford canceled an order for a follow-up CT scan to monitor a Veteran’s lung nodules. The test wasn’t due to be performed until September 2017. Also in June, she canceled a CT to monitor fluid in a patient’s lung not due until November 2017. Records show Bickford selected “patient failed to contact clinic” in both cases. None of the records reviewed by USA TODAY contained personal information identifying patients.

    In the disciplinary case against Dettbarn, his supervisors alleged he was “disruptive” and didn’t send one patient’s images to be interpreted – accusations he denied. The investigation was initiated soon after he reported his concerns about the order cancellations.

    The Office of Special Counsel, a federal agency tasked with protecting whistle-blowers, is investigating, according to a letter from the office.

    Bickford declined to comment and referred questions to the Iowa City VA. In her sworn testimony, she blamed scheduling clerks for not indicating on orders that exams were scheduled. That led employees to assume there was a “dead order” even though a patient had a future appointment, she said, but she estimated that occurred only “maybe a half a dozen times.” When patients arrived for appointments, the errors were discovered, new orders were created and the exams went ahead, she said.

    The chief of radiology, Stanley Parker, did not respond to a message seeking comment at a number listed in public records. In his deposition in the case, he testified that he believed physician-review would have been done before canceling.

    Clark, the hospital spokesman, said Bickford's testimony about “annihilating” orders was not in context and referred to the “success of the process to right size the number” of outstanding radiology orders at the hospital.

    Clark said he doesn’t know how many orders were canceled at the facility because officials didn’t track it, but he said more than 4,000 were canceled in January and February 2017 in the southern part of the Midwest region.

    Clark said “most” canceled orders were from before 2015, though he didn’t know how many. He said “some” exam orders were “canceled without following proper policies or procedures.”

    In those instances, Clark said, “appropriate personnel actions were taken to correct the behavior, and staff reviewed the cancellations to ensure every order that required action was appropriately reviewed by a radiology provider.”

    Dettbarn has been detailed to a job collating VA records since July 2017. He said that whatever happens to him, he wants the public to know about what he called a “horrible shortcut” administrators took to improve the numbers. Dettbarn said Iowa City officials should do a clinical review like the Tampa VA to ensure Veterans weren’t harmed.

    “It’s so far beyond wrong what was done,” he said. “This is someone’s health care, this is their body, their life you’re screwing with, and people are playing doctor that aren’t physicians.”


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  • 3 charged

    Federal authorities filed charges Wednesday against three Bell County residents in an alleged scheme to defraud the U.S. Department of Veterans Affairs.

    A Temple couple — Christopher Sebek and Melissa Sebek — and Killeen resident Jeffrey Pearson, 55, are each charged for their alleged roles to defraud the VA of about $250,000.

    Christopher Sebek, 55, operations supervisor in the Engineering Department at the Olin E. Teague Veterans’ Medical Center in Temple, and Pearson, owner and operator of Whitetail Industrial Parts and Service, a Temple VA contractor, are both charged with one count of conspiracy to defraud the government and one count of theft of government property.

    Melissa Sebek, also 55, owner and operator of MS. Bookkeeping Services, faces a separate but related charge of one count of theft of government property.

    The charges were announced late Wednesday by Waco-based U.S. Attorney John F. Bash of the Western District of Texas and Special Agent in Charge James Ross of the VA Office of Inspector General Criminal Investigations Division, South Central Field Office.

    The charges resulted from VA investigations that uncovered a scheme at the Temple VA motor pool to secretly profit from VA purchase orders.

    According to a preliminary report obtained by the Austin American-Statesman in November, investigators claimed they uncovered a complex scheme involving the VA motor pool that had funneled business to a Killeen firm, Whitetail Industrial Parts and Service, that made at least $400,000 by padding purchases with 30 percent surcharges. More than $1.3 million reportedly was funneled through Whitetail.

    The report, which also detailed alleged abuses of power and other possible criminal actions, prompted U.S. Rep. John Carter, R-Round Rock, to demand answers on questionable activities at the Temple VA, part of the Central Texas VA Medical Center.

    Carter sent a letter to Department of Veterans Affairs Secretary David Shulkin and VA Inspector General Michael Missal last year and said he expected changes

    “Our military men and women have bravely served our nation, and I expect the VA system to provide the very best care when they return to civilian life,” Carter wrote. “I am encouraged by Central Texas VA Health Care System Director Christopher Sandles’ strong condemnation of the behavior by these employees, including his comment that a ‘day of reckoning’ has come for those employees that have mistreated Veterans.

    The scheme to defraud the Temple VA began in February 2012, according to court records.

    Christopher Sebek and Pearson allegedly agreed to steal money from the Temple VA. Over a five-year period, they allegedly submitted fraudulent invoices for payment reportedly for goods and services designated for the VA medical center. Sebek reportedly presented bogus invoices to the VA from his wife’s company.

    Those invoices, however, were used by Sebek to pay for personal items and to cover Pearson’s 30 percent commission on each invoice. Court records allege that Sebek stole two VAMC credit cards and used them to pay for personal expenses.

    If convicted, the defendants each face up to five years in federal prison on the conspiracy charge and up to 10 years in federal prison on the theft charge. All three will receive summonses for their initial appearance in federal court in Waco.

    Assistant U.S. Attorney Greg Gloff is the prosecutor in the case.


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  • 3 deaths found


    FAYETTEVILLE, Ark. (AP) — A Veterans Affairs hospital official says investigators have discovered 11 significant errors and three deaths in more than 30,000 cases originally seen by a pathologist officials say was working while impaired at the VA hospital in Fayetteville, Ark.

    Veterans Health Care System of the Ozarks spokeswoman Wanda Shull said Monday the families of the deceased veterans have been notified. Previously, investigators said one death was potentially the fault of Dr. Robert Morris Levy, who has denied working while impaired.

    Eleven errors merited institutional disclosure, meaning mistakes in patient care that could or did result in "death or serious injury." Officials have discovered 1,119 total errors, but not all resulted in change to clinical care.

    Pathologists have now reviewed 14,980 cases, just under half of the total cases dating back to 2005.


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  • 3 Marines killed


    WASHINGTON — The Pentagon says the remains of three U.S. Marines killed when their helicopter was shot down during the Vietnam War will be buried next week at Arlington National Cemetery.

    The Defense POW/MIA Accounting Agency announced Friday that the remains of the three men will be buried as a group with full military honors next Thursday. The three men are: Capt. John A. House II, of Pelham, New York; Lance Cpl. John D. Killen III, of Davenport, Iowa; and Cpl. Glyn L. Runnels Jr., of Birmingham, Alabama.

    The Pentagon says their remains were identified in March 2017.

    Military officials say House, the oldest at 28, was the pilot of the Sea Knight helicopter that crashed after being hit by enemy fire on June 30, 1967. Four others also were killed, including 18-year-old Killen and 21-year-old Runnels.


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  • 7 Investigates


    PITTSVILLE, Wis. (WSAW) – More than two years after 7 Investigates witnessed a disabled north central Wisconsin Veteran tell his congressional representatives about U.S. Department of Veterans Affairs loopholes leaving Veterans liable for their own emergency medical bills, some of those same lawmakers are now seeking reelection as the loopholes remain.

    In the summer of 2016, disabled Pittsville Gulf War Veteran Jerry Zehrung told staff for Sen. Tammy Baldwin, Sen. Ron. Johnson, and Rep. Sean Duffy about VA leaders not guaranteeing emergency bill payments if Veterans are treated at their closet non-VA emergency room. And Veterans not being able to purchase extra health insurance at a discount, like every other eligible American, in case VA insurance does not cover their emergency bill.

    "Everyday this legislation is delayed is another day another Veteran has to ask themselves 'should I go the ER or should I wait?" Zehrung said in February.

    Zehrung said the loopholes kept him from going to the ER twice over the last couple years, after he dislocated his hip that was injured during his war service, and back in 2016, when he woke up with blood on his pillow.

    "I wasn't worried about my heath at that moment. I was worried about is my family's financial future going to be destroyed," Zehrung said in 2016.

    What Zehrung did not know is his, and so many other Veterans’ stories, are tied into 86-year-old Minnesota Air Force Veteran Richard Staab's story.

    In 2010, the VA secretary was ordered to cover emergency medical bills Veterans are "personally liable" for. However, the VA denied Staab's claim one year later because he went to his closest non-VA ER when a heart attack and stoke almost killed him. In the end, he was left with a $48,000 out-of-pocket bill.

    "And for the VA to call that non-emergent, that's just ridiculous," Staab’s lawyer Jacqueline Schuh said in January.

    Staab became the face of this loophole when he sued and won his appeal. However, the VA kept appealing until last year.

    In January, Schuh thought the legislative fix, now called the ‘Staab Rule,’ meant thousands of Veterans could finally be reimbursed for their emergency room bills. Wisconsin lawmakers also told 7 Investigates they hoped Veterans would not have future billing problems.

    "And so there is a process going forward to pay those bills," former VA Sec. David Shulkin told 7 Investigates in January.

    However, today, Schuh said Staab still has not been reimbursed. And another one of Staab's emergency medical bills, from last year, is now tied up in a lawsuit.

    As Staab, again, faced denials, this summer a new video showed up on the VA's emergency medical care webpage. There, the VA laid out what emergency bills they will cover under the Staab Rule.

    For Veterans whose emergencies are related to a disability from their service, the VA now says they will pay, "As long as the VA was not reasonably available."

    In the past, however, national VA call centers can end up telling Wisconsin Veterans "reasonable" emergency care is located hours away from where they live.

    "Emergency room care within the VA system for me is Pittsville to Madison. Pittsville to Madison is over 120 miles away,” Zehrung said in 2016. “So, while I'm having a massive heart attack, I should go to Madison for ER care?"

    For Veterans, whose emergencies are not related to an injury from their time in service, there is more fine print, including requiring the Veteran to have received, “Care at a VA facility in the last 24 months.”

    If the Veteran also has extra, private health insurance, the VA says it cannot pay "similar payments" to "co-pays, coinsurance, and deductibles."

    Sen. Baldwin’s office tells 7 investigates as a result of the Trump Administration’s Veterans Affairs Department’s interpretation of what is “similar payment,” the VA is denying emergency medical reimbursements.

    Sen Baldwin told 7 Investigates the VA’s interpretation, "Is severely limiting reimbursements to our Veterans."

    Sen. Baldwin, and six other senators expressed their frustration about how the VA is interpreting the Staab Rule in a letter sent to VA Office of Regulatory Policy and Management Director Michael Shores back in March.

    During her Feb. interview with 7 Investigates, Baldwin hinted another law may eventually be necessary if the Staab Rule did not work like lawmakers feel it should.

    "Given the bi-partisan group of senators I'm working with, I think there will be a commitment to introduce legislation," Baldwin said in Feb.

    In an anonymous VA Public Affairs statement, department staff reiterated how they are, “Prohibited by law from reimbursing an otherwise eligible Veteran’s copay, cost share or deductible he or she owes to a health-care plan.”

    For the VA to make those payments, the staff member said, “Congress would need to amend this section of the law.”

    While the statement did not address the use of the VA’s use of the term “similar payments” in denying payments, they did say Veterans have to provide, “Documentation that their remaining financial liability for a claim is other than a copay, cost share or deductible.”

    7 investigates has learned the MISSION Act, which Baldwin, Duffy and Johnson all supported when it became law in June, might be a potential starting point for fixing future payments.

    Part of the current law allows Veterans to receive walk-in care at urgent care-type clinics, if that medical facility receives federal funding.

    “I am continuing my work with a bipartisan group of Senators to build off of the MISSION Act and move a legislative fix forward that can pass with support from both parties,” Baldwin told 7 Investigates.

    Sen. Ron Johnson has not said if he would support that, but his spokesperson Aaren Johnson tells 7 Investigates the senator does support extending emergency room reimbursements back to 2010, when the Emergency Care Fairness Act was signed into law.

    Rep. Sean Duffy’s spokesperson Mark Bednar did not offer comment on using the MISSON Act as a framework for an emergency care billing fix, but did say, “The congressman supports providing comprehensive emergency care coverage for Veterans when the VA is a secondary payer.”

    While Duffy's Democratic opponent Margaret Engebretson said she would support expanding the MISSION Act to including emergency care, the campaign manager for Baldwin’s Republican challenger, state Sen. Leah Vukmir, did not answer that question, only saying she supports more options.

    Full Statements

    From Sen. Tammy Baldwin:

    “We need to make sure that when our nation’s Veterans need emergency care, they can get the care they need. If they need emergency care they should be able to go to any emergency room to get it, and I believe their VA health care should cover it. I strongly disagree with the way the VA is implementing the Staab rule and unfortunately, the Trump Administration is severely limiting reimbursements to our Veterans. Given the fact that the VA refuses to implement the final rule as it should be, I am continuing my work with a bipartisan group of Senators to build off of the MISSION Act and move a legislative fix forward that can pass with support from both parties.”

    From Sen. Ron Johnson’s Deputy Press Sec. Aaren Johnson:

    - Senator Johnson supported the VA MISSION Act. This law includes language that directs the VA Secretary to improve Veteran access to walk-in/urgent care (became law in June).

    - Senator Johnson’s staff has reached out to the VA for an update on the status of the January 2018 Staab rule and emergency care coverage for Veterans. The senator supports the VA extending its January 2018 rule on emergency room reimbursements to apply to claims that have been filed since the Veterans’ Emergency Care Fairness Act was signed into law in 2010.

    From Rep. Sean Duffy’s spokesperson Mark Bednar:

    - Congressman Duffy applauds the Trump administration for finally ending the Obama administration’s lawsuit to avoid paying for Veterans’ emergency care. Congressman Duffy and his staff have been in contact with the VA for an update on the Staab rule, including swift implementation of the reimbursement policies that are now fully in place. Congressman Duffy has also reiterated to the VA that he supports further changes to provide reimbursement for Veterans prior to the April 2016 court case.

    - The VA’s secondary-payer laws are clear about the VA’s inability to pay things like co-pays, deductibles, and co-insurance for Veterans who hold other health insurance (OHI), and the Staab rule is not related to that.

    - The VA already covers emergency room care for Veterans at non-VA facilities if the Veteran does not have other health insurance (OHI), and Congressman Duffy supports that. Congressman Duffy also supports providing comprehensive emergency care coverage for Veterans when the VA is a secondary payer, which is now the law thanks to the new Staab Rule.

    From Duffy Democratic Challenger Margaret Engebretson: "The intent of the Congress is clear - individuals with VA care should be reimbursed for expenses incurred when receiving necessary treatment at community emergency rooms. I will join with bipartisan efforts to close any remaining loopholes in VA rules regarding reimbursement for emergency room visits, and I will support legislation to accomplish this goal, if needed."

    From State Sen. Leah Vukmir Campaign Manager Jess Ward: “As a military mom, Leah Vukmir knows our Veterans deserve high quality emergency care. Right now, there are only two VA emergency departments in Wisconsin, and it is ludicrous to think a Veteran from Superior should receive emergency care in Madison or Milwaukee. Unfortunately, too much federal red tape gets in the way, and Leah is committed to ensuring our Veterans have more access and more options in emergency situations.”

    VA Public Affairs statements

    Q: What is your response to Sen. Baldwin’s statement?

    A: Based on VA’s interpretation of Title 38 United States Code 1725(c)(4)(D), Reimbursement for Emergency Treatment, VA is prohibited by law from reimbursing an otherwise eligible Veteran’s copay, cost share or deductible he or she owes to a health-care plan. For VA to make such payments, Congress would need to amend this section of the law.

    Q: When are Veterans eligible for Staab Rule reimbursements?

    A: Veterans may receive reimbursement for emergency claims when it is determined that their episode of care meets the eligibility criteria outlined in 38 Code of Federal Regulations 17.1002, Substantive Conditions for Payment or Reimbursement. Additionally, Veterans will need to provide documentation that their remaining financial liability for a claim is other than a copay, cost share or deductible. When this occurs, VA will be able to reimburse as secondary payer to a Veteran’s other health insurance.

    Q: How many reimbursement requested under the Staab rule have been received in total since Feb. 1, 2010. Of this number, how many requests have been denied? What is that specific breakdown for the state of Wisconsin.

    A: Once the rulemaking published and the pending claims processed, these claims became part of our normal workload. They are not tracked separately.

    Q: How many Staab rule reimbursement requests have been received since January of this year? Of this number, how many requests have been denied? What is that specific breakdown for the state of Wisconsin.

    A: Once the rulemaking published and the pending claims processed, these claims became part of our normal workload. They are not tracked separately.

    Q: Are cases dating back to Feb. 1, 2010, when the Veterans Emergency Care Fairness Act of 2009 was signed into law, eligible for reimbursement? Or are you only reimbursing claims after April 8, 2016, when an appeals court ruled in favor of Richard Staab.

    A: Following the court’s decision in the Staab case, VA held claims pending from the date of the decision, April 8, 2016, to the date VA published the interim final regulation, January 9, 2018, when processing for these claims began. All of the held claims were processed earlier this year. At this point, VA will process any claims received and will consider them under the revised authority.


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  • Suicidal Veterans 002

    Washington (CNN)Burdened by suicidal thoughts, Justin Miller, a 33-year-old Veteran from Minnesota, reached out to the Department of Veterans Affairs in February for help, telling responders on the VA crisis line that he had access to firearms.

    Miller was advised to visit his local VA emergency department, which he did immediately.

    According to an inspector general report, Miller was admitted to the Minneapolis mental health unit after he described in detail symptoms of severe emotional anguish to VA clinicians.

    After four days under observation, he was discharged.

    Miller exited the hospital upon being released from care but never left the facility's grounds that day.

    Police found him dead in his car from a self-inflicted gunshot wound less than 24 hours later.

    With the permission of Miller's parents, Minnesota Democrat Rep. Tim Walz, the ranking member of the House Veterans Affairs Committee, shared this tragic story during a hearing on Capitol Hill on Thursday as lawmakers addressed the issue of suicide prevention among Veterans and former service members.

    "It is infuriating to know that there is a possibility that Justin's death could have been prevented. It should outrage us all that an entire health care system failed at something so serious and that it claimed to be their highest clinical priority," Walz said.

    Investigators were unable to determine "that any one, or some combination, was a causal factor" in Miller's death, despite identifying several "deficits in care provided to the patient."

    However, the investigation did find that staff members at the Minnesota medical center, including the suicide prevention coordinator, did not properly follow protocol while handling Miller's case and, according to Walz, failed to utilize the three-step REACH VET process, in which a clinician can assess a Veteran's risk of suicide so that he or she receives the proper level of care.

    "This is profoundly unacceptable," the Minnesota Democrat said about the inspector general's findings, which he called "deeply disturbing."

    And that frustration was only compounded by the fact that this was not the first time the inspector general had investigated many of these shortcomings.

    "The finding that the Minneapolis VA failed to sufficiently sustain relevant recommendations OIG made in 2012 should outrage us all," he said.

    Paul Sherbo, a spokesman for the Minneapolis VA Health Care System, told CNN that their "deepest condolences go out to Justin Miller's family and loved ones" and said that in response to his suicide and the inspector general's review, they have redoubled their efforts "to ensure every Veteran receives the best possible care. This includes improving care collaboration across departments and disciplines -- from initial treatment and planning to discharge and medication management -- and engaging family members in Veterans' mental health treatment plans, whenever possible."

    Sherbo added that the Minneapolis VA Health Care System has started implementing the inspector general's recommendations and would complete all but one this year. He also encouraged Veterans in crisis to visit the nearest VA health care facility, where they can receive same-day urgent primary and mental health care services, and provided the 24-hour national suicide prevention hotline: 1 (800) 273-8255.

    Young Veterans at risk

    The circumstances surrounding Miller's death, including his age and the use of a firearm, also seem to highlight two of the major issues related to Veteran suicide, according to data outlined in a new report released by the VA on Wednesday.

    The suicide rate among younger Veterans who, like Miller, fall between the ages of 18 and 34, continues to increase, a VA analysis of suicide data from 2005 to 2016 reveals.

    "Rates of suicide were highest among younger Veterans (ages 18--34) and lowest among older Veterans (ages 55 and older). However, because the older Veteran population is the largest, this group accounted for 58.1 percent of Veteran suicide deaths in 2016," the report says.

    The use of firearms as a method of suicide also remains high, according to the data, as the percentage of suicide deaths that involved firearms rose from 67% in 2015 to 69.4% in 2016.

    Although the overall number of suicides among Veterans decreased slightly between 2015 and 2016, the VA is bracing for an increase over the next five years as thousands of Vietnam Veterans enter mid-60s, joining what is already the largest age group.

    Additionally, VA officials acknowledged that the average daily number of Veterans who take their own lives has held steady for years despite efforts to combat the problem.

    "In 2016, about 20 current or former service members died by suicide each day. Of these, six had been in recent VA health care and 14 had not," VA spokesman Curtis Cashour told CNN, explaining that Wednesday's suicide prevention report defines Veterans "as those who had been activated for federal military service and were not currently serving at the time of their death."

    "VA also presents the yearly suicide count of never federally activated former Guardsmen and Reservists," he said.

    This report "simply reiterates what many of us have known for a long time: that our fight to end the tragic epidemic of Veteran suicide is far from over," Walz said in a statement.

    "We must continue to work together to provide Veterans with immediate access to quality, culturally competent mental healthcare and make bipartisan progress toward eliminating Veteran suicide entirely," he said.

    VA officials have said they would prefer to move away from using the per-day metric as an indicator of suicide rates, arguing that it does not account for changes in population size and can be misleading.

    But for now, lawmakers and department officials seem to believe that number appropriately underscores the severity of the issue.

    "Most of us have heard VA's staggering and heartbreaking statistic that every day, twenty Veterans end their own lives. Twenty," Republican Rep. Phil Roe, chairman of the House Committee on Veterans' Affairs, said during Thursday's hearing ahead of testimony from several suicide prevention experts.

    "We also know that over the past several years VA has invested significant resources towards addressing that number which stubbornly has not changed... We have the expertise. We have the support of the President. We can and must reduce suicide among Veterans. There is no excuse not to," he said.

    Where is the money going?

    President Donald Trump's recently confirmed VA Secretary Robert Wilkie told Senate lawmakers Wednesday that suicide prevention is a top priority for the department under his leadership and noted that the VA published "a comprehensive national Veteran suicide prevention strategy that encompasses a broad range of bundled prevention activities to support the Veterans who receive care in the VA health care system as well as those who do not come to us for care."

    He also highlighted the executive order signed by Trump in January intended to assist service members and Veterans during their transition from uniformed service to civilian life, "focusing on the first 12 months after separation from service, a critical period marked by a high risk for suicide."

    But despite a new budget of more than $200 billion, some critics argue that the VA continues to spend its money in the wrong ways.

    "Senior leaders like awareness campaigns and spend millions of dollars on them. They make a big splash in the media. It is measurable in how many outputs -- "views" or "hits" websites or social media pages get --- but does not generate outcomes," according to Jacqueline Garrick of the Whistleblowers for America.

    "These campaigns do not work because they cannot change behavior," she said in a statement to Congressional lawmakers.

    Rajeev Ramchand, a suicide prevention expert at the Rand Corp., told CNN that "while it may make people feel good, there is very little evidence that public awareness campaigns have a significant impact on suicide rates.

    "We do have evidence that public screening at emergency departments can reduce future suicide attempts," he said.

    However, he did note that areas with less evidence "should not be ignored as a comprehensive view of Veteran suicide prevention requires a thorough understanding of the environment where those events are occurring."

    In addition to developing and addressing the limitations around analytical tools like REACH VET, Ramchand told CNN that there are also a lot of things that "we know work," including initiatives that promote screening patients at emergency departments and then identifying those who are high-risk so that they receive the appropriate care.

    "Promoting quality evidence-based care... we know these things work, so let's get people to do them and do them more systematic way," he said.

    Troubling allegations

    In a written statement submitted to Congress, Garrick also said that her organization has been contacted by several VA employees who shared troubling accounts of workplace dysfunction that are having a direct impact of the quality of care provided and seem to undermine the programs currently in place.

    "At one VA medical center, a suicide prevention coordinator reported that they do not have time to complete suicide assessments or write prevention plans with every Veteran who potentially needs one because of the case load and its complexity," Garrick said.

    "She had 35 patients at one time. Administrators directed to note patients as 'moderate risk' for suicide so as not to raise red flags in the system. When a Veteran died by suicide on VA property, her supervisor refused to conduct a root cause analysis because that would be too time consuming," she added.

    According to Garrick, this VA employee asked to remain anonymous due to fear of retaliation for speaking out.

    CNN has independently contacted the employee and agreed withhold their name and place of work at the request of the individual.

    When asked for comment about the broader issue raised in the whistleblower statement, VA spokesman Curtis Cashour would only say: "VA asked CNN for specific details regarding these allegations so the department could look into them, and CNN could not provide them."

    "CNN's publishing of such vague allegations without any details that would allow the department to investigate them is highly irresponsible because it does nothing to help fix any issues that may exist and could actually discourage Veterans from seeking VA care," Cashour said.

    Griffin Anderson, a spokesman for the Democrats on the House Veterans Affairs Committee, told CNN that lawmakers take the allegations in the Whistleblowers of America report seriously and that the statement "certainly alludes to an alarming and unacceptable trend that we are going to look into."

    While the committee has not received a formal complaint pertaining to this specific allegation, Anderson said that lawmakers would work with the suicide coordinator in question to pursue an OIG investigation should they come forward.


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  • Vet Suicide Conv


    WASHINGTON — Melissa Bryant said the 5,520 flags placed along the National Mall Wednesday to illustrate the toll of Veteran suicide this year alone were more than just a visual reminder of the scope of the problem.

    “When we came out here this morning to plant these flags, every one of us had a friend or family member in mind,” said Bryant, chief policy officer for Iraq and Afghanistan Veterans of America. “Some of us standing here could have been one of these flags, but for an intervention.”

    The event — which has become an unfortunately annual occurrence for Veterans advocates — is part of a broader push in recent weeks by lawmakers, Veterans groups and Veterans Affairs officials to bring the issue of suicide among former military members back into public consciousness.

    Last month, VA officials released new data that showed the overall rate of suicides among Veterans has held steady at around 20 a day for roughly a decade, but researchers are seeing a troubling increase in the rate of younger Veterans taking their lives.

    Those realities come despite a concerned push in recent years by policy makers who have increased crisis intervention and mental health treatment resources for Veterans.

    Rep. Mark Takano, D-Calif., and vice ranking member of the House Veterans’ Affairs Committee, said the next step for Congress is to ensure that VA facilities are properly staffed to respond to the needs of suicidal Veterans, and to better identify what programs are working to help stem the problem.

    Last week, in a hearing before that committee, health experts said they see a gap in integrating those lessons learned into local community services, to provide a broader safety net for Veterans in distress.

    But to help fix that gap that, advocates said, they need to remind the public of the problem.

    “I have seen far too many Veterans and members of my community fall to suicide,” Said Kristen Rouse, founding director of the New York City Veterans Alliance, at Wednesday’s event. “What we see behind us represents a national crisis … These are Veterans from your home state, from your hometown, from your home city.”

    During Wednesday’s event — held between the Capitol building and the Washington Monument, in an area with heavy tourist foot traffic — dozens of onlookers stopped to take pictures of the display and talk to the advocates involved.

    Stephanie Keegan, whose son Daniel served in Afghanistan but died in 2016 because of delays in receiving treatment for his post-traumatic stress disorder, said she was grateful to share her families struggles with those visitors.

    “It absolutely makes a difference,” she said. “Not enough people understand the problem and the consequences of our wars. As a country, we need to pay more attention.”

    To contact the Veteran Crisis Line, callers can dial 1-800-273-8255 and select option 1 for a VA staffer. Veterans, troops or their families members can also text 838255 or visit for assistance.


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  • Robert Wilkie 10


    In a wide-ranging interview with NPR, Secretary of Veterans Affairs Robert Wilkie said his department is on the mend after a tumultuous 2018.

    "I do think it is better, because the turmoil of the first half of this year is behind us, the waters are calmer. We're not where we need to be, but we're heading in that direction," he said.

    Early in Donald Trump's presidency, the VA was considered an island of stability in an unpredictable administration.

    Secretary David Shulkin was a hold-over from the Obama administration, already familiar with the VA's massive bureaucracy. Bipartisan reforms moved through Congress with relative speed, and Trump could point to a list of legislative accomplishments.

    But the president fired Shulkin last March after weeks of intrigue during which VA political appointees plotted openly to oust him. Trump's first nominee to replace Shulkin, Rear Adm. Ronny L. Jackson, sank under accusations of misconduct (which are still being investigated by the Pentagon).

    Numerous high-ranking officials left the department, and records showed that friends of the president outside of government - who weren't even Veterans - had been lobbying Trump at Mar-a-Lago on how to run the VA.

    Wilkie takes charge

    After a stint as acting VA secretary, Robert Wilkie was confirmed by the Senate last July. Since then, Wilkie says he's been "walking the post," visiting as many VA facilities as he can. And he's reached the same conclusion as many of his predecessors.

    "I have been incredibly impressed by the caliber of VA employee I've encountered everywhere, from Alaska to Massachusetts to Florida," Wilkie told NPR's Steve Inskeep.

    "I have no quarrel with the quality of medical care our Veterans receive. My biggest problem is actually getting them into the system so that they can receive that care, which means the problems are primarily administrative and bureaucratic," said Wilkie, himself a Veteran of the Navy and a current Air Force reservist, who counts generations of Veterans in his family.

    "I am the son of a Vietnam soldier. I know what happened when those men and women came home," Wilkie said. "So that is incredibly important to me."

    Wilkie is navigating an important moment for the VA – while major reforms have already been passed by Congress, he's the one who has to implement them. And plenty of political controversy hides in the details.

    The VA Mission Act of 2018 was signed into law in June. It's intended to consolidate about a half-dozen programs The VA uses to buy Veterans private health care at a cost of billions of dollars, into one streamlined system.

    Critics fear that leaning too much on private care will bleed the VA's own medical centers, and lead to a drop in quality there – and amounts to a starve-the-beast strategy of privatization.

    Wilkie says that won't happen and is not President Trump's goal, but he has yet to present a budget for expanded private care to the White House and to Congress.

    "You're not going to privatize this institution. I certainly have never talked about that with anyone in this administration," Wilkie said.

    Resisting outside influence

    Wilkie also maintains that he has had little contact with the group of outside advisers who meet with the president at Mar-a-Lago, including CEO of Marvel Comics Ike Perlmutter and Florida doctor Bruce Moscowitz. Records show they had extensive communication with the previous VA secretary, sometimes influencing policy decisions.

    "I met with them when I was visiting the West Palm Beach VA - my first week as acting (secretary), and have not had any meetings with them ever since that day," Wilkie said. "I'll be clear. I make the decisions here at the department, in support of the vision of the president."

    Despite rumors that Wilkie would clear out many of the Trump political appointees who clashed with former secretary Shulkin, he said he didn't expect more staffing changes.

    The one notable departure is Peter O'Rourke, who was acting secretary for two months while Wilkie went through the confirmation process. O'Rourke clashed repeatedly with Congress and the VA's inspector general. Wilkie himself cited a Wall Street Journal report that O'Rourke is poised to go and said he's "on leave."

    "I think there will be an announcement soon about a move to another department in the federal government – I know that he's looking for something new," said Wilkie, "He's on leave."

    Another major new plan that Wilkie must implement is a $10 billion, 10-year plan to make the VA's medical records compatible with the Pentagon's.

    He once again mentioned his father's experience as a wounded combat Vet.

    "He had an 800-page record, and it was the only copy, that he had to carry with him for the rest of his life. He passed away last year," said Wilkie.

    "One of the first decisions I made as the acting secretary was to begin the process of creating a complete electronic health care record that begins when that young American enters the military entrance processing station to the time that that soldier, sailor, airman, Marine walks into the VA."

    But that process has actually been underway for a decade – with little to show and about a billion dollars already spent on the effort. The non-partisan Government Accountability Office says it's in part because neither the Pentagon nor the VA was put in charge of the effort — which is still the case. Wilkie says he has signed an agreement with the Pentagon to jointly run it with clear lines of authority.

    "I think we'll have more announcements later in the year when it comes to one belly-button to push for that office," he said.

    As for staff shortages, another perennial complaint at the VA, Wilkie acknowledged there are 35- to 40,000 vacancies at the agency.

    "We suffer from the same shortages that the private sector and other public health services suffer from, particularly in the area of mental health," he said.

    New legislation passed this year gives Wilkie the authority to offer higher pay to medical professionals.

    "I'm using it to attract as many people as we can into the system," said Wilkie

    But Wilkie also added that he was shocked, upon taking the post, that it's not clear how many additional people are needed – because it's not even clear how many people are working at VA.

    "I had two briefings on the same day and two different numbers as to how many people this agency employs."

    Wilkie says he's in the process of finding out the answer to that question, and many others, as he starts his second 100 days in office.


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  • Cabins for Homeless


    The cabins will house up to 21 Veterans and were built on land leased from theU.S. Department of Veteran Affairs.

    TOGUS — Tim Buckmore is delighted by his new digs, even if the cable TV hasn’t arrived yet.

    Until this summer, Buckmore, 57, was one of dozens of homeless Veterans living in Maine. Now, he’s among 19 Veterans who have moved into small houses on a quiet corner of the VA Maine Healthcare Systems-Togus campus.

    For at least seven years, various organizations and agencies have been developing the so-called “Cabin in the Woods” housing project, which cost $5.1 million to build and is located on 11 acres of land that have been leased from the U.S. Department of Veterans Affairs.

    On Friday, they celebrated the project’s opening with a ribbon-cutting ceremony that was attended by more than 100 guests and dignitaries. The project is part of a larger effort to end Veteran homeless and was developed by Volunteers of America Northern New England, a Brunswick-based group.

    Of the roughly 2,280 people who were homeless in Maine last year, 131 were Veterans, according to U.S. Census data compiled by the U.S. Interagency Council on Homelessness.

    Multiple Veterans who have received new housing through Cabin in the Woods said Friday they appreciated the natural surroundings and lack of noise pollution on the 11-acre property, where 21 cabins have been built. Each of the properties are free-standing and contain one or two bedrooms. The site also includes an office and community space, and is within walking distance of the medical facilities on the 500-acre hospital campus.

    Buckmore, who worked as a generator mechanic in the U.S. Army from 1983 to 1989, has been intermittently homeless for the last three years. He first learned about Cabin in the Woods from a social worker at the Bread of Life Ministries’ Veterans shelter in Augusta. Now, he particularly appreciates the quiet natural setting and the radiant heating that comes out of the floor of his one-bedroom cabin.

    “This is really nice and quiet,” said Buckmore, a Gardiner native, during a tour of the pre-furnished home. “I’d like to see more of these go up.”

    This past summer, Buckmore suffered two strokes and now uses a cane and wheel chair to move around. As someone who has worked in the mental health field and been diagnosed with depression, anxiety and bipolar disorder, he also hopes the new housing will bring stability to a vulnerable population of Veterans.

    “There’s a high suicide rate among homeless Veterans,” he said. “Something like this can help take their mind off anything bad they’re thinking about.”

    Buckmore’s one qualm, he said, is that Spectrum has yet to run cable television to the new homes. But he added, “That could be a blessing in disguise.”

    Multiple groups provided funding and donations for the Cabin in the Woods project, including the Maine State Housing Authority, the U.S. Department of Housing and Urban Development, the Home Depot and T.D. Bank Charitable foundations. At the ceremony on Friday morning, officials from some of those groups delivered prepared remarks.

    There were also speeches by two members of Maine’s congressional delegation, U.S. representatives Chellie Pingree and Bruce Poliquin, and delegates for U.S. senators Susan Collins and Angus King. Also attending the event was Poliquin’s predecessor as representative of Maine’s 2nd District, Mike Michaud, who served as chairman and ranking member of the House’s Committee on Veterans Affairs.

    Another speaker was Ryan Lilly, the former director of the Togus system who was recently elevated to another role in the U.S. Department of Veterans Affairs: director of its New England systems.

    Just as some cities have eradicated poverties in their homeless populations, Maine is trying to do the same, Lilly said. After the ceremony, he said the Togus campus still has between 30 and 50 acres that could be developed and that the agency is now considering whether it could lease out land for a similar project oriented toward seniors.

    “It was our first experience with this process,” Lilly said. “We’re thinking about what we can do next.”

    While there are other housing developments for Veterans around the country, Lilly said that Cabin in the Woods is unique because it’s in a secluded area and its units are individual homes, as opposed to apartments.

    Another Veteran to benefit from the new housing project is Jesse McGahuey, 41, who last month moved into a two-bedroom cabin with his wife Sheena, 33, and their 5-year-old son, Jerrick. While living on federal land isn’t a perfect arrangement, they said that the arrangement has made it considerably easier for McGahuey to attend his weekly medical appointments at Togus.

    McGahuey suffered a series of injuries during and outside his service in the U.S. Army from 2000 to 2002. As a child, he suffered a brain injury. Then, when he was working as a heavy equipment operator while stationed at Fort Lewis in Washington, he was pulled under a piece of machinery, injuring his legs and back. Finally, in 2014, he was working at an oil-change business in Waterville when a driver accidentally lost control of her car, giving McGahuey a head injury and exacerbating the previous problems.

    After that 2014 accident, McGahuey lost the ability to work or pay for housing. Since then, his family has spent long periods camping outside. They were one of the first families to apply for housing in Cabin in the Woods, and they’re now able stay there with subsidized rental costs.

    Now that some stability has been reintroduced to their lives, McGahuey hopes that he can start taking classes at a community college and working again, even if it’s part time. His wife, Sheena, is unable to work and receives disability payments because of medical problems she suffered when giving birth.

    “This does ease the pressure of it,” Sheena McGahuey said. “It does help.”


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  • Amputees in High Heels


    Researchers from the Department of Veterans Affairs have played roles in a number of scientific and medical breakthroughs that have had a profound impact on modern life: the liver transplant, the nicotine patch and artificial lungs, to name just three.

    And now, as they seek to meet the needs of an increasingly diverse population of wounded and disabled Veterans from the current era of war, VA design experts say they're going beyond barebones medical needs and aiming to help Vets live more comfortably, with technology adapted to their lifestyle and interests. It's work that requires them to listen to Veterans more closely and involve them and their feedback in the development process to a greater extent than ever before.

    One example of this work can be seen at the Office of Research and Development of the Department of Veterans Affairs, where they've come up with a 3D-printed ankle and foot device for a prosthetic leg to give amputees adjustable heels.

    Thanks to this research, stilettos are no longer out of the question for Veteran amputees. Outside researchers at Johns Hopkins University and elsewhere have developed similar devices, but Dr. Andrew Hansen of the Minneapolis VA Healthcare System said the VA's "Shape & Roll" prosthetic foot is unisex.

    "This study focused on high heels, but the results work just as well for cowboy boots," Hansen said in a VA release.

    The adjustable-heel prosthetic was an example of VA's commitment to research in areas that haven't been pursued by the private sector, said Dr. Rachel Ramoni, the VA's chief research and development officer.

    "Actually, there's a couple of things going on with 3D printing; you can print a foot for every type of shoe," Ramoni told

    The foot-ankle prosthetic also demonstrates a willingness at the VA to take feedback from wounded and disabled Veterans themselves on what they need to accommodate the lifestyles they wish to return to or pursue, she said.

    Ramoni also cited current research into upper-arm prosthetics for women as an example of this work.

    "That's a small segment of the population; it's a small market," Ramoni said. "It's not an area where somebody would say 'Well, it's an obvious money making opportunity.' So it might not be good business, but it's the right thing to do."

    The other challenge with research on upper-arm prosthetics for women is that so little work has been done in the field previously, Ramoni said.

    "The sizing of the prosthetic is a big deal," she said, and "we don't know about women's upper arm satisfaction, because all of the surveys were designed for men."

    The work on adjustable heels and the upper-arm prosthetic research are among more than 2,000 projects involving 3,400 researchers now underway at the Office of Research and Development. ORD operates on a budget of about $722 million from the VA, supplemented by contributions from the National Institutes of Health, the Department of Defense and others, for a total of about $1.5 billion, Ramoni said.

    The money is being spent with a new emphasis on listening to Vets regarding where they want the research to go, Ramoni said.

    A Disabled Vet Tackles Design

    Dr. Rory Cooper was an Army sergeant in Germany in 1980 when he lost the use of his legs from spinal cord injuries in a bicycle accident.

    He now is a director and senior research career scientist for the Human Engineering Research Laboratories, a VA Rehabilitation Research and Development Center and home of the VA Technology Transfer Assistance Program.

    Cooper is also a Paralyzed Veterans of America distinguished professor at the University of Pittsburgh. As such, he is an advocate for what leaders in his field call "participatory action engineering," or, more simply put, listening to the people you're trying to help.

    Cooper said his frustration with the ivory-tower approach to human engineering grew out of his own experience trying to get a better wheelchair.

    "I was trying to solve some of my own problems," he said of his approach to design research. He found that he and other Veterans often were in "isolation" from the researchers.

    Cooper said that surveys and talking to the Veterans themselves are "ways to initiate the design process, rather than having somebody sitting at their desk or surfing their computer, trying to understand what you want."

    Designers and researchers should "start by asking [the Veterans]... to prioritize," Cooper said.

    He said his current research was focused on robotics, artificial intelligence and what he called "adaptive reconditioning technology" to help Veterans participate in sports and recreation.

    One such example: a robotic bed. One of the little-known everyday problems for disabled Veterans, and their caregivers, is getting in and out bed, Cooper said.

    "If you don't have the use of your arms or legs, or you're weakened, that's a huge problem," he said.

    The bed is currently a work in progress, but Cooper said the initial thought was to have a "chair-into-bed kind of a docking system, and the chair kind of puts you into the bed while a conveyer pulls you into the bed."

    A Secret Weapon: Veterans

    The VA has a major advantage over the teaching hospitals and the private sector in conducting wide-ranging tests and surveys that require huge numbers of volunteers, said Ramoni, the VA's chief research officer.

    "Veterans are absolutely core to our program," she said. "Our program is able to make these discoveries because of the thousands of VA patients volunteering here," and "what we do is driven by their needs."

    Outside researchers, she said, often ask how they can learn from current VA practices and how VA scientists get so many people involved in the development process.

    "We say what we have is not something you can learn; that you have a population of Veterans who want to continue to serve their fellow Veterans and the entire nation by participating in these studies," Ramoni said. "It's just amazing to me how committed Veterans are to continuing to serve and continuing to make discoveries that will help everybody."

    The Next Big Breakthrough

    Ramoni noted that VA's ongoing Million Veteran Program (MVP) on genome research has now enrolled more than 670,000 Veteran volunteers, to make it by far the world's largest genome database.

    In the program, begun in 2011, participants donate blood, from which DNA is extracted. Then a baseline and periodic follow-up surveys track the Veterans' military careers, and their health and lifestyles.

    The research seeks to determine whether the genetic information in the database could hold keys to preventing and treating diseases.

    "We believe MVP will accelerate our understanding of disease detection, progression, prevention and treatment by combining this rich clinical, environmental and genomic data," former VA Secretary Dr. David Shulkin said.

    The MVP research opened the possibility for determining whether genetic factors were contributors to PTSD and Gulf War illness, Ramoni said.

    Many Veterans shared the same experiences in the same places in combat, and others were in the same places in the Gulf War; some developed PTSD and Gulf War illness, others didn't, Ramoni said.

    "The question we all ask is, why is that? Are there genetic markers for PTSD susceptibility, or are there genetic markers for Gulf War illness? Genes might help reveal that," she said.


    #veterans #military #amputees #womenvets

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  • Bryan Perry


    An Army Veteran was left to die from a drug overdose while in the custody of an Oregon sheriff’s office as deputies laughed and filmed the entire ordeal, according to videos released Thursday.

    • Bryan Perry, a 31-year-old Iraq War Veteran and Purple Heart recipient, was arrested along with his girlfriend on suspicion of drug use. In the video, he is seen thrashing and groaning in pain while in custody on October 4, 2016, while Clackamas County Sheriff’s Office deputies are heard laughing and mocking his behavior.
    • “We should go show this to his girlfriend and be like, ‘You love this?,'” one deputy suggests, an apparent reference to Perry’s affirmation of love for his girlfriend before they were led to separate holding cells, according to 18 pages of documents released sheriff’s office along with the video.
    • Perry became unresponsive around 11:45 pm and was rushed to the hospital, where he was pronounced dead at around 12:16 am. An autopsy revealed that Perry had amphetamines and methamphetamines in his system at the time of his death, although he had told police he’d used heroin and bath salts at the time of his arrest.
    • The video and documents only came to light following a wrongful death lawsuit filed by Perry’s family and a resulting public records request from The Oregonian newspaper.
    • “I cannot comment on the pending lawsuit, which focuses primarily on Mr. Perry’s medical care provided by the Jail medical contractor,” Clackamas County Sheriff Craig Roberts said in a statement. “But I will say this: The laughter, substance, and tone of several comments heard from my employees in that video were inappropriate, and do not conform to our professional standards.”

    You can watch the entire video below. Warning: It’s disturbing — and infuriating.

    (Click on the source link at the bottom to view the video)


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  • AZ Homeless Vets


    An annual event sponsored by the Sonny Montgomery VA Medical Center is working to connect Mississippi's homeless Veterans with services they desperately need. MPB's Desare Frazier reports.

    Forty-year old Roselyn Hutton, is a U.S. Navy Veteran from Utica. When she was going through a divorce and attending college, Hutton says her G.I. Bill benefits didn't cover the cost of living during breaks, holidays and summers. She and her 9-year old son ended up going from house to house staying with people. Hutton sought help from the homeless program at the Sonny Montgomery VA Medical Center in Jackson.

    "And I was able to utilize their services in order to be able to sustain life and still be able to go to school and still drill a little while and still take care of my son," said Hutton.

    Hutton, says she now works as a medical supply technician at the VA facility and she's a homeowner. Hutton is at the medical center's annual Standdown event in Jackson encouraging homeless Veterans to take advantage of all the services available. Kimberly Moore is with the medical center. She says state and community agencies link Veterans with services that include finding a job, housing and medical care. Moore wants to make it convenient for them.

    "To prevent Veterans from having to go here for one thing, another place for another, bringing all the services under one roof. This is where Veterans can come, they can fellowship with their fellow Veterans, relax, and just get back on their feet with this resources," said Moore.

    Moore says 150 to 200 homeless Veterans attend the program. Navy Vet Roselyn Hutton tells them:

    "We deserve it. We served this country. It's important to know what benefits and what things are available to us," said Hutton.

    A Standdown event is scheduled for September 29, in Greenville.


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  • Suicide Prevention Month


    The Army is committed to the health, safety, and well-being of its Soldiers, Department of the Army civilians, and families. To emphasize this commitment, the Army is joining the nation in observing September as National Suicide Prevention Month.

    Every person has a responsibility and commitment to reach out and help fellow Soldiers, civilians, or family members who need the strength of the Army. Together, a difference can be made by helping those who are at risk and suicides can be prevented.

    Effective suicide prevention requires everyone to be aware of the risk factors for suicide and know how to respond.

    If a person seems suicidal, the time to take action is now. Talk to that person before it is too late. Be direct and talk openly. Listen, and allow them to express their feelings.

    Battle buddies are the front line in surveillance and detection of high-risk behavior. Be a buddy, learn the warning signs of suicide, and find out how to help someone threatening suicide.

    Employ ACE

    Ask, care, escort, or ACE, is an easy-to-remember acronym that any Soldier, leader, family member, or civilian can use.

    • Ask your buddy – Have the courage to ask the question, but stay calm. Ask the question directly, “Are you thinking of killing yourself?”
    • Care for your buddy – Remove any means that could be used for self-injury. Calmly control the situation; do not use force. Actively listen to produce relief.

    Escort your buddy — Never leave your buddy alone. Escort to the chain of command, a chaplain, a behavioral health professional, or a primary care provider.

    Know the signs

    Do you know the warning signs for suicide?

    If anyone you know exhibits the following signs, get help as soon as possible by contacting a mental health professional or by calling the National Suicide Prevention Lifeline at 800-273-TALK.

    • Threatening to hurt or kill oneself or talking about wanting to hurt or kill oneself.
    • Looking for ways to kill oneself by seeking access to firearms, available pills, or other means.
    • Talking or writing about death, dying, or suicide when these actions are out of the ordinary for the person.
    • Feeling hopeless.
    • Feeling rage or uncontrolled anger or seeking revenge.
    • Acting reckless or engaging in risky activities.
    • Feeling trapped.
    • Increasing alcohol or drug use.
    • Withdrawing from friends, family, and society. This includes feeling anxious or agitated, being unable to sleep, or sleeping all the time. It also includes experiencing dramatic mood changes or seeing no reason for living or having no sense of purpose in life.


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  • Army Vet Survives


    Adam Greathouse is an Army Veteran, corporal in the Third Infantry Division, Field Artillery.

    In 2001, near the end of his duty day in Kosovo, his sergeant gave him the rest of the day off so he took a nap. When he woke up, he couldn’t move. There was pressure on his chest and he started hallucinating.

    He was sent to a German university hospital where his organs started failing, his heart became enlarged, tubes going in and out of his body, all while he passed in and out of consciousness. He had no control. With the magnitude of trauma to his body, having lost oxygen to his brain, he suffered a traumatic brain injury (TBI).

    Suffering from a severe anoxic event that damaged many organs including his lungs and brain, he went into a coma lasting two months. He was diagnosed with a traumatic brain injury (TBI) including partial amnesia, memory loss, and physical paralysis.

    Uncertain of his condition, months went by and depression set in. Beaten to the core both physically and mentally, he lay there broken, waiting to die. He had lost more than half his body weight and was frail with hardly any muscle mass.

    Mental toolbox pulled him through

    With the help of VA, Greathouse has learned to adapt to the disabilities caused by the TBI over the years. He pulls tools from his mental toolbox to handle life’s situations and to maintain his current active lifestyle. Each night, he sets cell phone alarms to make sure he is on time in the morning. He does brain training games before bed.

    Today he helps other Veterans conquer challenges as an ambassador at the National Veterans Summer Sports Clinic. His first VA Adaptive Sports event was the National Disabled Veterans Winter Sports Clinic in 2012, which he followed up with the National Veterans Summer Sports Clinic later that year.

    Drives five hours to volunteer

    In 2014, he started volunteering at the Huntington VA Medical Center in West Virginia as the first voluntary recreational therapy peer support specialist, driving more than three times a week over two and a half hours each way.

    He was very involved with sports before his injuries, so he continues to eat right and stay active. In social settings, he says he must be fully present to not deter his concentration, knowing how many distractions are all around him.

    Volunteering weekly has given him a sense of purpose.

    “I know that when I was in the process of going through it if someone I should have been able to count on said they were going to be there and they didn’t show up, then I would know the whole system failed and I would never come back. I’m not going to let that happen,” he said.

    “Suddenly, BAM, I’m a soldier again,” Adam said, after sharing how much these clinics have brought him back from the darkest days of his life.

    He frequently takes his children out surfing and snowboarding, knowing how many years he missed, watching them from the sidelines, unable to walk. He bought his first house in 2017 and is fixing it up with his dad. You can’t miss him in the crowd, just look for the man with the biggest smile.

    “It’s an honor to be here and watch my brothers and sisters grow in confidence every day. By the end of the week, they have permanent smiles! It’s a life saver, a game changer,” Adam said of the 2018 Summer Sports Clinic.

    “My life was spared for a reason. I couldn’t have done it on my own. I have three people to thank for getting me through it: My mom for her fierce faith in God, my nurse in Germany who put up a picture of my kids, reminding me of why I should fight, and my nurse case manager in Huntington, Cheryl, who pushed me past my own limits.”

    Greathouse was also named as a Veteran of the Day.


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  • Ask A Vet


    Here is the first thing to know about Veterans: No single voice can represent them. Each service member is shaped not only by their race and gender, but also the branch of the military they chose, the rank they held, where and if they deployed, and so much more. The breadth and variety of our experiences in our big ol’ machine of war are immense, and it would be foolhardy to let some jackass who rolled around Iraq in a tank 15 years ago speak for everyone.

  • Ask A Vet 002


    Welcome to Ask A Veteran, a place for civilians (or anyone!) to ask questions about the military or Veterans issues.

    Alex asks: I teach social studies in a public high school in NYC. I did not serve. Many of my students see military service as their only chance to change their prospects for the future. They idealize the benefits the recruiters describe without, I fear, giving real thought to what comes with their signature. I’m looking for some questions to ask kids (and their parents/extended family, who are often supportive of enlistment) to get them to contextualize what they’re signing up for and to get them to be thoughtful about what military service would likely mean for them.

    First, allow me to applaud your dedication to your students. Anyone brave enough to face teenagers every day and still care about their future is someone who should walk tall in this forum. You live life in constant danger of being owned by those Juul-wielding savages and somehow are still invested in their betterment as people. I salute you.

    Now, on to the matter hand: If my read on your question is correct, you are trying to approach this matter with sensitivity and an open mind, but the underlying vibe I get is, “How can I convince these kids not to sign up for military service?” Of course, given the lack of interest and accountability in the Forever War from our government (and, by extension, the American populace), your concern is not unfounded. You’re also right to be skeptical of recruiters; they are under enormous pressure to meet their recruitment quotas, and that pressure manifests in selling dreams that often go unfulfilled.

    But consider, for a moment, the benefits of military service that your students find appealing. An enlistment bonus? It may be more money than that student has ever seen before — and possibly more than the family has ever seen before (which may explain the parental support for enlistment). Money for college? Frankly, going through college as an adult on the G.I. Bill seems to me like a better recipe for success than starting to accrue student loan debt at age 18.

    I am, admittedly, a tainted source on this matter. My father, an Air Force pilot, was the first person in my family to graduate from college thanks to the military. I went to an expensive university not because my family had money, but because I had four years of my life to give to the Marines. I grew up believing that the military was a way for bright people from humble roots to gain entry into the middle class, and because I am able to look back on the benefits it gave me — tenacity, courage, confidence, character — I am unable to discourage others from the path.

    Back to your students. We mustn’t forget the strongest siren song of all: The promise of adventure and world travel. This promise can deliver, or it can bite you in the ass. Or both. I often joke that the Marine Corps gave me a tour of the world’s deserts, but the specifics are more interesting than the punchline they serve. For three years, I lived a ten-minute drive from Joshua Tree National Park; the Mojave is mountainous and full of hardy plant life that erupts in color during the short spring when the hard rains release the smell of creosote. I spent the month after 9/11 in the Western Desert of Egypt — long flat stretches of brown sand punctuated by rock formations that were both easier and harder to navigate than the Mojave, depending on your map skills. In Kuwait, where we staged before the invasion of Iraq, the only feature was the horizon. Kuwait can go eat shit.

    And that still only scratches the surface of what I saw and learned in four years. I lived in Kentucky and developed a taste for bourbon thanks to the Armor Officer Basic Course at Fort Knox. I’ve been to Australia with the best friends I’ll ever have; we taught locals the dice game Ship, Captain, Crew. I’ve crossed the Indian, Pacific, and Atlantic Oceans on Navy ships. I’ve flown in helicopters and driven tanks and landed on a beach in a hovercraft. I can hit a man-sized target from 500 yards with an M16 using only iron sights. What might a civilian life have offered me out of college? Safety, I suppose. But less of everything that was vibrant and meaningful, and nothing that made me who I am today.

    I do not mean to whitewash the danger. It is a deadly job even in peacetime. A good friend of mine, John Wilt, a lieutenant who was my classmate both in high school and at the Marines’ Basic Officer Course, was killed in an aircraft accident when he was at flight school. One of my Marines was airlifted from Twentynine Palms to the Naval Medical Center at Balboa after he got his head partially crushed during routine maintenance of an Abrams tank; he lived after surgeons cut open his skull to relieve the swelling from his brain.

    Combat is worse, of course. I have the benefit of hindsight about my experience because I didn’t get shot in the head like my buddy Brian McPhillips. I have the luxury of nostalgia because, unlike my friend Andy Stern, my life didn’t end with an IED exploding in my face. My lot in life is to go around repeating their names to people who can never know them. As my body gives way to middle age, their names are as familiar and well-worn as a rosary, but their pictures always stop me in my tracks. The youth of the dead is breathtaking, and I can barely believe that I stood shoulder to shoulder with them — that I was ever so young, and believed myself invincible.

    You said you were looking for questions to ask kids that would “get them to contextualize what they’re signing up for.” But I’m not sure that’s possible. How can you give young people wisdom without experience? They will be drawn to the military the way I was drawn to it — for the benefits, yes, but also to fill a hole inside them, a deep-seated craving to challenge and prove themselves. They will be drawn to service knowing, intellectually, that it is dangerous, but without really believing that the danger can touch them. Their peers will drive recklessly or do drugs or similarly dangerous things, and none of them will ever believe that harm can come to them. It is a feature of youth, not a bug.

    I do not wish to discourage your noble effort, but I don’t want you tilting at windmills, either. I will leave you, and your students, with the best reflection I have on my military service: It is a wonderful thing to have done, but it was often miserable to do. Or, more succinctly: It is a great thing to do with your life — if it doesn’t kill you.


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  • Beer and Wine


    With beer and wine for sale at 12 commissaries nationwide, sales seem to be chugging right along -- pun intended.

    Beer and wine hit some commissary shelves for the first time ever in July as Pentagon officials explore ways to lure more customers into stores. Operated through a partnership with the military exchange system much like the one under which commissaries carry tobacco, proceeds from sales go back to the exchange, not to the commissary.

    Since the initial rollout, the system has sold about $150,000 in beer and wine, Kevin Robinson, a Defense Commissary Agency (DeCA) spokesman, said in an email.

    The items are currently carried only on store shelves, not in cooler cases. And if what's available at Port Hueneme, California, is any indication, selection is very limited. In mid-September, that store had only a selection of light beers and low-cost red and white wine bottles and boxes.

    Robinson said the system hasn't yet received enough feedback to determine whether patrons like that selection.

    It is "still too early yet to gauge overall patron response since this rollout is still within the 90-day initial deployment to 12 stores," he said.

    Officials also haven't announced a rollout of beer and wine at stores outside the 12 pilot locations, although an April 27 Pentagon memo states that availability systemwide will occur "efficiently and expediently thereafter" after the 90-day test.


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  • Robert Wilkie 13


    U.S. Veterans Affairs Secretary Robert Wilkie doesn’t want any sunlight on his agency’s “shadow rulers.” By blowing off a recent congressional document request, Wilkie is blocking the public from determining whether a secretive trio of outsiders is calling the shots at the VA.

    Wilkie was just confirmed by the Senate in late July. His handling of the data request from the House Veterans’ Affairs Committee raises serious questions about his judgment so early in his tenure. After the scandal involving clinic wait times, public faith in the VA is lagging. Yet Wilkie’s stunning refusal last month to turn over the documents undermines trust even further, creating the damning perception that his priority isn’t Veterans but protecting the three outsiders, all of whom belong to President Donald Trump’s glitzy Mar-a-Lago club.

    The Pulitzer Prize-winning ProPublica news organization first reported about the behind-the-scenes decisionmakers in a story published Aug. 7. E-mails and other documents obtained through the Freedom of Information Act revealed that the three have “leaned on VA officials and steered policies affecting millions of Americans.” They weighed in on high-level staffing changes, meddled with a major software contract and pushed the agency to make a seismic and expensive push — outsourcing care to private providers.

    One of the three also wanted the agency to bring in his son to develop an app. Despite this access to agency inner circles, none of three men ever served in the military. Nor is their expertise relevant. The three men are: Marvel Entertainment Chairman Ike Perlmutter, attorney Marc Sherman and Bruce Moskowitz, a doctor who runs a company catering to wealthy medical patients.

    The congressional request for additional documents, filed on Aug. 8 by Rep. Tim Walz, the Veterans’ Affairs Committee’s ranking member, is sensible. The documents obtained by the reporters may have been redacted. The congressional request would also go beyond the correspondence the reporters were able to obtain through the Freedom of Information law. A thorough review is a must, especially when Veterans sense that “an ideological war is being waged within the VA below the radar of the media and of the public,’’ said Paul Rieckhoff, founder and director of the Iraq and Afghanistan Veterans of America advocacy group. “Veterans’ healthcare, benefits and general well-being are ending up as collateral damage.”

    Yet on Sept. 15, Wilkie tersely declined the House committee’s document request. His reasons do not hold up to scrutiny. He said the documents are the subject of ongoing litigation. Yet that lawsuit was filed after the congressional committee’s data request. And its existence does not exempt the agency from complying with the committee’s request.

    Walz, who is also the Minnesota DFL gubernatorial candidate, gave a deadline extension — until Oct. 31 — in a forceful letter this month. It is Wilkie’s best interest to meet that. Failure will sour the VA’s relationship with a key oversight committee and will only accelerate the public trust deficit in him and the agency.

    A noncommittal response this week from a VA spokesman about whether Wilkie will release the documents did not inspire confidence. Wilkie made a mistake saying no once. He owes it to his agency and more important, to the 9 million Veterans served by VA medical facilities, to correct course.


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  • VA Qtrly Research


    Dr. Steve Martino is chief of psychology at the VA Connecticut Healthcare System and professor of psychiatry at Yale School of Medicine. He specializes in the treatment of patients with substance use disorders, including those with co-occurring conditions. He also does research in the area of implementation science and how to move best practices into real-world clinical settings.

    Dr. Marc Rosen is an addiction psychiatrist at the VA Connecticut Healthcare System and professor of psychiatry at Yale School of Medicine. He is the director of addiction recovery services at VA Connecticut, and conducts research on substance use disorders and related problems for affected Veterans.


    • Dr. Rosen and his team conducted a pilot study that used the VA compensation and pension exam to engage Veterans who were applying for a service-connected disability because of musculoskeletal pain.
    • The pilot study showed that Veterans assigned to brief counseling were more likely to obtain pain treatment at a VA facility than those receiving the usual compensation and pension exam without additional counseling.
    • The pilot study also showed that when Veterans with risky substance use were assigned to counseling, they were significantly less likely to engage in risky use than those not assigned to this counseling.
    • The new study involves delivering the counseling by phone from a single hub site to Veterans having compensation exams throughout New England.

    VARQU spoke with the two researchers about their work on chronic pain management among Veterans.

    The Department of Defense, National Institutes of Health, and VA have just co-funded a large grant to study non-drug approaches to pain management. What is the significance to the VA health system?

    Dr. Rosen: This project has the potential to engage Veterans early in non-opioid pain treatment, and interrupt what can really be a harmful and dangerous course.

    How did VAConnecticut become part of the larger grant?

    MR: There are about 600,000 post-9/11 Veterans who are service-connected for back or neck pain. We had a developmental grant to intervene with people who were applying for service connection for musculoskeletal disorders. In the pilot study, most of the Veterans applying for service-connection for musculoskeletal disorders had considerable pain and impairment, and a high proportion were engaged in risky substance use. We found that they were amenable to intervention and that it helped them engage in VA pain-related treatment.

    Dr. Martino: In addition, we also found that as a result of the early intervention, Veterans reduced their risky substance use, as well. So we thought that this was a very promising approach to bring forward to the grant application.

    Can you tell us about your study, "Screening, Brief Intervention, and Referral to Treatment for Pain Management"?

    MR: That's the title of the study, actually; it’s not the title of the grant. I like the title of the grant better, it's more descriptive. The title is actually a pretty good summary: "Engaging Veterans Seeking Service Connected Payments in Pain Treatment."

    So why is that a good point in time to have this discussion with Veterans? Why not in the clinician's office?

    SM: Well one of the main reasons is these Veterans may not be in the health service system of the VA. They are reporting problems they are experiencing, and may not be aware of the services they could avail to help themselves. There's traditionally been a limited amount of information provided to Veterans at the point at which they are seeking a disability compensation exam, just because the nature of the exam is really determination for disability, not a clinical assessment.

    Marc's work has been fairly innovative in trying to use this as a point to provide Veterans who are seeking disability evaluations an opportunity to learn more about what is available to them and try to engage them in various services. And so that's why we think this is a great opportunity to work with Veterans who are experiencing chronic pain and who may have risky substance use—to try and get them engaged in services that they currently are not participating in.

    Can you walk us through a brief description of this intervention?

    MR: We talk to the Veterans a little bit about their claim: We ask them about their pain and inform them of the variety of services available at the VA health care system. We explain that pain treatment can involve not only medication, but also attending to other aspects of whole-body health. We then allow that many people in pain drink or use drugs to relieve their pain, and ask the Veteran about the extent of his or her substance use.

    There's a format for this type of brief substance use counseling that Dr. Martino is an expert in. We follow that format to engage Veterans in reducing their substance use. That style of working with people is based on motivational interviewing. And so a large part of what we are doing is to motivate Veterans to participate in non-drug treatments, and commit to reducing or stopping their risky substance use. And engaging in specialized addiction services if that makes sense and they are willing to do so.

    Part of the counseling involves not giving people exactly what they are expecting. The Veterans are coming for a compensation claim, and we are trying to say, "Hey, there are also some treatments available here that you are entitled to—that you've earned." We are also taking Veterans whose presenting complaint is pain and saying, "Substance use is something that could make your pain worse. Here are some ways you might want to think about that." We think that Veterans who have filed a claim are at a teachable moment.

    How is motivational interviewing different from a traditional doctor/patient interaction?

    SM: Motivational interviewing has been around for several decades. It began in the risky alcohol use field, and then has cut across all types of behavioral problems where motivation is part of the issue—particularly in the medical field. So the style of interaction really involves being very patient-centered, being empathic, collaborative, being compassionate to the needs of patients, and in particular being attentive to the ways in which patients speak about their problems that might support them making a change.

    So what people do when using motivational interviewing as a framework is try to illicit or draw out people's reasons for change and get people to elaborate more about those matters, such that they talk themselves into changing based on their own motivation. It's a way of helping people talk themselves into changing based on what is unique about their own experiences.

    You mentioned whole-body wellness earlier. Many studies show that opioids are not effective for long-term pain. What are some of the other treatments that might help patients deal with their pain?

    MR: There are non-opioid medications. There are various physical treatments like physical therapy, exercise and activity, chiropractic services. There are mind-body based treatments like yoga and mindfulness. And there are psychological treatments like cognitive behavioral therapy and relaxation techniques. And finally, treating other issues that make pain worse: poor sleep makes pain worse, depression makes pain worse. Treating conditions that we know how to treat well can make a big difference.

    SM: The mantra is that people need multi-modal pain care, and that the idea of medication as the sole form of treatment for chronic pain relief is misguided. We are trying to help people find a variety of ways in which they can approach pain treatment in order to get the best possible outcomes.

    MR: There is a vicious cycle that people in pain can get into, in which they become less active, which is depressing. They don't sleep well which worsens their overall physical condition, which worsens their pain. A lot of these treatments involve interrupting that vicious cycle.

    Can you tell us about the different phases of your study?

    SM: For all of these grants, there is an initial preparation phase where we have to meet certain milestones to prepare for the pragmatic trial. That's a two year process. And at the end of the two years, those grantees who are successful in meeting their milestones presumably will continue to be funded for a four-year pragmatic trial. And we fully expect to be successful and be funded for pragmatic trial.

    We have several things that we will be doing in phase one. First because we will be moving from the pilot trial which was done at VA Connecticut to all eight medical centers in VISN 1, we will get a grip on how pain care services and addiction services are delivered at each of those medical centers.

    We will be doing semi-structured interviews and qualitatively analyzing them, to appreciate the various factors that are at play at each medical site. We'll be talking with community medical providers and administrators and primary care folks, including nurse care managers, and anyone else who can tell us what's unique about their medical center.

    We will also be pilot testing this early intervention with five Veterans at each of the medical centers. The original trial was done face-to-face, in person. For this trial we will be using a hub-and-spoke model—so they'll be clinicians based in VA Connecticut who will be delivering the intervention entirely by phone. We want to see how that goes and if there are any adjustments that we need to make before we go to the full trial.

    Another key feature of the two-year preparation phase is it is very hard to characterize Veterans' use of non-drug treatments. There aren't codes for many of these treatments in the electronic medical record. So we have partnered with investigators from George Washington University to use what's called natural language processing, to develop algorithms that will basically use computer programs to screen CPRS (Computerized Patient Record System) for Veteran's use of non-drug treatment modalities.

    Another important piece of this study is the cost-effectiveness. How much is this all going to cost? And what kind of impact will this have on the budgets of medical centers, if they wanted to implement this if we were to be successful? So we also have a health economic component to this, and we will also be devising our methods for costing out everything for the trial.

    If this all works, would it be something that the clinicians could provide at the different medical centers, or would it be delivered through telehealth?

    SM: One of the reasons why we decided to do this within a VISN is because the VA is organized in regions—networks of medical centers organized together. Our hope would be if we could demonstrate this hub-and-spoke model, centered in a VISN, is effective, then it could be replicated in many other VISNs across the country. So we would be advocating for a telehealth means of administering this, which would provide greater access to people who may not be able to physically get to a medical center or who receive most services at rural sites across the country.

    MR: One feature of the VA that would facilitate the adoption of this is that VA regions receive capitated payments for each Veteran, but the amount of payment is based on what services the Veteran receives. So if a Veteran comes to a hospital and only has a compensation and pension exam, that region gets a limited amount of money. If providers engage the Veteran in treatment, the region gets more money for that Veteran. So unlike in some other healthcare systems, the region doesn't lose money by providing more comprehensive care.

    What are your long-term goals for this study?

    MR: Our first goal is to test the intervention as proposed. We tested this at a single site: It was done through face-to-face encounters, and it was promising. This next study is needed to see if it works in a setting in which we are treating many more people by phone, which is likely going to be less expensive and more easily spread throughout the region.

    So the first goal is to evaluate the cost and benefits of this intervention, and see what works in the real world, not just in a research setting.

    If it does works, then we would like to see it rolled out nationwide. We are not testing in some super complicated, super expensive form that couldn't be done anywhere else. We are testing it as a relatively simple phone call and evaluation and referral. The hope is, if the results merit it, that this will be adopted in other regions.

    SM: That last point I think is very important. The way we are studying this is consistent with the way that services are often delivered in VA. So we are hoping that this will make it attractive to the broader health care system because they will be able to relate to it. From an implementation standpoint, it won't be discrepant with what is commonly done here.

    MR: Sometimes it is hard to get health care systems to do things that will bring long-term benefits because the problems are subtle or the harms are long term. The harm from the opioid epidemic isn't subtle, and there's a real consensus that we need to treat pain better, and intervene early. In this case, I don't think it will be hard to convince decision makers that early, better pain treatment is necessary; this is a cause that people have embraced.

    SM: The other feature of this study that I think will be attractive to providers is we are creating a model where the providers are not going to be asked to do much more than what they are already doing. We are creating a system that complements what they are doing. One of the things that you hear constantly when you try to bring more behavioral interventions into medical centers is "We are too busy." They are very taxed. Asking them to do one more thing that is often seen as outside of their usual scope of practice is a difficult ask. So this is something that we think clinicians have not only embraced as a goal, but have embraced because it is not taxing all the other duties and responsibilities that they have.


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  • Burn Pit Widower


    It was in 2009 when Brian Muller first met his wife, Amie.

    "We actually met at a music venue. And at the time I was playing music in a band and she had some friends there that were at the event," Muller, 45, from Woodbury, Minn., recalls in a recent interview with Fox News. "Her friends forced her to go out. I forced myself to go out and just to see some music."

    He remembers how they discussed her service with the Minnesota Air National Guard.

    "We ended up talking about what she does with the military," he says, "and at that time, she was doing a project to make video memorials for gold star families. Families that lost loved ones in Iraq or Afghanistan or any type of war."

    "She asked me to write a song for those videos. And that's how we kind of started our relationship, as-- friends, and then it developed from there."

    Brian has never served in the military but was impressed by Amie's service -- including her two tours in Iraq.

    "She wanted to fly, and she joined the Air Force. And she got deployed and had her life kind of uprooted there for a while."

    Amie was stationed at the Iraqi air base in Balad during both of her tours in 2005 and 2007. While her active service was already behind her, the effects from her time on that base still lingered.

    "She didn't really want to talk about her time over there," Brian says. "Anytime a door would slam or a loud noise, she'd get startled very easily. She had a lot of PTSD [episodes] from just little things."

    A decade after returning from Iraq, Amie's physical health also suffered. She was diagnosed with Stage III Pancreatic Cancer.

    "I still remember Amie getting the call, and she looked at me," Muller says about the day they found out about her diagnosis back in April 2016.

    "We walked around the corner just to make sure the kids didn't see. I could tell by the look in her face how scared she was. And I just kind of listening in to the call. And we just started shaking.

    Both she and Brian believed it was related to her exposure to open-air burn pits used to destroy trash generated on the base. Nearly every U.S. military installation in Iraq during the war used the crude method of burn pit disposal, but Balad was known for having one of the largest operations, burning nearly 150 tons of waste a day.

    The smoke generated from these pits hung above Amie's barracks daily.

    "She talked about the burn pits even before she got cancer," Muller recalls, "and how the fact that they would change the filters on these ventilation systems quite frequently. And every time they'd change it would just be this black soot, so thick that you would think you'd have to change it every hour."

    "After she told me what they were burning, you know, all I thought about is all the campfires that we had in our backyard. You don't burn Styrofoam. You don't burn plastic. We all know that, but they were burning all those things. Highly toxic."

    As early as Operation Desert Storm in 1991, burn pits were used at U.S. military bases in Iraq. At the height of the Iraq War in 2005, more than 300,000 troops were stationed there and potentially exposed to the smoke and fumes from burn pits.

    Thousands of Veterans and former contractors returned from the Middle East and have developed rare cancers, respiratory problems, and blood disorders from what they claim are their exposure to toxins from the flaming pits. More than 140,000 active-service members and retirees have put their names on a Burn Pit Registry created by the Department of Veterans Affairs.

    After Amie was diagnosed and her treatment began, she and her family went public with her story in the hopes that it would bring awareness to the dangers she and countless Veterans faced after what they believe was a result of burn pit exposure.

    Amie succumbed to her illness just nine months after she first diagnosed.

    In her absence, Brian continued Amie's work in raising awareness by sharing her story. He also worked closely with Sen. Amy Klobuchar, D-Minn., toward getting "The Helping Veterans Exposed To Burn Pits Act" -- a bipartisan bill recently presented in Washington and signed by President Trump -- passed.

    The bill will help fund a new center by the Department of Veterans Affairs that will study the effects of burn pit exposure and eventually assist with treatment plans. He also started the Amie Muller Foundation, which helps other Veterans who were diagnosed with pancreatic cancer.

    "I just hope that our Vets are going to get the help they need," Brian says, "and it's not going bring back Amie, my wife, but it's going to get Veterans the help they need."

    But recent findings show that the Pentagon was aware of the dangers of burn pits during the height of the war in Iraq.

    Fox News recently obtained a series of memos drafted by top officials at Balad during the same years that Amie served at the base. The authors of the documents -- which include commanding officers as well as environmental officials -- stated that the operation of burn pits was a danger to those stationed there and that precautions needed to be taken urgently to improve conditions.

    "In my professional opinion, there is an acute health hazard for individuals," reads a line from one memo written by a Bioenvironmental Engineering Flight Commander and the Chief of Aeromedical Services at Balad in 2006. "There is also the possibility for chronic health hazards associated with the smoke."

    The memo also includes an assessment of the pits in Balad where one environmental inspector said that Balad's burn pit was "the worst environmental site I have personally visited."

    After inquiries by Fox News regarding the memos, Officials for the Department of Defense said that they would look into the matter and explained their procedural policy and that open-air burn pits are to be operated in a manner that prevents or minimizes risk.

    "DOD does not dispose of covered waste in open-air burn pits during contingency operations except when the combatant commander determines there are no feasible alternative methods available," reads the statement provided by a Defense Department spokeswoman. "DOD minimizes other solid waste disposal in open-air burn pits during contingency operations. Generally, open-air burn pits are a short-term solution. For the longer term, we use incinerators, engineered landfills, or other accepted solid waste management practices whenever feasible."

    Muller finds the memos troublesome.

    "I don't understand why they didn't do something," he says after being shown a copy of the memos. "These are people that volunteered to serve our country, and it just disgusts me to see memos like that, from high ranking officers that expressed this concern."

    Muller adds that the underlying issue is a lack of accountability.

    "The issue is they were doing something they shouldn't have done, that they constantly warned was an environmental hazard," he says. "And our Vets are getting sick. Our Vets are dying."

    "You know, there was a fellow that did a video--'Delay, Deny and Hope You Die.' And that's kind of what's been going on. They're delaying this as long as possible so that they won't have to deal with as many claims, because most of them will die before they do anything about it."

    Muller also believes that Amie would have never fallen ill if it wasn't for the fact that she was stationed at Balad.

    "I don't think she would have gotten cancer. I really don't. Maybe she would have later in life. Maybe it would have been some other type of cancer. I don't know," he says. "But something caused inflammation -- for something to grow in her body for a long period of time before it was ever seen and diagnosed. There was something going on with all of the Vets when they got back."

    In a recent interview with Fox News, Gen. David Petraeus, the former commander of U.S. Central Command and Multi-National Force-Iraq in 2007, offered an explanation when asked about why burn pits were used on military bases, conceding that the realities of war kept concerns about how to dispose of waste a low priority at that time.

    "At that time we weren't worried about burn pits," The general said back in September. "We were worried about just getting enough water for our troops in the really hot summer. We were looking forward to the time where we might get some real food, real rations, as opposed to MREs and so forth."

    The general also expressed that the U.S. has a commitment toward helping those Veterans.

    "It's a sacred obligation," Petraeus said. "But comparing what our VA does to any other country's care of Veterans... this is the gold standard. Certainly, a gold standard that can always improve, without question. This is an issue, though, where we have a sacred obligation, and we need to meet that obligation."

    Muller believes the general's recent comments to be a sign of a move in the right direction.

    "When you start seeing men in uniform, or women in uniform, people higher up in the military starting to voice their concerns, you know we're making progress."


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  • Jim Sherman


    COLORADO SPRINGS, Colo. (KKTV) - Hundreds of Veterans in our community who are turning 65 years old will need to find a new doctor. Right now, they go to Evans Army Hospital on Fort Carson. Fort Carson told our 11 Call for Action team they are making changes to make room for an influx of active duty soldiers.

    Jim Sherman, a 64-year-old Veteran, gets his care at Evans Army Hospital. But he got a letter saying when he turns 65, because he is eligible for Medicare and TRICARE, his coverage will change and that he will no longer be able to see his doctor at Evans.

    "I was discharged almost 40 years ago, and since that time, that's where I've received my care," Sherman said. "I'm down there -- not every week, maybe every other week, and definitely every month."

    "To just kick everybody to the curb, is not right," he added.

    We reached out to Fort Carson and they told us about 365 letters were sent out to beneficiaries.

    Evans Army Community Hospital said in a statement: "Our mission atEvansArmyCommunityHospital is to ensure the medical readiness of active-duty Soldiers atFortCarson. Due to the increased assignment of Soldiers toFortCarson, Evans is reaching its capacity to provide quality healthcare to our beneficiaries. Evans is notifying beneficiaries approaching their 65th birthday about changes to their healthcare eligibility within the medical treatment facility. Once beneficiaries turn 65, their coverage becomes TRICARE for Life after they enroll in Medicare Part A & B. TRICARE for Life is a Medicare-wraparound coverage for TRICARE-eligible beneficiaries. We are trying to provide beneficiaries sufficient time to find primary care providers in the local community before they turn 65. TRICARE for Life beneficiaries will continue to receive Emergency Care and other services on a space-available basis atEvansArmyCommunityHospital, such as the Pharmacy, Laboratory and Radiology."

    If patients are over 65 and have been getting care at Evans for more than a year, they can stay at the hospital.

    "I am where I want to be," said Sherman. "That's really the only home that I've ever known for hospital care."

    Jim turns 65 in January. He applied for an exception and is waiting to find out if he can stay at Evans.

    In the next two years, Fort Carson said they expect to see an increase of about 1,000 soldiers and 1,500 family members.


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  • Wait Times 002


    The VA Debt Management Center just announced it reduced call wait times by over 75 percent while also increasing calls taken by 40 percent from 2016 to 2018.

    As part of the agency’s Veteran-focused initiatives, they agency reduced call wait times from 21 minutes in 2016 to under 5 minutes during 2018. The initiatives include increasing staff levels, improving technology, and driving better employee development.

    “The team at the DMC has enhanced services to our Veterans,” said VA Secretary Robert Wilkie. “It’s our mission to take care of our Veterans, no matter what their needs are. DMC is in concert with our priority of improving customer service and will continue to gather customer feedback through direct feedback, surveys and outreach in FY19 to further enhance the Veterans’ experience.”

    According to the press release:

    For the past three years, DMC received around 1 million calls annually with an average call wait time of about 21 minutes. In FY 2017, DMC launched a series of internal efficiencies and process improvements to enhance contact center capabilities.

    Initiatives included enhancing staffing levels to meet demand, enhancing contact center technology, focusing on employee development and engagement, and implementing an automated 12-month payment plan.

    These Veteran-focused initiatives represent a 79 percent reduction over two years to the average time for waiting and a 40 percent increase of actual calls taken. These are all indicators of successful initiatives providing a better experience for Veterans and VA employees.

    The DMC’s inbound contact center serves as the central point for Veterans and their family members to make payment arrangements, or receive guidance regarding the collection process on overpayments which could include debts created from education or pension payments.

    Debt counselors at the DMC work with callers in a professional and service-oriented manner to help them understand their options to address overpayments with Veterans either through extended repayment plans, the dispute process, compromise process or waiver process

    DMC’s contact center provides debt counseling for the Veterans Benefits Administration, and consolidated collection services of non-health care debt for Veterans Health Administration and National Cemetery Administration, enabling these entities to focus resources on accomplishing their core missions.

    DMC has provided centralized debt collection programs of Veteran benefit overpayments since 1975 and became a fee-for-service Enterprise Center in 1996.

    This is great news for Veterans trying to deal with the agency as a debt collector.


    What is not great is the amount of information the agency publishes for Veterans dealing with the Debt Management Center for the first time. The agency gives us little information about how to advocate for yourself and what elements of your fact set to focus on when creating your argument – – whether for a waiver or to plainly dispute the alleged debt in full.

    They instead focus on how to pay and how to submit a waiver with no limited discussion of disputing the alleged debt in full.

    Ever have a run in with DMC? If you have a debt story, I would like to hear it below.

    Any idea how the Fair Debt Collection Practices Act might apply to VA or one of its contractors attempting to collect an illegitimate debt from a disabled Veteran?


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  • Unsterile Tools


    When the Department of Veterans Affairs released the annual ratings of its hospitals this fall, the facility in Atlanta dropped to the bottom, while the one in West Haven, Conn., shot to the top. It was something of a mystery as to why.

    The Atlanta hospital was downgraded to one star from three on the agency’s five-star scale, even though there had been only a “trivial change” in its quality data from the year before, according to the department. The Connecticut hospital climbed to five stars from three, even though numerous operations had to be performed elsewhere or canceled at the last minute because of problems with sterilization of surgical tools, according to an internal assessment and other accounts cited by Senator Richard Blumenthal in a letter to the agency.

    Veterans Affairs set up the rating system in 2012 in the hope of pushing its hospitals to improve, and it has been increasingly aggressive in using the ratings to hold hospital managers accountable. Leaders with low ratings can be ousted, as happened last week in Atlanta, where the chief of staff and heads of the emergency department, primary care and clinical access services were removed because of low scores.

    But former senior officials at the agency and experts in health care metrics say the system can be confusing, and so arbitrary that hospitals may gain and lose stars based only on statistical error. More than a dozen hospitals improved care but lost stars; another did not improve and gained one.

    What is most worrisome to some experts is the role that the star ratings now play in grading performance of hospitals and their managers. They say it creates an incentive to conceal problems rather than grapple with them, in order to collect bonuses or sidestep penalties.

    “It’s a big mistake,” said Dr. Ken Kizer, a former under secretary for health at Veterans Affairs who is widely credited with pioneering the use of health care quality metrics at the agency.

    Dr. Kizer said that it made sense to track quality measures when the goal was improving patient outcomes, and the agency had made important strides in that way. But he said that using the data to single out hospitals for discipline could lead to problems like the 2014 wait-time scandal, when managers who could not meet goals for prompt scheduling of patient appointments started keeping secret off-the-books waiting lists.

    “It’s the same pathology that perverted things then,” Dr. Kizer said. “As soon as you tie metrics to pay or performance, they become subject to gaming.”

    The gaming can put patient care on the line. At the hospital in Roseburg, Ore., administrators turned away some of the sickest patients to keep them from affecting the facility’s scores, doctors there have said.

    The chief of surgery at another Veterans’ hospital in a major metropolitan area said in an interview that administrators discussed whether the hospital should not perform certain operations because they could impact the hospital’s quality statistics.

    “That kind of thinking is driven by these ratings,” said the surgeon, who spoke on the condition of anonymity, adding that he feared being fired if he spoke publicly. “My life right now is continuously filling out reports and going to meetings, trying to figure out how to improve the numbers.”

    There is broad consensus in health care that quality should be tracked and reported, but little agreement on the best way to do it. As in education and law enforcement, a drive to collect data and use it to direct strategy has led to both improvements and frustrations. Often, experts say, the way care is measured can alter the care itself, and not always for the better.

    The Department of Veterans Affairs defended its hospital rating system, saying in a statement that it “has been successful in moving systemwide performance upward.” But the department declined to make key officials available to discuss the system.

    The ratings may soon take on even more importance. A law signed in June may allow more Veterans to get care from private providers if Veterans’ hospitals fall short of performance standards.

    Veterans Affairs has been tracking hundreds of health care metrics for decades, but it had no overall performance gauge for its 146 hospitals until 2012, when it started using a process called Strategic Analytics for Improvement and Learning, or Sail, to combine many of the metrics into a single score. Executive performance and pay were tied to Sail scores in 2015 in the wake of the wait-time scandal.

    The department has reported steady improvement in Sail scores, noting in September that 71 percent of Veterans’ hospitals did better this year than in 2017. But experts say some of that improvement may exist only on paper.

    The former quality director of a large Veterans’ hospital with a five-star rating, who spoke on the condition of anonymity to avoid harming a continuing relationship with the agency, said the hospital employed two analysts whose full-time job was to find ways to improve the Sail data. Some of their work focused on spotting ways that services could be improved, but much of it focused on finding ways to improve the numbers, such as by changing how patients’ conditions were entered in hospital records. “We learned how to take the test,” the director said.

    Sail was designed by Dr. Peter Almenoff, a longtime hospital administrator who was moved to a quality control post in the department in 2008 despite questions about his track record. This spring he was also put in charge of the team that revamps hospitals that get low ratings.

    The department refused multiple requests to interview Dr. Almenoff, and he did not respond to direct inquiries seeking comment.

    Veterans Affairs now relies on Sail to warn about failing hospitals. But Dr. Stephan Fihn, who was the department’s chief quality and performance officer before he retired this year, says the system is not reliable.

    “It has serious flaws and always has,” Dr. Fihn said. “The first is statistical: The numbers may not be mathematically sound. Second, it’s not transparent and lacks independent oversight.”

    A draft internal evaluation in 2014 found that combining dozens of metrics into a single Sail score was “akin to adding apples and oranges and trying to express the total as the number of pineapples.”

    An outside audit in 2015 found that many of the score’s ingredients had “never been assessed to see if they were actually valid measures of quality,” and that hospitals could gain or lose a star solely from statistical error.

    According to the report, 70 percent of Veterans’ hospital directors interviewed by the auditors with a promise of anonymity said Sail scores did not accurately reflect the quality of their hospitals.

    The New York Times contacted eight Veterans’ hospitals, including those in Atlanta and West Haven, asking to interview their directors about Sail. None were willing.

    “A lot of people don’t like this system, but they won’t speak up because they are afraid of what will happen,” Dr. Fihn said.

    Problems in measuring health care quality are not confined to Veterans’ hospitals. A 2015 comparison of four popular commercial systems used by private hospitals found their ratings so inconsistent that not one of the 844 hospitals examined earned a top rating from all four.

    Medicare tried to institute a five-star hospital grading system, but postponed releasing the latest results indefinitely in July after several hospitals threatened to sue, saying the grading method was inaccurate.

    Veterans’ hospitals, however, do not have that option, nor can they choose among commercial rating systems.

    The department says its star ratings help keep Veterans informed. But Dr. David Shulkin, who was President Trump’s first secretary of Veterans affairs, says the stars are not much help in gauging progress from year to year or in making comparisons with nearby civilian hospitals, because Sail grades Veterans’ hospitals on a national curve.

    “It’s not useful for our patients. It’s confusing. I wanted to move away from Sail,” said Dr. Shulkin, who clashed with political appointees in the department and was dismissed by Mr. Trump in March.

    Agency employees say that only Dr. Almenoff and a few members of his staff know exactly how the system weighs and adjusts the 60 publicly available measures that go into a score.

    “That’s the problem with Sail — what happens to make the scores is invisible,” Dr. Fihn said. “A person could move the stars arbitrarily, and you would have no way of knowing.”

    That lack of transparency became a problem for Lisa Nashton, who is in charge of tracking quality at the Veterans’ hospital in Columbia, S.C.

    After the hospital received one star, Dr. Almenoff visited the facility in 2016 to brief the staff on ways to improve. While he was there, Ms. Nashton said, she took him out to dinner to talk more about quality metrics.

    The effort seemed to pay off. The hospital got its rating up to three stars that year, and it looked forward to a similar rating in 2017, Ms. Nashton said, because it had sustained its quality measures at basically the same level.

    So when the word came that the hospital had actually lost a star, “it was a gut punch,” she said. “I kept going over the numbers again and again. I compared us to other hospitals. The math didn’t make sense.”

    Ms. Nashton said she then alerted the department’s Office of Accountability and Whistleblower Protection that Sail was statistically unsound and open to gaming, and submitted a lengthy paper showing how a host of problems made the system a “credibility crisis waiting to happen.”

    The reply came nearly a year later: The department planned to take no action.


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  • Vets Teamed to Raise Millions


    On October 19, 2018, a crowd of over 700 guests gathered at Pier Sixty at Manhattan's Chelsea Piers for one reason: to help provide mental healthcare to the men and women who fight for our freedoms. During their 6th annual gala, Headstrong, an organization that provides cost-free, stigma-free, and bureaucracy-free mental healthcare to post-9/11 military Veterans, put on a fun-filled event — and raised over $2 million in the process.

    Headstrong is making a huge impact on the Veteran community.

    "We have served over 750 Veterans over 16,000 therapy sessions by 150 best-in-class clinicians in 23 cities across the country. All through private donations. Simply incredible," said Army Veteran and Headstrong Executive Director Joe Quinn."

    During the event, three Veterans seeking treatment through Headstrong, Amanda Burrill, Derek Coy and James Byler, opened up about their struggles and successes in finding effective mental healthcare. Their stories inspired the hundreds in attendance.

    Despite the seriousness of the organization's goals, the night wasn't without a good dose of levity — after all, it was more than a fundraiser, it was a celebration. World War II Veteran and former POW, Ewing Miller, was celebrating his 95th birthday — and he did so by being served cake by actor Jake Gyllenhaal and late night host Seth Meyers.

    Ewing Miller served from 1942 to 1945. On February 5, 1945, his aircraft was shot down — he was the sole survivor. He endured capture by the Germans until he was eventually freed by legendary military leader, General George S. Patton. Ewing earned several decorations during his time in service, including the Purple Heart, the Air Medal with two clusters, the POW Medal, the World War II Victory Medal, and the European-African-Middle Eastern Campaign medal.

    When the lights finally dimmed on the evening's celebrations, Headstrong had raised over $2 million, which will be used to directly improve the lives of many post-9/11 Veterans that are struggling with mental health — and it's a cause worth championing. Marine Veteran and Founder of Headstrong, Zach Iscol, said,

    "When you put goal-oriented Veterans together with top mental healthcare providers, they get better. The panic attacks go away, the anxiety goes away, the anger goes away, the self-medicating goes away…they blossom."

    To learn more about Headstrong, their initiatives, and what you can do to support Veteran mental healthcare, visit their website.


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  • Disabled Vets


    What's Not Talked About?

    Throughout the history of warfare, service members have been placed in unimaginable situations, often situations in which they have to make difficult decisions. Frequently, decisions made during deployment have lifelong consequences. Many Veterans have expressed a desire to be the person they were before they experienced trauma, and they often try to suppress or avoid memories of the trauma they have lived through. However, the use of avoidant coping strategies has been found to be counterproductive in the long run. By attempting to avoid the traumatic events service members have experienced, they end up exacerbating the intensity and frequency of their trauma memories and the sequelae and symptoms of those memories over time.

    Some Veterans are able to move past trauma with minimal dysfunction in their lives; however, for others, the traumatic event creates havoc and chaos. Trauma symptoms can become so problematic that they result in family discord, divorce, social dysfunction, significant substance use, employment difficulty, physical health difficulties, legal problems, and more. And the disruption of service members’ lives as a result of trauma symptoms is hardly uncommon. Due to the dysfunction and negative impact of trauma and its symptoms in the lives of service members, the VA has recognized and developed the VA disability rating system. The disability rating system considers both physical and mental health-related conditions. The more areas of a Veteran’s life that are impacted (i.e. social and occupational difficulty or physical limitation and/or pain), the more financial compensation that Veteran potentially could be warranted. I am a firm believer that Veterans are entitled to every dollar that they are afforded and then some...Many can argue that the lifelong implications and symptoms that Veterans have to endure cannot be quantified or compensated with a dollar amount. The VA does its best to equitably compensate Veterans based on their level of dysfunction. However, if the Veteran could eliminate the disabling experience that initiated their impairing symptoms, it is possible that they could exceed the amount of their VA compensation by functioning optimally in the civilian sector. Essentially, they would be able to have a greater positive economic impact and earn a higher living wage if they did not experience disabling symptoms. Given the high level of training military members receive, the values, discipline, and structure instilled by military training and service often lead most Veterans to make dependable, hard-working, and effective employees.

    Disability Rating System

    According to the VA Disability Rating System, in the year 2000, the average compensation provided to Veterans through the disability rating system was about $20 billion for 2.3 million Veterans. In 2013, that number rose to 3.5 million Veterans receiving $54 billion in compensation. This number has continued to rise over the last several years and will hopefully continue to do so, enabling Veterans to receive the compensation they deserve. A major reason for the spike in Veterans receiving compensation is the continued 14-year wars in Iraq and Afghanistan. When service members are sent to war and later return home, there are often significant consequences to service—economics being one of them. Unfortunately, many Veterans who are still in need of services and compensation for VA benefits have not taken advantage of the services offered. Many factors impact Veterans’ decisions not to seek care— a main one being stigma. Two examples of stigma are: one, a Veterans’ hesitation to seek mental health services due to being perceived as “weak” or “vulnerable;” and, two, the possibility of having negative career or job implications as the result of potentially impairing symptoms. As I have said in a previous blog, it takes a nation to build a military and go to war. And, it takes a nation to welcome them home. Compensating our Veterans for their service is the first of many steps that should be afforded to Veterans for their sacrifice. If we send people to war, it is a fundamental imperative that we take care of them when they come home. The tide is changing, and the VA has gone to great lengths to decrease wait times for compensation and pension evaluations so that Veterans are streamlined through the process. There is no perfect system, and the pendulum has and is continuing to shift in the right direction so that our brothers and sisters in arms are taken care of.

    To specify the rating system with an example, if a Veteran diagnosed with PTSD has a 50 percent service-connected disability rating and they have a spouse and one child, they would receive $978.64 each month. Yearly, that is roughly $11,745. The pay for a Veteran that is 100 percent serviced-connected increases significantly. They would approximately $3200 monthly. Although this money is not taxed, many Veterans still struggle to make ends meet. Anecdotally, there is a misconception that if a Veteran receives a 100 percent service connection, they will be able to live a “lavish” lifestyle. That is simply not true. This money can definitely help decrease financial distress, however, many Veterans still struggle to pay for things they and their families need.

    Once a Veteran receives a disability rating and compensation is provided, there can be fear that the disability rating might be decreased or taken away if the VA finds evidence the Veteran’s symptoms have improved to a more manageable level. Once Veterans receive a service-connected percentage of disability, it is not a fixed rate for life—although it could be. The VA has the right to decrease the compensation rate if the Veteran shows material improvement in their ability to function in daily life whether that be in relation to a physical or mental health-related condition. According to the Department of Veteran’s Affairs Service Connected Disability website (2017), if a Veteran has less than a 100 percent disability rating, has been receiving compensation for less than five years, and has shown medical and social improvement, the VA can reduce the percentage of disability and compensation based on the evidence found. However, if a Veteran has been receiving benefits for longer than 20 years, it is considered a continuous rating and the VA cannot lawfully reduce the rating. At 10 years, a Veteran’s rating cannot be terminated, but it can be reduced. If a Veteran’s disability rating is reduced, a Veteran has the option of requesting a reexamination, and they should contact a Veterans’ Service Organization representative to advocate on their behalf.

    The VA provides great and well-needed services, and they save lives every day. Unfortunately, some Veterans walk away from the VA dissatisfied and displeased. There is no perfect mental health and medical system, and the disability rating scale is not perfect either. There is no one program that provides a “fix all” solution. What it will take is public and private partnerships moving forward in order to maximize reach and expand access, frequency, and quality of care.

    Many Veterans who receive benefits fear their benefits may be taken away at any point in time. Unfortunately, this fear of disability ratings potentially being lowered if there is substantial evidence that the Veteran has made improvement deters people from seeking and fully engaging in well-needed treatment. For instance, if a service-connected Veteran engages in an evidenced-based trauma-focused treatment for PTSD that has been shown to reduce symptoms upon full completion, and as a result of that treatment their overall dysfunction decreases, that Veteran could be at risk of decreased disability ratings if that improvement is documented and gathered during a medical evaluation. Veterans who know the disability rating system may be deterred from seeking care at the VA because of that potential. The more dysfunction one has, the more money they receive; so increased symptomology is incentivized and reinforced. If Veterans struggle with employment and optimal functioning, it makes sense that those Veterans may not want to show improvement. This is one lens to look through.

    Unfortunately, there is no perfect solution to this problem. However, there has been plenty of debate about possible solutions. One solution discussed would be to extend the time period between the rating system from the initial evaluation and reevaluation. This solution could assist with decreasing stigma and reducing the fear of losing a percentage rating with the potential benefit of encouraging people to fully engage in well-needed treatment. This would allow Veterans to seek a high standard of care, receive benefits, and practice their skill-sets learned with a longer time to adjust for life stressors that may continue to exacerbate symptoms. If there is no reoccurrence of symptoms, then one may experience a reduction in compensation. If there continues to be notable impairment, then the percentage of disability rating could stay the same or increase. Another potential solution is to continue the private-public partnership so that Veterans can receive care outside of the VA. If Veterans fear that making progress would jeopardize their disability rating when seeking care at the VA, those concerns are potentially lessened with treatment in the private sector. These issues about disability ratings and improvement in functioning are only a few of the many issues debated in the current Veterans’ issues climate. Although they are hotly debated, the pendulum is moving in the right direction by placing our Veterans first.


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  • Charity for Vets


    To hear Army Veteran Troy D. Walker tell it, Dog Tag Furniture’s mission to aid Vets began after a service buddy killed himself and the family couldn’t afford a funeral.

    The Department of Veterans Affairs can only provide a few hundred dollars, the Minnesota man told “Fox and Friends” on Sept. 23, 2017.

    “The body was going to go unclaimed and be put in a baggie,” Walker said.

    Walker recalled going into debt to help pay his friend’s funeral costs and then realized no organizations existed to solely help fund Veterans' funerals.

    Roughly six years later, Dog Tag Furniture builds and sells wooden American flags and other patriotic products, billing itself on social media and TV interviews as an organization funding Veteran funerals via donations and wooden flag sales.

    “The money goes to pay for the funerals of these families who cannot afford one,” Walker told “Fox and Friends” during a return appearance on Nov. 22, 2017.

    “I hold the personal responsibility to make sure every dollar I received goes out to funerals," he said.

    But now, Walker, his wife Ranemma and Dog Tag Furniture are under investigation by the FBI and U.S. Postal Service amid allegations of money laundering and wire fraud in “a scheme to defraud donors who made charitable donations to their company,” according to court records.

    “Troy Walker...both solicited donations to Dog Tag Furniture and sold wooden flags to customers of Dog Tag Furniture by falsely representing to donors and customers that Dog Tag Furniture was a charitable organization and that all of the proceeds of donations and sales would be used to provide funerals for military Veterans,” according to a sworn affidavit attached to a federal search warrant request from last month.

    “Instead of using their money to pay for funerals for military Veterans, Troy and Ranemma Walker used a significant portion of the money for their own purposes," the affidavit added.

    “Personal purchases” allegedly included tattoo parlor payments, private school tuition for the Walkers’ children, $9,000 at Disney resorts, $5,000 in “food and entertainment expenses” and $7,000 to a law firm representing the couple “in connection with a dispute with the City of Norwood Young America,” according to the affidavit, which Military Times obtained from the U.S. Department of Justice.

    Walker has not been charged with a crime and the federal probe into misconduct allegations noted in the affidavit continues, according to Department of Justice officials.

    Although the charity received about $490,000 in sales and donations from August 2017 to July 2018, Dog Tag Furniture allegedly covered the expenses of just two funerals at a total cost of $3,295, federal authorities allege.

    Walker, 38, declined to comment on the allegations through Robb Leer, his Minneapolis-based spokesman.

    Dog Tag Furniture’s criminal defense attorney, Marsh Halberg, did not dispute some of the spending allegations detailed in the affidavit but said “the Walkers were sloppy in the use of their private checkbooks and the corporate checkbook.”

    The Walkers paid for other funerals, but those payments came out of their private accounts, he said.

    Because federal authorities have seized their electronic records “we’re kind of handicapped in that,” Halberg said.

    “They were not living an affluent lifestyle,” Halberg said. “These people were not used to that. They weren’t business savvy in that sense.”

    The Walkers did take a Disney trip, Halberg said, but the organization’s board of directors “encouraged them to do that.”

    The federal search warrant affidavit claims that Walker told radio host Glenn Beck during an April interview that his organization pays an average of $3,600 per funeral and has funded about 200 of them but law enforcement "has found no evidence of Dog Tag Furniture providing any funds for other funerals, including the funerals Walker specifically referenced on social media, such as…an unnamed female Minnesota National Guard member” and two others.

    About $17,000 in Dog Tag Furniture funds instead went to pay Walker’s mortgage “after the residence went into foreclosure in or about August 2017,” according to the affidavit.

    “In lieu of salary, the organization paid for basic living expenses so they could continue to live,” defense attorney Halberg said. “They did pay for mortgages and food.”

    Dog Tag Furniture was founded in 2015 as a for-profit corporation, according to the federal search warrant affidavit.

    It was initially created to provide a second income to bankroll a future trip to Disney World, but turned altruistic after Walker’s friend killed himself, according to the organization’s website.

    Walker applied for tax-exempt, non-profit status in September 2017 and received an approval letter from the Internal Revenue Service in February, a copy of which was shared with Military Times.

    Although walker told Beck during his radio interview that neither he nor his wife drew salaries from Dog Tag Furniture, about $90,000 was transferred from the organization’s checking account to the Walkers' personal coffers between August 2017 and July 2018, according to the affidavit.

    The transfers occurred when "the Walkers’ personal bank accounts had limited other sources of income,” wrote Christine Kroells, a U.S. Postal Inspector, in her affidavit seeking a search warrant.

    The affidavit states the couple received unemployment benefits and what appeared to be worker’s compensation payments in 2017 and 2018, but Walker denies they received unemployment assistance.

    During the Nov. 22, 2017, appearance on Fox and Friends, Walker said he nearly lost his home a few months earlier but “a donor stepped forward and got me caught up on my mortgage” after his initial appearance on the show.

    “I was getting into so much debt with this flag building business,” he added.

    That contribution was part of a flood of Dog Tag Furniture purchases and donations Walker reported receiving after his first Fox and Friends appearance. Dog Tag Furniture’s website crashed after that first appearance, he said, with folks sending pledges ranging between $5 and $5,000.

    “Within five minutes of me being on the show I found out my voicemail can only hold 112 messages,” he added.

    While welcoming him back for his second spot on the show, Fox host Ainsley Earhardt announced that “Troy’s website received over $100,000 in sales, thanks to you, our amazing, generous viewers," in the hours following the first appearance.

    “I love that even when you were in dire straits, you use all the money still to pay for funerals, because you get your paycheck from the military,” Earhardt said.

    “Thank you for fighting for our country,” she added.

    Dog Tag Furniture portrays itself as an organization where Veterans help Veterans.

    Its logo features two hanging military identification tags forming a “22,” an oft-reported estimate of how many Veterans kill themselves each day, and Walker notes his Army service in videos on the organization’s website.

    “I was a ’19-Kilo,’ which translates to Abrams tank crewman,” Walker said in one website video. “Yes, I drove around the big beast of the battlefield.”

    But military service records show it’s been a long time since Walker drew Army pay.

    Walker enlisted in 1999 and left active duty in 2002, and his most recent rank change was to private, or E-1, in November of 2001, according to service records.

    Walker disputed the 2001 demotion in an email forwarded by his spokesman.

    “After 9/11 some of us didn’t get paid due to the pentagon (sic) damage, I wasn’t paid for almost 4 months and told my commander no pay, no training and walked off post until I got paid,” Walker wrote. “After I got paid, I was given an article 15 for AWOL and reduced from E-4 to E-3 and promoted back in a few months, not sure why it says E-1???”

    Walker said he served in the “Inactive Reserves” until 2009, when he was honorably discharged. Army officials reported he was in the Individual Ready Reserve from 2002 to 2007.

    Army officials said he was administratively separated from the service but declined to characterize the nature of his discharge.

    When Military Times requested a copy of Walker’s DD214 discharge form or other service records that might shed light on the alleged discrepancies, his spokesman wrote in an email that “since Feds searched and seized his computers and files late last month — Troy was left without any hard copy paper files or his hard drive to access files like this from.”

    “All my battle buddies have seen my interviews and have NEVER publicly disputed anything I said in regards to my service,” Walker said in an email forwarded to Military Times.

    The federal search warrant executed last month does not appear to be the only time law enforcement has searched Walker’s home.

    Carver County Sheriff’s Office deputies combed it as well, according to an April press release from the agency.

    In March, authorities said Walker provided Carver County deputies with a suspicious email he asserted was written by an official from his town of Norwood Young America, about an hour’s drive from Minneapolis.

    But deputies determined the message had been sent through Walker’s own IP address, “suggesting the email had come through Walker’s own computer(s),” the press release states.

    An email from someone named “Jacob” also claimed Norwood Young America officials were harassing Walker but county investigators found it also came from Walker’s IP address, the agency wrote.

    Like federal probes, local investigations often peter out without prosecutors indicting their targets.

    Angella Erickson — the criminal division manager for the Carver County Attorney’s Office — told Military Times that the matters raised in the sheriff’s release remain under investigation but there are “no current pending charges” against Walker or his wife.

    In an email shared with Military Times through his spokesman, Walker said the Carver County allegations are “actually what started this investigation.” In fact, he wrote, the county charges “were dismissed shortly after for lack of evidence” and he blamed local prosecutors for instigating the wider federal probe.

    “Since they could not get me on those charges, they called the FBI,” he continued. “That is why our books are so (wacky) is because they keep getting taken.”

    Erickson disputed Walker’s allegation and said local officials did not contact federal law enforcement about him.

    “To my knowledge, the Carver County Sheriff’s Office is not involved with any investigation by the FBI,” she said.

    Defense attorney Halberg said Dog Tag Furniture is “pausing everything” because of “negative publicity.”


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  • Research Funding

    Today, the president signed a bill that increases federal research funding and takes important steps to better support our nation's care partners. Through its tireless advocacy work, the Parkinson's community played a role in the passage of this important law.

    Law Bolsters Funding for Research

    A critical provision provides funding for the National Neurological Conditions Surveillance System. This database will capture demographic information on people living with neurological diseases, which is key to helping researchers target their work and increase understanding of these conditions. While it was signed into law in late 2016, the database was never funded or implemented. But with the passage of this bill, it now can become a reality. (As the law does not specify which diseases the National Neurological Conditions Surveillance System will track, the Foundation is working with the Centers for Disease Control and Prevention, which will house the database, to push for the inclusion of Parkinson's.)

    The law also includes a $2 billion funding increase for the National Institutes of Health (NIH). The NIH is the largest public funder of Parkinson's research, investing $169 million in the disease in 2017. This funding boost is key to supporting the foundational research the agency carries out to better understand, diagnose and treat various health conditions.

    Throughout 2018, the Parkinson's community made a strong push for these funding priorities. Thousands of people with Parkinson's and their loved ones sent their lawmakers more than 46,000 emails asking for money for the database and the NIH. These funding successes are a testament to the critical work of Parkinson's advocates across the country.

    New Council Seeks to Better Support Care Partners

    Another significant provision in the law provides $300,000 to fund activities outlined in the RAISE Family Caregivers Act. This act was signed into law in January 2018, thanks in part to the advocacy efforts of the Parkinson's community, and directs the government to create a national strategy to better support the estimated 40 million care partners across the country. The $300,000 will be used to create a Family Caregiving Advisory Council, which will identify actions that communities, providers, policymakers and others can take to better assist care partners.

    We encourage you to reach out to you legislators to thank them for passing this law. This helps members of congress better understand how they can use their votes to pass bills that positively impact our community. You can quickly send your lawmakers an email on our website.


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  • Vets Felony Charges


    Majority in Felony Veterans Treatment court appear for drug, alcohol offenses

  • Vet Pensions


    VIRGINIA BEACH, Va. (WAVY) -- 10 On Your Side is helping Veterans prepare for a new rule that goes into effect on Thursday, Oct. 18.

    According to the U.S. Department of Veterans Affairs, pensions will change beginning Thursday for those of you using long-term care services.

    Shannon Laymon-Pecoraro, a lawyer with Hook Law Center, says failing to plan is planning to fail when it comes to these changes.

    "In a region like ours that is home to so many military Veterans, we think it’s important to tackle this issue head-on so people can start to address these changes before they take effect," Laymon-Pecoraro said.

    Laymon-Pecoraro is referring to Veterans like Frank Rough, a retired senior chief who served in Vietnam.

    "I planned all my life for retirement and to have that possibly taken away so I could have Veterans benefits is crazy," said Rough.

    Rough is talking about changes that could make it more difficult to qualify for certain important benefits, according to Hook Law. That's why Rough and other Veterans attended a Hook Law seminar regarding the changes.

    The VA pension program is a needs-based benefit for wartime Veterans who served at least 90 days active duty service, who have limited or no income, who are 65 and older and who may have a permanent and non-service connected disability.

    What's at risk? According to Hook Law, aid and attendance pension up to $2,170 per month for a Veteran and spouse -- which is money that could be used for long-term care.

    With the new rules, assets cannot exceed $123,600 to get the long-term benefits.

    According to the seminar presentation, gifts that you made in the past 36 months -- either to a family member or to an irrevocable trust and an investment in an annuity -- would be penalized with the new rules.

    This means you could be prohibited from qualifying for VA pension benefits for up to five years, depending on the amount of the gift.

    "I'm getting older and I may need long-term care and if I go into long term care and they start taking the money I've saved - that's awful," said Rough.

    So, what should you do between now and Oct. 18?

    Laymon-Pecoraro said, "Assess are there any significant transfers you want to make or any assets you want protected so that you can then qualify for this benefit if you think you may need within the next 3 to 5 years."

    It is important to note this change does not affect all Veterans.

    According to Hook Law, if you are receiving VA service-connected disability or compensation payments, your benefits will not be affected.


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  • Salathiel Gaymon Sr


    More than a year after her father died in his car in the parking lot of the Wilmington Veterans Administration Medical Center, Shelatia Dennis still struggles to understand why.

    Salathiel M. Gaymon Sr.'s body was found April 25, 2017, more than 17 hours after he walked out of the facility after his regular treatment in the Hemodialysis Unit.

    Dennis believes her father shouldn't have been discharged without having his condition assessed more closely.

    Gaymon's death prompted an investigation by the Department of Veterans Affairs Office of Inspector General, which published a report in September that judged the VA harshly but didn't place blame.

    The unit nursing staff did not appropriately monitor the patient's medical status, the report said, but could not "substantiate" that the care contributed to his death.

    An autopsy indicated that Gaymon had cardiovascular and kidney disease and "probably" suffered a fatal cardiac arrhythmia.

    The report did say that based on the available information and review of the electronic health record, quality of care concerns were identified related to Gaymon's clinical management while in the dialysis unit.

    Changes at the VA

    Wilmington VA Medical Center Director Vincent Kane said a day doesn't go by that he and his staff don't think about the events leading up to the tragedy. He was appointed shortly after Gaymon's death.

    The OIG report and internal analyses sparked changes in staffing and procedures, including many within the dialysis unit and police department.

    "If we could go back in time and know what we know now, I'm confident this wouldn't happen," Kane said. "We're committed to never letting something like this happen again."

    Chief among the 14 recommendations from the OIG was having the proper number of staff members in the Hemodialysis Unit and providing continuous education in all areas of the unit.

    According to Kane, that has happened and is now ongoing.

    "We've added a tremendous amount of staff since my arrival," said Kane. "We want to make sure we have processes and staffing in place to prevent tragedies moving forward."

    The police department has a new chief and those involved in the Gaymon tragedy were disciplined.

    Appointed rounds directed by VA policy were not done, meaning no one noticed Gaymon.

    "Those rounds should have happened. It's devastating to us," Kane said. "We've added more cameras and a training officer to make sure officers are compliant."

    A man of principles

    Dennis described her father as a man whose love of family was matched only by his love of God.

    She said he had no problem expressing the love and pride for his family and was an affectionate man who couldn't encourage his kids and grandchildren enough.

    But Dennis said her father also was all about advocacy and justice and often spoke out against injustices in the world. That is why one of his favorite musicians was Bob Marley, she said.

    Dennis believes what happened to her father was an injustice.

    "The quality of care that he was given was very poor," Dennis said recently from her Dover home on what would have been her father's 64th birthday. "It seems like anything that could have gone wrong did go wrong. It makes me so angry that they could get away with this."

    Questionable discharge

    Dennis said her father's blood glucose readings were through the roof that day in the Hemodialysis Unit, he was administered the wrong medication at the wrong time, his blood pressure was critically high and he was allowed to be discharged.

    "He was not OK," she said. "How could they not see something was wrong? If they had, maybe we wouldn't have had to have a funeral in May."

    Gaymon had been a regular patient at the Wilmington VA Medical Center since 1997 after he was diagnosed with diabetes. His medical records indicate he was often "noncompliant" in his treatment regimen and his diabetes was "uncontrolled" from 1997 to 2017.

    Dialysis was initiated in early 2016, and a few months later a kidney specialist ordered a blood sugar reading prior to each of his dialysis treatments.

    Critical to Gaymon's treatment were differences of opinions about unit policies concerning the patient's finger-stick blood sugar check.

    Gaymon's blood sugar was obtained 38 minutes after starting dialysis and it was shown to be critically high.

    According to the OIG report, a unit registered nurse believed it was acceptable to test the blood sugar within an hour of beginning treatment.

    The Office of Inspector General staff found no such policy.

    The OIG determined that the combination of the timing of the blood glucose test, which found Gaymon's blood sugar critically high and sparked a "routine" call for insulin rather than "stat," or immediately, resulted in more than a two-hour difference in treatment.

    The OIG report said the nursing staff did not check Gaymon's blood glucose before releasing him.

    Contributing issues

    Policies regarding treatment of Gaymon's critically high blood pressure also were called into question by the report.

    Gaymon was given medication to bring down his high blood pressure and then released 18 minutes thereafter.

    The medication given reduces blood pressure within 30 to 60 minutes, with the maximum decrease occurring within two to four hours, the report said.

    The report also said there was no evidence that staff conducted a full clinical assessment or provided Gaymon with instructions regarding the effects of the medication, including drowsiness and a recommendation not to drive.

    Dennis said video from the facility showed an unsteady, unhealthy individual in medical distress as her father walked out of the dialysis unit and fell on the hood of his car before getting in it.

    "The report was more confirmation," she said. "We already had a gut feeling that there was very poor quality of care and that there was definitely negligence on their part. We just didn't understand to what extent."

    Undignified death

    Dennis believes that even though the nurses and doctors failed her father, the Department of Veterans Affairs Police had an opportunity to "pick up the slack had they been doing their job."

    If police had done timely rounds in the parking lots as policy requires, they would have noticed Gaymon sitting in his car in a no-parking zone in valet parking.

    A hospital volunteer came across Gaymon in his car and alerted police.

    "If they would have noticed him within an hour, that might have been enough time to alert the doctors and get some help," Dennis said. "There was no dignity in the way he died."

    The officers were supposed to walk or drive the facility every hour, "so long as they are not on another call or doing a report.”

    The report said the facility's police officers violated policies by leaving the patient’s car in a visible illegal parking spot for more than 17 hours.

    Dennis recognizes her father's death affected changes, but said she will forever hold the facility accountable for taking her father away "too soon."

    "There were so many opportunities for people to make decisions that would have supported his life being sustained," Dennis said. "The healthcare was obviously the first misstep. But if the police force would have been doing its job, my father might still be alive today."


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    Veterans who served at Fort Drum, New York during certain years may have been exposed to Agent Orange, a toxic herbicide used during the Vietnam War.


    A document from the Department of Defense (DoD) shows that a formulation of 2,4-D and 2,4,5-T, the two ingredients in Agent Orange, were tested by the U.S. Army Chemical Corps in an approximately four square mile area of Fort Drum in the summer of 1959. According the document, thirteen drums totaling 715 gallons of Agent Purple, made up of concentrated butyl esters of 2,4-D and 2,4,5-T, were sprayed by helicopters over 2,560 acres of Fort Drum.


    The Court of Appeals for Veterans Claims recently issued a decision in a case in which a Veteran claimed service connection for multiples conditions due to exposure to Agent Orange at Fort Drum. The Court’s decision discussed numerous documents that the Veteran submitted for his claim which detail the use of Agent Orange and other herbicides at Fort Drum as early as 1959 up to the 1970s.


    The Veteran served in the United States Army from February 1971 to December 1972. He then entered the US Army Reserves and spent two weeks training at Fort Drum, New York in August 1974. In December 2004, he applied for service connection for diabetes mellitus, a heart condition, hypertension, and erectile dysfunction due to exposure to Agent Orange at Fort Drum. He was denied service connection and eventually appealed twice to the Court of Appeals for Veterans Claims.


    To support his claim of exposure to Agent Orange, the Veteran submitted a report from the Chemical Systems Laboratory at Aberdeen Proving Ground dated for July 1981, which discussed investigators finding ten five-gallon metal cans which contained chemicals found in Agent Orange. The report discussed how the herbicides were not properly stored at the base. The report also detailed testing in 1961 of an “experimental defoliant mixture” along the road of the base, and an herbicide that was similar to Agent Orange being used during the 1950s up to the early 1970s. Finally, from 1969 to 1978, herbicides similar to Agent Orange were also used along certain roads in the main impact area of Fort Drum.

    According to the documents detailed in the Court’s decision, Agent Orange was not only tested at Fort Drum, but it was also used for maintenance and to increase visibility around the base.


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  • Depression awareness


    Behavioral health experts say frequent deployments and other aspects of military life can contribute to clinical depression, a condition that negatively impacts mood and behavior. Depression may be more common in the armed forces community than among the civilian population, but it seems to me we still have a culture that may prevent service members from seeking help.

    If depression is something you don’t want to talk about, then let me tell you about my brother. Army Sgt. 1st Class Ruben Leal joined the Army in 1975 and became a tanker, a year after I enlisted and became a Special Forces medic. Ruben always had a smile on his face. He was outgoing and athletic, and also technically and tactically proficient on the job. He was a highly respected and decorated soldier, selected to participate in elite fraternal organizations such as the Sergeant Audie Murphy Club.

    Ruben considered me, his older brother, to be his hero. But truthfully, Ruben was mine. Both of us had come a long way from our troubled childhood.

    By December 1991, I was a senior ROTC instructor in San Antonio, and Ruben was a platoon sergeant at Fort Hood. He’d returned from a deployment in the Gulf War several months earlier. We were less than 200 miles apart, but it might as well have been 2,000. We were both so busy that we didn’t see each other as often as we should have.

    During our telephone conversations, my brother never talked about struggling with depression. Ruben was a proud man, and back then, it wasn’t really the Army’s way to focus on behavioral health issues after deployment – or really, ever.

    Still, I was a trained medic, and Ruben was my brother. When he died by suicide Dec. 4, 1991, I felt tremendously guilty. I realized the signs of depression were there, and I had missed them. I’d missed all of them.

    I don’t blame the military for Ruben’s death. I recognize his combat deployment experiences may have been a contributing factor in triggering a clinical depression that had roots in our dysfunctional upbringing. Since his death, I’ve struggled with depression, too. But I’ve gotten help, and I want to encourage others to do so as well.

    Three years after my brother’s death, I retired from the Army and used my GI benefits to earn accreditation as a licensed vocational nurse. Then I completed a two-year registered nurse program. I’ve dedicated the past eight years of my career to helping patients in the Warrior Transition Unit. A lot of injuries we’re seeing today aren’t only physical injuries, they’re also behavioral health injuries.

    This is my mission now: to encourage everyone to recognize the signs of clinical depression so they can get help -- for themselves or for others. Those signs include feeling negative, worthless, or guilty; loss of interest in previously enjoyable activities; sleeping too little or too much; or feeling restless or anxious.

    Today, my eyes and ears are open to people who are struggling. I ask them, “Do you want to talk to me about it? If you do, I’m ready to listen. But if you don’t, let’s find someone for you to talk to, now. I’ll walk with you. I’m here to help.”

    I tell people with depression that there’s hope. There are a lot of things we can do as health care providers, as senior leaders, as clergy. We can help you, we can get you to the right people. Please let us help you. Opening up is the first step.

    We’re all in this together. I ask you to reach out to help someone else. I ask you to reach out to help yourself.


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  • Da Nang


    The dioxin contamination of soil in Da Nang was worse than expected, experts said at a conference reviewing the cleanup on Tuesday.

    The event, organized by the National Steering Committee for Post-war Clearance of Ordnance and Toxic chemicals and USAID, shared some details on dioxin cleanup at the Da Nang International Airport, a U.S. air base during the Vietnam War.

    Pham Quang Vu, head of the Air Force and Air Defense’s Military Science Division, said earlier calculations had underestimated the actual contamination at the airport.

    He said the actual amount of contaminated soil is 162,500 cubic meters and not 72,900 cubic meters as earlier estimated.

    Anthony Kolb, chief of USAID’s environmental remediation unit, explained that experts only took soil samples from the surface and from that determined the depth to which the dioxin could have penetrated.

    The dioxin had percolated three meters deeper than expected, he said at the conference in Da Nang.

    Vu said the miscalculation could be attributed to the fact this was the first time this particular technology was used to remove dioxin from the soil on such a large scale. It involves heating the contaminated soil while covering it in concrete.

    The finding could help make future dioxin assessments more accurate, especially at another ongoing cleanup project at the Bien Hoa Air Base in the southern province of Dong Nai. Bien Hoa is considered one of the worst dioxin-contaminated spots, with some 850,000 tons of soil feared contaminated.

    "We expect to cleanse 500,000 cubic meters of contaminated soil in Bien Hoa, meaning 50 hectares of land," Chung said.

    Since 2012, when the Da Nang project was initiated, it has cleaned 94,600 cubic meters of soil at the airport, reducing the dioxin level from 1,200 parts per trillion (ppt) to below 150ppt, and has placed 68,000 cubic meters of contaminated soil in the southwestern part of the airport, which contained less than 1,000ppt of dioxin, under long-term management. Dioxin concentration of 100ppt is considered high.

    Kolb of USAID said 32.4 hectares of land has been cleaned.

    "This project is the most ambitious we have ever undertaken."

    Da Nang has been off the official list of dioxin contaminated spots in Vietnam after the cleanup, Vu said.

    The cost of the work is budgeted at around $108.5 million, with $106 million coming from ODA grants.

    Vietnam still has 28 dioxin hotspots, including airports in several cities and provinces which were used by the U.S. military during the Vietnam War.

    The government hopes to complete the task of decontaminating the country’s soil by 2030.

    Dioxins and dioxin-like compounds were contained in Agent Orange, which was sprayed by the U.S. military from 1961 to 1971 to clear jungle hideouts of Vietnamese soldiers. Some 80 million liters of the deadly defoliant are said to have been sprayed over 78,000 square kilometers (30,000 square miles) of Vietnamese territory.

    The chemical, which stays in the soil and at the bottom of lakes and rivers for generations, was later found to be capable of damaging genes, causing deformities in the offspring of exposed individuals.

    The Vietnam Red Cross estimates 2.1 to 4.8 million Vietnamese were directly exposed to Agent Orange and other chemicals that have been linked to cancers, birth defects and other chronic diseases since the war.


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  • Agent Orange 004


    GRAND RAPIDS, Mich. — A chemical sprayed on troops by the US military during the Vietnam War is continuing to impact the lives of Veterans and their families. One Michigan Vietnam Veteran is teaming up with the group Vietnam Veterans of America to do something about it.

    Philip Smith conducts meetings like this one Saturday in Grand Rapids throughout Michigan to warn Veterans about a silent killer many of them are unaware of Agent Orange.

    Smith serves as the director for Vietnam Veterans of America.

    “When Admiral Zumwalt was alive and he was the Admiral of the Navy.” “’He says don’t spray that stuff ‘well guess what we did and the ultimate factor is the disease that came down with it afterward,” he said.

    It was a herbicide used to eliminate forest cover and crops during the Vietnam War. Agent Orange is a toxic chemical that’s known to be associated with several illnesses and diseases. Many of them are considered deadly.

    “I’ve got a charcoal foot now because of it which went crooked. I had open heart surgery a little less than two years ago because of it,” said Jeron Hendricks, a Vietnam War Veteran.

    Hendricks served in Vietnam and says he now suffers from a number of illnesses impacting his legs and heart, but he was only able to receive compensation from the Veterans Administration four years after being able to prove his conditions were in fact related to the herbicide Agent Orange.

    “If things start happening to you, your family members, or relatives and nobody can figure it out well it’s a good chance if you were in service that this is part of that reason,” Hendricks said.

    And the chemical is just one of the Tactical Use rainbow herbicides impacting America’s Veterans. Information that the Vietnam Veterans of America are sharing by setting up presentations such as this in hopes of getting Veterans the knowledge they need to get the proper care and money that they deserve.

    “A lot of them are coming forward now saying ‘well I got some of these symptoms what do we do,” and that’s where Phil comes in he helps them get a claim into the VA and they get compensated for it and it also puts them on the record that they’re Agent Orange,” said Ken Rogge, the VVA Michigan first vice president.

    Over the last few years, more Veterans have come forward with claims about Agent Orange related illnesses and now signs of its impact are reaching past the Veterans to children, grandchildren and into further generations.

    To learn more about Agent Orange click here.


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  • Vet Benefits


    Different government programs have different Veteran criteria

    There is no standardized legal definition of "military Veteran" in the United States. Veteran benefits weren't created all at one time. They've been added one at a time for more than 200 years, and each time Congress passed a new law authorizing and creating a new Veteran benefit, it included eligibility requirements for that particular benefit.

    Whether or not one is considered a "Veteran" by the federal government depends upon which Veteran program or benefit one is applying for.

    Veterans' Preference for Federal Jobs

    Veterans are given preference when it comes to hiring for most federal jobs. However, in order to be considered a Veteran for hiring purposes, the individual's service must meet certain conditions.

    Preference is given to those honorably separated Veterans (this means an honorable or general discharge) who served on active duty in the Armed Forces. Retirees at or above the rank of major or equivalent are not entitled to preference unless they qualify as disabled Veterans.

    For more information about the Veteran's Preference Hiring Program, see the Federal Government's Veteran's Preference Web Page.

    Home Loan Guarantee

    Military Veterans are entitled to a home loan guarantee (within dollar limits) when they purchase a home. While this is commonly referred to as a "VA Home Loan," the money is not actually loaned by the government. Instead, the government acts as a sort of co-signer on the loan, and guarantees the lending institution that they will cover the loan if the Veteran defaults. This can result in a substantial reduction in interest rates, and a lower down payment requirement.

    For more information, see the VA's Home Loan Guarantee Web site.

    Burial in a VANational Cemetery

    To qualify as a Veteran for the purposes of burial in a VA National Cemetery also depends on the conditions and period of service. Any member of the Armed Forces of the United States who dies on active duty is obviously eligible.

    Any Veteran who was discharged under conditions other than dishonorable is usually eligible as well.

    Service beginning after September 7, 1980, as an enlisted person, and service after October 16, 1981, as an officer, must be for a minimum of 24 continuous months or the full period for which the person was called to active duty (as in the case of a Reservist called to active duty for a limited duration) to qualify for VA National Cemetery burial.

    Undesirable, bad conduct, and any other type of discharge other than honorable may or may not qualify the individual for Veterans benefits, depending upon a determination made by a VA Regional Office. Cases presenting multiple discharges of varying character are also referred for adjudication to a VA Regional Office.

    For more criteria for burial at Arlington National Cemetery can be viewed on the VA's National Cemetery's Web Site.

    Military Funeral Honors

    The Department of Defense (DOD) is responsible for providing military funeral honors. "

    Upon the family's request, every eligible Veteran receives a military funeral honors ceremony, to include folding and presenting the United States burial flag and the playing of Taps. The law defines a military funeral honors detail as consisting of two or more uniformed military persons, with at least one being a member of the Veteran's parent service of the armed forces.

    For more information, see the DoD's Military Funeral Honors Web site.

    Active DutyMontgomery GI Bill

    In all cases, the ADMGIB expires 10 years after discharge or retirement. To be eligible, one must have an honorable discharge. To retain MGIB benefits after discharge, in most cases, one must serve at least 36 months of active duty, if they had a four-year active duty contract, or at least 24 months of active duty, if they signed up for a two or three-year active duty contract (there are some exceptions to this rule).

    For complete details, see our ADGIB Article.

    Post-9/11 GI Bill

    If you have at least 90 days of aggregate active duty service after September 10, 2001, and are still on active duty, or if you are an honorably discharged Veteran or were discharged with a service-connected disability after 30 days, you may be eligible for this VA-administered program. See details.

    Service-Disabled VA Life Insurance

    To be eligible for basic Service-Disabled Veterans Insurance (S-DVI), a Veteran must have been released from active duty under other than dishonorable conditions on or after April 25, 1951. He/she must have received a rating for a service-connected disability and must be in good health except for any service-connected conditions. An application must be made within two years of the granting of service-connection for a disability.

    For complete details, see the VA Life Insurance Web site.

    VA Disability Compensation

    Disability compensation is a benefit paid to a Veteran because of injuries or diseases that happened while on active duty or were made worse by active military service. It is also paid to certain Veterans disabled from VA health care.

    The amount of basic benefit paid varies depending on the nature of your disability. Note: You may be paid additional amounts, in certain instances, if:

    • you have very severe disabilities or loss of limb(s)
    • you have a spouse, child(ren), or dependent parent(s)
    • you have a seriously disabled spouse

    For complete information, see the VA's Disability Compensation Web site.

    VA Disability Pension

    Disability Pension is a benefit paid to wartime Veterans with limited income who are no longer able to work.

    You may be eligible if:

    • you were discharged from service under other than dishonorable conditions
    • you served 90 days or more of active duty with at least 1 day during a period of wartime. (However, anyone who enlisted after September 7, 1980, generally has to serve at least 24 months or the full period for which a person was called or ordered to active duty in order to receive any benefits based on that period of service)
    • you are permanently and totally disabled, or are age 65 or older
    • your family income is below a yearly limit set by law

    VA Medical Care

    The Veterans Health Administration (VHA) provides a broad spectrum of medical, surgical, and rehabilitative care to eligible Veterans.

    If you have a discharge other than honorable, you may still be eligible for care. As with other VA benefits programs, the VA will determine if your specific discharge was under conditions considered to be other than dishonorable.

    The length of your service may also matter. It depends on when you served. There’s no length of service requirement for:

    • Former enlisted persons who started active duty before September 8, 1980, or
    • Former officers who first entered active duty before October 17, 1981

    The number of Veterans who can be enrolled in the health care program is determined by the amount of money Congress gives VA each year. Since funds are limited, VA set up priority groups to make sure that certain groups of Veterans are able to be enrolled before others.

    For more information, see the VA's Health Care Web site.


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  • DoD FDA working together


    In a move to better serve the unique needs of the nation’s warfighters, leaders from the U.S. Food and Drug Administration and the Office of the Assistant Secretary of Defense for Health Affairs signed a memorandum of understanding to foster and prioritize the development of critical medical products.

    The signing of the memorandum formalizes the partnership between the FDA and the Department of Defense that was authorized under a law enacted by Congress in 2017. Under this law, DoD is able to request help in speeding up development and review of products used to diagnose, treat, or prevent serious or life-threatening diseases and conditions faced by service members. It also allows for emergency use of medical products for threats that pose a specific risk to service members, including biological, chemical, radiological, or nuclear agents.

    The FDA will continue to work with DoD to evaluate how to best access medical products that serve the military’s medical needs and rush review of priority DoD medical products. The FDA will also provide advice for the development and manufacturing of these products, and examine those that are already under development to determine which will streamline review.

    The memorandum directs specific actions between the agencies, including semi-annual meetings at the senior-leader levels, quarterly meetings with FDA centers, and collaborations on emergency use of products.

    Dr. Terry Rauch, acting deputy assistant secretary of Defense for Health Readiness Policy and Oversight, said the memorandum enables the Military Health System to speak through one voice with the FDA on strategic issues and to move forward on urgent needs with a prioritized DoD list for the FDA to focus on.

    “DoD and FDA have always been committed to safe and effective products for our service members, and this [memorandum] really solidifies the needed relationship to provide these most effectively,” said Rauch. “We have already seen increased readiness due to the collaborative efforts with the approval of three medical products since the release of the law.”

    The FDA has approved the use of an auto-injector for nerve agent exposure, a prophylactic drug for malaria, and the RECELL system for point-of-care skin regeneration in trauma patients. These products were approved after the release of the law, and the memorandum strengthens these efforts even further, he said.

    “These products are critical to warfighter readiness in deployed environments and to the far-forward care settings that we face,” said Rauch. “Battlefield trauma and prolonged field care are at the forefront of challenges in military medicine.”

    Earlier this year, the FDA granted emergency use authorization for DoD’s use of freeze-dried plasma. Rauch described it as a life-saving product designed for austere environments, which can now be used in a much more streamlined process under the authorization. In addition, the FDA approved a new malaria prophylactic drug, tafenoquine, in August.

    “The FDA has been incredibly helpful and forward-leaning with all aspects of interaction on DoD medical product development,” said Rauch. “We are grateful that there is an increased interest by the leadership to drive collaboration, and we are leveraging that interest to the fullest.”


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  • Dominoes


    Recreational therapist Lauren Reynaga had never played dominoes before her internship and subsequent employment with VA North Texas.

  • Dothan Closes


    DOTHAN, Ala. (WDHN) - Dothan's Veterans Affairs clinic is closing, leaving thousands of military Veterans with major questions about where they will receive health care in the future.

    Nov. 30, 2018, will be the final day of operation for the Alexander Drive location across from Southeast Alabama Medical Center.

    There are contracted employees along with a small number of actual federal government employees in this facility.

    Once it closes, almost 5,000 patients — military Veterans — will be forced to use other VA options.

    WDHN is committed to finding more answers as to what the future holds for local VA patients.


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  • Agent Orange 003


    For decades, the military and the VA have repeatedly turned to one man to guide decisions on whether Agent Orange harmed Vets inVietnam and elsewhere.

    His reliable answer: No.

    A FEW YEARS AGO, retired Maj. Wes Carter was picking his way through a stack of internal Air Force memos, searching for clues that might help explain his recent heart attack and prostate cancer diagnosis. His eyes caught on several recommendations spelled out in all capital letters:




    A Pentagon consultant was recommending that Air Force officials quickly and discreetly chop up and melt down a fleet of C-123 aircraft that had once sprayed the toxic herbicide Agent Orange across Vietnam. The consultant also suggested how to downplay the risk if journalists started asking questions: “The longer this issue remains unresolved, the greater the likelihood of outside press reporting on yet another ‘Agent Orange Controversy.’”

    The Air Force, Carter saw in the records, had followed those suggestions.

    Carter, now 70, had received the 2009 memos in response to public records requests he filed after recalling the chemical stench in a C-123 he crewed on as an Air Force reservist in the years after the Vietnam War. He’d soon discovered that others he’d served with had gotten sick, too. Now it seemed he’d uncovered a government-sanctioned plan to destroy evidence of any connection between the aircraft, Agent Orange and their illnesses. And the cover-up looked like it had been set in motion by one man: Alvin L. Young.

    Carter had gotten his first glimpse of “Dr. Orange.”

    Young had drawn the nickname decades earlier as an Air Force expert on herbicides used to destroy enemy-shielding jungle in Vietnam. Since then — largely behind the scenes — the scientist, more than anyone else, has guided the stance of the military and U.S. Department of Veterans Affairs on Agent Orange and whether it has harmed service members.

    Young tested the weed killer for the Air Force during the war, helped develop a plan to destroy it at sea a decade later — a waste of good herbicides, he’d said — then played a leading role in crafting the government’s response to Veterans who believed the chemicals have made them sick. For a while, he even kept a vial of Agent Orange by his desk.

    Throughout, as an officer and later as the government’s go-to consultant, Young’s fervent defense hasn’t wavered: Few Veterans were exposed to Agent Orange, which contained the toxic chemical dioxin. And even if they were, it was in doses too small to harm them. Some Vets, he wrote in a 2011 email, were simply “freeloaders,” making up ailments to “cash in” on the VA’s compensation system.

    Over the years, the VA has repeatedly cited Young’s work to deny disability compensation to Vets, saving the government millions of dollars.

    Along the way, his influence has spawned a chorus of frustrated critics, including Vets, respected scientists and top government officials. They argue that Young’s self-labeled “investigations” are compromised by inaccuracies, inconsistencies or omissions of key facts, and rely heavily on his previous work, some of which was funded by Monsanto Co. and Dow Chemical Co., the makers of Agent Orange. Young also served as an expert for the chemical companies in 2004 when Vietnam Vets sued them.

    “Most of the stuff he talks about is in no way accurate,” said Linda S. Birnbaum, director of the National Institute of Environmental Health Sciences, part of the National Institutes of Health, and a prominent expert on dioxin. “He’s been paid a hell of a lot of money by the VA over the years, and I think they don’t want to admit that maybe he [isn’t] the end all and be all.”

    Birnbaum, whose agency studies how environmental factors affect health, questions how Young’s training in herbicide science qualifies him to draw some conclusions. “He is not an expert when it comes to the human health effects,” she said.

    Others complain that Young spent years using his government authority to discount or resist new research, then later pointed to a lack of research to undercut Vets’ health claims.

    “For really almost 40 years, there has been a studious, concerted, planned effort to keep any study from being done and to discredit any study that has been done,” said Jeanne M. Stellman, an emeritus professor at Columbia University. Stellman, a widely published Agent Orange researcher, has repeatedly clashed with Young and the VA.

    There’s a reason. In an era in which the military and the VA are facing a barrage of claims from Vets alleging damaging chemical exposures, from burn pits in Afghanistan to hidden munitions in Iraq, Stellman said Young provides a reliable response when it comes to Agent Orange: No.

    Anyone who set foot in Vietnam during the war is eligible for compensation if they become ill with one of 14 cancers or other ailments linked to Agent Orange. But Vets with an array of other illnesses where the connection is less well established continue to push for benefits. And those Vets who believe they were exposed while serving elsewhere must prove it — often finding themselves stymied.

    It’s not just the Vets. Some of their children now contend their parents’ exposure has led to their own health problems, and they, too, are filing claims.

    In recent years, Young, 74, has been a consultant for the Department of Defense and the VA, as well as an expert witness for the U.S. Department of Justice on matters related to dioxin exposure. By his own estimate, he’s been paid “a few million” dollars over that time.

    “He’s an outstanding scientist,” said Brad Flohr, a VA senior advisor for compensation, defending the agency’s decision to hire Young in spite of the controversy surrounding his work. “He’s done almost everything there is. He’s an excellent researcher into all things, not necessarily just Agent Orange.”

    In an interview and emails, Young defended his role. To date, he said, there’s no conclusive evidence showing Agent Orange directly caused any health problems, only studies showing a statistical association. It’s an important distinction, he says.

    “I’ve been blamed for a lot of things,” Young said. He likened the criticism he faces to Republican presidential nominee Donald Trump’s smearing of “Crooked Hillary” Clinton after 30 years of public service: “They say, ‘Crooked Young.’”

    Young said he believes most sick Vets are simply suffering from the effects of old age, or perhaps war itself, rather than Agent Orange. It’s a point even critics say has some validity as Vets have grown older during the benefits battle. His critics, he said, are as biased against the herbicide as he is accused of being for it. “Who’s an impartial expert? Name one for me, by all means.”

    When Carter came across Young’s name, he knew nothing of the controversy that surrounded him. He also had no need for benefits related to Agent Orange: He was already receiving full disability compensation from the VA for a back injury suffered during the first Gulf War.

    Reading the memos after his 2011 cancer diagnosis, it seemed clear there was a link between Agent Orange and illnesses plaguing those who’d flown aboard C-123s.

    But to get answers — and to help others get benefits — he’d have to take on Dr. Orange.

    IN THE SUMMER OF 1977, a VA claims worker in Chicago took a call from the sobbing wife of a Veteran claiming “chemicals in Vietnam” had caused his cancer. The woman mentioned a mist sprayed from above to kill plants on the ground. The claims specialist, Maude DeVictor, called the Pentagon and was transferred to Capt. Alvin Young, who knew more about the chemicals used in Vietnam than perhaps anyone.

    By then, Young, who’d gained an appreciation for herbicides on his family’s farm, had a doctorate in herbicide physiology and environmental toxicology and had spent nearly a decade studying defoliants for the Air Force. In 1961, the U.S. began spraying millions of gallons of herbicides across Vietnam’s thick jungles. Then, in 1971, it halted the effort after the South Vietnamese media reported a surge in birth defects in areas where the chemicals had been used — a political decision, according to Young, who didn’t believe the claims.

    DeVictor peppered Young with questions on the phone that day. Within weeks, she’d identified more than two dozen other Vets who believed their contact with Agent Orange had made them sick. DeVictor prepared a memo on what she had learned and shared her findings with a reporter, spurring national media attention on Agent Orange for the first time.

    “Dr. Young was very helpful. Without him, I wouldn’t have known anything,” said DeVictor. She was later fired by the VA; she claimed for speaking out about the herbicide.

    Young publicly refuted many of the comments attributed to him — especially those suggesting Agent Orange might have harmed Vets — and criticized media reports that he felt sensationalized the risks. But the episode was a turning point, moving Young from the Air Force’s internal herbicide expert to public defender of Agent Orange.

    Over the next decade, as concern grew about the effects of Agent Orange, Young was repeatedly promoted to positions of increasing influence, despite public clashes with prominent politicians and some federal health experts. In 1980, an exasperated Rep. Tom Daschle, D-South Dakota, who later became the Senate’s Majority Leader, challenged Young’s testimony before a House subcommittee by rattling off recent studies and media reports that suggested Vets had suffered because of Agent Orange. “I really find it somewhat interesting,” Daschle said, “that they are all wrong and he is correct.”

    Moments earlier, Young had said he didn’t doubt the competency of other authors, they just couldn’t match his 12 years of analyzing records. “It is a very complex issue,” he said.

    Young’s genial, almost folksy style belied a resolute confidence that while his listeners’ opinions might differ, no one knew Agent Orange as well as he did.

    In a 1981 Air Force research paper titled “Agent Orange at the Crossroads of Science and Social Concern,” Young questioned whether some Vets were using Agent Orange “to seek public recognition for their sacrifices in Vietnam” and “to acquire financial compensation during economically depressed times.” The paper earned him an Outstanding Research Award from the Air Force’s staff college.

    The same year, the Air Force assigned Young to serve as director of the VA’s new Agent Orange Projects Office, in charge of planning and overseeing initial research into emerging health claims. Here, too, he attracted congressional ire. Sen. Alan Cranston, R-California, warned the VA’s chief medical director in 1983 that Young’s dismissive comments about possible health risks might cause the public to doubt the “sincerity of the VA’s effort.”

    Soon after that, the White House tapped Young to serve as a senior policy analyst for its Office of Science and Technology Policy, giving him broad influence over the nation’s policy on dioxin. Over the next several years, the Reagan administration was accused of obstructing, stalling and minimizing research into Agent Orange.

    In 1986, another House committee faulted Young for undermining a planned study of chemical company workers exposed to dioxin. Young maintained that previous studies conducted by Monsanto and Dow of their workers “might have been enough,” the panel’s report said.

    Young recently denied interfering with that research but took credit for helping to shut down a major Centers for Disease Control and Prevention study of Vietnam Vets in 1987 that sought definitive evidence of a link between health issues and Agent Orange. Young said data on who had been exposed wasn’t reliable enough, though others argued that military records on spray missions and troop movements would have sufficed.

    In the end, answering the question of who was exposed was taken out of the hands of the scientists. Under pressure from Vets and their families, Congress passed the Agent Orange Act. Signed into law by President George H. W. Bush in 1991, it presumed that all Vets were exposed if they set foot in Vietnam during the war or traveled in boats on its rivers. And it provided compensation for them if they had certain conditions linked to exposure.

    In Young’s view, the Vets won; the science lost. By his final years at the White House, he was tiring of the battle. Young said emotions had risen so high he began “receiving threats to my family, threats to me.”

    CARTER DIDN’T SERVE IN VIETNAM and thus wasn’t covered by the Agent Orange Act. His connection to the herbicide began in 1974, when for six years he served as a crew member on a C-123 as part of his reserve duty at Westover Air Reserve Base in Massachusetts.

    During the war, C-123s criss-crossed southeast Asia, mostly ferrying troops and supplies. A few dozen were modified for spraying herbicides and insecticide. Back home, most were stripped of the spray gear, cleaned and put into service with the Air Force reserves.

    For Carter, the planes were an exhilarating break from his civilian marketing gig — even though when they flew through rain clouds, water seeped into the cabins and they were always too hot or too cold. He often flew on a C-123 that had been nicknamed “Patches” because it was hit almost 600 times by enemy bullets in Vietnam — then patched up with metal. Over the years, he served as an aeromedical evacuation technician, flight instructor and flight examiner.

    Even then, Patches’ former duties in Vietnam worried Carter and other reservists, who complained about the overpowering odor coming from it. But after an inspection, he said, “the wing commander assured us that the aircraft was as safe as humanly possible.”

    Patches was sent in 1980 to the National Museum of the Air Force near Dayton, Ohio, where it was displayed outside because of its chemical odor. Then, in 1994, during a restoration attempt, Air Force staff toxicologists said samples from the plane showed it was “heavily contaminated” with the dioxin TCDD, an unfortunate byproduct of manufacturing Agent Orange. Later, other planes were also found to be contaminated.

    But no one alerted Carter or any of the 1,500 to 2,100 reservists who’d flown them at least two weekends a month plus two weeks a year, often for years. Instead, most of the contaminated planes were quarantined in Arizona at Davis-Monthan Air Force Base, a sprawling airplane graveyard nicknamed “the Boneyard.” In 2010, at Young’s recommendation, they were destroyed.

    One year later, when Carter learned he had prostate cancer, his best friend from the reserves found out he did, too. With a few phone calls, Carter quickly tallied five from his old squadron with prostate cancer. The sixth he called had died. His squadron commanders and others tied to the planes also had Agent Orange-related illnesses.

    “Nearly two months into this project,” Carter wrote on a blog he kept, “it seems I have trouble finding crewmembers who don’t have AO-illnesses!”

    DECADES AFTER the last of the military’s Agent Orange was supposedly incinerated aboard a ship in the Pacific Ocean, Army Vet Steve House went public in 2011 with a surprising claim: He and five others had been ordered in 1978 to dig a large ditch at a U.S. base in South Korea and dump leaky 55-gallon drums, some labeled “Compound Orange,” in it. One broke open, splashing him with its contents. More than three decades later, House was suffering from diabetes and nerve damage in his hands and feet — ailments that researchers have associated with dioxin exposure.

    Around the same time House came forward, other ailing Vets recounted that they, too, had been exposed to Agent Orange on military bases in Okinawa, Japan.

    The Pentagon turned to a familiar ally.

    “I just heard back from Korea and the situation has ‘re-heated’ and they do want to get Dr. Young on contract,” one defense department official wrote to others in June 2011, according to internal correspondence obtained by ProPublica and The Virginian-Pilot through the Freedom of Information Act.

    By then, Young had established a second career. From his home in Cheyenne, Wyoming, he and his son ran a sort of Agent Orange crisis management firm. His clients: the federal government and the herbicide’s makers — both worried about a new wave of claims.

    In 2006, under contract for the Defense Department, Young had produced an 81-page historical report listing everywhere Agent Orange had been used and stored outside of Vietnam, and emphasizing that even in those places, “individuals who entered a sprayed area one day after application … received essentially no ‘meaningful exposure.’” Among the scholarly references cited were several of his own papers, including a 2004 journal article he co-authored with funding from Monsanto and Dow. That conflict of interest was not acknowledged in the Defense Department report.

    In an interview, Young said the companies’ financial support essentially paid the cost of publishing, but did not influence his findings. He and his co-authors, he said, “made it very clear” in the journal that Dow and Monsanto had funded the article. “That doesn’t mean that we took the position of the companies.”

    The Pentagon also hired Young to write a book documenting its history with herbicides. Published in 2009, the book made Young Agent Orange’s official biographer.

    In 2011, facing the new claims involving South Korea and Okinawa, the Defense Department asked Young and his son to search historical records and assess the evidence. In both cases, they concluded that whatever the Vets thought they’d seen or handled, it wasn’t Agent Orange. Young’s son did not respond to a request for comment.

    Alvin Young dismissed the claims of House and other Vets from Korea, saying he found no paperwork that showed the herbicide had been moved to their base. “Groundless,” Young told the Korea Times newspaper in 2011.

    In Okinawa, Young was similarly dismissive, even after dozens of barrels, some labelled Dow Chemical Co., were found buried under a soccer field. The barrels were later found to contain high levels of dioxin. But Young told the Stars and Stripes newspaper, they were likely filled with discarded solvents and waste.

    Young never spoke to the Vets in either case.

    “Why would I want to interview the Veterans, I know what they’re going to say,” Young told ProPublica, saying he focused on what the records showed. “They were going to give the allegation. What we had to do is go and find out what really happened.”

    In 2012, Young’s firm was hired again, this time by the VA, in part to assess the claims of other groups who believed they’d been sickened by their exposure to Agent Orange. One was led by Carter, a man whose determination appeared to match Young’s.

    “Mr. Carter,” Young recalled recently, “was a man on a mission.”

    FROM ALMOST THE MOMENT Carter came upon Young’s name in the Air Force documents, he’d been consumed by the scientist’s pivotal role. He began documenting Young’s influence on a blog he’d set up to keep fellow C-123 reservists informed. “Memo after memo from him showed exquisite sensitivity to unnecessary public awareness … what he calls ‘misinformation’ about Agent Orange. Best to keep things mum, from his perspective,” Carter wrote in a July 2011 post.

    An Agent Orange activist who heard about Carter’s efforts sent him an email exchange between Young and a Veteran named Lou Krieger. Krieger had been corresponding with Young about herbicide test sites in the United States and had mentioned that he believed the controversy over the C-123 aircraft represented “another piece of the puzzle.”

    In a flash of anger, Young had written back, “The only reason these men prepared such a story is that they are hoping they can cash in on ‘tax free money’ for health issues that originate from lifestyles and aging. There was no exposure to Agent Orange or the dioxin, but that does not stop them from concocting exposure stories about Agent Orange hoping that some Congressional member will feel sorry for them and encourage [the VA] to pay them off.

    “I can respect the men who flew those aircraft in combat and who made the sacrifices, many losing their lives, and almost all of them receiving Purple Hearts,” Young wrote, “but these men who subsequently flew them as ‘trash haulers,’ I have no respect for such freeloaders. If not freeloading, what is their motive?”

    Young’s response offended Carter. He pressed his Freedom of Information Act campaign with renewed vigor, requesting a slew of new records from the Air Force and the VA. He later filed lawsuits, with the help of pro-bono lawyers, against the agencies for withholding documents. The government eventually gave him the records and paid his lawyers’ fees.

    Carter worked the non-military world as well, soliciting letters from doctors, researchers and government officials who had expertise with toxic chemicals, some of whom had clashed with Young in the past. Several responded with letters supporting his cause, even a few who worked for federal agencies.

    The head of the Agency for Toxic Substances and Disease Registry, a part of the CDC, wrote in March 2013 that based on the available information, “aircrew operating in this, and similar, environments were exposed to TCDD [dioxin].”

    And a senior medical officer at the National Institute for Environmental Health Sciences wrote, “it is my opinion that the scientific evidence is clear” that exposure to dioxin is not only possible through the skin but has been associated with a number of health conditions, including cancer, heart disease and diabetes.

    Carter also found support in Congress from Sen. Richard Burr, R-North Carolina, and Sen. Jeff Merkley, D-Oregon, who began writing the VA regularly to advance Carter’s cause.

    He sent missive after missive filled with his findings and the letters of support he’d received to the prestigious Institute of Medicine, a congressionally chartered research organization hired by the VA to assess the science behind the claims of Carter and other C-123 Vets. If the VA was going to grant them benefits, Carter realized, he had to first convince this group of researchers that he was right.

    “It didn’t take long to realize that the VA had a lot of resources working against us and we found none working for us,” he said.

    One of those resources was Young, whom the agency had given a $600,000 no-bid contract to write research reports on Agent Orange.

    Young had approached the VA in 2012, offering to assess Vets’ claims that they’d been exposed to herbicides outside of Vietnam and weren’t covered by the Agent Orange Act.

    Over the next two years, Young and his son wrote about two-dozen reports examining issues such as whether Vets who served in Thailand, Guam or aboard Navy ships off the coast of Vietnam could have been exposed. In most cases, they concluded exposure was unlikely. The reports buttressed the VA’s rejection of claims by members of those groups, just as Young’s Pentagon reports were cited to deny those of individual Vets.

    In November 2012, Young turned in the first of several reports discounting the claims of Carter and his group. “All the analytical and scientific studies suggested that if they were exposed, that exposure was negligible,” he wrote. Although some samples taken from the C-123s showed minimal traces of dioxin, it was nothing to be concerned about, Young wrote, since dioxin sticks to surfaces and was unlikely to affect anyone who came in contact with the planes.

    Though Young dismissed the Vets’ claims, Carter’s campaign clearly bothered him. In a June 2013 email to a VA staffer, Young criticized the Air Force for releasing all of his correspondence to Carter.

    A couple months later he wrote: “You and I knew that the preparations of these investigative reports were going to show that in most cases the allegations are without any evidence. We can expect much more media interest as more and more Veteran claims are rejected on the basis of the historical records and science.”

    Young’s contract with the VA and emails were later disclosed to Carter as a result of his FOIA requests and a lawsuit against the VA. The emails showed that Young had also discounted the opinions of other experts, including the VA’s own researchers when they linked Agent Orange to prostate cancer.

    “It is clear the VA researchers do not understand what really occurred in Vietnam,” he wrote in May 2013 to several VA leaders, “and that the likelihood of exposure to Agent Orange was essentially negligible.”

    FOR THREE YEARS, Carter and Young had circled each other. Carter in his blog and in at least one intemperate email; Young in dismissive reports and notes to the VA. Finally in June 2014, they were face to face in Washington D.C. where an Institute of Medicine panel would weigh the evidence to determine which man was right.

    They lived just 45 minutes apart — Young in Wyoming and Carter in Colorado — but had never met. Now they sat next to each other to deliver testimony.

    Carter, who was now in a wheelchair, told panel members that their task should be straight-forward: Did the evidence show — more likely than not — that he and his crewmates had been exposed? “I’m probably the only bachelor’s degree person in this room, but I know the airplane,” he said.

    Young, who followed him, gave a rundown on the planes’ uses during the Vietnam War and their return to this country. He then defended the destruction of the planes, leaving out his role as the consultant who told the military to do it.

    “Those aircraft had been out there for almost 25 years. How long do you maintain an aircraft?” he said, adding later, “Those aircraft had a stigma.”

    Young had been at odds with the IOM before. An earlier panel had embraced a method to estimate troop exposure to Agent Orange, angering Young and his allies who didn’t believe it was possible.

    But the hours-long hearing on C-123s, in which an array of experts spoke, ended with no hint of which way the panel was leaning. As the months wore on without a decision, Carter began to wonder if he had wasted the past few years of his life. “I wasn’t a grandpa or a retiree or a hobbyist or a churchman, the things that usually follow in retirement,” he said. “I was ill and I was tired. It’s a lot of money. Every time I went back to Washington, there goes another fifteen hundred bucks.”

    Finally, on a crisp January morning in 2015, the IOM was ready to announce its decision. Carter and his wife Joan had flown in and now they sat holding hands in a conference room. Joining them were VA and Air Force officials, members of the IOM staff and journalists. Four lawyers who had helped him showed up too, as well as supportive congressional aides. Young, the man who’d fueled his quest, wasn’t there.

    At the front of the room, Emory University’s nursing school dean began to deliver the results of the institute’s report. Carter heard the words “could have been exposed,” and knew he’d won. “That was the moment that I really understood.” Carter and his wife squeezed hands, then hugged with happiness and relief when the meeting ended.

    The committee had rejected Young’s position that the dioxin residue found on interior surfaces of the C-123s would only have come off with a chemical wipe, dismissing that claim as “conjecture and not evidence-based.” His argument that dioxin wouldn’t be absorbed through a crew member’s skin was also wrong, the committee determined, and appeared to be based on an irrelevant Dow-funded study of contaminated soil. Further, Young’s overall description of the chemical properties and behavior of TCDD, a dioxin contaminant, were “inaccurate.”

    Joan Carter said it was her husband’s most meaningful mission, “a kind of a legacy of some good work, some definitive good work that he could leave behind.” It allowed him to help “a far greater circle of fellow Veterans, most of whom he never met.”

    Within weeks, Young protested to the IOM that it had “ignored important historical and scientific information … some material was misinterpreted, and there was a failure to focus on the science instead of who or what agency provided the information.”

    The IOM stood by its findings, and several months later, the VA approved disability benefits for the ailing C-123 Veterans. In a statement, VA Secretary Robert McDonald called it “the right thing to do.”

    In an interview, Young said the IOM panelists got it wrong — a retort he’s used for decades whenever his findings have been challenged.

    “Unfortunately,” he said, they “did not have a good handle on the science.”

    THE IOM’S DISMISSAL of Young’s findings has not dampened the military’s reliance on him.

    The Pentagon once again has signed Young on as a consultant, this time to track where herbicides were used at bases in the United States.

    Pentagon officials declined to answer detailed questions about Young’s work, including how much he’s been paid. Spokesman Lt. Col. James B. Brindle would only say that Young is the “most knowledgeable subject matter expert” on Agent Orange and that his personal views “are not relevant to the historical research he was contracted to perform.”

    While the VA didn’t renew Young’s contract when it expired in 2014, a VA official said the department wouldn’t hesitate to hire him again if he was the most qualified person. Flohr, the VA senior advisor, said Young was chosen for his expertise — not his position on the Vets’ exposure. “It was purely scientific, the research he did,” he said, “no bias either way on his part or our part.”

    In a subsequent statement, the VA said it makes decisions on Agent Orange “only after careful and exhaustive reviews of all the medical/scientific evidence. … Our obligation remains to the Veterans we serve.”

    Young’s continued work for the government comes as a surprise to those who squared off against him a generation ago. “As a physician, as a dioxin scientist, as an Agent Orange researcher, as a Vietnam-era Veteran, I’m just appalled by that personally,” said Dr. Arnold Schecter, who has written a major textbook on dioxin and who has feuded with Young.

    Today, despite his loss to Carter, Young is unwavering in his belief that his research is “great.” Among his few regrets: Putting controversial opinions — such as calling C-123 reservists freeloaders — in emails that could be obtained through public records requests.

    Young said he, too, was exposed to Agent Orange while testing the chemicals over the years, and in that way has a deeply personal interest in the research.

    “Give me some credit,” Young said. “Hell, I’ve got 40 years working out there on these issues. I have a great deal of experience. … Am I wrong? I could be wrong. I’ve always said I don’t understand it all.”


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  • Video Visits


    This summer, VA launched a telehealth expansion initiative that includes significantly increasing the number of outpatient providers capable of offering video visits. VA Video Connect is an application that uses the camera on your phone, tablet or computer to create a secure connection with a member of your VA care team from the comfort of your home or wherever is convenient for you.

    If you’re a Veteran who is interested in using VA Video Connect, first consult with your VA care team to see if video appointments can be part of your care plan. Video appointments will display in your list of appointments in VA Online Scheduling. You can check to see if your facility currently participates in VA Online Scheduling at this link.

    How Do I Get Started?

    Before a VA Video Connect appointment is scheduled, a provider must determine if a video appointment is appropriate for you. Your provider will discuss the logistics and details of the video visit, and designated staff members will assist you to determine how you will connect to a video visit at home.

    Video visits are currently being scheduled for patients by designated scheduling staff. In the future, Veterans will be able to schedule video visit appointments through the VA Online Scheduling application.

    When your appointment is scheduled, you will receive an email with a link to join a virtual medical room. In the coming months, that link will also be available in VA Online Scheduling when you view your upcoming appointments.

    If you’re using a non-iOS system (e.g., desktop, laptop, Android device, etc.), just click the appointment link at your scheduled day and time to start your video visit. If you plan to use an iOS device for the video visit, you must install the VA Video Connect App on your device. You can find iOS download information on this page of the VA App Store and read more about how to get started with VA Video Connect in this My HealtheVet article.

    If you need help with VA Online Scheduling or VA Video Connect, call the VA Help Desk at 1-877-470-5947 (for TTY assistance, dial 711). The Help Desk is open weekdays from 7 a.m. – 7 p.m. CT.

    Feedback Wanted

    Finally, VA wants to hear about your experiences trying VA Video Connect and VA Online Scheduling. The feedback will help us make future improvements to the applications.

    • For VA Video Connect, go to the app’s page on the VA App Store and click the “Feedback To VA” tab.
    • The VA Online Scheduling Feedback tab is located under the User Menu when you are logged into the application.

    Both brief feedback forms include a few questions and an opportunity to provide comments. Your comments are anonymous and valuable to our app development teams.


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  • CO Homeless Vets


    HUD, VA team up to places homeless Vets in permanent housing

    Funding from the U.S. Housing and Urban Development and the Veterans Affairs departments will help provide permanent homes to about 100 homeless Veterans in Colorado.

    The $782,869 in rental assistance announced this week comes from the HUD-Veteran Affairs Supportive Housing program, which combines rental assistance from HUD with case management and clinical services by the VA.

    “We are lucky to have such strong partnerships with the VA and housing authorities throughout the state and the Rocky Mountain region, all of whom work together to build on the success of the HUD-VASH Program,” HUD Rocky Mountain Deputy Regional Administrator Eric Cobb said in a statement.

    As part of the program, VA medical centers assess Veterans experiencing homelessness before referring them to local housing agencies for vouchers. The decisions are based on a variety of factors, including the duration of homelessness and the need for longer term, more intensive support.

    Veterans participating in the HUD-VA housing program rent privately owned housing and generally contribute no more than 30 percent of their income toward rent. The VA offers eligible homeless Veterans clinical and supportive services through its medical centers across the U.S., Guam, Puerto Rico and the Virgin Islands.


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  • 5 Drs Out at Mn


    ATLANTA -- In another blow to Marietta-based MiMedx, the Veterans Affairs Medical Center in Minneapolis has parted ways with four podiatrists and a dermatologist over improprieties with the company's bio-pharma products, a VA spokesman confirmed for The Atlanta Journal-Constitution.

    The company is under fire amid accusations of "channel stuffing" by ex-employees -- lobbying friendly doctors and medical staffers to overstock and over-use products, thereby inflating revenue reports and driving up stocks.

    In May, three South Carolina VA workers were indicted on federal health care fraud charges, accused of excessive use of MiMedx products on Veterans after accepting gift cards, meals and other inducements from a company representative. Two of the three workers were also charged with accepting bribes.

    The company has launched an internal investigation, and in June, MiMedx announced that it will revise more than five years of financial statements. In July, prominent Atlanta businessman Parker "Pete" Petit stepped down as the company's CEO and chairman. The company remains under scrutiny from the U.S. Department of Justice, the U.S. Securities and Exchange Commission, the Food and Drug Administration and the Department of Veterans Affairs.

    Details behind the Minneapolis doctors' departures aren't clear. The spokesman, Ralph Heussner, said the VA proposed terminating all five, but each opted to resign or retire. He confirmed that the proposed terminations involved issues with MiMedx products.

    Huessner explained in an email that the doctors "engaged in behavior that is not in line with the norms and values of the department.

    "VA has made clear that it will hold employees accountable when they to fail to live up to the high standards taxpayers expect from us," the email said, "and that's exactly what we're doing in this case."


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  • Dr Barbara Temeck


    A career VA administrator and surgeon, Temeck was charged with three counts of improperly writing prescriptions for controlled substances for a friend who also is married to a former high-ranking VA official. Temeck testified that she had been long involved in the friend’s medical care and did nothing wrong. She also says Glassman pursued the case as part of larger VA retaliation against Temeck’s efforts to crack down on how the Cincinnati VA had been run.

  • Gillibrand 002


    WASHINGTON — The sponsor of legislation that would help certain naval Veterans who served in the Vietnam War obtain compensation for health complications caused by Agent Orange exposure is hopeful the legislation will move forward, despite expressed opposition from the U.S. Department of Veterans Affairs.

    Naval Veterans who served on the shore of Vietnam do not get compensation from the Veterans Administration for complications caused by exposure to the herbicide Agent Orange, said U.S. Sen. Kirsten Gillibrand, D-N.Y.

    The Agent Orange Act of 1991 only allowed compensation for soldiers who served, boots on the ground, inland or sailors who served on inland water ways, but Veteran organizations are pushing Congress to pass legislation that would add sailors stationed just off-shore during the war, arguing it is possible those sailors could have been exposed.

    “I have known Navy Veterans who have died waiting for this legislation to pass,” said Command Sgt. Maj. Gary Flaherty, director of Columbia County Veterans Services. “There are a lot of unhappy Veterans. There is no question in our minds when those planes flew over spraying Agent Orange it affected the sailors on the deck of ships on the shoreline.”

    In the past, Flaherty said the cancer-causing herbicide could have been carried to ships anchored offshore by wind or into ships’ potable water drawn from the ocean and filtered.

    The House of Representatives passed the Blue Water Navy Vietnam Veterans Act on June 25 with a 382-0 vote.

    The Senate Committee on Veterans Affairs has held the bill since June 28.

    “Senator Gillibrand has had productive conversations with Committee on Veterans Affairs Chairman U.S. Sen. Johnny Isakson, R-Ga., about his concerns and they have discussed ideas for modifications,” according to a statement from Gillibrand’s office. “We are hopeful that Chairman Isakson will produce a bill with small modifications very soon and that the Senate would be able to vote on it without any further delay.”

    The committee held a hearing on the bill Aug. 1 and VA Undersecretary for Benefits Administration Paul Lawrence told members of the committe the department opposes the legislation.

    “We oppose this bill,” Lawrence said. “We know it is incredibly difficult to hear from groups of Veterans who are ailing and ill. There is no conclusive science from the institute of medicine to support claims of exposure.”

    Lawrence arguedthe bill would set a precedent that the department would have to pay Veterans’ claims regardless of the scientific evidence.

    The VA is conducting a health study that compares the health effects on Vietnam Veterans who did not serve inland, including nearly 1,000 Blue Water Navy Veterans, with non-Veteran populations, which will start to be published in 2019, Lawrence said.

    “They have been studying this for 50 years,” Flaherty said. “This is the closest this bill has ever been. It is time to stop stalling, stop studying and give these Veterans what they deserve.”

    Agent Orange exposure can cause many health complications including chronic B-cell leukemias, Hodgkin lymphoma, ischemic heart disease, multiple myeloma, Non-Hodgkin lymphoma, Parkinson’s disease, peripheral neuropathy, porphyria cutanea tarda — characterized by liver dysfunction — prostate cancer, respiratory cancers and soft tissue sarcomas, which attacks muscle, fat, blood and lymph vessels and connective tissues, and diabetes according to the website for the U.S. Department of Veterans Affairs.

    Randy Staats, of Hudson, served as a deckhand on the USS New Jersey from 1967 to 1969 and was anchored off the Vietnam shore during that time at points all along the coast. Staats suffers from diabetes, a condition he has requested compensation for more than 10 times since 1992 and has been denied every time, he said.

    “They just told me I wasn’t going to get it because Blue Water Navy Veterans are not entitled to it,” Staats said. “They are waiting for most of us to die and then they will give it to us. If it was their kids over there, they would have this thing passed already.”


    Lawrence also told committee members in August that the VA opposes the way Congress plans to pay for the bill through increasing fees charged as part of the VA Home Loan programs. Veterans with disabilities are exempt from funding fees.

    “The funding plan for [the bill] is unfortunate,” said Greene County Veterans Service Agency Director Michelle Romalin Deyo. “It is disconcerting that the funding for benefits payable to our Blue Water could be at the expense of other Veterans.”

    Under the bill passed by the House rates for Veterans using the loan programs would be as follows:

    • From 2.15 percent to 2.40 percent of the loan amount for loans with no down payment and first-use of the VA guarantee benefit.
    • From 3.3 percent to 3.8 percent of the loan amount for loans with no down payment on subsequent use of the loan benefit.
    • From 1.50 percent to 1.75 percent of the loan amount for loans with a 5 percent down payment.
    • From 1.25 percent to 1.45 percent of the loan amount for loans with a 10 percent down payment.

    “Though the VA Home Loan Guarantee Funding Fee is only collected from Veterans who are not rated by the VA with a service-connected disability with certain exceptions; that doesn’t mean it won’t affect our disabled Veterans,” Deyo said. “Veterans with pending original claims, will generally not be eligible for the funding fee waiver — not until they have a VA Rating Decision of 10 percent service-connected disabled or greater. The funding fee is already a sizable fee.”

    The increases would take effect Jan. 1 next year and return to current levels after Sept. 30, 2026.

    Funding fees haven’t been raised since 2004.

    “In June, the House unanimously approved the Blue Water Navy Vietnam Veterans Act 382-0 and the Senate should follow suit immediately to get these Veterans the benefits they deserve,” said U.S. Rep. John Faso, R-19, who voted for the bill. “After enactment of the Agent Orange Act of 1991, the VA determined that benefits for Veterans made sick by agent orange would only be available to those with “boots on the ground” or served on inland waterways. I believe this determination was wrong.”

    Deyo works with many Blue Water Navy Veterans, and hopes the bill passes soon.

    “We do have a significant population of Blue Water Veterans affected by herbicide exposure-related illnesses considered presumptive for so-called ‘Boots on the Ground’ Veterans,” Deyo said. “So, I am very hopeful that Congress will find another resource, outside of existing VA programs, to make sure our Blue Water Veterans are finally compensated, and all of the corresponding benefits are extended to them and their dependents, without further delay.”


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  • Glyphosate Monsanto


    Lead Trial Counsel Reveals Evidence That Led to Historic Win Against Monsanto

    Last month, a jury ruled in favor of plaintiff Dewayne Johnson1,2,3,4,5 in a truly historic case against Monsanto. Mr. Johnson — the first of over 8,000 cases pending against the infamous chemical company which has since been bought by Bayer AG6,7 — claimed Monsanto’s Roundup caused his Non-Hodgkin lymphoma. According to the landmark ruling, Monsanto “acted with malice or oppression” and was responsible for “negligent failure” by not warning consumers about the carcinogenicity of this pernicious weed killer. Monsanto has been ordered to pay $289 million in damages to Johnson.

    In The Highwire video featured below, medical journalist Del Bigtree takes a deep dive into this groundbreaking win, revealing evidence presented to the jury — email correspondence and corporate documents that created a comprehensive narrative of corporate malfeasance and collusion with U.S. regulatory agencies — ultimately leading the jury to give Johnson a quarter of a billion dollars in damages.

    Summary of Monsanto’s Battle to Squash Evidence of Carcinogenicity

    The beginning of the end for Monsanto really began in 2015, when the International Agency for Research on Cancer (IARC), the cancer research arm of the World Health Organization (WHO) and the “gold standard” in carcinogenicity research, reclassified glyphosate as a “probable human carcinogen.”8,9

    This determination was based on evidence showing the popular weed killer can cause Non-Hodgkin lymphoma and lung cancer in humans, along with “convincing evidence” it can cause cancer in animals. In response, Monsanto launched an all-out attack on IARC and its researchers, and even lobbied to strip IARC of its U.S. funding.

    Then, in January 2017, the American Chemistry Council, of which Monsanto is a member, went on to form a front group called Campaign for Accuracy in Public Health Research,10 the express purpose of which is to discredit the IARC and seek to reform the IARC Monographs Program, which evaluates and determines the carcinogenicity of chemicals.11 As reported by the Union of Concerned Scientists on July 11, 2018:12

    “A rider [was added to] the House version of theHHS [Department of Health and Human Services] appropriations bill that would prevent the National Institutes of Health from lending any financial support toIARC unless it agrees to push for reforms atIARC that have been called for by [industry ally U.S. Rep.] Lamar Smith and the House Science Committee at the bequest of the chemical industry.”

    Monsanto Fought — and Lost — Proposition 65 Cancer Warning Label

    Following the IARC’s determination that glyphosate is probably carcinogenic to humans in 2015, California’s Environmental Protection Agency’s Office of Environmental Health Hazard Assessment (OEHHA) announced it intended to list glyphosate as a chemical known to cause cancer under Proposition 65, which requires consumer products with potential cancer-causing ingredients to bear warning labels.

    Monsanto filed formal comments with OEHHA saying the plan to list glyphosate as a carcinogen should be withdrawn. When OEHHA refused to cave, Monsanto sued OEHHA in January 2016 to stop the glyphosate/cancer classification. OEHHA filed a motion to dismiss the lawsuit and a Fresno, California, superior court judge ruled on their behalf in February 2017.

    Alas, Monsanto continued filing legal appeals to block the cancer warning from being implemented. In its latest attempt, Monsanto tried to have a provision of the law removed that allows the OEHHA from taking scientific findings from outside experts — such as the IARC — into consideration.

    Mere days after Johnson’s verdict, Monsanto lost against California yet again. As reported by Sustainable Pulse:13

    “This decision leaves in place lower court decisions upholding a provision of the voter-approved initiative that allows outside expert scientific findings to be considered when adding chemicals to the public list of carcinogens … ‘Monsanto doesn’t have the right to decide which scientific experts are permitted to inform the public about cancer-causing chemicals.


    By refusing to consider this case, the Supreme Court has allowed Proposition 65 to keep working the way voters intended when the initiative was passed in 1986,’ said Avinash Kar, senior attorney with the Natural Resources Defense Council.”

    This is another piece of good news, as this means California will be able to require Roundup and other glyphosate-containing products to bear a cancer warning label, and since companies rarely want to go through the extra work of making different product labels for different states, this likely means all Americans will finally be informed of the fact that Roundup is carcinogenic.

    Evidence Shows EPA Colluded With Monsanto to Hide Evidence of Carcinogenicity

    Throughout its legal battles, Monsanto has relied heavily on evidence by the U.S. Environmental Protection Agency (EPA) which, despite IARC findings, has continued to maintain that glyphosate is probably not carcinogenic to humans.

    However, internal documents obtained during the discovery process of Johnson’s case revealed the EPA colluded with Monsanto to protect the company’s interests — actually manipulating and preventing key investigations into glyphosate’s cancer-causing potential. You can review key documents from this case on the U.S. Right to Know website.14

    A 2017 Spiegel article15 also delves into some of this damning evidence, which includes correspondence that clearly reveals Monsanto knew Roundup had safety problems, and in more ways than one:

    “The Monsanto researchers also behaved irresponsibly when it comes to the question of Roundup’s absorption into the body,” Spiegel writes. “In their own animal experiments back in 2002, the company’s experts discovered that ‘between 5 and 10 percent’ of the substance penetrated the skin of rats.


    The rate was much higher than expected and the result had the potential to ‘blow’ the ‘Roundup risk evaluations,’ reads one email. As a consequence, the author of the email wrote: ‘We decided thus to STOP the study.’ Laboratory animals also absorbed more Roundup ingredients through the digestive tract than had been hoped for.


    Above all, the Monsanto papers show that the experts were very aware of a fact that is often lost in the public debate: In addition to glyphosate, herbicides like Roundup contain other dangerous chemicals that are necessary to enable the active ingredient to penetrate hard plant walls, among other things. These ingredients are often more harmful than the active ingredient on its own.”

    Summary of Johnson’s Case

    In the video featured below, Del Bigtree interviews Baum Hedlund attorney Brent Wisner, lead trial counsel for Johnson and thousands of other plaintiffs who believe their Non-Hodgkin lymphoma — a type of cancer that starts in your white blood cells (lymphocytes), which are part of your immune system — was caused by Roundup exposure.

    More than 500 of these cases are currently pending in a multidistrict litigation (MDL) with the U.S. District Court in San Francisco.16 While the MDL procedure is similar to a class-action suit in that it consolidates pretrial proceedings, each case will get its own jury trial, and the outcomes will vary depending on the strength of the evidence in any given case.

    Johnson’s lawsuit was filed in state court rather than through an MDL and was granted an expedited trial due to the fact that he’s nearing death.17,18,19 In California, if the plaintiff dies, no punitive damages can be awarded, so Johnson agreed to be the first one to take Monsanto on.

    Johnson, a 46-year-old husband and father of two, sprayed an estimated 150 gallons of Roundup 20 to 40 times per year while working as a groundskeeper for the Benicia school district in California, from 2012 through late 2015.20

    Johnson was diagnosed with a rare and deadly form of Non-Hodgkin lymphoma called mycosis fungoides in August 2014. He told his doctor the rash he’d developed that summer would worsen after exposure to the herbicide. His lawsuit, filed in 2016 after he became too ill to work, accused Monsanto of hiding the health hazards of Roundup.

    His court case, presided by Superior Court Judge Suzanne Ramos Bolanos, began June 18, 2018, and ended August 10 with a ruling in his favor.21 As mentioned, the jury awarded Johnson $289 million in damages — an amount that effectively wipes out Monsanto’s reserve fund for environmental and litigation liability, which according to Bloomberg22 totaled $277 million as of August 2018.

    Robert F. Kennedy Jr. on Monsanto’s Corporate Culture and Toxic Legacy

    Wisner is also joined by co-counsel Robert F. Kennedy Jr., who has been an environmental lawyer for 30 years, who commented on Monsanto’s “antidemocratic and antihumanistic” corporate ways, saying:

    “We really were up against an industry that has employed all of the techniques pioneered by the tobacco industry.


    Over 60 years, Big Tobacco killed 1 out of every 5 of its customers who used its products as directed, was able to avoid any kind of regulatory interference, because it pioneered these techniques of ghostwriting science, compromising science, corrupting public officials, capturing the agencies that are supposed to protect Americans from pollution, and Monsanto really was part of the group that pioneered those techniques — and also of using ad hominem attacks.


    Monsanto is the same company that was making DDT and masterminded and orchestrated the attack on Rachael Carson … [they] tried to personally destroy her, as she died of cancer. On agent orange, it led the fight to deny rights and deny compensation to tens of thousands of American Veterans who had been exposed inVietnam to this terrible chemical.


    I’ve been suing one of Monsanto’s chemicals for 35 years, PCBs, which Monsanto is the only producer of. It contaminated theHudson River. In more recent years, I’ve brought a series of lawsuits against Monsanto because of the PCBs put into caulking in American schools. Half the schools built between 1950 and 1977 have calking in their windows filled with PCBs.


    Monsanto knew PCB was carcinogenic and an endocrine disruptor and children should never be exposed to it. And it knew PCB was about to be heavily regulated if it got banned. So, it ordered all of its sales forces to … [get rid of it by selling] it for caulking for schools. This is the mentality of a very corrupt corporate culture.”

    Trial Counsels Discuss the Evidence Against Monsanto

    As noted by Kennedy, until now, Monsanto has had a reputation of being untouchable. Wisner finally broke the magic spell with his phenomenal ability to create a comprehensive narrative, showing exactly how Monsanto has been able to get away with murder, and producing the evidence needed to support that narrative.

    As mentioned, Wisner was able to show corporate correspondence and documents that clearly discussed Monsanto’s inability to prove Roundup is noncarcinogenic. In fact, Monsanto toxicologist Donna Farmer, Ph.D., who in 2016 appeared on the TV show “The Doctors” defending the safety of Roundup, years earlier had written an email stating:

    “The terms glyphosate and Roundup cannot be used interchangeably, nor can you use “Roundup” for all glyphosate-based herbicides anymore. For example, you cannot say that Roundup is not a carcinogen … we have not done the necessary testing on the formulation to make that statement.”

    Indeed, as Wisner notes, Roundup is not just glyphosate. It also contains a number of surfactants to solubilize it and other chemicals, and the synergistic action between all of these chemicals has actually been shown to be far more toxic than glyphosate alone.

    This was recently confirmed in tests23 conducted by the U.S. National Toxicology Program (NTP). According to the NTP’s summary of the results, glyphosate formulations significantly alter the viability of human cells by disrupting the functionality of cell membranes. In layman’s terms, Roundup kills human cells.

    Recent research24,25 by the highly respected Ramazzini Institute in Italy also reveals daily ingestion of glyphosate at the acceptable daily dietary exposure level set by the EPA alters sexual development in rats, produces changes in the intestinal microbiome, and exhibits genotoxic effects.

    Wisner made every effort to get Farmer to testify. Not only did she evade being served, when they were finally able to catch her, Monsanto “fought tooth and nail” to prevent her from taking the stand. They ultimately won, and Wisner was not able to get her to testify. Still, email correspondence to and from Farmer was revealing enough.

    Success Became Monsanto’s Downfall

    According to Kennedy and Wisner, the extreme success of Roundup is ultimately what became its downfall. Roundup is now the most widely used agricultural chemical in the history of the world, and its sheer pervasiveness led to increased scientific investigation. With that increased scrutiny by independent researchers, more and more evidence of harm was published.

    Secondly, in 2005 Monsanto started recommending the off-label use of Roundup as a desiccant on non-GMO grains. Essentially, by spraying Roundup on the grain right before harvest, it dries the grain, making it easier to harvest and allows the farmer greater profits, as they’re penalized when grain contains moisture. The greater the moisture content of the grain at sale, the lower the price they get.

    As a result of this successful campaign, farmers began spraying Roundup directly on food preharvest, whereas previously it was primarily used as weed control. This is why we’re now finding glyphosate in just about everything — it’s been found in every processed food tested, in air samples, rain samples, municipal water supplies, soil samples, breast milk and urine.

    Related reading: Toxic Weed Killer Glyphosate Found in Most Foods Sold in the U.S.

    According to Bigtree, two recent studies even revealed the presence of glyphosate in several vaccines, including the pneumococcal, Tdap, hepatitis B (which is injected on the day of birth), influenza and MMR. The MMR vaccine had the highest amounts at 0.8 parts of glyphosate per billion.

    Ironically, one of Farmer’s talking points during her appearance on “The Doctors” was that IARC was looking at the effects of injected glyphosate, which is not how it’s used. Yet now we’re finding vaccines are contaminated with glyphosate, and is in fact injected directly into the bodies of young children.

    Related reading: Monsanto Strikes Again — Tests Confirm Most Vaccines Contain Glyphosate Herbicide

    Kennedy notes the majority of glyphosate used since its inception has actually been used in the last five years alone. And, as contamination has been detected, concern about its safety has been increasingly strengthened. These factors are ultimately what allowed Wisner to present such a compelling case against Monsanto.

    Public Health Impact of Roundup is Likely to be Enormous

    Keep in mind that Johnson’s case is just the beginning. Every day, the law firm of Baum Hedlund is receiving calls from people asking if their cancer might have been caused by Roundup exposure, Kennedy says. Many are farmers, but many are also avid gardeners and people who have used the chemical extensively around their private property.

    Eventually, he believes other disease categories may be added to the growing mountain of lawsuits against Monsanto. Aside from the over 8,000 cases of plaintiffs with Non-Hodgkin lymphoma, the evidence also suggests glyphosate and/or Roundup may be linked to liver cancer (which is now occurring in children), brain tumors and health problems associated with endocrine disruption.

    Indeed, aside from its carcinogenic potential, independent research has connected glyphosate-based herbicides with a growing list of disturbing health and environmental effects. For example, glyphosate has been shown to:

    Affect your body’s ability to produce fully functioning proteins

    Inhibit the shikimate pathway (found in gut bacteria)

    Interfere with the function of cytochrome P450 enzymes (required for activation of vitamin D and the creation of nitric oxide and cholesterol sulfate)

    Chelate important minerals

    Disrupt sulfate synthesis and transport

    Interfere with the synthesis of aromatic amino acids and methionine, resulting in folate and neurotransmitter shortages

    Disrupt the human and animal gut microbiome by acting as an antibiotic

    Destroy the gut lining, which can lead to symptoms of gluten intolerance

    Impair methylation pathways

    Inhibit pituitary release of thyroid stimulating hormone, which can lead to hypothyroidism26,27

    Shocking Evidence of Ghostwriting Revealed During Johnson’s Trial

    In their interview, Bigtree and Wisner discuss some of the most revelatory pieces of information brought up during Johnson’s trial. As mentioned earlier, you can review many of these so-called “Monsanto Papers” on the U.S. Right to Know website.28

    You can also read “Spinning Science & Silencing Scientists: A Case Study in How the Chemical Industry Attempts to Influence Science,”29 a minority staff report dated February 2018, prepared for U.S. House members of the Committee on Science, Space and Technology.

    For example, in a November 1, 2015, email, William Heydens, safety lead for Monsanto, writes to John Acquavella, a former employee: “I thought we discussed previously that it was decided by our management that we would not be able to use you or Larry [Kier] as panelists/authors because of your prior employment at Monsanto …” to which Acquavella responds, “We call that ghostwriting and it is unethical.”

    According to Wisner, after IARC published its findings on glyphosate, Monsanto “orchestrated a public outcry” by convening a “panel of independent experts” who reviewed the data and published an analysis of the evidence. “The problem was, they were written by Monsanto employees and former employees,” Wisner says.

    In the email exchange above, Heydens wanted to remove Acquavella’s name from the report so that people would not know he was part of it, and Acquavella was reminding him that this strategy, which is known as ghostwriting, is unethical, and that they could not do that.

    In the end, the report did list Acquavella as an author, but it specifically states that Monsanto had no influence over the report and did not write any part of it. Yet email correspondence shows Heydens actively writing and editing it. All of this evidence was shown to the jury, and these outright lies are ultimately what prompted them to award punitive damages totaling a quarter of a billion dollars.

    In “The Monsanto Papers: Poisoning the Scientific Well,”30 a paper published in The International Journal of Risk & Safety in Medicine, June 2018, Leemon McHenry writes:

    “The documents reveal Monsanto-sponsored ghostwriting of articles published in toxicology journals and the lay media, interference in the peer review process, behind-the-scenes influence on retraction and the creation of a so-called academic website as a front for the defense of Monsanto products …


    The use of third-party academics in the corporate defense of glyphosate reveals that this practice extends beyond the corruption of medicine and persists in spite of efforts to enforce transparency in industry manipulation.”

    The Parry Report

    As mentioned, correspondence by Farmer reveals Monsanto had never actually conducted any carcinogenicity or safety studies on the Roundup formulation. In 1999, Dr. James Parry, a geneticist at Swansea University at the time (he died a year later), was hired by Monsanto to evaluate the genotoxic potential of glyphosate.

    After reviewing the available research, Parry found that “glyphosate is capable of producing genotoxicity both in vivo and in vitro by a mechanism based upon the production of oxidative damage.” In his report, known as The Parry Report, he also noted that: “On the basis of the study of Lioi et al … I conclude that glyphosate is a potential clastogenic,” meaning a mutagenic agent that can break, delete, add or rearrange chromosomes.

    In other words, Monsanto’s own expert was telling them they had a serious problem. Parry noted that the real danger appears to be the synergistic effect between glyphosate and other chemicals in the formula, such as the surfactants, and he told the company they had to study the formulated product as a whole. He also listed specific types of studies he felt needed to be done.

    Internal email correspondence reveals other Monsanto scientists discussed ways in which they might be able to “move Dr. Parry from his position” that glyphosate was toxic. Parry, who had signed a secrecy agreement with the company, never published these findings. What did Monsanto do?

    They avoided the toxicity issues simply by never doing any of the research on the formulation. A September 16, 1999, email from Heydens, himself a Ph.D. toxicologist, reads in part:

    “We want to find/develop someone who is comfortable with the genotox profile of glyphosate/Roundup and who can be influential with regulators and Scientific Outreach operations when genotox issues arise. My read is that Parry is not currently such a person, and it would take quite some time and $$$/studies to get him there. We simply aren’t going to do the studies Parry suggests …”

    The Williams, Kroes and Munro Report

    What’s more, Monsanto buried The Parry Report. Regulators were never informed of its contents. Shortly after The Parry Report was concluded, another report was published, called the Williams, Kroes and Munro Report, which was supposed to be a comprehensive review of the genotoxic profile of glyphosate. It found no problems at all, concluding glyphosate is completely safe.

    Guess which report was sent off to regulators and used by the EPA to support its conclusion that glyphosate is nontoxic? You guessed it: The Williams, Kroes and Munro Report, issued in 2000. During trial, Wisner stressed to the jury that all of this is clear evidence of malice. It proves the company had a conscious disregard for human health.

    The Williams, Kroes and Munro Report also appears to have been of Monsanto’s own making. In an email to Farmer dated February 19, 2015, Heydens writes:

    “A less expensive/more palatable approach might be to involve experts only for the areas of contention, epidemiology and possibly MOA [mode of action] (depending on what comes out of theIARC meeting), and we ghostwrite the exposure tox & genotox sections.


    An option would be to add Greim and Kier orKirkland to have their names on the publication, but we would be keeping the cost down by us doing the writing and they would just edit and sign their names so to speak. Recall that is how we handled Williams, Kroes & Munro, 2000.”

    As noted by Wisner, not only did Monsanto bury The Parry Report, which revealed they had a serious health problem on their hands, they ghostwrote a report that claimed the complete opposite. That fabricated “evidence” allowed them to sidestep toxicity concerns for the next 15 years.

    “That is fraud … That’s evil,” Wisner says.

    The jury obviously agreed.

    Science Clearly Demonstrates Glyphosate is Carcinogenic

    “I’m 34 years old. I will try these cases until I’m 90 if I have to,” Wisner says. “If I have to put Bayer in bankruptcy, I will. We have the goods here, and it just shows rampant corporate malfeasance.” Monsanto, meanwhile, insists there are 800 studies produced over the last 40 years showing glyphosate and Roundup is safe.

    “It’s garbage,” Wisner says. “The 800 studies they’re talking about are not about whether it causes cancer. They’re looking at stuff that you have to look at — does it cause eye irritation, does it cause your hair to change color, does it cause skin rashes — all these volumes of tests that test all these random things …


    But when it comes to cancer, there’s only been about 13 animal studies and about six or seven epidemiology studies. And when you actually look at the data, actually look at the science, and I showed this jury every single one of those studies.


    I walked through them one by one … and with the exception of two or three, they are positive … They show clear correlation. They show that glyphosate causes tumors … creates tumors in mice, that it’s causing Non-Hodgkin lymphoma in humans …”

    One particularly powerful study showed that when people are exposed to Roundup via skin contact (the individuals in this study had been doused with Roundup via aerial sprayings), there’s clear evidence of genetic damage. Every single person that had been exposed to the aerial spray showed evidence off this genetic damage.

    Bayer Bought a Nightmare

    Clearly, Bayer has purchased a nightmare, and may be suffering some buyer’s remorse right about now. Indeed, virtually every single person on the planet is now ingesting and being injected or in some way is exposed to Roundup, and the evidence of serious health consequences just keeps growing. The liability is almost beyond comprehension. Time will tell whether Monsanto’s toxic legacy will put Bayer out of business.

    Related reading: Harvest of Greed – The Merger of Bayer and Monsanto

    In the meantime, it’s up to each of us to take whatever precautions we can to avoid exposure. That includes avoiding using Roundup and other glyphosate-based herbicides at home, convincing local companies to stop using it in public areas and around schools, and by buying organic foods whenever possible and taking steps to detoxify our bodies.

    Wisner brings up more evidence presented in court, and I highly recommend watching the interview in its entirety. Considering the evidence, it’s really no wonder Wisner won this case, and it surely does not bode well for Bayer-Monsanto, seeing how there are many thousands more cases just like it waiting in the wings.

    And, according to Wisner, he has hundreds of documents that are even more damning than those brought to bear during Johnson’s trial, which was rushed to trial. So, he’s confident he will continue to win these cases and, hopefully, change the world for the better.

    Sources and References:


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  • Gout


    Avoiding the Ache and Agony

    Sudden, painful swelling at the base of the big toe is often the first warning sign of gout. It can affect other joints as well. Without treatment, gout can lead to severe joint damage and make it hard for you to move. The good news is, most types of gout are treatable, especially if caught early.

    About 4% of adults in the U.S. have been diagnosed with gout. It’s a form of arthritis—in fact, the 2nd most common form after osteoarthritis. And it’s a growing problem.

    “The prevalence of gout more than doubled nationwide between the 1960s and 1990s, and the increases have continued into the 1990s and 2000s,” says Dr. Hyon Choi, a physician who studies gout at Boston University School of Medicine.

    Experts suspect that climbing rates of obesity and high blood pressure are partly to blame for the rise in gout. Gout has also been linked to other medical conditions, such as kidney problems, diabetes, and heart disease.

    Gout is caused by tiny needle-like crystals that build up in the joints, leading to sudden inflammation and intense pain. The crystals are made of uric acid, a substance that normally dissolves in the blood and passes out of the body in urine. But in people with gout, high blood levels of uric acid allow crystals to form in the joints and sometimes in the kidneys, where they create kidney stones.

    Uric acid comes from the breakdown of substances called purines. Purines are naturally found in your body’s tissues and in many foods. Eating purine-rich foods—such as organ meats, mussels, and mushrooms—can bring on or worsen a gout attack. Alcohol or stress can also trigger an episode.

    Gout symptoms usually arise at night. It normally affects one joint at a time, often in the feet, hands, elbows, or knees.

    “Gout primarily affects men who are middle aged or older,” Choi says. “Postmenopausal women are at risk too, especially if they are obese or have high blood pressure or unhealthy dietary habits, such as drinking large amounts of alcohol or sugary soda.”

    The risk also rises if you have a family member with gout or if you take certain medicines, such as water pills (diuretics) or low-dose aspirin.

    Early gout attacks tend to fade within a week. It may be months or even years before the next attack hits. But over time, gout may appear more often and last longer if left untreated.

    Most people with gout can control their symptoms through lifestyle changes and medications. Non-steroidal anti-inflammatory drugs (NSAIDs) can ease the swelling and pain of sudden attacks. Oral or injected steroids and a drug called colchicine can also help.

    If frequent gout attacks become a problem, doctors may prescribe uric acid-lowering medicines. But once begun, these drugs often must be taken long term.

    “If it’s left untreated, gout can eventually lead to damage and deformity of the joints—a condition called chronic gout,” says Choi. “In general, chronic gout arises only after many years of suffering.”

    If you have repeated attacks of pain and swelling in your joints, talk to a health care provider. “If you have gout, the earlier you’re diagnosed and treated—along with making healthy lifestyle changes—the better off you’ll be,” says Choi.


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  • Dental Coverage

    Military retirees eligible for the new dental and vision coverage — as well as active duty families eligible for the new vision benefit — can start researching their options in earnest now, with the release of new rates for 2019.

    The enrollment period for coverage under the Federal Employee Dental and Vision Insurance Program, or FEDVIP, is Nov. 12 to Dec. 10, but the time to start comparisons is now, said Kathy Beasley, director of government relations, health affairs, for the Military Officers Association of America.

    For retirees, the FEDVIP replaces the Tricare Retiree Dental Program, which ends Dec. 31. In order to have dental and vision coverage on Jan. 1, retirees must sign up during the enrollment period. Active duty families are still eligible for dental coverage under Tricare, but if they want the new vision coverage, they must sign up during the enrollment period.

    “We want to get this information out as soon as we can to give people extra time to make their decisions,” Beasley said, noting the Office of Personnel Management had provided the information early, in advance of being published on The rate information is available here, and will be available in early October on the website, along with a comparison tool that helps in making the choice.

    The rates and options vary among the different plans, but according to Beasley, officials with the Office of Personnel Management said the average gross dental premium for 2019 increases by 1.2 percent compared to rates for 2018. That does vary; for example, the FEP BlueDental rates for 2019 are decreasing on average by 6.8 percent for the high option and by 7.8 percent for the standard option, according to William A. Breskin, senior vice president of government programs for the Blue Cross Blue Shield Association.

    The actual premium will depend on the plan chosen, but across the carriers, the average dental premium rates for 2019:

    Average biweekly dental premium*

    Average monthly dental premium*




    Self + 1



    Self + family



    *Actual premium may be higher or lower

    *Actual premium may be higher or lower

    The average vision gross premium is decreasing by 2.8 percent in 2019.

    The actual premium will depend on the plan chosen, but across the carriers, the average vision premium rates for 2019:

    Average biweekly vision premium*

    Average biweekly vision premium*




    Self + 1



    Self + Family



    *Actual premium may be higher or lower

    *Actual premium may be higher or lower

    It’s difficult to compare costs under the new plan with current costs under the Tricare Retiree Dental Program because the TRDP is a “one size fits all” program.

    Beasley said many MOAA members have said they looked at the 2018 FEDVIP prices compared to TRDP, and can’t find the exact same coverage and prices for comparison purposes. The FEDVIP offers a variety of different plans and options, with 10 different companies offering dental options for dental coverage, and four different companies offering vision coverage.

    She said officials at OPM, the Defense Health Agency, military service organizations and Veterans service organizations have joined forces in the last few months to get the word out to retirees about the new retiree dental plan options, but some apparently don’t know about the changes. She said she was in Huntsville, Alabama, giving a briefing, and about half of the retirees she spoke to had heard about the changes.

    As retirees evaluate their choices for the new dental plan, Beasley suggests that if they like their current dentist, they should ask their dentist whether they accept a FEDVIP plan, and talk about next year’s dental needs.

    “Your dentist knows your dental health and what you might anticipate in the future," she said. "Do your due diligence and look at the pricing. Use the plan comparison tool, and make your decision based on that.”


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  • Alzheimer


    Over time, people with Alzheimer’s disease become less able to manage around the house. For example, they may forget to turn off the oven or the water, how to use the phone during an emergency, which things around the house are dangerous, and where things are in their own home.

    As a caregiver, you can do many things to make the person’s home a safer place. Think prevention—help avoid accidents by controlling possible problems.

    While some Alzheimer’s behaviors can be managed medically, many, such as wandering and agitation, cannot. It is more effective to change the person’s surroundings—for example, to remove dangerous items—than to try to change behaviors. Changing the home environment can give the person more freedom to move around independently and safely.

    Create an Alzheimer’s-Safe Home

    Add the following items to the person’s home if they are not already in place:

    • Smoke and carbon monoxide detectors in or near the kitchen and in all bedrooms
    • Emergency phone numbers (ambulance, poison control, doctors, hospital, etc.) and the person’s address near all phones
    • Safety knobs and an automatic shut-off switch on the stove
    • Childproof plugs for unused electrical outlets and childproof latches on cabinet doors

    You can buy home safety products at stores carrying hardware, electronics, medical supplies, and children’s items.

    Lock up or remove these potentially dangerous items from the home:

    • Prescription and over-the-counter medicines
    • Alcohol
    • Cleaning and household products, such as paint thinner and matches
    • Poisonous plants—contact the National Poison Control Center at 1-800-222-1222 or to find out which houseplants are poisonous
    • Guns and other weapons, scissors, knives, power tools, and machinery
    • Gasoline cans and other dangerous items in the garage

    Moving Around the House

    Try these tips to prevent falls and injuries:

    • Simplify the home. Too much furniture can make it hard to move around freely.
    • Get rid of clutter, such as piles of newspapers and magazines.
    • Have a sturdy handrail on stairways.
    • Put carpet on stairs, or mark the edges of steps with brightly colored tape so the person can see them more easily.
    • Put a gate across the stairs if the person has balance problems.
    • Remove small throw rugs. Use rugs with nonskid backing instead.
    • Make sure cords to electrical outlets are out of the way or tacked to baseboards.
    • Clean up spills right away.

    Make sure the person with Alzheimer’s has good floor traction for walking. To make floors less slippery, leave floors unpolished or install nonskid strips. Shoes and slippers with good traction also help the person move around safely.

    Minimize Danger

    People with Alzheimer’s disease may not see, smell, touch, hear, and/or taste things as they used to. You can do things around the house to make life safer and easier for the person.


    Although there may be nothing physically wrong with their eyes, people with Alzheimer’s may no longer be able to interpret accurately what they see. Their sense of perception and depth may be altered, too. These changes can cause safety concerns.

    • Make floors and walls different colors. This creates contrast and makes it easier for the person to see.
    • Remove curtains and rugs with busy patterns that may confuse the person.
    • Mark the edges of steps with brightly colored tape so people can see the steps as they go up or down stairs.
    • Use brightly colored signs or simple pictures to label the bathroom, bedroom, and kitchen.
    • Be careful about small pets. The person with Alzheimer’s may not see the pet and trip over it.
    • Limit the size and number of mirrors in your home, and think about where to put them. Mirror images may confuse the person with Alzheimer’s disease.
    • Use dishes and placemats in contrasting colors for easier identification.


    People with Alzheimer's may experience loss of sensation or may no longer be able to interpret feelings of heat, cold, or discomfort.

    • Reset your water heater to 120°F to prevent burns.
    • Label hot-water faucets red and cold-water faucets blue or write the words "hot" and "cold" near them.
    • Put signs near the oven, toaster, iron, and other things that get hot. The sign could say, "Stop!" or "Don't Touch—Very Hot!" Be sure the sign is not so close that it could catch on fire. The person with Alzheimer's should not use appliances without supervision. Unplug appliances when not in use.
    • Pad any sharp corners on your furniture, or replace or remove furniture with sharp corners.
    • Test the water to make sure it is a comfortable temperature before the person gets into the bath or shower.


    A loss of or decrease in smell is common in people with Alzheimer’s disease.

    • Use good smoke detectors. People with Alzheimer’s may not be able to smell smoke.
    • Check foods in your refrigerator often. Throw out any that have gone bad.


    People with Alzheimer’s may not taste as well as before. They also may place dangerous or inappropriate things in their mouths.

    • Keep foods like salt, sugar, and spices away from the person if you see him or her using too much.
    • Put away or lock up things like toothpaste, lotions, shampoos, rubbing alcohol, soap, perfume, or laundry detergent pods. They may look and smell like food to a person with Alzheimer’s disease.
    • Keep the poison control number (1-800-222-1222) by the phone.
    • Learn what to do if the person chokes on something. Check with your local Red Cross chapter about health or safety classes.


    People with Alzheimer’s disease may have normal hearing, but they may lose their ability to interpret what they hear accurately. This loss may result in confusion or overstimulation.

    • Don't play the TV, CD player, or radio too loudly, and don't play them at the same time. Loud music or too many different sounds may be too much for the person with Alzheimer’s to handle.
    • Limit the number of people who visit at any one time. If there is a party, settle the person with Alzheimer’s in an area with fewer people.
    • Shut the windows if it's very noisy outside.
    • If the person wears a hearing aid, check the batteries and settings often.

    It may not be necessary to make all these changes; however, you may want to re-evaluate the safety of the person’s home as behavior and abilities change. For more on home safety and Alzheimer’s, read Home Safety Checklist for Alzheimer’s Disease.

    Is It Safe to Leave the Person with Alzheimer's Alone?

    This issue needs careful evaluation and is certainly a safety concern. The following points may help you decide.

    Does the person with Alzheimer's:

    • Become confused or unpredictable under stress?
    • Recognize a dangerous situation, for example, fire?
    • Know how to use the telephone in an emergency?
    • Know how to get help?
    • Stay content within the home?
    • Wander and become disoriented?
    • Show signs of agitation, depression, or withdrawal when left alone for any period of time?
    • Attempt to pursue former interests or hobbies that might now warrant supervision, such as cooking, appliance repair, or woodworking?

    You may want to seek input and advice from a healthcare professional to assist you in these considerations. As Alzheimer's disease progresses, these questions will need ongoing evaluation.

    For more home safety tips, visit the Home Safety Checklist for Alzheimer's Disease.

    For More Information About Home Safety and Alzheimer's

    NIA Alzheimer’s and related Dementias Education and Referral (ADEAR) Center

    1-800-438-4380 (toll-free)

    This email address is being protected from spambots. You need JavaScript enabled to view it.">This email address is being protected from spambots. You need JavaScript enabled to view it.

    The National Institute on Aging’s ADEAR Center offers information and free print publications about Alzheimer’s disease and related dementias for families, caregivers, and health professionals. ADEAR Center staff answer telephone, email, and written requests and make referrals to local and national resources.

    Family Caregiver Alliance

    1-800-445-8106 (toll-free)

    This email address is being protected from spambots. You need JavaScript enabled to view it.">This email address is being protected from spambots. You need JavaScript enabled to view it.

    Eldercare Locator

    1-800-677-1116 (toll-free)


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  • Military Discounts


    Many companies offer military discounts, which is an awesome way to show their appreciation for all military Veterans have done for our country. As a Veteran, I certainly appreciate the gesture, and I try to thank the company offering the discount whenever it is possible. As well-meaning as the military discounts are, however, they sometimes cause problems because there is no general standard among stores regarding discount eligibility. In this article we will cover some helpful information about military discounts, including how to get them, how to find “hidden” military discounts, what to expect, and what to do if the discount isn’t honored.

    Military Discount Eligibility

    Let’s start off with the most important topic – who is eligible for a military discount. This is probably the most debated topic I’ve seen regarding military discounts. Unfortunately, there isn’t one standard. The important thing to remember is that stores aren’t required to give military discounts – it’s a privilege, not a right. The stores set the rules, and we as military members and Veterans, should honor the standards set by the stores. Let’s take a look at some different groups of people who are commonly offered military discounts at various locations:

    • Active duty military
    • Current Guard / Reserve
    • Retirees
    • Military dependents (anyone with a DoD issued military or dependent ID)
    • Veterans (proof of service may or may not be required)

    As you can see, there is a wide range of people in this list. And it doesn’t always make sense. Many stores which offer military discounts do so out of generosity, but sometimes their policies are made without understanding how the military ID card system works. Compounding this is the fact that there isn’t a standard for a national Veterans ID card – yet (legislation has been passed into law, but the cards haven’t been issued yet). As a result, some military discount policies are misguided.

    For example, some stores offer discounts for dependents of active duty service members or retirees, while they don’t offer discounts for Veterans who served, but are no longer on active duty and didn’t reach retirement (this group of people represents the largest group of Veterans).

    I will be the first to say that it doesn’t make sense to give a military discount to a dependent, who is someone who never wore the uniform, then deny a discount to someone who served, but didn’t retire. Yes, spouses and dependents make sacrifices on the home front, but they don’t warrant greater recognition than someone who served in a combat zone, but didn’t remain in the military through retirement. (I am qualified to make this statement as I both both served in a combat zone, and was a military spouse after I separated from the military – my wife served on active duty while I was a civilian).

    But here is the kicker: it doesn’t matter what you or I think – we don’t make the rules. The stores make the rules, and as this is an act of generosity on their part, it’s always best to honor their wishes.

    Finding Hidden Military Discounts

    Many stores publicize military discounts, while others don’t announce them publicly. You will be surprised how often companies will offer you a military discount if you just ask for it. All it takes is a simple question while you are ordering or checking out. Just ask, “do you offer a military discount?” In some cases you will be told no, but sometimes you will be pleasantly surprised. Just ask, and always thank the person if you receive a discount. And if not, no hard feelings. Remember, this is an act of generosity on their part, not a right Veterans deserve.

    *Bonus tip: Your odds of success increase substantially when asking for a military discount on a military related holiday, such as Memorial Day, Fourth of July, Veterans Day or other national holidays. In fact, many stores don’t offer military discounts, except on these holidays.

    Proving Military Service

    After determining eligibility, the next most important thing is to be able to prove you served in the military. If you are on active duty, or are a retiree, then this likely isn’t a problem, as you should have a military ID Card. But proving military service can be a lot more difficult for a military Veteran who didn’t retire, and isn’t receiving disability from the VA.

    Unfortunately, there is currently no standard for proving military service, outside of carrying around your current military or retiree ID card, or a DD Form 214. Carrying your DD Form 214 isn’t always a good idea as it has your Social Security Number and other personal information on it. The good news is Congress has passed a law that will allow Veterans to get an official Veterans ID card through the VA. We don’t have word on when they will begin issuing these ID cards, but it looks like it will be sometime in 2017.

    Here are the current forms of ID cards you can use to show proof of service:

    Again, because there is no standard, some stores only accept certain forms of ID or proof of service.

    What to Do if a Store Doesn’t Honor a Military Discount

    As mentioned above, some military discounts are seemingly misguided regarding who is eligible, and who is not. But it’s not our place to make that judgment. As military discounts are made out of the generosity of the store offering the discount, it’s in our best interest as military members and Veterans to accept a discount with humble thanks when it is offered, and be understanding when it is declined.

    If you believe you should be eligible for a discount, then politely ask to speak with a manager and explain the situation. But always be sure to fully understand the company’s policies on military discounts before doing so (and keep in mind policies may change at any time, so be sure to be up to date).

    One of the biggest complains we have heard is about Home Depot and Lowes discounts. These companies offer military discounts everyday, however, they have changed the eligibility a few times, so the military discounts may only be available to a segment of the military and Veteran population. Be sure to review their corporate policies before arguing with management about the discount you are “entitled to.” Here is the Lowe’s corporate policy.

    Remember, military discounts are an act of generosity, not a right. It is never worth making a scene over getting a military discount.


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  • SD 100 Homeless Vets


    About 100 homeless Veterans in San Diego County will receive vouchers for subsidized housing through $1.1 million in funds released this week from the U.S. Department of Housing and Urban Development and the U.S. Department of Veterans Affairs.

    The money will fund 50 housing vouchers administered by the city of San Diego Housing Commission and 50 vouchers administered by the San Diego County Housing Authority.

    The new vouchers are in addition to 1,031 vouchers already in use to subsidize housing for San Diego Veterans countywide.

    “We have few responsibilities greater than making sure those who have sacrificed so much in service to their country have a home they can call their own,” HUD Secretary Ben Carson said in a statement Thursday.

    “The housing vouchers awarded today ensure homeless Veterans nationwide have access to affordable housing and the critical support services from the VA,” Carson said.

    Nationwide, $35.3 million has been released to fund 4,077 Veterans Affairs Supportive Housing vouchers. Of that, $18.3 million is going to California for 1,658 vouchers.

    The rental assistance announced Thursday is provided through the HUD-VASH Program, which combines rental assistance from HUD with case management and clinical services provided by the VA.

    “When our neighbors answer our country’s call to service, we must answer their call when they return home,” HUD Deputy Regional Administrator Wayne Sauseda said in the news release. “Together with the VA, HUD remains committed to meeting the supportive housing needs of Veterans, so that, one day, we end Veteran homelessness in San Diego.”

    Since 2008, more than 93,000 vouchers have been awarded and about 150,000 homeless Veterans have been served through the HUD-VASH program nationwide.

    More than 600 public housing agencies administer the HUD-VASH program, and this most recent award includes 22 new agencies, increasing coverage to many communities.

    The program also helps VA Medical Centers assess Veterans experiencing homelessness before referring them to local housing agencies for vouchers.

    Decisions are based on how long a person has been homeless and the need for longer-term care, among other factors.

    Veterans participating in the HUD-VASH program rent privately owned housing and generally contribute no more than 30 percent of their income toward rent. VA offers eligible homeless Veterans clinical and supportive services through its medical centers across the U.S., Guam, Puerto Rico and the Virgin Islands.


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  • Womens Mental Health

    Women currently comprise approximately 16 percent of the United States military. As of 2016, service women are permitted to serve in any military position for which they meet the gender-neutral performance standards and requirements. These expanded roles have increased the cadre of responsibilities that service women have, as well as increased their potential challenges. As such, it is more important than ever for military leadership, researchers, and health care providers to understand women’s health.

    The Departments of Veterans Affairs (VA) and Defense (DOD) collaborated to host the National VA/DOD Women's Mental Health Mini-Residency Aug. 28-30 in Arlington, Virginia. This mini-residency brought together more than 150 VA and DOD mental health providers so they could gain knowledge and skills in the provision of gender-sensitive care to women Veterans and service members. Specific topics included:

    • Complex trauma
    • Psychopharmacology
    • Safety planning
    • Suicide prevention
    • Compassion fatigue
    • Sexual functioning
    • Impact of health conditions
    • Ostracism, and many others

    During the mini-residency, attendees developed an action plan to disseminate these best practices and facilitate practice change at their local facilities -- to optimize women's mental health care in VA and DOD. Requests from DOD mental health providers to attend in person far exceeded the number of spots available, so we posted all DOD presentations and posters on the mini-residency website for you to read, download and share with colleagues.

    Today also marks the start of Women’s Health Month, a time to highlight women’s health, to include the mental health of service women. Throughout the month, we will showcase some of the exciting presentations from the mini-residency through our Clinician’s Corner blog series.

    Dr. Nancy Skopp, PHCoE research psychologist, will describe the impact of gender stereotypes on diagnosis and treatment. Dr. Laura Miller of the Hines Jr. VA Hospital in Hines, Illinois, will highlight mental health across the female lifespan, and Dr. Margaret Altemus of the Yale School of Medicine in New Haven, Connecticut, will discuss perinatal and postpartum depression. Dr. Lauren Messina of the Consortium for Health and Military Performance will discuss a total force fitness approach to physical and mental health, which can help women and men improve their emotional health and manage symptoms of mental health disorders.

    For updated research and resources, be sure to check out our Women’s Mental Health webpage and follow us on Facebook for more women’s mental health-related posts and resources. Like, comment and share on your channels so we can promote women’s health awareness, and particularly the importance of women’s mental health, during October.


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  • DVA Logo 29

    CLARKSVILLE, Tenn. – (CLARKSVILLENOW) – The United States Department of Veterans Affairs (VA) has released a data sheet from 2016 that details the suicide rate of Veterans in Tennessee, compared to the Veteran suicide rates in the southern region and the nation; as well as the general suicide rates in Tennessee, the southern region, and the nation.

    There was a total of 156 Veteran suicides in the state of Tennessee in 2016. Broken up by age range, the numbers are as follows:

    • 18-34: 26
    • 35-54: 38
    • 55-74: 66
    • 75+: 26

    By comparison, there were 2,611 Veteran suicides in the southern region, and 6,079 in the nation.

    Further, it was found that there was a total of 1,070 general suicides in Tennessee, 17,011 in the southern region, and 43,427 in the nation.

    There was a Veteran suicide rate (based on per 100,000 people) of 32.8 in Tennessee, 30.6 in the southern region, and 30.1 in the nation. This indicates that Veteran suicide rate in Tennessee was not significantly different from the national Veteran suicide rate.

    Despite that conclusion, it was also found that the Tennessee Veteran suicide rate of 32.8 was significantly higher than the general national suicide rate, which was found to be 17.5. The general suicide rate for the southern region was found to be 18.2.

    You can view the data sheet in its entirety here.

    If you are a Veteran or a family member of a Veteran, and you struggle with depression, there are resources available to help you. If you are in the Clarksville area, one such resource is Soldiers and Families Embraced, or SAFE. SAFE is an organization dedicated to counseling and helping Veterans and Veterans’ families. For more information on SAFE, you can read about some of their methodologies and processes. You can also listen to a Clarksville’s Conversation interview with the executive director of SAFE, Lantz Smith.


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  • Ind Unemploy


    As a VA claims processor, Veterans often ask me about Individual Unemployability (IU), also called Total Disability based on Individual Unemployability (TDIU). The following is a more formal version of what I tell them.

  • VA Qtrly Research


    Dr. Joseph Frank is a primary care physician at the VA Eastern Colorado Health Care System in Denver. He is also a health services researcher at the HSR&D Center of Innovation for Veteran-Centered and Value-Driven Care. His research is focused on improving the safety and effectiveness of chronic pain care for Veterans. As a physician, he is particularly interested in how VA can provide chronic pain care in primary care settings.

    VARQU spoke with Frank about the work he is doing to help Veterans who are living with chronic pain.


    • Tapering or stopping long-term opioid medications in Veterans who have chronic pain can be a challenging process.
    • The scientific evidence guiding the assessment of the risks and benefits of long-term opioid therapy and/or dose reduction or discontinuation for individual patients is limited.
    • A team-based approach to multimodal pain care could help both physicians and their patients.
    • Further research is needed to identify the systems and resources that are necessary to adequately support physicians and patients as they consider opioid tapering.

    Welcome, Dr. Frank. Can you tell us about the three different lines of research that you are pursuing?

    The first of those is for patients who are taking opioid medications long term. For these patients, the process of stopping or reducing those medications—sometimes referred to as opioid tapering—can be very challenging. We need to understand how to deliver high-quality pain care during and after opioid tapering.

    The second line of research focuses on who delivers this care. As with many chronic conditions, primary-care physicians are most effective when working as part of a team. I am interested in how we should design teams in primary care to deliver pain care that is patient-centered and effective.

    And finally, as a primary care physician, I know it's critical that we help patients get involved in and lead their own plans for pain management. As a researcher, I believe this means we must also help patients get involved in pain research; therefore, I am very interested in how we can better involve patients in all phases of the research process.

    You have received a VA Career Development Award to study tapering opioid medications for patients on long-term therapy. What areas will you be investigating as part of this award?

    We will be investigating several different areas. The first of those is a national survey of Veterans who are on long-term opioid medications to learn more about their perceptions of and experiences with opioid tapering. We know that opioid prescribing rates are decreasing over recent years within VA. But we don't know how these changes are affecting Veterans who have been on these medications long-term. And we don't know what their goals are as it relates to their own use of opioid medications.

    The second aspect of this work is to engage Veterans in the development of a primary care-focused program to support opioid tapering. We will be gathering Veteran stakeholders as well as VA provider stakeholders to conduct a series of meetings and incorporate their perspectives in the development of a program to provide patient-centered opioid-tapering support.

    And finally, the long-term goal is to pilot this intervention and understand what it means for Veterans. As I mentioned, pain care is changing rapidly in the VA. So I think a challenge in the years ahead will be to continue to learn quickly from research that is ongoing and to make sure that the intervention that we are developing will take advantage of the latest science in this area. With our approach to engaging Veterans early in the process, we will have a unique opportunity to incorporate both the latest science as well as Veterans’ experiences to come up with something that is valuable to the Veterans that we serve.

    What is the VA policy for tapering or reducing opioid use in Veterans?

    VA policy is guided by the most recent guidelines released by the departments of Veterans Affairs and Defense. The guideline was released just last year, in 2017. The guideline recommends that for patients who are on long-term opioids, it is important to assess the risks and benefits of ongoing treatment with opioid medications for the individual Veteran. That guideline also notes that it is important to assess the risks and benefits of tapering. This is challenging currently because we don't have much evidence to help providers assess those risks and benefits. So the decision-making is challenging, but importantly should focus on the individual Veterans and their unique needs.

    Importantly, what that policy does not include is a recommendation to reduce opioid dose based on dose alone or without attention to individual risks and benefits. I think a place where we risk getting beyond the evidence, beyond the VA guidelines, and other related guidelines is by unilaterally making changes to medications that don't take into consideration an individual patient's unique needs.

    Can you tell me about the benefits and limitations of using opioid medications long-term for chronic pain?

    I think the goal of using medications, any medications, particularly opioids long-term for a condition like chronic pain, is that they improve function and quality of life. I think we are moving away from measuring pain severity on a simple zero to 10 scale, and trying to think more broadly about individual patients’ long-term goals, especially as it relates to their ability to do the things they want to do. So I think when they are beneficial, it is because they are helping patients function well and improve their quality of life.

    I think important risks often travel alongside those benefits. We have seen in prior studies that people may take these medications with some ambivalence, as they experience both benefits and some side effects. Side effects differ based on the individual patient, but can include decreased energy, cognitive impairment, and some other meaningful side effects that they experience day to day.

    And then I think the risk of serious harms such as overdose or a new opioid use disorder diagnosis are front and center in the minds of policymakers and providers. In our prior work talking with patients, they told us that the pain they experience day to day is more salient than the more abstract risks for future harms. And so it can be a real challenge for physicians and providers to get on the same page prioritizing goals and concerns about potential future harms.

    You published a paper that discussed the scientific evidence on strategies to safely taper opioid medications. Can you tell us what you found?

    This was a systematic review conducted by a great team of VA researchers doing work on this topic. Together, we identified 67 studies that examined opioid tapering and came to three key conclusions. First, the quality of evidence was very low for each of our key questions. Health care systems and health care providers are working to take urgent action to prevent opioid-related harms. However, for patients taking these medications long-term, it's important that we balance this urgency with caution, because we have so little evidence to guide opioid tapering currently.

    I think the second key point is that we found very few studies that addressed the effect of opioid tapering on important adverse events such as overdose. We want to find effective strategies to prevent harms such as overdose, and we need to learn more about how tapering affects this risk.

    And third, we found that opioid tapering may improve pain, function, and quality of life for some patients. Importantly, the fair-quality studies that showed these positive results examined voluntary tapering in the context of multidisciplinary pain management programs. More work is needed to better understand the effects of tapering when it occurs in primary care, which is where most of our pain management is happening in VA.

    In a different study, you interviewed a group of primary care physicians to find out about their experiences with tapering opioid therapy. What did they say are their greatest challenges?

    We conducted focus groups with 40 providers across three health care systems here in Denver, Colorado. We identified three key themes related to their perceived barriers to opioid tapering. First, providers that we spoke with described discussions of opioid tapering with their patients to be uniquely emotionally charged, and at times, exhausting. Health care systems are asking providers to have these conversations more often these days, and it's important that we recognize the impact on providers as well as the impact on patients.

    Second, providers described a sense that they had inadequate resources to support opioid tapering, specifically, but also chronic pain care generally. They described a lack of training specific to this process, as well as a lack of other team members and resources in their clinics and communities.

    And third, they reported that opioid tapering did not go well when there was a lack of trust between their patient and themselves.

    You also mentioned in that study that you identified several best strategies that would help primary care physicians safely taper opioids. What are they?

    In addition to barriers, the primary care physicians that we spoke with also identified strategies that they found helpful. They noted the importance of empathizing with their patients' experiences—both their experience of pain and their concern about making medication changes. We have learned from patients that this process can be very anxiety-provoking. And so providers noted the importance of acknowledging that anxiety.

    Providers also described opioid tapering as a long-term process that benefits from planning and preparation. They described ways in which working with individual patients to think long-term about goals as it relates to the medication was a productive process.

    And finally they reported feeling supported by guidelines and local policies that sought to standardize care processes related to opioid prescribing and opioid tapering.

    What types of strategies would you like to see developed to help primary care physicians work with chronic pain patients and assist them in tapering opioids?

    That's an important question. I think first it takes a team. And in a system like the VA, it will take guidance to help teams develop effective processes in their own local sites. Primary care providers, nurses, psychologists, pharmacists—the list goes on. Each provider has a unique expertise that may be helpful to patients during opioid tapering. The challenge ahead is to create systems that connect each patient with the right team at the right time during opioid tapering and chronic pain management generally.

    The VA is leading in this area with some very interesting work to compare different types of teams and to understand which Veterans benefit from which team structure. It will be important that we learn from those ongoing studies and as researchers try and help leaders in VA integrate those lessons into routine care as quickly as we can.

    I'll mention two other resources that I think are potentially impactful in VA. The first is an important role for peer support. While I as a primary care physician try to help my patients know what to expect during opioid tapering, I think a fellow Veteran who has been through the process can provide practice insights and support that I just can't match.

    And finally, as we discussed, opioid medications are just one tool in the chronic pain toolkit. I think it's important that we continue to improve Veterans' access to the full range of treatments and continue to improve the quality of evidence that guides our approach to multimodal pain care.


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  • Vets with TBI


    Traumatic brain injuries, a frequent consequence of the wars in Iraq and Afghanistan, can lead to such debilitating symptoms as irritability, depression, insomnia, memory deficits—and post-traumatic headaches, which are similar to migraine headaches.

    Migraine is a potentially disabling disorder, causing severe headaches that can last days at a time and pose huge health care costs to the patient and society. A key component of migraines is photophobia, an extreme sensitivity to light. Photophobia can be so harmful that it may force people to wear sunglasses indoors.

    Enter Dr. Levi Sowers, a principal investigator in the Center for the Prevention and Treatment of Visual Loss at the Iowa City VA Health Care System.

    Sowers is leading a study aimed at learning more about regions of the brain that may play a role in migraines and photophobia. He and his team have been focusing mostly on the posterior thalamus. It’s just above the brain stem between the cerebral cortex and the midbrain.

    The main function of the posterior thalamus is to relay motor and sensory signals to the cerebral cortex. It’s also a hub for light and headache pain. Sowers and his colleagues are taking things a step further by zeroing in on a molecule that’s produced in nerve cells of the brain and spinal cord called calcitonin gene-related peptide (CGRP). It plays an important role in triggering migraine headaches.

    The goal of the study is to understand more about how CGRP acts and to apply that knowledge to brain-stimulation techniques, which involve activating and deactivating areas of the brain with electrical, magnetic, or light stimulation. The hope is that precise targeting with stimulation will lower CGRP in the brain and thereby also ease photophobia and headaches.

    Migraine headaches are a neurological disorder

    Currently, nearly 40 million people suffer from migraines, which usually involve a severe throbbing pain on one side of the head. The dilation and constriction of blood vessels were once thought to be the main source of migraine pain. Now, migraine headaches are believed to be one symptom of a greater neurological disorder involving nerve pathways and brain chemicals that is called migraine.

    The Department of Defense and the Defense and Veterans Brain Injury Center estimate that 22 percent of combat casualties from Iraq and Afghanistan involve brain injuries, compared with 12 percent of Vietnam combat casualties. Up to 80 percent of service members who have other blast injuries may also have traumatic brain injuries.

    In the future, Sowers plans to pursue research that explores the level of migraines in Vets with mild, moderate, and severe traumatic brain injury (TBI).

    Current treatments for post-traumatic headache and photophobia are inadequate due to a poor understanding of where CGRP acts in the body to induce headaches, Sowers says. Therapies don’t reduce photophobia between episodes of headache. Successful reduction of light sensitivity in patients with post-traumatic headache may lessen patient discomfort between and during headache attacks, he adds.

    “One of the big questions remaining in the headache field is where CGRP is acting to contribute to migraines,” says Sowers, who is also a research scientist at the University of Iowa. “We hypothesized that CGRP in the posterior thalamus may play an important role in headache-related photophobia. We’re also looking at other regions controlled by CGRP that could be involved with light-aversive behavior. These regions can be targeted by stimulation techniques.”

    He adds: “Every day, targeted brain stimulation methods are getting better and better. This could one day help Veterans. We’re excited about what this holds for the future.”

    In addition to the posterior thalamus, Sowers and his team are looking at the amygdala, the hippocampus, and the cerebellum in relation to photophobia. Any of those regions could be targets for brain stimulation techniques, he says.

    “We believe if we can identify critical areas involved in photophobia, then any of these targeted approaches could one day be effective in treating migraine,” Sowers says. “However, we need to first understand how these brain areas work during states of migraine or post-traumatic headache.”

    The Food and Drug Administration (FDA) has approved certain types of brain stimulation to treat such disorders as anxiety, depression, epilepsy, obsessive-compulsive disorder, Parkinson’s disease, and insomnia. But the FDA hasn’t approved brain stimulation techniques for the treatment of TBI and PTSD.

    Researchers stimulate nerve cells in mice

    Thus far, in lab research, Sowers’ team has identified brain regions that may be critical to photophobia in mice and has found pain and light sensitivity in the rodents that mimic migraines based on similar characteristics in humans. That knowledge could apply to photophobia in people, Sowers says, noting that there are correlates between the brain regions in humans and mice.

    The researchers begin by subjecting the mice to blast-related injuries, the most common type of TBI in Veterans who have served in Iraq and Afghanistan. The team then measures the rodents’ sensitivity to light through use of a light and dark box. The mice are allowed to move freely between a well-lit side of the box and a dark side of the box. The ones more sensitive to light spend more time on the dark side.

    In the mice that are more light-sensitive, Sowers and his team are using a combination of genetic manipulation and light to affect the firing of neurons, or nerve cells. That process is known as optogenetics, a biological technique that involves the use of light to control cells in living tissue, typically neurons. It allows the researchers to target specific brain regions that they believe are involved in triggering post-traumatic headache and to change the firing of nerve cells in those regions. The process also gives the researchers “pinpoint control over the time when we stimulate the nerve cells and which ones we’re stimulating in the brain,” Sowers says.

    The researchers are trying to learn what neurons in a region like the posterior thalamus are doing. They stimulate the neurons by shining a light on that region via a fiber-optic probe that’s inserted into the mouse’s head.

    Both peripheral and central neurons produce CGRP.

    Sowers explains that the investigators have thus far discovered axonal injury, or nerve damage, after blast-induced mild TBI in the posterior thalamus of the mice.

    “Axonal damage means the neurons are damaged, which can cause them to be easily excited,” he says. “In theory, it could lead to light sensitivity in that particular brain region, or heightened sensitivity to pain and other sensory signals in that brain region.”

    Sowers hopes he and others in the medical community can someday use optogenetics to target human brain regions that are involved in triggering post-traumatic headache.

    “That would be really cool,” he says. “In fact, this optogenetic technique has already been used in non-human primates. We’re still many years away from being able to do specific targeting in people. But the goal is when we stimulate these brain regions that correlate with a human then we can go back and possibly target these regions with what we now have to hopefully treat migraine or post-traumatic headache.”

    He and his team hope to publish results later this year.

    Work could also yield insights on PTSD, epilepsy

    Sowers’ work falls under the umbrella of an RR&D grant that has multiple aims related to understanding post-traumatic headache and migraines in Veterans with TBI. In another phase of the grant, he’ll be a senior co-author on a paper in which scientists probed a preclinical model of pain induced by CGRP. They specifically looked at how the molecule is playing a role in spontaneous headache pain in mice, which is facial grimacing, and whether or not that pain can be treated with anti-migraine drugs.

    In an extension of that research, the scientists are injecting CGRP into mice with brain injuries to learn if such trauma makes them more susceptible to migraines and if TBI increases the amount of CGRP in a mouse. The researchers are then testing an antibody that is supposed to attack the CGRP and control light-sensitivity.

    The antibody is similar to a new class of anti-migraine drugs called the CGRP monoclonal antibody. The FDA recently approved the first in this series called erenumab (sold as Aimovig).

    “The drugs we are using look very promising in mice,” Sowers says. “It’s possible that they could be very promising to treat the pain of post-traumatic headache.”

    In addition to post-traumatic headache and migraines, Sowers believes his research may ultimately lead to a better understanding of mental health disorders, such as PTSD, and neurological diseases, such as epilepsy.

    “Veterans with migraine headaches have a strong correlation with PTSD,” Sowers says. “So perhaps insights that we find in our studies of migraines and post-traumatic headache in mice could translate to PTSD research. Also, a number of the brain regions we’re looking at are important for epileptic seizures. So if we understand what CGRP is doing in migraines, perhaps we can use that knowledge to treat or understand other neurological or mental health disorders.”


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  • VA Qtrly Research


    Thirteen articles based on outcomes and policy recommendations from VA's Health Service Research and Development state-of-the-art conference on "Non-pharmacologic Approaches to Chronic Musculoskeletal Pain Management" were published in a special supplement of the Journal of General Internal Medicine. The conference brought together experts from VA, the Department of Defense, and the National Institutes of Health to discuss the existing knowledge base on non-opioid therapies for chronic pain.

    The thrust of the SOTA was to review the effects of complementary and integrative health (CIH) on pain and opioid use; discuss the different approaches to chronic pain; and share ideas on the larger topic of non-opioid therapies.

    "Evidence clearly shows that no single therapy is the best approach for a majority of patients with chronic musculoskeletal pain," Drs. Robert Kerns, Erin Krebs, and David Atkins wrote in the introduction. "Like analgesic medication, non-pharmacologic therapies generate meaningful clinical improvement in only a subset of patients."

    Because there is no one best therapy for chronic pain, they recommend that health systems and payers offer multiple options for pain management to patients. CIH therapies like yoga, massage, or mindfulness-based stress reduction are equally as important as structured exercise or cognitive behavioral therapy, they point out.

    It is also important for clinicians to use a multimodal, stepped model of care that allows individual Veterans to try different kinds of therapy, if the first one doesn't work. The researchers suggest that type of multimodal care can be best implemented by primary care physicians who don't just treat patients for pain, but also for other contributing conditions like diabetes.

    Because VA is an integrated health system that provides comprehensive care, wrote the authors, it is well-suited to offer the type of multimodal care that is best for chronic pain patients.


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  • Keith Thompson


    Army Veteran Keith Thompson (pictured above) is no stranger to conquering life’s challenges.

    A 2006 motorcycle accident left the former firefighter in a 27-day coma and paralyzed from the waist down. Not one to be kept down, Thompson strives to be the best at everything he does and that paid dividends at this year’s National Veterans Wheelchair Games (NVWG) held in Orlando, Florida.

    Thompson was awarded the prestigious Spirit of the Games trophy, an award presented to “the Veteran that through their athletic achievement, leadership and support of their fellow Veterans exemplifies the values of the games.”

    To illustrate the award’s significance, Thompson was selected from the record-setting 611 athletes that participated in this year’s games and is the 32nd recipient since the award’s creation in 1987. The theme for this year’s games was “Conquer the Challenge,” and that’s exactly what Thompson did.

    “There are no limits,” said Thompson. “My wife told me I can do anything I want. I just have to do it from a chair.”

    Thompson defines the word competitor. He’s competed in various events over his NVWG career including archery, trap shooting, air rifle, air pistol, 9-ball, shot put, discus, javelin, boccia ball and softball.

    Played through multiple injuries

    While at this year’s games, Thompson attempted to catch a softball hit his way when he fell out of his chair and dislocated his shoulder. Also, in 2016, Thompson competed at the NVWG despite having a broken wrist and torn rotator cuff after being rear-ended by a distracted driver. He truly knows no limits.

    “We are all at the games to compete and leave our best on whatever field we play on,” Thompson said.

    Thompson was introduced to Carl Vinson VAMC when he accompanied a friend to the medical center to check on the status of his benefits. Tamara Jackson, administrative officer for acute care, suggested Thompson also apply for benefits and suggested the Sandersville, Ga. resident consider recreation therapy. It wasn’t long before recreational therapist Charlene James urged Thompson to try adaptive sports and in 2011, he attended his first NVWG.

    When he’s not practicing for the games, Thompson spends time with his wife of 17-years, Janice, and managing his medical transportation service, 3D Enterprises.

    Keith Thompson is no stranger to life’s challenges. However, he is an example all people can emulate when striving for something that seems unobtainable.


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  • Homeless Vet Finds Kindness


    BEDFORD — At 2 a.m. on a chilly May morning, Norman Franks sat slumped in a chair in a TV lounge at the Department of Veterans Affairs medical center, fighting for snatches of sleep under the glare of ceiling lights, he said.

    A Navy Veteran of the late 1970s, Franks had led a troubled life. His addiction to crack cocaine led to a long series of armed robberies, which led to 15 years in prison. Now, he found himself homeless.

    Franks wanted a clean start, but first he needed a place to live. With no good options, he made his way to the Bedford Veterans complex, an outpost of a sprawling federal agency that takes its motto from Abraham Lincoln’s promise “to care for him who shall have borne the battle.”

    They had to take him in, Franks thought.

    Instead, he spent the night in the woods, shivering under a tarp. He stayed there for four of the next five nights, then spent the next four months in a cramped tent in a campsite on the grounds of Hanscom Air Force Base.

    As the weeks passed, Franks fell deeper into despair. But slowly, unexpectedly, he was reclaiming some of his life, thanks to a devoted group of strangers — members of an American Legion post, volunteers from a Catholic parish, even from a congressman’s staff — who felt obliged to aid a Veteran in need.

    “We had to help this man,” said Catherine Giorato, an auxiliary member at American Legion Post 221 in Bedford. “If we turn away a Veteran at the American Legion, we should be ashamed of ourselves.”

    Franks, 58, is angry at how the VA handled his case, arguing that he never should have been turned away that May night when the temperature fell into the 40s, or to have lived at a campground for so long.

    When he arrived at the hospital that May evening, Franks said, he was told by a VA social worker that he might be able to sleep undisturbed in the TV lounge. But in the middle of the night, Franks said, he was awoken by a rap on the chair and ordered to leave.

    “I don’t have any place to go,” he mumbled.

    “I don’t give a [expletive]. You’re out,” the VA security officer answered, according to Franks.

    Wearing only a T-shirt and shorts, Franks stumbled into the night and dropped to the ground at the half-hidden edge of the VA property, resting against a tree and wrapped in the tarp he had taken from a small VA dump truck.

    VA officials said they have no record of an encounter that night between Franks and VA security officers. Under the Bedford VA’s policy, any Veteran who turns up homeless can be sheltered in the urgent-care area if no other beds are available, agency officials said.

    Franks did contact the VA by phone three days later and discuss housing options, officials added. The next day, Franks declined an offer to be placed in a Haverhill facility affiliated with the VA, according to Ken Link, chief of social work services at the Bedford VA.

    “Mr. Franks was offered multiple shelter options, but he did not care for the shelter options we were offering him,” Link said.

    Those options included transportation to the New England Center and Home for Veterans in Boston and other facilities closer to Bedford. But Franks said he declined because posttraumatic stress from his years in the Navy and prison have made living in close quarters nearly impossible.

    As it turned out, Franks was not on his own. Help came from the American Legion, where Franks’s first, desperate call in the following days was answered by Giorato, a Massachusetts Institute of Technology locksmith who tends bar at the post.

    “He explained he had no place to stay, and he asked if we could do anything,” Giorato said. “So, I spoke with everybody at the bar. People started taking $20 bills out of their wallets, and we probably raised $200” for a night’s stay in a hotel across the street.

    A few days later, Franks called again.

    “It was pouring rain. It was terrible. He had no food,” Giorato said. “I picked him up and took him to Stop & Shop, where we bought about $120 of food. I kept saying, ‘Get this, get this, get this.’ He was very proud and very embarrassed and kept saying, ‘That’s too much money.’ ”

    The post also pitched in with blankets and other basic comforts.

    “I found him very sincere, a nice man, and down on his luck,” Giorato said. “He couldn’t have been more apologetic.”

    Franks said he soon was directed to the Hanscom campsite and helped by a local chapter of the St. Vincent de Paul Society, a Catholic organization that assists people in need. Its members took him shopping for camping equipment, bought him gift cards for groceries, and paid the $18 daily fee charged by FamCamp, the Air Force campsite, Franks said.

    Through it all, Franks said, he regularly called VA officials and caseworkers. In the summer, he was approved for placement at Bedford Green, a VA-linked development of 69 furnished apartments for older Veterans who are homeless or at imminent risk of becoming so.

    But that approval was suspended after the VA determined Franks had behavioral issues that might affect other residents at the complex, Link said.

    “He was not ready, and there was concern it would not be conducive to the overall health of the environment,” according to the social work chief.

    Franks said he became increasingly distraught.

    “I was thinking about going back to my old ways, robbing somebody,” Franks said. “But I couldn’t do it. People were taking care of me. They were stepping up. They’ve been unbelievable.”

    Yet with cold weather only a few months away, Franks wondered anew where he would live. Help arrived once more, this time from the office of US Representative Seth Moulton of Salem, a Marine Corps Veteran whose staff made calls on his behalf, Franks said.

    Finally, Franks found a federally subsidized apartment on his own in Acton, where he moved Sept. 26. The VA provided a tenant voucher for the new apartment, helped with the application, and referred him to movers.

    “We really do want to help homeless Veterans, and we want homeless Veterans to feel encouraged to come here,” Link said.

    When Franks moved to his new apartment, following a stop at a furniture bank that helps the poor and homeless, the two-bedroom unit felt like a palace. Giorato, the post auxiliary member who answered his plea, said she is thrilled.

    “I hope we continue to keep in touch,” Giorato said. “I still want to help him with whatever he needs — dishes, glasses. Between all of us girls, we have extra things in our basements.”

    For his part, Franks said he hopes to be licensed soon to operate heavy equipment in Massachusetts. He has been trained for the job, he said, and wants to move ahead and leave his past behind.

    “I did my time. I’m not going back. I’m focused on going forward,” Franks said.

    He also does not want to be homeless again.

    “If I can help just one other Vet from being in this position, then this has been worth it,” Franks said. “No one should be living in the woods for four months.”


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  • Privitization Protest


    ST. CLOUD-- A group of Veterans, union members, and St. Cloud VA employees protested VA privatization in the rain Thursday evening.

    After the passing of the Veteran Access Choice and Accountability Act in 2014 and the VA Mission Act in 2018, the group is concerned that government and special interest groups looking to privatize will lessen the quality of care provided to Veterans.

    Gregg James, Vice President for District 8 of the American Federation of Government Employees says the biggest problem with the VA today is understaffing.

    "[The VA is] still considered the number one single-source health provider in the country. Nintey-two percent of Veterans like the care that they get. The issue is with getting them in and getting their appointments, and that's hard to do when you're down 35,000 people across the country."

    Should the VA system become privatized locally or nationwide, the group believes an influx of Veteran patients will place extra stress on private healthcare companies and impact all citizens trying to access care. James says the VA is still best equipped to handle the wounds of war.

    "They're the number one provider for folks that have prosthetics. Nobody is better equipped to deal with the wounds of war than the VA."

    Nationwide, there is a shortage of about 35,000-40,000 VA employees and growing concerns that the current system is not as successful as it used to be.


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  • Low rating Atlanta VAMC


    ATLANTA - Huge developments in the leadership at Atlanta VA Health Care System. The Department of Veterans Affairs announced temporary changes to the top brass in Atlanta after receiving low ratings.

    “As Secretary Wilkie has said, Veterans deserve the best healthcare possible, and the steps we are taking today are designed to ensure that’s exactly what the Atlanta VAMC is providing,” Veterans Integrated Service Network 7 Director Leslie Wiggins was quoted as saying in a release sent to FOX 5 News.

    The VA launched an investigation following the drop in ratings. It will be conducted by the department’s Office of Accountability and Whistleblower Protection and the Veterans Health Administration’s Office of the Medical Inspector.

    “To be clear, this is not an indication of misconduct on the part of any Atlanta VAMC employee. Rather, we are making these changes out of an abundance of caution so that Veterans can have the utmost confidence in the facility’s commitment to quality of care,” Wiggins was quoted as saying.

    The changed include the following moves:

    • Chief of Staff David Bower has decided to retire, and Dr. Ashley Slappy will serve as acting chief of staff
    • Deputy Chief of Staff Sanjay Ponkshe will be detailed to a staff position in primary care
    • Emergency Department Chief Robert Forster will be detailed to a staff position in Tele-Urgent Care, and Dr. Melissa Stevens will serve as acting emergency department chief
    • Clinical Access Services Chief Lee Singleton will be detailed to the Veteran Experience Office and Ms.Tammy Robinson will serve as acting clinical access services chief
    • Primary Care Chief Raman Damineni voluntarily stepped down to a primary care staff position, and Dr. Cedrella Jones-Taylor will serve as acting primary care chief

    “Upon the conclusion of the OAWP and OMI investigations, which are expected to take approximately 30 days, we will reevaluate the Atlanta VAMC’s leadership needs,” Wiggins said.


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  • Maine VA helps Vets


    Veterans at the 3rd Annual Community Reintegration Outing at the Dew Haven Maine Zoo and Rescue pictured above. It’s not often you get to tear yourself away from the trials and tribulations of life to just take a break and have fun. More so, it’s difficult to reach outside of ourselves and connect to others. Just ask Veteran Dan Martins, peer support specialist for VA Maine Healthcare System.

    “I was a hermit myself for two years after the Navy. I just wanted to be left alone. But it’s amazing what happens when you leave your four walls and get out there.”

    Dan Martins and Pete Cayouette started a community reintegration program three years ago. They are two of five peer support specialists whose mission is to help Veterans get back into the community.

    Community groups like Bread of Life Ministries and Volunteers of America have joined VA in this effort, providing resources, socialization and basic human necessities to Veterans who have lost their way.

    Veteran George: “I up and left New York because I had to leave the environment there. My buddies were all overdosing and I knew I just had to get away from the situation. This is my seventh day in Maine.”

    George and 31 other Veterans came out for the 3rd Annual Community Reintegration Outing at the Dew Haven Maine Zoo and Rescue to have fun, build camaraderie, network, make new friends, and to just spend some time outdoors.

    Dave Anderson, a member of the Waterville Elks lodge #905 since 2006, along with his team from the Elks’ Veterans Committee, cooked up some barbeque before the tour started.

    “I’m proud to be one of the supporters of the Veterans Committee and help Veterans who are down and out or with anything they need.”

    The Elks Lodge has been supporting Veterans since the First World War, from putting in the first field hospital to making sure a Veteran mother of six has furniture and appliances after being displaced.

    “Today we brought a bunch of Veterans out here from the Togus VA, the homeless shelter and Bread of Life Ministries, to develop more camaraderie between the Veterans. I’ve met most of them over the years. Some of them are in and out of homelessness and some have already found housing they stay with.

    “But once they develop a relationship with each other, through VA and through the Elks, we like to treat them to a barbecue, and this is the day for this year. We’ve been doing it a few years now and I think we will keep on doing it,” said Anderson.


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  • Managing Pain

    Moving Beyond Opioids

    Most people experience some kind of pain during their lives. Pain serves an important purpose: it warns the body when it’s in danger. Think of when your hand touches a hot stove. But ongoing pain causes distress and affects quality of life. Pain is the number one reason people see a doctor.

    A class of drugs called opioids is often used to treat pain. One reason, explains NIH pain expert Dr. Michael Oshinsky, is that opioids work well for many people. Opioids can stop the body from processing pain on many levels, from the skin to the brain. Because they work throughout the body, he says, “Opioids can be very effective for multiple types of pain.”

    But opioids also produce feelings of happiness and well-being. And they’re reinforcing: the more people take them, the more they crave them. This can lead to addiction, or continuing to take opioids despite negative consequences. Scientists have not yet been able to develop opioids that reduce pain without producing these addicting effects, Oshinsky explains.

    The longer someone takes opioids, the more they need to take to get the same effect. This is called tolerance. Taking higher doses of opioids increases the risk of overdose. The U.S. is now in the grip of an opioid crisis. Every day, more than 100 Americans die from an opioid overdose. This number includes deaths from prescription opioids.

    “We don’t need ‘better’ opioids. We need to move away from the reliance on opioids for developing pain treatments,” Oshinsky says.

    NIH is funding research into new and more precise ways to treat pain. It’s also working to develop new treatments to combat opioid misuse and addiction.

    Opioids Not Always Needed

    Opioids are often prescribed for acute pain. Acute pain is short-term pain, the kind experienced after an accident or an operation. But other drugs may be just as effective for acute pain, even after surgery, explains Dr. Dena Fischer, a dental health expert at NIH. Some of these drugs, like acetaminophen or ibuprofen, don’t require a prescription.

    People may think that prescription drugs work better for acute pain. But that’s often not the case, Fischer says. Using something other than an opioid first can be especially important to manage acute pain in fields such as dentistry, she adds.

    Many people receiving opioid prescriptions from dentists are teens or young adults who have never been prescribed an opioid before.

    “Research is starting to tell us that people who receive an opioid prescription as a teenager have a tendency to continue to take opioids for non-medical purposes in the long term,” Fischer says.

    Healthcare providers who decide their patient needs an opioid are now being encouraged to give only a few pills at a time. People who receive shorter prescriptions are less likely to misuse their pills by taking more than prescribed or taking them after the pain is gone. This also cuts down the chance that the pills could be taken by others.

    When Pain Is Chronic

    Managing chronic pain is more complicated than treating acute pain. More than 25 million people in the U.S. alone live with chronic pain, which is pain that lasts more than three months.

    Many things can cause chronic pain. For example, Oshinsky says, a muscle that was damaged in an accident may heal relatively quickly. But if a nerve was also hurt, it can continue to send pain signals long after the body has repaired the muscle.

    Other types of chronic pain are driven by brain changes, explains Dr. David Williams, an NIH-funded pain researcher at the University of Michigan. When these changes happen, the brain continues to perceive pain even though the injury has healed.

    For people with this type of chronic pain, sometimes called central pain, opioids and some other kinds of pain medications can actually make the pain worse.

    Research has shown that talk therapies, such as cognitive behavioral therapy, can help many people with chronic central pain. These types of therapies “emphasize behaving in different ways or thinking in different ways that alter the perception of pain,” Williams explains. “Pain is a combination of a sensory and an emotional experience.”

    Cognitive behavioral therapy can also help people with chronic pain manage related health problems, such as problems sleeping, feeling tired, or trouble concentrating. This can increase quality of life for people with chronic pain. It can also have overlapping effects.

    “Pain processing and sleep and thinking and mood all share the same neurotransmitters in the brain,” Williams says. “So, by improving something like sleep, you’re also improving pain.”

    Non-opioid drugs can help some people with chronic pain too, Oshinsky says. Many of these drugs were first developed to treat different health conditions, such as seizures, depression, or anxiety. But they can also change the way the brain processes pain.

    Some people benefit from devices that stimulate the nerves directly to block pain signals from reaching the brain, Oshinsky adds. Different devices can work on different parts of the nervous system, from the nerves in the skin to the spinal cord.

    People with certain types of pain have also been shown to benefit from exercise, acupuncture, massage therapy, or yoga.

    Expanding the Options

    The alternatives to opioids we have now don’t work for everyone’s pain. More non-opioid, non-addictive treatment options could help reduce the number of opioids prescribed each year.

    Recently, NIH launched the Helping to End Addiction Long-Term (HEAL) Initiative to address the shortage of effective medications for chronic pain and other issues contributing to the opioid crisis.

    Some of the research funded by HEAL will focus on understanding how chronic pain develops. A better understanding of how acute pain becomes chronic could reveal new treatment targets.

    Researchers funded by HEAL also hope to learn how to predict who will develop chronic pain from acute pain. This information could be used to guide early pain management, Oshinsky explains. HEAL will fund research into new treatments for opioid misuse and addiction as well.

    More options for pain management could help doctors better personalize pain treatment. “It could be a little more like precision medicine, where you try to identify what flavor of pain the patient has, and then match the treatments we have available to the needs of that patient,” Williams explains.


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  • learn from his suicide

    The suicide of Marine Corps Veteran Justin Miller earlier this year prompted a federal review of the Minneapolis VA system. The final report released last week criticizes a communications breakdown at the VA. Meanwhile, Miller's family is still wondering what happened to him, and why he didn't get the help he needed.

    Miller had his first piano lesson at 3 years old. He took to it so fast, pretty soon he outpaced his big sister, Alissa Harrington.

    "The joke is that I'm the musical slouch of the family because I only play four instruments," she said.

    By high school, Harrington said, her brother was leading the school marching band with his trumpet. At 17, the Marines recruited him to play in the military band.

    He was proud when he knew that he was going to be a Marine, and was going to play music.

    Harrington said the family wasn't all that nervous about Miller becoming a Marine. He was in the band. It was a guaranteed assignment.

    They wanted to believe all he had to do was look sharp and blow those pretty high notes.

    But the U.S. government doesn't train Marines just to play music. And in summer 2005, the Marines sent him to the Middle East.

    "He was deployed to Iraq," said Harrington. "So he was in Iraq with his trumpet and a gun."

    Miller was assigned guard duty, standing watch over the gates of an air base.

    Something happened there that changed her brother, Harrington said. She's still piecing together the details.

    "He would tell one of us that he had to shoot camels," she said. "He'd tell another one of us that sometimes those camels had riders."

    And to the people he knew really well, he said sometimes the camels were wired with explosives. They blew up when he shot them.

    "He was a soldier, but he was a musician. That type of trauma was not something he was expecting to have to process," Harrington said.

    Miller finished his deployment and came home. He trained to become an electrician, like his dad. He played his trumpet for the Coon Rapids American Legion. He started playing piano again, as he'd done as a kid.

    Then, in February of this year, he called a Veterans crisis hotline, and checked himself into the mental health unit of the Minneapolis VA. He was having suicidal thoughts and needed help.

    After four days of treatment, Miller was released. He walked to his car, climbed in and took his own life with a gun. He was 33.

    Those last four days of Miller's life have become the subject of a federal review.

    An exhaustive report released last week by the Office of the VA Inspector General shows a breakdown of communication across the Minneapolis VA system.

    The facility employs suicide prevention coordinators who work with high-risk patients.

    But Miller was never flagged as a high-level suicide risk, so he never got that help.

    Miller told several nurses that he had easy access to guns, but denied that fact to others. No one noticed the inconsistency.

    When his parents called the VA, looking for updates, some departments didn't even know Miller had been discharged.

    It was only after that phone call when VA staff searched their parking lot and found Miller's body.

    Harrington had none of this information until the Inspector General's report was released.

    "And it was a lot of the same raw guttural emotions all over again. The same way when we found out that he had died in the first place," she said.

    She doesn't blame the doctors or nurses for what happened. She says a lack resources and funding stopped them from helping her brother.

    She hopes that telling his story will change things at the VA.


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  • Male Breast Cancer

    Mike Partain got the shock of his life five years ago when he was diagnosed with breast cancer at the age of 39. That he got breast cancer at all is surprising. It's so rare that for every 100 women who get it, just one man will.

    “Five years ago I was just an ordinary father of four, husband of 18 years. And one night, my then-wife gave me a hug and she felt a bump on my chest,” he said in an interview with Dr. Nancy Snyderman airing tonight at 10pm/9CT on NBC News’ Rock Center with Brian Williams. 

    When his doctor delivered the devastating news in a phone call, Partain’s first thought was, “What contest in hell did I win to deserve this?”

    After his diagnosis, Partain was desperate to answer the question, “why”? He said, “I don't drink. I don't smoke. I've never done drugs. There is no history of breast cancer in my family.” 

    But everything changed after he saw a news report, where a former Marine drill instructor named Jerry Ensminger told Congress how his 9-year-old daughter Janey died of leukemia, and that he believed her death was caused by drinking water at Camp Lejeune contaminated with chemicals.

    “My knees buckled,” Mike said, “I grabbed the back of the couch and I sat there.  I was like, ‘Oh my God, this is what happened.’”

    The son of a Marine, Partain was born at Camp Lejeune in North Carolina. He soon learned that there had been a long history of suspicion about the water at Camp Lejeune.

    “The entire time my mother was pregnant with me, we were drinking high levels of tetrachloroethylene, trichloroethylene, and benzene in our water” he said. Partain believes these chemicals caused his breast cancer.

    The Center for Disease Control and Prevention (CDC) estimates that between 500,000 and 1 million people were exposed to the contaminated water from 1953 to 1987, when the last of several contaminated wells were closed.

    Partain has found 83 other men who lived or served at Camp Lejeune who have also been diagnosed with male breast cancer.

    Peter Devereaux, a 50-year-old a former Marine, is one of them. He was diagnosed in 2008.

    Devereaux remembers when his doctor first let him know he had breast cancer.

    “I was just like, whooo. Even now I've said that so many times, it still takes your breath away,” he said.

    Dr. Katherine Ruddy, a medical oncologist at Dana Farber Cancer Institute in Boston, is Devereaux’s doctor.

    “When Peter was first diagnosed, he had a stage III cancer.  And approximately a year later, we did find that he had distant metastases to his bones,” said Ruddy.  She says his cancer is terminal.

    Click here for more of Peter Devereaux's story.

    Like Devereaux, most men tend to get diagnosed at later stages than women do, which decreases their survival, according to Ruddy. Devereaux needed a mastectomy and hormone treatment, both of which are common for men with male breast cancer.  But the side effects of hormone treatments affect men differently than women, according to Ruddy.

    “Men are not used to hot flashes and I think it is a particularly challenge for men to deal with the side effects of our treatments, including the hot flashes from our endocrine therapies that just are not something that they went into this expecting to feel,” Ruddy said.

    It is not just the disease that upsets the men from Camp Lejeune. They are angry because of how they believe they got cancer.

    Click here to read the Marine Corps’ full response to NBC News regarding water contamination at Camp Lejeune

    A Lab reports from 1980 show that the United States Marine Corps started routinely testing tap water back in 1980. Testing eventually revealed one sample that contained 280 times the acceptable standard of Trichloroethylene (TCE), a chemical which can cause cancer.

    For more on Camp Lejeune and its drinking water, click here.

    Some of the chemicals were linked to a dry cleaner off base that has since closed. But a recently-released report found that the worst contamination came directly from the Marine Corps, because of its industrial waste practices and from leaking fuel storage tanks. One document, released by the CDC in December 2012, details how over 1 million gallons of fuel seeped into the ground from underground storage tanks, contaminating the camp’s well water.

    Officials say that while testing of the tap water began in 1980, it took them four years to determine exactly which wells were contaminated, and that once those wells were identified, they were shut down immediately. Partain says the Marine Corps should have closed the wells earlier. “They chose to keep those wells on for whatever reason and did not begin shutting the wells down until 1984,” he said.

    As for any connection between the chemicals in the water and cancer, Marine Corps officials maintain that "reliable scientific evidence is lacking" to prove one way or another whether the water contamination caused any illness. But Dr. Richard Clapp, one of the nation’s most respected experts in cancer and the environment, disagrees.

    “The level [of contamination] in the drinking water was the highest that I've ever seen,” said Clapp, an epidemiologist at the University of Massachusetts, Lowell. “I've been working on this kind of thing for 30 years. I have never heard of a community that's had the levels of contaminants that they had at Camp Lejeune.”

    He has examined the data from Camp Lejeune and says he believes the contamination and the cancers are related. “The cluster of disease-- for example, male breast cancer-- may also turn out to be the highest that's been seen anywhere. “

    Click here to read the Marine Corps’ full response to NBC News regarding water contamination at Camp Lejeune

    Though the Marine Corps has not acknowledged a link between the bad water and any illness, Congress felt there was enough evidence to act to help the Veterans who believed the water at Camp Lejeune made them sick. In 2012 the president signed a law providing health benefits to Camp Lejeune Veterans and their families who can prove the contamination made them sick.

    The law lists several types of diseases that may be related to the poisoned water at Camp Lejeune, including childhood leukemia as well as cancers of the kidney, lung, bladder and breast. But it has been hard for the male breast cancer patients who believe they’re cancer was caused by contaminated water at Camp Lejeune to get benefits, which are managed through the Veteran’s Administration.

    One former Camp Lejeune Marine, Tom Gervasi, says he has been denied benefits several times. He says that for him, time is of the essence.

    “I've got stage 4 terminal cancer. My survival is minimal. What I worry about is my wife, and her being taken care of by the VA and the Marine Corps, if at all possible,” Gervasi said.

    The men are waiting on a report due out this year from the CDC's Agency for Toxic Substances and Disease Registry (ATSDR) that they believe may help them prove it was the water that made them sick, and that the Marine Corps is, in fact, responsible.

    Partain and Camp Lejeune families say the CDC analysis, which began more than 20 years ago, is taking too long. Dr. Christopher Portier, the director of the ATSDR told NBC News “I think we are late on this one.” Now he says he is pushing his staff to finish quickly. “Our responsibility for these people is to do the absolute best science, make sure we get it exactly right so nobody can challenge any of our results when we're done.”

    As everyone waits for the report, Partain and his men want the Marine Corps and the Veterans Administration to step up and take care of their Marines and their families. Partain asks, “When is the leadership of the Marine Corps going to stand up and say we made a mistake?”

    For more on Camp Lejeune and its drinking water:

    Register to receive notifications regarding Camp Lejeune Historic Drinking Water, by clicking here or call (877) 261-9782.

    Click here to visit the Agency for Toxic Substances and Disease Registry (ATSDR) 


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  • Fred Plichta


    Fred Plichta, the World War II Veteran whose unlikely friendship led to a 2015 trip to Washington, D.C., that was chronicled by the Free Press, died Saturday of lung cancer.

    He was 91 years old.

    Plichta was born in Detroit to Fred and Emma (Serembia) Plichta on March 3, 1927. He was a Free Press newspaper carrier as a child, and was drafted into the U.S. Army in 1945, serving in the 88th Infantry Division in Europe.

    He was humble about his service, and proud of the country he served. He often wore a signature black cowboy hat with the words "WWII Veteran" printed in bold at the center.

    "They all think I'm a big hero," he said during a trip to the National World War II Memorial in 2015, which was funded by donors and put together by a friend who wanted him to see the memorial before he lost his vision to macular degeneration. "I tell them I'm not. But they all say you're a World War II Vet, and I say, no, I'm not. I didn't get into the high battles. No, I don't think what I had to do was important. It's not like getting shot at every day.

    "They tell me it was important, but I look at men with no arms and no legs.... I feel a little embarrassed that everyone is making a fuss over me."

    After the war, Plichta married Catherine Bowling and had two sons, Fred Plichta and Jack Plichta, and two daughters, Linda Plichta of Monroe and Teresa (Randall) Coulter of Prescott, as well as eight grandchildren and 11 great grandchildren. He worked for more than three decades as a truck driver for the City of Detroit. He lived in Monroe for many years and was an active member of St. Paul's Lutheran Church and the Monroe VFW Post 1138.

    His parents, wife and two sons preceded him in death.

    Visitation is set for 1-9 p.m. Wednesday at The Allore Chapel, Martenson Family of Funeral Homes, 203 E. Elm Ave. Monroe. Military honors are planned for 11 a.m. Thursday at the chapel, followed by a funeral service at 11:15 a.m. Entombment is planned for 11 a.m. Friday at Glen Eden Memorial Park, 35667 W. Eight Mile Road, Livonia.


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  • Justice 003


    HARRISBURG - The United States Attorney’s Office for the Middle District of Pennsylvania announced today that Jason Ehrhart, age 48, ofThompsontown,Pennsylvania, and Jason’s former wife, Laurie Ehrhart, age 48, ofNewport,Pennsylvania, were charged with defrauding a disabled Veteran, the Veteran’s Administration, and the Social Security Administration out of $316,360.

    According to United States Attorney David J. Freed, Jason Ehrhart is charged by way of a criminal information with one count of health care fraud. Jason’s former wife, Laurie Ehrhart, is charged in an indictment with one count of health care fraud and one count of conspiracy to commit health care fraud.

    According to the charges, a Veteran who was a former resident of Perry County, Pennsylvania, was diagnosed with multiple sclerosis while serving in the U.S. Army in 1985.   The Veteran later began receiving disability benefits from the Department of Veterans Affairs (VA) and the Social Security Administration (SSA) and was eventually hospitalized on a permanent basis at the VA hospital inLebanon,Pennsylvania, onNovember 8, 2004.

    OnAugust 8, 2006, the Veteran was deemed by the VA to be incompetent to handle his own financial affairs. As a result, onOctober 2, 2006, Jason Ehrhart successfully applied to serve as the Veteran’s VA Fiduciary and Legal Custodian. Under the terms of a Fiduciary Agreement, Jason Ehrhart agreed to use all of the Veteran’s VA disability benefits exclusively for the Veteran’s benefit. The agreement warned him that the funds were not for his personal use. The Fiduciary Agreement also required Jason Ehrhart to submit an annual accounting to the VA with respect to the amount of money spent on the Veteran’s behalf.

    The charges allege, however, that between October 2006 and August 2016, Jason Ehrhart and Laurie Ehrhart, who was then Jason’s wife, misspent $316,360 of the Veteran’s VA and Social Security disability benefits on themselves.

    While Jason Ehrhart served as the Veteran’s VA Fiduciary and Legal Custodian, all of the Veteran’s VA benefits, plus most of his Social Security disability checks, were deposited into a checking account Jason opened as a legal custodian account in the Veteran’s name. Altogether, $476,260 in federal benefits ($422,828 in VA disability, $48,187 in Social Security disability, and $5,244 in VA clothing allowance) were deposited into the account between January 2009 and August 2016.

    The charging documents alleged that, at least $316,360 of the $476,260 was misappropriated by Jason and Laurie Ehrhart and converted to their own use. Checks totaling $218,832 ($96,202 payable to Jason Ehrhart and $122,630 payable to Laurie Ehrhart), some of which exceeded $5,000, $6,000 and $7,000, were drawn against the account. Of the $218,832, $157,742 was allegedly deposited into Jason and Laurie Ehrhart’s joint checking account at the Juniata Valley Bank (JVB) and at least $23,496 was converted to cash. Thereafter, it is alleged that the funds in the joint JVB account were employed by Jason and Laurie Ehrhart to pay personal expenses.

    The charging documents further allege that another $7,174 in checks were made payable to Jason and Laurie Ehrhart’s two minor children. Jason Ehrhart allegedly instructed the children to take the checks to the bank, cash them, and surrender the cash to him.

    Another $19,890 in checks were allegedly made payable to another couple who were Jason and Laurie Ehrhart’s best friends. According to the charges, Jason Ehrhart regularly treated the couple and their children to dinners out and at least two, all-expense paid vacations to Disney World inFlorida, purchased two automobiles for the family, and paid for the wife’s dental work.

    To conceal his embezzlements, it is alleged that Jason Ehrhart submitted eight false annual accountings to the VA in which he falsely claimed he spent $402,408 on the Veteran’s behalf between October 2006 and October 2015. According to the charges, the itemized expenditures in the accountings were grossly inflated. For example, Jason Ehrhart claimed he paid the mortgage on the Veteran’s residence ($1,631 per month) plus the Veteran’s share of the mortgage on his mother’s residence ($881) after she died in May 2011. However, the lenders against both properties obtained judgments and they were eventually foreclosed and sold.

    According to the charges, Jason Ehrhart also falsely claimed in the annual accountings that he spent thousands on miscellaneous expenditures for the Veteran, including storage unit rentals, vehicle maintenance bills, state and local taxes, life and auto insurance, and credit card bills. However, in 2016 the Veteran’s specially equipped wheelchair van, for which Jason Ehrhart claimed he spent approximately $32,395 for vehicle maintenance, was found broken down and abandoned along aPerryCounty roadside.

    The Veteran died at the Lebanon VA Hospital onJuly 30, 2018.

    Laurie Ehrhart was arraigned on the charges before U.S. Magistrate Judge Susan E. Schwab this afternoon and released on her own recognizance. No date has yet been set for Jason Ehrhart’s initial appearance on the charges.

    The Department of Veteran Affairs, the Office of Inspector General, the Pennsylvania State Police, and the Social Security Administration’s Office of Inspector General investigated the case. Assistant United States Attorney Kim Douglas Daniel is prosecuting the case.

    Indictments and Criminal Informations are only allegations. All persons charged are presumed to be innocent unless and until found guilty in court.

    A sentence following a finding of guilt is imposed by the Judge after consideration of the applicable federal sentencing statutes and the Federal Sentencing Guidelines.

    The maximum penalty under federal law for this offense is 10 years of imprisonment, a term of supervised release following imprisonment, and a fine. Under the Federal Sentencing Guidelines, the Judge is also required to consider and weigh a number of factors, including the nature, circumstances and seriousness of the offense; the history and characteristics of the defendant; and the need to punish the defendant, protect the public and provide for the defendant's educational, vocational and medical needs. For these reasons, the statutory maximum penalty for the offense is not an accurate indicator of the potential sentence for a specific defendant.


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  • Deb Goldberg


    Three Veterans are suing the state treasurer for denying them a Veterans bonus for receiving a discharge that was not honorable after multiple tours of duty.

    Massachusetts offers Veterans who served after the Sept. 11, 2001 terrorist attacks a Welcome Home bonus as long as they receive an honorable discharge. The bonus is $1,000 for Veterans who served in Iraq or Afghanistan and $500 for those who served elsewhere for at least six months.

    The case pending in Suffolk Superior Court, which will have a hearing this Thursday, is about whether someone who served multiple tours of duty but was not honorably discharged from the final one is eligible for the benefit. Treasurer Deborah Goldberg and the Veterans' Bonus Appeal Board said those Veterans are not eligible.

    The case is Jeffrey Machado, Herik Espinoza, and Washington Santos vs. Goldberg and the Veterans' Bonus Appeal Board.

    Machado served in the U.S. Army from March 2011 to September 2014. He struggled with returning to post-combat life and received an "other than honorable" discharge for a domestic violence-related violation of military regulations. He applied for Welcome Home bonuses for his deployment to Afghanistan and his service domestically. The Veterans' Bonus Division of the treasurer's office denied his request because of his discharge.

    Machado appealed, arguing that he was honorably discharged from his first tour of duty, so he should receive the benefit for that service. The board disagreed and found that the Army had characterized his entire service as dishonorable.

    Similarly, Espinoza served three tours of duty, received an "other than honorable" discharge, and applied for Welcome Home bonuses for his service during his first two tours.

    Espinoza was on active duty in the U.S. Army from November 2004 to February 2016. He applied for a bonus for his deployment to Afghanistan in 2011-2012, for which he received an Army Commendation Medal.

    The board reached the same conclusion as in Machado's case. Both cases were decided May 30, 2017.

    This April, attorneys for Machado and Espinoza asked to add a third plaintiff. Santos was in a similar situation, in which he appealed a bonus denial after he received an "other than honorable" discharge after three tours of duty, having served in Qatar, Korea and Afghanistan and earned multiple medals for his service.

    Santos had filed his own lawsuit, seeking to represent all Veterans in a similar situation - which he estimated could be as high as 4,000.

    "The Massachusetts Legislature has long chosen to recognize the virtues and sacrifices of those who serve in the armed forces by providing to them special benefits, among them a Welcome Home Bonus for returning post-9/11 service members who deployed to war," attorneys for Santos wrote in his complaint. "However, the State Treasurer - charged with administering the Bonus program - has violated that long tradition by unfairly and unlawfully withholding the Bonus from thousands of Massachusetts Veterans."

    Santos' brief argues that often, less than honorable discharges stem from conduct related to mental or physical problems that come from military service, such as post-traumatic stress disorder or brain injury.

    Nearly 7 percent of post-Sept. 11, 2001 Veterans have received a less than honorable discharge. A May 2017 report by the federal government found that 62 percent of Veterans separated from the military for misconduct over a four-year period had been diagnosed with a mental health condition, such as PTSD.

    Goldberg and the appeal board, in briefs filed by Attorney General Maura Healey's office, argue that the state law establishing the bonus states clearly that the Veteran must have been discharged "under honorable conditions." Under that law, they argue, these Veterans are not eligible for the bonus.

    "It is rational and serves a legitimate purpose for the state, on one hand, to pay the bonus to applicants whose then-known conduct is 'honorable,' and on the other hand, not to pay the bonus to applicants whose then-known conduct is other than honorable," wrote Assistant District Attorney Maryanne Reynolds. "'Honorable' service has been the hallmark of the bonus, and similar bonuses in the past."

    The treasurer's office still approves the vast majority of applications it receives. Between fiscal 2015 and fiscal 2018, the office received 5,881 applications for the Welcome Home Bonus and denied 467 of them. The office paid out $5.32 million in bonuses during those years.


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  • Vets in Congress


    At the Cleveland Clinic’s 2018 Medical Innovation Summit, the theme was “Disruption: Reimagining Healthcare.” While speaking at the conference John Boehner, former Speaker of the House, did not hold back with his comments about the Department of Veterans Affairs.

    Specifically, Boehner referred to the VA as “hopeless” and unnecessary, stating that the VA “provide[s] substandard care to our Veterans who deserve the best care.

    He also elaborated that “real doctors” were most likely not working at the VA.

    Although Boehner was quick to dole out criticism, he did not offer much in the way of solutions. In this regard, Boehner’s comments hardly fall into the category of “disruption,” which, by definition, is “to interrupt the normal progress or activity of something.”

    Criticizing the VA without offering productive solutions has unfortunately become the normal course of business for most politicians and thus can hardly be considered disruptive. If Boehner truly wanted to disrupt the conversation around VA health care and reimagine what it looks like in the future, he could have paired his criticism with a challenge to his former colleagues in Congress to do better.

    Such a challenge would be timely as the midterm elections are only two weeks away and more importantly, this election cycle, a great deal of attention has been placed on the number of military Veterans running for office.

    With a high likelihood of many new military Veterans joining the 116th Congress, why didn’t Boehner challenge those who have experience seeking VA health care to take the job of reforming the system more seriously?

    As highlighted by this map compiled by With Honor, there are nearly 200 Veterans running for the House alone. Although it is unlikely that all Veterans running for office will find themselves victorious on Election Day, what is likely is that the number of Veterans serving in Congress will significantly increase and many of those Veterans will be new to Congress. With more Veterans that are new to Congress, they will bring with them a fresh perspective that includes a greater, first-hand understanding of the Veterans’ health-care system both at the VA and in their communities.

    Overall, most Americans agree that electing more Veterans to Congress is a good thing. To this end, military service is regarded as the most important factor for undecided voters when choosing a candidate. However, much of the coverage regarding electing more Veterans to office thus far has centered around broad policy slogans such as “principles before politics” and how Veterans’ intrinsic call to duty makes them our nation’s best hope for breaking loose from the hyper-partisanship currently gripping congress. These concepts are important and should not be ignored.

    However, once Election Day is over, newly elected candidates and incumbents alike, whether military Veterans or not, will have to move past their generic talking points and toward productive policy solutions.

    Despite being Veterans themselves, fixing the VA has not been a platform many of these Veterans have campaigned on nor one that many Veteran incumbents have made a priority.

    The VA has long been an anathema to Members of Congress. Despite the fact that the House Veterans’ Affairs Committee’s jurisdiction touches literally every Congressional district, the committee assignment is generally considered one of the least-desired in all of Congress, as evidenced by high turnover and the high proportion of new members.

    Indeed, in the wake of the Phoenix VA scandal in 2014, the Huffington Post reported the simple reason that Congress had not yet fixed the VA was because serving on the House or Senate Veterans’ Affairs Committee “comes with no opportunity to rake in campaign cash.”

    With a high likelihood of many of the Veterans running for Congress being elected, it is likely that several will end up on the House Veterans’ Affairs Committee. Will these new members stay on the Committee despite its limited fundraising potential? Or will they too, like many of the predecessors, arrive in Washington with the best of intentions, only to succumb to the worst of politics and only follow the campaign cash?

    Obviously, the future paths that new Veteran Members of Congress chooses, remains to be seen. However, if any of these new members are truly interested in disrupting the process and reimagining the future when it comes to VA health care, then let’s challenge those Veterans elected to the 116th Congress to make VA reform a top priority.

    A coalition of Veteran members who are truly engaged in the issues impacting the VA, despite its lack of fundraising potential, coupled with a sincere desire to fix things, would certainly be a more disruptive force than more criticism along party lines without solutions.

    It’s worth a try, isn’t it?


    {jcomments on}

  • Alzheimers



    On January 4, 2011, the National Alzheimer's Project Act (NAPA) (Public Law 111-375) was signed into law. The Act defines "Alzheimer's" as Alzheimer's disease and related dementias (AD/ADRD) and requires the Secretary of the U.S. Department of Health and Human Services (HHS) to establish the National Alzheimer's Project to:
     Create and maintain an integrated National Plan to overcome Alzheimer's disease;
     Coordinate Alzheimer's disease research and services across all federal agencies;
     Accelerate the development of treatments that would prevent, halt, or reverse the course of Alzheimer's disease;
     Improve early diagnosis and coordination of care and treatment of Alzheimer's disease.
     Decrease disparities in Alzheimer's disease for ethnic and racial minority populations that are at higher risk for Alzheimer's disease; and,
     Coordinate with international bodies to fight Alzheimer's disease globally.

    The law also establishes the Advisory Council on Alzheimer's Research, Care, and Services (Advisory Council) and requires the Secretary of HHS, in collaboration with the Advisory Council, to create and maintain a National Plan to overcome AD/ADRD.
    NAPA offers a historic opportunity to address the many challenges facing people with AD/ADRD and their families. Given the great demographic shifts that will occur over the next 30 years, including the doubling of the population of older adults, the success of this effort is of great importance to people with AD/ADRD and their family members, caregivers, public policy makers, and health and social service providers.

    Alzheimer's disease (AD) is an irreversible, progressive brain disease that affects as many as 5.3 million Americans.1 It slowly destroys brain function, leading to cognitive decline (e.g., memory loss, language difficulty, poor executive function), behavioral and psychiatric disorders (e.g., depression, delusions, agitation), and declines in functional status (e.g., ability to engage in activities of daily living (ADLs) and self-care).2 In 1906, Dr. Alois Alzheimer first documented the disease when he identified changes in the brain tissue of a woman who had memory loss, language problems, and unpredictable behavior. Her brain tissue included abnormal clumps (amyloid plaques) and tangled bundles of fibers (neurofibrillary tangles). Brain plaques and tangles, in addition to the loss of connections between neurons, are the main pathological features of AD.3 However, other pathologic features occur commonly in the brain of older Americans diagnosed with AD and these are thought to also contribute to the burden of dementia in the United States.4, 5
    In addition to AD, this National Plan addresses Alzheimer's Disease-Related Dementias (ADRD) consistent with the approach Congress used in NAPA. ADRD include frontotemporal dementia (FTD), Lewy body dementia (LBD), vascular cognitive impairment/dementia, and mixed dementias -- especially Alzheimer's mixed with cerebrovascular disease or Lewy bodies. It is often difficult to distinguish between AD and ADRDs in terms of clinical presentation and diagnosis. Some of the basic neurodegenerative processes have common pathways. People with these forms of dementia and their families and caregivers face similar challenges in finding appropriate and necessary medical care and community-based services. As such, many of the actions described in this plan are designed to address these conditions collectively.
    The first symptom of AD, and sometimes ADRD, is often memory impairment. However, in ADRD, poor attention and executive function, behavioral disorders, visual disturbances, sleep disruption or motor symptoms can often be the presenting symptoms. As the disease progresses, memory can decline, and other functions like language skills and decision making become more difficult. Personality and behavior changes often occur. Over time, a person with the disease may no longer recognize family and friends. Eventually, persons who survive with AD/ADRD are completely reliant on others for assistance with even the most basic ADLs, such as eating.6, 7
    In more than 90% of people with AD/ADRD, symptoms do not appear until after age 60, and the incidence of the disease increases with age. The causes of AD/ADRD are not completely understood, but researchers believe they include a combination of genetic, environmental, and lifestyle factors.6 The importance of any one of these factors in increasing or decreasing the risk of developing AD/ADRD may differ from person to person. In rare cases, known as early or younger-onset dementia, people develop symptoms in their 30s, 40s, or 50s. A significant number of people with Down syndrome develop dementia in their 50s, often placing increased burden on their families and caregivers.
    AD/ADRD is a major public health issue and will increasingly affect the health and well-being of the population. Unless the diseases can be effectively treated or prevented, the number of Americans with AD/ADRD will increase significantly in the next two decades. The Bureau of the Census estimates that the number of people age 65 and older in the United States will almost double, to 88 million by 2050. The prevalence of people with AD/ADRD doubles for every 5-year interval beyond age 65. Without a preventive treatment or cure, the significant growth in the population over age 85 that is estimated to occur between 2015 and 2050 (from 6.3 million to 19 million) suggests a substantial increase in the number of people with AD/ADRD.
    Significant emotional, physical, and financial stress is placed on individuals with AD/ADRD and their family members. Unpaid caregivers, such as family members and friends, provide the majority of care for people with AD/ADRD in the community. Unpaid caregivers often do not identify themselves as such; they may be a wife, daughter, husband, parent, son, or friend helping a person whom they care about. However, the intensive support required for a person with AD/ADRD can negatively impact the caregiver's emotional and physical health and well-being, and their ability to work. Unpaid caregivers often report symptoms of depression and anxiety, and they have poorer health outcomes than their peers who do not provide such care.7
    Dementia care costs are significant and often a burden to families and others providing unpaid care. Recent estimates from one nationally representative study found that paid and unpaid care costs for people older than age 70 with dementia in the United States in 2010 were between $159 billion and $215 billion. These figures include direct medical expenditures, costs for long-term services and supports (LTSS) including institutional and home and community-based services (HCBS), and two different estimates of the value of unpaid care provided by family members and friends. These costs could rise dramatically with the increase in the numbers of older adults in coming decades. Care costs per person with dementia in 2010 ranged from $75,000 to $83,000 depending on how unpaid care costs were estimated.8 These national dementia care costs are comparable to, if not greater than, those for heart disease and cancer.9
    Caring for people with the disease also strains health and long-term care systems. Individuals with AD/ADRD use a disproportionate amount of health care resources; for instance, they are hospitalized 2-3 times as often as people of the same age who do not have the disease.10 Similarly, estimates from national data show that nearly seven out of ten residents in assisted living residences have some form of cognitive impairment.11 As the number of people with AD/ADRD grows over the next three decades, these diseases will place a major strain on these care systems as well as on Medicare and Medicaid, the major funders of institutional, clinical care, and HCBS. Although Medicaid, a program for eligible low income Americans, covers long-term care such as nursing home care and HCBS, Medicare does not. Most Americans underestimate the risk of disability and the need for long-term care. More than half of older adults turning 65 today will develop a disability such as AD/ADRD serious enough to require LTSS, although most will need assistance for less than 2 years. About one in seven will have a disability for more than 5 years. On average, an American turning 65 today will incur $138,000 in future LTSS costs. Families will pay about half of the costs themselves out-of-pocket, with the rest covered by current public programs and private insurance.12

    The National Plan was designed to address the major challenges presented by AD/ADRD:
    7. While research on AD/ADRD has made steady progress, there are no pharmacological or other interventions to definitively prevent, treat, or cure the diseases.
    8. While HHS and other groups have taken steps to develop quality measures to assess dementia care and to improve the training of the health and long-term care workforce -- for both paid and unpaid caregivers -- there is room for improvement.
    9. Family members and other unpaid caregivers, who take on the responsibility of caring for a loved one with AD/ADRD, also need services and supports. The majority of people with AD/ADRD live in the community, where their families provide most of their care. The toll of caregiving can have major implications for caregivers and families as well as population health, with about one-third of caregivers reporting symptoms of depression.11, 13
    10. Stigmas and misconceptions associated with AD/ADRD are widespread and profoundly impact the care provided to and the isolation felt by people with AD/ADRD and their families and caregivers.
    11. Public and private sector progress is significant but should be coordinated and tracked. In addition, data to track the incidence, prevalence, trajectory, and costs of AD/ADRD are limited.

    The enactment of NAPA provided an opportunity to focus the Nation's attention on the challenges of AD/ADRD. In consultation with stakeholders both inside and outside of the Federal Government, this National Plan represents the blueprint for achieving the vision of a nation free of AD/ADRD.
    Central to and guiding the National Plan are the people most intimately impacted by AD/ADRD -- those who have the diseases and their families and other caregivers. Individuals with AD/ADRD and their caregivers receive assistance from both the clinical health care system and long-term care including HCBS, legal services, and other social services. Both the clinical care and community/support environments need better tools to serve people with AD/ADRD and their unpaid caregivers. Ongoing and future research seeks to identify interventions to assist clinicians, supportive service providers, HCBS providers, persons living with dementia, and caregivers. All of these efforts must occur in the context of improved awareness of the diseases and its impacts, and the opportunities for improvement. The Plan aims to address these key needs. HHS is committed to tracking and coordinating the implementation of NAPA and making improvements aimed at achieving its ambitious vision.
    The National Plan continues to be guided by three principles:
    12. Optimize Existing Resources, and Improve and Coordinate Ongoing Activities. The first step in developing the National Plan was to set up a federal interagency working group and conduct an inventory of all federal activities involving AD/ADRD. In creating the Plan, HHS and its partners sought to leverage these resources and activities, improve coordination, and reduce duplication of efforts to better meet the challenges of AD/ADRD. The activities included in the inventory comprise ongoing work and new opportunities created legislation and authority. The federal working group process continues to improve coordination and awareness throughout the Federal Government and set in motion commitments for further collaboration. Further, this process has allowed for identification of non-AD-specific programs and resources that may be leveraged to advance AD/ADRD care and prevention.
    13. Support Public-Private Partnerships. The scope of the problem of AD/ADRD is so great that partnerships with a multitude of public and private stakeholders are essential to making progress. The original National Plan began the partnership process by identifying areas of need and opportunity. The plan continues to rely on the Advisory Council in particular to identify key areas where public-private partnerships can improve outcomes.
    14. Transform the Way We Approach Alzheimer's Disease and Related Dementias. The National Plan recognizes that this undertaking will require continued, large-scale, coordinated efforts across the public and private sectors. With principles 1 and 2 above, as well as the ambitious vision that the Federal Government has committed to through this plan, HHS and its federal partners seek to take the first of many transformative actions that will be needed to address these diseases. Through an ongoing dialogue with the Advisory Council, the Federal Government continues to identify the most promising areas for progress and marshal resources from both within and outside the government to act on these opportunities.

    Achieving the vision of eliminating the burden of AD/ADRD starts with concrete goals. Below are the five that form the foundation of the National Plan:
    15. Prevent and Effectively Treat Alzheimer's Disease and Related Dementias by 2025.
    16. Enhance Care Quality and Efficiency.
    17. Expand Supports for People with Alzheimer's Disease and Related Dementias and their Families.
    18. Enhance Public Awareness and Engagement.
    19. Track Progress and Drive Improvement.

    2017 UPDATE
    This is the 2017 Update to the National Plan. In order to create a focused and accessible document, agencies have provided narrative descriptions of activities that were completed in 2016, as well as some which are ongoing and have updates. This provides a clear report of progress that was made since the last plan update in August 2016. For more information about ongoing or previously completed projects, please consult Appendix 3: Implementation Milestones.
    The activities outlined in this National Plan Update vary in scope and impact, and include:
     Immediate actions that the Federal Government has taken and will take;
     Actions toward the goals that can be initiated by the Federal Government or its public and private partners in the near term; and
     Longer-range activities that will require numerous actions by federal and non-federal partners to achieve.

    The National Plan was never designed to be a "Federal Plan". The 2017 Plan Update includes a number of activities and projects submitted by non-federal partners. These items have been organized according to the Goals and Strategies in the Plan. Active engagement of public and private sector stakeholders is critical to achieving these national goals. In the case of many of the long-range activities, the path forward will be contingent upon resources, scientific progress, and focused collaborations across many partners. Over time, HHS will work with the Advisory Council and stakeholders to incorporate and update additional transformative actions.
    Additionally, in an effort to clearly respond to the annual recommendations made by the non-federal members of the Advisory Council, the 2017 National Plan Update includes an appendix (Appendix 2) in which relevant federal agencies have briefly responded to the recommendations made by the Advisory Council. Fulfilling the recommendations is contingent on limitations on legislative authority, resources, and data among the federal agencies and the Federal Government, and this appendix makes clear which recommendations have been addressed and which would require congressional authority or additional resources.


     Research continues to expand our understanding of the causes of, treatments for, and prevention of AD/ADRD. Goal 1 seeks to develop effective prevention and treatment modalities by 2025. Ongoing research and clinical inquiry can inform our ability to delay onset of AD/ADRD, minimize its symptoms, and delay its progression. Under this goal, HHS will prioritize and accelerate the pace of scientific research and ensure that as evidence-based solutions are identified and quickly translated, put into practice, and brought to scale so that individuals with AD/ADRD can benefit from increases in scientific knowledge. HHS will identify interim milestones and set ambitious deadlines for achieving these milestones in order to meet this goal.
    In 2016/2017, Goal 1 showed substantial progress across a spectrum of research areas, thanks to the continued support from our national leadership and the American public, the dedication of study volunteers and their families and caregivers, and the valued work of clinicians and scientists.
    Federal funding devoted to AD/ADRD research has expanded over the past several years, reflecting intensified national interest in finding ways to treat these devastating diseases. The National Institutes of Health (NIH) played a lead role by redirecting $50 million in funding in fiscal year (FY) 2012 and allocating $40 million in FY 2013 to promising avenues of AD/ADRD research. Federal appropriations increases to the NIH budget by $100 million in FY 2014 and $25 million in FY 2015, primarily directed toward AD/ADRD research, were also approved. However, the biggest increases in funding came in FY 2016 and FY 2017, following Congressional passage of the Consolidated Appropriations Act 2016 (P.L. 114-113) and the Consolidated Appropriations Act, 2017 (P.L. 115-31). The FY 2016 appropriations directed an unprecedented additional $350 million toward AD/ADRD research, with an additional $400 million provided for this research in FY 2017; increasing overall NIH funding from Congress for AD/ADRD research by $912 million from FY 2012 to FY 2017. In FY 2017 alone, NIH estimates spending $1.4 billion on AD/ADRD research. This enormous infusion of resources enabled the launch and expansion of research programs and invigorated investigator-initiated research, further accelerating progress towards the Plan's ultimate research goal: finding effective interventions to treat or prevent AD/ADRD by 2025. [See]
    NIH was already poised to integrate the extraordinary new funds into its research portfolio. In July 2015, NIH released the first of what is now an annual professional judgment budget for Congress -- and the American people -- estimating the costs of accomplishing the research goals of the National Plan to Address Alzheimer's Disease. This report is known as a "bypass budget" because of its direct transmission to the President and subsequently to Congress without modification through the normal federal budget process. The most recent estimate, submitted in July 2017, outlines funding needs for the most promising research approaches for FY 2019. [See]
    The NIH will continue to prepare these estimates through FY 2025. Only two other areas of biomedical research have previously been the subject of this special budget approach: cancer and HIV/AIDS. [See]
    Planning for the annual bypass budget and NIH's current AD/ADRD research portfolio are informed by research implementation milestones based on recommendations for AD/ADRD developed at a series of the NIH-convened research summits (described below). [See;; and]


     Alzheimer's Disease Research Summit Advances Research Agenda. In February 2015, the NIH Alzheimer's Disease Research Summit 2015: Path to Treatment and Preventionexpanded on the research agenda set in place at the first of such summits held in 2012. The 2015 gathering brought hundreds of experts in AD and other chronic diseases together to identify critical knowledge gaps and set priorities for the kinds of new resources, infrastructure, and multi-stakeholder partnerships needed to fully realize emerging research opportunities. The next Alzheimer's Disease Research Summit, taking place in March 2018 as well as a summit in 2017 to address care and services research will include national and international experts, research funders, public and private stakeholders, and members of the National Advisory Council on Aging. Summit proceedings will be open to the public and recommendations developed out of the meeting will inform priority setting at NIH and other federal agencies.
    For more information, see:
    2016 Summit on Alzheimer's Disease-Related Dementias (ADRD) Research. NIH also hosted the Alzheimer's Disease-Related Dementias 2016 Summit in March 2016 to update the recommendations on national research priorities for FTD, LBD, multiple etiology dementia, vascular contributions to cognitive impairment and dementia (VCID), and health disparities in dementia that came out of the 2013 ADRD Summit. The meeting drew hundreds of experts across diverse fields of dementia research as well as advocates, patients, and caregivers. Their goals were to review and update recommendations based on scientific progress, to prioritize the important scientific questions that need to be answered to advance our understanding of these complex disorders, and to identify how federal and non-governmental organizations (NGOs) can further and most effectively collaborate to address these research priorities. Final recommendations from the meeting were approved by the National Advisory Neurological Disorders and Stroke Council in September 2016, and then were developed as ADRD prioritized research milestones, which were presented at the NAPA Advisory Council in February 2017. These milestones guide NIH's ADRD research priorities and help track progress toward the goal of preventing and effectively treating AD/ADRD by 2025.
    For more information, see:

     Investigator-Initiated Research. In 2016, investigator-initiated research offered new insights into the complex molecular, biological and genetic factors that influence disease onset and progression. This work expands our basic understanding of AD/ADRD.
    Collaborating on Drug Targets. Accelerating Medicines Partnership - Alzheimer's Disease (AMP-AD) is part of the Accelerating Medicines Partnership (AMP), a bold venture among the NIH, ten biopharmaceutical companies, and several non-profit organizations aiming to identify and validate the most promising biological targets of disease for new diagnostic and drug development. To date, over 100 novel candidate targets have been identified and are being evaluated in collaboration with industry partners.
    For more information, see:
    Promising Drugs to Treat or Prevent Alzheimer's Disease. Currently over 50 National Institute on Aging (NIA)-supported clinical trials for AD/ADRD treatment and prevention are underway. In addition, NIH supports about 80 projects aiming to discover and develop new therapeutics for AD/ADRD.
    Identifying Genetic Risk and Prevention Factors. NIH funds cutting-edge research into the genetic underpinnings of AD/ADRD, analyzing how genome sequences -- the order of nucleotides in a cell's DNA -- may contribute to increased risk or protect against the disease. The ultimate goal is to find new pathways for treatments and prevention.
    The Alzheimer's Disease Sequencing Project (ADSP) generated three sets of data in the Discovery Phase to determine the order of all 3 billion letters of individual genomes: (1) Whole-genome sequence (WGS) for 584 participants; (2) Whole Exome Sequence (WES) for ~5,000 each of AD cases and controls; and (3) WES of an enriched sample set comprised of over 800 AD cases from multiply affected families and 171 Hispanic controls. In 2016, the ADSP completed the sequencing for the next phase of the project, the Discovery Extension Phase, which has two components: (1) the ADSP Discovery Family-Based Extension Study: To further assess the genomes in multiply affected families; and (2) the ADSP Discovery Case-Control Based Extension Study: To increase the diversity of sample sets. The total number of WGS available for analysis is now well over 4,000. Additional NIA-funded studies that are sharing their data with the ADSP bring that total close to 7,000 whole-genomes.
    By 2016, using a combination of genetic analysis approaches, more than two dozen genetic regions of interest had been identified that play a role in AD risk. The specific regions are now being closely examined to determine what genes and cellular pathways are involved.
    The NIA Genetics of Alzheimer's Disease Data Storage Site (NIAGADS) was established to share genetic/genomic and phenotypic data with the research community. In 2016, they responded to data requests from 60 labs at 43 institutions in order to facilitate the sharing of sequence data with the genetics community. NIAGADS has established several data and information technology resources for the research community at-large, and provides a web user interface that integrates AD/ADRD genetic findings with other genetic data for rapid analysis of the sequence data.
    Also in 2016, NIA funded the Genomic Center for Alzheimer's Disease (GCAD). The mission of this Center is to identify genetic variants that cause or influence risk, or protect against AD, and to identify the underlying genes affected by these variants. Its goals are to facilitate AD gene discovery, harmonize all ADSP sequence and genetic and phenotypic data, and to coordinate ADSP data analysis. To date the sequence data for more than 4,000 subjects has been quality control checked and harmonized.
    For more information, see:
    Genes for Healthy Aging. In 2016, a group of NIH-supported scientists found that genes that promote cognitive health may also help protect against chronic disease of old age, including AD. The "Wellderly" study focused on exceptional individuals from across the United States aged 80-105 who had not developed any chronic medical condition or diseases, including heart disease, cancer, stroke, stroke, AD, Parkinson's disease, or diabetes. In genome-wide association study analyses, two of the top three hits associated with healthy aging were genes previously linked to cognitive function, suggesting that protection against cognitive decline contributes to healthy aging. This is the first large WGS study to focus on health rather than disease. Future studies of this kind will likely reveal additional genes and drug targets that could help protect against AD and other chronic diseases of old age.
    For more information, see:
    Testing Therapies at Earliest Stages of Alzheimer's Disease. Several NIA-supported clinical trials are testing new paradigms about when the disease starts, and if intervening in symptom-free but at-risk people in the earliest stages of the disease might forestall symptoms and delay progression. In 2014, recruitment began for the Anti-Amyloid Treatment in Asymptomatic Alzheimer's study, which is testing the drug solanezumab in 1,000 cognitively normal volunteers, age 65-85, who through imaging have been shown to have enough of the amyloid protein in the brain to put them at-risk for developing AD, but do not show clinical symptoms of the disease. This study is still actively recruiting participants. Another trial, the Generation Study, launched in early 2016, will test whether two drugs targeting amyloid, CAD106 and CNP520, can prevent or delay AD/ADRD symptoms in symptom-free older volunteers at high genetic risk for the disease. Recruitment continues for over 1,000 volunteers who carry two copies of the APOE e4 allele, a gene risk factor for Late-Onset Alzheimer's Disease (LOAD).
    For more information, see:
    A Genetic Connection between Immunity and Alzheimer's. In 2016, a group of researchers supported by the NIH found that Alzheimer's disease shares biological mechanisms with autoimmune diseases. The team used a new genetic approach to analyze data from 17,008 people with AD and 37,154 age-matched controls from four consortia in Europe and North America. The team identified two autoimmune disease-linked genetic alterations that increased AD risk. The first alteration has been linked to psoriasis, while the second has been linked to both Crohn's disease and inflammatory bowel disease (IBD). The genetic variation linked to Crohn's and IBD correlated with a 50% faster rate of cognitive decline in people with AD, mild cognitive impairment (MCI), and in healthy controls. This discovery adds to the mounting evidence that the immune system plays a key role in the development of AD.
    For more information, see:
    Lifestyle Alzheimer's Disease Prevention. NIH is studying whether lifestyle interventions, such as diet, exercise, and cognitive enrichment, may be preventive interventions for cognitive decline and AD. Currently, a number of NIH-funded clinical trials are underway to test whether exercise can influence AD onset and progression. For example, one active study is currently recruiting participants and using brain imaging and cognitive measures to investigate the effects of cycling on cognition and hippocampal volume.
    NIA has recently funded the Exercise in Adults with Mild Memory Problems (EXERT) trial to test whether moderate/high aerobic exercise and stretching can slow the progression of MCI to AD in adults over 65. This 18-month long trial is actively recruiting participants.
    For more information, see:
    Discovering the Molecular, Cellular, and Genetic Causes of Alzheimer's Disease and Related Dementias. NIH funds a broad range of research to understand the underlying causes of dementia, which is an important first step for developing new treatments and prevention strategies. To better understand the vascular contributions to AD/ADRD, NIH launched the Molecular Mechanisms of the Vascular Etiology of Alzheimer's Disease Consortium (M2OVE-AD) in March 2016. The 5-year, $30 million program brings together over a dozen research teams working on five complementary projects. Scientists from diverse fields using the latest methodologies will work collaboratively towards shared goals: to dissect the complex molecular mechanisms by which vascular risk factors influence AD/ADRD and identify new targets for treatment and prevention.
    In the fall of 2016, NIH added a new team to the M2OVE-AD Consortium to zero in on the how sex differences impact the trajectory of the disease; with the largest current study of gene expression mechanisms in postmortem human brains in AD. It is hoped that this closer look at the sex differences in disease progression can provide major insights related to the overall understanding of AD biology, and help direct us toward new drugs targeted specifically for women or men at-risk for dementia.
    Recently, NIH-funded scientists have found links between cerebrovascular diseases, cognition, and brain aging by using data from large population studies, and are exploring new targets and strategies to reduce FTD-related pathologies. In addition, researchers identified a role of tau pathology in LBD, and are developing animal models to study genetic causes of LBD.
    In addition to continuing support for investigator-initiated research, in 2016, NIH released requests for applications (RFAs) to stimulate research on how to better study and diagnose small vessel disease in the brain as it relates to cognitive decline and dementia, and created a new cross-disciplinary program to investigate the molecular mechanisms of tau toxicity in FTD. In 2017, NIH released a new ADRD funding opportunity to create the FTD Sequencing Consortium that would support WGS and replication studies to find and validate new risk genes for FTD.
    For more information, see:
    Bridging the Preclinical to Clinical Development Gap. In 2017, NIH launched the Model Organism Development and Evaluation for Late-onset AD, an initiative that will create the next generation of mouse models to be used in preclinical efficacy testing of candidate therapeutics. The new models will be based on newly identified LOAD risk genes and will undergo extensive molecular, pathological and clinical staging to align the pathologic features in mice with corresponding stages of human disease.
    For more information, see:
    Addressing Health Disparities. Race and ethnicity, and socioeconomic status can influence AD/ADRD risk and outcomes. To identify and better understand biological, behavioral, sociocultural and environmental factors that influence health differences, NIH is supporting several new research efforts: some researchers will focus on improved recruitment and cognition assessment tools for health disparities, while others examine disparities in access to and use of LTSS, which includes institutional care and HCBS, for persons with dementia. A primary goal is to develop treatment and prevention strategies that are effective and culturally appropriate among diverse populations.
    One recent study, for example, looked at possible genetic influences that might explain differences in AD prevalence among African Americans and non-Hispanic Whites. Researchers found an increased genetic risk for AD in African Americans due to variations in a gene for the brain's system for clearing out beta-amyloid protein fragments. The team confirmed that this deletion mutation was associated with increased AD risk in two large African American populations, but found the mutation virtually absent in samples from over 3,000 non-Hispanic Whites.
    For more information, see:
    NIA Enhances Information on Alzheimer's Clinical Trials Participation. NIA continues to promote participation in AD/ADRD clinical trials, studies, and registries through our Alzheimer's Disease Education and Referral (ADEAR) website portal; clinical trials listing and monthly e-alert to more than 35,000 subscribers; social media messages through Facebook and Twitter; promotion of the Recruiting Older Adults into Research (ROAR) toolkit of customizable materials for aging services and public health professionals to use in community settings and social media in English, Spanish, and Chinese, and collaboration with the Administration for Community Living (ACL), Centers for Disease Control and Prevention (CDC), Food and Drug Administration (FDA) and the Patient-Centered Outcomes Research Institute (PCORI)-funded Alzheimer's and Dementia Patient/Caregiver-Powered Research Network to encourage research participation among older adults.
    For more information, see:
    Developing a National Recruitment Strategy. With substantial community and stakeholder involvement, NIA is leading efforts to provide practical approaches to help study sites and researchers overcome the challenges and barriers in recruiting and retaining the right volunteers, at the right times, in the right studies. In facilitation with the Alzheimer's Association and collaboration with government, private, and academic stakeholders, NIA is developing the National Strategy for Recruitment and Participation in Alzheimer's Disease Clinical Research. In 2017, NIA convened a workshop for experts from academia, communications, advocacy, and clinical care and research to identify the best strategies for engaging a range of audiences, including minority and underrepresented groups, in the clinical research enterprise.
    VA Targets Dementia Research. The U.S. Department of Veterans Affairs (VA) Office of Research and Development (ORD) has ongoing specialty AD RFAs for biomedical laboratory or clinical research to include FTD, LBD, and/or VCID in addition to AD/ADRD.
    VA Collaborates with NIA. VA/ORD and NIA have initiated the Strategic Partnership to Advance Research and Knowledge, which is a joint VA-NIA cooperative partnership of shared dementia research priorities with the goal to develop and implement a sustainable framework to facilitate supportive resources and co-funding.
    Frontotemporal Degeneration Disorders Registry. The FTD Disorders Registry LLC (FTDDR) is an independent non-profit entity co-founded by the Association for Frontotemporal Degeneration (AFTD) and the Bluefield Project for the Cure. The shared vision for a patient registry to serve the frontotemporal disorders community was realized with the formal design, build, and beta testing of the web interface occurring throughout 2016. The FTDDR is a Contact and Research Registry, where research recruitment is initially focused in the United States and Canada, while Contract Registry enrollment is international. The Registry welcomes persons diagnosed with FTD, their caregivers, family and friends to join. Research participation is primarily comprised of data collection via online surveys; de-identified data will be cultivated, aggregated and analyzed. This dynamic online database will function as the central resource for the lay community and the research/development community with overriding objectives to support research, clinical trial recruitment, and drug development. Spring 2017 marks the formal FTDDR public launch.
    For more information, see:
    Treat Frontotemporal Degeneration. In May 2016, the Alzheimer's Drug Discovery Foundation (ADDF) and AFTD launched the Treat FTD Fund to support clinical trials testing novel or repurposed drugs for FTD and related disorders (bvFTD, PPA, PSP, CBD, FTD/ALS). The Treat FTD Fund will build on recent successes of both foundations in early-stage drug discovery and biomarker development, and leverages new ongoing efforts under development by AFTD such as the recently launched FTDDR and a $5 million FTD Biomarker Initiative. Running clinical trials in FTD patients will help investigators learn how best to target this unique patient population and will employ advances in biomarkers as they develop. Through this partnership, ADDF and AFTD propose to invest $10 million over 10 years to fund at least five innovative clinical trials subject to review by an appointed Joint Steering Committee.
    For more information, see:
    Lewy Body Dementia Patient Engagement. The Lewy Body Dementia Association (LBDA) launched a new initiative to help drive participation in clinical research studies. This multi-pronged initiative included a webinar about participating in clinical trials, a new section on LBDA's website about new studies and clinical trials, and social media and email campaigns.
    For more information, see:
    Patient-Powered and Caregiver-Powered Research. UsAgainstAlzheimer's has partnered with the Mayo Clinic, University of California, San Francisco, and University of Florida in the Alzheimer's Disease Patient and Caregiver-Powered Network (AD-PCPRN), funded by PCORI. The project's goal is to accelerate development of effective treatments of AD/ADRD. It is intended to connect patients, caregivers and researchers focused on developing, conducting and disseminating patient-centered dementia research. Through the GALAXY platform developed with UsAgainstAlzheimer's, the AD-PCPRN provides potential clinical trial participants a brief assessment aid powered by Roobrik to map a course of action and a trial matching service, powered by Antidote. The AD-PCPRN is governed by a Governance Council of leaders in AD, advocacy, caregiving and other areas. Providing insights to the Governance Council are four Advisory Councils, whose nearly 45 members include leaders in the AD patient/caregiver community, communications and outreach, diversity outreach and research, and registries/clinical trials.
    Screening for Dementia in Persons with Intellectual and Developmental Disabilities (IDD). The National Institute on Disabilities, Independent Living, and Rehabilitation Research (NIDILRR) is funding a study, led by Dr. Peter Blanck of Syracuse University that is examining cognitive status of older African Americans with IDD with a goal of learning more about the impact of dementia on long-term outcomes and quality of life. In addition, Dr. Matt Janicki and his colleagues at the University of Illinois, Chicago's NIDILRR funded Research and Training Center on Aging with Developmental Disabilities, have produced a rich body of knowledge about cognitive decline and dementia in persons with IDD. Their work includes a useful instrument for detecting early-onset and presence of dementia in persons with IDD.
    For more information, see:

     Strengthening Clinical Trials with Neuroimaging. The Alzheimer's Disease Neuroimaging Initiative (ADNI), initially launched by NIH in 2004 as a landmark public-private partnership, looks at how evolution of clinical symptoms and neurocognitive testing in healthy controls, people with MCI, and people with mild AD, correlates with changes in multiple biomarkers reflecting disease development. In 2016, ADNI moved into a critical new phase of discovery with ADNI3. With $40 million in NIH funding support over the next 5 years, plus an anticipated $20 million in private sector investment, the new effort will add brain scans that detect the amount and location of tau protein tangles -- a second hallmark of AD -- with ongoing collection of initial study neuroimaging and biofluid biomarkers.
    For more information, see:
    Collaborating on Biomarker Research. One of the primary goals of the previously-noted AMP is to identify and characterize biomarkers and targets for intervention. The AMP-AD Biomarkers Project is a consortium of three NIA-supported Phase II/III secondary prevention trials testing several anti-amyloid therapies. Imaging and fluid biomarker panels already included in these trials will be supplemented with tau PET imaging and novel fluid biomarkers. Screening and baseline data from the trials will be made broadly available through the Global Alzheimer's Association Interactive Network collaborative platform. Trial data and biological samples will also be shared after completion of the trials.
    For more information, see:
    Identifying Biomarker Trajectories Over Time. In late 2015, NIH launched a new initiative to identify biomarkers and track the progression of AD in people with Down syndrome. Costing an estimated $37 million over 5 years, the NIH Alzheimer's Biomarker Consortium-Down Syndrome is supporting teams of researchers using brain imaging, including amyloid and tau PET, fluid and tissue biomarkers, as well as neuropsychological measures in research that may one day lead to effective interventions for all people with dementia. Two research teams are working collaboratively to identify and track AD-related changes in the brain and cognition of over 500 Down syndrome volunteers, aged 25 and older.
    For more information, see:
    Discovering Biomarkers for Alzheimer's Disease and Related Dementias. In addition to its ongoing support of several large collaborative projects and consortia that seek to discover biomarkers for FTD, NIH is supporting three programs that aim to discover and/or develop biomarkers for small vessel disease in the brain and LBD:
     In 2016, NIH established a small vessel VCID Biomarkers Consortium (MarkVCID), which consists of seven biomarker development project sites and one coordinating center across the United States, to develop and validate candidate human biomarkers for small vessel disease in the brain. The 5-year program's overall goal is to deliver high-quality biomarkers ready for use in clinical trials.
     NIH is supporting longitudinal studies that leverage the existing Parkinson's disease Biomarkers Program (PDBP) infrastructure to discover biomarkers for LBD. These studies began enrollment in March 2017 and will enroll 590 participants with clinical follow-up and biospecimen collection.
     In 2017, NIH solicited LBD projects that could lead to early diagnosis, improved differential diagnosis, and/or discovery of new therapeutic targets. Funded projects would utilize existing data and biospecimens from the PDBP and ADNI/National Alzheimer's Coordinating Center databases to study unique clinical or biological characteristics of LBD patients.

    For more information, see:
    Early Detection of Cognitive Impairment, including Dementias, in Everyday Clinical Settings. Diagnostic tools for AD/ADRD that are accurate and reliable are crucial not only in guiding clinical care and developing a long-term care plan, but also in facilitating clinical research and recruiting the right subset of participants to clinical trials. To address the unmet need for early detection of cognitive impairment and dementia when a patient, relative, or care provider voices a concern in primary care settings, NIH released a new funding opportunity in early 2017 to develop easy-to-use diagnostic tests or tools that are standardized and take 5 minutes or less to administer in everyday clinical settings.
    For more information, see:
    Frontotemporal Degeneration Biomarkers Initiative. In January 2017, AFTD proudly announced the recipients of the first six awards funded through its major new funding opportunity, the FTD Biomarkers Initiative. Through 2018, AFTD anticipates awarding up to $5 million to support innovative approaches to the discovery and development of biomarkers that differentiate FTD from other neurodegenerative disorders, discriminate between FTD subtypes, identify underlying molecular pathologies, confirm pharmacodynamic modulation of disease pathways and track disease progression. A key feature of the initiative is the requirement for award recipients to commit to the open exchange of data and results. The FTD Biomarkers Initiative has been made possible by a generous multi-year donation from the Samuel I. Newhouse Foundation.
    For more information, see:
    Comprehensive Lewy Body Dementia Symptoms Checklist. LBDA's free, downloadable Comprehensive LBD Symptoms Checklist was used in a recent study by researchers at Newcastle University in the United Kingdom to tease out what symptoms of dementia with Lewy bodies (DLB) may aid in the early diagnosis during the MCI stage. Ten early symptoms were identified, with a score of 2 or more strongly suggesting MCI-DLB.
    For more information, see:

     Innovative Planning Tool Expanded. The International Alzheimer's Disease Research Portfolio (IADRP) -- a free, searchable database providing a global overview of AD research and funding -- is an invaluable tool for assessing and planning AD research projects. Funding organizations, researchers, and advocates are discovering IADRP's merits to help them coordinate strategies, leverage resources, avoid duplication, and identify promising areas of growth. Since NIH launched the database in 2012, in collaboration with the Alzheimer's Association, IADRP has amassed data on nearly 7,000 unique projects from 2008 through 2016, reflecting more than $5.7 billion in research funding worldwide. The number of contributors is growing, too. During the past 5 years, more than 35 funding organizations across 11 countries have joined the IADRP effort.The Common Alzheimer's Disease Research Ontology used in IADRP is also undergoing a significant update to the topic and themes that are used to categorize AD and ADRD funding data. The changes will reflect current research investment, as well as highlight emerging areas of science.
    For more information, see:
    Dementia with Lewy Bodies Consortium Annual Meeting. The first annual meeting of the newly createdDementia with Lewy Bodies (DLB) Consortium was held in early 2017. The funding for the consortium comes from NIH, NIA and the National Institute of Neurological Disorders and Stroke (NINDS), and the annual meeting is funded by the LBDA. This Consortium fills a vital gap in LBD research infrastructure.
    For more information, see:
    Late-Stage Alzheimer's Drug Pipeline. In March 2016, the UsAgainstAlzheimer's network ResearchersAgainstAlzheimer's (RA2) released an analysis of AD drugs in Phase 3 clinical trials and, in September 2016, an analysis of Phase 2 drugs. These reports described to patients, caregivers and researchers the drugs that could potentially reach the market in the next 5 years and explored whether our health care system would be ready for them. RA2 presented an updated report on Phase 2 and Phase 3 drugs in development at the Alzheimer's Association International Conference (AAIC) in London in July 2017.
    Global Alzheimer's Platform Updates. In October 2016, the Global Alzheimer's Platform (GAP) Foundation fully implemented its novel recruitment model to increase referrals to the University of Kansas Alzheimer's Disease Center (KU ADC) through the establishment of the Memory Strings Kansas City Alliance. The model strives to develop and support a community-wide culture to support AD trials and continually drive appropriate referrals to research centers in the GAP network. Key local Alliance members include committed principal investigators; health care professionals and health insurers; community-based organizations that support African Americans and Latinos; federal, state and local government officials; leaders of commercial entities, non-government organizations, and respected individuals; and those interested in funding local research efforts. The Alliance focus on primarily activating primary care physicians has produced encouraging results: Q4 2016 referrals were up 200% at KU ADC and enrollments were up 150% when compared to Q4 2015 results. GAP has committed to roll-out this model in four more communities is 2017. GAP is building a global network of optimized clinical trial sites -- now numbering nearly 50 -- that are certified to meet industry-accepted quality and performance criteria.

     Reporting Research Findings. NIA operates the ADEAR Center, the primary Federal Government resource for information about AD/ADRD, research, and caregiving. The ADEAR Center educates the public about the latest research findings and clinical trial participation via free, evidence-based information available online and in print. In addition, NIA disseminates research findings through the media, social media, and annual research progress reports.
    For more information, see:
    Resources for the Dementia Services Community. The interagency ROAR (NIH, ACL, CDC) group hosted an update in the popular webinar series in 2017 for professionals on AD/ADRD resources that drew 500+ participants and offered continuing education credit. Free continuing education is available to professionals who need it when they view recorded webinars from 2017 and earlier series. This continuing education is available through 2018.
    For more information, see:
    Exploring the Evidence for Prevention. In 2015, NIH initiated a project involving the Agency for Healthcare Research and Quality (AHRQ), and the National Academies of Sciences, Engineering, and Medicine (NASEM), to conduct a systematic review of the evidence on prevention of clinical AD-type dementia, MCI, and age-related cognitive decline (AHRQ), and to shape these findings into a set of recommendations for public health practice and research (NASEM). This effort is driven by the intense interest in recent years -- in the United States and internationally -- to identify ways to reduce the risk for cognitive decline and AD/ADRD. Ultimately, the effectiveness of 13 interventions was explored by the Minnesota Evidence-based Practice Center (supported by AHRQ). While most interventions showed no evidence of benefit to delay cognitive decline or AD; some forms of cognitive training were found to improve performance on specific tasks, though the transfer of benefits to other cognitive areas may be limited. A review of the available evidence also showed that some types of physical activity, and vitamin B12 plus folic acid may benefit cognitive performance in some areas for adults with normal cognition. A report from NASEM detailing recommendations for public health messaging based on these findings was released in June 2017.
    For more information see:

     High-quality care for people with AD/ADRD requires an adequate supply of culturally-competent professionals with appropriate skills, ranging from direct care workers to community health and social workers, to HCBS providers, to primary care providers and specialists. High-quality care should be provided from the point of diagnosis onward in settings including doctor's offices, hospitals, people's homes and nursing homes. Person-centered quality should be measured accurately and inter-operably across all settings of care, coupled with quality improvement tools. Further, care should address the complex care needs that persons with AD/ADRD have due to the physical, cognitive, emotional, and behavioral symptoms of the disease and any co-occurring chronic conditions. High-quality and efficient care often depends on: (1) smooth transitions between care settings; (2) coordination among health care and LTSS providers; and (3) dementia-capable health care.


     Person-Centered Counseling Training Program. HHS promotes person-centered planning and self-direction, where people receiving HCBS are empowered to have more control and direction over the HCBS they receive. ACL completed its development of a six-course training program for person-centered planning and counseling. The program addresses cognitive disabilities and dementia in each of the following courses:
    1. Introduction to the "No Wrong Door" System.
    2. Introduction to Person-Centered Planning.
    3. Person-Centered Planning and Implementation.
    4. Introduction to the Long-Term Services and Supports System.
    5. Who We Serve.
    6. Protection and Advocacy.

     Each of these courses trains front line Person-Centered Counseling Professionals in the skills necessary to assist older adults who need supports and people with disabilities in reaching their goals for community living in a respectful and dignified manner. Each course teaches the learner how to use specific tools to interact with each person in a way that gives him or her control over the goal-setting process, and helps foster the development of meaningful and trusting relationships. Pilot-testing of the training program is occurring in 2017 in 13 states.
     For more information, see:
    Dementia-Specific Guidelines and Curricula. Completed in November 2015, the Health Resources and Services Administration (HRSA) created and disseminated a repository of dementia curricula and practice guidelines for providers across the care continuum, including physicians, nurses, social workers, psychologists, other health care professionals, direct care workers, and informal caregivers. The repository is hosted on the HRSA website.
    For more information, see:
    Healthy Brain Initiative. The CDC Healthy Brain Initiative (HBI) began in 2005 through a congressional appropriation that established the AD-specific segment of the Healthy Aging Program. The HBI addresses cognitive health from a public health perspective to catalyze action at the state and local level. The Healthy Brain Initiative: The Public Health Road Map for State and National Partnerships, 2013-2018, the second in the Road Map series, was released in 2013. This Road Map, which was designed to complement the National Plan, identifies 35 actions that state and local public health agencies and their partners can implement to promote cognitive health and address cognitive impairment and the needs of caregivers. CDC's funded partners are integral to accomplishing these actions, the Alzheimer's Association, the Balm in Gilead, and the Healthy Brain Research Network (HBRN) (a consortium of six Prevention Resource Centers). The 2013-2015 Interim Progress Report, and the corresponding Dissemination Guide, released in late 2015, highlight selected HBI Road Map accomplishments and future directions.
    For more information, see:
    Implemented Road Map Actions in States. CDC supported a successful collaboration with the Alzheimer's Association in September 2015-September 2020 to implement a Road Map for action on care and services in several states. In FYs 2014-2017, CDC provided supplemental funds to support cognitive decline and caregiver surveillance through the Behavioral Risk Factor Surveillance System (BRFSS) in states. In 2015 and 2016, 51 states and territories participated in the cognitive decline module and 40 with the caregiver module. CDC also supported the Association of State and Territorial Health Officials and the National Association of Chronic Disease Directors to implement priority action items from the HBI Road Map of particular significance to their constituencies in select states across the United States. A major focus of CDC's efforts to support the actions of the HBI Road Map and the Healthy People 2020 objectives related to dementia is to "educate and empower the nation." To meet that challenge, CDC initiated a number of special interest projects within the CDC Prevention Research Center (PRC) program.
    For more information, see:
    Public Health and Economic Costs. CDC funded a project designed to promote public health understanding regarding the economic costs associated with AD/ADRD by examining different economic models to estimate community and inpatient care, as well as the societal costs associated with losses of productivity and quality of life by persons living with AD/ADRD and their caregivers. The University of Washington PRC began conducting a review of the literature and will examine de-identified data from the Group Health Cooperative to calculate costs and make recommendations for improvement to allow states and localities to better forecast dementia care costs.
    Curriculum for Use in Schools of Public Health. CDC supported the development of A Public Health Approach to Alzheimer's and Other Dementias, a new curricular resource developed by the Centers for Technical Assistance and Training in the Emory University's Rollins School of Public Health. This flexible, introductory curriculum will help faculty prepare undergraduates for careers in which they need to apply public health approaches to address AD as a multi-layered, growing public health challenge. The Centers mapped the curriculum to established competencies.
    The modular design enables use in entirety or as stand-alone modules. Each module has a slide set and faculty guide with learning objectives, list of relevant competencies, talking points, and teaching aids. Microsoft Office formats enable users to adapt materials for integration into existing undergraduate courses or other educational offerings.
    For more information, see:
    Oregon Dementia Training for Alzheimer's Disease and Related Dementias Staff. With funding from an ACL Alzheimer's Disease Supportive Services Program (ADSSP) grant, Oregon was able to provide dementia training for over 600 statewide Aging and Disability Resource Center (ADRC) Information and Assistance and Options Counseling staff. Nine online modules were developed to address ADRC staff roles in addressing issues including person-centered care for people with dementia, communication, information and referral options, decision support for people and families, care transitions, advance planning, and specific needs for people with IDD. The training is part of Oregon's efforts to increase dementia-capability of its ADRC system and statewide LTSS.
    Educate Health Care Providers. HRSA, in collaboration with the HHS Office on Women's Health (OWH), supported the development of a Medscape continuing education course on assessing, managing, and treating AD/ADRD in the context of multiple chronic conditions. This educational offering, titled "Bidirectional Impact of Alzheimer's Disease and Common Comorbid Conditions" was released in September 2016. A total of 7,107 learners accessed the site in the first 6 months.
    In FY 2015, HRSA combined and redesigned its four geriatrics programs into the Geriatrics Workforce Enhancement Program (GWEP). The GWEP supports transforming clinical training environments by developing a health care workforce that maximizes patient and family engagement to improve health outcomes for older adults by integrating geriatrics with primary care. The GWEP aims to provide the primary care workforce with the knowledge and skills to care for older adults by collaborating with community partners to address gaps in health care for older adults through individual, system, community, and population-level changes. In addition, the GWEP also supports training of patients, families, caregivers, direct care workers, health professions providers, students, residents, and fellows who will provide health care to older adults, and the faculty who train these individuals.
    All GWEP awardees identified significant needs for dementia training. In FY 2017, HRSA supported 44 GWEP awardees totaling approximately $38.7 million; $5.978 million was used to provide dementia education and training. In FY 2015, GWEP awardees provided 402 continuing education offerings and trained 43,148 participants on AD/ADRD.
    IHS Workforce Partnerships. The Indian Health Service (IHS) initiated a series of partnerships to increase workforce skills and competency in caring for individuals with dementia and their families. IHS has met with HRSA GWEP grantees to discuss opportunities for training in IHS, Tribal, and Rural Indian Health programs. IHS partnered with the VA to introduce VA's Rural Interdisciplinary Team Training (RITT) in small, rural IHS and Tribal facilitates; eight sites were trained in FY 2016- FY 2017 and RITT training will be provided to clinics serving the Aleutian and Pribiloff Islands in August 2017. In October 2015, IHS collaborated with ACL in support of the Banner Alzheimer's Institute Inaugural National Conference on Alzheimer's Disease/Dementia in Native American Communities, bringing together clinical staff, Tribal aging services staff, Tribal leadership, and researchers. In April 2016, IHS held a web-based course on AD/ADRD as part of the IHS Clinical Rounds series. In November 2016, the Banner Institute partnered with ACL, IHS, and the Centers for Medicare & Medicaid Services (CMS) to provide both professional and para-professional training in AD/ADRD as part of a national conference on Tribal Long-Term Services and Supports in Minneapolis, Minnesota.
    VA Geriatric Scholars Toolkit. VA's Geriatric Scholars staff training program has created a Geriatric Scholars Toolkit covering 12 clinical topics in geriatrics, including dementia. Each topic contains two sections: (1) clinical assessment, management, and treatment; and (2) educational materials for patients and their caregivers. More than 2,800 toolkits have been disseminated to VA rural clinics, community living centers (CLCs), program participants, and local and national VA leaders in geriatrics. In addition, more than 330 toolkits have been made available to the public through the federal library system. Toolkit pages or links to information are also available for downloading online; the Toolkits have been viewed over 900 times to date.
    For more information, see:
    VA Rural Interdisciplinary Team Training. The RITT program is a component of the VA Geriatric Scholars Program, through which VA has been delivering on-site education to rural VA clinics since 2010. The VA Employee Education System sponsors accreditation for Continuing Medical Education (CME) credits/Continuing Education Units (CEU). The curriculum focuses on: (1) efficiency and teamwork in primary care to care for older patients; (2) recognizing geriatric syndromes and red flags; (3) distinguishing dementia, delirium and depression; and (4) brief evidence-based tools for cognitive assessment. With funding from the VA Office of Rural Health, 20 sessions will be completed in 2017 and over 100 rural VA Community-Based Outpatient Clinics have participated.
    IHS Rural Interdisciplinary Team Training. The RITT program is a component of the VA Geriatric Scholars Program, which VA has been delivering on-site to IHS and Tribal Health Program (THP) clinics since 2016. The VA Employee Education System sponsors accreditation for CME/CEU, and IHS/THP clinicians are able to receive continuing education credits through the TRAIN platform for interagency sharing of training products. The curriculum focuses on: (1) efficiency and teamwork in primary care to care for older patients; (2) recognizing geriatric syndromes and red flags; (3) distinguishing dementia, delirium and depression; and (4) brief evidence-based tools for cognitive assessment. So far, in 2017, five sessions have been scheduled or completed and others are being planned. The activity is funded by the VA Office of Rural Health.
    Staff Training in Assisted Living Residences-VA in VA Community Living Centers. STAR-VA is an interdisciplinary behavioral approach to managing challenging behaviors among VA CLC (i.e., nursing home) residents with dementia, adapted from Dr. Linda Teri's Staff Training in Assisted Living Residences (STAR) program. The STAR-VA intervention entails four core components: (1) Creating realistic expectations of individuals with dementia; (2) Promoting effective communication with individuals with dementia; (3) Identifying and changing activators and consequences of challenging behaviors (ABCs); and (4) Increasing personally relevant pleasant events through a structured process. In STAR-VA, a CLC mental health professional and registered nurse are trained to train the entire CLC team to collaborate on behavioral assessment and care planning. Between 2010 and 2017, 83 VA CLCs have participated in STAR-VA training. Evaluation outcomes include significant decreases in the frequency and severity of target behaviors and decreased symptoms of depression, anxiety, and agitation among participating veterans.
    For more information, see:
    VA Psychotropic Drug Safety Initiative. VA aims to ensure veterans have access to high-quality, evidence-based pharmacological treatments for mental health and substance use disorders. To this end, in December 2013 the VA's Veterans Health Administration (VHA) launched the Psychotropic Drug Safety Initiative (PDSI), a nationwide psychopharmacology quality improvement program at VA medical facilities. PDSI supports facility and Veterans Integrated Service Network quality improvement initiatives by providing quarterly scores on 35 prescribing performance metrics; informatics tools that identify actionable patients with opportunities for improvement in their care, updated daily; a virtual learning collaborative; technical assistance for quality improvement implementation; and training and educational resources. PDSI Phase 2 (October 2015-June 2017) focused on improving evidence-based prescribing among older veterans in both outpatient and long-term care settings. The four aims for Phase 2 include: (1) improving the quality of prescribing among veterans with dementia by decreasing inappropriate use of antipsychotics and benzodiazepines; (2) decreasing benzodiazepine and sedative hypnotic use; (3) increasing metabolic monitoring among older veterans prescribed an antipsychotic; and (4) decreasing use of highly anticholinergic medications.
    Strengthen State Aging, Public Health, and Intellectual and Developmental Disability Workforces. HRSA GWEP awardees are collaborating with 30 Area Agencies on Aging (AAAs) and 15 Quality Improvement Organizations (QIOs) to strengthen state aging, public health, and IDD workforces. HHS will coordinate with states to develop a workforce in aging, public health, and IDD that is AD-capable and culturally-competent. For example, the Gateway GWEP is partnering with the AAAs throughout Missouri to provide training statewide in Cognitive Stimulation Therapy for individuals with mild-to-moderate dementia. Group participants take part in a number of engaging activities to help stimulate the brain and interact with others in a group atmosphere. An example of a collaboration with a QIO is at the University of Iowa's GWEP, known as the Interprofessional Strategic Healthcare Alliance for Rural Education (iSHARE). iSHARE partners with Telligen, which is providing quality facilitators who document patient outcomes data for iSHARE in the clinics of their primary care partners. Telligen has access to CMS data across several states, and iSHARE and Telligen are working together to determine whether it is possible to promote cross-GWEP partnerships by working on dementia training. If successful, regional/national collaboration may be undertaken as a pilot project.
    Develop and Disseminate a Unified Primary Care Alzheimer's Disease Curriculum. HRSA worked with federal partners at ACL, CDC, CMS, OWH, and VA on a contract to develop a Dementia Curriculum for Health Care Professionals. The curriculum is designed to build a workforce with the skills to provide high-quality care, ensure timely and accurate detection and diagnosis, and identify high-quality dementia care guidelines and measures across care settings. A Technical Expert Panel (TEP) consisting of dementia experts, HRSA and the federal partners identified module topics. Specifically, 16 core modules along with 13 caregiving modules have been developed and pilot-tested. The core modules were built upon the ACT on Alzheimer's preparing Minnesota communities training materials and address various high-priority issues related to the detection, management and treatment of AD. The developed materials are appropriate for guided teaching by faculty in academia and continuing education programs and are appropriate for interprofessional clinical audiences. The caregiver modules development was supported by the OWH. Thirteen modules were produced, four targeted to providers as a means to enhance their interaction with and integration of the caregiver in the medical care team and the remaining nine targeted to family caregivers to encourage and refer them to resources to support them in maintaining their own health, safety and well-being while providing care for someone with AD/ADRD.
    The materials can be found on the HRSA website. GWEP awardees and other educators will use these materials and adapt them as needed to meet local needs.
    For more information, see:
    Public Health Live Webcasts on Dementia Care. "Public Health Live" is a monthly webcast series designed to provide continuing education opportunities on public health issues. In 2015, the New York State Department of Health (NYSDOH), in conjunction with the State University of New York and Albany Medical College, offered the webcast "Alzheimer's Disease and Advanced Directives: A Primer for Primary Care Physicians." Offerings for 2017 include "Clinical and Ethical Indications for Cognitive Impairment Screening in Primary Care" and "Healthy Communities: An Assessment and Implementation Framework to Achieve Inclusion of Persons with Disability."
    For more information, see:
    Dementia Friendly America Provider Tools. Dementia Friendly America (DFA) is a multi-sector, national collaborative of cross sector organizations and individuals seeking to foster communities across the United States that are equipped to support people living with dementia and their caregivers. Dementia-friendly communities foster the ability of people living with dementia to remain in the community and engage and thrive in day to day living; basic things like going to the store or the bank. The community also buoys the caregiver by adding extra supports such as respite programs. DFA has developed provider tools and resources that support timely and accurate diagnosis, education for families after a diagnosis of AD/ADRD, offers dementia care guidelines, fosters safe transitions of care, and advances coordinated and integrated health and longer services and supports. Links to the resources can be found at the DFA website.
    For more information, see:
    Resources for Clinicians. NIA continues to expand its efforts to educate clinicians about recent research findings; clinical practice tools for assessment, diagnosis and management of cognitive impairment; training materials; a patient checklist handout in English and Spanish, and other resources, which are available online in a mini-portal of resources for professionals.
    For more information, see:
    Improvements in the Home Care Workforce. CMS took steps in 2016 to outline strategies states can use to stabilize the Medicaid home care workforce, an important element of dementia care.
    For more information, see:

     Linking the Public to Diagnostic and Clinical Management Services. ACL has new educational opportunities for family members of and service providers for persons with IDD about changes that may indicate the onset of dementia. Two webinars and an issue paper became available in 2015.
    For more information, see:
    Gerontological Society of America Report. A report is available that summarizes the discussion of a workgroup convened to outline the pathway from detection to diagnosis to management using evidence-supported tools. These tools can be integrated into clinical work flow, including the assessment opportunity created by the inclusion of cognitive impairment detection as a required element of the Medicare Annual Wellness Visit (AWV). The workgroup involved a team of experts that the Gerontological Society of America assembled from across the public, private, and academic sectors.
    For more information, see:

     Educate Physicians and Other Health Care Providers About Accessing Long-Term Services and Supports. One barrier to counseling and support is that health care providers are not aware of available services and how to access them. To address this need, HRSA is collaborating with federal partners, public and private entities, the health care provider community, and community-based organizations to effectively educate primary care providers and other health care practitioners, direct services workers, and patients, families, and caregivers about and services and supports available to assist persons living with dementia, as well as their caregivers. All 44 GWEPs provide this training and 32 GWEPs partner with the Alzheimer's Association. For example, the Alzheimer's Association in St. Louis, Missouri, is providing Baseball Reminiscence Leagues for persons with a dementia diagnosis. The Gateway GWEP, which created the original Baseball Reminiscence League for veterans, now refers persons with a dementia diagnosis and an interest in baseball to these specialized support groups as part of their current GWEP/Alzheimer's Associations partnership.
    Massive Online Open Course on Coursera - Living with Dementia: Impact on Individuals, Caregivers, Communities and Societies. This free course involves five self-paced modules which examine the psychological, social, and economic impacts on persons and their families as well as society at-large. Health professionals and students, family caregivers, friends of and affected individuals, and others interested in learning about dementia and quality care will benefit from completing the course. Led by Drs. Nancy Hodgson and Laura Gitlin, participants will acquire foundational knowledge in the care of persons with AD and other neurocognitive disorders. The course will move to an open access format such that it will be continuously offered. It will be available on Coursera in the summer of 2017.
    For more information, see:
    New York State Programs for Alzheimer's Disease and Other Dementias. In 2015, NYSDOH's Alzheimer's Disease Program implemented a new $25 million strategy to support people with AD/ADRD and their caregivers, and the programs continue to make progress into 2017. This initiative represented the single largest state investment in these services in the state's history and made a significant difference in the lives of the targeted population. The initiative is based on evidence that demonstrates that providing an array of caregiver services in the community helps avoid unnecessary hospitalizations and emergency room visits, delays nursing home placement, and improves caregiver burden and mental health outcomes. All of the projects within the initiative are participating in a comprehensive evaluation to measure the impact on caregivers throughout the state.
    For more information, see:
    Association for Fronto-Temporal Dementia Travel Grants. AFTD offers modest financial assistance for people with FTD and caregivers interested in attending an FTD education conference. In FY 2016, AFTD awarded 60 Comstock Travel Grants to help people defray the costs of travel and lodging to attend an FTD focused education conference.
    For more information, see:

     National Research Summit on Care and Services for Persons with Dementia, Family Members, and Caregivers. Under the auspices of the NAPA Advisory Council, planning is fully underway for a National Research Summit on Care and Services for Persons with Dementia, Family Members, and Caregivers. The goal of this research summit is to identify what we know and what we need to know in order to accelerate the development, evaluation, translation, implementation, and scaling up of comprehensive care, services, and supports for persons with dementia, their families, and other caregivers. The Summit is focused on research that is needed to improve quality of care and outcomes across care settings, including quality of life and the lived experience of persons with dementia and their caregivers.
    Cross-cutting themes of the Summit include:
     Diversity (SES, race, ethnicity, culture, language, literacy, geographic locations)
     Disparities
     Etiologies and Disease Stages
     Care Settings (home, community, assisted living, nursing home, and medical/health care settings)
     Training and Workforce Issues
     Technology
     Differential Impact on Women

    Anticipated outcomes of the Summit include:
     Recommendations for research priorities to inform federal agencies, foundations, and other private sector organizations.
     Identification of evidence-based programs, strategies, and approaches that can be used now to improve care and services.
     Research milestones to track and guide acceleration and advancement of evidence-informed care and services.
     Spread of information to the public including people living with dementia and their caregivers.

    The Summit will be held on October 16-17, 2017 at NIH.
    For more information, see:
    Clarify and Disseminate Information on Privacy, Autonomy, and Safety Issues for Physicians. Based on the recommendation of the Advisory Council to clarify information on privacy, HHS will develop information for physicians on privacy, autonomy, and safety issues. This resource will help providers better understand these issues and the balance between safety, privacy, and autonomy. HHS will disseminate this information through the trainings provided by the GWEP awardees in Strategy 2.A.
    Elder abuse and elder justice are important topics, especially for persons living with dementia. Sixteen GWEPs have produced training materials for primary care providers on this important topic. For example, the University of Washington's Northwest GWEP has produced two online modules: Elder Mistreatment and Elder Investment Fraud to address these critical issues.
    For more information, see:
    Dementia Caregiving Network. The Dementia Caregiving Network (DCN) is an interprofessional Hartford Change AGEnts Initiative working to achieve improvements in services, supports, and care for persons with dementia and their family caregivers, supported by the John A. Hartford Foundation. Since January 2014, DCN has identified core concepts that define or influence practice change activities in dementia caregiving. One project involves developing a database of existing caregiver support interventions for agencies to access to determine which programs to adapt. Another project involves identifying ways to modify electronic records to identify families of persons with dementia. Yet another project involves evaluating and critiquing existing measurement sets. Finally, another project involves advancing a model for care management through managed care organizations.
    For more information, see:
    Home and Community-Based Services Quality. Measuring quality in HCBS settings, where few endorsed measures exist, has become increasingly important in the new cross-setting health care paradigm, especially as Medicaid funding continues to shift from institutional to cost-effective community-based care. CMS recently received CAHPS® endorsement for its HCBS Experience of Care Survey.
    For more information, see:
    Improved Care in the Nation's Long-Term Care Facilities. CMS issued a final rule in 2016 that made major changes to improve the care and safety of the nearly 1.5 million residents in the nation's 15,000 long-term care facilities (nursing homes) that participate in Medicare and Medicaid. The policies in the final rule help to reduce unnecessary hospital readmissions and infections, improve quality, and strengthen safety measures for residents. The rule also strengthens staffing provisions, requires person-centered care, includes a specific requirement for dementia training, betters discharge planning, and updates infection prevention and control protocols.
    For more information, see:
    VA Dementia Care Recommendations. VA's VHA Dementia Steering Committee Recommendations have been updated and are now posted online. The recommendations provide guidance to improve the health and well-being of veterans by increasing access to best practices in care for veterans living with dementia, their families, or other caregivers. The recommendations, which are not themselves formal VHA policy or mandates, are interdisciplinary, VA-specific, and comprehensive; combine published evidence with VA experts' experience; and address dementia recognition, diagnosis, treatment at different stages, care coordination, administrative matters, research, and education.
    For more information, see:
    VA Clinician Fact Sheet on Detection of Cognitive Impairment. VHA's National Center for Health Promotion and Disease Prevention (NCP) Clinician Fact Sheet, Detection of Cognitive Impairment, has been updated and is now posted online. VHA does not recommend routine screening for cognitive impairment in asymptomatic older adults (those presenting with no signs or symptoms of cognitive impairment). Instead, it recommends that VHA Primary Care clinicians should be alert to early signs or symptoms of cognitive impairment and evaluate as appropriate. The NCP Clinician Fact Sheet includes lists of warning signs that clinicians may notice or that patients and caregivers may report, plus elements of a structured diagnostic evaluation if warning signs are present.
    For more information, see:
    Factors Influencing the Progression of Disability in Older Adults. Information about the health and disability status of older adults at a point in time is known, but information on how this changes over time at the person level is more limited. For example, how do physical limitations change over time? How rapidly does someone go from needing only assistance with bathing to needing help with other self-needs? We know that women tend to live longer than men, but are there differences in how rapidly disability progresses once it begins? The HHS Office of the Assistant Secretary for Planning and Evaluation's (ASPE's) project uses the National Health and Aging Trends Study (NHATS) data from 2011 to 2015 to study the progression of disability and the implications for caregiving needs. Outcomes data are being tabulated each year (death, long-stay nursing home admission, residential care admission, continued or increased use of informal/paid care). Those who develop dementia after 2011 would be studied, but most cases would already have dementia or symptoms in 2011, and the course of their condition would be followed through 2015. The effects of demographic characteristics (age, sex, race, marital status, income, education) on the incidence of disability and their effect on its progression are being studied as well.
    Trends in Residential Care Settings for Older Adults. Most long-term care for older Americans is provided by family and friends in the home. When the needs become greater than home care can provide, nursing home admission is often used. However, increasingly older Americans are relying on care in an array of facility-based settings, such as assisted living facilities. ASPE's project is analyzing trends in residential care, using data at various points in time from several data sources, including the Medicare Current Beneficiary Survey (MCBS), NHATS, and the National Study of Long-Term Care Places (NSLTCP). This project will present the estimates, explain why they would be expected to differ across sources, and analyze the resulting trends. The sources also contain some information on the characteristics of facilities and residents. This information is being analyzed to further determine the role such places play in the long-term care system, and to better understand the reasons for differences in the estimates across sources.

     Alzheimer's Disease Supportive Services Program. ACL continues to support state grantees and their partners in the implementation of dementia-capable LTSS systems. The grantees are lead dementia agencies within their states, in direct response to recommendations from the Advisory Council. Grantees are: (1) developing a "no wrong door" service system; (2) ensuring access to comprehensive, sustainable services for people with dementia and their family caregivers; and (3) implementing evidence-based or informed interventions as part of their programs. In 2016, ADSSP expanded to include two new states -- Texas and Michigan. This program's focus on dementia-capability and direct services through evidence-based interventions and targeted training is in direct response to the recommendations of the Advisory Council. ACL anticipates continuation of the ADSSP with new grants in 2017.
    Alzheimer's Disease Initiative-Specialized Supportive Services. ACL continues to support 32 Alzheimer's Disease Initiative-Specialized Supportive Services (ADI-SSS) grantees and their partners, which are located across the country and in Puerto Rico. The grantees are operating within dementia-capable systems and implementing new programs designed to provide more effective services to: (1) individuals living alone in the community with dementia; (2) individuals with IDD who have or are at-risk of developing dementia; (3) caregivers who need behavioral symptom management training or expert consultations to help them care for family members; and (4) provision of effective care/supportive services for individuals living with moderate to severe AD/ADRD and their caregivers. Grantees include a broad range of existing dementia-capable public and private entities. Grantees have tailored their programs to address service gaps in the communities they serve, including implementation of evidence-based and evidence-informed interventions. ACL anticipates the continuation of the ADI-SSS program, with new funding in 2017.
    ACL National Alzheimer's and Dementia Resource Center. ACL continues to fund a resource center that supports ACL grantees, their partners, and the larger Aging and Disability Networks in developing and implementing dementia-capable programs, dementia-friendly communities, specialized supportive services, and evidence-based programs. In addition to providing technical assistance, the National Alzheimer's and Dementia Resource Center (NADRC) manages an annual webinar series that is open to the general public, writes issue briefs on program-related topics, and evaluates and summarizes program results. NADRC staff also manages and facilitates grantee learning opportunities that result in resources that are beneficial to program activities and also made available to the general public. The NADRC website is home to numerous resources developed both in house and through agency grant programs.
    For more information, see:
    Examining Models of Dementia Care. ASPE has completed a study examining dementia care models across settings using a framework to understand what providers are doing to provide care to individuals living with dementia and their families. The project is intended to better understand what "innovative" dementia care providers have in common and what practices may inform future understandings of quality dementia care. The project involves an environmental scan of best practices in dementia care, and a series of five case studies conducted across the country and in a range of dementia care settings. The results will inform future research related to developing quality measures and standards. ASPE has also conducted additional work to review the literature on outcomes of models or programs for dementia care to better understand how effective they are at improving the quality of life or health for people living with dementia and/or their caregivers.
    For more information, see:
    Georgia Alzheimer's and Related Dementias State Plan. The Georgia Alzheimer's and Related Dementias (GARD) State Plan Advisory Group continues to meet to implement the GARD State Plan and to create a more dementia-capable Georgia. In June 2016, the Georgia Department of Human Services Division of Aging Services hired the very first GARD State Plan Coordinator. There are currently six workgroups made up of stakeholders from various sectors including health care, social services, and public policy. These workgroups include: Workforce Development; Service Delivery; Public Safety; Outreach and Partnerships; Policy; and Healthcare, Research and Data Collection. The current initiatives of GARD are focused on improved dementia education and training, implementation of person-centered care, and early and accurate diagnosis of dementia.
    Minnesota: Dementia-Capable State. Minnesota is building a dementia-capable state through the synergistic efforts of a host of dementia collaborations including:
     The ACT on Alzheimer's® Collaborative's many accomplishments include: (1) Dementia-Friendly Communities now at 40 and counting; (2) Dementia Curriculum developed by leading experts in Minnesota; and (3) culturally infused Provider Practice Guidelines, 1,500 physicians and care coordinators have trained in these dementia care best practices. In Minnesota, the Health Care Summit advanced the adoption of the practice guidelines in health care systems with three major health care organizations leading the way and more in the wings. The state's Caregiver initiative lead to the funding of the Dementia Grants program where culturally sensitive caregiver education and services are targeted.
     National Family Caregiver Support Program Act -- Minnesota has developed a statewide network of over 100 dementia-capable caregiver consultants who have or are completing the Minnesota culturally infused Caregiver Consultation training and Advanced Dementia-Capability training online and in-person training. Also, through Minnesota's current ADI-SSS grant the Resources for Enhancing Alzheimer's Caregivers' Health (REACH) Community is being embedded as a routine caregiver consultation service.
     The State of Minnesota ADI-SSS grant being implemented through 2017 delivers culturally infused Dementia-Capability training to the statewide network of aging services and health care providers via a Learning Management System that combines online and in-person training. Courses are tailored for the learner at three levels based on their prior knowledge, skills and job function. The Dementia-Capability training also addresses those with IDD and persons with dementia living alone. Cultural Consultants provide guidance and education to aging service providers and communities to increase understanding of the norms and values of diverse clients with dementia and their caregivers. Physician and care coordination training is delivered in collaboration with ACT Dementia-Capable Communities.
    West Virginia Coordinated Action, Response, Education and Support about Families Living with Dementia. The initiative's aim is to help organizations and individuals in non-profit, law enforcement, faith, business and other communities learn about dementia so they can assist and enhance the quality of life for individuals living with dementia. In addition, West Virginia Coordinated Action, Response, Education and Support (WV CARES) will connect individuals and families living with dementia to national, state and local resources for education and support. The Blanchette Rockefeller Neurosciences Institute is leading the effort along with key partners throughout the state including AARP, Alzheimer's Association-West Virginia Chapter, the Claude W. Benedum Foundation, the Manahan Group, the West Virginia Bureau of Senior Services, and the West Virginia Sheriff's Association.
    Outcomes for Phase I of this initiative are: (1) educate West Virginians about the prevalence, early warning signs and symptoms of AD/ADRD, as well as the economic impact of the disease; (2) establish dementia-friendly faith communities that are a safe, supportive and welcoming environment for people with dementia; (3) establish dementia-friendly financial/legal services as legal and financial advisors may be the first to identify cognitive decline; (4) encourage dementia-friendly businesses that are meeting the needs of customers and employees; and (5) ensure dementia awareness among emergency response and law enforcement personnel.
    WV CARES is part of the DFA network as the only statewide initiative of the network's six pilot sites.
    For more information, see:
    Supported Decision Making Resource Center. ACL is promoting supported decision making (SDM) because it is a valuable option in helping people with dementia and others who may have cognitive issues exert control over choices made in their lives. SDM can also improve current guardianship arrangements for older adults and people with disabilities who need support. SDM is a more inclusive alternative than guardianship that uses trusted friends, family members and advocates to assist people with disabilities understand and make their own choices. SDM shows great promise for increasing self-determination and improving quality of life outcomes. ACL supports a national training, technical assistance, and resource center to explore and develop SDM as an alternative to guardianship. Among the center's projects is development of resources for professionals that include legal documents, standards for persons involved in SDM, research to discover how people use SDM, and evaluation of its effectiveness. The ultimate goal is to develop a model that will help states and individuals consider alternatives to guardianship by 2019.
    For more information, see:
    Analysis of New Payment and Service Options for Medicare-Medicaid Dual Eligible Beneficiaries. ASPE is currently engaged in a project to produce targeted research briefs on options for expanding the Programs of All-Inclusive Care for the Elderly (PACE). PACE was established as a permanent Medicare and Medicaid benefit by the Balanced Budget Act of 1997, and it attempts to help nursing home eligible older adults avoid institutional care by providing them with an appropriate, tailored mix of coordinated acute care and HCBS. PACE is designed for the frail elderly. To be eligible, participants must be 55 or older and certified by their state of residence as being eligible for nursing home level of care. The PACE Innovation Act gives the Secretary of HHS the authority to test changes to the PACE model, such as serving individuals under the age of 55, and people who do not meet the current nursing home level of care criteria, but may be at-risk of entering a nursing home. The anticipated deliverables for this project include four research briefs that address the policy implications, benefit design, and financing structure of an expanded PACE program, including a descriptive analysis of subpopulations of dual eligible beneficiaries under age 55. Nationally, nearly half (49% comp) of PACE participants have been diagnosed with dementia, therefore lessons from the PACE model may have strong applicability to the field of dementia care broadly. Reports are expected by December 2017.
    Resources for Enhancing Alzheimer's Caregivers Health VA. As part of the VA's Caregiver Support Program, the Memphis Caregiver Center has been training staff since 2011 to deliver the REACH-VA caregiver program. Over 1,000 VA staff have been trained. In 2017, through a partnership between VA's Office of Care Management and Social Services and Office of Rural Health, REACH-VA is offered directly from Memphis to caregivers of veterans and veterans who are caregivers. A recent article reported that after caregiver participation in REACH-VA, caregivers are better able to manage the behavioral concerns of the person with dementia and their own stress and burden; in addition, health care costs for the person with dementia are decreased.
    VA Models of Non-institutional Long-Term Care. VHA has implemented innovative programs to provide patient-centered alternatives to long-term institutional care. New models of care have included programs focusing on dementia care, care coordination, and/or caregiver support. A summary report on Veterans Health Administration (VHA) Innovative Dementia Models of Care: Patient-Centered Alternatives to Institutional Extended Care was posted online. The report described a number of innovative programs developed and implemented at VA medical facilities, along with some initial results and lessons learned from the projects.
    VHA continues to offer a range of innovative dementia care programs in urban, suburban and rural areas that provide veteran and caregiver support through multi-media communication, education, in home services, outpatient services, and interaction with primary care teams.
    Examples of some of these sustained, successful innovative programs include the following:
     The Caring for Older Adults and Caregivers at Home program is a home-based dementia care program that assists veterans and their caregivers through support, education, and referrals with the aim of delaying nursing home placement, reducing caregiver burden, and improving dementia care. The program has been recognized by VA's Office of Rural Health as a Promising Practice based on improved access, strong partnerships/working relationships, evidence of clinical impact, return on investment, operational feasibility, and customer satisfaction.
     The VA Mobile Adult Day Health Care (ADHC) program, also known as the ADHC Mobile Veteran Program, is a therapeutically-oriented outpatient program that serves to enhance veterans' quality of life and alleviate isolation and depression by maximizing their physical, mental, and social abilities and well-being. The program provides support and respite care for families and other caregivers of veterans who are functionally impaired and/or socially isolated, enabling the veteran to maintain residence in a supportive home environment. VHA establishes community partnerships, usually with Veteran Service Organizations, that donate the use of their site. VHA staff travel to the site during specified days, as agreed upon with the community partner. veterans must have a designated VA primary health care provider who provides orders while the veteran is enrolled in the program. The VA Mobile ADHC program treatment team recommendations are communicated to the primary health care provider based on the veteran's individual need.

    For more information, see:
    VA Care of Patients with Complex Problems. VA is working to identify promising care models for veterans with complex medical, neurocognitive, and psychiatric comorbidities with behaviors that can be disruptive to safe and effective care across inpatient and nursing home care settings. Many of these veterans have dementia. Preliminary focus is on interdisciplinary behavioral consultation models and transitional care models to facilitate discharge to appropriate levels of care and decrease behavioral readmissions.
    Medicare-Medicaid Accountable Care Organization Model. CMS announced a new model that builds on the Medicare Shared Savings Program, where Medicare Accountable Care Organizations (ACOs) that hit spending and quality targets are able to share in savings with CMS. This particular model will consider Medicaid savings, as the enrollees will be dually eligible for Medicare and Medicaid, and could include long-term care services. CMS intends to enter agreements with as many as six states.
    For more information, see:
    Research Continues to Seek New and Effective Ways to Improve Care. An overwhelming majority of older adults want to continue living at home as they age. In recognition, the Collaborative Aging (in Place) Research using Technology (CART) Initiative unites NIH, other government agencies, academic, and industry experts to develop and test tools that track changes in older adults' health status and activities unobtrusively in real time, so they can remain at home as long as possible. Launched in October 2016, the $9 million, 4-year project, which includes contributions from a number of NIH institutes and VA, will start with a pilot project in more than 200 homes in rural and urban communities across the United States. The potential benefits for older adults and their families and/or caregivers are many as more people could stay in their own homes as they age, comfortably and safely.
    For more information, see:
    Translation of Care of Persons with Dementia in their Environments in a Publicly-Funded Home Care Program. This home-based intervention involves up to 12 home visits; a nurse provides education to caregivers as to common concerns (constipation, detection of pain, incontinence, hydration and importance of taking care of self), conducts a brown bag medication review, takes blood and urine from the person with dementia and does a visual inspection of skin integrity; an occupational therapist meets with families to assess abilities of person with dementia and to work with caregiver to provide strategies for managing their care challenges and educate them as to the nature of the disease and ways to support daily functioning.
    Activities include:
     NIA-funded trial ongoing in Connecticut to translate this approach in Medicaid Waiver Program (Principal Investigator, Dr. Richard Fortinsky, Co-Investigator, Dr. Laura Gitlin).
     ACL-funded project to Maine's Adult Day Serves to integrate Adult Day Plus and Care of Persons with Dementia in their Environments (COPE) Intervention.
     ACL-funded project to Orange County, North Carolina to integrate COPE/Tailoring Activities for Persons with Dementia and Caregivers (TAP) into home care services.
     Australia-funded translational study of COPE in various settings (hospital to home, home care, social service agencies).
     COPE as part of the MIND model being tested under the CMS's (Innovation Center) Health Care Innovation Awards (HCIAs).
     COPE being integrated into a program for Managed Care to be delivered by Volunteers of America.
    Patterns of Care and Home Health Utilization for Community-Admitted Medicare Patients. The Medicare home health payment policy for fee-for-service (FFS) has undergone several changes in the past decades. There have also been overall increases in Medicare home health utilization. Growth in utilization has been particularly strong for community-admitted users (those individuals for whom home health episodes are not preceded by a hospitalization or post-acute care (PAC) stay). MedPAC has suggested that this is indicative of the fact that some beneficiaries may be using the home health benefit as a long-term care benefit.14 Several alternative explanations for the growth of the community-admitted users are plausible. Indeed, a recent Academy Health meeting on PAC noted that as the American population ages, those with chronic conditions will likely cycle between post-acute and chronic care services.15 ASPE has begun a study to better understand the growth in use of the Medicare home health benefit by community-admitted users. This research will focus on detailed beneficiary characteristics and the trajectory of care of the community-admitted users to clarify the source of the growth in the benefit for this group of beneficiaries using home health, identify possible gaps in care or inefficient use of services, and inform benefit design. A report will be available later in 2017.

     Preventable Hospitalizations. CDC worked with partners to conduct a review of interventions related to dementia and decreasing preventable hospitalizations, as well as a systematic review of caregiver interventions. The findings from this review will help to inform the current state of evidence-based strategies and interventions related to the Healthy People topic area "Dementias, including Alzheimer's disease" and its objective "To reduce the proportion of preventable hospitalizations in persons with diagnosed Alzheimer's disease and other dementias." A publication that described the results is available.
    For more information, see:
    Initiative to Reduce Avoidable Hospitalizations Among Nursing Facility Residents. The first phase of the Initiative ended in 2016 and has shown reductions in avoidable hospitalizations. A recent Health Affairs article details results from 2015 evaluation and final results are expected in the fall of 2017. In 2016, Phase Two of the Initiative to Reduce Avoidable Hospitalizations among Nursing Facility Residents launched which provides enhanced payments to participating nursing facilities for the treatment of the six most common conditions associated with potentially avoidable hospitalizations: pneumonia, congestive heart failure, chronic obstructive pulmonary disease/asthma, skin infections, dehydration, and urinary tract infections. Additionally, this model includes payments to practitioners in nursing facilities that are similar to the payments they would receive for treating patients in hospitals. Practitioners also will be paid for engaging in multi-disciplinary care coordination and caregiver engagement. The Initiative is taking place in nearly 260 nursing facilities across seven states, Alabama, Colorado, Indiana, Missouri, Nevada, New York, and Pennsylvania.
    For more information, see:
     Initiative to Reduce Avoidable Hospitalizations Among Nursing Facility Residents Shows Promising Results, Health Affairs, March 2017, 36:3441-45
    Nursing Home Compare Improvements. In July 2016, nursing homes were required to submit daily staffing data that is traceable to an auditable source. CMS is collecting the staffing data now and plans to have new staffing measures derived from it on Nursing Home Compare (NHC) in early 2018.
    For more information, see:
    Improved Care Planning for Medicare Beneficiaries. In 2013, CMS began paying separately under the Medicare Physician Fee Schedule for transitional care management services for the transition of Medicare beneficiaries back into the community following discharges from certain settings. In 2015 CMS began paying separately under the Medicare Physician Fee Schedule for chronic care management (CCM) services for beneficiaries with multiple chronic conditions. In 2017, CMS began separate Medicare Physician Fee Schedule payment for additional care management services, including payment for: complex CCM for Medicare patients with multiple chronic conditions; behavioral health integration services including services furnished using the "psychiatric Collaborative Care Model"; and cognitive and functional assessment and care planning for beneficiaries with cognitive impairment (e.g., AD/ADRD). The latter, billed under code G0505 for 2017, must be furnished by a physician or other appropriate billing practitioner (e.g., nurse practitioner or physician assistant). The service includes a cognition-focused evaluation, including a pertinent history and examination; medical decision making of moderate or high complexity; functional assessment (for example, ADLs), including decision making capacity; use of standardized instruments to stage dementia; medication reconciliation and review for high-risk medications; evaluation for neuropsychiatric and behavioral symptoms (including depression), including use of standardized instruments; evaluation of safety (for example, home safety), including motor vehicle operation, if applicable; identification of caregivers, caregiver knowledge, caregiver needs, social supports, and the willingness of caregiver to take on caregiving tasks; advance care planning and addressing palliative care needs, if applicable and consistent with beneficiary preference; creation of a care plan, including initial plans to address any neuropsychiatric symptoms (NPS) and referral to community resources as needed (for example, adult day programs, or support groups); and care plan shared with the beneficiary or caregiver with initial education and support.

     Evaluate Evidence on Care Integration. HHS continued to explore how service delivery models that integrate acute care and LTSS add value beyond that of the traditional, fragmented care system. The project will have a special focus on integrated care functions for people with disabilities and cognitive impairment, and will describe payment policies that promote integrated care. This information will help HHS compare and evaluate existing integrated care interventions and support their growth. Information from the project will facilitate the expansion of promising integrated care models to improve care for Medicare and Medicaid beneficiaries with AD/ADRD.
    Alzheimer's Disease and Related Dementias Affinity Group. CMS regularly convenes its staff experts through an AD/ADRD "Affinity Group" to align and coordinate efforts, and to advance programs and policies in this important area. In 2017, the AD/ADRD Affinity Group, with the help of ACL, sponsored a 1-day training on person-centered planning for individuals with dementia and other conditions.
    Long-Term Care "Rebalancing". CMS issued the annual LTSS expenditure report, which summarizes national trends in LTSS (institutional care, and HCBS) data and spending, the percent of Medicaid spending used for LTSS, the HCBS portion of total LTSS expenditures, state spending variation, population groups, and shifts in federal statutory authorities used by states to deliver HCBS.
    For more information, see:
    New York State Centers of Excellence for Alzheimer's Disease. NYSDOH invested $4.7 million to create regional Centers of Excellence for Alzheimer's Disease (CEADs) to enhance the quality of dementia diagnoses and care across the state. Ten CEADs were designated and funded in the amount of $470,000 to provide integrative and comprehensive medical services for the diagnosis of AD/ADRD; coordinate patient care and treatment for people with AD/ADRD; support and refer patients and their caregivers to community services; promote the benefits of participation in research; demonstrate strong working relationships with community organizations and care providers; promote public awareness about AD/ADRD; and train health care providers and students in health care professions on the detection, diagnosis and treatment of AD/ADRD.

     Alzheimer's Disease Initiative-Specialized Supportive Services. ACL continues to use Prevention and Public Health Funds to support 21 ADI-SSS grantees and their partners, which are located across the country and in Puerto Rico. The grantees are operating within dementia-capable systems and implementing new programs designed to provide more effective services to: (1) individuals living alone in the community with dementia; (2) individuals with IDD who have or are at-risk of developing dementia; (3) caregivers who need behavioral symptom management training or expert consultations to help them care for family members; and (4) provision of effective care/supportive services for individuals living with moderate to severe AD/ADRD and their caregivers. Grantees include a broad range of existing dementia-capable public and private entities including AD-specific organizations, academic institutions, an organization dedicated to services for the IDD community, a health system, states and several local community organizations. Grantees have tailored their programs to address service gaps in the communities they serve and use evidence-based and evidence-informed interventions to do so. ACL anticipates the continuation of the ADI-SSS program, with new funding in 2016.
    Veterans-Directed Long-Term Services and Supports. ACL and VHA continue to partner in supporting states' efforts to develop and better coordinate no wrong door systems of access to services. Together they lead the national expansion of Veteran-Directed Home and Community-Based Services (VD-HCBS) with the goal of assuring that veterans of all ages receive the care they need in their homes and communities, and are provided appropriate supports that allow them to remain there. In many cases, veterans in VD-HCBS hire individuals they are most comfortable with including family, friends and neighbors, to provide the services and supports they require. Veterans with dementia who reside in VA and community nursing facilities have been successfully transitioned back into the community with the support of VD-HCBS.
    Comparing Outcomes for Dually Eligible Beneficiaries in Integrated Care Models. ASPE has a project underway to determine the feasibility of an analysis that compares selected health outcomes and quality measures for Medicare-Medicaid dual eligible beneficiaries participating in managed care models that align Medicare and Medicaid benefits, such as Medicare Advantage Dual Eligible Special Needs Plans (D-SNPs), Medicare Advantage Fully Integrated D-SNPs, and PACE, to outcomes for dually eligible beneficiaries who are not participating in these models. Dually eligible beneficiaries are almost three times more likely to have dementia as their Medicare-only counterparts, therefore programs that serve large numbers of dually eligible beneficiaries are likely to also serve people with dementia. This study aims to better understand whether dually eligible beneficiaries fare differently in different integration models across a number of categories including but not limited to, mortality, nursing home utilization, hospital readmissions, and chronic conditions (inclusive of AD/ADRD or Senile Dementia, as identified in CMS's Chronic Conditions Data Warehouse). The project deliverables include an environmental scan of existing research comparing outcomes for dually eligible beneficiaries in Special Needs Plans and PACE to outcomes for beneficiaries who are not participating in these models, an analysis plan, and an exploratory analysis that will inform a report on the feasibility of the analysis plan given the current data available. Reports are forthcoming in 2018.
    Policy Options for Medicare-Medicaid Dual Eligible Beneficiaries. ASPE has a project underway to identify policy options for using Medicare Advantage D-SNPs as a platform to integrate care for dual eligible beneficiaries. D-SNPs are a type of Medicare advantage managed care plan that enroll only dual eligible beneficiaries and are required to provide or coordinate all Medicare and Medicaid benefits for their enrollees. Twenty-two percent of older people with dementia are duals, and the number is increasing, and this population could benefit from the coordinated and aligned care offered by D-SNPs. This project produced a report detailing policy options, considerations, and challenges for using D-SNPs as a scalable platform for broader integration of Medicare and Medicaid benefits. A report is forthcoming by December 2017.
    Analysis of Pathways to Dual Eligible Status. ASPE has a project underway to identify the frequency with which the various eligibility pathways to dual eligible status are utilized and to understand the circumstances and characteristics of individuals surrounding their transition to dual status. Individuals become dually eligible for Medicare and Medicaid programs through multiple pathways. They can become eligible for one of the programs before the other, based on age, disability, or income; or they may simultaneously become eligible for both programs. However, current understanding of these pathways remains limited. Differences in the pathways to dual eligibility have implications for Medicare and Medicaid spending and service use patterns. Understanding these differences can inform policy efforts to support the dual eligible population and individuals at-risk for becoming dually eligible. Nearly one-quarter (23%) of dual eligible beneficiaries over the age of 65 have AD/ADRD. A report is forthcoming in December 2017.
    New York State Alzheimer's Disease Caregiver Support Initiative for Under-served Communities. NYSDOH allotted $1.5 million to fund a wide range of caregiver support and respite services for caregivers of individuals with AD/ADRD, either or both of whom are members of under-served communities. Fifteen contractors, funded at $100,000 each, provide culturally-competent support initiatives and stress reduction strategies for caregivers of diverse under-served populations across the state. Contractors provide extensive outreach, intake and assessment, referral, and at least one of the following core services: support groups, education, caregiver wellness, and joint enrichment.
    Addressing Disparities in Alzheimer's Disease and Other Dementias in New York State. NYSDOH allocated $250,000 for a demonstration project with the goal of increasing AD/ADRD screenings in primary care settings for African American and Hispanic populations, to promote earlier diagnosis and treatment of AD/ADRD among these populations, and to connect those diagnosed with AD/ADRD to community support, medical services, and clinical trials. Long-term objectives include effective disease management, continued community residence, and decreased caregiver burden.

     Families and other unpaid caregivers play a central role in caring for people with AD/ADRD and may need supports beyond the care provided in settings such as doctors' offices, hospitals, and nursing homes. Supporting people with AD/ADRD and their families and caregivers includes providing access to tools that they need and helping to plan for future needs with the goal of maintaining safety and dignity. Under this goal, the Federal Government and partners will undertake strategies and actions that will support people with the disease and their families and caregivers.


     National Brain Health Center for African Americans. CDC supported the development of the National Brain Health Center for African Americans (NBHCAA). The mission of NBHCAA is to raise awareness of the issues of cognitive health among African Americans by working through networks of faith-based institutions and by establishing partnerships with organizations and individuals dedicated to our mission. The three areas of focus of brain health education, mobilization and advocacy, and networking. NBHCAA serves as an information hub on the human brain that must be shared throughout all networks that reach and touch approximately 40 million African Americans living in the United States.
    For more information, see:
    Training African American Nurses about Brain Health. With CDC support, the Balm in Gilead in partnership with the National Black Nurses Association trained African American nurses from 14 chapters of the National Black Nurses Association across the United States in 2016. Additional training are ongoing in 2017.
    Alzheimer's and Dementia Training for Aging Professionals. ACL hosted Alzheimer's and dementia training workshops, including a half-day session, at a national conference of aging professionals. The sessions provided information on initiatives designed to improve community-based care for individuals living with dementia and their caregivers.
    For more information, see:
    National Alzheimer's Call Center. Through the National Alzheimer's Call Center, ACL funds the operation of a national information and counseling service for persons with AD/ADRD, their family members and informal caregivers. The National Alzheimer's Call Center is available to people in all United States and territories, 24 hours a day, 7 days a week, 365 days a year to provide expert advice, care consultation and information and referrals nationwide, at the national and local levels, regarding AD/ADRD. The Alzheimer's Association, which received the ACL grant, is currently in the fourth year of a 5-year funding period which will end July 31, 2018.
    Indian Country Aging Programs. Indian Country programs involve educational efforts and implementation of a proven caregiver support program. Education involves: consumer fact sheets on dementia in Indian Country, conference presentations, training programs, and webinars.
    For more information, see:
    Training Resources for IHS Staff. IHS completed a review of training resources for IHS nursing staff. Articles in the IHS Primary Care Provider highlighted person-centered goals and strategies for improving care for persons with dementia. IHS collaborated with HRSA to engage the HRSA-funded GWEPs in strategies to improve recognition and diagnosis of dementia.
    Currently eight GWEPs partner with federally recognized Tribal populations and one collaborates with a non-federally recognized Tribal population. The nine GWEPs have developed a Native Populations Interest Group in preparation for exchanging training materials. The University of Wyoming is currently developing culturally-relevant dementia training material for Native American people on the Wind River Reservation by creating a pictorial version of the Alzheimer's Association's Know the 10 Signs: Early Detection Matters.
    Outreach and Training in Indian Country. IHS provided training at the National Meeting of the Title VI Directors (the ACL-funded Aging Network) on AD/ADRD and outreach and education at the National Indian Council on Aging Biennial Meeting. IHS, CMS, and ACL provide technical assistance in the development of LTSS through the jointly sponsored LTSS Technical Assistance website and shared Tribal models of LTSS in the monthly webinar series and co-sponsored a Tribal LTSS conference in Minneapolis, Minnesota, in November 2016, with a focus on AD/ADRD.
    For more information, see:
    Language to Assist with the Indian Health Care Improvement Act. IHS developed sample language to assist tribes to make use of new authorities under the Indian Health Care Improvement Act to provide LTSS and supports tribes to include specific language regarding delivery of LTSS in funding agreements.
    Oregon Caregiver Training. Initial funding approved by the Oregon Legislature in 2013 was renewed in 2015 to support free statewide funding for paid and family caregivers, and for public safety workers. More than 1,400 caregivers have participated in training to date. Oregon Care Partners is a collaboration among a number of Oregon organizations that came together to support this statewide training effort. Training is offered both in-person and online, with topics addressing AD/ADRD, challenging behaviors, and geriatric medication management and safety.
    For more information, see:
    Cultural Infusion in Dementia Training. The State of Minnesota is creating a dementia-capability online training that is infused with culturally specific information to reflect the norms and values of diverse cultural groups. This material is developed by cultural experts who provide a series of in-person and video conference training sessions to statewide aging service providers, medical clinics and others. The presentations focus on the issues that affect the person with dementia and caregiver, as well as tips on how the aging network providers address dementia in a specific ethnic/cultural community.
    New York State Alzheimer's Disease Community Assistance Program. The Alzheimer's Disease Community Assistance Program (AlzCAP), expanded in 2015 to a $5 million project, promotes effective patient management, education and support for people with AD/ADRD, family caregivers, health care personnel, volunteers, community agencies, and first responders. New York State funds the Coalition of Alzheimer's Association Chapters, which oversees subcontracts with six New York State Alzheimer's Association Chapters across the state and CaringKind in New York City. AlzCAP provides care planning and consultation; caregiver training; support groups; 24-hour helpline; community awareness; and increased training for important constituencies.
    Dementia Friendly America Supports for People with Dementia and Their Families. DFA provides communities with tools and resources that provide guidance on how each sector of the community can adopt sector-specific practices to become dementia-friendly. This includes advance planning, optimal clinical practices, dementia-friendly business practices, inclusion practices for faith communities, dementia-friendly disaster planning, first response, housing, public spaces and transportation and dementia-friendly customer relations. Communities identify and implement change goals that can result in increased supports for people with dementia and their families. This has led to respite care, new meaningful engagement opportunities and enhanced clinical and community supports. These changes can foster dignity, safety and rights of people with AD/ADRD. The cumulative desired results of this work include a safer and more welcoming environment that supports family caregivers.
    For more information, see:
    Geriatric Competent Care. CMS's Medicare Medicaid Coordination Office held several webinars for its Geriatric-Competent Care series. The Integrated Care Resource Center helps health professionals in all settings and disciplines expand their knowledge and skills in the unique aspects of caring for older adults with AD, and in working with their caregivers. Webinars addressed several elements of dementia.
    For more information, see:
    Comprehensive Primary Care Plus Model Payment for Dementia. Comprehensive Primary Care Plus (CPC+) is a national advanced primary care medical home model through CMS's Innovation Center that aims to strengthen primary care through regionally-based multi-payer payment reform and care delivery transformation. In 2017, CPC+ supports 2,891 primary care practices of 13,090 clinicians serving more than 1.76 million Medicare beneficiaries in 14 diverse regions. CPC+ has three payment elements: a care management fee, a performance-based incentive payment, and payment under the Medicare Physician Fee Schedule. Participating providers will receive a monthly additional fee for care management of enrolled Medicare beneficiaries with complex needs, including dementia.
    For more information, see:
    Connected Care. CMS is working to raise awareness of the benefits of CCM services for Medicare beneficiaries with multiple chronic conditions. Connected Care is a nationwide effort in FFS Medicare that includes a focus on racial and ethnic minorities and rural populations, which have higher rates of chronic disease. Resources include a toolkit for providers, a partner toolkit with resources/activities, and beneficiary education, including a poster/postcard.
    For more information, see:
    Latinos and Alzheimer's Disease: New Numbers Behind the Crisis. In September 2016, LatinosAgainstAlzheimer's network released a report in partnership with the University of Southern California Edward R. Roybal Institute on Aging entitled Latinos and Alzheimer's Disease: New Numbers Behind the Crisis. The report noted that without a medical breakthrough that prevents, cures or slows the disease progression, United States Latinos living with AD are projected to increase from 379,000 in 2012 to 1.1 million by 2030 and 3.5 million by 2060 -- an 832% increase. In addition, the report found that the cumulative direct and indirect costs of AD on the United States Latino community, including millions of family caregiver, would ultimately cost the United States economy $373 billion by 2030 and $2.35 trillion (in 2012 dollars) by 2060. The report's findings highlight the urgency of addressing the disparate impact of Alzheimer's on United States Latinos, who are 50% more likely than non-Hispanic Whites to develop the disease.
    For more information, see:
    "Forget Me Not" Play. In partnership with Axovant, AfricanAmericansAgainstAlzheimer's network organized educational events in six cities in 2016, through performances of the play Forget Me Not. The play raises awareness for AD by focusing on one African American family's struggle with the disease, through comedy and relatability. The play covers the ramifications of the disease's impact and effect on the members of the family, as they try to cope with their father's diagnosis. The events reached almost exclusively African American audiences with information about AD and opportunities to connect with local clinical trial resources, including potential trial enrollment.
    Engaging Faith Leaders in Caregiver Support. In 2016, ClergyAgainstAlzheimer's network published a Leader's Guide for Seasons of Caring. The Leader's Guideprovides guidance and structure for support groups based on the network's interfaith volume, Seasons of Caring: Meditations for Alzheimer's and Dementia Caregivers. Nationally renowned author and retired Reverend Dr. Richard L. Morgan based the Leader's Guide on more than 60 years of pastoral care for those with AD. Seasons of Caring includes 140 original meditations representing 17 faith traditions offering words of hope, encouragement and understanding.


     Economic Impacts of Programs to Support Unpaid Caregivers. ASPE has begun a study on the economic impacts of programs to support informal caregivers. Informal caregiving is likely to grow in the coming decades as the baby boomer cohort ages. Not only will there likely be an increased need for caregiving, as disability increases with age, but the ratio of individuals potentially available for caregiving will decrease. For some caregivers of older adults and persons with disabilities, providing care may make it difficult or impossible to have paid employment, or if they do have employment, may make it difficult to advance their career. If they take time out of the labor force, they may face obstacles to returning to employment at all, or at a similar level of responsibility and pay than when they left. Both the direct costs in lost wages of not working, as well as the loss of seniority and retirement benefits may leave some caregivers economically vulnerable when they themselves age. In addition to the costs and benefits to caregivers, there are costs and benefits to the nation of informal caregiving. Inasmuch as unpaid caregiving replaces paid caregiving, unpaid caregivers may provide a net benefit to the country, reducing federal, state, and local caregiving expenditures. However, increased informal caregiving may also lead to reduced labor force participation, resulting in lower national economic growth as the number of individuals performing informal caregiving increases. Lack of support for informal caregivers may also lead to burnout and placement of the care recipient in a facility that is more costly to the government than earlier support services such as HCBS may have been.
    This research aims to provide a framework for policy makers to begin estimating costs and benefits of policies and programs aimed to help caregivers, including, for example, respite care, paid family leave, and workplace flexibility policies. While researchers have established a number of relationships that can help inform government policies that impact informal caregiving, there are both gaps in knowledge, and lack of a consistent consideration of policies from an economic perspective. This project will organize existing information around caregiving to better understand the economic impacts of caregiving.
    Lifespan Respite Care. ACL continues to support the expansion and enhancement of state Lifespan Respite Care programs which are coordinated systems of accessible, community-based respite care services for family caregivers of children and adults of all ages with special needs, to give them a break from the demands of caregiving. These programs are designed to reduce duplication of effort and assist in the development of respite care infrastructures at the state and local levels. Lifespan Respite Care programs work to improve the delivery and quality of respite services available to families across the age and disability spectrum, including those with dementia. Lifespan Respite Care programs advance the following objectives:
     Expand and enhance respite services in the states.
     Improve coordination and dissemination of respite services.
     Streamline access to programs.
     Fill gaps in service where necessary.
     Improve the overall quality of the respite services currently available.
    Adult Day Care and Residential Care State Policy Compendia. ASPE recently updated two policy compendia examining state approaches to regulation of long-term care settings. The first compendium examines state regulation around adult day services (ADS) -- a non-residential service that provides services outside of an individual's home for less than a full day to older adults and younger adults with physical disabilities. These services also meet unpaid caregivers' need for respite in order to work, fulfill other obligations, and recover from the demands of continuous caregiving. Many caregivers who use ADS are providing care to family members with dementia who need constant supervision to ensure their safety. The second compendium examines state approaches to residential care, including assisted living. Residential care provides 24-hour supervision, meals, and assistance with ADLs. States vary in their approaches to licensure for residential care facilities.
    For more information, see:
    Effect of Dementia on Hospitalization and Emergency Department Use in Residential Care Facilities. ASPE recently released a report examining the experiences of individuals living in residential care facilities (including assisted living) who have dementia. Understanding the availability and adequacy of these services is critical to understanding the range of options available to individuals with functional and cognitive limitations. These papers examine dementia care in residential care facilities based on analysis from the National Center for Health Statistics (NCHS)-ASPE National Survey of Residential Care Facilities. The analysis found that:
     Half of residential care facility residents aged 65+ had severe cognitive impairment.
     Nearly one-quarter of all residential care facility residents had at least one hospitalization and more than one-third had at least one emergency department visit in the past 12 months.
     Among residential care facility residents, living in a special care unit for dementia or a facility that only serves individuals with AD/ADRD decreases the risk of hospitalization.

    For more information, see:
    CMS-led Caregiver Workgroup. This workgroup is an ongoing joint effort between CMS and its partner organizations (non-profit organizations, federal partners, and others). Held quarterly in Washington, DC; the agenda topics are open for partners to present and give updates.
    Reducing Caregiver Stress. We are continuing to learn more about what affects and supports caregivers, particularly a role that new technologies may be able to play. To build on new technological capabilities, in March 2017, NIH invited small business to submit applications for a new approach to caregiving -- the use of socially-assistive robots, to address the needs and conditions of caregivers to older people with AD/ADRD.
    These robots, it is envisioned, could help caregivers with difficult or physically stressful tasks. Additionally, they could function as companions that may help in reducing the effects of loneliness experienced by people with dementia or offer psychosocial support by enhancing social connections and communications; provide physiological support through use of techniques like biofeedback; and assist with care management and ADLs.
    For more information, see:
    Maintaining Caregiver Health and Well-Being. The State of Minnesota received an ACL ADSSP expansion grant in 2015 to pilot a collaboration between a medical center and an aging services provider to identify caregivers of people with AD/ADRD and connect them to an aging service provider for dementia-capable caregiver consultation including individualized dementia education, care planning and support services. A short screen included in the rooming process identifies patients who are caregivers and their level of stress. A positive screen initiates a caregiver protocol embedded in the electronic medical record. The caregiver is linked to the aging service provider (caregiver consultant) via the clinic's care coordinator. The clinic and aging service provider share information regarding the health of the caregiver and supports received through a shared release of information. After pilot completion, the goal is to roll out this protocol to the medical center's remaining clinics and showcase the project for other health care systems.
    Dementia: Awareness, Screening Testing and Support of Caregivers. In 2015, the Minnesota State Legislature appropriated funds to the Minnesota Board on Aging for a competitive grant program focusing on dementia and its impact on caregivers. The goals of the grants are to increase awareness of AD/ADRD, increase the rate of cognitive testing, promote the benefits of early diagnosis of dementias, and/or connect caregivers of persons with dementia to education and resources. Twenty grantees were selected, including aging service providers, community health boards, a hospital and a major university. Fourteen of the grantees have some component of their project focused on ethnic and cultural communities including Latino/Hispanic, Somali, African American, American Indian, Lao, Korean, LGBT and Holocaust survivors. The projects include innovative ideas such as: using an online App to reach and support caregivers in an ethnic community; identifying and supporting female employees who are caregivers and work in a supermarket chain; and training staff of fitness centers about how to recognize symptoms of dementia and offer fitness services.
    Testing and Scaling up the New Ways for Better Days: Tailoring Activities for Persons with Dementia and Caregivers Program. TAP is an intervention that provides activities tailored to abilities of persons with dementia and trains caregivers in their use. Pilot randomized clinical trial data suggest its efficacy in reducing behavioral symptoms and improving caregiver abilities and time spent in providing care. This approach has been tested in the home and also in hospital settings with occupational therapists as interventionists.
    Activities include:
     NIA-funded trial that is ongoing in Baltimore to test efficacy.
     Australia-funded a trial in Sydney, Australia with individuals with FTD.
     The program is currently being used in Scotland (it will be part of their dementia care approach), Australia, England, Brazil, various United States. ACL has funded several sites using the program.

    Access to the training program is in the form of online training modules. A face-to-face and virtual launch party was held May 26, 2016, to showcase the program. The initial training target is occupational therapists nationally and internationally. Modifications to the program are underway so that other professionals are able to use this approach.
    For more information, see:
    Translation and Evaluation of the Adult Day Service Plus Program. ADS Plus augments ADS with a systematic approach to supporting families. Staff of ADS (e.g., social worker, care manager, intake specialist, occupational therapist, nurse) can be trained to provide ADS Plus. Pilot data in three centers showed that ADS Plus increased the number of days using ADS, decreased nursing home placement, improved caregiver well-being including decreasing depressive symptoms, and enhanced sense of self-efficacy.
    Activities include:
     Through funding from ACL, ADS sites in Maine are using ADS Plus combined with elements from TAP and COPE.
     NIA-funded study to test ADS Plus in 30 sites across the country.
     Plan to add sites and also develop an online program to train ADS staff nationally.
    New York State Alzheimer's Disease Regional Caregiver Support Initiative. New York State is providing a total amount of $15 million to offer a wide range of caregiver support and respite services. Ten regional contractors, reaching every county in the state and funded at $1.5 million each, provide support services to promote the mental and physical well-being of caregivers. Services include support groups, respite services, care consultation, family consultation, and education for caregivers. Additional offerings consist of caregiver wellness programs, joint enrichment opportunities to include the person with dementia and their caregiver, and technology-based services. Contractors utilize strong community relationships and have a robust media presence to promote and connect caregivers with services.
    NASEM Study on Family Caregiving for Older Adults. The study analyzed the prevalence of family caregiving and the demographic, societal, and technological trends that influence it. It also examined caregivers' roles and responsibilities, both current and expected in the future, and the impact of the caregiver role on individual health, employment, and well-being. Caregivers' unmet needs and the gap between the projected demand for caregivers and the population available to serve as caregivers was assessed and differences associated with race and ethnicity, culture, rural residence, and geography were examined. The study also reviewed the evidence of the effectiveness of potential supports for family caregivers and care recipients across a range of settings including, for example, in medical homes and other primary care settings, HCBS settings, acute care hospitals, and residential facilities. These included, for example, models of team-based care that include the family caregiver as member; approaches to training providers regarding the caregiver role; and models for training caregivers for their various roles.
    For more information, see:
    Respite Grants. Since 2009, AFTD has been offering Comstock Respite Grants to help full-time unpaid caregivers get a much needed break from caring for a loved one with an FTD disorder at home. In FY 2016, AFTD awarded 132 annual grants of $500 to help FTD caregivers cover the costs of short-term respite care for a loved one or family member. There are few requirements to qualify for a Comstock Respite Grant other than caring for a loved one with a documented diagnosis of FTD at home.
    For more information, see:


     Understanding How Families Find and Access Long-Term Services and Supports. Little is known about how families and older adults gather information, make decisions, and access long-term care when a loved one needs assistance such as after a dementia diagnosis. In 2015, ASPE undertook an exploratory qualitative research project to examine where families gather information, how they make decisions, how well these arrangements work, and how local factors influence this process. The project includes focus groups with caregivers in four communities in one state, as well as an environmental scan of the resources for finding LTSS in these communities.
    Helping Persons with Dementia Communicate Their Care Desires. Many families face difficult care choices for their loved ones with advanced dementia who often have lost the ability to communicate meaningfully. These choices are usually made in nursing homes and other institutional settings, often with a limited amount of time to discuss and decide. To address this gap, NIH-supported researchers developed a Goals of Care (GOC) intervention, which combined a video decision aid and a structured care plan meeting for family decision makers. Their main goals were to evaluate if the GOC intervention improved quality of communication and decision making, and whether it would improve palliative care for people with advanced dementia. The study showed that the intervention improved end-of-life communication, enhanced palliative care plans, and reduced hospital transfers for nursing home residents with advanced dementia.
    For more information, see:
    Dementia Caregivers' Technology Preferences: Design Insights from Qualitative Interviews. This study by Shreve, Baier, Epstein-Lubow, and Gardner, and published in Gerontechnology, was intended to determine which information technology design characteristics and functionality family caregivers of adults with dementia would find most helpful. Emerging information technology may ease the burden of family caregivers, particularly those caring for adults with AD/ADRD. User-driven information technology design methods can determine which information technology design characteristics and functionality family caregivers of adults with dementia would find most helpful. Family caregivers were overwhelmingly receptive to the idea of website or smartphone technology interventions and detailed specific needs that technology could address, including alleviating the psychological burden and social isolation inherent in caregiving, providing access to information and resources, and helping them to ensure care recipients' safety and track the progression of disease. The findings highlight potential technology solutions to address the overwhelming social isolation and stresses prevalent among family caregivers of adults with AD/ADRD. Given the unmet needs of this growing group of consumers, researchers and developers of information technology should incorporate caregiver perspectives, both during the design process and in the resulting products themselves.
    For more information, see:
    AFTD Support Group Affiliation Initiative. The Support Group Affiliation Initiative connects volunteer support group facilitators to AFTD, and each other, for networking, education and peer support. To date, 71 facilitators from groups in 27 states have joined this growing network dedicated to providing FTD-specific support. By affiliating with AFTD, support group facilitators can: attend ongoing trainings by FTD experts as well as troubleshooting and networking calls with affiliated peers, and gain access to AFTD-branded materials to help educate group members and promote the group locally. AFTD's has always offered assistance to FTD support groups. Through this initiative, AFTD can ensure more people living with FTD and their caregivers have access to high-quality and FTD-specific support systems and services.
    For more information, see:


     Office of Long-Term Care Ombudsman Programs. ACL's Office of Long-Term Care Ombudsman Programs (OLTCOP) continues to provide training, technical assistance, and federal regulations that help states' long-term care ombudsman (LTCO) programs to better meet the needs of individuals living with dementia in long-term care facilities. These activities include a National Ombudsman Resource Center (NORC) webinar titled: LTCOP Rule: Supporting Person-Centered Advocacy -- Complaint Investigations and Abuse Reporting. OLTCOP continues to identify the complaint trend of improper evictions from both nursing homes and board and care settings; this has been the top complaint in nursing homes for the past 5 years and state Ombudsman programs report that persons with dementia who do not have their needs properly addressed are often at-risk of an eviction. The OLTCOP, along with other ACL staff, participate in a workgroup convened by CMS to identify systemic strategies to address this trend. In addition, the OLTCOP continues to work with states regarding the implementation of the LTCO rule, which became effective on July 1, 2016. ACL's Regional Support Centers incorporated states' LTCO rule implementation into their 2016 annual reviews and provide ongoing technical support focusing on conflict free, person-centered complaint resolution strategies. ACL will continue its evaluation of the impact of LTCO programs and practices generally, including those that affect residents living with dementia and their families.
    Elder Abuse Prevention. ACL's National Center on Elder Abuse (NCEA) is dedicated to protecting all from the many forms of elder abuse, including those with dementia. NCEA has rebranded and updated its fact sheets, research briefs and training materials. Many of these materials are adaptable to assist families in crisis especially when their family member has lost the capacity to make their own decisions and may be especially susceptible to harm by others. For example, a research brief on dementia is available. NCEA also consults with Alzheimer's Association chapters on elder abuse issues.
    For more information, see:
    Model Approaches to Legal Assistance. The Model Approaches to Statewide Legal Assistance Systems (Model Approaches) grants help states develop and implement effective approaches for integrating low cost legal mechanisms into statewide legal/aging service delivery networks in order to enhance overall service delivery capacity. One program notable achievement is in Maine, which involved the launch of a financial institutions training initiative called Senior$afe. The grantee worked with representatives from the Maine Office of Securities, Maine Bureau of Professional and Financial Regulation, Adult Protective Services (APS), the Maine Bankers Association, and the Maine Credit Union League. Maine's grantee also developed a streamlined reporting system for financial institutions who wish to make a report without a customer's consent. Nebraska established a partnership with the Nebraska Bankers' Association through the APS state office to address financial exploitation issues. Several bankers who participated in training intend to work with APS on elder abuse and financial exploitation issues.
    Volunteer Representative Payee Pilot Program. The Social Security Administration (SSA) and ACL collaborated in development and testing of protocols and materials to assist in the identification and training of individuals to serve as volunteer representative payees. The materials developed include a manual for program implementation, protocol guidance relating to communications between SSA and APS, and forms for referrals. SSA is in the process of finalizing online training modules and continues to build awareness of the program through listening sessions and presentations. Once the modules are complete, SSA will conduct a media campaign to build awareness of this volunteer program.
    National Partnership to Improve Dementia Care in Nursing Homes. The focus of the National Partnership to Improve Dementia Care in Nursing Homes continues to be on the improvement of comprehensive dementia care in nursing homes across the country. The Partnership's larger mission is to enhance the use of non-pharmacologic approaches and person-centered dementia care practices. In September 2014, the National Partnership, a public-private coalition, established a national goal of reducing the use of antipsychotic medications in long-stay nursing home residents by 25% by the end of 2015, and 30% by the end of 2016. Both goals were achieved and new goals are currently under development. CMS continues to monitor the reduction of antipsychotics, as well as possible consequences of the partnership, by utilizing antipsychotic measures on NHC; the agency's public reporting website. Data from NHC are also used to report progress quarterly, both nationally and regionally.
    For more information, see:
    Person and Family Engagement Strategy. CMS issued a new Strategy to enhance person and family engagement that establishes definitions and consistency for frequently used terms to help people engage more fully in their health care, and serve as a guide to support meaningful, intentional application of person and family engagement principles to CMS's policies and programs addressing health and well-being.
    For more information, see:


     Picture of Housing and Health Part 2: Medicare and Medicaid Use Among Older Adults in HUD-Assisted Housing, Controlling for Confounding Factors. ASPE and the U.S. Department of Housing and Urban Development (HUD) released a follow-up report to the 2014 Picture of Housing and Health: Medicare and Medicaid Use Among Older Adults in HUD-Assisted Housing. This second report Picture of Housing and Health Part 2 analyzed health care utilization and spending, taking into account confounding factors. The first report found a high prevalence of chronic conditions and higher health care utilization for HUD-assisted Medicare beneficiaries compared to unassisted beneficiaries. The study sought to understand whether the higher utilization could be explained by the characteristics of the sample. This second report finds that after taking into account characteristics associated with health care utilization and payment, HUD-assisted Medicare beneficiaries do not consistently have higher utilization and payment for health care services than unassisted Medicare beneficiaries.
     HUD-assisted Medicare-Medicaid enrollees were generally less likely to use certain Medicare-covered services, such as acute inpatient stays and skilled nursing facility stays, and they had significantly lower Medicare FFS payments than unassisted Medicare-Medicaid enrollees.
     However, HUD-assisted Medicare-Medicaid enrollees were much more likely to use Medicaid-covered community-based supportive services such as personal care services, durable medical equipment, and HCBS, and have higher Medicaid FFS payments.

     This suggests that perhaps HUD-assisted Medicare-Medicaid enrollees were more aware of Medicaid-covered community-based supportive services than unassisted Medicare-Medicaid enrollees. While this indicates that HUD-assisted beneficiaries are not using more acute health care services than unassisted beneficiaries after controlling for confounding factors, they still represent a high risk, high needs group with a high prevalence of chronic conditions and disabilities. The study demonstrates that HUD-assisted Medicare-Medicaid enrollees may still be a fruitful target group for policy interventions, but that the interventions may vary depending on the type of Medicare beneficiary and the geographic location.
     For more information, see:
    Support and Services at Home Program. ASPE and HUD continue to evaluate the Support and Services at Home (SASH) program in Vermont. Early findings show a promising model of coordinated health and supportive services within affordable housing settings. Using claims data for a sample of Medicare FFS beneficiaries, the evaluation analyzed health care utilization and expenditures among SASH participants and a comparison group of Medicare beneficiaries living in affordable housing properties in Vermont. Analysis of Medicare claims data indicated that SASH participants in the early panels -- which included 40% of the site-based participants with Medicare coverage -- had lower rates of all-cause hospital admissions compared to non-participants. However, there was no evidence that the SASH program reduced the rates of emergency room visits. Medicare claims data also showed that, among the site-based SASH participants in early panels, growth in annual Medicare expenditures was slower by an estimated $1,227 per beneficiary per year. These same beneficiaries in the early panels also had slower rates of growth for hospital and specialty physician costs. Forthcoming products will show outcomes from the first 4 years of the program.
    For more information, see:
    Unlicensed Care Homes. ASPE released a report examining unlicensed care homes. Unlicensed care homes provide room, board and some level of services for two or more unrelated individuals, but are not licensed or certified by the state. These homes often serve very vulnerable individuals such as individuals with serious mental illness or other disabilities, or older adults with functional limitations and limited financial resources. Some of these homes are legally unlicensed while others operate illegally. The goal of this exploratory study was to understand how unlicensed care homes function as a residential care option, the types of individuals who reside in them, their characteristics including quality and safety and the policies that influence the supply of and demand for these homes. While exploratory in nature, the findings highlight potential issues of safety, abuse and financial exploitation in unlicensed care homes.
    For more information, see:

     Most of the public is aware of AD/ADRD; more than 85% of people surveyed can identify the disease and its symptoms. AD/ADRD is also one of the most feared health conditions. Yet there are widespread and significant public misperceptions about diagnosis and clinical management. These issues can lead to delayed diagnosis, and to people with the disease and their caregivers feeling isolated and stigmatized. Enhancing public awareness and engagement is an essential goal because it forms the basis for advancing the subsequent goals of the National Plan. A better understanding of AD/ADRD will help engage stakeholders who can help address the challenges faced by people with the disease and their families and caregivers. These stakeholders include a range of groups such as health care providers who care for people with AD/ADRD and their caregivers, employers whose employees request flexibility to care for a loved one with the disease, groups whose members are caregivers, and broader aging organizations. The strategies and actions under this goal are designed to educate these and other groups about the disease.


     Memory Sunday: Increasing Awareness of Alzheimer's Disease in Church Congregations. CDC supported the Balm in Gilead to develop and implement Memory Sunday, the Second Sunday in June, as a designated Sunday, within congregations serving African Americans, that provides education on AD: prevention, treatment, research studies and caregiving. The purpose of Memory Sunday is to bring national and local attention to the tremendous burden that AD/ADRD are having on the African American community; to utilize the power and influence of the African American pulpit to bring awareness; to distribute the facts about AD; to encourage participation in research studies; and to support persons living with AD and their caregivers.
    For more information, see:
    Alzheimer's Disease Resource Information. CDC developed in 2017 Alzheimer's and Healthy Aging Program Updates, which is a monthly email sent to more than 63,000 subscribers. Material contained in the emails are primary Federal Government resources for information about AD/ADRD, research, and caregiving.
    For more information, see:
    Cognitive Health Awareness. ACL rolled out a campaign to change the way consumers aged 60-70 think about their brains and brain health. The campaign encourages older adults to talk about their brain health and take steps to reduce associated risks. Those experiencing MCI are encouraged to seek medical attention. The What is Brain Health? Campaign's website is currently available and its launch focused on St. Louis and Las Vegas in 2015. Focus areas in 2016 were San Francisco and Chicago. Both years' efforts have national elements. Development of a What is Brain Health?Campaign for Hispanic audiences is underway in 2017.
    For more information, see:
    Alzheimer's Disease Information. NIA operates ADEAR Center, the primary Federal Government resource for information about AD/ADRD, research, and caregiving. The ADEAR Center educates the public about the latest research findings and provides evidence-based information online, in print and via a call center. Information about AD/ADRD, participation in clinical trials, and caregiving is freely available. NIA promotes ADEAR's resources through outreach in the research and care communities and through the media & advocacy organizations, via weekly e-alerts to more than 50,000 subscribers, and social media outreach to more than 10,000 followers. Beginning in late 2017, NIA will also manage to continue to expand public outreach about AD/ADRD.
    For more information, see:
    Public Outreach on Brain Health. The Brain Health Resource, a presentation toolkit on brain health as we age, was developed by ACL with NIH and CDC, for use at senior centers and in other community settings. Written in plain language, the evidence-based resource explains what people can do to help keep their brains functioning best. In 2016, the toolkit was expanded to include materials in Spanish and a new brain health module entitled, Medicine, Age, and Your Brain.
    NIH unveiled the Mind Your Risks public health campaign to educate people with high blood pressure about the importance of controlling blood pressure in midlife (ages 45-65) to help reduce the risk of having a stroke and possibly developing dementia later in life. The website includes research highlights, such as the Northern Manhattan Study, a NIH-funded investigation of the predictors of stroke, cognitive impairment, and dementia in a tri-ethnic community that may inform future intervention programs for prevention of stroke and cognitive decline in diverse populations.
    For more information, see:
    Public Health Research Network. CDC created the new HBRN in 2014, a thematic network in CDC's PRCs. The Network's activities build on the mission of CDC's HBI to better understand attitudes and perceived changes in cognitive functioning over time through public health surveillance, build a strong evidence base for communication (e.g., messaging) and programmatic interventions to improve or maintain cognitive function, and help to translate that evidence base into effective public health programs and practices in states and communities. The PRCs include the University of Washington Health Promotion Research Center (Coordinating Center), Oregon Health and Science University Center for Healthy Communities; University of Arizona Prevention Center; University of Illinois at Chicago PRC; University of Pennsylvania PRC; and University of South Carolina PRC.
    For more information, see:
    Message Development and Testing. CDC funded the development and dissemination of science-based, culturally-relevant messages and strategies that promote awareness about cognition and cognitive impairment, including AD/ADRD. The University of Pennsylvania PRC will assess perceptions about cognitive health and impairment among non-Hispanic White and African American adults aged 50 or older living in the Philadelphia area. This work is now being tested across the country with different populations at HBRN sites.
    Dementia Chart Book. ASPE is completing a chart book, Older Adults with Dementia and Their Caregivers in 2015: Key Indicators from the National Health and Aging Trends Study, which includes important information on the population of community-dwelling people with dementia in the United States and their caregivers. Dementia was more prevalent among people who were over age 80, had lower educational attainment, and were not non-Hispanic White. Older adults with dementia were more likely than those without dementia to have multiple chronic conditions, have functional limitations, experience depressive symptoms, or to need assistance. Older adults with dementia received significantly more hours of care per month than those without dementia. They had more informal caregivers and received more hours of care from those caregivers. More information and data are available in the chart book, which will be released in fall 2017.
    AFTD Educational Webinar Series. AFTD's Educational Webinar Series invites expert medical researchers, clinicians and other professionals to address issues important to all whose lives are impacted by FTD. These webinars represent both the clinical and care sides of FTD. Space is limited for people to participate live, but the recorded webinar is available to all on AFTD's website.
    For more information, see:
    Lewy Body Dementia: State of the Science. LBDA published a new report in 2016 called Lewy Body Dementia: State of the Science. Written for the general public and specifically the LBD community, this white paper highlights the progress made in LBD and promising areas for further study. A two page "brief" was also published.
    For more information, see:
    USAgainstAlzheimer's 2016 Summit. The 2016 Summit expanded to include a pilot Alzheimer's and Dementia Disparities Summit, co-hosted by the African American and Latino Networks and Leaders Engaged on Alzheimer's Disease, co-convened by UsAgainstAlzheimer's. More than 70 diverse academic, research, industry and federal stakeholders explored ways to eliminate disparities in AD/ADRD. The convening formulated the first-ever community driven action plan to increase awareness, understanding and action on AD among communities of color.
    We Won't Wait Campaign. WomenAgainstAlzheimer's network launched a campaign, We Won't Wait, with 25 organizational partners. It is the first-ever widespread effort to define AD as the 21st century's primary economic justice and health crisis for women, through collaborations with private sector companies that reach women; advocacy organizations in health, women's rights and business; and a women's leadership circle to disrupt the conversations about this disease. The campaign has five pillars: (1) multiply public funding for AD research; (2) demand sex-based research into AD; (3) alleviate the economic injustice of AD; (4) improve families' access to diagnosis, treatment and clinical trials; and (5) promote risk reduction strategies and ideas for living well with AD.


     Resources for Enhancing Alzheimer's Caregivers' Health into Indian Country. IHS and ACL are partnering with the REACH-VA training team at the University of Tennessee Health Sciences Center in REACH into Indian Country, a project funded by the Rx Foundation to implement the REACH caregiver support intervention across Indian Country. The initial goal of REACH caregiver support services, to be in at least 50 Tribal communities by February 2018, has nearly been reached. IHS and ACL continue work with VA to adapt and implement the REACH-VA program of caregiver support in Tribal communities through both public health nursing and the Tribal aging network, and are now focusing on increasing the impact of caregiver support services in those communities and on sustaining the initiative following the end of Rx Foundation funding. REACH-VA is an evidence-based translation that uses structured interventions to provide caregivers of people with dementia with tools and skills to manage ongoing caregiving challenges. VA is a source of clinical expertise in diagnosis and management of dementia for many Native veterans. IHS is building on VA work to test strategies for early recognition among family members, as well as clinical and aging services staff.
    For more information, see:…/10.1007%2Fs13142-017-0505-1
    Dementia Friendly America Community Toolkit. DFA offers a four phase community toolkit that convenes community leaders and supports them through a community change process that raises awareness about dementia. As communities undertake the toolkit they help foster awareness of dementia and its impact. The toolkit process provides each sector of the community with guides that help individuals in that sector interact with people living with dementia. Additionally, the Dementia Friends program is aligned with international efforts to consistently educate and raise awareness of dementia, its impact and how to interact with people living with dementia.
    For more information, see:


     World Dementia Research Leaders. In October 2016, representatives from NIH participated in the 24th Management Board Meeting of the European Union (EU) Joint Programme on Neurodegeneration (JPND) and delivered a presentation on the IADRP managed by NIA. Over 30 member countries participated in the meeting; focused on the overall goal of increased international collaboration.
    World Frontotemporal Degeneration Awareness Week. From September 25-October 9, 2016, people whose lives have been touched by FTD took part in the second annual World FTD Awareness Week. Across the country and around the world, families hosted gatherings at local restaurants, held conferences and other cultural events, participated via social media and told their stories to raise awareness of FTD. Global collaboration can improve quality of life for people facing FTD and drive treatment toward a cure.
    For more information, see:
    Global CEO Initiative Updates. In 2014, the Global CEO Initiative on Alzheimer's Disease (convened by UsAgainstAlzheimer's) joined the Organization for Economic Cooperation and Development, the government of Switzerland and Alzheimer's Disease International to host an annual global regulators and payers workshop. The 2016 workshop, the third in this series, focused on applying lessons from other diseases to AD payer and regulator challenges. Also in 2016, these meetings sparked "The Lausanne Dialogue on Alzheimer's" and spurred work at the country-level, most recently in Japan, the United States and Switzerland.
    For more information, see:

     The Federal Government is committed to better understanding AD/ADRD and its impact on individuals, families, the health and long-term care systems, and society as a whole. Data and surveillance efforts are paramount to tracking the burden of AD/ADRD on individual and population health, and will be used to identify and monitor trends in risk factors associated with AD/ADRD, and assist with understanding health disparities among populations such as racial and ethnic minorities. HHS will make efforts to expand and enhance data infrastructure and make data easily accessible to federal agencies and other researchers. This data infrastructure will help HHS in its multi-level monitoring and evaluation of progress on the National Plan.


     New Tool Enables Easier Tracking of NIH Research Milestones. NIH launched the Alzheimer's Disease and Related Dementias Research Implementation Milestone Database, a user-friendly web-based tool to track NIH funding initiatives and activities, targeting milestones aimed at achieving the Plan's ultimate research goal. Through the milestone database's linkage to IADRP, this resource encourages funders to coordinate and collaborate to maximize the impact of their collective investment in dementia research. It provides the public an easy-to-use but comprehensive window into the full landscape of research funded by NIH and provides a platform for other funders to also post their funding opportunities. Milestones currently track the entire AD/ADRD research landscape, including basic, translational, and clinical and health services research. The new AD/ADRD milestones from the NINDS-led summit in 2016 were added to the database in 2017.
    For more information, see:
    CDC Data Reports and Publications -- Increase in Alzheimer's Disease Deaths. CDC released Deaths From Alzheimer's Disease -- United States, 1999-2014 in May 2017. The authors found that death rates for AD have increased 55% from 1999 through 2014. These increases were seen in most states, all age groups, and all racial and ethnic groups examined. This article includes a county-level map of AD deaths that shows higher rates in the Southeast and some areas of the Midwest and West.
    For more information, see:
    Behavioral Risk Factor Surveillance System Data and Data for Action. CDC worked with partners and revised the BRFSS Cognitive Decline and Caregiving Optional Modules, which were approved as official optional modules beginning in 2015. In 2015 and 2016, 51 states and territories collected data using the Cognitive Decline Module and 40 states collected data using the Caregiving Module. Additional states are collecting data using the Cognitive Caregiving Modules in 2017. Findings from the 2015 cognitive and caregiving data are publically available on CDC's Healthy Aging Data Portal and fact sheets and infographics were developed for each participating states. Findings from 2016 BRFSS will be released late in 2017.
    For more information, see:
    National Health and Nutrition Examination Survey. CDC supported the development and collection of subjective cognitive decline and cognitive functioning data from the in-person National Health and Nutrition Examination Survey (NHANES) are publically available for download and analysis. These data were collected in adults 60 years and older as part of the 2011-2012 and 2013-2014 data collection cycles. The data included in this release include results from three tests of cognitive function: (1) the Consortium to Establish a Registry for Alzheimer's Disease (CERAD) Word Learning subtest; (2) a test of Animal Fluency; and (3) the Digit Symbol Substitution Test.
    For more information, see:
    CDC's Healthy Aging Data Portal. The portal was updated with CDC Updates Public Data Portal on the Health of Older Adults. CDC recently updated the Healthy Aging Data Portal, which provides access to a range of national, regional, and state data on older adults. This resource was developed by the National Center for Chronic Disease Prevention and Health Promotion. It allows users to examine data on key indicators of health and well-being for older Americans, such as tobacco and alcohol use, screenings and vaccinations, and mental and cognitive health.
    2015 BRFSS data includes data on cognitive decline from 35 states and data on caregivers from 24 states. Portal users can retrieve CDC data by indicator or by geographic area, and then use these data to develop reports and create customized maps, charts, and graphics. Public health professionals can use the data to create a snapshot of the health of older adults in their states, which can help them prioritize and evaluate public health interventions.
    For more information, see:
    Needs Assessment Toolkit. CDC supported the Alzheimer's Association to develop a Needs Assessment Toolkit that serves as Guidance and Resources for State Public Health Agencies on Comprehensive Needs Assessments Related to Alzheimer's and Other Dementias. This document aims to increase the use of information and insights to appropriately respond to the growing public health burden associated with AD/ADRD through comprehensive needs assessments. These are at the core of a state's ability to effectively use information to develop, implement, and maintain state plans that are focused either exclusively on AD/ADRD, or more broadly on the incorporation of cognitive health and impairment into other state public health plans. Public health agencies have a high level of expertise related to developing and conducting needs assessments. This toolkit has been developed to help states leverage their expertise in conducting needs assessments to enhance their ability to gather and use information specifically related to AD/ADRD.
    For more information, see:
    Diagnostic Coding for Dementia. HHS continues to partner with VA and other federal partners to examine AD/ADRD diagnostic codes and coding practices for federal agencies to use in analyses of administrative data to enhance reporting. The work will help prioritize research, clinical services, and caregiving resources.
    Quality Measures Under Consideration. CMS publishes a list of quality and cost measures (the "MUC List") under consideration for certain Medicare quality and value-based purchasing programs annually. The current list includes MUC 16-317, Safety Concern Screening and Follow-Up for Patients with Dementia: "Percentage of patients with dementia or their caregiver(s) for whom there was a documented safety screening in two domains of risk: dangerousness to self or others and environmental risks; and if screening was positive in the last 12 months, there was documentation of mitigation recommendations, including but not limited to referral to other resource."
    For more information, see:
    Progress in Dementia Measure Development. Measures have been in development to examine the evidence base and measurement gaps to develop de novo electronic clinical quality measures (eCQMs) related to dementia care. CMS has worked on two measures: (1) Cognitive Impairment Assessment Among Older Adults (75 years and older) -- Cognitive Impairment; and (2) Documentation of a Health Care Partner for Patients with Dementia or MCI -- Health Care Partner. The measures are under consideration for use in CMS's Quality Payment Programs.
    For more information, see:


     Healthy People 2020. CDC, in collaboration with NIH and ACL, released the midcourse review data for the Healthy People 2020 topic areas, Dementias Including Alzheimer's Disease.
    For more information, see:
    Non-Federal Items in the 2017 National Plan. The 2017 Plan Update includes a number of activities by non-federal partners. These partners were invited to contribute to the Plan Update to show progress made outside the federal agencies involved in NAPA, and to expand the focus of the National Plan more broadly to national work. These items have been organized according to the goals and strategies of the Plan. Additionally, in an effort to clearly respond to the annual recommendations made by the non-federal members of the Advisory Council, the 2017 Plan Update includes an appendix (Appendix 2) in which relevant federal agencies have directly responded to the recommendations made by the public Advisory Council members. Fulfilling the recommendations is contingent on limitations on legislative authority, resources, and data among the federal agencies and the Federal Government, and this appendix makes clear which recommendations have been addressed and which would require congressional authority or additional resources.

    Administration for Children and Families
    Administration for Community Living
    Administration on Aging
    Administration on Intellectual and Developmental Disabilities
    Agency for Healthcare Research and Quality
    Alzheimer's Association
    Association of State and Territorial Health Officials
    Association for Frontotemporal Degeneration

    Blanchette Rockefeller Neurosciences Institute

    Centers for Disease Control and Prevention
    Centers for Medicare & Medicaid Services
    Consumer Finance Protection Bureau

    Dementia Friendly America
    Department of Defense
    Department of Education
    Department of Health and Human Services
    Department of Housing and Urban Development
    Department of Justice
    Department of Labor
    Department of Veterans Affairs

    Food and Drug Administration

    General Accountability Office
    Georgia Department of Human Services
    Gerontological Society of America

    Health Resources and Services Administration

    Indian Health Service
    Institute of Medicine

    John A. Hartford Foundation

    Lewy Body Dementia Association

    Minnesota Board on Aging

    National Academies of Sciences, Engineering, and Medicine
    National Alzheimer's and Dementia Resource Center
    National Brain Health Center for African Americans
    National Center for Chronic Disease Prevention and Health Promotion
    National Center for Health Promotion and Disease Prevention
    National Center for Health Statistics
    National Center on Elder Abuse
    National Human Genome Research Institute
    National Indian Council on Aging
    National Institute of Neurological Disorders and Stroke
    National Institute on Aging
    National Institute on Disabilities, Independent Living and Rehabilitation Research
    National Institute on Minority Health and Health Disparities
    National Institutes of Health
    National Quality Forum
    National Science Foundation
    New York State Department of Health

    Office of Civil Rights
    Office of Global Affairs
    Office of Intergovernmental and External Affairs
    Office of the Assistant Secretary for Planning and Evaluation
    Office of the Assistant Secretary for Preparedness and Response
    Office of the Assistant Secretary for Public Affairs
    Office of the Assistant Secretary for Health
    Office of the National Coordinator of Health Information Technology
    Office of the Surgeon General
    Office of Women's Health
    Oregon Department of Human Services
    Organization for Economic Cooperation and Development

    Patient-Centered Outcomes Research Institute

    Social Security Administration
    Substance Abuse and Mental Health Services Administration


    Veterans Health Administration

    West Virginia Bureau of Senior Services


     Since 2012, the National Plan and its accompanying recommendations have catalyzed progress in the field of AD/ADRD.
    The 2017 Recommendations from the public members of the Advisory Council, and the responses from the relevant federal agencies are presented below. As stated previously, fulfilling the recommendations is contingent on limitations on legislative authority, resources, and data among the federal agencies and the Federal Government, and this appendix makes clear which recommendations have been addressed and which would require congressional authority or additional resources.
    The 2017 National Plan should continue to provide a robust, comprehensive, and transformative scientific Road Map for achieving the goal of preventing, effectively treating, and providing effective care and services for AD/ADRD by 2025.
     A Road Map for accomplishing the primary goal of the Plan should include input from experts in the field through research summits on AD/ADRD including a research summit on care and services.
     Recommendations from these summits and the research community should be re-evaluated each year and translated into milestones.
     Include specific research milestones to:
     Reduce racial/ethnic/socioeconomic disparities in AD/ADRD.
     Re-evaluate research priorities among AD/ADRD across all research areas (e.g., from identifying disease modifying treatments to identifying effective care and services).
     Include and prioritize specific milestones for populations at high risk for AD/ADRD (e.g., people with Down syndrome, African Americans).
     Increased attention should be paid to person-centered and family-centered outcomes with respect to research planning and the delivery of care and services.

    CMS Response
    CMS has supported work led by ASPE to engage in efforts to plan research summits on ADRD, including a fall 2017 summit on care and services. Through the "Connected Care" campaign, CMS, working with HRSA, is raising awareness of the benefits of Medicare's CCM service for beneficiaries with multiple chronic conditions including ADRD, and furnishing resources for implementation across all diverse populations. CMS is driving efforts to empower beneficiaries and their providers to make decisions, take ownership of their care, and make certain they have the information they need to make informed choices.
    NIH Response
    NIH will continue to engage a broad range of stakeholders, including academia, industry, NGOs, and individuals directly affected by AD/ADRD, in advancing the goals of the National Plan. This Plan focuses on identifying effective interventions and improving care and services, and its future updates will build upon research advances and emerging opportunities, and will be informed by additional research summits as well as feedback from the broader community. Upcoming summits that will provide guidance regarding future implementation of the Plan's goals include a summit focused on AD/ADRD care and services research in October 2017, and large AD and ADRD summits in 2018 and 2019, respectively.
    NIH leadership and staff continues to update its specific research plans and cost estimates annually, as outlined in each year's Bypass Budget for Alzheimer's Disease and Related Dementias. Part of this process involves regularly updating, implementing, and tracking a broad set of specific AD/ADRD research milestones. To enable federal agencies and other organizations to track progress in reaching these milestones, NIH has made a searchable database available to the public. The Advisory Council's recommendations regarding specific research milestones will greatly contribute to these NIH planning processes.
    For more information, see:

    A top priority remains the urgent need to continue to increase annual federal research funding sufficient to meet the 2025 goal.
     At present, the United States spends less than 0.5% of its annual care costs for ADRD on research, therefore investments in research should be increased to achieve the primary goal of the National Plan.
     Initial estimates suggested that $2 billion or more per year is needed and more accurate estimates can be generated by the Professional Judgment Budget.
     The annual professional judgment budget recommended by the Alzheimer's Accountability Act and prepared by the NIH should reflect the science-driven funding needs for the budget year to enable investigators to reach the 2025 goal of the plan.
     This investment would be applied to AD/ADRD research initiatives spanning basic, translational, clinical, care and services research.
    NIH Response
    As a component of HHS under the Executive Branch of the United States government, NIH cannot comment on targets for -- or algorithms that could be used to estimate -- the total research funds needed for AD/ADRD research, beyond the President's Budget and the estimate that NIH submits as part of the Bypass Budget for Alzheimer's Disease and Related Dementias.
    For more information, see:

    The 2017 National Plan should develop research goals aimed at the establishment of recommendations to improve uptake, spread and delivery of evidence-based and evidence-informed care and services.
     Enhance methodologies to effectively engage persons with dementia and families in research on care decision making and planning.
     Develop and implement quality care measures across all settings that include person-centered and family-centered outcomes.
     Identify and evaluate (non-drug) care strategies that reduce disease burden and delay disease progression and evaluate their costs and downstream effects.
     Study comprehensive dementia care from time of diagnosis to end-of-life and associated costs.
     Develop and evaluate effective care programs across diverse settings (e.g., home, nursing home, assisted living, community-based programs, primary care), disease etiologies and disease trajectories to address key clinical features including NPS and functional decline.
     Develop and evaluate technologies to link families to care providers, share information more efficiently, deliver care interventions, monitor health and symptom status and promote home safety.
     Convene a conference of key stakeholders to identify a meaningful pathway or pipeline for developing and testing non-pharmacological treatments, and scaling up and implementing effective approaches.
    CMS Response
    CMS, through its work to implement the National Quality Strategy and the CMS Quality Strategy, seeks to ensure person-centered and family-centered care across the health care landscape in partnership with beneficiaries, families, and caregivers. As one example, CMS regularly solicits nominations for TEP members for CMS measure development and maintenance contractors to provide input to the contractor on the development, selection, and maintenance of measures for which CMS measure contractors are responsible. Convening a TEP is one important step in the measure development or re-evaluation process that CMS uses to ensure transparency, and provides an opportunity to include multi-stakeholders early in the process. CMS, through its Medicaid Testing Experience and Functional Tools grants, is developing and testing electronic LTSS plans, personal health record systems, and Functional Assessment Standardized Items to use technology to better link beneficiaries, providers, and caregivers.
    NIH Response
    Research on provision of care and services for individuals with AD/ADRD and their families is an important research priority at NIH; the NIA has played a key role in developing the 2017 National Research Summit on Care, Services and Supports for Persons with Dementia and their Caregivers. The NIA looks forward to integrating recommendations from the 2017 Summit into its future planning and Funding Opportunity Announcement (FOA) development, following the meeting. Examples of past contributions include two FOAs (PAR-15-348 and PAR-15-351) released in September 2015 that focused on identifying, characterizing and addressing the needs of formal and informal caregivers and care recipients. Both funding announcements are open to receive applications through September 2018. In 2017, NIA released three additional FOAs aimed at research on improving care and utilizing new technologies to positively impact care ( PAS-17-027: Improving Quality of Care and Quality of Life for Persons with Alzheimer's Disease and Related Dementia at the End of Life; RFA-AG-17-065: Pragmatic Trials for Dementia Care in Long-Term Services and Supports (LTSS) Settings; and PAR-17-107: Development of Socially-Assistive Robots (SARs) to Engage Persons with Alzheimer's Disease (AD) and AD-Related Dementias (ADRD), and their Caregivers. Additionally, as the number of seniors wanting to age in place continues to rise, efforts by NIH, VA, academic and industry leaders are aiming to help to achieve this goal. Through the CART Initiative launched in 2016, research investigators will be able to validate existing and new technology (e.g., sensors, Apps, robots, etc.) that could track changes in older adults' health status and activities unobtrusively in real time. NIH scientists hope CART will help elders remain independent while avoiding hospitalizations and transitions into care facilities and see the project as potentially transformative for the field of aging research and care for older adults.
    For more information, see:

    Emphasis should be given to the standardization of terminology in dealing with cognitive and dementing disorders.
     A federally-led working group of thought leaders should be convened to identify existing barriers, opportunities and recommend strategies to develop consistent language for cognitive disorders among the scientists, care providers and the public.
     Engage all of the stakeholders around these issues to reduce the use of confusing or conflicting terminology and propose improved terminology for the benefit of persons with dementia, their family members and caregivers and the scientific and service communities.
    NIH Response
    NIH supports the effort to standardize language in this area of research, and devoted a special session to this topic at the recent Alzheimer's Disease-Related Dementias 2016 Summit, specifically to discuss issues and challenges regarding nomenclature and to gather suggestions on how to move forward. One of that Summit's draft recommendations proposed that a working group be organized to include all stakeholders and convene a workshop to develop a coherent nomenclature for all dementias. Once the NAPA Advisory Council establishes this working group, it will develop a plan for taking next steps and gathering public input on the issue. NIH recognizes that standardization is critical, but standards developed and applied for different types of stakeholders (e.g., research vs. public) may need to be interoperable rather than identical.
    One of the ADRD 20016 Summit's recommendations, now formalized as one of the ADRD Prioritized Research Milestones (Topic 2 Focus Area 2), is to organize a working group of all dementia stakeholders and convene a meeting to develop a consistent nomenclature in dementia research and care. At the National Research Summit on Care, Services, and Supports for Persons with Dementia and their Caregivers in October 2017, there will be another session on nomenclature to discuss challenges associated with dementia nomenclature such as stigma and limited access to care and services.
    This NAPA Council recommendation broadens the scope of the nomenclature issue, and emphasizes the need for a national effort that requires participation from all stakeholders and coordination across not only the Federal Government but also the entire community involved in dementia care and research. It will be crucial to bring scientists, clinicians, individuals with AD/ADRD, families, and caregivers together to be on the same page, and at the same time develop standards that can be applied for different types of stakeholders. An important part of the goal will be to increase the lay public's understanding of dementia diagnoses by using plain and clear language without sacrificing accuracy of terminology.
    For more information, see:

    As recommended in the National Plan the United States government should support global efforts to address issues of research, care and services.
     United States public and private entities should acknowledge and scrutinize the work of the World Dementia Council and the World Health Organization (WHO).
     Continued collaborations on international research efforts should be promoted.
    NIH Response
    NIH communicates regularly on global efforts in a variety of forums with government representatives and many other stakeholders in the international dementia community. Staff welcome these discussions and resulting opportunities for collaborations. As one critical example, NIA and the Alzheimer's Association developed the IADRP tracking system, in order to catalog, search, and interrogate projects in this area of research supported by NIH, other United States federal and state agencies, several voluntary organizations, and many international funders. The United States welcomes additional participation in this database by governmental organizations or NGOs. IADRP currently captures more than 7,000 unique projects conducted by more than 4,000 researchers across more than 1,000 institutions -- supported by 35 public, private and international funding organizations in 11 countries: the United States, Australia, Brazil, Canada, Czech Republic, France, Italy, the Netherlands, Poland, United Kingdom, and Germany -- reflecting more than $5.7 billion in research funding worldwide. In October 2016, representatives from NIH participated in the 24th Management Board Meeting of the EU JPND and delivered a presentation of IADRP. Over 30 member countries participated in the meeting; focused on the overall goal of increased international collaboration. Additionally, multiple NIA-supported programs such as the Dominantly Inherited Alzheimer's Network, ADNI3, and the Health and Retirement Study include international sites.
    In addition, NIA continues to co-host quarterly international funders conference calls with the Alzheimer's Association -- which offers an opportunity for NIH and other organizations to discuss research priorities and initiatives.
    As a third example, foreign institutions are eligible to apply for funding to support research solicited in both of the FOAs for Research on Informal and Formal Caregiving for Alzheimer's Disease (PAR-15-348 and PAR-15-351), which specifically encouraged both national and cross-national population-based research, and in the Health Disparities and Alzheimer's Disease FOA (PAR-15-349). In 2017, NIH released an additional FOA aimed at Improving Quality of Care and Quality of Life for Persons with Alzheimer's Disease and Related Dementia at the End of Life (FOAs PAS-17-027), which is also open to foreign institutions.
    For more information, see:

    A major area of emphasis for the 2017 National Plan should include the enhancement of recruitment efforts for randomized controlled trials for AD/ADRD.
     A major challenge in the development of effective therapies for AD/ADRD has been the inefficient recruitment of participants in clinical trials.
     Emphasis should be placed on the enhancement of diversity and inclusiveness in these efforts.
     The documentation of recruitment goals should be required in applications for randomized controlled trials and incentives should be in place for meeting those goals.
    NIH Response
    With substantial community and stakeholder involvement, NIA is leading efforts to provide practical approaches to help study sites and researchers overcome the challenges and barriers in recruiting and retaining the right volunteers, at the right times, in the right studies. With facilitation by the Alzheimer's Association and in collaboration with a wide group of government, private, and academic stakeholders, NIA is developing a National Strategy for Recruitment and Participation in Alzheimer's Disease Clinical Research. In 2017, NIA convened a workshop for experts from academia, communications, advocacy, and clinical care and research to identify the best strategies for engaging a range of audiences, including minority and underrepresented groups, in the clinical research enterprise. When the strategy is finalized, attention will turn to its implementation, not only for actions that can be considered by the Federal Government, but by stakeholders in government, academia, advocacy, medicine and the public with an interest in progress in AD research.

    The National Plan should continue to promote early detection and diagnosis of AD/ADRD by encouraging cognitive assessment while at the same time CMS works to confirm measurement strategies to track progress through the implementation of new quality measures.
     Specifically, within the next year, CMS should implement the new quality measure: Cognitive Impairment Assessment Among At-Risk Older Adults. Percentage of patients age 75 years or older at the start of the measurement period with documentation in the electronic health record (EHR) at least once during the measurement period of: (1) results from a standardized cognitive impairment assessment tool; or (2) a patient or informant interview.
     The cognitive assessment should be conducted per the guidance provided by the Medicare Detection of Cognitive Impairment Workgroup's Recommendations: Alzheimer's Association recommendations for operationalizing the detection of cognitive impairment during the Medicare AWV in a primary care setting. Alzheimer's & Dementia. March 2013; 9 (2)141-150.
    CMS Response
    Dementia: Cognitive Assessment (Percentage of patients, regardless of age, with a diagnosis of dementia for whom an assessment of cognition is performed and the results reviewed at least once within a 12 month period, is available as an applicable measure in the new Quality Payment Program for Merit-Based Incentive Payment System physicians and groups. CMS develops and tests an array of measures for many of its quality programs that could impact beneficiaries with dementia, and continues its work as a measure developer to develop and implement performance measures for use in multiple programs across care settings. CMS has worked on developing two electronic clinical quality measures (eCQMs) to address quality of care for patients at-risk of or who have cognitive impairment: (1) Cognitive Impairment Assessment Among Older Adults (75 years and older) -- Cognitive Impairment Assessment; and (2) Documentation of a Health Care Partner for Patients with Dementia or MCI -- Health Care Partner. Next steps during the pre-rulemaking process would be inclusion in the annual CMS Measures Under Consideration (MUC) List.
    IHS Response
    The IHS will continue to develop workforce training and community education strategies to enhance recognition of cognitive impairment and effective diagnosis.
    NIH Response
    Given that treatments are very likely to be most effective the earlier they are instituted, NIH released a new FOA in 2017 to increase early detection of cognitive impairment, including dementia, when a patient or a caregiver voices a concern in primary care and other everyday clinical settings. The goal is to create a research consortium to develop and test clinical paradigms that utilize cognitive assessment tools (new or existing) that are simple to use, standardized, and can be quickly administered in a primary care setting. This includes addressing barriers that are unique to health disparities populations in the United States. This funding opportunity is directly responsive to one of the ADRD 2016 Prioritized Research Milestones, and aims to address the issue of under-detection of cognitive impairment by validating and standardizing cognitive assessment tools into user-friendly paradigms suitable for primary care in typical large and diverse populations in the United States.
    With respect to education on early detection and diagnoses, several NIA resources are already available to support clinicians in assessing and managing patients with cognitive impairment; see the "Assessing Cognitive Impairment," "Managing Cognitive Impairment," and the "Patient Checklist" sections of the Alzheimer's and Dementia Resources for Professionals web page. Moreover, clinicians can use the "Talking with Your Patients About Cognitive Problems" chapter of NIA's new Talking with Your Older Patient resource to initiate conversations about these and other related issues. NIH strongly supports moving forward with an educational outreach campaign to clinicians.
    For more information, see:

    CMS should annually report data by state/region and by diagnosis regarding the use of the new G0505 billing code.
     The new G0505 billing code provides for cognition and functional assessment using standardized instruments with development of recorded care plan for the patient with cognitive impairment, history obtained from patient and/or caregiver, in office or other outpatient setting or home or domiciliary or rest home.
    CMS Response
    Because it is a new service, CMS does not have information on utilization for code G0505 at present. CMS may monitor utilization data in the future.

    Federal agencies should offer and support educational efforts that improve health care providers' ability to recognize early signs of dementia, including AD/ADRD, and to offer counseling to individuals and their caregivers, as well as connect them to local services and resources.
     A working group of health professional associations should be convened to develop competencies in delivering evidenced-based dementia care across care settings.
     Training related to quality dementia care should be included in curricula and continuing education sessions for health professionals.
     Specifically, training should enhance health care provider awareness and understanding of the Medicare AWV, knowledge of validated cognitive assessment tools, methods for reporting all dementia-related quality measures active in the Quality Payment Program, and the Cognitive Impairment Assessment and Planning Code G0505.
    CMS Response
    CMS continues its work with the OWH and HRSA to promote current policies and practices that improve the ability of caregivers for persons living with ADRD to manage or sustain their own health, and is helping its partners package training "modules" to educate and support caregivers. CMS continues to address (e.g., Medicare Learning Network, National Partnership to Address Dementia Care in Nursing Homes, the Long-Term Care Final Rule, and other policy issuances) dementia care training for health providers.
    NIH Response
    With respect to education on early detection and diagnoses, several NIA resources are already available to support clinicians in assessing and managing patients with cognitive impairment; see the "Assessing Cognitive Impairment," "Managing Cognitive Impairment," and the "Patient Checklist" sections of the Alzheimer's and Dementia Resources for Professionals web page. Moreover, clinicians can use the "Talking with Your Patients About Cognitive Problems" chapter of NIA's new Talking with Your Older Patientresource to initiate conversations about these and other related issues. NIH strongly supports moving forward with an educational outreach campaign to clinicians.
    For more information, see:

    The Advisory Council on Alzheimer's Research, Care and Services should devote one meeting to advancing the work ASPE has conducted with RTI International on defining best practices for comprehensive dementia care.
     Specific topics should include: (1) an in-depth description of the Examining Models of Dementia Care report and appendices; (2) federal agency reporting of current innovative services for persons with dementia and their caregivers; and (3) non-federal reporting from health systems and/or payers of exemplar population health solutions for dementia care. Advisory Council discussion of next steps to advance consensus definitions of best practice models, including measurement targets for clinical outcomes and value-based outcomes concerning cost and the care experience.
    ASPE Response
    The Examining Models of Dementia Care: Final Report is published and available on the ASPE and NAPA websites. As was discussed during the April 2017 NAPA Advisory Council meeting, there are a number of different directions in which to pursue future research, and ASPE would welcome the opportunity to discuss these opportunities in greater detail with the Advisory Council at-large, or with one or more of the relevant NAPA subcommittees.
    For more information, see:

    CMS should use the results of evidenced-based programs combined with definitions of best practices for comprehensive dementia care to provide adequate payment and incentives for providing evidenced-based care. This could include a comprehensive risk-based payment for reimbursement of comprehensive dementia care services.
     For example, CMS should use the results of evidenced-based programs, combined with definitions of best practices for comprehensive dementia care, to create a fixed Per Beneficiary Per Month (PBPM) payment for reimbursement of comprehensive dementia care services. The first target for the PBPM payment model should be community-dwelling persons with dementia and their caregivers who are not eligible for (or do not have access to) a PACE.
     CMS should establish a system for determining that accountable entities receiving PBPM payments have the ability to supply all essential elements of comprehensive dementia care.
     Congress and/or federal agencies should authorize and/or designate funding to conduct large-scale evaluation of the PBPM payment model for comprehensive dementia care; and, if the evaluations replicate the value proven by CMS dementia demonstration projects, then CMS should implement the PBPM model nationwide.
    CMS Response
    CMS periodically offers opportunities for states and other entities to apply for demonstrations, waivers, and models and other special initiatives through the Medicaid program, and the Center for Medicare and Medicaid Innovation (the Innovation Center). States and accountable entities (such as Medicare ACOs), when applying for/implementing such opportunities, have some discretion in choosing what topics to address (e.g., AD/ADRD) within these. The Innovation Center is focused on testing new payment and service delivery models, and evaluating and sharing the results. Occasionally, there may be a path to wider adoption in a CMS program, should a model meet statutory and other criteria. Such adoption would be subject to a formal rulemaking process including opportunities for public comment. Public and private payers such as state Medicaid agencies, state and local governments, managed care plans, private insurers, and other entities are encouraged to review the results of CMS model testing and demonstration results, and adopt best practices.CMS will keep stakeholders appraised of future opportunities to provide input as models, including those that address ADRD and/or behavioral health, are developed.

    Changes to national health care must ensure continuation of support that is critical to people living with dementia and their caregivers including Medicare AWVs that include cognitive assessment, protection for pre-existing conditions, funding for person-centered and family-centered research on dementia, and support for innovative models of care.
    CMS Response
    CMS is driving efforts to empower beneficiaries, consumers, and their providers to make decisions, take ownership of their care, and make certain they have the information they need to make informed choices.

    Federal agencies, national health and aging organizations, states, and other industry stakeholders should identify ways to implement recommendations that result from the October 2017 National Research Summit on Care, Services and Supports for Persons with Dementia and their Caregivers.
    Combined Federal Response
    The member agencies of the NAPA Advisory Council are committed to research that improves the lives of individuals with dementia and their caregivers. We will identify any and all recommendations from the Summit, and consider them as we develop and update our research milestones.
    For more information, see:

    Congress, federal agencies, and states must expand efforts to address the needs of family caregivers, including caregivers from diverse racial/ethnic/socioeconomic groups, caregivers of younger adults and people with IDD, and children and youth who provide care for older adults. Particular support is needed to expand and scale effective caregiver interventions for diverse racial/ethnic/socioeconomic groups; address reimbursement, training, and HIPAA policy and practice barriers to enable health care providers to provide care planning with family caregivers; increase support for respite care; and address the financial burden to family caregivers. To accomplish this:
     Increase federal funding by at least 50% for ACL dementia-specific funding that supports state, Tribal, and community dementia interventions by 2020.
     Use results of October 2017 Care Summit to build and fund a research and translation strategy to address clinical care, and LTSS.
     90% of people with AD/ADRD and their key family and friend caregivers have access to a community-based education or support program on dementia caregiving by 2025.
     Amend the Older Americans Act (OAA) to allow additional OAA services to be provided to younger adults with dementia.
     Double funding for the National Family Caregiver Support Program, including funding for tribes under the OAA Title VI, by 2020.
     Educate health care providers on HIPAA by 2020, including clarification on HIPAA implementation, ways to support person-centered plans and advance care planning, addressing HIPAA concerns, and the provision of care when the person may not be competent. This should be accomplished by CMS, HRSA and states.
     Designate the primary caregiver role in both the caregiver's own medical record, and in the care recipient/patient's medical record systems by 2020.
     Expand Medicare benefits to ensure individuals with AD/ADRD and their families receive information, care coordination, caregiver supports, and HCBS.
     Expand innovative paid and volunteer respite programs.
     Promote state expansion of respite care through Medicaid waiver programs or state-funded respite services.
     Establish tax and Social Security credits for family caregivers by 2020.
     Increase by at least 50% funding for Medicaid's Money Follows the Person demonstration program, self-directed HCBS programs, and caregiving options that pay friend/family caregivers.
     Expand the Family Medical Leave Act and state laws to expand paid family leave for family caregivers.
     Identify the roles, prevalence, and impact of caregiving among young children, including children in immigrant, minority, and Tribal populations, who provide care for older adults with dementia.
     Provide resources to states, tribes, and communities to provide outreach and support to families and children where children provide caregiving for older relatives with dementia.
    ACL Response
    ACL continues to make federal funding available for dementia-specific programs that support state, Tribal, and community dementia interventions. Funded programs promote development of new dementia-capable service systems across the country, expansion of existing systems, as well as caregiver education and support. Other recommendations in this section would require changes to federal law or appropriations.
    CMS Response
    CMS beneficiaries may have a representative of their choosing (including an emergency contact) with access to information and participates in health care discussions with their knowledge and consent, as well as a legal representative such as an individual who has a power of attorney for health care, a guardian, or health care surrogate or proxy appointed in accordance with state law act on their behalf, if they are unable to make their own decisions. CMS regularly works with its HRSA partners, and provides education and information through a variety of venues on an array of topics (e.g., Open Door forums, Medicare Learning Network, "Grand Rounds," etc.). CMS is ushering in a new era for the federal-state Medicaid partnership where states have even more freedom to design programs that meet the spectrum of diverse needs of their Medicaid population, and is empowering states to advance the next wave of innovative solutions to Medicaid's challenges through solutions that focus on improving quality, accessibility, and outcomes in the most cost-effective manner. States, as administrators of the Medicaid program, are in the best position to assess the unique needs of their respective Medicaid-eligible citizens and to drive reforms that result in better health outcomes. CMS will continue to provide technical assistance to states that want to provide self-directed service delivery mode options and paid family caregiver options in their Medicaid HCBS programs.
    IHS Response
    IHS will review the findings of the October 2017 Care Summit to inform priorities in support of spread of evidence-based services in Tribal communities. Additionally, IHS continues efforts to expand caregiver support services through the REACH intervention in Tribal communities.
    NIH Response
    NIH recognizes the importance of research to understand and address caregiver needs. The REACH intervention, supported by NIH, developed the first intensive caregiver support intervention to be proven effective, through rigorous testing, in an ethnically diverse population. The REACH intervention is currently being translated more broadly through the VA, with participating centers in 15 states. The VA is also partnering with ACL, IHS, and a private foundation to adapt and implement REACH in Tribal communities. In addition, NIH is currently supporting the design, development, implementation and dissemination of numerous other ADRD-related interventions, as well as evidence-based tools and training materials to help support the many and various needs of caregivers for example, the New York University Caregiver Intervention.
    For more information, see:

    Federal agencies, states, and health systems must take steps to increase identification of people with dementia who live alone, and to provide programs and services to meet the needs of this population.
     Increase by at least 50% ACL dementia funding for community Gatekeeper programs that train community partners to identify and connect at-risk and live alone individuals to community aging services.
     Double funding for the National Family Caregiver Support Program by 2020, including specific outreach and support to families who care for individuals who live alone.
     Identify existing information from federal agencies including ACL, CMS, HUD, Department of Transportation (DoT) or others, on the prevalence and housing situation for individuals who may have dementia and live alone.
     Identify best practices for housing and transportation services that can meet the needs of individuals with cognitive impairment or dementia who live alone.
    ACL Response
    ACL continues to make federal funding available for dementia-specific programs that support state, Tribal, and community dementia interventions. ACL's funded programs promote development of new initiatives designed to identify and provide supportive services to at-risk and/or under-served populations, including individuals who live alone. Other recommendations in this section would require changes to federal law or appropriations.
    CMS Response
    CMS established the Medicaid Innovation Accelerator Program (IAP) with the goal of improving health and health care for Medicaid beneficiaries by supporting states' ongoing efforts related to payment and delivery system reforms through the provision of technical assistance, tools development and cross-state and national learning opportunities. In 2017, IAP launched the second "track" of the State Medicaid-Housing Agency Partnerships. The goals of the State Medicaid-Housing Agency Partnerships are to develop public and private partnerships between Medicaid and housing systems and to support states in the creation of detailed action plans that foster additional community living opportunities for Medicaid beneficiaries. Consistent with statute, CMS does not provide funds for room and board. Program support begins this fall and runs for 9 months. It will offer intensive, hands-on technical support to move state Medicaid agencies towards building sustained collaborations with housing partners, and those from other service agencies.
    NIH Response
    NIH supports research to identify people with dementia who live alone. In a recent study supported by NIA, it was estimated that of people with dementia living in the community, 14.3% live by themselves. The identification of the needs of persons living alone with dementia can lead to continued health-focused research on this vulnerable population. NIA values this population and recognizes that more research is needed in this area.
    For more information, see:

    Federal agencies, states, and health systems must increase efforts to assess, prevent, and manage behavioral symptoms associated with dementia through effective programs and services and improved workforce knowledge and skills.
     Incorporate AD/ADRD standards, including standards for effective ways to address behavioral symptoms, into all relevant clinical and LTSS quality measures by 2022.
     Increase by at least 50% dementia funding for training and scaling of evidence-based behavioral symptom management interventions for persons with AD/ADRD.
     Double HRSA funding for geriatric workforce training that includes increased dementia training to address challenging behavioral symptoms.
    ACL Response
    ACL continues to make federal funding available for dementia-specific programs that support state, Tribal, and community dementia interventions. ACL's funded programs promote development of new and/or expanded efforts to address behavioral symptoms attributable to AD/ADRD. All ACL AD/ADRD grant programs require inclusion of evidence-based and evidence-informed interventions in support of individuals living with AD/ADRD and their caregivers. Other recommendations in this section would require changes to federal law or appropriations.
    CMS Response
    Last year CMS, with the assistance of ACL, released a set of "FAQs" that discuss strategies to ensure the health and safety of Medicaid beneficiaries at-risk of wandering, including people with ADRD. These focus on how person-centered planning can be used to identify any appropriate restrictions while facilitating individualized services and community integration. CMS also furnished guidance to states on suggested approaches to strengthen and stabilize the Medicaid home care workforce.
    IHS Response
    IHS will be exploring the use of Project Extension for Community Healthcare Outcomes (ECHO) to provide both clinical consultation and training in the diagnosis and management of dementia in Tribal communities. The IHS and ACL partner in training the Tribal Aging Network in the recognition and management of ADRD in Tribal communities.

    Federal agencies, states, national health and aging organizations, and community partners must continue to expand public awareness and training, reduce stigma, and help connect people to information and available resources. Outreach should include children and youth, diverse racial/ethnic/socioeconomic groups, and people with IDD.
     Increase and coordinate federal agency, state, and national organization funding for innovative outreach and messages, in order to reach diverse populations.
     Increase information developed for children and youth using video and social media, and provided through school curriculum and youth-serving organizations.
     Develop expanded partnerships to support outreach through groups such as unions, community colleges/adult education, community and faith organizations, and first responders.
     Increase engagement of national health-related organizations (e.g., Down syndrome, heart, and diabetes) in providing information and resources addressing dementia.
     Study ways these websites may be used to further expand outreach to diverse racial/ethnic and socioeconomic groups.
    ACL Response
    ACL continues to make federal funding available for dementia-specific programs that support state, Tribal, and community dementia interventions. ACL's funded programs promote outreach to and services for diverse and under-served populations, including dementia-friendly community education efforts. Other recommendations in this section would require changes to federal law or appropriations.
    IHS Response
    IHS is working with the Alzheimer's Association and the National Indian Council on Aging to increase understanding and awareness of ADRD in Tribal communities.
    NIH Response
    Beyond research-specific efforts, NIH is also committed to continuing to enhance and provide evidence- based information, resources, and referrals through the ADEAR Center to specific populations of people with AD/ADRD and their caregivers including younger people, non-traditional families, people with IDD, such as Down syndrome, and racial and ethnic minorities who are at increased risk of acquiring AD/ADRD. NIA plans to convene a meeting of federal communicators at agencies involved in AD/ADRD research, care and services to enhance collaboration outreach generally and in the upgrading and promotion of and for an increasingly diverse public audience.

    Action Number Action Description
    (from Plan) Method of Action Lead Agency Partner(s) Project Completion Date/Status Activities in 2016 and 2017
    Goal 1: Prevent and Effectively Treat Alzheimer's Disease and Related Dementias by 2025
    Strategy 1.A: Identify Research Priorities and Milestones
    1.A.1 Regularly convene an AD Research Summit to update priorities. Summit held 2015.
    Summit scheduled for March 1-2, 2018. NIH/NIA National & international experts, public & private stakeholders, Research Subgroup, academia, industry, professional & advocacy groups Second Summit February 2015
    Third Summit March 2018 2015 AD Research Summit
    1.A.2 Solicit public & private input on AD/ADRD research priorities. Developed recommendations & milestones from 2015 AD Research Summit based on feedback from external stakeholders.
    Presented recommendations & milestones during IADRFC calls. NIH/NIA Ongoing
    Recommendations--March 2015
    Milestones released--July 2015
    Recommendations & Milestones will be updated following the next Summit in March 2018 2015 AD Summit Recommendations
    2017 National Research Summit on Care, Services and Supports for Persons with Dementia and their Caregivers
    Updated AD Research Implementation Milestones
    1.A.3 Regularly update the National Plan & refine Goal 1 strategies & action items based on feedback & input. Update Goal 1 elements of the National Plan to reflect new insights & input from the community. ASPE Advisory Council, NIH/NIA & Research Subgroup Ongoing
    1.A.4 Update research priorities & milestones. Updated research priorities & milestones. ASPE Advisory Council, NIH/NIA & Research Subgroup Ongoing
    1.A.5 Create a timeline with milestones for achieving Goal 1. Create & update milestone document. NIH/NIA, NIH/NINDS Ongoing Updated AD Research Implementation Milestones:
    Full set of milestones through 2025
    2018 Milestones
    2019 Milestones
    Updated the searchable AD/ADRD Research Implementation Milestones Database
    1.A.6 Regularly convene an ADRD Summit to review progress on ADRD research recommendations & refine & add new recommendations as appropriate, based on recent scientific discoveries. Convene third summit in 2019. NIH/NINDS Research Subgroup, academia, industry, professional & advocacy groups Second Summit Held March 29-30, 2016
    Third Summit expected 2019 The updated recommendations from ADRD 2016 Summit were approved by NINDS Advisory Council in September 2016 & presented to the NAPA Council in February 2017. Final recommendations became the ADRD Summit 2016 Prioritized Research Milestones, which can be found here:
    1.A.7 Convene a workshop focused on research needs related to Down syndrome & AD/ADRD. Hold a workshop to solicit input on special research priorities & timelines AD/ADRD among people with Down syndrome. NIH/NIA DSRTF, RDS Ongoing
    11th Meeting of the Down Syndrome Consortium: A Public-Private Partnership Input solicited on special research priorities related to Down syndrome research.
    11th Meeting of the Down Syndrome Consortium: A Public-Private Partnership including several NIH ICs (NICHD, NCI, NHLBI, NHGRI, NIDCR, NIDCD, NIDDK, NIMH, NINDS, NIA, & NIMHD)
    NIA & NICHD collaborated to produce & disseminate information for people with Down syndrome & their families on the interplay of these conditions & the importance of participating in research. Efforts include a fact sheet, "Alzheimer's Disease in People with Down Syndrome", & outreach via email & social media
    Alzheimer's Biomarker Consortium-Down Syndrome aims to identify biomarkers that indicate AD is developing or progressing & track the AD process in people with Down syndrome.
    Additionally, the NIA is currently funding a Phase I clinical trial to investigate the safety & tolerability of an immunotherapy vaccine for treatment of Alzheimer's in adults with Down syndrome
    Strategy 1.B: Expand Research Aimed at Preventing and Treating Alzheimer's Disease and Related Dementias
    1.B.1 Expand research to identify the molecular & cellular mechanisms underlying AD/ADRD, & translate this information into potential targets for intervention. Develop an integrated interdisciplinary basic science research agenda to enable the identification & selection of therapeutic targets. NIH/NIA Potential research partners in the public & private sectors Ongoing Ongoing & newly released NIH FOAs:
     PAR-17-047: Selective Cell & Network Vulnerability in Aging & AD
     PAR-17-039: Comparative Biology of Neurodegeneration
     PAR-17-033: Integrative Research to Understand the Impact of Sex Differences on the Molecular Determinants of AD Risk & Responsiveness to Treatment
     PAR-17-031: Role of Age-Associated Metabolic Changes in AD
     PAR-17-029: Dynamic Interactions between Systemic or Non-Neuronal Systems & the Brain in Aging & in AD
     PAS-17-028: Mechanisms & Interactions Among Neurodegenerative Diseases
     PAR-16-371: Phenotypic & Functional Characterization of ApoE2 to Inform Translation Strategies for Aging-Related Conditions
     PAR-15-358: Capturing Complexity in the Molecular & Cellular Mechanisms Involved in the Etiology of AD (R01)
     PAR-15-357: Understanding AD in the Context of the Aging Brain
     PAR-15-350: Emerging Directions for Addressing Health Disparities in AD
     PAR-15-349: Health Disparities & AD
    AMP-AD Activities are also relevant:
    1.B.2 Expand genetic epidemiologic research to identify risk & protective factors for AD/ADRD. Conduct WGS to identify areas of genetic variation that correspond to risk factors of AD/ADRD. NIH/NIA Potential research partners in the public & private sectors Ongoing Ongoing & newly released FOAs:
     PAR-17-214: Limited Competition: Analysis of Data from NIA's ADSP Follow-Up Study
     PAR-16-371: Phenotypic & Functional Characterization of ApoE2 to Inform Translation Strategies for Aging-Related Conditions
     PAR-16-205: NIA LOAD Family-Based Study
     PAR-16-047: NIAGADS
     NOT-AG-16-033: Notice of Information: The ADSP Policy on the Publication of Study-Related Data
     RFA-AG-16-002: ADSP Replication Phase Analysis Studies
     PAR-16-406: Limited Competition: Additional Sequencing for the ADSP
     PAR-15-356: Major Opportunities for Research in Epidemiology of AD & Cognitive Resilience
    Continue to support efforts through the ADSP, ADGC & NIAGADS.
    Next generation sequence Data are available for 17,588 subjects (cases, controls & family members) including phenotype & individual-level information
    1.B.3 Increase enrollment in clinical trials & other clinical research through community, national, & international outreach. Identify approaches & coordination points for these efforts; develop an action plan that incorporates these ideas; collaborate to increase awareness among health & social service providers. NIH/NIA, ACL, CDC, VA FDA, VA, CDC, HRSA, CMS, in partnership with the private sector Ongoing In 2016, NIA launched an effort to identify & disseminate effective approaches & best recruitment & retention practices. With facilitation by the Alzheimer's Association & in close collaboration with experts from government, private, & academic sectors, these approaches will be outlined in the still-in-development National Strategy for Recruitment & Participation in AD Clinical Studies.
    NIA continues to promote participation in AD/ADRD clinical trials, studies, & registries through our ADEAR website portal (; clinical trials listing & monthly e-alert to more than 35,000 subscribers; social media messages through Facebook & Twitter; promotion of the ROAR toolkit of customizable materials for aging services & public health professionals to use in community settings & social media( inEnglish, Spanish, & Chinese, & collaboration with ACL, CDC, FDA & the PCORI-funded Alzheimer's & Dementia Patient/Caregiver-Powered Research Network to encourage research participation among older adults..
    In June 2017, NIH hosted a workshop entitled Inclusion Across the Lifespan, to examine the science of inclusion of various populations in clinical trials & studies.
    1.B.4 Monitor & identify strategies to increase enrollment of racial & ethnic minorities in AD/ADRD studies. Track enrollment in NIH AD/ADRD studies; identify & implement next steps for engaging & enhancing research participation by racial & ethnic minorities; raise awareness of need for participation. NIH/NIA, NIH/NIMHD ACL Ongoing Ongoing & newly released FOAs:
     PAR-15-350: Emerging Directions for Addressing Health Disparities in AD
     PAR-15-349: Health Disparities & AD
    In 2016, NIA launched an effort to identify & disseminate effective approaches & best recruitment & retention practices, with a particular focus on reaching diverse communities. In facilitation with the Alzheimer's Association & in close collaboration with experts from government, private, & academic sectors, these approaches will be outlined in the still-in-development National Strategy for Recruitment & Participation in AD Clinical Studies.
    In 2015, the ROAR team continued to promote a toolkit of customizable materials for aging services & public health professionals to use in community settings & social media, & expanded the potential reach by translating materials into Spanish & Chinese.
    In June 2017, NIH hosted a workshop entitled Inclusion Across the Lifespan, to examine the science of inclusion of various populations in clinical trials & studies.
    1.B.5 Conduct clinical trials on the most promising pharmacologic interventions. Identify partnerships with private sector participants to voluntary share information about new & ongoing clinical trials. Develop partnerships to better coordinate federal & private sector review of the status & progress of the trials & emerging opportunities. Review the status & progress of clinical trials annually. NIH/NIA VA Ongoing FOAs for clinical trials have been released:
     PAR-16-364: hase III Clinical Trials for the Spectrum of AD & Age-related Cognitive Decline
     PAR-16-365: Pilot Clinical Trials for the Spectrum of AD & Age-related Cognitive Decline
     RFA-AG-17-005: Alzheimer's Clinical Trials Consortium
    See also AMP. Part of this initiative seeks to identify biomarkers that can predict clinical outcomes by incorporating selected biomarkers into 2 NIH-funded clinical trials, which include industry support, designed to delay or prevent disease onset.
    A list of ongoing AD/ADRD trials & information about enrolling is available as in the FY18 Bypass Budget. A newer update will be available in the upcoming bypass document set for release in the summer of 2017.
    Coordination of federal, non-federal, & international AD/ADRD research, including clinical trials, can be found in the IADRP.
    1.B.6 Continue clinical trials on the most promising lifestyle interventions. Conduct annual reviews of the status & progress of clinical trials. NIH/NIA VA Ongoing Trials are ongoing & planned; vehicles for inventorying trials are in place.
    NIA has funded the EXERT trial to test whether moderate/high aerobic exercise & stretching can slow the progression of MCI to AD in adults over 65. This 18-month long trial is actively recruiting participants.
    Ongoing & New FOAs include:
     PAR-16-364: Phase III Clinical Trials for the Spectrum of AD & Age-related Cognitive Decline
     PAR-16-365: Pilot Clinical Trials for the Spectrum of AD & Age-related Cognitive Decline
     RFA-AG-17-005: Alzheimer's Clinical Trials Consortium
    A list of ongoing AD/ADRD trials & information about enrolling is available as in the FY18 Bypass Budget. A newer update will be available in the upcoming bypass document set for release in the summer of 2017.
    IADRP facilitates tracking research efforts, including treatment studies.
    Strategy 1.C: Accelerate Efforts to Identify Early and Presymptomatic Stages of Alzheimer's Disease and Related Dementias
    1.C.1 Identify imaging & biomarkers to monitor disease progression. Conduct annual reviews of ADNI to identify & monitor disease progression. NIH/NIA ADNI Partners Ongoing Ongoing reporting & monitoring of ADNI activities, continuing on an annual basis, along with provision of research funding on developing & testing diagnostic tools.
    ADNI's activities are & will continue to be monitored & reviewed on an annual basis
    Ongoing FOAs include:
     PAR-15-359: Novel Approaches to Diagnosing AD & Predicting Progression
     PAR-15-350: Emerging Directions for Addressing Health Disparities in AD
     PAR-15-349: Health Disparities & AD
    1.C.2 Maximize collaboration among federal agencies & the private sector. Identify additional partnership opportunities with the private sector & facilitate collaborative efforts to enhance identification of risk factors & early biomarkers. NIH/NIA FDA Ongoing NIH, FDA, 10 biopharmaceutical companies, & multiple non-profit organizations launched an unprecedented public-private partnership in February 2014. One of the main goals of this effort is to identify biomarkers for AD/ADRD.
    AMP-AD (Projects A & B)
    ADNI is also a public-private partnership between NIH, the Canadian government, & over 20 biopharmaceutical companies & non-profit organizations.
    Strategy 1.D: Coordinate Research with International Public and Private Entities
    1.D.1 Inventory AD/ADRD research investments. International AD Research Database launched July 2012 & continually updated. NIH/NIA Ongoing IADRP now includes data from over 35 public & private funding organizations across 11 countries.
    The Common AD Research Ontology is also undergoing a significant update to the topics & themes that are used to categorize AD & ADRD funding data. The changes will reflect current research investment as well as highlight emerging areas of science.
    1.D.2 Expand international outreach to enhance collaboration. Invite international colleagues to meet & discuss AD/ADRD research priorities & collaboration through regular meetings in person & via teleconference. NIH/NIA Ongoing AD Funders' meeting held during the 2016 AAIC; quarterly funders' calls led by NIA & Alzheimer's Association. Also, IADRP which includes data from over 35 public & private funding organizations across 11 countries is publicly-available for use.
    In October 2016, representatives from NIH participated in the 24th Management Board Meeting of the EU JPND & delivered a presentation on the IADRP managed by the NIA. Over 30 member countries participated in the meeting; focused on the overall goal of increased international collaboration.
    Strategy 1.E: Facilitate Translation of Findings into Medical Practice and Public Health Programs
    1.E.1 Leverage public & private collaborations to facilitate dissemination, translation, & implementation of research findings. Disseminate research findings through various media & in partnership with organizations, particularly those involving interventions in treatment & care. NIH/NIA FDA, ACL, CDC, partner organizations Ongoing NIA continues to expand our efforts to educate clinicians about recent research findings; clinical practice tools for assessment, diagnosis & management of cognitive impairment; training materials; a patient checklist handout in English & Spanish, & other resources, which are available online in a mini-portal of resources for professionals.
    1.E.2 Continue to promote use of ADEAR to educate the public about the latest research findings. Prepare & disseminate regular reports on AD/ADRD research findings. NIH/NIA NIH/NIA ADEAR, ACL, CDC, FDA, CMS, HRSA, VA, partner organizations Ongoing NIA routinely disseminates information on ADRD research findings. See:
    ADEAR Center
    Progress in Alzheimer's research is also reported in the annual Bypass Budget proposal.
    1.E.3 Issue guidance about drugs for early-stage AD/ADRD. Issue recommendations about standards for evaluating the effectiveness of treatments for early-stage AD/ADRD. FDA Ongoing Draft Guidance for Industry: Alzheimer's disease: Developing Drugs for the Treatment of Early Stage Disease
    1.E.4 Expand & disseminate research on co-occurring conditions & dementias. Literature review to be disseminated through CDC's public health network, AoA's Aging Network, & NIA research network. CDC ACL/AoA, NIH/NIA Ongoing In January 2016, CDC released the Progress Report of public health Road Map action item accomplishment & next steps. In 2017, the development process of the 3rd Road Map began that will identify action items for public health professionals related to cognitive health through 2023. The 3rd Road Map will be released in late 2018.
    1.E.5 Provide information to the public on brain health. Develop & disseminate a brain health resource to aging, disability, & public health professionals. ACL/AoA, NIH/NIA, NIH/NINDS, CDC CMS, HRSA, VA, private partners Ongoing On February 2, 2016, NINDS launched a public health campaign on link between hypertension & cognitive decline for integration with the HHS Million Hearts Campaign.
    The Brain Health Resource, a presentation toolkit on brain health as we age, was developed by ACL with NIH & CDC for use at senior centers & in other community settings. Written in plain language, the evidence-based resource explains what people can do to help keep their brains functioning best. In 2016, the toolkit was expanded to include materials in Spanish & a new brain health module entitled, Medicine, Age, & your Brain.
    Goal 2: Enhance Care Quality and Efficiency
    Strategy 2.A: Build a Workforce with the Skills to Provide High-Quality Care
    2.A.1 Educate health care providers. Educate providers through HRSA's GWEPs about how to: (1) work with people with the disease, & their families, (2) link people to support services in the community, identify signs of caregiver burden & depression, & (3) detect cognitive impairment & assess/diagnose AD/ADRD. HRSA CMS, NIH/NIA, CDC collaboration Ongoing HRSA, in collaboration with the HHS/OWH, supported the development of a second Medscape continuing education course on assessing, managing, & treating AD/ADRD in the context of multiple chronic conditions. This educational offering, titled "Bidirectional Impact of Alzheimer's Disease & Common Comorbid Conditions" was released in September 2016. A total of 7,107 learners accessed the site in the first 6 months.
    In FY 2017, HRSA supported 44 GWEP awardees totaling approximately $38.7 million; $5.978 million was used to provide dementia education & training.
    NIA continues to expand our efforts to educate clinicians about recent research findings; clinical practice tools for assessment, diagnosis & management of cognitive impairment; training materials; a patient checklist handout in English & Spanish, & other resources, which are available online in a mini-portal of resources for professionals.
    NIA produced & disseminated Assessing Cognitive Impairment in Older Patients: A Quick Guide for Primary Care Physicians
    2.A.2 Encourage providers to pursue careers in geriatric specialties. Educate providers about opportunities through: the HRSA GWEP. HRSA Ongoing In FY 2015, GWEP awardees provided 402 continuing education offerings & trained 43,148 participants on AD/ADRD.
    2.A.3 Strengthen state aging, public health, & IDD workforces. Educate the workforces through various means including online training, webinars, fact sheets & other tools. ACL/AoA HRSA Ongoing HHS will coordinate with states to develop workforces in aging, public health, & IDD that are AD-capable & culturally-competent. ACL collaborated with HRSA to provide AD/ADRD training to the Aging Network. One example is the New Jersey GEC, which provided a series of trainings to the Aging Services Network in August/September 2015. Over 2,100 health professional & caregivers from the AAAs participated in the trainings. In addition, HRSA GWEP awardees are collaborating with 32 AAAs & 15 QIOs to strengthen state aging, public health, & IDD workforces.
    HRSA GWEP awardees are collaborating with 32 AAAs & 15 QIOs to strengthen state aging, public health, & IDD workforces.
    2.A.4 Develop & disseminate a voluntary unified primary care AD/ADRD curriculum. Develop a voluntary curriculum for primary care practitioners. HRSA CMS, NIH/NIA, VA Ongoing HRSA partnered with federal partners at ACL, CDC, CMS, HHS/OWH, & VA on a contract to develop a Dementia Curriculum for Health Care Professionals. The curriculum is designed to build a workforce with the skills to provide high-quality care, ensure timely & accurate detection & diagnosis, & identify high-quality dementia care guidelines & measures across care settings. The curriculum was available as of July 2017.
    2.A.5 Ensure aging & public health network providers have access to research-based up-to-date information on AD/ADRD. Webinars with representatives from the Aging Network, ADCs, ADEAR, the National Alzheimer's Call Center & Elder Locator, & other federal partners to ensure aging & public health workforces receive recent, updated & culturally-competent information. ACL/AoA, NIH/NIA CDC, AHRQ Ongoing NIH initiated a project involving AHRQ & NASEM, to conduct a systematic review of the evidence on prevention of clinical AD-type dementia, MCI, & age-related cognitive decline (AHRQ), & to shape these findings into a set of recommendations for public health practice & research (NASEM).
    The NASEM report, detailing recommendations for public health messaging based on findings were released in June 2017.
    For more information see:
    AHRQ report
    NASEM report
    Free continuing education is available to professionals who need it when they view recorded webinars. This continuing education is available through 2016.
    The interagency ROAR (NIH, ACL, CDC) group hosted an update in the popular webinar series in 2017 for professionals on AD/ADRD resources that drew 500+ participants & offered continuing education credit. Free continuing education is available to professionals who need it when they view recorded webinars from 2017 & earlier series. This continuing education is available through 2018.
    2.A.6 Engage the public health workforce on brain health. Conduct briefings with federal, state, & local public & private partners regarding the HBI: The Public Health Road Map for State & National Partnerships, 2013-2018. CDC ACL, NIH/NIA Ongoing CDC in collaboration with the HBRN has developed a Scholars Program to assist in the training of graduate-level students in brain health. Students engage in a variety of educational, partnership, & research activities. This program in year 2 of a 5-year funding cycle.
    CDC in collaboration with the Alzheimer's Association developed A Public Health Approach to Alzheimer's & Other Dementias. This introductory curriculum describes the role of public health in addressing the epidemic of AD/ADRD. Its 4 modules each contain a comprehensive faculty guide & slide deck. Whether you're teaching a public health course at an academic institution or delivering health education at the local level, explore how you can adapt this flexible resource to fit your needs.
    2.A.7 Strengthen the ability of primary care teams in Indian Country to meet the needs of people with AD/ADRD & their caregivers. Incorporate training for AD/ADRD into the online continuing education curriculum for IHS, Tribal, & Urban program nursing. IHS Ongoing Web-based course on AD/ADRD April-June 2016 IHS Clinical Rounds. On agenda of IHS Nursing Leadership meeting May 17, 2016. Clinical training on diagnosis & management of AD/ADRD for ACL/IHS/CMS LTSS conference, November 2016. Banner Alzheimer's Institute National Alzheimer's meeting October 2015. Review of online IHS nurse training resources completed. Exploring use of Project ECHO to support diagnosis & management of ADRD.
    2.A.8 Develop a baseline understanding of self-reported competence & confidence of IHS, Tribal & Urban Indian Health nursing staff in care of individuals with dementia. Assess nursing in IHS, Tribal, & Urban Indian Health programs on self-reported competence, confidence, & recent training specific to care for individuals with dementia. IHS Ongoing Survey pilot-tested at 1 Tribal site.
    2.A.9 Improve educational resources for primary care staff caring for individuals with dementia & their family. Pilot-test the HRSA curriculum for care of AD/ADRD in IHS, Tribal, & Urban Indian Health Programs. IHS HRSA Ongoing Pilot-test in 6 sites when the curriculum is available.
    2.A.10 Decision Support for Clinicians. Develop & pilot-test decision support tools for clinicians using the IHS EHR. IHS Ongoing In development.
    2.A.11 Interdisciplinary Team Training in recognition, assessment, & management of dementia in small rural Indian Health facilities. Provide the VA RITT to 10 IHS & Tribal sites with a focus on dementia care. IHS VA Ongoing Eight trainings completed. Two more scheduled as well as training in Alaska in partnership with the Aleutian-Pribilof Islands Association.
    2.A.12 Strengthen states' ability to provide & sustain dementia-capable HCBS. Grants to states & technical assistance on high-quality person-centered dementia care. Develop learning collaboration & tool to evaluate dementia-capability. ACL/AoA CMS Ongoing Products in 2015 include: Tools for Screening, Identification, Referral, & Care Planning for People with AD & Their Caregivers.
    2.A.13 Fill service gaps in dementia-capable systems by expanding the availability of specialized services & supports to target previously under-served populations. Grants to states & localities. ACL/AoA CMS Ongoing This is an ongoing project assuming continuing congressional appropriations.
    2.A.14 Strengthen the long-term care workforce. Provide technical assistance to states. DoL, CMS HHS Technical assistance ongoing Final Rule issued October 2013.
    2.A.15 Improve HCBS LTSS provided through state Medicaid waivers. Hold webinars, national calls, & provide information to key stakeholders. CMS Ongoing As 1 example, CMS is supporting state Medicaid agencies in community integration through HCBS. One targeted area of support is helping a select number of Medicaid agencies plan & implement quality & outcome incentives in their HCBS programs.
    2.A.16 Disseminate CMS Hand-in-Hand dementia training materials in VA CLCs. Share with federal partners a summary report on implementation & evaluation of VA's dissemination of CMS Hand-in-Hand dementia training materials in VA CLCs. VA ASPE,ACL, HRSA Ongoing This is an ongoing project. Evaluation activities were underway in 2017.
    Strategy 2.B: Ensure Timely and Accurate Diagnosis
    2.B.1 Identify & disseminate a variety of appropriate assessment tools. Identify a variety of appropriate assessment tools that can be used in a variety of outpatient settings, including the Medicare AWV, to assess cognition. Complete the development of the "toolbox" of cognitive assessment tools. Disseminate recommended tools to practitioners. NIH/NIA CDC Ongoing Searchable database of assessment tools
    Updated fact sheet on the AWV for FFS Medicare providers
    In 2015, NIA developed a mini-portal of resources for professionals, including the clinician quick guides "Assessing Cognitive Impairment in Older Adults" & "Managing Older Patients with Cognitive Impairment."
    2.B.2 Educate family members of & service providers for persons with IDD about changes that may indicate the onset of dementia. Develop fact sheets & tools to aid in identifying the onset of dementia. ACL/AIDD National Task Group on Intellectual Disabilities & Dementia Practice Ongoing Two webinars & an issue paper were made available in 2015
    Resources: Webinar: IDD & Dementia--California Webinar
    2.B.3 Increase awareness of AD/ADRD in Tribal & Urban Indian Communities & of the availability of services for Individuals with dementia & their families. Pilot-test AD/ADRD awareness strategies in communities in which REACH into Indian Country is implemented, through both health care & aging services settings. IHS ACL Ongoing The focus of the REACH intervention in its final year will be on increasing awareness of ADRD in those communities served by REACH & increasing use of REACH caregiver support services.
    Strategy 2.C: Educate and Support People with Alzheimer's Disease and Related Dementias and Their Families upon Diagnosis
    2.C.1 Educate physicians & other health care providers about accessing LTSS. Increase knowledge of available resources among doctors, nurses, & hospitals. HRSA CMS, VA, ACL Ongoing One barrier to counseling & support is that health care providers are not aware of available services or how to access them. To increase knowledge of these resources among physicians, nurses, & hospitals, HRSA is partnering with federal partners, public & private entities, the health care provider community, & community organizations that provide LTSS to effectively educate physicians & other health care providers, direct services workers, & patients, families, & caregivers about support resources & services available to assist people with AD/ADRD, as well as their caregivers. These activities will continue as part of the training in Action 2.A.1. CMS is doing other work through its Innovation Center to facilitate this goal.
    2.C.2 Connect American Indians & Alaska Natives to AD/ADRD resources. As new resources become available, they will be distributed through a variety of venues to Indian Country. IHS ACL/AoA, NIH/NIA Ongoing The focus on increasing support to caregivers has been through spread of REACH into Indian Country, with the goal of offering this intervention to those with AD/ADRD & their families.
    Strategy 2.D: Identify High-Quality Dementia Care Guidelines and Measures Across Care Settings
    2.D.1 Explore dementia care guidelines measures. Convene meetings with public & private organizations to discuss dementia care practices; develop/identify 3-5 evidence-based guidelines of best dementia practices; include guidelines in the National Guidelines Clearinghouse; disseminate guidelines to consumer & clinical stakeholders, as well as quality measure developers. CMS ASPE, AHRQ Ongoing
    2.D.2 Solicit stakeholder input on meaningful outcomes to drive quality measurement. Convene listening sessions with relevant stakeholders. CMS ASPE Ongoing Initial target met; continuing work of reviewing literature & guidelines continues to support quality measure development & implementation.
    2.D.3 Clarify & disseminate information on privacy, autonomy, & safety issues for physicians. Develop information for physicians on privacy, autonomy, & safety issues. This resource will help providers better understand these issues & the balance between safety, privacy, & autonomy. HRSA Ongoing HHS will disseminate this information through the trainings provided by GWEP awardees.
    2.D.4 Training Resources for IHS Staff. Review of training resources for IHS nursing staff highlighting person-centered goals & strategies for improving care for persons with dementia. IHS HRSA Ongoing IHS collaborated with HRSA to engage the HRSA-funded GWEPs in strategies to improve recognition & diagnosis of dementia.
    Currently 8 GWEPs partner with federally recognized Tribal populations & 1 collaborates with a non-federally recognized Tribal population. The 9 GWEPs have developed a Native Populations Interest Group in preparation for exchanging training materials. The University of Wyoming is currently developing culturally-relevant dementia training material for Native American people on the Wind River Reservation by creating a pictorial version of the Alzheimer's Association's "Know the 10 Signs: Early Detection Matters".
    2.D.5 Understanding trends in residential care settings for older adults. Analyze trends in residential care, using data at various points in time from several data sources, including MCBS, NHATS, & NSLTCP. ASPE Ongoing
    2.D.6 Study factors influencing the progression of disability in older adults. Use the NHATS 2011-2015 data to study the progression of disability & the implications for caregiving needs. ASPE Ongoing
    Strategy 2.E: Explore the Effectiveness of New Models of Care for People with Alzheimer's Disease and Related Dementias
    2.E.1 Evaluate the effectiveness of relevant CMMI models for people with AD/ADRD. Examine changes in care quality & care coordination among people with AD/ADRD. CMS/CMMI NIH/NIA Ongoing At this time CMS has several HCIAs that impact people with AD/ADRD & their caregivers. The evaluation results for the HCIA Round 1 awards were released in March 2017 (see Plan updates). HCIA Round 2 First Annual Evaluation Report was released in August 2016.
    Third Annual Evaluation Report Released in March 2017.
     Disease-Specific
     Complex/High-Risk Patient Targeting
    HCIA-2 First Evaluation Report was released in August 2016
    2.E.2 Evaluate the effectiveness of the Independence at Home Demonstration. Examine whether health & functional status outcomes are improved among people with AD/ADRD in this demonstration. CMS/CMMI Ongoing Year 2 Results
    2.E.3 Develop a SDM model as an alternative to guardianship. Support a national training, technical assistance, & resource center to explore & develop SDM as an alternative to guardianship. ACL/AoA Started in 2015, expected completion in 2019
    2.E.4 Analyze new payment & service options for Medicare-Medicaid dual eligible beneficiaries. Produce targeted research issue briefs on options for expanding PACE. ASPE Ongoing
    2.E. 5 Analyze "quality dementia care" practices across settings. Case studies conducted across settings to better understand what innovative dementia care providers are doing to provide quality care. ASPE Complete, report expected July 2017
    2.E.6 Analyze reimbursements for high-quality, community-based, ambulatory mental health & substance use disorder services. Two year demonstration program of Certified Community Behavioral Health Clinics. ASPE SAMHSA Ongoing
    2.E.7 Studying home health utilization. Study to better understand the growth in use of the Medicare home health benefit by community-admitted users--those individuals for whom home health episodes are not preceded by a hospitalization of PAC stay. ASPE Ongoing
    Strategy 2.F: Ensure that People with Alzheimer's Disease and Related Dementias Experience Safe and Effective Transitions between Care Settings and Systems
    2.F.1 Implement & evaluate new care models to support effective care transitions for people with AD/ADRD. Evaluate care transition demonstration programs. CMS ACL/AoA Ongoing
    2.F.2 Assess the adequacy of HIT standards to support the exchange of information at times of referrals & transitions in care for persons with AD/ADRD. Convene partners to explore feasibility & timing. ASPE ONC, CMS Ongoing
    Strategy 2.G: Advance Coordinated and Integrated Health and Long-Term Services and Supports for Individuals Living with Alzheimer's Disease and Related Dementias
    2.G.1 Implement & evaluate care coordination models. Implement & evaluate care coordination models. CMS Ongoing Multiple care coordination models & guidance on care coordination continue across CMS.
    2.G.2 Evaluate evidence on care integration. Issue report on findings. ASPE Ongoing
    2.G.3 Assess the adequacy of HIT standards for care plans to support the needs of persons with AD/ADRD. Convene partners to explore feasibility & timing. ASPE ONC Ongoing
    Strategy 2.H: Improve Care for Populations Disproportionally Affected by Alzheimer's Disease and Related Dementias and for Populations Facing Care Challenges
    2.H.1 Create funding opportunities for organizations to improve care for these specific populations. Fund dementia-capable systems to implement new programs designed to provide more effective services to:
    (1) individuals living alone in the community with dementia;
    (2) individuals with IDD who have or are at-risk of developing dementia;
    (3) caregivers who need behavioral symptom management training or expert consultations to help them care for family members; &
    (4) provision of effective care/supportive services for individuals living with moderate to severe AD/ADRD & their caregivers. ACL/AoA Ongoing ACL awarded 11 grants in 2015.
    ACL anticipates awarding 10 new grants in 2016. Note that future grants are contingent on availability of funding.
    2.H.2 Enhance understanding of models of family support for people with IDD as they age. Explore promising models, release report. ASPE Ongoing
    2.H.3 Compare outcomes for dual eligible beneficiaries in integrated care models. Determine the feasibility of an analysis that compares selected health outcomes & quality measures for Medicare-Medicaid dual eligible beneficiaries participating in managed care models. ASPE Ongoing
    Goal 3: Expand Supports for People with Alzheimer's Disease and Related Dementias and Their Families
    Strategy 3.A: Ensure Receipt of Culturally Sensitive Education, Training, and Support Materials
    3.A.1 Distribute materials to caregivers. Distribute training & education materials through federal agencies & state & local networks. ACL NIH/NIA, ADEAR Ongoing Networks serving caregivers have frequent opportunities for webinars, consultation, & grants to better serve caregivers.
    Fact sheets
    NIA's ADEAR continues to offer free information on AD/ADRD caregiving
    3.A.2 Utilize HIT for caregivers & persons with AD/ADRD. Identify tools, evaluate, & disseminate findings. AHRQ Completion expected July 2016
    Ongoing, completion expected 2019 Grant #1P50 HS 019917 awarded & used to create Elder Tree, a suite of electronic services to support older adults & their caregivers. The Elder Tree tool is being evaluated. Recruited 400 people who have used the suite, participants were surveyed. Analysis underway & results will be available by July 2016.
    Grant #5R18HS027836 awarded to evaluate use of remote sensory technology to help manage persons with AD/ADRD & study impact on ability of caregivers to manage family member with AD/ADRD. Recruited 60 caregivers, systems installed & caregivers trained. The recruitment goal is 100.
    3.A.3 Increase awareness of the importance of brain health in culturally sensitive ways. Increase awareness of brain health, specifically AD/ADRD & caregiving among African Americans. CDC Ongoing CDC supported the development of NBHCAA. The mission of Brain Health Center is to raise awareness of the issues of cognitive health among African Americans by working through networks of faith-based institutions & by establishing partnerships with organizations & individuals dedicated to our mission. The 3 areas of focus of brain health education, mobilization & advocacy, & networking. The Brain Health Center serves as an information hub on the human brain that must be shared throughout all networks that reach & touch approximately 40 million African Americans living in the United States.
    Memory Sunday: Increasing Awareness of AD in Church Congregations. CDC supported the Balm in Gilead to develop & implement Memory Sunday, the Second Sunday in June, as a designated Sunday, within congregations serving African Americans, that provides education on Alzheimer's: prevention, treatment, research studies & caregiving. The purpose of Memory Sunday is to bring national & local attention to the tremendous burden that Alzheimer's & other Dementias are having on the African American community; to utilize the power & influence of the African American pulpit to bring awareness; to distribute the facts about Alzheimer's; to encourage participation in research studies & to support persons living with Alzheimer's & their caregivers.
    Strategy 3.B: Enable Family Caregivers to Continue to Provide Care while Maintaining Their Own Health and Well-Being
    3.B.1 Develop & disseminate evidence-based interventions for people with AD/ADRD & their caregivers. Identify specific evidence-based interventions that can be developed into training materials or new programs; develop training materials and/or design intervention programs based on NIH/NIA research. NIH/NIA AHRQ, CMS, CDC, ACL/AoA Ongoing Resources for dissemination
    NIA's ADEAR continues to offer free information on AD/ADRD research & interventions
    Ongoing & newly released FOAs:
     PAR-15-348: Research on Informal & Formal Caregiving for AD (R01)
     PAR-15-351: Research on Informal & Formal Caregiving for AD (R21)
     PAR-17-107: Development of SARs to Engage Persons with AD/ADRD, & their Caregivers (R41/R42)
     PAS-17-027: Improving Quality of Care & Quality of Life for Persons with AD/ADRD at the End of Life
    NIA staff has had several discussions with AoA staff about interventions that might be ready for dissemination within the AoA network.
    NIA & AoA have jointly supported a FOA for translation of evidence-based research.
    NIA staff have participated in numerous meetings with AoA to share information & discuss opportunities to work together on dissemination of interventions within the AoA network.
    3.B.2 Provide effective caregiver interventions through AD-capable systems. Work with states to identify caregiver interventions for dissemination. ACL/AoA Ongoing New grants are awarded each year as funding permits.
    3.B.3 Collaborate to share information on LTSS with Tribal providers. Various dissemination mechanisms such as webinars & sharing materials with relevant networks. ACL/AoA IHS, CMS Ongoing Presentations occur at Indian Country meetings & webinars. November 2016 Tribal LTSS conference in Minneapolis, MN. Ongoing webinar series through the CMS/IHS/ACL LTSS technical assistance website. A CMS-funded baseline survey of Tribal LTSS is in development.
    3.B.4 Continue to promote use of the National Alzheimer's Call Center to provide information, advice, & support to people with dementia or their caregivers. AoA will continue to contribute funding to this public-private effort. ACL/AoA Alzheimer's Association Ongoing AoA will continue to contribute funding to this public-private effort, assuming Congressional appropriations continue.
    3.B.5 Make behavioral symptom management education & training available to caregivers. Award grants. ACL/AoA CMS Ongoing 2015 grants made & more anticipated in 2016.
    3.B.6 Examine technological solutions to support family caregivers. Grant awarded--awaiting results. AHRQ December 2019 Grant #5R18HS027836 awarded to evaluate use of remote sensory technology to help manage persons with AD/ADRD & study impact on ability of caregivers to manage family member with AD/ADRD. Recruited 60 caregivers, systems installed & caregivers trained. The recruitment goal is 100.
    3.B.7 Adapt & Implement REACH in Tribal Communities. Working in partnership with ACL, the University of Tennessee Health Sciences Center, & the Rx Foundation implement the REACH intervention as REACH into Indian Country. IHS ACL/AoA. VA, University of Tennessee Health Sciences Center Ongoing Baseline in February 2015 was 3 communities (the REACH-VA Pilot Sites). 47 communities reached as of April 2017.
    Implementation began in February 2015, with 47 Communities as of December 2016.
     Website Developed
     Brochure Developed
    Implementation in 50 Tribal communities by February 2018. Focus in final year is on sustainability.
    3.B.8 Determine economic impacts of programs to support informal caregivers. Provide a framework for policy makers to begin to estimate costs & benefits of policies & programs aimed to help caregivers. ASPE Ongoing
    Strategy 3.C: Assist Families in Planning for Future Care Needs
    3.C.1 Understand how families find & access LTSS. Exploratory qualitative research project to examine where families gather information, how they make decisions, how well arrangements work, & how local factors influence the process. ASPE Ongoing
    3.C.2 Understand long-term care financing & service delivery models. Development of series of long-term care financing proposals through actuarial & micro-simulation modeling. ASPE Ongoing
    Strategy 3.D: Maintain the Dignity, Safety and Rights of People with Alzheimer's Disease and Related Dementias
    3.D.1 Monitor, report & reduce inappropriate use of antipsychotics in nursing homes. National Partnership to Improve Dementia Care. CMS ACL/AoA, NORC Ongoing CMS continues to make progress on the National Partnership to Improve Dementia Care.
    3.D.2 Incorporate elder abuse awareness into Aging Network activities. Eldercare Locator & other Aging Network & prevention programs providers to recognize warning signs of abuse. ACL/AoA Private partner/grantees Ongoing