Evaluation of the Disability Determination Process for Traumatic Brain Injury in Veterans (2019) / Chapter Skim
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3 Disability Determination Process for Veterans with Traumatic Brain Injury
3 Disability Determination Process for Veterans with Traumatic Brain Injury
Pages 57-82
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From page 57... ...
The degree of disability for a given disabling condition depends on a number of factors, including the diagnosis (coded according to the Veterans Affairs Schedule for Rating Disabilities [VASRD] , which provides criteria for translating medical information into a disability rating)
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From page 58... ...
DEPARTMENT OF VETERANS AFFAIRS DISABILITY DETERMINATION PROCESS FOR RESIDUALS OF TRAUMATIC BRAIN INJURY The adjudication process for VA disability compensation involves the following key stakeholders: the veteran, the Veterans Health Administration (VHA) , the Veterans Benefits Administration (VBA)
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From page 59... ...
. C&P = compensation and pension; DBQ = Disability Benefits Questionnaire; DEMO = Disability Examination Management Office; TBI = traumatic brain injury; VA = Department of Veterans Affairs; VASRD = Veterans Affairs Schedule for Rating Disabilities; VBA = Veterans Benefits Administration; VHA = Veterans Health Administration.
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From page 60... ...
VBA staff work across 57 regional offices to process claims. Claims processors are veterans service representatives (VSRs)
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From page 61... ...
. It should be noted that in determining a disability percentage for residuals of traumatic brain injury, an RVSR might consider information from more than one DBQ.
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From page 62... ...
.6 THE DISABILITY BENEFITS QUESTIONNAIRE AND A SCHEDULE FOR RATING DISABILITIES FOR RESIDUALS OF TBI The committee was tasked with making a determination of the adequacy of the tools and protocols used by the VA to provide TBI examinations and to make recommendations for 5 38 United States Code (U.S.C.)
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From page 63... ...
The DBQ provides a standardized report format for medical examinations and opinions to guide the documentation of C&P exams. The C&P examiners use DBQs to provide medical information that is directly relevant to determining a disability rating, which enables the VA's rating specialists, the RVSRs, to have the information they need to start processing a claim by using the VASRD.
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From page 64... ...
. Furthermore, memory, attention, concentration, and executive function are grouped into one facet, leaving the VHA or VBA clinician to choose one level of functional status for those four areas (see Appendix D TBI DBQ)
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From page 65... ...
. The TBI DBQ focuses primarily on a person's ability to find his or her way in familiar and unfamiliar surroundings and to use assistive devices such as GPS, a global positioning system.
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From page 66... ...
. Difficulties with behavioral and emotional regulation are often poorly understood by others, and there is a tendency to attribute the maladaptive behavior to the person or their "personality" rather than recognizing the brain injury as the source (or, at a minimum, as an exacerbating factor)
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From page 67... ...
The committee recommends that the Department of Veterans Affairs convene experts from both the Veterans Health Administration and the Veterans Benefits Administration, including clinicians who diagnose and assess residuals of traumatic brain injury (TBI) , to regularly update the Veterans Affairs Schedule for Rating Disabilities and the Disability Benefits Questionnaire for residuals of TBI to better reflect the current state of medical knowledge.
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From page 68... ...
. The committee recommends that the Department of Veterans Affairs add insomnia, vestibular dysfunction, and near-vision dysfunction to the Disability Benefits Questionnaire for residuals of traumatic brain injury.
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From page 69... ...
, April 30, 2018) : • VHI Veterans Health Initiative Traumatic Brain Injury Independent Study (VA 8339)
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From page 70... ...
And, as noted in Chapter 2, the committee recommends that the VA allow other health care professionals with TBI training and experience to make TBI diagnoses. The committee believes that it is the training and experience in diagnosing and treating TBI over time, not necessarily the medical specialty, that render a health care specialist capable of an accurate TBI diagnosis.
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From page 71... ...
The increase in the percentage of exams performed by contractors is notable because there are several differences in how VHA clinicians and VBA contractors conduct C&P exams. First, VBA contractors often do not have the same access to VHA medical records that VHA clinicians do.
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From page 72... ...
The committee recommends that the Department of Veterans Affairs provide the Veterans Benefits Administration contractors with the same training and access to medical records as Veterans Health Administration clinicians to ensure equitable disability determinations for all veterans. QUALITY ASSURANCE IN THE ADJUDICATION OF DISABILITY COMPENSATION CLAIMS FOR RESIDUALS OF TBI Given its broader task of providing recommendations for legislative or administrative action for improving the adjudication of veterans' claims for impairments arising from TBI, the committee reviewed the protocols the VA has in place for assuring quality of its processes.
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From page 73... ...
Training Required for Veterans Service Representatives As described previously, RVSRs are the personnel within VBA who determine if a veteran's condition is service-connected and, if so, provide the veteran with a disability rating percentage using criteria in the VASRD. The committee spoke with a former RVSR to understand the training and oversight that the VA requires of RVSRs (personal communication with VBA, August 6, 2018)
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From page 74... ...
, VBA assesses the quality of its rating process using two systems: a compensation service quality review team (QRT) , which operates at each facility where claims are processed for disability, and the national level Systematic Technical Accuracy Review (STAR)
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From page 75... ...
, in a report titled A 21st Century System for Evaluating Veterans for Disability Benefits, offered a number of recommendations to the VA on updating the disability evaluation process. Two of the recommendations bear on the question of assuring and improving the quality of the system, and the current committee asked the VA to comment on progress related to these recommendations.
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From page 76... ...
Recommendation 5-4 was: "The rating process should have built-in checks or periodic evaluations to ensure inter-rater reliability as well as the accuracy and validity of rating across impairment categories, ratings, and regions." In its written response, VBA stated that it conducts quality reviews at both the local and national level to assess the accuracy of claims processing (personal communication with VBA, May 2018)
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From page 77... ...
Furthermore, they fail to take into account some basic medical knowledge concerning how residuals of TBI might manifest and affect disability. The committee recommends that the Department of Veterans Affairs convene experts from both Veterans Health Administration and Veterans Benefits Administration, including clinicians who diagnose and assess residuals of traumatic brain injury (TBI)
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From page 78... ...
These nearvision problems occur commonly after TBI and can result in not only diplopia but also blurred vision, headache, nausea, and an inability to maintain focus while reading and doing other closerange visual activities. The committee recommends that the Department of Veterans Affairs add insomnia, vestibular dysfunction, and near-vision dysfunction to the Disability Benefits Questionnaire for residuals of traumatic brain injury.
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From page 79... ...
2017. Vestibular consequences of mild traumatic brain injury and blast exposure: A review.
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From page 80... ...
2016. Cervical spine involvement in mild traumatic brain injury: A review.
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From page 81... ...
2016c. DEMO traumatic brain injury examination course.
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