DOD and VA
Preliminary Observations on Efforts to Improve Health Care and Disability Evaluations for Returning Servicemembers Gao ID: GAO-07-1256T September 26, 2007In February 2007, a series of Washington Post articles disclosed troublesome deficiencies in the provision of outpatient services at Walter Reed Army Medical Center, raising concerns about the care for returning servicemembers. These deficiencies included a confusing disability evaluation system and servicemembers in outpatient status for months and sometimes years without a clear understanding about their plan of care. The reported problems at Walter Reed prompted broader questions about whether the Department of Defense (DOD) as well as the Department of Veterans Affairs (VA) are fully prepared to meet the needs of returning servicemembers. In response to the deficiencies reported at Walter Reed, the Army took a number of actions and DOD formed a joint DOD-VA Senior Oversight Committee. This statement provides information on the near-term actions being taken by the Army and the broader efforts of the Senior Oversight Committee to address longer-term systemic problems that impact health care and disability evaluations for returning servicemembers. Preliminary observations in this testimony are based largely on documents obtained from and interviews with Army officials, and DOD and VA representatives of the Senior Oversight Committee, as well as on GAO's extensive past work. We discussed the facts contained in this statement with DOD and VA.
While efforts are under way to respond to both Army-specific and systemic problems, challenges are emerging such as staffing new initiatives. The Army and the Senior Oversight Committee have efforts under way to improve case management--a process intended to assist returning servicemembers with management of their care from initial injury through recovery. Case management is especially important for returning servicemembers who must often visit numerous therapists, providers, and specialists, resulting in differing treatment plans. The Army's approach for improving case management for its servicemembers includes developing a new organizational structure--a Warrior Transition Unit, in which each servicemember would be assigned to a team of three key staff--a physician care manager, a nurse case manager, and a squad leader. As the Army has sought to staff its Warrior Transition Units, challenges to staffing critical positions are emerging. For example, as of mid-September 2007, over half the U.S. Warrior Transition Units had significant shortfalls in one or more of these critical positions. The Senior Oversight Committee's plan to provide a continuum of care focuses on establishing recovery coordinators, which would be the main contact for a returning servicemember and his or her family. This approach is intended to complement the military services' existing case management approaches and place the recovery coordinators at a level above case managers, with emphasis on ensuring a seamless transition between DOD and VA. At the time of GAO's review, the committee was still determining how many recovery coordinators would be necessary and the population of seriously injured servicemembers they would serve. As GAO and others have previously reported, providing timely and consistent disability decisions is a challenge for both DOD and VA. To address identified concerns, the Army has taken steps to streamline its disability evaluation process and reduce bottlenecks. The Army has also developed and conducted the first certification training for evaluation board liaisons who help servicemembers navigate the system. To address more systemic concerns, the Senior Oversight Committee is planning to pilot a joint disability evaluation system. Pilot options may incorporate variations of three key elements: (1) a single, comprehensive medical examination; (2) a single disability rating done by VA; and (3) a DOD-level evaluation board for adjudicating servicemembers' fitness for duty. DOD and VA officials hoped to begin the pilot in August 2007, but postponed implementation in order to further review options and address open questions, including those related to proposed legislation. Fixing these long-standing and complex problems as expeditiously as possible is critical to ensuring high-quality care for returning servicemembers, and success will ultimately depend on sustained attention, systematic oversight by DOD and VA, and sufficient resources.
GAO-07-1256T, DOD and VA: Preliminary Observations on Efforts to Improve Health Care and Disability Evaluations for Returning Servicemembers
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Testimony:
Before the Subcommittee on National Security and Foreign Affairs,
Committee on Oversight and Government Reform, House of Representatives:
United States Government Accountability Office:
GAO:
For Release on Delivery Expected at 10:00 a.m. EDT:
Wednesday, September 26, 2007:
DOD and VA:
Preliminary Observations on Efforts to Improve Health Care and
Disability Evaluations for Returning Servicemembers:
Statement of John H. Pendleton, Acting Director:
Health Care:
Statement of Daniel Bertoni, Director:
Education, Workforce, and Income Security:
GAO-07-1256T:
GAO Highlights:
Highlights of GAO-07-1256T, a testimony before the Subcommittee on
National Security and Foreign Affairs, Committee on Oversight and
Government Reform, House of Representatives
Why GAO Did This Study:
In February 2007, a series of Washington Post articles disclosed
troublesome deficiencies in the provision of outpatient services at
Walter Reed Army Medical Center, raising concerns about the care for
returning servicemembers. These deficiencies included a confusing
disability evaluation system and servicemembers in outpatient status
for months and sometimes years without a clear understanding about
their plan of care. The reported problems at Walter Reed prompted
broader questions about whether the Department of Defense (DOD) as well
as the Department of Veterans Affairs (VA) are fully prepared to meet
the needs of returning servicemembers. In response to the deficiencies
reported at Walter Reed, the Army took a number of actions and DOD
formed a joint DOD-VA Senior Oversight Committee.
This statement provides information on the near-term actions being
taken by the Army and the broader efforts of the Senior Oversight
Committee to address longer-term systemic problems that impact health
care and disability evaluations for returning servicemembers.
Preliminary observations in this testimony are based largely on
documents obtained from and interviews with Army officials, and DOD and
VA representatives of the Senior Oversight Committee, as well as on
GAO‘s extensive past work. We discussed the facts contained in this
statement with DOD and VA.
What GAO Found:
While efforts are under way to respond to both Army-specific and
systemic problems, challenges are emerging such as staffing new
initiatives. The Army and the Senior Oversight Committee have efforts
under way to improve case management”a process intended to assist
returning servicemembers with management of their care from initial
injury through recovery. Case management is especially important for
returning servicemembers who must often visit numerous therapists,
providers, and specialists, resulting in differing treatment plans. The
Army‘s approach for improving case management for its servicemembers
includes developing a new organizational structure”a Warrior Transition
Unit, in which each servicemember would be assigned to a team of three
key staff”a physician care manager, a nurse case manager, and a squad
leader. As the Army has sought to staff its Warrior Transition Units,
challenges to staffing critical positions are emerging. For example, as
of mid-September 2007, over half the U.S. Warrior Transition Units had
significant shortfalls in one or more of these critical positions. The
Senior Oversight Committee‘s plan to provide a continuum of care
focuses on establishing recovery coordinators, which would be the main
contact for a returning servicemember and his or her family. This
approach is intended to complement the military services‘ existing case
management approaches and place the recovery coordinators at a level
above case managers, with emphasis on ensuring a seamless transition
between DOD and VA. At the time of GAO‘s review, the committee was
still determining how many recovery coordinators would be necessary and
the population of seriously injured servicemembers they would serve.
As GAO and others have previously reported, providing timely and
consistent disability decisions is a challenge for both DOD and VA. To
address identified concerns, the Army has taken steps to streamline its
disability evaluation process and reduce bottlenecks. The Army has also
developed and conducted the first certification training for evaluation
board liaisons who help servicemembers navigate the system. To address
more systemic concerns, the Senior Oversight Committee is planning to
pilot a joint disability evaluation system. Pilot options may
incorporate variations of three key elements: (1) a single,
comprehensive medical examination; (2) a single disability rating done
by VA; and (3) a DOD-level evaluation board for adjudicating
servicemembers‘ fitness for duty. DOD and VA officials hoped to begin
the pilot in August 2007, but postponed implementation in order to
further review options and address open questions, including those
related to proposed legislation.
Fixing these long-standing and complex problems as expeditiously as
possible is critical to ensuring high-quality care for returning
servicemembers, and success will ultimately depend on sustained
attention, systematic oversight by DOD and VA, and sufficient
resources.
To view the full product, including the scope and methodology, click on
GAO-07-1256T. For more information, contact John H. Pendleton at (202)
512-7114 or pendletonj@gao.gov; or Daniel Bertoni, at (202) 512-7215 or
bertonid@gao.gov.
[End of section]
Mr. Chairman and Members of the Subcommittee:
We are pleased to be here today as you examine issues related to the
provision of care and services for our returning servicemembers. In
February 2007, a series of Washington Post articles disclosed
troublesome deficiencies in the provision of outpatient services at
Walter Reed Army Medical Center, raising concerns about the care for
returning servicemembers and conditions at Army facilities across the
country. Deficiencies at Walter Reed included poor living conditions, a
confusing disability evaluation system, and servicemembers in
outpatient status for months and sometimes years without a clear
understanding about their plan of care or the future of their military
service.
The reported problems at Walter Reed prompted broader questions about
whether the Department of Defense (DOD) as well as the Department of
Veterans Affairs (VA) are fully prepared to meet the needs of the
increasing number of returning servicemembers as well as veterans.
Several review groups were tasked with investigating the reported
problems and identifying recommendations. In February 2007, the
Secretary of Defense established the Independent Review Group, which
reported its findings in April 2007.[Footnote 1] In March 2007, the
President established both the Task Force on Returning Global War on
Terror Heroes and the President's Commission on Care for America's
Returning Wounded Warriors, commonly referred to as the Dole-Shalala
Commission. The Task Force reported its findings in April 2007[Footnote
2] and the Dole-Shalala Commission reported its findings in July
2007.[Footnote 3] In August 2007, the President announced that he had
directed the Secretaries of DOD and VA to study and implement the
recommendations made by the Dole-Shalala Commission. See appendix I for
a summary of selected findings from each of the review groups.
The three review groups identified common areas of concern, including
inadequate case management to ensure continuity of care;[Footnote 4]
confusing disability evaluation systems; the need to better understand
and diagnose traumatic brain injury (TBI) or post-traumatic stress
disorder (PTSD),[Footnote 5] sometimes referred to as "invisible
injuries;" and insufficient data sharing between DOD and VA of
servicemembers' medical records. Problems in these areas have been long-
standing and the subject of much past work by GAO.[Footnote 6] For
example, we have reported that major disability programs, including the
VA's disability programs, are neither well aligned with the 21st
century environment nor positioned to provide meaningful and timely
support.[Footnote 7] Specifically, challenges exist related to ensuring
timely provision of services and benefits as well as interpreting
complex eligibility requirements, among other things. In January 2003,
we designated modernizing federal disability programs as a high-risk
area.[Footnote 8]
In response to Walter Reed deficiencies reported by the media, the Army
took several actions, most notably initiating the development of the
Army Medical Action Plan in March 2007. The plan, designed to help the
Army become more patient-focused, includes more than 150 tasks for
establishing a continuum of care and services, optimizing the Army
Physical Disability Evaluation System, and maximizing coordination of
efforts with VA. According to the Army, most of the tasks in the
Medical Action Plan are to be completed by January 2008.
In May 2007, DOD established the Wounded, Ill, and Injured Senior
Oversight Committee (Senior Oversight Committee) to bring high-level
attention to addressing the problems associated with the care and
services for returning servicemembers, including the concerns that were
being raised by the various review groups. The committee is co-chaired
by the Deputy Secretaries of Defense and Veterans Affairs, and also
includes the military service Secretaries and other high-ranking
officials within DOD and VA. To conduct its work, the Senior Oversight
Committee has established workgroups that have focused on specific
areas including case management, disability evaluation systems, TBI and
psychological health, including PTSD, and data sharing between DOD and
VA.[Footnote 9] Each workgroup includes representation from DOD,
including each of the military services, and VA. The workgroups report
their efforts and recommendations to the Senior Oversight Committee,
which directs the appropriate components of DOD and VA to act. The
Senior Oversight Committee was established for a 12-month time frame,
which will end in May 2008.
Today, our remarks are based on preliminary observations drawn from our
ongoing reviews as well as extensive past work. Our statement addresses
the near-term actions being taken by the Army, as well as the broader
efforts of the Senior Oversight Committee to address longer-term
systemic problems that affect care for returning servicemembers, in the
following four areas: case management, disability evaluation systems,
TBI and PTSD, and data sharing between DOD and VA. We focused on
efforts of the Army because it has the majority of servicemembers in
Operation Iraqi Freedom and Operation Enduring Freedom, and, as a
result the majority of returning servicemembers needing care and
rehabilitation go to Army facilities. We also focused on the efforts of
the Senior Oversight Committee because it was specifically established
to address concerns about the care and services provided to returning
servicemembers. Our testimony is based largely on documents obtained
from and interviews with Army officials, including the Army's Office of
the Surgeon General, and DOD and VA representatives of the Senior
Oversight Committee. Specifically, we reviewed Army's staffing data
related to the initiatives established in the Army Medical Action Plan.
We did not verify the accuracy of these data; however, we interviewed
agency officials knowledgeable about the data, and we determined that
they were sufficiently reliable for the purposes of this statement. We
visited Walter Reed Army Medical Center in August 2007 to talk with
officials about how they are implementing the Army's Medical Action
Plan and to obtain views from servicemembers about how the efforts are
affecting their care. Our findings are preliminary and it was beyond
the scope of our work for this statement to review the efforts under
way in other military services or throughout DOD and VA. We discussed
the facts contained in this statement with DOD and VA, and we
incorporated their comments where appropriate. We are conducting the
work we began in June in accordance with generally accepted government
auditing standards.
In summary, the Army took near-term actions to respond to reported
deficiencies about the care and services provided to its returning
servicemembers, and the Senior Oversight Committee is undertaking
efforts to address more systemic problems. However, challenges remain
to overcome long-standing problems and ensure sustainable progress in
the four areas we reviewed: (1) case management, (2) disability
evaluation systems, (3) TBI and PTSD, and (4) data sharing between DOD
and VA.
* Case management: The Army has developed a new organizational
structure--Warrior Transition Units--for providing an integrated
continuum of care for its returning servicemembers. Within each unit, a
servicemember is assigned to a team of three critical staff--physician,
nurse case manager, and squad leader--who manage the servicemember's
care. As of mid-September, 17 of the 32 units had less than 50 percent
of staff in place in one or more of these critical positions. To
facilitate continuity of care across departments, the Senior Oversight
Committee is developing a plan to establish recovery coordinators to
oversee the care of severely injured servicemembers across federal
agencies, including DOD and VA. This action is being taken to address a
recommendation by the Dole-Shalala Commission. Although initial
implementation is slated for mid-October 2007, as of mid-September, the
committee had not determined how many federal recovery coordinators
will be needed. This is partly because it is still unclear exactly what
portion of returning servicemembers these recovery coordinators will
serve.
* Disability evaluation systems: The Army is pursuing several
initiatives to help streamline the disability evaluation process for
its servicemembers--for example, by reducing the caseloads of staff who
help servicemembers navigate the system--and has taken steps to help
mitigate servicemembers' confusion, such as providing additional
briefings about the process and an online tool. To address more
systemic concerns about the timeliness and consistency of DOD's and
VA's disability evaluation systems, the Senior Oversight Committee is
planning to pilot a joint DOD/VA disability evaluation system that may
include variations of three elements: (1) a single, comprehensive
medical examination; (2) a single disability rating performed by VA;
and (3) a DOD-level retention board for adjudicating servicemembers'
fitness for duty. The departments initially slated the pilot to begin
on August 1, 2007, but the date has slipped as DOD and VA continue to
review pilot options and take steps to address key questions including
those related to emerging legislative proposals and long-standing
challenges.
* TBI and PTSD: To improve the care provided to servicemembers with TBI
and PTSD, both the Army and the Senior Oversight Committee have efforts
under way to improve screening, diagnosis, and treatment of these
conditions. As part of the Army Medical Action Plan, the Army has
established policies to provide training on mild TBI and PTSD to all
its nurse case managers and psychiatric nurses, among others. As of
September 13, 2007, 6 of the Army's 32 Warrior Transition Units had
completed training for all of these staff. The Senior Oversight
Committee has developed a policy for DOD and VA to establish a national
Center of Excellence for TBI and PTSD that will coordinate the efforts
of the two departments related to promoting research, awareness, and
best practices on these conditions.
* Data sharing: DOD and VA have been working for almost 10 years to
facilitate the exchange of medical information. The Army has service-
specific efforts under way to improve the sharing of data between its
military treatment facilities and VA. Also, the Senior Oversight
Committee has developed a workgroup to accelerate data-sharing efforts
between the two departments and to help provide for the data-sharing
needs of other efforts being overseen by the Senior Oversight
Committee. The need for DOD and VA to share patient data continues to
be critical. For example, data sharing is important to the proposed
recovery coordinators who will require timely and reliable patient
information to ensure continuity of care across the many organizational
seams in DOD and VA.
Given the importance of all these issues for providing appropriate and
high-quality care to our returning servicemembers, it is critical for
top leaders at DOD and VA to continue to implement as well as to
oversee these efforts to ensure the goals of the efforts are achieved
in a timely manner, particularly since there is an increasing need to
provide care to servicemembers.
Background:
DOD and VA offer health care benefits to active duty servicemembers and
veterans, among others. Under DOD's health care system, eligible
beneficiaries may receive care from military treatment facilities or
from civilian providers. Military treatment facilities are individually
managed by each of the military services--the Army, the Navy,[Footnote
10] and the Air Force. Under VA, eligible beneficiaries may obtain care
through VA's integrated health care system of hospitals, ambulatory
clinics, nursing homes, residential rehabilitation treatment programs,
and readjustment counseling centers. VA has organized its health care
facilities into a polytrauma system of care[Footnote 11] that helps
address the medical needs of returning servicemembers and veterans, in
particular those who have an injury to more than one part of the body
or organ system that results in functional disability and physical,
cognitive, psychosocial, or psychological impairment. Persons with
polytraumatic injuries may have injuries or conditions such as TBI,
amputations, fractures, and burns.
Over the past 6 years, DOD has designated over 29,000 servicemembers
involved in Operation Iraqi Freedom and Operation Enduring Freedom as
wounded in action, and almost 70 percent of these servicemembers are
from the Army active, reserve, and national guard components.
Servicemembers injured in these conflicts are surviving injuries that
would have been fatal in past conflicts, due, in part, to advanced
protective equipment and medical treatment. The severity of their
injuries can result in a lengthy transition from patient back to duty,
or to veterans' status. Initially, most seriously injured
servicemembers from these conflicts, including activated National Guard
and Reserve members, are evacuated to Landstuhl Regional Medical Center
in Germany for treatment. From there, they are usually transported to
military treatment facilities in the United States, with most of the
seriously injured admitted to Walter Reed Army Medical Center or the
National Naval Medical Center. According to DOD officials, once they
are stabilized and discharged from the hospital, servicemembers may
relocate closer to their homes or military bases and are treated as
outpatients by the closest military or VA facility.
Returning injured servicemembers must potentially navigate two
different disability evaluation systems that generally rely on the same
criteria but for different purposes. DOD's system serves a personnel
management purpose by identifying servicemembers who are no longer
medically fit for duty. The military's process starts with
identification of a medical condition that could render the
servicemember unfit for duty, a process that could take months to
complete. The servicemember goes through a medical evaluation board
proceeding, where medical evidence is evaluated, and potentially unfit
conditions are identified. The member then goes through a physical
evaluation board process, where a determination of fitness or unfitness
for duty is made and, if found unfit for duty, a combined percentage
rating is assigned for all unfit conditions and the servicemember is
discharged from duty. The injured servicemember then receives monthly
disability retirement payments if he or she meets the minimum rating
and years of duty thresholds or, if not, a lump-sum severance payment.
VA provides veterans compensation for lost earning capacity due to
service-connected disabilities. Although a servicemember may file a VA
claim while still in the military, he or she can only obtain disability
compensation from VA as a veteran. VA will evaluate all claimed
conditions, whether they were evaluated by the military service or not.
If the veteran is found to have one or more service-connected
disabilities with a combined rating of at least 10 percent,[Footnote
12] VA will pay monthly compensation. The veteran can claim additional
benefits, for example, if a service-connected disability worsens.
While Efforts Are Under Way to Respond to Both Army-Specific and
Systemic Problems, Challenges Are Emerging:
While the Army took near-term actions to respond to reported
deficiencies in care for its returning servicemembers, and the Senior
Oversight Committee is undertaking efforts to address more systemic
problems, challenges remain to overcome long-standing problems and
ensure sustainable progress. In particular, efforts were made to
respond to problems in four key areas: (1) case management, (2)
disability evaluation systems, (3) TBI and PTSD, and (4) data sharing
between DOD and VA. The three review groups identified several problems
in these four areas including: a need to develop more comprehensive and
coordinated care and services; a need to make the disability systems
more efficient; more collaboration of research and establishment of
practice guidelines for TBI and PTSD; and more data sharing between DOD
and VA. While efforts have been made in all four areas, challenges have
emerged including staffing for the case management initiatives and
transforming the disability evaluation system.
Efforts to Improve Case Management for Servicemembers Under Way, but
Human Capital and Other Challenges Are Surfacing:
The three review groups reporting earlier this year identified numerous
problems with DOD's and VA's case management of servicemembers,
including a lack of comprehensive and well-coordinated care, treatment,
and services. Case management--a process intended to assist returning
servicemembers with management of their clinical and nonclinical care
throughout recovery, rehabilitation, and community reintegration--is
important because servicemembers often receive services from numerous
therapists, providers, and specialists, resulting in differing
treatment plans as well as receiving prescriptions for multiple
medications. One of the review groups reported that the complexity of
injuries in some patients requires a coordinated method of case
management to keep the care of the returning servicemember focused and
goal directed, and that this type of care was not evident at Walter
Reed.[Footnote 13] The Dole-Shalala Commission recommended that
recovery coordinators be appointed to craft and manage individualized
recovery plans that would be used to guide the servicemembers' care.
The Dole-Shalala Commission further recommended that these recovery
coordinators come from outside DOD or VA, possibly from the Public
Health Service, and be highly skilled and have considerable authority
to be able to access resources necessary to implement the recovery
plans. The Army and the Senior Oversight Committee's workgroup on case
management have initiated efforts to develop case management approaches
that are intended to improve the management of servicemembers' recovery
process. See table 1 for selected efforts by the Army and Senior
Oversight Committee to improve case management services.
Table 1: Selected Army and Senior Oversight Committee Efforts to
Improve Case Management:
U.S. Army:
* Established a new organizational structure for providing care to
returning servicemembers that combines active duty and reserve
servicemembers who are in outpatient status;
* Established a case management approach that includes a primary care
physician, nurse case manager, and military squad leader who will
coordinate the management of a servicemember's recovery process.
Senior Oversight Committee:
* Developed policy requiring DOD and VA to establish a joint Recovery
Coordinator Program no later than October 15, 2007, to integrate care
and service delivery for returning servicemembers and their families.
The recovery coordinators are to be provided by VA;
* Mapped the case management process across the military services and
developed common roles and responsibilities for case managers for an
integrated DOD and VA approach and joint standards of practice and
training;
* Planning to develop DOD/VA oversight metrics to ensure accountability
and continuous process improvement.
Sources: Army and Senior Oversight Committee.
[End of table]
The Army's approach includes developing a new organizational structure
for providing care to returning active duty and reserve servicemembers
who are unable to perform their duties and are in need of health care-
-this structure is referred to as a Warrior Transition Unit. Within
each unit, the servicemember is assigned to a team of three key staff
and this team is responsible for overseeing the continuum of care for
the servicemember.[Footnote 14] The Army refers to this team as a
"triad," and it consists of a (1) primary care manager--usually a
physician who provides primary oversight and continuity of health care
and ensures the quality of the servicemember's care; (2) nurse case
manager--usually a registered nurse who plans, implements, coordinates,
monitors, and evaluates options and services to meet the
servicemember's needs; and (3) squad leader--a noncommissioned officer
who links the servicemember to the chain of command, builds a
relationship with the servicemember, and works along side the other
parts of the triad to ensure the needs of the servicemember and his or
her family are met. As part of the Army's Medical Action Plan, the Army
established 32 Warrior Transition Units, to provide a unit in every
medical treatment facility that has 35 or more eligible
servicemembers.[Footnote 15] The Army's goal is to fill the triad
positions according to the following ratios: 1:200 for primary care
managers; 1:18 for nurse case managers; and 1:12 for squad leaders.
This approach is a marked departure for the Army. Prior to the creation
of the Warrior Transition Units, the Army separated active and reserve
component soldiers into different units.[Footnote 16] One review group
reported that this approach contributed to discontent about which group
received better treatment.[Footnote 17] Moreover, the Army did not have
formalized staffing structures nor did it routinely track patient-care
ratios, which the Independent Review Group reported contributed to the
Army's inability to adequately oversee its program or identify gaps.
As the Army has sought to fill its Warrior Transition Units, challenges
to staffing key positions are emerging. For example, many locations
have significant shortfalls in registered nurse case managers and non-
commissioned officer squad leaders. As shown in figure 1, about half of
the total required staffing needs of the Warrior Transition Units had
been met across the Army by mid-September 2007. However, the Army had
filled many of these slots thus far by temporarily borrowing staff from
other positions.
Figure 1: Status of Warrior Transition Unit Staffing, as of September
13, 2007:
[See PDF for image]
Source: GAO analysis of Army data.
Note: Percentages do not add to 100 percent due to rounding.
[End of figure]
The Warrior Transition Unit staffing shortages are significant at many
locations. As of mid-September, 17 of the 32 units had less than 50
percent of staff in place in one or more critical positions. (See table
2.) Consequently, 46 percent of the Army's returning servicemembers who
were eligible to be assigned to a unit had not been assigned, due in
part to these staffing shortages. As a result, these servicemembers'
care was not being coordinated through the triad. Army officials
reported that their goal is to have all Warrior Transition Units in
place and fully staffed by January 2008.
Table 2: Locations Where Warrior Transition Units Had Less Than 50
Percent of Staff in Place in One or More Critical Positions, as of
September 13, 2007:
Location: Fort Hood, Texas;
Total number of servicemembers at location[A]: 743;
Critical positions: Physicians: [Empty];
Critical positions: Nurse case managers: x;
Critical positions: Squad leaders: x.
Location: Fort Lewis, Washington;
Total number of servicemembers at location[A]: 617;
Critical positions: Physicians: x;
Critical positions: Nurse case managers: x;
Critical positions: Squad leaders: [Empty].
Location: Fort Bragg, North Carolina;
Total number of servicemembers at location[A]: 586;
Critical positions: Physicians: [Empty];
Critical positions: Nurse case managers: x;
Critical positions: Squad leaders: [Empty].
Location: Fort Gordon, Georgia;
Total number of servicemembers at location[A]: 546;
Critical positions: Physicians: x;
Critical positions: Nurse case managers: [Empty];
Critical positions: Squad leaders: x.
Location: Fort Knox, Kentucky;
Total number of servicemembers at location[A]: 430;
Critical positions: Physicians: [Empty];
Critical positions: Nurse case managers: [Empty];
Critical positions: Squad leaders: x.
Location: Fort Carson, Colorado;
Total number of servicemembers at location[A]: 394;
Critical positions: Physicians: x;
Critical positions: Nurse case managers: x;
Critical positions: Squad leaders: x.
Location: Fort Campbell, Kentucky;
Total number of servicemembers at location[A]: 328;
Critical positions: Physicians: [Empty];
Critical positions: Nurse case managers: [Empty];
Critical positions: Squad leaders: x.
Location: Tripler, Hawaii;
Total number of servicemembers at location[A]: 237;
Critical positions: Physicians: [Empty];
Critical positions: Nurse case managers: [Empty];
Critical positions: Squad leaders: x.
Location: Fort Stewart, Georgia;
Total number of servicemembers at location[A]: 223;
Critical positions: Physicians: [Empty];
Critical positions: Nurse case managers: x;
Critical positions: Squad leaders: [Empty].
Location: Fort Riley, Kansas;
Total number of servicemembers at location[A]: 209;
Critical positions: Physicians: [Empty];
Critical positions: Nurse case managers: x;
Critical positions: Squad leaders: x.
Location: Fort Eustis, Virginia;
Total number of servicemembers at location[A]: 128;
Critical positions: Physicians: [Empty];
Critical positions: Nurse case managers: [Empty];
Critical positions: Squad leaders: x.
Location: Fort Sill, Oklahoma;
Total number of servicemembers at location[A]: 127;
Critical positions: Physicians: [Empty];
Critical positions: Nurse case managers: [Empty];
Critical positions: Squad leaders: x.
Location: West Point, New York;
Total number of servicemembers at location[A]: 99;
Critical positions: Physicians: [Empty];
Critical positions: Nurse case managers: [Empty];
Critical positions: Squad leaders: x.
Location: Fort Leonard Wood, Missouri;
Total number of servicemembers at location[A]: 78;
Critical positions: Physicians: [Empty];
Critical positions: Nurse case managers: [Empty];
Critical positions: Squad leaders: x.
Location: Fort Wainwright, Alaska;
Total number of servicemembers at location[A]: 51;
Critical positions: Physicians: [Empty];
Critical positions: Nurse case managers: x;
Critical positions: Squad leaders: [Empty].
Location: Fort Jackson, South Carolina;
Total number of servicemembers at location[A]: 45;
Critical positions: Physicians: [Empty];
Critical positions: Nurse case managers: x;
Critical positions: Squad leaders: x.
Location: Redstone Arsenal, Alabama;
Total number of servicemembers at location[A]: 4;
Critical positions: Physicians: N/A[B];
Critical positions: Nurse case managers: N/A[B];
Critical positions: Squad leaders: x.
Source: GAO analysis of Army data.
Note: Warrior Transition Units also include other positions, such as
social workers, occupational therapists, and administrative staff.
[A] Total number of servicemembers includes those in outpatient care--
assigned to a Warrior Transition Unit as well as in the Medical
Evaluation Board process and who have not been assigned to a Warrior
Transition Unit.
[B] No staff were authorized for this position.
[End of table]
The Senior Oversight Committee's approach for providing a continuum of
care includes establishment of recovery coordinators and recovery
plans, as recommended by the Dole-Shalala Commission. This approach is
intended to complement the military services' existing case management
approaches and place the recovery coordinators at a level above case
managers, with emphasis on ensuring a seamless transition between DOD
and VA. The recovery coordinator is expected to be the patient's and
family's single point of contact for making sure each servicemember
receives the care outlined in the servicemember's recovery plan--a plan
to guide and support the servicemember through the phases of medical
care, rehabilitation, and disability evaluation to community
reintegration.
The Senior Oversight Committee has indicated that DOD and VA will
establish a joint Recovery Coordinator Program no later than October
15, 2007. At the time of our review, the committee was determining the
details of the program. For example, the Dole-Shalala Commission
recommended this approach for every seriously injured servicemember,
and the Senior Oversight Committee workgroup on case management was
developing criteria for determining who is "seriously injured." The
workgroup was also determining the role of the recovery coordinators--
how they will be assigned to servicemembers and how many are needed,
which will ultimately determine what the workload for each will be. The
Senior Oversight Committee has, however, indicated that the positions
will be filled with VA staff. A representative of the Senior Oversight
Committee told us that the recovery coordinators would not be staffed
from the U.S. Public Health Service Commissioned Corps, as recommended
by the Dole-Shalala Commission. The official told us that it is
appropriate for VA to staff these positions because VA ultimately
provides the most care for servicemembers over their lifetime.
Moreover, Senior Oversight Committee officials told us that depending
on how many recovery coordinators are ultimately needed, VA may face
significant human capital challenges in identifying and training
individuals for these positions, which are anticipated to be complex
and demanding.
Efforts Are Under Way to Improve Disability Evaluation Processes, but
Challenges Remain in Transforming the Overall System:
As we have previously reported, providing timely and consistent
disability decisions is a challenge for both DOD and VA. In a March
2006 report about the military disability evaluation system, we found
that the services were not meeting DOD timeliness goals for processing
disability cases; used different policy, guidance and processes for
aspects of the system; and that neither DOD nor the services
systematically evaluated the consistency of disability
decisions.[Footnote 18] On multiple occasions, we have also identified
long-standing challenges for VA in reducing its backlog of claims and
improving the accuracy and consistency of its decisions.[Footnote 19]
The controversy over conditions at Walter Reed and the release of
subsequent reports raised the visibility of problems in the military
services' disability evaluation system. In a March 2007 report, the
Army Inspector General identified numerous issues with the Army
Physical Disability Evaluation System.[Footnote 20] These findings
included a failure to meet timeliness standards for determinations,
inadequate training of staff involved in the process, and servicemember
confusion about the disability rating system. Similarly, in recently-
issued reports, the Task Force on Returning Global War on Terror
Heroes, the Independent Review Group, and the Dole-Shalala Commission
found that DOD's disability evaluation system often generates long
delays in disability determinations and creates confusion among
servicemembers and their families. Also, they noted significant
disparities in the implementation of the disability evaluation system
among the services, and in the purpose and outcome of disability
evaluations between DOD and VA. Two reports also noted the adversarial
nature of DOD's disability evaluation system, as servicemembers
endeavor to reach a rating threshold that entitles them to lifetime
benefits. In addition to these findings about current processes, the
Dole-Shalala Commission questioned DOD's basic role in making
disability payments to veterans and recommended that VA assume sole
responsibility for disability compensation for veterans.
In response to the Army Inspector General's findings, the Army made
near-term operational improvements. For example, the Army developed
several initiatives to streamline its disability evaluation system and
address bottlenecks. These initiatives include reducing the caseloads
of evaluation board liaisons who help servicemembers navigate the
disability evaluation system. In addition, the Army developed and
conducted the first certification training for evaluation board
liaisons. Furthermore, the Army increased outreach to servicemembers to
address confusion about the process. For example, it initiated
briefings conducted by evaluation board liaisons and soldiers' counsels
to educate servicemembers about the process and their rights. The Army
also initiated an online tool that enables servicemembers to check the
status of their case during the evaluation process. We were not able to
fully assess the implementation and effectiveness of these initiatives
because some changes are still in process and complete data are not
available.
To address more systemic concerns about the timeliness and consistency
of DOD's and VA's disability evaluation systems, DOD and VA are
planning to pilot a joint disability evaluation system. DOD and VA are
reviewing multiple options that incorporate variations of the following
three elements: (1) a single, comprehensive medical examination to be
used by both DOD and VA in their disability evaluations; (2) a single
disability rating performed by VA; and (3) incorporating a DOD-level
evaluation board for adjudicating servicemembers' fitness for duty. For
example, in one option, the DOD-level evaluation board makes fitness
for duty determinations for all of the military services; whereas in
another option, the services make fitness for duty determinations, and
the DOD-level board adjudicates appeals of these determinations.
Another open question is whether DOD or VA would conduct the
comprehensive medical examination.[Footnote 21] Table 3 summarizes four
pilot options under consideration by DOD and VA.
Table 3: Summary of Pilot Options under Consideration by DOD and VA:
Option 1;
Comprehensive medical examination: Done by VA;
Single disability rating done by VA: Yes;
DOD-level evaluation board: Makes fitness determinations.
Option 2;
Comprehensive medical examination: Done by DOD;
Single disability rating done by VA: Yes;
DOD-level evaluation board: None. Services make fitness determinations.
Option 3;
Comprehensive medical examination: Done by VA;
Single disability rating done by VA: Yes;
DOD-level evaluation board: Adjudicates appeals of services' fitness
determinations.
Option 4;
Comprehensive medical examination: Done by VA;
Single disability rating done by VA: Yes;
DOD-level evaluation board: Conducts quality assurance reviews of
services' fitness determinations.
Source: GAO analysis of information provided by DOD.
Note: DOD and VA explored these options at pilot planning exercises
conducted in August 2007, but are also considering variations of these
options including combining portions of them. For example, one option
may be to have DOD conduct comprehensive medical examinations and to
have a DOD-level evaluation board make fitness determinations.
[End of table]
As recent pilot planning exercises verified, in addition to agreeing on
which pilot option to implement, DOD and VA must address several key
design issues before the pilot can begin. For example, it has not been
decided how DOD will use VA's disability rating to determine military
disability benefits for servicemembers in the pilot. In addition, DOD
and VA have not finalized a set of performance metrics to assess the
effect of the piloted changes. DOD and VA officials had hoped to begin
the pilot on August 1, 2007, but the intended start date slipped as
agency officials took steps to further consider alternatives and
address other important questions related to recent and expected events
that may add further complexity to the pilot development process. For
example, the Senior Oversight Committee may either choose or be
directed by the Congress to pilot the Dole-Shalala recommendation that
only VA and not DOD provide disability payments to veterans.
Implementing this recommendation would require a change to current law,
and could affect whether or how the agencies implement key pilot
elements under consideration. In addition, the Veterans' Disability
Benefits Commission, which is scheduled to report in October 2007, may
recommend changes that could also influence the pilot's structure.
Further, the Congress is considering legislation that may require DOD
and VA to conduct multiple, alternative disability evaluation
pilots.[Footnote 22]
DOD and VA face other critical challenges in creating a new disability
evaluation system. For example, DOD is challenged to overcome
servicemembers' distrust of a disability evaluation process perceived
to be adversarial. Implementing a pilot without adequately considering
alternatives or addressing critical policy and procedural details may
feed that distrust because DOD and VA plan to pilot the new system with
actual servicemembers. The agencies also face staffing and training
challenges to conduct timely and consistent medical examinations and
disability evaluations. Both the Independent Review Group and the Dole-
Shalala Commission recommended that only VA establish disability
ratings. However, as we noted above, VA is dealing with its own long-
standing challenges in providing veterans with timely and consistent
decisions.[Footnote 23] Similarly, if VA becomes responsible for
servicemembers' comprehensive physical examinations, it would face
additional staffing and training challenges, at a time when it is
already addressing concerns about the timeliness and quality of its
examinations. Further, while having a single disability evaluation
could ensure more consistent disability ratings, VA's Schedule for
Rating Disabilities is outdated because it does not adequately reflect
changes in factors such as labor market conditions and assistive
technologies on disabled veterans' ability to work. As we have
reported, the nature of work has changed in recent decades as the
national economy has moved away from manufacturing-based jobs to
service-and knowledge-based employment.[Footnote 24] Yet VA's
disability program remains mired in concepts from the past,
particularly the concept that impairment equates to an inability to
work.
Efforts Under Way to Improve Screening, Diagnosis, and Treatment for
TBI and PTSD:
The three independent review groups examining the deficiencies found at
Walter Reed identified a range of complex problems associated with DOD
and VA's screening, diagnosis, and treatment of TBI and PTSD, signature
injuries of recent conflicts. Both conditions are sometimes referred to
as "invisible injuries" because outwardly the individual's appearance
is just as it was before the injury or onset of symptoms. In terms of
mild TBI, there may be no observable head injury and symptoms may
overlap with those associated with PTSD. With respect to PTSD, there is
no objective diagnostic test and its symptoms can sometimes be
associated with other psychological conditions (e.g., depression).
Recommendations from the review groups examining these areas included
better coordination of DOD and VA research and practice guidelines and
hiring and retaining qualified health professionals. However, according
to Army officials and the Independent Review Group report, obtaining
qualified health professionals, such as clinical psychologists, is a
challenge, which is due to competition with private sector salaries and
difficulty recruiting for certain geographical locations. The Dole-
Shalala Commission noted that while VA is considered a leader in PTSD
research and treatment, knowledge generated through research and
clinical experience is not systematically disseminated to all DOD and
VA providers of care. Both the Army and the Senior Oversight Committee
are working to address this broad range of issues. (See table 4.)
Table 4: Selected Army and Senior Oversight Committee Efforts to
Improve Screening, Diagnosis, and Treatment of TBI and PTSD:
U.S. Army:
* Providing mild-TBI and PTSD training for social workers, nurse case
managers, psychiatric nurses, and psychiatric nurse practitioners;
* Exploring ways to track incidents on the battlefield (e.g., blasts)
that may result in TBI or PTSD;
* Examining procedures for screening servicemembers for mild TBI and
PTSD prior to an involuntary release from the Army to ensure that
servicemembers are not inappropriately separated for behavioral
problems.
Senior Oversight Committee:
* Developed policy requiring DOD and VA to establish a national Center
of Excellence for TBI and PTSD no later than November 30, 2007;
* Establishing common educational and training materials and screening
processes for mild TBI and PTSD, as well as consistent definitions for
mild-TBI diagnosis.
Sources: Army and Senior Oversight Committee.
[End of table]
The Army, through its Medical Action Plan, has policies in place
requiring all servicemembers sent overseas to a war zone to receive
training on recognizing the symptoms of mild TBI and PTSD. The Army is
also exploring ways to track events on the battlefield, such as blasts,
that may result in TBI or PTSD. In addition, the Army recently
developed policies to provide mild TBI and PTSD training to all social
workers, nurse case managers, psychiatric nurses, and psychiatric nurse
practitioners to better identify these conditions. As of September 13,
2007, 6 of the Army's 32 Warrior Transition Units had completed
training for all of these staff.
A Senior Oversight Committee workgroup on TBI and PTSD is working to
ensure health care providers have education and training on screening,
diagnosing, and treating both mild TBI and PTSD, mainly by developing a
national Center of Excellence as recommended by the three review
groups.[Footnote 25] This Center of Excellence is expected to combine
experts and resources from all military services and VA to promote
research, awareness, and best practices on mild TBI as well as PTSD and
other psychological health issues. A representative of the Senior
Oversight Committee workgroup on TBI and psychological health told us
that the Center of Excellence would include the existing Defense and
Veterans Brain Injury Center--a collaboration among DOD, VA, and two
civilian partners that focuses on TBI treatment, research, and
education.[Footnote 26]
Efforts Under Way to Facilitate Data Sharing between DOD and VA:
DOD and VA have been working for almost 10 years to facilitate the
exchange of medical information. However, the three independent review
groups identified the need for DOD and VA to further improve and
accelerate efforts to share data across the departments. Specifically,
the Dole-Shalala Commission indicated that DOD and VA must move quickly
to get clinical and benefit data to users, including making patient
data immediately viewable by any provider, allied health professional,
or program administrator who needs the data. Furthermore, in July 2007,
we reported that although DOD and VA have made progress in both their
long-term and short-term initiatives to share health information, much
work remains to achieve the goal of a seamless transition between the
two departments.[Footnote 27] While pursuing their long-term initiative
to develop a common health information system that would allow the two-
way exchange of computable health data,[Footnote 28] the two
departments have also been working to share data in their existing
systems. See table 5 for selected efforts under way by the Army and
Senior Oversight Committee to improve data sharing between DOD and VA.
Table 5: Selected Army and Senior Oversight Committee Efforts to
Improve DOD and VA Data Sharing:
U.S. Army:
* Army Medical Department is developing a memorandum of understanding
regarding sharing of medical data between Army military treatment
facilities and VA.
Senior Oversight Committee:
* Developed policy requiring DOD and VA to develop a plan to execute a
single Web portal to support the care and needs of servicemembers and
veterans by December 31, 2007;
* Developed data sharing policies requiring DOD and VA to (1) develop a
plan for interagency sharing of essential health images, such as
radiology studies, by March 31, 2008;
(2) ensure that all essential health and administrative data are made
available and viewable to both departments, and requiring that progress
be reported by a scorecard no later than October 31, 2008.
Sources: Army and Senior Oversight Committee.
[End of table]
As part of the Army Medical Action Plan, the Army has taken steps to
facilitate the exchange of data between its military treatment
facilities and VA. For example, the Army Medical Department is
developing a memorandum of understanding between the Army and VA that
would allow VA access to data on severely injured servicemembers who
are being transferred to a VA polytrauma center. The memorandum of
understanding would also allow VA's Veterans Health Administration and
Veterans Benefits Administration access to data in a servicemember's
medical record that are related to a disability claim the servicemember
has filed with VA. Army officials told us that the Army's medical
records are part paper (hard copy) and part electronic, and this effort
would provide the VA access to the paper data until the capability to
share the data electronically is available at all sites.[Footnote 29]
Given that DOD and VA already have a number of efforts under way to
improve data sharing between the two departments, the Senior Oversight
Committee, through its data sharing workgroup, has been looking for
opportunities to accelerate the departments' sharing initiatives that
are already planned or in process and to identify additional data
sharing requirements that have not been clearly articulated. For
example, the Senior Oversight Committee has approved several policy
changes in response to the Dole-Shalala Commission, one of which
requires DOD and VA to ensure that all essential health and
administrative data are made available and viewable to both agencies,
and that progress is reported by a scorecard, by October 31, 2008. A
representative of the data sharing workgroup told us that the
departments are achieving incremental increases to data sharing
capabilities and plan to have all essential health data--such as
outpatient pharmacy, allergy, laboratory results, radiology reports,
and provider notes--viewable by all DOD and VA facilities by the end of
December 2007.[Footnote 30] Although the agencies have recently
experienced delays in efforts to exchange data, the representative said
that the departments are on track to meet all the timelines established
by the Senior Oversight Committee.
A Senior Oversight Committee workgroup on data sharing has also been
coordinating with other committee workgroups on their information
technology needs. Although workgroup officials told us that they have
met numerous times with the case management and disability evaluation
systems workgroups to discuss their data sharing needs, they have not
begun implementing necessary systems because they are dependent on the
other workgroups to finalize their information technology needs. For
example, the Senior Oversight Committee has required DOD and VA to
establish a plan for information technology support of the recovery
plan to be used by recovery coordinators, which integrates essential
clinical (e.g., medical care) and nonclinical aspects (e.g., education,
employment, disability benefits) of recovery, no later than November 1,
2007. However, this cannot be done until the case management workgroup
has identified the components and information technology needs of these
clinical and nonclinical aspects, and as of early September this had
not been done. Data sharing workgroup representatives indicated that
the departments' data sharing initiatives will be ongoing because
medications, diagnoses, procedures, standards, business practices, and
technology are constantly changing, but the departments expect to meet
most of the data sharing needs of patients and providers by end of
fiscal year 2008.
Concluding Observations:
Our preliminary observations are that fixing the long-standing and
complex problems spotlighted in the wake of Walter Reed media accounts
as expeditiously as possible is critical to ensuring high-quality care
for our returning servicemembers, and success will ultimately depend on
sustained attention, systematic oversight by DOD and VA, and sufficient
resources. Efforts thus far have been on separate but related tracks,
with the Army seeking to address service-specific issues while DOD and
VA are working together to address systemic problems. Many challenges
remain, and critical questions remain unanswered. Among the challenges
is how the efforts of the Army--which has the bulk of the returning
servicemembers needing medical care--will be coordinated with the
broader efforts being undertaken by DOD and VA.
The centerpiece of the Army's effort is its Medical Action Plan, and
the success of the plan hinges on staffing the newly-created Warrior
Transition Units. Permanently filling these slots may prove difficult,
and borrowing personnel from other units has been a temporary fix but
it is not a long-term solution. The Army can look to the private sector
for some skills, but it must compete for personnel in a civilian market
that is vying for medical professionals with similar skills and
training.
Perhaps one of the most complex efforts under way is that of
redesigning DOD's disability evaluation system. Delayed decisions,
confusing policies, and the perception that DOD and VA disability
ratings result in inequitable outcomes have eroded the credibility of
the system. Thus, it is imperative that DOD and VA take prompt steps to
address fundamental system weaknesses. However, as we have noted, key
program design and operational policy questions must be addressed to
ensure that any proposed system redesign has the best chance for
success and that servicemembers and veterans receive timely, accurate,
and consistent decisions. This will require careful study of potential
options, a comprehensive assessment of outcome data associated with the
pilot, proper metrics to gauge success, and an evaluation mechanism to
ensure needed adjustments are made to the process along the way.
Failure to properly consider alternatives or address critical policy
and procedural details could exacerbate delays and confusion for
servicemembers, and potentially jeopardize the system's successful
transformation.
Mr. Chairman, this completes my prepared remarks. We would be happy to
respond to any questions you or other members of the subcommittee may
have at this time.
For further information about this testimony, please contact John H.
Pendleton at (202) 512-7114 or pendletonj@gao.gov or Daniel Bertoni at
(202) 512-7215 or bertonid@gao.gov. Contact points for our Offices of
Congressional Relations and Public Affairs may be found on the last
page of this statement. GAO staff who made major contributions to this
report are listed in appendix II.
[End of section]
Appendix I: Selected Issues Identified by Three Review Groups following
the Reporting of Deficiencies at Walter Reed:
In the aftermath of deficiencies identified at Walter Reed Medical
Center, three separate review groups--the President's Commission on
Care for America's Returning Wounded Warriors, commonly referred to as
the Dole-Shalala Commission; the Independent Review Group, established
by the Secretary of Defense; and the President's Task Force on
Returning Global War on Terror Heroes--investigated the factors that
may have led to these problems. Selected findings of each report are
summarized in table 6.
Table 6: Selected Findings of Review Groups Reporting on Walter Reed
Army Medical Center Deficiencies:
Review groups: President's Commission on Care for America's Returning
Wounded Warriors (Dole-Shalala Commission): (July 2007);
Findings:
* A patient-centered recovery plan is needed for all seriously injured
servicemembers;
* Department of Defense's (DOD) disability and compensation systems
need to be "completely restructured.";
* DOD and the Department of Veterans Affairs (VA) must work to
aggressively prevent and treat post-traumatic stress disorder (PTSD)
and traumatic brain injury (TBI) and reduce perceived stigma of both
conditions;
* Support for servicemembers' families must be strengthened, including
expanding DOD respite care and extending the Family and Medical Leave
Act for up to six months for spouses and parents of the seriously
injured;
* DOD and VA should work together to quickly share clinical and
administrative data with each other. A "My eBenefits" page for
servicemembers should be established;
* DOD and VA must assure that Walter Reed Army Medical Center has the
clinical and administrative staff it needs, until its closure in 2011.
Review groups: Secretary of Defense's Independent Review Group on
Rehabilitative Care and Administrative Processes at Walter Reed Army
Medical Center and National Naval Medical Center: (April 2007);
Findings:
* Comprehensive care, treatment, and administrative services not
provided to the outpatient in a collaborative manner at Walter Reed
Army Medical Center;
* Lack of clear, consistent standards for qualifications and training
of outpatient case managers across the Army, Navy, and Air Force;
* Lack of early identification techniques and comprehensive clinical
practice guidelines for TBI and its overlap with PTSD, within the
military health system, results in inconsistent diagnosis and
treatment;
* Serious difficulties administering the Physical Disability Evaluation
System due to significant variance in policy and guidelines among the
military services. The current process is cumbersome, inconsistent, and
confusing to providers, patients, and families;
* No common automated interface exists between the clinical and
administrative systems within DOD and among the services, or between
DOD and VA.
Review groups: President's Task Force on Returning Global War on Terror
Heroes: (April 2007);
Findings:
* DOD's and VA's disability evaluation systems are confusing, time
consuming, and sometimes inconsistent among the services and between
DOD and VA;
* No formal agreements for how active duty servicemembers should be
managed when they receive services from both DOD and VA;
* No agreements on definition of case management, functions of case
managers, or how DOD and VA case managers should transfer patients to
one another to assure continuity of care;
* Servicemembers with mild to moderateTBI can be particularly difficult
to diagnose given the lack of easily visible symptoms;
* While VA provides a comprehensive medical benefits package for
enrolled veterans, the current paper and online versions of the
required paperwork for certain benefits packages do not allow for
identification of Operation Enduring Freedom / Operation Iraqi Freedom
veterans. Further, the online application does not provide e-
authentication or e- signature capabilities thereby requiring veterans
to submit signed applications and complete the entire form, including
some data they have already supplied VA.
Sources: President's Commission on Care for America's Returning Wounded
Warriors, the Independent Review Group, and the President's Task Force
on Returning Global War on Terror Heroes.
[End of table]
[End of section]
Appendix II: GAO Contacts and Staff Acknowledgments:
GAO Contacts:
John H. Pendleton at (202) 512-7114 or pendletonj@gao.gov or Daniel
Bertoni at (202) 512-7215 or bertonid@gao.gov:
Acknowledgment:
In addition to the contact named above, Bonnie Anderson, Assistant
Director; Michele Grgich, Assistant Director; Jennie Apter; Janina
Austin; Joel Green; Christopher Langford; Chan My Sondhelm; Barbara
Steel-Lowney; and Greg Whitney, made key contributions to this
statement.
[End of section]
Related GAO Products:
DOD Civilian Personnel: Medical Policies for Deployed DOD Federal
Civilians and Associated Compensation for Those Deployed. GAO-07-1235T.
Washington, D.C.: September 18, 2007.
Global War on Terrorism: Reported Obligations for the Department of
Defense. GAO-07-1056R. Washington, D.C.: July 26, 2007.
Information Technology: VA and DOD Are Making Progress in Sharing
Medical Information, but Remain Far from Having Comprehensive
Electronic Medical Records. GAO-07-1108T. Washington, D.C.: July 18,
2007.
Defense Health Care: Comprehensive Oversight Framework Needed to Help
Ensure Effective Implementation of a Deployment Health Quality
Assurance Program. GAO-07-831. Washington, D.C.: June 22, 2007.
DOD's 21st Century Health Care Spending Challenges, Presentation for
the Task Force on the Future of Military Health Care. Statement
delivered by David M. Walker, Comptroller General of the United States.
GAO-07-766-CG. Washington, D.C.: April 18, 2007.
Veterans' Disability Benefits: Long-Standing Claims Processing
Challenges Persist. GAO-07-512T. Washington, D.C.: March 7, 2007.
DOD and VA Health Care: Challenges Encountered by Injured
Servicemembers during Their Recovery Process. GAO-07-589T. Washington,
D.C.: March 5, 2007.
VA Health Care: Spending for Mental Health Strategic Plan Initiatives
Was Substantially Less Than Planned. GAO-07-66. Washington, D.C.:
November 21, 2006.
VA and DOD Health Care: Efforts to Provide Seamless Transition of Care
for OEF and OIF Servicemembers and Veterans. GAO-06-794R. Washington,
D.C.: June 30, 2006.
Post-Traumatic Stress Disorder: DOD Needs to Identify the Factors Its
Providers Use to Make Mental Health Evaluation Referrals for
Servicemembers. GAO-06-397. Washington, D.C.: May 11, 2006.
Military Disability System: Improved Oversight Needed to Ensure
Consistent and Timely Outcomes for Reserve and Active Duty Service
Members. GAO-06-362. Washington, D.C.: March 31, 2006.
VA and DOD Health Care: Opportunities to Maximize Resource Sharing
Remain. GAO-06-315. Washington, D.C.: March 20, 2006.
VA and DOD Health Care: VA Has Policies and Outreach Efforts to Smooth
Transition from DOD Health Care, but Sharing of Health Information
Remains Limited. GAO-05-1052T. Washington, D.C.: September 28, 2005.
Federal Disability Assistance: Wide Array of Programs Needs to be
Examined in Light of 21st Century Challenges. GAO-05-626. Washington,
D.C.: June 2, 2005.
Veterans' Disability Benefits: Claims Processing Problems Persist and
Major Performance Improvements May Be Difficult. GAO-05-749T.
Washington, D.C.: May 26, 2005.
DOD and VA: Systematic Data Sharing Would Help Expedite Servicemembers'
Transition to VA Services. GAO-05-722T. Washington, D.C.: May 19, 2005.
VA Health Care: VA Should Expedite the Implementation of
Recommendations Needed to Improve Post-Traumatic Stress Disorder
Services. GAO-05-287. Washington, D.C.: February 14, 2005.
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.
Footnotes:
[1] Independent Review Group, Rebuilding the Trust: Report on
Rehabilitative Care and Administrative Processes at Walter Reed Army
Medical Center and National Naval Medical Center (Arlington, Va., April
2007).
[2] Task Force on Returning Global War on Terror Heroes, Report to the
President (April 2007).
[3] President's Commission on Care for America's Returning Wounded
Warriors, Serve, Support, Simplify (July 2007).
[4] Case management is a process for guiding a patient's care from one
provider, agency, organizational program, or service to another.
[5] TBI is an injury caused by a blow or jolt to the head or a
penetrating head injury that disrupts the normal function of the brain.
PTSD is an anxiety disorder that can develop after exposure to a
traumatic ordeal in which physical harm occurred or was threatened.
[6] See the end of this statement for a list of related GAO products.
[7] GAO, Federal Disability Assistance: Wide Array of Programs Needs to
be Examined in Light of 21st Century Challenges, GAO-05-626
(Washington, D.C.: June 2, 2005).
[8] GAO, High-Risk Series: An Update, GAO-07-310 (Washington, D.C.:
January 2007).
[9] Additional workgroups are examining the condition of DOD and VA
facilities as well as issues about personnel, pay, and financial
support systems, among others.
[10] The Navy is responsible for the medical care of servicemembers in
the Marine Corps.
[11] The system is composed of categories of medical facilities that
offer varying levels of services.
[12] VA determines the degree to which veterans are disabled in 10
percent increments on a scale of 0 to 100 percent.
[13] Independent Review Group, Rebuilding the Trust: Report on
Rehabilitative Care and Administrative Processes at Walter Reed Army
Medical Center and National Naval Medical Center (Arlington, Va.: April
2007).
[14] The Warrior Transition Unit also includes other staff, such as
human resources and financial management specialists.
[15] The Army also established three Warrior Transition Units in
Germany.
[16] Active-duty servicemembers were typically placed in Medical Hold
units, while Reserve and National Guard servicemembers were placed into
separate Medical Holdover units.
[17] Independent Review Group, Rebuilding the Trust: Report on
Rehabilitative Care and Administrative Processes at Walter Reed Army
Medical Center and National Naval Medical Center.
[18] GAO, Military Disability System: Improved Oversight Needed to
Ensure Timely and Consistent Outcomes for Reserve and Active Duty
Service Members, GAO-06-362 (Washington, D.C.: Mar. 31, 2006).
[19] For additional information on VA disability claims processing, see
GAO, Veterans' Disability Benefits: Long-Standing Claims Processing
Challenges Persist, GAO-07-512T (Washington, D.C.: Mar. 7, 2007); and
GAO, Veterans' Disability Benefits: Processing of Claims Continues to
Present Challenges, GAO-07-562T (Washington, D.C.: Mar. 13, 2007).
[20] Office of the Inspector General, Department of the Army, Report on
the Army Physical Disability Evaluation System, (Washington, D.C.: Mar.
6, 2007).
[21] On August 31, 2007, the Senior Oversight Committee directed DOD
and VA to create by October 1, 2007 a single, standardized examination
to be used by DOD to determine fitness for all seriously injured
servicemembers and by VA to determine disability ratings, but it did
not specify which agency will be responsible for conducting the
examinations.
[22] H.R. 1538, as passed by the Senate on July 25, 2007, Sec. 154.
[23] To help address processing challenges, VA hired about 1,000 new
disability claims processing employees since January 2007.
[24] GAO, High-Risk Series: An Update, GAO-03-119 (Washington, D.C.:
Jan. 1, 2003) and SSA and VA Disability Programs: Re-Examination of
Disability Criteria Needed to Help Ensure Program Integrity, GAO-02-597
(Washington, D.C.: Aug. 9, 2002).
[25] VA has a national Center on PTSD that was required to be
established by the Veterans' Health Care Act of 1984. This center
advances the clinical care and social welfare of veterans though
research, education, and training of clinicians in the causes,
diagnosis, and treatment of PTSD.
[26] In April 2007, VA established policy requiring all Operation Iraqi
Freedom and Operation Enduring Freedom veterans receiving care within
the VA system to be screened for TBI. Additionally, if the screen
determines that the veteran might have TBI, then the veteran must be
offered further evaluation and treatment by providers with expertise in
this area.
[27] GAO, Information Technology: VA and DOD Are Making Progress in
Sharing Medical Information, but Remain Far from Having Comprehensive
Electronic Medical Records, GAO-07-1108T (Washington, D.C.: July 18,
2007).
[28] Computable data are data in a format that a computer application
can act on--for example, to provide alerts to clinicians of drug
allergies.
[29] Officials from Walter Reed Army Medical Center told us that Walter
Reed already has the capability to share this data electronically.
[30] DOD facilities in combat zones may not have this capability
because they operate in a different environment with different
informational technology capabilities.
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