Vocational Rehabilitation
More VA and DOD Collaboration Needed to Expedite Services for Seriously Injured Servicemembers Gao ID: GAO-05-167 January 14, 2005More than 10,000 U.S. military servicemembers, including National Guard and Reserve members, have been injured in the conflicts in Afghanistan and Iraq. Those with serious injuries are likely to be discharged from the military and return to civilian life with disabilities. The Department of Veterans Affairs (VA) offers vocational rehabilitation and employment (VR&E) services to help these injured servicemembers in their transition to civilian employment. GAO has noted that early intervention--the provision of rehabilitation services as soon as possible after the onset of a disability--is a practice that significantly facilitates the return to work. GAO examined how VA expedites VR&E services to seriously injured servicemembers and the challenges VA faces in its efforts to do so.
VA has taken steps to expedite vocational rehabilitation and employment services for servicemembers returning from Afghanistan and Iraq with serious injuries. The agency has instructed its regional offices to make seriously injured servicemembers a high priority for all VA assistance, including VR&E services, and has asked DOD to provide data that would help VA identify and monitor this population. It has also deployed additional staff to five major Army military treatment facilities where the majority of the seriously injured are treated. Pending an agreement with DOD for sharing data, VA has relied on its regional offices to learn who the seriously injured are and where they are located. We found that the regional offices we reviewed had developed information that varied in completeness and reliability. We also found that VA does not have a policy for maintaining contact with those with serious injuries who may later be ready for VR&E services but did not initially apply for VR&E. Nevertheless, some regional offices did attempt to maintain contact while other regional offices did not. VA faces significant challenges in expediting VR&E services to seriously injured servicemembers. These include: the inherent challenge that individual differences and uncertainties in the recovery process make it difficult to determine when a servicemember will be ready to consider VR&E services; DOD's concerns that VA's outreach, including early intervention with VR&E, could work at cross purposes to military retention goals for servicemembers whose discharge from military service is not yet certain; and the lack of access to data from DOD that would allow VA to readily know which servicemembers are seriously injured and where they are located. VA and DOD generally concurred with our findings and recommendations.
RecommendationsOur recommendations from this work are listed below with a Contact for more information. Status will change from "In process" to "Open," "Closed - implemented," or "Closed - not implemented" based on our follow up work.
Director: Team: Phone:GAO-05-167, Vocational Rehabilitation: More VA and DOD Collaboration Needed to Expedite Services for Seriously Injured Servicemembers
This is the accessible text file for GAO report number GAO-05-167
entitled 'Vocational Rehabilitation: More VA and DOD Collaboration
Needed to Expedite Services for Seriously Injured Servicemembers' which
was released on January 26, 2005.
This text file was formatted by the U.S. Government Accountability
Office (GAO) to be accessible to users with visual impairments, as part
of a longer term project to improve GAO products' accessibility. Every
attempt has been made to maintain the structural and data integrity of
the original printed product. Accessibility features, such as text
descriptions of tables, consecutively numbered footnotes placed at the
end of the file, and the text of agency comment letters, are provided
but may not exactly duplicate the presentation or format of the printed
version. The portable document format (PDF) file is an exact electronic
replica of the printed version. We welcome your feedback. Please E-mail
your comments regarding the contents or accessibility features of this
document to Webmaster@gao.gov.
This is a work of the U.S. government and is not subject to copyright
protection in the United States. It may be reproduced and distributed
in its entirety without further permission from GAO. Because this work
may contain copyrighted images or other material, permission from the
copyright holder may be necessary if you wish to reproduce this
material separately.
Report to the Ranking Democratic Member, Committee on Veterans'
Affairs, House of Representatives:
United States Government Accountability Office:
GAO:
January 2005:
Vocational Rehabilitation:
More VA and DOD Collaboration Needed to Expedite Services for Seriously
Injured Servicemembers:
GAO-05-167:
GAO Highlights:
Highlights of GAO-05-167, a report to the Ranking Democratic Member,
Committee on Veterans' Affairs, House of Representatives:
Why GAO Did This Study:
More than 10,000 U.S. military servicemembers, including National Guard
and Reserve members, have been injured in the conflicts in Afghanistan
and Iraq. Those with serious injuries are likely to be discharged from
the military and return to civilian life with disabilities. The
Department of Veterans Affairs (VA) offers vocational rehabilitation
and employment (VR&E) services to help these injured servicemembers in
their transition to civilian employment. GAO has noted that early
intervention”the provision of rehabilitation services as soon as
possible after the onset of a disability”is a practice that
significantly facilitates the return to work. GAO examined how VA
expedites VR&E services to seriously injured servicemembers and the
challenges VA faces in its efforts to do so.
What GAO Found:
VA has taken steps to expedite vocational rehabilitation and employment
services for servicemembers returning from Afghanistan and Iraq with
serious injuries. The agency has instructed its regional offices to
make seriously injured servicemembers a high priority for all VA
assistance, including VR&E services, and has asked DOD to provide data
that would help VA identify and monitor this population. It has also
deployed additional staff to five major Army military treatment
facilities where the majority of the seriously injured are treated.
Pending an agreement with DOD for sharing data, VA has relied on its
regional offices to learn who the seriously injured are and where they
are located. We found that the regional offices we reviewed had
developed information that varied in completeness and reliability. We
also found that VA does not have a policy for maintaining contact with
those with serious injuries who may later be ready for VR&E services
but did not initially apply for VR&E. Nevertheless, some regional
offices did attempt to maintain contact while other regional offices
did not.
Seriously Injured Army Servicemembers Receive Treatment at Five Major
Army Medical Facilities and Relocate to One of 57 VA Regions after
Medical Stabilization:
[See PDF for image]
[End of figure]
VA faces significant challenges in expediting VR&E services to
seriously injured servicemembers. These include: the inherent challenge
that individual differences and uncertainties in the recovery process
make it difficult to determine when a servicemember will be ready to
consider VR&E services; DOD‘s concerns that VA‘s outreach, including
early intervention with VR&E, could work at cross purposes to military
retention goals for servicemembers whose discharge from military
service is not yet certain; and the lack of access to data from DOD
that would allow VA to readily know which servicemembers are seriously
injured and where they are located.
VA and DOD generally concurred with our findings and recommendations.
What GAO Recommends:
GAO recommends that:
* VA and the Department of Defense (DOD) collaborate to reach an
agreement for VA to have access to information that both agencies
agree is needed to promote recovery and return to work for seriously
injured servicemembers.
* VA develop a policy and procedures for regional offices to maintain
contact with seriously injured servicemembers who do not initially
apply for VR&E services.
www.gao.gov/cgi-bin/getrpt?GAO-05-167.
To view the full product, including the scope and methodology, click on
the link above. For more information, contact Cynthia Bascetta at (202)
512-7215 or BascettaC@gao.gov.
[End of section]
Contents:
Letter:
Results in Brief:
Background:
VA Has Taken Steps to Expedite Vocational Rehabilitation and Employment
Services for Seriously Injured Servicemembers:
VA Faces Significant Challenges in Expediting Services to Seriously
Injured Servicemembers:
Conclusions:
Recommendations:
Agency Comments:
Appendix I: Comments from the Department of Veterans Affairs:
Appendix II: Comments from the Department of Defense:
Related GAO Products:
Figures:
Figure 1: Seriously Injured Army Servicemembers Receive Treatment at
Five Major Army Medical Facilities and Relocate to One of 57 VA Regions
after Medical Stabilization:
Figure 2: VA's Early Intervention Could Work at Cross Purposes to DOD's
Retention Evaluation Process:
Abbreviations:
DOD: Department of Defense:
MTF: Military Treatment Facility:
VR&E: Vocational Rehabilitation and Employment:
VA: Department of Veterans Affairs:
United States Government Accountability Office:
Washington, DC 20548:
January 14, 2005:
The Honorable Lane Evans:
Ranking Democratic Member:
Committee on Veterans' Affairs:
House of Representatives:
Dear Mr. Evans:
Since the onset of U.S. operations in Afghanistan in October 2001 and
Iraq in March 2003, the Department of Defense (DOD) has reported that
more than 10,000 service men and women have been injured in combat.
While many return to active duty after they are treated, others who are
more seriously injured are likely to be discharged from their military
obligations and return to civilian life with disabilities. In addition
to cash compensation, the Department of Veterans Affairs (VA) offers
vocational rehabilitation and employment (VR&E) services to help
veterans with disabilities restore their lives and participate in the
civilian workforce. We have reported that intervening early after a
disabling injury increases the likelihood that an individual will
successfully return to work.[Footnote 1] Moreover, there is growing
awareness that people with disabilities can and want to work and that
changes in the nature of work and advances in assistive technologies
help them to do so. Further, as the U.S. workforce is projected to
shrink, the U.S. economy will need all who are able to participate in
the paid labor force. Because federal disability programs, including
VA's, lack emphasis on the potential for vocational rehabilitation to
return people to work and also rely on outmoded assumptions about the
relationship between impairment and work, we have designated these as
"high-risk" programs.[Footnote 2]
In view of the importance of early intervention in returning people who
have been disabled to work, you asked that we review how quickly VA is
able to provide VR&E services to seriously injured servicemembers from
Afghanistan and Iraq who are likely to become veterans with
disabilities. We assessed (1) how VA expedites VR&E services to these
seriously injured servicemembers and (2) the challenges VA faces in its
efforts to do so.
To address these objectives, we reviewed VA's formal and informal
procedures for expediting VR&E services to seriously injured
servicemembers returning from Afghanistan and Iraq. We reviewed
applicable laws and regulations. We interviewed officials at VA's
central office and at 12 of VA's 57 regional offices. Five of these
offices are located near the five major Army medical treatment
facilities treating the majority of the seriously injured Army
servicemembers: Brooke Army Medical Center at Fort Sam Houston, Texas;
Darnall Army Community Hospital at Fort Hood, Texas; Eisenhower Army
Medical Center at Fort Gordon, Georgia; Madigan Army Medical Center at
Fort Lewis, Washington; and Walter Reed Army Medical Center in
Washington, D.C. The corresponding VA regional offices are Houston and
Waco, Texas; Atlanta, Georgia; Seattle, Washington; and Washington,
D.C. We selected the other seven regional offices based on Army data
indicating that servicemembers injured in Afghanistan and Iraq are
being treated at military treatment facilities in their regions. They
are Buffalo, New York; Denver, Colorado; Muskogee, Oklahoma; Nashville,
Tennessee; New Orleans, Louisiana; Wichita, Kansas; and Winston-Salem,
North Carolina. Our findings for these regional offices cannot be
generalized to all of VA's regional offices. We focused on Army
servicemembers, including activated National Guard and Reserve, because
they constituted the majority of servicemembers wounded in Afghanistan
and Iraq. In addition, we visited Walter Reed Army Medical Center in
Washington, D.C., where most seriously injured Army servicemembers are
initially treated. We also interviewed DOD officials about their
efforts to work with VA on the transition of injured servicemembers
being discharged from active duty. We conducted our work between April
2004 and November 2004 in accordance with generally accepted government
auditing standards.
Results in Brief:
We found that VA has taken steps to expedite VR&E services for
seriously injured servicemembers returning from Iraq and Afghanistan.
VA has instructed its regional offices to make seriously injured
servicemembers a high priority for all VA assistance and asked DOD to
share data that would help VA identify and monitor them. Because most
seriously injured servicemembers are initially treated at major
military treatment facilities, VA deployed staff to these sites to
provide information on VA benefits programs, including VR&E services,
to servicemembers injured in the conflicts in Afghanistan and Iraq. To
ensure the identification and monitoring of all seriously injured
servicemembers, VA initiated a memorandum of agreement proposing that
DOD systematically provide information on them, including their names,
location, and medical condition. Pending an agreement with DOD, VA
instructed its regional offices to establish local liaison with
military medical treatment facilities in their areas to learn who the
seriously injured are, where they are located, and the severity of
their injuries. Reliance on local relationships, however, has resulted
in varying completeness and reliability of information developed by the
12 regional offices in our review. We also found that VA has no policy
for VR&E staff to maintain contact with seriously injured
servicemembers who do not apply for VR&E services. Nevertheless, some
offices reported efforts to maintain contact with these servicemembers,
noting that some who are not initially ready to consider employment
when contacted about VR&E services may be receptive at a future time.
We found significant challenges to VA's efforts to expedite VR&E
services. An inherent challenge is that individual differences and
uncertainties in the recovery process make it difficult to determine
when a seriously injured service member will be ready to consider VR&E
services. Additionally, given that VA is conducting outreach to
servicemembers whose discharge from military service is not yet
certain, VA is challenged by DOD's concerns that VA's outreach about
benefits, including early intervention with VR&E services, could work
at cross purposes to the military's retention goals. Finally, VA is
currently challenged by a lack of access to DOD data that would, at a
minimum, allow the agency to readily identify and locate all seriously
injured servicemembers. VA officials we interviewed both in the
regional offices and at the central office reported that this
information would provide them with a more reliable way to identify and
monitor the progress of those servicemembers with serious injuries.
However, DOD officials reported that they have privacy concerns about
the type of information that VA had requested and the time that VA
wants it to be provided.
To improve VA's efforts to expedite VR&E services, we recommend that VA
and DOD collaborate to reach agreement about information that VA needs
to promote the recovery and return to work of seriously injured
servicemembers and that VA develop a policy and procedures for
maintaining contact with those who do not initially apply for VR&E
services. VA and DOD provided written comments on a draft of this
report. Both VA and DOD generally concurred with our findings and
recommendations.
Background:
VA's VR&E program is designed to ensure that veterans with disabilities
find meaningful work and achieve maximum independence in daily living.
In 2004, VA estimates that it spent more than $670 million on its VR&E
program to serve about 73,000 participants. This represents about 2
percent of VA's $37 billion budget for nonmedical benefits, most of
which involves cash compensation for veterans with disabilities.
VR&E services include vocational counseling, evaluation, and training
that can include payment for tuition and other expenses for education,
as well as job placement assistance. Interested veterans generally
apply for VR&E services after they have applied and qualified for
disability compensation based on a rating of their service-connected
disability. This disability rating--ranging from 0 to 100 percent in 10
percent increments--entitles veterans to monthly cash payments based on
their average loss in earning capacity resulting from a service-
connected injury or combination of injuries. To be entitled to VR&E
services, veterans with disabilities generally must have at least a 20
percent disability rating and an employment handicap as determined by a
vocational rehabilitation counselor. Although cash compensation is not
available to servicemembers until after they separate from the
military, they can receive VR&E services prior to separation under
certain circumstances.[Footnote 3] To make these services available
prior to discharge, VA expedites the determination of eligibility for
VR&E by granting a preliminary rating, known as a memorandum rating.
VA's outreach to servicemembers who plan to apply for veterans'
disability compensation has been part of its transition assistance
program, which was established in 1990.[Footnote 4] Either in group
sessions or in one-on-one encounters, VA provides servicemembers with
information about disability benefits and services, which includes the
VR&E program, and offers assistance in applying for them. In addition,
VA administers a pre-discharge program that expedites the disability
compensation claims processing for servicemembers who are pending
discharge. This program also helps VR&E staff identify those who could
benefit from vocational rehabilitation and employment services. VA has
recently included activated National Guard and Reserve members in its
outreach efforts.
Servicemembers injured in Iraq and Afghanistan are surviving injuries
that would have been fatal in past conflicts, due, in part, to advanced
protective equipment and medical treatment. However, the severity of
their injuries can result in a lengthy transition from injured
servicemember to veteran. Initially, most seriously injured
servicemembers, including activated National Guard and Reserve members,
are brought to Landstuhl Regional Medical Center in Germany for
treatment. From there, they are transported to the appropriate U.S.
medical facilities, which are usually major military treatment
facilities (MTFs) but may also be VA medical centers. According to DOD
officials, once stabilized and discharged from the hospital,
servicemembers usually relocate to be closer to their homes or military
bases and are treated as outpatients by the closest VA or military
hospital. (See fig. 1.) At this point, the military generally begins to
assess whether the servicemember will be able to remain in the
military, a process that could take months to complete. The process can
take even longer if the servicemember appeals the military's initial
disability decision.
Figure 1: Seriously Injured Army Servicemembers Receive Treatment at
Five Major Army Medical Facilities and Relocate to One of 57 VA Regions
after Medical Stabilization:
[See PDF for image]
[End of figure]
In response to recommendations made by the VA Vocational Rehabilitation
and Employment Task Force, VA is beginning to change its approach to
VR&E to better reflect contemporary views of disability. The Secretary
of Veterans Affairs established this external task force in 2003 to
conduct a comprehensive review of VA's VR&E program.[Footnote 5] In
addition, faced with the immediate need to provide benefits and
services to a new generation of veterans with disabilities, VA in
August 2003 formed an internal task force to develop and implement
policies to improve the transition of injured servicemembers back to
civilian life. Known as the Seamless Transition Task Force, it included
ad hoc participation from DOD.[Footnote 6] Although this task force's
initial priority was to ensure the continuity of medical care for
injured servicemembers as they transition from military to VA health
care, it has also coordinated efforts to ensure access to all other VA
benefits, including VR&E services.
We have previously reported on the importance of early intervention to
maximize the work potential of individuals with disabilities. We have
also reported, however, that current federal disability programs offer
little opportunity for early intervention with individuals who apply
for compensation. These programs require lengthy assessments in which
applicants must focus on demonstrating their work limitations rather
than their abilities and potential to work.[Footnote 7] Consequently,
vocational rehabilitation is typically introduced late in the process.
Furthermore, we have designated federal disability programs, including
VA's, as high-risk programs because they lack emphasis on the potential
for vocational rehabilitation to return people to work and also rely on
outmoded assumptions about the relationship between impairment and
work.
VA Has Taken Steps to Expedite Vocational Rehabilitation and Employment
Services for Seriously Injured Servicemembers:
VA has instructed its regional offices to make seriously injured
servicemembers a high priority for all VA assistance and asked DOD to
provide data that would ensure VA's ability to identify and monitor
this population. Because many seriously injured servicemembers are
initially treated at major military treatment facilities, VA has
deployed staff to these sites to provide information on all veterans'
benefits, including VR&E services. To ensure the identification and
monitoring of all seriously injured servicemembers, VA initiated a
memorandum of agreement proposing that DOD share a range of
information, including the names of those with serious injuries, their
medical condition, and their military status. As of December 2004, a
formal agreement with DOD had not been reached. In the meantime, VA has
instructed its regional offices to develop local liaison with DOD in
order to identify and assist seriously injured servicemembers. The 12
regional offices we reviewed have developed information of varying
completeness and reliability. However, once regional offices have
identified and contacted seriously injured servicemembers, VA has no
policy for VR&E staff to maintain contact with those individuals who do
not apply for VR&E services while in the hospital or after they return
home. Nevertheless, some regional offices reported maintaining contact
with these servicemembers while others did not.
VA Has Instructed Its Regional Offices to Make Seriously Injured
Servicemembers a High Priority and Asked DOD for Data to Help Identify
Them:
In a September 2003 letter, VA instructed its regional offices to
provide priority consideration and assistance to seriously injured
servicemembers returning from Afghanistan and Iraq. VA specifically
instructed regional offices to focus on servicemembers whose
disabilities are definitely or likely to result in military separation.
Minimally, this includes servicemembers with injuries DOD has
classified as "very serious," "serious," or in a "special
category."[Footnote 8] In this letter, VA instructed its regional
offices to assign a case manager to each seriously injured
servicemember who applies for disability compensation. In addition, VA
noted the particular importance of early intervention for those who are
seriously injured and emphasized that seriously injured servicemembers
applying for VR&E should receive the fastest possible service.
Moreover, VA reminded VR&E staff that they can initiate evaluation and
counseling and, in some cases, authorize training before a
servicemember is discharged.
Since most seriously injured servicemembers are initially treated at
major MTFs, VA has detailed staff to these facilities.[Footnote 9]
These staff have included VA social workers and disability compensation
benefits counselors. In addition to these staff, at Walter Reed, where
the largest number of seriously injured servicemembers has been
treated, VA's Washington D.C. regional office has since 2001 provided a
vocational rehabilitation counselor to work with hospitalized patients.
To identify and monitor those whose injuries may result in a need for
VA services, including vocational rehabilitation, VA has asked DOD to
share data about injured servicemembers. VA has been working to develop
a formal agreement with DOD on what specific information to share. In
the spring of 2004, VA submitted a draft memorandum of agreement to
DOD's Office of the Assistant Secretary of Defense for Health Affairs
proposing that DOD provide lists of all injured servicemembers admitted
to MTFs. In addition, VA requested personal identifying information,
medical information, and DOD's injury classification for each listed
servicemember. VA also requested monthly lists of servicemembers being
evaluated for medical separation from military service. Several VA
officials and regional office staff we interviewed said that systematic
information from DOD would provide them with a way to more reliably
identify and monitor seriously injured servicemembers. As of December
2004, a formal agreement with DOD was still pending.
VA Regional Offices Have Relied on Local Liaisons with MTFs In Order to
Identify Seriously Injured Servicemembers Who May Need Assistance:
In the absence of a formal arrangement to ensure that DOD provides data
on seriously injured servicemembers, VA has relied on its regional
offices to obtain information about them. In its September 2003 letter,
the agency asked the regional offices to coordinate with staff at MTFs
and VA medical centers in their areas to ascertain the identities,
medical conditions, and military status of the seriously injured. While
VA officials reported to us that they had provided veterans' benefits
information to injured servicemembers, they did not have complete and
reliable data as to how many of these were seriously injured.
In response to guidance by VA's central office, every regional office
has designated a coordinator to serve as a point of contact with MTFs
and VA medical centers, as well as other VA regional offices, in order
to monitor injured servicemembers as they relocate across the country.
When servicemembers are discharged from an MTF, VA officials told us
that the affiliated VA regional office coordinator notifies the
coordinator in the region to which the person relocates. The new
coordinator contacts the seriously injured servicemember to discuss any
claims that have been filed and to provide those who have not already
done so an opportunity to apply for other benefits, including VR&E
services. Regional officials we interviewed reported that they have
followed VA's instructions to keep updated logs of all contacts they
have with seriously injured servicemembers. Regional offices are
required to send these logs to VA's central office, which uses them to
monitor outreach.
In our review of 12 regional offices, we found that they have developed
different information sources resulting in varying levels of
information on seriously injured servicemembers. The nature of the
local relationships between VA staff and military staff at MTFs was a
key factor in the completeness and reliability of the information that
the military provided. For example, the military MTF staff at one
regional office provided VA staff with only the names of new patients
with no indication of the severity of their condition or the theater
from which they were returning. Another regional office reported
receiving lists of servicemembers for whom the Army has initiated a
medical separation in addition to lists of patients with information on
the severity of their injuries. Some regional offices were able to
capitalize on longstanding informal relationships. For example, the VA
coordinator responsible for identifying and monitoring the seriously
injured at one regional office had served as an Army nurse at the local
MTF and was provided all pertinent information. In contrast, staff at
another regional office reported that local military staff did not
until recently provide them with information on seriously injured
servicemembers admitted to the MTF.
Once they have identified the seriously injured servicemembers,
regional office staff reported that they are largely following
outreach, coordination, and case management procedures outlined in VA's
September 2003 guidance. Under these procedures, disability
compensation benefit counselors usually conduct VA's initial outreach
by contacting hospitalized servicemembers to provide information on all
veterans' benefits, including VR&E. Traditionally responsible for
taking applications and processing disability compensation claims,
these staff members are neither vocational rehabilitation experts nor
are they generally trained to work with persons who have serious
injuries. Accordingly, VA reported that it has begun requiring all
staff members who provide in-person or telephone outreach to receive
training on how to interact with seriously injured servicemembers. VR&E
staff reported that they generally rely on the benefits counselors to
notify them of injured servicemembers at MTFs who are interested in or
who apply for VR&E. Only then would a vocational rehabilitation
counselor or counseling psychologist usually contact the hospitalized
servicemember to begin counseling and evaluation. In one regional
office, VR&E staff said that they do not contact injured servicemembers
until they apply for services and obtain a memorandum rating
establishing their eligibility.
The Washington, D.C. regional office has assigned a vocational
rehabilitation counselor to be available on site at Walter Reed Army
Medical Center, where a large number of seriously injured
servicemembers are treated. Although VA also deployed benefits
counselors to Walter Reed who are responsible for outreach activities
and the provision of information on all VA benefits, the VR&E counselor
works with hospitalized patients specifically to offer and provide
vocational counseling and evaluation. She reported attempting to
contact all patients within 48 hours of their arrival and visiting them
routinely thereafter to establish rapport. Her primary mission is to
work with servicemembers who will need to prepare for civilian
employment, although she told us that her early intervention efforts
could also help servicemembers who are able to remain in the military.
According to VA staff, many seriously injured servicemembers are not
ready or able to consider VR&E services when they are first contacted.
Yet, we found that VA has no policy for maintaining contact with those
servicemembers who do not apply for VR&E services when they were in the
hospital or when they returned to a home base or to their residence.
Several regional offices reported that they do not stay in contact with
these individuals while others attempt to do so in various ways. One
office said it is considering contacting them after one year. Another
regional VR&E officer reported that staff ask the servicemembers to
specify when they would like to be contacted for further information or
to begin program participation. Staff at this regional office noted
that they are strong advocates of early intervention. They said that
they try to contact servicemembers as soon as possible to establish
rapport and provide VR&E program information even before the
servicemembers are physically ready to begin developing a vocational
rehabilitation plan. At the same time, they noted that readiness to
participate in VR&E varies by individual and that professional judgment
is required to balance effective outreach with an approach that could
be viewed as intrusive.
VR&E program officials noted the potential value of maintaining contact
with seriously injured servicemembers who may not initially be ready to
participate when initially contacted by VA, but they also recognized
the need to focus resources on those who do participate. Nevertheless,
officials from a veterans service organization told us that it is
critical to maintain contact with seriously injured veterans who do not
initially apply for VR&E because they may need months or even years
before they are ready. In our prior work, we have also noted that
maintaining contact with individuals who have disabilities may help
encourage their return to work.[Footnote 10]
VA Faces Significant Challenges in Expediting Services to Seriously
Injured Servicemembers:
While experts and advocates for individuals with disabilities attest to
the value of early intervention for returning people to work, VA is
challenged to reach injured servicemembers early for several reasons.
First, determining the best time to approach recently injured
servicemembers and gauge their personal receptivity to consider
employment in the civilian sector is inherently difficult. The nature
of the recovery process is highly individualized and requires
professional judgment to determine the appropriate time to begin
vocational rehabilitation. Further, because VA is trying to prepare
servicemembers who are still on active duty for a transition to
civilian life, DOD is concerned that VA's efforts may be working at
cross purposes to the military's retention goals. Finally, because VA
lacks systematic information from DOD on seriously injured
servicemembers, VA cannot ensure that all servicemembers and veterans
who could benefit from the VR&E program have the opportunity to receive
services at the appropriate time.
Individual Differences in the Recovery Process Complicate the Timing of
Early Intervention:
Individual differences and uncertainties in the recovery process make
it inherently difficult to determine when a seriously injured
servicemember will be ready to consider vocational rehabilitation.
Since the appropriate time to intervene depends to a large extent on
the individual's medical condition and personal readiness, the time to
broach the subject of a return to work, whether in the military or the
civilian labor force, will vary. Regional office staff reported that
many servicemembers are eager to return to military duty and do not
intend to consider a career outside military service. They also
reported that many injured servicemembers need time to recover and
adjust to the likelihood that they may have to leave the military and
prepare for civilian employment.
Because of the individual differences in receptivity to VR&E, VA staff
reported needing to monitor the condition of seriously injured
servicemembers and to engage them more than once during their recovery
to be able to gauge their readiness for VR&E. One regional VR&E
official told us that VA could benefit from more collaboration with DOD
medical staff in order to make decisions on the appropriate timing of
VR&E intervention. The vocational rehabilitation counselor at Walter
Reed reported visiting servicemembers routinely, including evenings and
weekends, so that she would be available when they were ready to
discuss their need for vocational rehabilitation. For one patient, she
reported visiting him 12 times before he expressed interest in VR&E. In
some locations, VA staff reported participating in pre-discharge
planning meetings with military and medical staff, which they said
helped them stay informed about the servicemember's condition and
likely discharge and provided an opportunity to include VR&E in their
discharge planning.
VA Is Challenged by DOD's Concern that Early Intervention Could Work at
Cross Purposes to Military Retention:
VA is also challenged by DOD's concern that outreach about VA benefits,
including disability compensation and VR&E services, could work at
cross purposes to military retention goals. In particular, DOD
expressed concern about the timing of VA's outreach to servicemembers
whose discharge from military service is not yet certain. To expedite
VR&E services, VA's outreach process may overlap with the military's
process for evaluating servicemembers for a possible return to duty.
According to DOD officials, it may be premature for VA to begin working
with injured servicemembers who may eventually return to active duty.
(See fig. 2.) With advances in medicine and prosthetic devices, many
serious injuries no longer result in work-related impairments. Army
officials who track injured servicemembers told us that many seriously
injured servicemembers overcome their injuries and return to active
duty. Recognizing this potential, both Congress[Footnote 11] and the
President have recently expressed interest in seeing the military
provide the retraining needed to support the return of injured
servicemembers to their military occupations or other occupations
within the military if possible. In an attempt to enable more amputees
to return to active duty, Walter Reed Army Medical Center plans to open
a new rehabilitation center in 2005.
Both VA and DOD officials suggested that the earliest appropriate time
for VA to intervene for regular active duty servicemembers would be
when it is clear that the servicemember will not be retained by the
military. Currently, VA can only provide VR&E services to active duty
servicemembers who are pending discharge due to a disability. VR&E
services could begin earlier for injured members of the National Guard
and Reserve since these individuals usually expect to return to their
previous civilian employment. They may need VR&E services to return to
their prior employment or to prepare for a different occupation in the
civilian economy.
Figure 2: VA's Early Intervention Could Work at Cross Purposes to DOD's
Retention Evaluation Process:
[See PDF for image]
[End of figure]
VA Is Also Challenged by the Lack of Access to Systematic Data
Regarding Seriously Injured Servicemembers:
In the absence of a formal information sharing agreement with DOD, VA
does not have systematic access to DOD data about the population who
may need its services. Specifically, VA cannot reliably identify all
seriously injured servicemembers or know with certainty when they are
medically stabilized, when they are undergoing evaluation for a medical
discharge, or when they are actually medically discharged from the
military. VA has instead had to rely on ad hoc regional office
arrangements at the local level to identify and obtain specific data
about seriously injured servicemembers. While regional office staff
generally expressed confidence that the information sources they
developed enabled them to identify most seriously injured
servicemembers, they have no official data source from DOD with which
to confirm the completeness and reliability of their data nor can they
provide reasonable assurance that some seriously injured servicemembers
have not been overlooked. In addition, informal data sharing
relationships could break down with changes in personnel at either the
MTF or the regional office.
DOD officials expressed their concerns about the type of information to
be shared and when the information would be shared. DOD noted that it
needed to comply with legal privacy rules on sharing individual patient
information.[Footnote 12] DOD officials told us that information could
be made available to VA "upon separation" from military service, that
is, when a servicemember enters the separation process. At this time,
servicemembers would undergo assessment by a physical evaluation board,
which DOD officials said typically takes between 30 to 90 days and
usually results in a medical discharge from the military. However,
prior to separation, information can only be provided under certain
circumstances, such as when a patient's authorization is
obtained.[Footnote 13]
Conclusions:
VA has taken steps to help the nation's newest generation of veterans
move forward with their lives, particularly those who return from
combat with disabling injuries. VA has made seriously injured
servicemembers a priority and, among other measures, deployed staff to
major MTFs to conduct outreach to them prior to separation. However, VA
benefits counselors are usually the first VA representatives to contact
injured servicemembers. While they may provide an overview of all VA
benefits, they may not emphasize vocational rehabilitation and
employment services.
The importance of early intervention for returning individuals with
disabilities to the workforce is well documented in the vocational
rehabilitation literature. However, the lack of an agreement with DOD
for systematic data sharing impedes VA's attempt to identify all
seriously injured servicemembers who might benefit from such
intervention. It also poses the risk that some who are discharged with
disabilities may be overlooked and not afforded the opportunity for
VR&E. As VA recognizes, the current ad hoc approach of their regional
offices for obtaining information is not the most efficient way to
proceed. Furthermore, because individuals with disabilities vary in
their readiness and need for VR&E services, maintaining contact with
them would better ensure that VR&E staff know when the person is ready
to participate. Because VA has no policy for maintaining contact with
those who do not apply for VR&E, opportunities to rehabilitate veterans
who have sustained serious injuries in Afghanistan and Iraq may be
lost.
At a time when the U.S. labor force is projected to shrink, it is
imperative that those who can work, whether in military or civilian
jobs, are well supported in their efforts to do so. VA's early VR&E
efforts, rather than working at cross purposes to DOD goals, could
facilitate servicemembers' return to the same or different military
occupation, or to a civilian occupation, if they were not able to
remain in the military. In this regard, the prospect for early
intervention with VR&E services presents both a challenge and an
opportunity for VA and DOD to collaborate to provide better outcomes
for this new generation of seriously injured servicemembers.
Recommendations:
To improve VA's efforts to expedite VR&E services to seriously injured
servicemembers, we recommend that VA and DOD collaborate to reach an
agreement for VA to have access to information that both agencies agree
is needed to promote servicemembers' recovery and return to work.
We also recommend that the Secretary of Veterans Affairs direct the
Under Secretary for Benefits to develop a policy and procedures for
regional offices to maintain contact with seriously injured
servicemembers who do not initially apply for VR&E services, in order
to ensure that they have the opportunity to participate in the program
when they are ready.
Agency Comments:
In commenting on a draft of this report, VA concurred with our findings
and recommendations. VA emphasized that access to DOD information is
crucial to promoting servicemembers' recovery and return to work and,
to that end, is currently negotiating an agreement to allow VA to
obtain protected medical information on servicemembers prior to their
discharge for VA benefits purposes. In addition, VA noted that its
follow-up policies and procedures include sending veterans information
on VR&E benefits upon notification of a disability compensation award
and 60 days later. However, we believe a more individualized approach,
such as maintaining personal contact, could better ensure the
opportunity for veterans to participate in the program when they are
ready. VA noted that it is currently reviewing its outreach and follow-
up procedures for injured servicemembers and will make any appropriate
revisions. VA's written comments are reprinted in appendix I.
DOD also concurred with our findings and recommendations. DOD stated
its commitment to retaining seriously injured servicemembers who are
able and willing to return to duty. DOD also noted that a draft
memorandum of agreement for information sharing between VA and DOD is
under consideration by the two departments and the military services.
DOD's written comments are reprinted in appendix II.
As agreed with your office, unless you publicly announce the contents
of this report earlier, we plan no further distribution of this report
until 30 days after the date of this letter. We will then send copies
of this report to the Secretary of Veterans Affairs, the Secretary of
Defense, appropriate congressional committees, and other interested
parties. The report will also be available on GAO's Web site at http:/
/www.gao.gov.
If you or your staff have any questions regarding this report, please
call me at (202) 512-7215 or Irene Chu, Assistant Director, at (202)
512-7102.
Susan Bernstein, Connie Peebles Barrow, Margaret Boeckmann, William
R. Chatlos, Clarette Kim, Joseph J. Natalicchio, and Roger Thomas also
made key contributions to this report.
Sincerely yours,
Signed by:
Cynthia A. Bascetta:
Director, Education, Workforce, and Income Security Issues:
[End of section]
Appendix I: Comments from the Department of Veterans Affairs:
THE SECRETARY OF VETERANS AFFAIRS:
WASHINGTON:
January 7, 2005:
Ms. Cynthia Bascetta:
Director:
Education, Workforce, and Income Security Issues:
U. S. Government Accountability Office:
441 G Street, NW:
Washington, DC 20548:
Dear Ms. Bascetta:
The Department of Veterans Affairs (VA) has reviewed the Government
Accountability Office's (GAO) draft report, VOCATIONAL REHABILITATION:
More VA and DOD Collaboration Needed to Expedite Services for Seriously
Injured Servicemembers, (GAO-05-167). VA concurs with GAO's findings
and recommendations. Further discussion is included in the enclosure.
VA appreciates the opportunity to comment on your draft report.
Sincerely yours,
Signed by:
Anthony J. Principi:
Enclosure:
DEPARTMENT OF VETERANS AFFAIRS (VA) COMMENTS TO GOVERNMENT
ACCOUNTABILITY OFFICE (GAO) DRAFT REPORT, VOCATIONAL REHABILITATION:
More VA and DOD Collaboration Needed to Expedite Services for Seriously
Injured Servicemembers (GAO-05-167):
To improve VA's efforts to expedite VR&E services to seriously injured
servicemembers, we recommend that VA and DOD collaborate to reach an
agreement for VA to have access to information that both agencies agree
is needed to promote servicemembers' recovery and return to work.
Concur-The Department of Veterans Affairs (VA) concurs with this
finding and recommendation. VA recognizes that access to DoD
information is crucial to promote servicemembers' recovery and return
to work. VA has been working closely with DoD with a goal of providing
a seamless transition to all servicemembers who will enter the VA
system. To that end, a Memorandum of Understanding is currently being
negotiated that will allow VA to obtain from DoD the servicemembers'
protected medical information prior to discharge from service. VA's
Office of General Counsel is confident that there are exceptions in the
Privacy Rule that permit service medical information to be disclosed
for VA benefits purposes and has pressed the case with DoD's General
Counsel.
We, also recommend that the Secretary of Veterans Affairs direct the
Under Secretary for Benefits to develop a policy and procedures for
regional offices to maintain contact with seriously injured
servicemembers who do not initially apply for VR&E services, in order
to ensure that they have the opportunity to participate in the program
when they are ready.
Concur-VA concurs with this finding and recommendation. VBA has
developed specific policies and procedures that address outreach and
follow-up activities for injured servicemembers, including those that
do not file a claim for Vocational Rehabilitation and Employment (VR&E)
benefits during their initial contacts with VA. That guidance is
contained in Veterans Benefits Administration (VBA) Letter 20-03-36. A
brief outline of those activities follows.
Enclosure:
DEPARTMENT OF VETERANS AFFAIRS (VA) COMMENTS TO GOVERNMENT
ACCOUNTABILITY OFFICE (GAO) DRAFT REPORT, VOCATIONAL REHABILITATION:
More VA and DOD Collaboration Needed to Expedite Services for Seriously
Injured Servicemembers (GAO-05-167):
First, the regional office director will contact the servicemember when
he or she arrives in the regional office's jurisdiction. Regional
offices have Operation Enduring Freedom/Operation Iraqi Freedom
coordinators and case managers. The coordinator ensures that the
injured servicemember is personally provided information on all VA
benefits and services. The coordinator enters information on the
servicemember into a tracking log and establishes a diary for follow-up
activity.
When a claim for compensation is received, a Veterans Service Center
case manager is assigned to that case. The case manager contacts the
veteran and again reviews all benefits and services available through
VA, including VR&E benefits. Compensation is awarded after the
servicemember is discharged from the military. When the veteran
receives his or her first disability compensation award, VA sends
another application for VR&E benefits along with information explaining
the program. The case is diaried for follow-up in 60 days. If no
application for vocational rehabilitation and employment benefits is
received by the end of the 60 days, VR&E sends a motivation packet to
the veteran.
VBA is currently reviewing all policies and procedures contained in VBA
Letter 20-03-36, and will revise them as determined appropriate.
[End of section]
Appendix II: Comments from the Department of Defense:
THE ASSISTANT SECRETARY OF DEFENSE:
HEALTH AFFAIRS:
WASHINGTON, D C 20301-1200:
JAN 04 2005:
Ms. Cynthia A. Bascetta:
Director, Health Care-Veterans' Health and Benefits Issues:
U.S. Government Accountability Office:
441 G Street. N.W:
Washington, DC 20548:
Dear Ms. Bascetta:
This is the Department of Defense (DoD) response to the Government
Accountability Office (GAO) draft report, "VOCATIONAL REHABILITATION
More VA and DoD Collaboration Needed to Expedite Services for Seriously
Inured Servicemembers," dated January 2004 (GAO Code 130370/GAO-05-
167).
DoD appreciates the opportunity to comment on the draft report and
concurs with the GAO findings and recommendations with the attached
comments.
Please direct any questions to my points of contact on this matter, Mr.
Kenneth Cox (functional) at (703) 681-0039, ext. 3602 and Mr Gunther J.
Zimmerman (Audit Liaison) at (703) 681-3492 ext 4065.
Sincerely,
Signed by:
William Winkenwerder, Jr., MD:
Enclosures.
1. Overall Comments:
2 Technical Comments:
GAO DRAFT REPORT - DATED DECMEBER 14, 2004 (GAO CODE-130370/GAO-05-
167):
"VOCATIONAL REHABILITATION: More VA and DoD Collaboration Needed to
Expedite Services for Seriously Injured Servicemembers:
DEPARTMENT OF DEFENSE COMMENTS Technical Comments:
No technical comments received from the Services to date.
GAO DRAFT REPORT - DATED DECEMBER 14, 2004 (GAO CODE-130370/GAO-05-
167):
"VOCATIONAL REHABILITATION: More VA and DoD Collaboration Needed to
Expedite Services for Seriously Injured Servicemembers:
DEPARTMENT OF DEFENSE COMMENTS:
This draft report provides a review of the Department of Veterans'
Affairs efforts to provide rehabilitative services and employment
retraining to active duty members injured in Operation Enduring
Freedom/Operation Iraqi Freedom.
Overall Comments:
* The Government Accountability Office (GAO) report accurately depicts
the Department of Defense's (DoD) commitment to retaining seriously
injured servicemembers who have the potential and the desire to be
returned to duty whenever possible.
* The GAO reports that the Department of Veterans Affairs (VA) is also
challenged by lack of access to systematic data regarding seriously
injured Service members. GAO recommends that the two departments
"collaborate to reach an agreement for VA to have access to information
that both agencies agree is needed to promote recovery and return to
work for seriously injured Service members."
DoD is collaborating with VA to develop a Memorandum of Agreement (MOA)
establishing responsibilities for each department regarding the sharing
of personal health information data in such a manner that it supports
the seamless transition of Service members and is in compliance with
applicable Health Insurance Portability and Accountability Act privacy
requirements. At the time of this draft report, a draft of the MOA has
been developed and is being coordinated with relevant subject matter
experts in both departments and the military services.
* DoD offers the technical comments on the following page.
[End of section]
Related GAO Products:
VA and Defense Health Care: More Information Needed to Determine if VA
Can Meet an Increase in Demand for Post-Traumatic Stress Disorder
Services. GAO-04-1069. Washington, D.C.: September 20, 2004.
VA Vocational Rehabilitation and Employment Program: GAO Comments on
Key Task Force Findings and Recommendations. GAO-04-853. Washington,
D.C.: June 15, 2004.
VA Benefits: Fundamental Changes to VA's Disability Criteria Need
Careful Consideration. GAO-03-1172T. Washington, D.C.: September 23,
2003.
High-Risk Series: An Update. GAO-03-119. Washington, D.C.: January
2003.
Major Management Challenges and Program Risks: Department of Veterans
Affairs. GAO-03-110. Washington, D.C.: January 2003.
SSA and VA Disability Programs: Re-Examination of Disability Criteria
Needed to Help Ensure Program Integrity. GAO-02-597. Washington, D.C.:
August 9, 2002.
Military and Veterans' Benefits: Observations on the Transition
Assistance Program. GAO-02-914T. Washington, D.C.: July 18, 2002.
SSA Disability: Other Programs May Provide Lessons from Improving
Return-to-Work Efforts. GAO-01-153. Washington, D.C.: January 12, 2001.
Vocational Rehabilitation: Opportunities to Improve Program
Effectiveness. GAO/T-HEHS-98-87. Washington, D.C.: February 4, 1998.
Veterans Benefits Administration: Focusing on Results in Vocational
Rehabilitation and Education Programs. GAO/T-HEHS-97-148. Washington,
D.C.: June 5, 1997.
Vocational Rehabilitation: VA Continues to Place Few Disabled Veterans
in Jobs. GAO/HEHS-96-155. Washington, D.C.: September 3, 1996.
SSA Disability: Return-to-Work Strategies From Other Systems May
Improve Federal Programs. GAO/HEHS-96-133. Washington, D.C: July 11,
1996.
SSA Disability: Program Redesign Necessary to Encourage Return to Work.
GAO/HEHS-96-62. Washington, D.C.: April 24, 1996.
FOOTNOTES
[1] GAO, SSA Disability: Return-to-Work Strategies From Other Systems
May Improve Federal Programs, GAO-96-133 (Washington, D.C.: July 11,
1996).
[2] GAO, High-Risk Series: An Update, GAO-03-119 (Washington, D.C.:
Jan. 2003).
[3] Hospitalized military personnel pending discharge may receive all
vocational rehabilitation and employment benefits--such as counseling,
evaluation, and training--except for the monthly subsistence allowance.
38 U.S.C. §§ 3102, 3104, and 3113.
[4] GAO, Military and Veterans' Benefits: Observations on the
Transition Assistance Program, GAO-02-914T (Washington, D.C.: July 18,
2002).
[5] VA Vocational Rehabilitation and Employment Task Force. Report to
the Secretary of Veterans Affairs: The Vocational Rehabilitation and
Employment Program for the 21st Century Veteran (Washington, D.C.:
March 2004).
[6] DOD has supported transition assistance in various ways. For
example, the VA/DOD Joint Executive Committee was established in
February 2002 to further promote collaboration between the two
agencies, including resolving obstacles to information sharing. The
committee is chaired by the Deputy Secretary of Veterans Affairs and
the Under Secretary of Defense for Personnel and Readiness. In
addition, the Army--in cooperation with VA--established the Disabled
Soldier Support System (DS3) in April 2004 as an advocacy group and
information clearinghouse to clarify the services available to disabled
soldiers as they transition to civilian life.
[7] GAO, SSA Disability: Program Redesign Necessary to Encourage Return
to Work, GAO/HEHS-96-62 (Washington, D.C.: Apr. 24, 1996).
[8] Army regulations classify illness and injuries as "very serious"
when life is imminently endangered; as "serious" when there is a cause
for immediate concern but there is no imminent danger to life; and as
"special category" when the patient has a particular condition, such as
loss of limb or sight, a psychiatric condition, paralysis, or a
permanent disfigurement.
[9] These six facilities are Brooke Army Medical Center in Texas;
Walter Reed Army Medical Center in Washington, D.C; Madigan Army
Medical Center in Washington; Darnall Army Community Hospital in Texas;
Eisenhower Army Medical Center in Georgia; and the Bethesda Naval
Medical Center in Maryland. We focused on the five Army medical
treatment facilities.
[10] GAO, SSA Disability: Return-to-Work Strategies From Other Systems
May Improve Federal Programs, GAO/HEHS-96-133 (Washington, D.C: July
11, 1996).
[11] Congress expressed its sense that the Secretary of Defense should
develop protocols that include options for injured servicemembers who
are highly motivated to return to active duty service and for them to
be retrained to perform military missions for which they are fully
capable. Ronald W. Reagan National Defense Authorization Act for Fiscal
Year 2005, Pub. L. No. 108-375, § 588, Oct. 28, 2004, the "Sense of
Congress Regarding Return of Members to Active Duty Service upon
Rehabilitation from Service-Related Injuries."
[12] Health Insurance Portability and Accountability Act (HIPAA)
Privacy Rule, 45 C.F.R. Parts 160 and 164.
[13] 45 C.F.R. § 164.508(a).
GAO's Mission:
The Government Accountability Office, the investigative arm of
Congress, exists to support Congress in meeting its constitutional
responsibilities and to help improve the performance and accountability
of the federal government for the American people. GAO examines the use
of public funds; evaluates federal programs and policies; and provides
analyses, recommendations, and other assistance to help Congress make
informed oversight, policy, and funding decisions. GAO's commitment to
good government is reflected in its core values of accountability,
integrity, and reliability.
Obtaining Copies of GAO Reports and Testimony:
The fastest and easiest way to obtain copies of GAO documents at no
cost is through the Internet. GAO's Web site ( www.gao.gov ) contains
abstracts and full-text files of current reports and testimony and an
expanding archive of older products. The Web site features a search
engine to help you locate documents using key words and phrases. You
can print these documents in their entirety, including charts and other
graphics.
Each day, GAO issues a list of newly released reports, testimony, and
correspondence. GAO posts this list, known as "Today's Reports," on its
Web site daily. The list contains links to the full-text document
files. To have GAO e-mail this list to you every afternoon, go to
www.gao.gov and select "Subscribe to e-mail alerts" under the "Order
GAO Products" heading.
Order by Mail or Phone:
The first copy of each printed report is free. Additional copies are $2
each. A check or money order should be made out to the Superintendent
of Documents. GAO also accepts VISA and Mastercard. Orders for 100 or
more copies mailed to a single address are discounted 25 percent.
Orders should be sent to:
U.S. Government Accountability Office
441 G Street NW, Room LM
Washington, D.C. 20548:
To order by Phone:
Voice: (202) 512-6000:
TDD: (202) 512-2537:
Fax: (202) 512-6061:
To Report Fraud, Waste, and Abuse in Federal Programs:
Contact:
Web site: www.gao.gov/fraudnet/fraudnet.htm
E-mail: fraudnet@gao.gov
Automated answering system: (800) 424-5454 or (202) 512-7470:
Public Affairs:
Jeff Nelligan, managing director,
NelliganJ@gao.gov
(202) 512-4800
U.S. Government Accountability Office,
441 G Street NW, Room 7149
Washington, D.C. 20548:
