Defense Health Care

Post-Deployment Health Reassessment Documentation Needs Improvement Gao ID: GAO-10-56 November 19, 2009

The Department of Defense (DOD) implemented the post-deployment health reassessment (PDHRA), which is required to be administered to servicemembers 90 to 180 days after their return from deployment. DOD established the PDHRA program to identify and address servicemembers' health concerns that emerge over time following deployments. This report is the second in response to a Senate Armed Services Committee report directing the Government Accountability Office (GAO) to review DOD's administration of the PDHRA, and to additional congressional requests. In this report, GAO examined (1) the extent to which DOD's central repository contains PDHRA questionnaires for active and Reserve component servicemembers who returned from deployment to Iraq or Afghanistan and (2) how DOD monitors the administration of the PDHRA to Reserve component servicemembers. To conduct this review, GAO performed a quantitative analysis using DOD deployment and PDHRA data, reviewed relevant PDHRA policies, and interviewed DOD officials.

DOD policy requires that the military services electronically submit PDHRA questionnaires to DOD's central repository. Based on two separate queries to this repository in 2009, GAO did not find PDHRA questionnaires for a substantial percentage of the 319,000 active and Reserve component servicemembers who returned from deployment to Iraq or Afghanistan between January 1, 2007, and May 31, 2008. GAO's first query on April 15, 2009, showed that only 77 percent of this population of interest had questionnaires in the central repository, leaving approximately 74,000 servicemembers without questionnaires in the repository. On September 4, 2009, GAO queried DOD's central repository again to update its April 2009 data and found that DOD's central repository was still missing PDHRA questionnaires for about 72,000 servicemembers, or 23 percent of the servicemembers in GAO's original population of interest. When PDHRA questionnaires are not in DOD's central repository, DOD does not have reasonable assurance that servicemembers to whom the PDHRA requirement applies were given the opportunity to fill out the questionnaire and identify and address health concerns that could emerge over time following deployment. DOD uses four methods to monitor the contractor, Logistics Health, Inc. (LHI), that administers the PDHRA to Reserve component servicemembers. The four monitoring methods are: (1) reviews of periodic reports from LHI; (2) inspections of LHI's administration of the PDHRA; (3) feedback on LHI's administration of the PDHRA from military service officials; and (4) weekly telephone discussions with LHI staff. These methods are used to help ensure that the objective of the PDHRA program is being met for Reserve component servicemembers. Through these methods, DOD identified a number of potential problems that may pose risks to the PDHRA program objective and to the welfare and safety of Reserve component servicemembers. However, GAO found that when monitoring the administration of the PDHRA to Reserve component servicemembers, DOD does not maintain clear documentation that is consistent with federal internal control standards. GAO found that the documentation generated by DOD generally did not clearly describe the potential problems, the actions taken to address the problems, and whether these actions had resolved the problems. Overall, this lack of clear documentation does not allow DOD to have reasonable assurance that potential problems related to the administration of the PDHRA to Reserve component servicemembers have been addressed and resolved.

Recommendations

Our 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-10-56, Defense Health Care: Post-Deployment Health Reassessment Documentation Needs Improvement This is the accessible text file for GAO report number GAO-10-56 entitled 'Defense Health Care: Post-Deployment Health Reassessment Documentation Needs Improvement' which was released on November 19, 2009. 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 Congressional Addressees: United States Government Accountability Office: GAO: November 2009: Defense Health Care: Post-Deployment Health Reassessment Documentation Needs Improvement: GAO-10-56: GAO Highlights: Highlights of GAO-10-56, a report to congressional addressees. Why GAO Did This Study: The Department of Defense (DOD) implemented the post-deployment health reassessment (PDHRA), which is required to be administered to servicemembers 90 to 180 days after their return from deployment. DOD established the PDHRA program to identify and address servicemembers‘ health concerns that emerge over time following deployments. This report is the second in response to a Senate Armed Services Committee report directing GAO to review DOD‘s administration of the PDHRA, and to additional congressional requests. In this report, GAO examined (1) the extent to which DOD‘s central repository contains PDHRA questionnaires for active and Reserve component servicemembers who returned from deployment to Iraq or Afghanistan and (2) how DOD monitors the administration of the PDHRA to Reserve component servicemembers. To conduct this review, GAO performed a quantitative analysis using DOD deployment and PDHRA data, reviewed relevant PDHRA policies, and interviewed DOD officials. What GAO Found: DOD policy requires that the military services electronically submit PDHRA questionnaires to DOD‘s central repository. Based on two separate queries to this repository in 2009, GAO did not find PDHRA questionnaires for a substantial percentage of the 319,000 active and Reserve component servicemembers who returned from deployment to Iraq or Afghanistan between January 1, 2007, and May 31, 2008. GAO‘s first query on April 15, 2009, showed that only 77 percent of this population of interest had questionnaires in the central repository, leaving approximately 74,000 servicemembers without questionnaires in the repository. On September 4, 2009, GAO queried DOD‘s central repository again to update its April 2009 data and found that DOD‘s central repository was still missing PDHRA questionnaires for about 72,000 servicemembers, or 23 percent of the servicemembers in GAO‘s original population of interest. When PDHRA questionnaires are not in DOD‘s central repository, DOD does not have reasonable assurance that servicemembers to whom the PDHRA requirement applies were given the opportunity to fill out the questionnaire and identify and address health concerns that could emerge over time following deployment. DOD uses four methods to monitor the contractor, Logistics Health, Inc. (LHI), that administers the PDHRA to Reserve component servicemembers. The four monitoring methods are: (1) reviews of periodic reports from LHI; (2) inspections of LHI‘s administration of the PDHRA; (3) feedback on LHI‘s administration of the PDHRA from military service officials; and (4) weekly telephone discussions with LHI staff. These methods are used to help ensure that the objective of the PDHRA program is being met for Reserve component servicemembers. Through these methods, DOD identified a number of potential problems that may pose risks to the PDHRA program objective and to the welfare and safety of Reserve component servicemembers. However, GAO found that when monitoring the administration of the PDHRA to Reserve component servicemembers, DOD does not maintain clear documentation that is consistent with federal internal control standards. GAO found that the documentation generated by DOD generally did not clearly describe the potential problems, the actions taken to address the problems, and whether these actions had resolved the problems. Overall, this lack of clear documentation does not allow DOD to have reasonable assurance that potential problems related to the administration of the PDHRA to Reserve component servicemembers have been addressed and resolved. What GAO Recommends: GAO recommends that DOD (1) ensure that PDHRA questionnaires for all servicemembers to whom the requirement applies are in DOD‘s central repository and (2) require that the information obtained when monitoring the PDHRA program is documented in a manner consistent with internal control standards. DOD concurred with the recommendations. View [hyperlink, http://www.gao.gov/products/GAO-10-56] or key components. For more information, contact Randall B. Williamson at (202) 512-7114 or williamsonr@gao.gov. [End of section] Contents: Letter: Background: DOD's Central Repository Did Not Contain PDHRA Questionnaires for a Substantial Percentage of Servicemembers Who Returned from Deployment to Iraq or Afghanistan: DOD Uses Four Methods to Monitor the Administration of the PDHRA to Reserve Component Servicemembers, but Does Not Clearly Document Its Monitoring: Conclusions: Recommendations for Executive Action: Agency Comments and Our Evaluation: Appendix I: Scope and Methodology: Appendix II: Sample Post-Deployment Health Reassessment Questionnaire (DD 2900), January 2008: Appendix III: Post-Deployment Health Reassessment Questionnaires in DOD's Central Repository and Services' Databases: Appendix IV: DOD's Documentation of Its Monitoring of the Administration of the Post-Deployment Health Reassessment: Appendix V: Comments from the Department of Defense: Appendix VI: GAO Contact and Staff Acknowledgments: Related GAO Products: Tables: Table 1: Servicemembers Who Returned from Deployment to Iraq or Afghanistan Between January 1, 2007, and May 31, 2008, without a PDHRA Questionnaire in DOD's Central Repository, as of September 4, 2009: Table 2: Servicemembers Who Returned from Deployment to Iraq or Afghanistan Between January 1, 2007, and May 31, 2008, without a PDHRA Questionnaire in DOD's Central Repository, as of April 15, 2009: Table 3: Number of Servicemembers Who Returned from Deployment to Iraq or Afghanistan between January 1, 2007, and May 31, 2008, with a PDHRA Questionnaire in Military Services' Databases That Was Not in DOD's Central Repository as of April 15, 2009, and Number of These Servicemembers with Questionnaire in Central Repository, as of September 4, 2009: Table 4: Fifteen Selected Potential Problems Related to the Administration of the PDHRA to Reserve Component Servicemembers, Identified by the DOD RHRP Office: Figure: Figure 1: Time Line of GAO's Quantitative Analysis: Abbreviations: AFHSC: Armed Forces Health Surveillance Center: CTS: Contingency Tracking System: DMDC: Defense Manpower Data Center: DMSS: Defense Medical Surveillance System: DOD: Department of Defense: LHI: Logistics Health, Inc. PDHRA: post-deployment health reassessment: RHRP: Reserve Health Readiness Program: [End of section] United States Government Accountability Office: Washington, DC 20548: November 19, 2009: Since September 2001, the Department of Defense (DOD) has relied on almost 2 million servicemembers to support ongoing contingency operations in Iraq and Afghanistan.[Footnote 1] Servicemembers deployed to Iraq and Afghanistan have engaged in intense and prolonged combat, placing them at risk for developing various physical and mental health conditions, such as post-traumatic stress disorder. In many cases, mental health conditions do not emerge until months after servicemembers return from deployment. As a result, in 2005, DOD implemented the post-deployment health reassessment (PDHRA), which is required to be administered 90 to 180 days after servicemembers return from deployment.[Footnote 2] The PDHRA is one of three deployment health assessments that DOD uses to assess the physical and mental health condition of servicemembers before and after their overseas deployments to such locations as Iraq and Afghanistan.[Footnote 3] DOD established the PDHRA to identify servicemembers' health concerns, including mental health concerns, that may surface several months following their return from deployment and to assess whether servicemembers need referrals for a further evaluation to address these health concerns. The PDHRA questionnaire consists of a demographic section to be filled out by the servicemember, a medical section for self-reported medical information from the servicemember, and a third section for a health care provider to fill out and sign. A recent study found that latent mental health concerns may disproportionately affect Army Reserve and Army National Guard soldiers over their active component counterparts.[Footnote 4] This 2007 study on servicemembers deployed to Iraq found that when the PDHRA was administered 90 to 180 days following deployment, Army Reserve and Army National Guard servicemembers reported higher rates of mental health concerns and were referred at substantially higher rates than their active component counterparts.[Footnote 5] Researchers noted that Army Reserve and Army National Guard servicemembers, unlike their active component peers, typically transition back to civilian life after their deployments. They may be particularly at risk for developing mental health conditions, due to their lack of interaction with fellow servicemembers following their return from deployment and the added stress of transitioning back to civilian life. DOD's military services administer the PDHRA to active component servicemembers, and DOD contracts with Logistics Health, Inc. (LHI) to administer the PDHRA to servicemembers in the Reserve component. [Footnote 6],[Footnote 7] While filling out the entire PDHRA questionnaire is encouraged, part of it is voluntary. The military services require active and Reserve component servicemembers to fill out only the demographic section of the questionnaire;[Footnote 8] servicemembers are not required to answer questions concerning their physical and mental health. The PDHRA questionnaire is filled out electronically and DOD requires that the military services electronically submit the questionnaires for both active and Reserve component servicemembers to DOD's central repository.[Footnote 9] For Reserve component servicemembers who fill out the PDHRA questionnaire through LHI, LHI staff are responsible for verifying that the questionnaires are transferred to the appropriate military service so that the military service can submit them to DOD's central repository. The central repository contains information from various health assessments and is used for many purposes, including health surveillance. We previously identified problems with DOD's oversight of the PDHRA. In 2008, we reported that DOD's deployment health quality assurance program, which DOD established to assess compliance with DOD's various deployment health assessments, lacked data that would allow the program--and therefore DOD--to accurately assess whether the military services ensure that servicemembers fill out the PDHRA questionnaire.[Footnote 10] DOD's quality assurance program uses data from DOD's central repository to monitor the extent to which active and Reserve component servicemembers fill out the PDHRA questionnaire and other DOD deployment health assessments, as required. However, DOD's quality assurance program does not monitor LHI's administration of the PDHRA to Reserve component servicemembers, and we did not include this in our 2008 report. The program also does not monitor whether separated servicemembers fill out the PDHRA questionnaire. In its report accompanying the National Defense Authorization Act for Fiscal Year 2008,[Footnote 11] the Senate Committee on Armed Services directed us to review DOD's implementation of the PDHRA to active component, Reserve component, and separated servicemembers. The House Committee on Armed Services and eight senators also expressed interest in this work. In this report, we examine: (1) the extent to which DOD's central repository contains PDHRA questionnaires for active and Reserve component servicemembers who returned from deployment to Iraq or Afghanistan and (2) how DOD monitors the administration of the PDHRA to Reserve component servicemembers. To determine the extent to which DOD's central repository contains PDHRA questionnaires for active and Reserve component servicemembers who returned from deployment to Iraq or Afghanistan, we conducted a quantitative analysis using DOD deployment and PDHRA data and reviewed our prior work on DOD's deployment health quality assurance program. We conducted our quantitative analysis using DOD data from two sources-- the Defense Manpower Data Center's (DMDC) Contingency Tracking System (CTS) and the Armed Forces Health Surveillance Center's (AFHSC) Defense Medical Surveillance System (DMSS). DMDC's CTS contains data on servicemembers deployed in support of the Overseas Contingency Operations including servicemembers' deployment dates and location of deployment. AFHSC's DMSS is DOD's central repository for various health assessments and other health surveillance data, including PDHRA questionnaires. We used CTS data to identify a population of interest: active component, Reserve, and National Guard servicemembers who had returned from deployments of greater than 30 days to Iraq or Afghanistan from January 1, 2007, through May 31, 2008.[Footnote 12] (See figure 1.) Figure 1: Time Line of GAO's Quantitative Analysis: [Refer to PDF for image: time line illustration] January 1, 2007 to May 31, 2008: Servicemembers return from deployment to Iraq or Afghanistan. Approximately April 1, 2007 to November 30, 2008: Servicemembers in this population fill out PDHRA questionnaire 90 to 180 days after returning from deployment.[A] April 15, 2009: GAO‘s first query of DOD‘s central repository. Late May and June, 2009: GAO‘s query of military services‘ databases. September 4, 2009: GAO‘s second query of DOD‘s central repository. Source: GAO. [A] Servicemembers may have also filled out the questionnaire after the 90-to 180-day reassessment period had elapsed. [End of figure] We determined the extent to which servicemembers in our population of interest had PDHRA questionnaires in DOD's central repository, AFHSC's DMSS, by asking AFHSC officials to query DMSS on two occasions--April 2009 and September 2009.[Footnote 13] We made our second query to account for any PDHRA questionnaires incorporated into DMSS after our initial analysis. On both occasions, AFHSC officials matched PDHRA questionnaires to CTS data using servicemembers' personal identifying information and the beginning and end deployment dates of a servicemember's most recent return from deployment during our time period. If a PDHRA questionnaire could not be identified in AFHSC's DMSS for a servicemember in our population of interest during our April 2009 query, we asked officials from the military services to query their own databases to identify PDHRA questionnaires for these servicemembers, as the military services collect PDHRA questionnaires in their own databases before transmitting them to DOD's central repository. Specifically, for this group of servicemembers, we asked military service officials to send us information from any questionnaires that they considered ready for transmission to DMSS that were filled out after the servicemember's end deployment date in CTS. We received these data from the military services in late May and June 2009. Next, using servicemembers' personal identifying information and end deployment dates, we matched the information from the PDHRA questionnaires the military services identified in their databases to our population of interest from CTS. Finally, we reviewed DOD policies, as well as those of the Army, Air Force, Navy, and Marine Corps, for submitting PDHRA questionnaires to DOD's central repository and interviewed DOD and military service officials knowledgeable about this process.[Footnote 14] We conducted data reliability assessments for each DOD and military service data source we used by reviewing related documentation, interviewing knowledgeable agency officials, and performing electronic data testing for missing data, outliers, and obvious errors. We determined that these data sources were sufficiently reliable for our purposes. We determined only the extent to which PDHRA questionnaires could be identified in AFHSC's DMSS or the military services' databases for our population of interest, and not the extent to which the servicemembers may have actually filled out a PDHRA questionnaire. To determine how DOD monitors the administration of the PDHRA to Reserve component servicemembers, we reviewed DOD's policies for monitoring its contract with LHI and interviewed DOD and military service officials responsible for the administration of the PDHRA to Reserve component servicemembers. We also reviewed DOD's contract with LHI and obtained and analyzed required reports and other documentation on LHI's performance related to the PDHRA portion of DOD's contract with LHI.[Footnote 15] We visited LHI's headquarters in La Crosse, Wisconsin, where we interviewed LHI staff to confirm our understanding of how LHI staff administers the PDHRA to Reserve component servicemembers. We reviewed DOD's monitoring of the administration of the PDHRA to Reserve component servicemembers to determine the extent to which these monitoring efforts were consistent with GAO's Standards for Internal Control in the Federal Government.[Footnote 16] Internal controls include components of an organization's management that provide reasonable assurance that program objectives are being achieved.[Footnote 17] To obtain more in-depth information on how DOD documents the information it obtains through its monitoring efforts, we examined documentation maintained by DOD's Reserve Health Readiness Program (RHRP) office, which is responsible for monitoring DOD's contract with LHI. Specifically, from among the potential problems that the RHRP office had identified as possibly posing a risk to the objective of the PDHRA program, we judgmentally selected 15 to review in detail and obtained all readily available RHRP documentation on those problems. We selected these 15 potential problems because the subject of each of these may have involved welfare and safety concerns for Reserve component servicemembers. Our findings related to the documentation of the 15 potential problems are for illustrative purposes only and are not generalizable to other RHRP office documentation. We conducted this performance audit from October 2008 to October 2009 in accordance with generally accepted government auditing standards. Those standards require that we plan and perform the audit to obtain sufficient, appropriate evidence to provide a reasonable basis for our findings and conclusions based on our audit objectives. We believe that the evidence obtained provides a reasonable basis for our findings and conclusions based on our audit objectives. For more detailed information on our scope and methodology, see appendix I. Background: DOD policy[Footnote 18] states that each military service must administer the PDHRA to active component, Reserve component, and separated servicemembers 90 to 180 days following deployment if they meet the following conditions: * deployed for greater than 30 days, * deployed to locations outside the continental United States, and: * deployed to locations without permanent military treatment facilities.[Footnote 19],[Footnote 20] The military services, using service-specific databases, identify active and Reserve component servicemembers to whom the PDHRA requirement applies and notify these servicemembers via various methods, such as postcards, e-mail, telephone, and face-to-face contact. The DOD policy that initiated the PDHRA program stated that the military services should contact servicemembers who separate before or during the reassessment period to offer them the opportunity to fill out the PDHRA questionnaire. However, there is no mechanism in place to offer separated servicemembers the opportunity to fill out the PDHRA questionnaire. Once these servicemembers have separated from military service, they have no further obligation to the military services and accordingly, cannot be required to fill out the PDHRA questionnaire. It can also be difficult to locate and contact servicemembers after they separate. Instead, the military services, with the exception of the Air Force, implemented policies to administer the PDHRA to active and Reserve component servicemembers as part of the separation process from the military.[Footnote 21] Although the Army formally implemented its policy to administer the PDHRA to servicemembers before they separate in April 2008, the practice had been in effect as early as January 2006. The Navy and Marine Corps implemented a similar policy in January 2009. According to Air Force officials, there are plans to implement a policy by December 2009. The PDHRA involves two steps--active or Reserve component servicemembers fill out a PDHRA questionnaire and then discuss their questionnaire health concern responses with health care providers. The PDHRA questionnaire consists of a demographic section, a medical section, and a third section for a health care provider to fill out and sign. The demographic section asks for servicemembers to provide information such as date of birth, gender, and marital status. The medical section of the questionnaire asks servicemembers to self-report information on their current physical and mental health condition and concerns. DOD considers a PDHRA questionnaire complete when a health care provider reviews and signs the questionnaire, regardless of whether servicemembers fill out the entire PDHRA questionnaire or only the demographic section.[Footnote 22] (See appendix II for a sample PDHRA questionnaire.) Methods of PDHRA Administration: The Army, Air Force, Navy, and Marine Corps require active and Reserve component servicemembers to whom the PDHRA requirement applies to fill out at least the demographic section of the PDHRA questionnaire. Although filling out the medical section is voluntary, DOD officials estimate that less than 1 percent of servicemembers who fill out the PDHRA questionnaire decline to fill out the medical section, with the exception of the Air Force, which reported a higher declination rate. [Footnote 23] Active component servicemembers typically fill out the PDHRA questionnaire online either prior to PDHRA on-site events or during such events, which are usually held at military installations. Similarly, Reserve component servicemembers may fill out the PDHRA questionnaire--administered by the contractor, LHI--online, prior to or during on-site events. In addition, LHI maintains call centers to administer the PDHRA to Reserve component servicemembers.[Footnote 24] Reserve component servicemembers who use LHI's call centers may fill out the demographic and medical sections of the questionnaire online or, with the help of call center staff, may fill out both sections of the questionnaire through the call centers.[Footnote 25],[Footnote 26] Health Care Provider Review and Referral for Further Evaluation: DOD requires that a health care provider[Footnote 27] review and discuss active and Reserve component servicemembers' health concern responses on the PDHRA questionnaire, including any physical and mental health concerns that servicemembers self-identify on their questionnaires.[Footnote 28],[Footnote 29] Health care providers use professional judgment to decide whether a further evaluation is needed, based on servicemembers' responses and other information revealed from the discussions with servicemembers.[Footnote 30] If referrals for a further evaluation are recommended, health care providers offer servicemembers information on obtaining a referral appointment. For example, a health care provider may provide information on obtaining an appointment at a military treatment facility or a Vet Center.[Footnote 31] Once a referral for a further evaluation is made, DOD does not require the military services to follow up to determine if active and Reserve component servicemembers have made or attended an appointment generated as a result of the health care provider's assessment. However, for Reserve component servicemembers, referral follow-up is part of LHI's administration of the PDHRA. LHI staff follow up within 72 hours with Reserve component servicemembers who have been issued a referral for a further evaluation through the call centers to ensure that these servicemembers have the information needed to obtain an appointment and to encourage servicemembers to schedule an appointment.[Footnote 32] In addition, LHI staff attempt to contact Reserve component servicemembers 30 days after medical referrals are issued, whether issued through PDHRA on-site events or through the call centers, to ask whether they scheduled and attended an appointment.[Footnote 33] If servicemembers did not, LHI staff ask if assistance is needed in scheduling an appointment. Each of the military services is required to electronically submit PDHRA questionnaires for both active and Reserve component servicemembers to DOD's central repository.[Footnote 34] The central repository is the single source of DOD-level health surveillance information. The central repository contains data on diseases and medical events and longitudinal data on personnel and deployments, including information from DOD's various deployment health assessments, such as the PDHRA. For Reserve component servicemembers who fill out PDHRA questionnaires through LHI, LHI staff are responsible for verifying that the questionnaires are submitted to the appropriate military service's database. The military services are then responsible for submitting the questionnaires from their respective databases to DOD's central repository. DOD's Deployment Health Quality Assurance Program: DOD established a deployment health quality assurance program in January 2004 to assess whether DOD's deployment health assessments, including the PDHRA, are conducted as required.[Footnote 35] The deployment health quality assurance program relies on data from DOD's central repository, data from the military services, and site visits to military installations to monitor and report on the extent of compliance among the military services with DOD's deployment health requirements, such as the number of active and Reserve component servicemembers that filled out the PDHRA questionnaire.[Footnote 36] According to DOD's deployment health quality assurance program manager, the program performed a site visit to Reserve units to validate data provided by the military services for the first time in October 2008, as part of its oversight of deployment health assessments, including the PDHRA. Prior to that, the quality assurance program only performed site visits to active component sites.[Footnote 37] On a quarterly basis, the quality assurance program reports to the military services on each service's compliance with deployment health requirements. The quality assurance program also reports annually to the Armed Services Committees of the House of Representatives and Senate on site visit findings and on deployment health assessment data, including the number and percentage of servicemembers with PDHRA questionnaires in DOD's central repository. Through its monitoring and reporting, DOD's quality assurance program helps ensure that DOD's deployment health assessments are conducted for active and Reserve component servicemembers as required. DOD's Contract with LHI to Administer the PDHRA to Reserve Component Servicemembers: DOD contracts with LHI to administer the PDHRA to Reserve component servicemembers.[Footnote 38] Although LHI administers the PDHRA to Reserve component servicemembers on behalf of DOD, the military services are responsible for identifying and notifying servicemembers to whom the PDHRA requirement applies and for submitting questionnaires to DOD's central repository. DOD's RHRP office is responsible for monitoring DOD's contract with LHI, which includes the administration of the PDHRA to Reserve component servicemembers, as well as the provision of other health services for this population, such as immunizations, physical examinations, and dental examinations and X- rays.[Footnote 39],[Footnote 40] DOD's contract with LHI is a performance-based contract and, as such, establishes performance standards that the RHRP office uses in monitoring and assessing LHI's performance in providing services to Reserve component servicemembers, including the administration of the PDHRA. For example, under its contract with DOD, LHI call center staff are required to answer 80 percent of incoming calls within 120 seconds. In monitoring LHI's performance, DOD's RHRP office helps ensure that the objective of the PDHRA program--to identify and address servicemembers' health concerns, including mental health concerns, that emerge over time following deployments--is achieved for Reserve component servicemembers. DOD's Central Repository Did Not Contain PDHRA Questionnaires for a Substantial Percentage of Servicemembers Who Returned from Deployment to Iraq or Afghanistan: On the two occasions we queried DOD's central repository, we did not find PDHRA questionnaires for a substantial percentage of the active and Reserve component servicemembers in our population of interest. DOD policy requires that the military services electronically submit questionnaires to DOD's central repository, which DOD uses as a key source of health surveillance information. The first of our two queries of DOD's central repository occurred on April 15, 2009. On this date, we found that the central repository contained PDHRA questionnaires for only 77 percent of the roughly 319,000 active component, Reserve, and National Guard servicemembers who, according to DOD DMDC deployment data, returned from deployment to Iraq or Afghanistan between January 1, 2007, and May 31, 2008.[Footnote 41],[Footnote 42] We could not identify PDHRA questionnaires in DOD's central repository on April 15, 2009, for a large number of servicemembers in our population--about 74,000 servicemembers--which represents the remaining 23 percent of our population of interest. We made our query nearly 1 year after the last servicemembers in our population returned from deployment.[Footnote 43] The percentage of PDHRA questionnaires absent from DOD's central repository for our population of interest varied by military service and component. For example, among military service components, this percentage ranged from a low of about 10 percent to a high of about 61 percent.[Footnote 44] (For more information on the extent to which servicemembers in our population of interest did not have PDHRA questionnaires in DOD's central repository as of April 15, 2009, see appendix III.) After determining that about 74,000 servicemembers in our population of interest did not have questionnaires in DOD's central repository based on our first query, we asked the military services whether these servicemembers had PDHRA questionnaires that could be identified in the services' own databases.[Footnote 45] With the help of the services, we found that approximately 7,000 servicemembers--or about 9 percent of the 74,000 servicemembers--had questionnaires in their respective military services' databases, but not in DOD's central repository. [Footnote 46] The number of questionnaires identified in the military services' databases that were not in the central repository varied by military service--ranging from over 300 questionnaires for Air Force and Navy servicemembers to about 3,000 for Army and Marine Corps servicemembers.[Footnote 47] On September 4, 2009, we queried DOD's central repository again to update our April 2009 data and determine whether any progress had been made in reporting questionnaires to the central repository. On this second query--15 months after the last servicemembers in our population of interest returned from deployment--we found that DOD's central repository was missing the same percentage of PDHRA questionnaires as had been missing in April. As a result of our September 2009 query, we still found PDHRA questionnaires for only 77 percent of the approximately 319,000 servicemembers in our original population of interest.[Footnote 48],[Footnote 49] While we identified slightly more questionnaires than we identified in our April query, we were still unable to identify questionnaires in the central repository for about 72,000 servicemembers.[Footnote 50],[Footnote 51] (See table 1.) Table 1: Servicemembers Who Returned from Deployment to Iraq or Afghanistan Between January 1, 2007, and May 31, 2008, without a PDHRA Questionnaire in DOD's Central Repository, as of September 4, 2009: Military service: Army; Component: Active component; Number of returning servicemembers: 132,247; Number of servicemembers without PDHRA questionnaire in central repository: 27,789; Percentage of servicemembers without PDHRA questionnaire in central repository: 21.01. Military service: Army; Component: Military service: National Guard; Number of returning servicemembers: Military service: 38,231; Number of servicemembers without PDHRA questionnaire in central repository: Military service: 6,018; Percentage of servicemembers without PDHRA questionnaire in central repository: Military service: 15.74. Military service: Army; Component: Military service: Reserve; Number of returning servicemembers: Military service: 15,817; Number of servicemembers without PDHRA questionnaire in central repository: Military service: 2,703; Percentage of servicemembers without PDHRA questionnaire in central repository: Military service: 17.09. Military service: Army; Component: Military service: Total; Number of returning servicemembers: Military service: 186,295; Number of servicemembers without PDHRA questionnaire in central repository: Military service: 36,510; Percentage of servicemembers without PDHRA questionnaire in central repository: Military service: 19.60. Military service: Air Force; Component: Active component; Number of returning servicemembers: 39,792; Number of servicemembers without PDHRA questionnaire in central repository: 5,487; Percentage of servicemembers without PDHRA questionnaire in central repository: 13.79. Military service: Air Force; Component: Military service: National Guard; Number of returning servicemembers: Military service: 8,583; Number of servicemembers without PDHRA questionnaire in central repository: Military service: 796; Percentage of servicemembers without PDHRA questionnaire in central repository: Military service: 9.27. Military service: Air Force; Component: Military service: Reserve; Number of returning servicemembers: Military service: 3,341; Number of servicemembers without PDHRA questionnaire in central repository: Military service: 1,879; Percentage of servicemembers without PDHRA questionnaire in central repository: Military service: 56.24. Military service: Air Force; Component: Military service: Total; Number of returning servicemembers: Military service: 51,716; Number of servicemembers without PDHRA questionnaire in central repository: Military service: 8,162; Percentage of servicemembers without PDHRA questionnaire in central repository: Military service: 15.78. Military service: Navy; Component: Active component; Number of returning servicemembers: 10,412; Number of servicemembers without PDHRA questionnaire in central repository: 4,882; Percentage of servicemembers without PDHRA questionnaire in central repository: 46.89. Military service: Navy; Component: Military service: Reserve; Number of returning servicemembers: Military service: 2,983; Number of servicemembers without PDHRA questionnaire in central repository: Military service: 1,056; Percentage of servicemembers without PDHRA questionnaire in central repository: Military service: 35.40. Military service: Navy; Component: Military service: Total; Number of returning servicemembers: Military service: 13,395; Number of servicemembers without PDHRA questionnaire in central repository: Military service: 5,938; Percentage of servicemembers without PDHRA questionnaire in central repository: Military service: 44.33. Military service: Marine Corps; Component: Active component; Number of returning servicemembers: 61,006; Number of servicemembers without PDHRA questionnaire in central repository: 19,761; Percentage of servicemembers without PDHRA questionnaire in central repository: 32.39. Military service: Marine Corps; Component: Military service: Reserve; Number of returning servicemembers: Military service: 6,644; Number of servicemembers without PDHRA questionnaire in central repository: Military service: 1,990; Percentage of servicemembers without PDHRA questionnaire in central repository: Military service: 29.95. Military service: Marine Corps; Component: Military service: Total; Number of returning servicemembers: Military service: 67,650; Number of servicemembers without PDHRA questionnaire in central repository: Military service: 21,751; Percentage of servicemembers without PDHRA questionnaire in central repository: Military service: 32.15. Military service: Total; Number of returning servicemembers: 243,457; Number of servicemembers without PDHRA questionnaire in central repository: 57,919; Percentage of servicemembers without PDHRA questionnaire in central repository: 23.79. Military service: Total; Component: Military service: Reserve component; Number of returning servicemembers: 75,599; Number of servicemembers without PDHRA questionnaire in central repository: 14,442; Percentage of servicemembers without PDHRA questionnaire in central repository: 19.10. Military service: Total; Component: Military service: Grand total; Number of returning servicemembers: 319,056; Number of servicemembers without PDHRA questionnaire in central repository: 72,361; Percentage of servicemembers without PDHRA questionnaire in central repository: 22.68. Source: GAO analysis of DOD data. Notes: This table displays information on servicemembers without a PDHRA questionnaire in DOD's central repository for a servicemember's most recent return from deployment from Iraq or Afghanistan between January 1, 2007, and May 31, 2008. We did not examine the extent to which a servicemember filled out a questionnaire for each return from deployment during this time period. DOD's Reserve components include servicemembers in the Army and Air National Guard, as well as the Army, Air Force, Navy, and Marine Corps Reserves. [End of table] The absence of 72,000 PDHRA questionnaires from DOD's central repository for servicemembers who should have filled them out hinders DOD's deployment health quality assurance program from effectively assessing the military services' compliance with PDHRA requirements. The program, which DOD established to assess whether DOD's deployment health assessments are conducted as required, relies in part on the presence of PDHRA questionnaires in the central repository. These questionnaires document the extent to which servicemembers were given the opportunity to fill out the questionnaire, as required under DOD policy. DOD officials specifically cited the importance of this documentation for helping the quality assurance program ensure that servicemembers have the opportunity to have their health concerns identified and addressed. However, the absence of questionnaires from the central repository for servicemembers who should have filled them out suggests either that not all of these servicemembers filled out the questionnaire or that questionnaires were filled out, but were not incorporated into DOD's central repository. When questionnaires for servicemembers from our population of interest are not in the central repository, DOD does not have reasonable assurance that all members of this vulnerable population of active component, Reserve, and National Guard servicemembers that deployed to Iraq or Afghanistan were administered the PDHRA questionnaire, which is intended to help identify deployment-related health concerns that emerge over time and facilitate the opportunity for servicemembers to address these concerns. DOD Uses Four Methods to Monitor the Administration of the PDHRA to Reserve Component Servicemembers, but Does Not Clearly Document Its Monitoring: DOD's Reserve Health Readiness Program (RHRP) office uses four methods to monitor LHI's administration of the PDHRA to Reserve component servicemembers. However, in using these methods, DOD's RHRP office does not always clearly document its monitoring of the PDHRA program. The office's documentation does not allow DOD to have reasonable assurance that potential problems that may relate to the welfare and safety of servicemembers have been addressed and resolved. DOD Uses Four Methods to Monitor the Administration of the PDHRA to Reserve Component Servicemembers: DOD's RHRP office uses four methods to monitor LHI's performance in administering the PDHRA to Reserve component servicemembers. More broadly, the RHRP office also uses the four methods to monitor whether the objective of the PDHRA program--to identify and address servicemembers' health concerns that emerge over time following deployments--is being met for Reserve component servicemembers. The four methods, which are identified in DOD's contract with LHI, are the following: * Reviews of periodic reports.[Footnote 52] The RHRP office receives several periodic reports that DOD requires from LHI on LHI's administration of the PDHRA to Reserve component servicemembers. DOD requires LHI to report aggregate information on LHI's administration of the PDHRA, including reports on its compliance with performance standards. For instance, the RHRP office receives a report on LHI's compliance with the performance standard requiring that LHI call center staff answer 80 percent of incoming calls within 120 seconds.[Footnote 53] In addition, LHI provides descriptive information on the number of Reserve component servicemembers administered the PDHRA, referred for a further evaluation, and contacted by LHI staff 30 days after receiving referrals.[Footnote 54] An RHRP official told us that the office reviews LHI's reports to examine data related to the administration of the PDHRA and identifies potential problems that could pose risks to servicemembers and the objective of the PDHRA program. For example, the number of servicemembers referred each month is compared against historical data to monitor any changes in the rate at which servicemembers receive referrals for physical and mental health concerns. * Inspections of the administration of PDHRA. The RHRP office also conducts inspections related to LHI's administration of the PDHRA to Reserve component servicemembers. The inspections have included observing PDHRA on-site events, at which servicemembers are administered the PDHRA, to assess the quality of LHI services delivered during the events. For instance, an RHRP official told us that he checks whether the events are staffed with a sufficient number of health care providers and administrative staff. In another instance, an RHRP official listened to LHI call center discussions between LHI staff and Reserve component servicemembers to examine how LHI staff administer the PDHRA.[Footnote 55] * Feedback on the administration of the PDHRA from military service officials. The RHRP office obtains informal feedback about how the PDHRA is being administered to Reserve component servicemembers through e-mail correspondence, telephone conversations, and in-person discussions with military service officials who are responsible for managing the PDHRA for their respective services. These officials told us that the RHRP office generally maintains open, informal communication channels through which they can and do express their concerns. * Weekly telephone discussions with LHI staff. An RHRP official said that weekly telephone discussions with LHI staff are held to obtain their feedback on the administration of the PDHRA to Reserve component servicemembers. In addition, during these discussions, an RHRP official and LHI staff discuss and address potential problems identified through the periodic reports, inspections, and military service feedback. The potential problems staff discuss may include those that could pose a risk to the PDHRA program objective and to the welfare and safety of Reserve component servicemembers. For example, some problems concerned how servicemembers were responding to questions on the PDHRA questionnaire. According to an RHRP official, these discussions serve as a forum to determine the actions DOD officials or LHI staff need to take to address identified problems and to verify that problems raised during previous discussions have been properly resolved. DOD Generally Does Not Clearly Document Its Monitoring of the PDHRA Program: When monitoring the administration of the PDHRA to Reserve component servicemembers, DOD does not maintain clear documentation that is consistent with good management practices outlined in federal internal control standards.[Footnote 56] According to these standards, internal control activities such as monitoring should be clearly documented in a manner that is accurate, timely, and helps provide reasonable assurance that program objectives are being achieved. Further, such documentation should be properly managed and maintained so that it is readily accessible and should allow someone other than the assigned officials to understand the identified potential problem, the actions taken to address the problem, and whether these actions have resolved the problem. Instead of adopting an approach that generated documentation consistent with management practices outlined in federal internal control standards, the RHRP office created an unsystematic, improvised approach for documenting potential problems that were identified through review of periodic reports, inspections, and feedback from military service officials and LHI staff. These problems may pose a risk to the PDHRA program objective. The RHRP office's approach solely relies on agendas and e-mail correspondence to document these potential problems and the actions taken to resolve them. * Weekly agendas with related notes. Prior to the weekly discussions with LHI staff, a typed agenda is prepared for discussion that lists the potential problems identified through monitoring activities. During these discussions, annotated brief handwritten notes are made on an agenda item and these notes are used to indicate that certain actions need to be taken by DOD officials or LHI staff to address an identified problem. When it appears that problems have been resolved, instead of documenting how the problem was resolved, the problem is not included on the agenda for the next week's discussion.[Footnote 57] A hard copy of the agenda is retained and filed in the RHRP office after each weekly discussion with LHI staff. * E-mail correspondence. The RHRP office receives and generates e-mail correspondence with LHI staff and military service officials that discusses potential problems identified through monitoring the administration of the PDHRA to Reserve component servicemembers. We found that the RHRP office's sole reliance on these agendas and e- mail correspondence did not always result in clear documentation--that is, documentation that is understandable and readily accessible to others outside the RHRP office. In particular, the agendas and e-mail correspondence we reviewed did not always clearly describe the decisions made and the actions taken to address identified problems in a manner that provides reasonable assurance that the problems have been resolved.[Footnote 58] An RHRP official acknowledged that he could not consistently rely on the agendas and e-mail correspondence to reconstruct information obtained through the office's internal control responsibility to monitor and address problems associated with the administration of the PDHRA to Reserve component servicemembers. Instead, this official relies on memory to recall such information. In our review of the documentation related to 15 potential problems we selected, we found that the RHRP office's documentation generally did not clearly describe the problem, the actions taken to address the problem, and whether these actions have resolved the problem.[Footnote 59] For example, on two September 2008 agendas for the weekly discussions with LHI staff, the agendas include a potential problem identified by DOD officials that 25 to 30 percent of servicemembers were not responding to questions on the PDHRA questionnaire about the number of alcoholic drinks they consumed on a typical day, and 18 percent were not responding to the questions about whether they were depressed. The RHRP office asked LHI staff if they were finding similar nonresponses to these questions from Reserve component servicemembers. However, the subsequent agendas--which the RHRP office relies on to track problems--do not contain any additional information about how this potential problem was resolved. There is no further information, including any related e-mail correspondence, on how this potential problem was addressed. This example raises questions about whether Reserve component servicemembers' mental health concerns--specifically those related to alcohol use and depression--are being consistently identified or whether any follow-up actions are needed to address this problem. We also reviewed e-mail correspondence related to the 15 selected potential problems, dated between March 4, 2008, and May 19, 2009, and found that it often contained vague information about the identified problems and the actions taken to resolve them.[Footnote 60] Some of these problems relate to the welfare and safety of servicemembers and require more information than is present in the available documentation to understand whether or how the problems were resolved. For example, we asked about an instance in which a military service official reported that an LHI health care provider failed to document on a Reserve component servicemember's PDHRA questionnaire why the servicemember with reported suicidal ideations did not get an immediate referral.[Footnote 61] The e-mail correspondence about this potential problem had gaps. For instance, while the e-mail correspondence indicates that the RHRP office asked LHI staff to look into the incident and contains a reply from LHI staff stating that they would investigate further, the e-mail correspondence does not document the final results of the LHI staff's investigation, including whether or how this potential problem was resolved. Although this potential problem is listed on several agendas, the agendas do not provide any more information about the problem or how it was resolved. Instead, an RHRP official told us that he relied on his memory to explain to us what happened and how it was resolved.[Footnote 62] This official told us he requested that LHI staff remind its health care providers to fully document the results of their physical and mental health assessments on Reserve component servicemembers' PDHRA questionnaires in the future. However, there is no documentation of this request to LHI staff or any documentation of plans to follow up to ensure that LHI staff carried out the request. (For more information on the documentation related to the 15 potential problems, see appendix IV.) In addition to being generally incomplete and unclear, the e-mail correspondence related to the potential problems is not readily accessible. E-mail correspondence about identified problems is placed into labeled folders within the office's e-mail system, but the labels are general and e-mail correspondence could appropriately be placed in a number of folders. An official told us that, as a result, he struggles in remembering into which folder a specific e-mail was placed. For example, e-mail correspondence about an identified problem about an Army Reserve servicemember's PDHRA questionnaire may be placed in either an Army PDHRA folder, a PDHRA complaints folder, or a standard operating procedures folder. Not having documentation that is readily accessible hinders the RHRP office's ability to promptly ensure that identified problems have been properly addressed. In addition, should LHI's performance diminish--for example, if LHI was not resolving identified problems--the lack of readily available documentation could compromise DOD's ability to take appropriate action. Conclusions: DOD established the PDHRA program in order to identify and address servicemembers' health concerns--including mental health concerns-- that emerge over time following deployments. The PDHRA questionnaire is a key tool in DOD's efforts to assess the physical and mental health condition of servicemembers who have returned from deployments to Iraq and Afghanistan, where exposure to intense combat can place servicemembers at risk for developing conditions, such as post- traumatic stress disorder. DOD's deployment health quality assurance program assesses the military services' compliance with the requirement to administer the PDHRA to active and Reserve component servicemembers to help ensure that servicemembers have the opportunity to have their health concerns identified and addressed through the PDHRA. However, our current findings show that the concerns we previously raised about DOD's quality assurance program remain. Specifically, the absence of PDHRA questionnaires in DOD's central repository for thousands of eligible active and Reserve component servicemembers continues to hinder the program's ability to assess the extent to which these servicemembers fill out the PDHRA questionnaire and have the opportunity to identify any health concerns that emerge over time following deployments. DOD officials have identified the presence of questionnaires in the central repository as important for the efforts of DOD's quality assurance program. Without this information, the program may not be able to accurately determine completion rates among the military services and thus provide reasonable assurance to DOD or to Congress that one of DOD's key health assessments is being administered as required. Ensuring that Reserve component servicemembers fill out the PDHRA questionnaire may be particularly important, as some evidence suggests that these servicemembers may be more likely to develop mental health conditions after returning from deployment when compared with their active component counterparts. Although DOD monitors the administration of the PDHRA to Reserve component servicemembers, documentation associated with this monitoring needs to be strengthened. The RHRP office has not always clearly documented--in a way that is consistent with federal internal control standards--information related to problems that may pose risks to the objective of the PDHRA program. Some of these potential problems also involve Reserve component servicemembers' welfare and safety. The office's improvised, unsystematic approach to documenting potential problems results in documentation that does not provide DOD with reasonable assurance that these problems have been resolved. Recommendations for Executive Action: To help DOD obtain reasonable assurance that all active and Reserve component servicemembers to whom the PDHRA requirement applies are provided the opportunity to have their health concerns identified, we recommend that the Assistant Secretary of Defense for Health Affairs and the military services take steps to ensure that PDHRA questionnaires are included in DOD's central repository for each of these servicemembers. To ensure adequate documentation of problems that may pose risks to the objective of the PDHRA program for Reserve component servicemembers, we recommend that the Assistant Secretary of Defense for Health Affairs require the RHRP office to document the information obtained through monitoring the PDHRA program in a manner consistent with federal internal control standards. Agency Comments and Our Evaluation: In written comments on a draft of this report, DOD concurred with our two recommendations. Specifically, DOD agreed with our recommendation that it take steps to ensure that PDHRA questionnaires are included in DOD's central repository for each servicemember to whom the PDHRA requirement applies. DOD stated that to implement this recommendation, it will take the following actions: work to correctly identify servicemembers who need to receive the PDHRA and work to identify and resolve any obstacles to transmission of data from the military services to AFHSC. Additionally, DOD stated that it sent a memorandum on October 15, 2009, to the military services' Surgeons General re- emphasizing the importance of deployment health requirements. DOD also agreed with our recommendation concerning documentation of problems that may pose risks to the objective of the PDHRA program for Reserve component servicemembers. DOD stated that during our engagement, the RHRP office recognized a need to improve documentation of its monitoring of the PDHRA program. DOD also stated in its response that the RHRP office established a more distinct and clear electronic filing system and began documenting not only potential problems with the PDHRA program, but also their resolution in a manner that DOD reports is sufficiently comprehensive, accessible, and understandable. We did not assess this new approach to documentation. DOD's written comments are included in their entirety in appendix V. DOD did not provide technical comments. We are sending copies of this report to the Secretary of the Department of Defense. The report will be available at no charge on GAO's Web site at [hyperlink, http://www.gao.gov]. If you or your staff have questions about this report, please contact me at (202) 512-7114 or williamsonr@gao.gov. Contact points for our Office of Congressional Relations and Public Affairs may be found on the last page of this report. GAO staff who made major contributions to this report are listed in appendix VI. Signed by: Randall B. Williamson: Director, Health Care: List of Congressional Addressees: The Honorable Carl Levin: Chairman: The Honorable John McCain: Ranking Member: Committee on Armed Services: United States Senate: The Honorable Ike Skelton: Chairman: The Honorable Howard P. McKeon: Ranking Member: Committee on Armed Services: House of Representatives: The Honorable Daniel K. Akaka: United States Senate: The Honorable Christopher S. Bond: United States Senate: The Honorable Barbara Boxer: United States Senate: The Honorable Tom Harkin: United States Senate: The Honorable Joseph I. Lieberman: United States Senate: The Honorable Claire McCaskill: United States Senate: The Honorable Patty Murray: United States Senate: The Honorable Bernard Sanders: United States Senate: [End of section] Appendix I: Scope and Methodology: To determine the extent to which post-deployment health reassessment (PDHRA) questionnaires are contained in the Department of Defense's (DOD) central repository for active and Reserve component[Footnote 63] servicemembers who returned from deployment to Iraq or Afghanistan, we conducted a quantitative analysis using DOD data from two sources--the Defense Manpower Data Center's (DMDC) Contingency Tracking System (CTS) and the Armed Forces Health Surveillance Center's (AFHSC) Defense Medical Surveillance System (DMSS).[Footnote 64] DMDC's CTS contains data on servicemembers deployed in support of the Overseas Contingency Operations[Footnote 65]--including data on servicemembers' deployment dates and location of deployment. We used CTS data to identify a selected population of interest: active component, Reserve, and National Guard servicemembers who had returned from deployments of greater than 30 days to Iraq or Afghanistan between January 1, 2007, and May 31, 2008.[Footnote 66] DMDC officials identified this population for us using servicemembers' deployment dates and locations. If a servicemember had multiple deployments during this period, we received data on a servicemember's most recent return from deployment during this time period. Although DOD initiated the PDHRA program in March 2005, the military services implemented the program at different times, with full implementation across all services in late 2006. In addition, servicemembers are not eligible to fill out a PDHRA questionnaire until 90 to 180 days after they have returned from deployment. Thus, when we requested data from DMDC in late fall 2008, we needed to focus on a population of servicemembers who had returned from deployment at least 180 days prior to our data request. Therefore, we focused our analysis on servicemembers who returned from deployment on or after January 1, 2007, and on or before May 31, 2008. As a secondary check that this population of interest had, in fact, deployed, we sent our population of interest to AFHSC officials, who compared our population to two other deployment rosters. The results of this match identified our final population of interest of approximately 319,000 servicemembers. AFHSC's DMSS is DOD's central repository for PDHRA questionnaires and the military services are required to submit questionnaires to this central repository. To determine the extent to which servicemembers in our population of interest had PDHRA questionnaires in DOD's central repository, we sent personal identifying information and beginning and end deployment dates from CTS for the servicemembers in our population of interest to AFHSC. AFHSC officials matched our population of interest to the PDHRA questionnaires in DMSS using a servicemember's personal identifying information and the beginning and end deployment dates as recorded in CTS and as reported by the servicemember on the PDHRA questionnaire.[Footnote 67] AFHSC officials then sent us data from identified questionnaires that had been incorporated into DMSS as of April 15, 2009. As the military services collect PDHRA questionnaires in their own databases before transmitting them to AFHSC's DMSS, we then asked officials from the military services to query their own databases to identify PDHRA questionnaires for servicemembers in our population of interest for which a PDHRA questionnaire could not be identified in DMSS. We provided the military services with a servicemember's personal identifying information and deployment end date from CTS and asked them to query their databases for any questionnaires that they would consider to be ready to transmit to AFHSC that were filled out after the deployment end date listed in CTS. The military services then queried their own databases and, for each servicemember that we sent to them for which they could identify a PDHRA questionnaire, returned to us the end deployment date listed on the PDHRA questionnaire and date of questionnaire completion. If a servicemember filled out multiple PDHRA questionnaires after the deployment end date listed in CTS, we received information from each of these questionnaires. We received these data from the military services in late May and June 2009. We then matched our population of interest to the information from the PDHRA questionnaires received from the military services' databases using a servicemember's personal identifying information and the end deployment date as recorded in CTS and as reported by the servicemember on the PDHRA questionnaire. Finally, in September 2009, we obtained additional data from AFHSC to update our April 2009 data. AFHSC officials matched information from the servicemembers in our population of interest without a questionnaire in DMSS as of April 15, 2009, to the PDHRA questionnaires in DMSS as of September 4, 2009, using a servicemember's personal identifying information and the beginning and end deployment dates as recorded in CTS and as reported by the servicemember on the PDHRA questionnaire. AFHSC officials then sent us data from identified questionnaires that had been incorporated into DMSS as of September 4, 2009. We conducted data reliability assessments for each DOD and military service data source we used by reviewing related documentation, interviewing knowledgeable agency officials, and performing electronic data testing for missing data, outliers, and obvious errors. We determined that these data sources were sufficiently reliable for our purposes. We determined only the extent to which questionnaires could be identified in AFHSC's DMSS or the military services databases for our population of interest, and not the extent to which the servicemembers actually filled out a PDHRA questionnaire. We interviewed officials from DMDC and AFHSC, the DOD deployment health quality assurance program, and Army, Air Force, Navy, and Marine Corps officials involved in the collection and transfer of PDHRA questionnaires from the military services' databases to AFHSC. We also reviewed DOD policies, as well as those of the Army, Air Force, Navy, and Marine Corps, for submitting PDHRA questionnaires to DOD's central repository. Finally, we reviewed our prior work on DOD's deployment health quality assurance program. To determine how DOD monitors the administration of the PDHRA to Reserve component servicemembers, we reviewed DOD's policies for monitoring its contract with Logistics Health, Inc. (LHI), the contractor that administers the PDHRA to Reserve component servicemembers. We also interviewed officials with DOD's Reserve Health Readiness Program (RHRP)--the DOD office responsible for monitoring LHI--along with military service officials responsible for managing the administration of the PDHRA to Reserve component servicemembers. We reviewed DOD's contract with LHI and obtained and analyzed contractually required reports and other documentation on LHI's performance related to the PDHRA portion of DOD's contract with LHI. [Footnote 68] We visited LHI's headquarters in La Crosse, Wisconsin, where we interviewed LHI staff to confirm our understanding of how LHI staff administers the PDHRA to Reserve component servicemembers. We additionally interviewed officials with the U.S. Army Medical Research Acquisition Activity, which provides support to DOD for the contract with LHI. We reviewed DOD's monitoring of the administration of the PDHRA to Reserve component servicemembers to determine the extent to which these monitoring efforts met or were consistent with GAO's Standards for Internal Control in the Federal Government.[Footnote 69] Internal controls include components of an organization's management that provide reasonable assurance that program objectives are being achieved.[Footnote 70] The RHRP office receives contractually required reports from LHI on its administration of the PDHRA and we obtained and reviewed monthly reports from May 2008 through April 2009 for the following four required reports: (1) the PDHRA monthly activity report, (2) the call center access report, (3) the data entry report, and (4) the PDHRA customer satisfaction survey report. We selected the PDHRA monthly activity and the call center access reports to review because the RHRP office told us that these reports provide information that is needed to monitor LHI's activities in administering the PDHRA to Reserve component servicemembers. The PDHRA monthly activity report provides aggregate information on LHI's PDHRA administration, such as the number of Reserve component servicemembers administered the PDHRA, referred for a further evaluation, and contacted by LHI 30 days after receiving referrals. The call center access report provides information on LHI's performance in operating its call center. In addition, we selected the data entry and PDHRA customer satisfaction survey reports to review because both reports provide information on performance standards associated with the PDHRA that LHI must meet to comply with the contract. The data entry report provides information on LHI's performance in entering PDHRA data into military services' databases, and the PDHRA customer satisfaction survey report provides information on whether LHI meets a performance standard associated with servicemember feedback on LHI's administration of the PDHRA. We also reviewed the documentation associated with the RHRP office's inspections of LHI's administration of the PDHRA from October 1, 2007, through May 6, 2009. We reviewed a list, provided by the RHRP office, of the feedback received from military service officials between January 1, 2008, and April 30, 2009. To obtain more in-depth information on how DOD documents the information it obtains through its monitoring efforts, we examined documentation maintained by the RHRP office on its monitoring. Specifically, we reviewed the RHRP office's agendas from the weekly telephone discussions with LHI staff and the office's e-mail correspondence, which the RHRP office uses to document its monitoring. We reviewed approximately 70 of the RHRP office's agendas for the period between October 1, 2007, and May 11, 2009. From the agendas and the provided list of military service feedback, we judgmentally selected 15 potential problems to review in further detail and asked the RHRP office to provide us with all of the documentation available on these problems, including any e-mail correspondence that related to the problem. We selected these 15 potential problems because the subject of each of these may have involved welfare and safety concerns for Reserve component servicemembers. The RHRP office provided us with e-mail correspondence dated between March 4, 2008, and May 19, 2009, related to the 15 potential problems. We reviewed the agendas and the available e-mail correspondence for the 15 selected problems to determine the actions taken to resolve the problems and how this information is documented and maintained. Our findings related to the documentation of the 15 potential problems are for illustrative purposes only and are not generalizable to other RHRP office documentation. We conducted this performance audit from October 2008 to October 2009 in accordance with generally accepted government auditing standards. Those standards require that we plan and perform the audit to obtain sufficient, appropriate evidence to provide a reasonable basis for our findings and conclusions based on our audit objectives. We believe that the evidence obtained provides a reasonable basis for our findings and conclusions based on our audit objectives. [End of section] Appendix II: Sample Post-Deployment Health Reassessment Questionnaire (DD 2900), January 2008: Servicemembers fill out the post-deployment health reassessment (PDHRA) questionnaire electronically on form DD 2900, which was originally issued in June 2005. The Department of Defense (DOD) issued a revised form DD 2900 in January 2008. This form must be completed electronically. Handwritten forms will not be accepted. Post-Deployment Health Re-Assessment (PDHRA: Privacy Act Statement: Authority: 10 U.S.C. 136, 1074f, 3013, 5013, 8013 and E.O. 9397. Principal Purpose(s): To assess your state of health after deployment in support of military operations and to assist military healthcare providers in identifying and providing present and future medical care you may need. The information you provide may result in a referral for additional healthcare that may include medical, dental or behavioral healthcare or diverse community support services. Routine Use(s): In addition to those disclosures generally permitted under 5 U.S.C. 552a(b) of the Privacy Act, to other Federal and State agencies and civilian healthcare providers, as necessary, in order to provide necessary medical care and treatment. Disclosure: Voluntary. If not provided, healthcare will be furnished, but comprehensive care may not be possible. Instructions: Please read each question completely and carefully before entering your response or marking your selection. You are encouraged to answer each question. Withholding or providing inaccurate Information may Impair a healthcare provider's ability to identify health problems and refer you to appropriate sources for additional evaluation or treatment. If you do not understand a question, please ask for help. Please respond based on your most recent deployment. Demographics: Last Name: First Name: Middle Initial: Social Security Number: Date of Birth (dd/mmm/yyyy): Today's Date (dd/mmm/yyyy): Date arrived theater (dd/mmm/yyyy): Date departed theater (dd/mmm/yyyy): Gender: Male: Female: Service Branch: Air Force: Army: Navy: Marine Corps: Coast Guard: Civilian Employee: Other: Marital Status: Never Married: Married Separated: Divorced: Widowed: Status Prior to Deployment: Active Duty: Selected Reserves - Reserve - Unit: Selected Reserves - Reserve - AGR: Selected Reserves - Reserve - IMA: Selected Reserves - National Guard - Unit: Selected Reserves - National Guard - AGR: Ready Reserves - IRR: Ready Reserves - ING: Civilian Government Employee: Other: Pay Grade: E1: E2: E3: E4: E5: E6: E7: E8: E9: O1: O2: O3: O4: O5: O6: O7: O8: O9: O10: W1: W2: W3: W4: W5: Other: Location of Operation: To what areas were you mainly deployed (land-based operations more than 30 days)? Please mark all that apply, including the number of months spent at each location. Country 1: Months: Country 2: Months: Country 3: Months: Country 4: Months: Country 5: Months: Since return from deployment I have: Maintained/returned to previous status: Transitioned to Selected Reserves: Transitioned to IRR: Transitioned to ING: Retired from Military Service: Separated from Military Service: Current Contact Information: Phone: Cell: DSN: Email: Address: Total Deployments in Past 5 Years: OIF: 1: 2: 3: 4: 5 or more: OEF: 1: 2: 3: 4: 5 or more: Other: 1: 2: 3: 4: 5 or more: Point of Contact who can always reach you: Name: Phone: Email: Mailing Address: This form must be completed electronically. Handwritten forms will not be accepted. Service Member's Social Security Number: 1. Overall, how would you rate your health during the Past Month? Excellent: Very Good: Good: Fair: Poor: 2. Compared to before your most recent deployment, how would you rate your health in general now? Much better now than before I deployed: Somewhat better now than before I deployed: About the same as before I deployed: Somewhat worse now than before I deployed: Much worse now than before I deployed: 3. During the past 4 weeks, how difficult have physical health problems (illness or injury) made it for you to do your work or other regular daily activities? Not difficult at all: Very difficult: Somewhat difficult: Extremely difficult: 4. During the past 4 weeks, how difficult have emotional problems (such as feeling depressed or anxious) made it for you to do your work, take care of things at home, or get along with other people? Not difficult at all: Very difficult: Somewhat difficult: Extremely difficult: 5. Since you returned from deployment, about how many times have you seen a healthcare provider for any reason, such as in sick call, emergency room, primary care, family doctor, or mental health provider? No visits: 1 visit: 2-3 visits: 4-5 visits: 6. Since you returned from deployment, have you been hospitalized? Yes: No: 7. During your deployment, were you wounded, injured, assaulted or otherwise physically hurt? If N0, skip to Question 8. Yes: No: 7a. If Yes, are you still having problems related to this wound, assault, or injury? Yes: No: Unsure: 8. In addition to wounds or injuries you listed in question 7., do you currently have a health concern or condition that you feel is related to your deployment? If No, skip to Question 9. Yes: No: Unsure: 8a. If Yes, mark the items) that best describe your deployment-related condition or concern: Fever: Dimming of vision, like the lights were going out: Cough lasting more than 3 weeks: Chest pain or pressure: Trouble breathing: Dizzy, light headed, passed out: Bad headaches: Diarrhea, vomiting, or frequent indigestion/heartburn: Generally feeling weak: Problems sleeping or still feeling tired after sleeping: Muscle aches: Trouble concentrating, easily distracted: Swollen, stiff or painful joints: Forgetful or trouble remembering things: Back pain: Hard to make up your mind or make decisions: Numbness or tingling in hands or feet: Increased irritability: Trouble hearing: Taking more risks such as driving faster: Ringing in the ears: Skin diseases or rashes: Watery, red eyes: Other (please list): 9a. During this deployment, did you experience any of the to following events? (Mark all that apply): (1) Blast or explosion (IED, RPG, land mine, grenade, etc.) Yes: No: (2) Vehicular accident/crash (any vehicle, including aircraft); Yes: No: (3) Fragment wound or bullet wound above your shoulders; Yes: No: (4) Fall; Yes: No: (5) Other event (for example, a sports injury to your head). Describe: 9b. Did any of the following happen to you, or were you told happened to you, Immediately after any of the event(s) you just noted in question 9a.? (Mark all that apply) (1) Lost consciousness or got "knocked out:" Yes: No: (2) Felt dazed, confused, or "saw stars:" Yes: No: (3) Didn't remember the event: Yes: No: (4) Had a concussion: Yes: No: (5) Had a head injury: Yes: No: 9c. Did any of the following problems begin or get worse after the event(s) you noted in question 9a.? (Mark all that apply) (1) Memory problems or lapses: (2) Balance problems or dizziness: (3) Ringing in the ears: (4) Sensitivity to bright light: (5) Irritability: (6) Headaches: (7) Sleep problems: 9d. In the past week, have you had any of the symptoms you indicated in 9c.? (Mark all that apply): (1) Memory problems or lapses: (2) Balance problems or dizziness: (3) Ringing in the ears: (4) Sensitivity to bright light: (5) Irritability: (6) Headaches: (7) Sleep problems: 10. Do you have any persistent major concerns regarding the health effects of something you believe you may have been exposed to or encountered while deployed? Yes: No: If No, skip to question 11. 10a. If Yes, please mark the item(s) that best describe your concern: Animal bites: Animal bodies (dead): Chlorine gas: Depleted uranium (If yes, explain): Excessive vibration: Fog oils (smoke screen): Garbage: Human blood, body fluids, body parts, or dead bodies: Industrial pollution: Insect bites: Ionizing radiation: JP8 or other fuels: Lasers: Loud noises: Paints: Pesticides: Radar/Microwaves: Sand/dust: Smoke from burning trash or feces: Smoke from oil fire: Solvents: Tent heater smoke: Vehicle or truck exhaust fumes: Other exposures to toxic chemicals or materials, such as ammonia, nitric acid, etc.: (If yes, explain): 11. Since return from your deployment, have you had serious conflicts with your spouse, family members, close friends, or at work that cause you worry or concern? Yes: No: Unsure: 12. Have you ever had any experience that was so frightening, horrible, or upsetting that, In The Past Month, you: a. Have had nightmares about it or thought about it when you did not want to? Yes: No: b. Tried hard not to think about it or went out of your way to avoid situations that remind you of it? Yes: No: c. Were constantly on guard, watchful, or easily startled? Yes: No: d. Felt numb or detached from others, activities, or your surroundings? Yes: No: 13a. In the Past Month, Did you use alcohol more than you meant to? Yes: No: b. In the Past Month, have you felt that you wanted to or needed to cut down on your drinking? Yes: No: c. How often do you have a drink containing alcohol? Never: Monthly or less: 2 to 4 times a month: 2 to 3 times a week: 4 or more times a week: d. How many drinks containing alcohol do you have on a typical day when you are drinking? 1 or 2: 3 or 4: 5 or 6: 7 to 9: 10 or more: e. How often do you have six or more drinks on one occasion? Never: Less than monthly: Monthly: Weekly: Daily: 14. Over the Past Month, have you been bothered by the following problems? a. Little interest or pleasure in doing things: Not at all Few or several days: More than half the days: Nearly every day: b. Feeling down, depressed, or hopeless: Not at all Few or several days: More than half the days: Nearly every day: 15. Would you like to schedule a visit with a healthcare provider to further discuss your health concern(s)? Yes: No: 16. Are you currently interested in receiving information or assistance for a stress, emotional or alcohol concern? Yes: No: 17. Are you currently interested in receiving assistance for a family or relationship concern? Yes: No: 18. Would you like to schedule a visit with a chaplain or a community support counselor? Yes: No: Health Care Provider Only: Provider Review and Interview: 1. Review symptoms and deployment concerns identified on form: Confirmed screening results as reported: Screening results modified, amended, clarified during interview: 2. Ask behavioral risk questions. Conduct risk assessment. a. Over the Past Month, have you been bothered by thoughts that you would be better off dead or of hurting yourself in some way? Yes: No: If Yes, about how often have you been bothered by these thoughts? Very few days: More than half of the time: Nearly every day: b. Since return from your deployment, have you had thoughts or concerns that you might hurt or lose control with someone? Yes: No: Unsure: 3. If member reports positive or unsure response to 2a. or 2b., conduct risk assessment. a. Does member pose a current risk for harm to self or others? No, not a current risk: Yes, poses a current risk: Unsure: b. Outcome of assessment: Immediate referral: Routine follow-up referral: Referral not indicated: 4. Alcohol screening result: No evidence of alcohol related problems: Potential alcohol problem (positive response to either question 13a. or 13b. and/or Audit-C (questions 13c.-e ) score of 4 or more for men or 3 or more for women). Refer to PCM for evaluation: Yes: No: 5. Traumatic Brain Injury (TBI) risk assessment: No evidence of risk based on responses to questions 9a.-d: Potential risk with persistent symptoms, based on responses to question 9d: Refer for additional evaluation: Yes: No: 6. Record additional questions or concerns identified by patient during interview: Assessment and Referral: After my interview with the service member and review of this form, there is a need for further evaluation and follow- up as indicated below. (More than one may be noted for patients with multiple concerns.) 7. Identified Concerns: Physical Symptom(s): Minor Concern: Major Concern: Already Under Care: Yes/No: Exposure Symptom(s): Minor Concern: Major Concern: Already Under Care: Yes/No: Depression symptoms: Minor Concern: Major Concern: Already Under Care: Yes/No: PTSD symptoms: Minor Concern: Major Concern: Already Under Care: Yes/No: Anger/Aggression: Minor Concern: Major Concern: Already Under Care: Yes/No: Suicidal Ideation: Minor Concern: Major Concern: Already Under Care: Yes/No: Social/Family Conflict: Minor Concern: Major Concern: Already Under Care: Yes/No: Alcohol Use: Minor Concern: Major Concern: Already Under Care: Yes/No: Other: Minor Concern: Major Concern: Already Under Care: Yes/No: 8. Referral Information: a. Primary Care, Family Practice: Within 24 hours: Within 7 days: Within 30 days: b. Behavioral Health in Primary Care: Within 24 hours: Within 7 days: Within 30 days: c. Mental Health Specialty Care: Within 24 hours: Within 7 days: Within 30 days: d. Other specialty care: Audiology: Within 24 hours: Within 7 days: Within 30 days: Cardiology: Within 24 hours: Within 7 days: Within 30 days: Dentistry: Within 24 hours: Within 7 days: Within 30 days: Dermatology: Within 24 hours: Within 7 days: Within 30 days: ENT: Within 24 hours: Within 7 days: Within 30 days: GI: Within 24 hours: Within 7 days: Within 30 days: Internal Medicine: Within 24 hours: Within 7 days: Within 30 days: Neurology: Within 24 hours: Within 7 days: Within 30 days: OB/GYN: Within 24 hours: Within 7 days: Within 30 days: Ophthalmology: Within 24 hours: Within 7 days: Within 30 days: Optometry: Within 24 hours: Within 7 days: Within 30 days: Orthopedics: Within 24 hours: Within 7 days: Within 30 days: Pulmonology: Within 24 hours: Within 7 days: Within 30 days: Urology: Within 24 hours: Within 7 days: Within 30 days: e. Case Manager, Care Manager: Within 24 hours: Within 7 days: Within 30 days: f. Substance Abuse Program: Within 24 hours: Within 7 days: Within 30 days: g. Health Promotion, Health Education: Within 24 hours: Within 7 days: Within 30 days: h. Chaplain: Within 24 hours: Within 7 days: Within 30 days: i. Family Support, Community Service: Within 24 hours: Within 7 days: Within 30 days: j. Military OneSource: Within 24 hours: Within 7 days: Within 30 days: k. Other: Within 24 hours: Within 7 days: Within 30 days: l. No referral made: 9. Comments: I certify that this review process has been completed. 10. Provider's signature and stamp: Ancillary Staff/Administrative Section: 11. Member was provided the following: Health Education and Information: Health Care Benefits and Resources Information: Appointment Assistance: Service member declined to complete form: Service member declined to complete interview/assessment: Service member declined referral for services: LOD: Other: 12. Referral was made to the following healthcare or support system: Military Treatment Facility: Division/Line-based medical resource: VA Medical Center or Community Clinic: Vet Center: TRICARE Provider: Contract Support: Community Service: Other: None: Source: DOD. [End of section] Appendix III: Post-Deployment Health Reassessment Questionnaires in DOD's Central Repository and Services' Databases: Department of Defense (DOD) policy requires that the military services electronically submit post-deployment health reassessment (PDHRA) questionnaires to DOD's central repository, which DOD uses as a key source of health surveillance information. We queried DOD's central repository on two occasions--April 2009 and September 2009. On April 15, 2009, we found that for approximately 23 percent of the roughly 319,000 servicemembers[Footnote 71] who, according to DOD deployment data, returned from deployment to Iraq or Afghanistan between January 1, 2007, and May 31, 2008, we could not identify questionnaires in the central repository (see table 2). Table 2: Servicemembers Who Returned from Deployment to Iraq or Afghanistan Between January 1, 2007, and May 31, 2008, without a PDHRA Questionnaire in DOD's Central Repository, as of April 15, 2009: Military service: Army; Component: Active component; Number of returning servicemembers: 132,247; Number of servicemembers without PDHRA questionnaire in central repository: 28,572; Percentage of servicemembers without PDHRA questionnaire in central repository: 21.61. Military service: Army; Component: National Guard; Number of returning servicemembers: 38,231; Number of servicemembers without PDHRA questionnaire in central repository: 6,083; Percentage of servicemembers without PDHRA questionnaire in central repository: 15.91. Military service: Army; Component: Reserve; Number of returning servicemembers: 15,817; Number of servicemembers without PDHRA questionnaire in central repository: 2,734; Percentage of servicemembers without PDHRA questionnaire in central repository: 17.29. Military service: Army; Component: Total; Number of returning servicemembers: 186,295; Number of servicemembers without PDHRA questionnaire in central repository: 37,389; Percentage of servicemembers without PDHRA questionnaire in central repository: 20.07. Military service: Air Force; Component: Active component; Number of returning servicemembers: 39,792; Number of servicemembers without PDHRA questionnaire in central repository: 5,622; Percentage of servicemembers without PDHRA questionnaire in central repository: 14.13. Military service: Air Force; Component: National Guard; Number of returning servicemembers: 8,583; Number of servicemembers without PDHRA questionnaire in central repository: 842; Percentage of servicemembers without PDHRA questionnaire in central repository: 9.81. Military service: Air Force; Component: Reserve; Number of returning servicemembers: 3,341; Number of servicemembers without PDHRA questionnaire in central repository: 2,024; Percentage of servicemembers without PDHRA questionnaire in central repository: 60.58. Military service: Air Force; Component: Total; Number of returning servicemembers: 51,716; Number of servicemembers without PDHRA questionnaire in central repository: 8,488; Percentage of servicemembers without PDHRA questionnaire in central repository: 16.41. Military service: Navy; Component: Active component; Number of returning servicemembers: 10,412; Number of servicemembers without PDHRA questionnaire in central repository: 4,968; Percentage of servicemembers without PDHRA questionnaire in central repository: 47.71. Military service: Navy; Component: Reserve; Number of returning servicemembers: 2,983; Number of servicemembers without PDHRA questionnaire in central repository: 1,066; Percentage of servicemembers without PDHRA questionnaire in central repository: 35.74. Military service: Navy; Component: Total; Number of returning servicemembers: 13,395; Number of servicemembers without PDHRA questionnaire in central repository: 6,034; Percentage of servicemembers without PDHRA questionnaire in central repository: 45.05. Military service: Marine Corps; Component: Active component; Number of returning servicemembers: 61,006; Number of servicemembers without PDHRA questionnaire in central repository: 20,203; Percentage of servicemembers without PDHRA questionnaire in central repository: 33.12. Military service: Marine Corps; Component: Reserve; Number of returning servicemembers: 6,644; Number of servicemembers without PDHRA questionnaire in central repository: 2,044; Percentage of servicemembers without PDHRA questionnaire in central repository: 30.76. Military service: Marine Corps; Component: Total; Number of returning servicemembers: 67,650; Number of servicemembers without PDHRA questionnaire in central repository: 22,247; Percentage of servicemembers without PDHRA questionnaire in central repository: 32.89. Military service: Total; Component: Active component; Number of returning servicemembers: 243,457; Number of servicemembers without PDHRA questionnaire in central repository: 59,365; Percentage of servicemembers without PDHRA questionnaire in central repository: 24.38. Military service: Total; Component: Reserve component; Number of returning servicemembers: 75,599; Number of servicemembers without PDHRA questionnaire in central repository: 14,793; Percentage of servicemembers without PDHRA questionnaire in central repository: 19.57. Military service: Total; Component: Grand total; Number of returning servicemembers: 319,056; Number of servicemembers without PDHRA questionnaire in central repository: 74,158; Percentage of servicemembers without PDHRA questionnaire in central repository: 23.24. Source: GAO analysis of DOD data. Notes: This table displays information on servicemembers without a PDHRA questionnaire in DOD's central repository for a servicemember's most recent return from deployment from Iraq or Afghanistan between January 1, 2007, and May 31, 2008. We did not examine the extent to which a servicemember filled out a questionnaire for each return from deployment during this time period. DOD's Reserve components include servicemembers in the Army and Air National Guard, as well as the Army, Air Force, Navy, and Marine Corps Reserve. [End of table] After determining that about 74,000 servicemembers in our population of interest did not have questionnaires in DOD's central repository based on our first query, we asked the military services whether these servicemembers had PDHRA questionnaires that could be identified in the services' own databases.[Footnote 72] With the help of the services, we found that approximately 7,000 servicemembers had questionnaires in their respective military services' databases, but not in DOD's central repository (see table 3).[Footnote 73] On our second query of the central repository, which occurred on September 4, 2009, questionnaires for about 1,000 of these 7,000 servicemembers were in the central repository. Table 3: Number of Servicemembers Who Returned from Deployment to Iraq or Afghanistan between January 1, 2007, and May 31, 2008, with a PDHRA Questionnaire in Military Services' Databases That Was Not in DOD's Central Repository as of April 15, 2009, and Number of These Servicemembers with Questionnaire in Central Repository, as of September 4, 2009: Military service: Army; Component: Active component; Number of servicemembers with PDHRA questionnaire in military services' database: 2,389; Number of these servicemembers with questionnaire in central repository as of September 4, 2009: 646. Military service: Army; Component: National Guard; Number of servicemembers with PDHRA questionnaire in military services' database: 198; Number of these servicemembers with questionnaire in central repository as of September 4, 2009: 9. Military service: Army; Component: Reserve; Number of servicemembers with PDHRA questionnaire in military services' database: 89; Number of these servicemembers with questionnaire in central repository as of September 4, 2009: 6. Military service: Army; Component: Total; Number of servicemembers with PDHRA questionnaire in military services' database: 2,676; Number of these servicemembers with questionnaire in central repository as of September 4, 2009: 661. Military service: Air Force; Component: Active component; Number of servicemembers with PDHRA questionnaire in military services' database: 281; Number of these servicemembers with questionnaire in central repository as of September 4, 2009: 3. Military service: Air Force; Component: National Guard; Number of servicemembers with PDHRA questionnaire in military services' database: 70; Number of these servicemembers with questionnaire in central repository as of September 4, 2009: 0. Military service: Air Force; Component: Reserve; Number of servicemembers with PDHRA questionnaire in military services' database: 3; Number of these servicemembers with questionnaire in central repository as of September 4, 2009: 0. Military service: Air Force; Component: Total; Number of servicemembers with PDHRA questionnaire in military services' database: 354; Number of these servicemembers with questionnaire in central repository as of September 4, 2009: 3. Military service: Navy; Component: Active component; Number of servicemembers with PDHRA questionnaire in military services' database: 284; Number of these servicemembers with questionnaire in central repository as of September 4, 2009: 8. Military service: Navy; Component: Reserve; Number of servicemembers with PDHRA questionnaire in military services' database: 71; Number of these servicemembers with questionnaire in central repository as of September 4, 2009: 9. Military service: Navy; Component: Total; Number of servicemembers with PDHRA questionnaire in military services' database: 355; Number of these servicemembers with questionnaire in central repository as of September 4, 2009: 17. Military service: Marine Corps; Component: Active component; Number of servicemembers with PDHRA questionnaire in military services' database: 2,938; Number of these servicemembers with questionnaire in central repository as of September 4, 2009: 380. Military service: Marine Corps; Component: Reserve; Number of servicemembers with PDHRA questionnaire in military services' database: 300; Number of these servicemembers with questionnaire in central repository as of September 4, 2009: 47. Military service: Marine Corps; Component: Total; Number of servicemembers with PDHRA questionnaire in military services' database: 3,238; Number of these servicemembers with questionnaire in central repository as of September 4, 2009: 427. Military service: Total; Component: Active component; Number of servicemembers with PDHRA questionnaire in military services' database: 5,892; Number of these servicemembers with questionnaire in central repository as of September 4, 2009: 1,037. Military service: Total; Component: Reserve component; Number of servicemembers with PDHRA questionnaire in military services' database: 731; Number of these servicemembers with questionnaire in central repository as of September 4, 2009: 71. Military service: Total; Component: Grand total; Number of servicemembers with PDHRA questionnaire in military services' database: 6,623; Number of these servicemembers with questionnaire in central repository as of September 4, 2009: 1,108. Source: GAO analysis of DOD and military services' data. Notes: DOD's Reserve components include servicemembers in the Army and Air National Guard, as well as the Army, Air Force, Navy, and Marine Corps Reserve. [End of table] [End of section] Appendix IV: DOD's Documentation of Its Monitoring of the Administration of the Post-Deployment Health Reassessment: The Department of Defense (DOD) contracts with Logistics Health, Inc. (LHI) to administer the post-deployment health reassessment (PDHRA) to Reserve component servicemembers.[Footnote 74] DOD's Reserve Health Readiness Program (RHRP) is responsible for monitoring LHI's administration of the PDHRA. To obtain more in-depth information on how the RHRP office documents the information it obtains through its monitoring of the administration of the PDHRA to Reserve component servicemembers, we examined documentation maintained by the RHRP office on its monitoring efforts. Specifically, from the potential problems that the RHRP office had identified as possibly posing a risk to the objective of PDHRA program, we judgmentally selected 15 to review in detail and obtained all available RHRP documentation from the RHRP office on those problems. We selected these 15 potential problems because the subject of each of these may have involved welfare and safety concerns for Reserve component servicemembers. We reviewed RHRP's documentation to determine the extent to which RHRP maintains documentation in a manner consistent with GAO's federal internal control standards.[Footnote 75] In particular, we examined the extent to which RHRP's documentation clearly documented any actions taken to address a problem and indicated whether the problem had been resolved. In general, the selected RHRP documentation we reviewed did not meet these standards. Nine of the 15 selected potential problems lacked documentation on the actions taken to address the problems and/ or lacked documentation of the problems' resolutions. Four of the 15 problems had documentation of the actions taken and their resolutions, however, RHRP's documentation was not sufficiently clear to allow us to independently understand what actions had been taken to address the problem or the problems' resolutions. Rather, an RHRP official had to explain to us what had occurred. Two of the 15 problems had documentation that allowed us to understand the actions taken to address the problems and the problems' resolutions. Table 4 summarizes the results of our analysis of RHRP's documentation. Table 4: Fifteen Selected Potential Problems Related to the Administration of the PDHRA to Reserve Component Servicemembers, Identified by the DOD RHRP Office: Potential problems identified by the RHRP office: 1. An LHI health care provider insufficiently documented the nature of a servicemember's suicidal ideations on the PDHRA questionnaire.[A]; GAO analysis of RHRP documentation: For these potential problems, documentation was lacking on the actions taken to address the problem and/or the problem's resolution. Potential problems identified by the RHRP office: 2. Reserve component servicemembers may not have been responding to questions on the PDHRA questionnaire about their alcohol consumption and whether they were depressed; GAO analysis of RHRP documentation: [Empty]. Potential problems identified by the RHRP office: 3. An LHI report may have contained inaccurate data; GAO analysis of RHRP documentation: [Empty]. Potential problems identified by the RHRP office: 4. LHI staff had difficulties contacting Reserve component servicemembers in following up on those who received medical referrals; GAO analysis of RHRP documentation: [Empty]. Potential problems identified by the RHRP office: 5. A higher than normal percentage of servicemembers were referred for a further evaluation; GAO analysis of RHRP documentation: [Empty]. Potential problems identified by the RHRP office: 6. Reserve component servicemembers may have had difficulty accessing the PDHRA call center; GAO analysis of RHRP documentation: [Empty]. Potential problems identified by the RHRP office: 7. Reserve component servicemembers may have been told by a military service official not to answer questions in the medical section of the PDHRA questionnaire; GAO analysis of RHRP documentation: [Empty]. Potential problems identified by the RHRP office: 8. Reserve component servicemembers may have been refusing to speak with a health care provider and refusing to answer specific questions on the PDHRA questionnaire; GAO analysis of RHRP documentation: [Empty]. Potential problems identified by the RHRP office: 9. A Reserve component servicemember calling LHI's call center to be administered the PDHRA was initially denied LHI PDHRA services; GAO analysis of RHRP documentation: [Empty]. Potential problems identified by the RHRP office: 10. Reserve component servicemembers calling LHI's call center to be administered the PDHRA may have been denied LHI PDHRA services and not administered the PDHRA; GAO analysis of RHRP documentation: For these potential problems, the RHRP office had some available documentation, but this documentation was not sufficiently clear to allow us to independently determine the actions taken to address each problem and to determine the ultimate resolution of each problem. Potential problems identified by the RHRP office: 11. Servicemembers who should not have been called by LHI may have been inappropriately called by LHI; GAO analysis of RHRP documentation: [Empty]. Potential problems identified by the RHRP office: 12. A PDHRA event may have lacked sufficient staff; GAO analysis of RHRP documentation: [Empty]. Potential problems identified by the RHRP office: 13. Health care providers may not have been documenting needed referrals for further evaluations when servicemembers declined the referrals; GAO analysis of RHRP documentation: [Empty]. Potential problems identified by the RHRP office: 14. Reserve component servicemembers screened through the LHI call center were not receiving the same informational brochures as servicemembers administered the PDHRA at PDHRA on-site events; GAO analysis of RHRP documentation: For these potential problems, the RHRP office had documentation of the actions taken to address each problem and the problem's resolution. Potential problems identified by the RHRP office: 15. Reserve component servicemembers did not know what to do to set up an appointment for a further evaluation; GAO analysis of RHRP documentation: [Empty]. Source: GAO. [A] Suicidal ideations are thoughts of harming or killing oneself, the severity of which can be determined by an assessment of these thoughts. [End of table] [End of section] Appendix V: Comments from the Department of Defense: Office Of The Assistant Secretary Of Defense: Health Affairs: Washington, DC 20301-1200: November 10, 2009: Randall Williamson: Director, Health Care: U.S. Government Accountability Office: 441 G. Street, N.W. Washington, DC 20548: Dear Mr. Williamson, This is the Department of Defense (DoD) response to the Government Accountability Office (GAO) draft report, GAO-10-56, "Defense Health Care: Post-Deployment Health Reassessment Documentation Needs Improvement," October 19, 2009 (GAO Code 290734). Thank you for the opportunity to review and comment on the draft report. Overall, we concur with the draft report's findings and conclusions. DoD considers the Post-Deployment Health Reassessment (PDHRA) to be an important means to identify Service members physical and emotional deployment-related concerns and facilitate resolution of those concerns. We must become more aggressive to ensure all eligible Service members are correctly identified and offered the opportunity to complete the PDHRA, and that the resultant assessments are placed in the DoD central repository. Similarly, the Reserve Health Readiness Program needs to improve the documentation of its multiple PDHRA program monitoring activities. More specific comments on the report's two recommendations are attached. The points of contact on this audit are Dr. Brian Sugden (Functional), who can be reached at (703) 681-3279, extension 167, and Mr. Gunther Zimmerman (Audit Liaison), who can be reached at (703) 681-4360. Sincerely, Signed by: Ellen P. Embrey: Deputy Assistant Secretary of Defense (Force Health Protection and Readiness): Performing the Duties of the Assistant Secretary of Defense (Health Affairs): Attachment: As stated: [End of letter] Government Accountability Office Draft Report: GAO-10-56/(GAO Code 290734): October 19, 2009: "Defense Health Care: Post-Deployment Health Reassessment Documentation Needs Improvement" Department Of Defense Comments To The Recommendations: Recommendation 1: "To help the Department of Defense (DoD) obtain reasonable assurance that all active and Reserve component Service members to whom the Post-Deployment Health Reassessment (PDHRA) requirement applies are provided the opportunity to have their health concerns identified, we recommend that the Assistant Secretary of Defense for Health Affairs and the military services take steps to ensure that PDHRA questionnaires are included in DoD's central repository for each of these Service members." DoD Response: Concur. The Government Accountability Office (GAO) draft report determined approximately 23 percent of the Post-Deployment Health Reassessment forms (DD Form 2900) that they expected to see in the Armed Forces Health Surveillance Center central data repository were missing. DoD will take three actions in response to this recommendation. DoD will work to correctly identify Service members who need to receive the PDHRA and not identify Service members who do not need it. DoD Instruction (DoDI) 6490.03, "Deployment Health," August 11, 2006, requires that the PDHRA be accomplished for deployments of more than 30 days to locations outside the continental United States with non-fixed U.S. medical treatment facilities, However, Service members who are shipboard and are not anticipated to be involved in operations ashore are exempt from the DoDI deployment assessments requirements. GAO populations of interest were those Service members who were identified within the Defense Manpower Data Center's (DMDC) Contingency Tracking System (CTS). The CTS database includes Service members in theater aboard ship who are exempt from the assessment requirement. The large percentage of Navy and Marine Corps personnel without a PDHRA in the central repository may partially explain the "missing" forms. The Navy is working with DMDC to accurately reflect deployment and subsequent assessment requirements. In addition, Service members who deployed again within the 90-180-day post-deployment window for the PDHRA, (i.e., approximately seven percent of the 74,000 Service members without a PDHRA in the central repository), would not be expected to have a PDHRA form at AFHSC. Second, the Acting Deputy Assistant Secretary of Defense, Force Health Protection and Readiness, sent a memorandum on October I5, 2009, to the Service Surgeons General re-emphasizing the importance of compliance with the DoDI 6490.03 PDHRA requirements. Service line commanders are briefed on the compliance with PDHRA requirements. Finally, the Services and the Armed Forces Health Surveillance Center (AFHSC) will work to identify and resolve the obstacles to transmission of data from the Services to AFHSC. To facilitate this work, DoD requests that GAO provide AFHSC the database of those Service members who were found to be in the Service database, but not the AFHSC repository as of the September 2009 query. Recommendation 2: "To ensure adequate documentation of problems that may pose risks to the objectives of the PDHRA program for Reserve component Service members, we recommend that the Assistant Secretary of Defense for Health Affairs require the Reserve Health Readiness Program (RHRP) office to document the information obtained through monitoring the PDHRA program in a manner consistent with federal internal control standards." DoD Response: Concur. DoD agrees that the RHRP's documentation of its monitoring of the PDHRA program needs improvement. Better documentation is needed to ensure continuity, as well as accomplishment of the PDHRA program objectives. The RHRP office recognized this during the GAO engagement and immediately began to better document their monitoring activities by (1) establishing a more distinct and clear electronic filing system, and (2) documenting not only the potential problems, but also their resolution in a manner that is sufficiently comprehensive, accessible, and understandable. [End of section] Appendix VI: GAO Contact and Staff Acknowledgments: GAO Contact: Randall B. Williamson, (202) 512-7114, williamsonr@gao.gov: Staff Acknowledgments: In addition to the contact named above, Mary Ann Curran, Assistant Director; Katherine L. Amoroso; Helen T. Desaulniers; Michael Erhardt; Martha A. Fisher; Krister Friday; Martha Kelly; Carolyn Kirby; Carolina Morgan; Lisa A. Motley; Julie E. Pekowski; William Woods; and Suzanne Worth made key contributions to this report. [End of section] Related GAO Products: Federal Contractors: Better Performance Information Needed to Support Agency Contract Award Decisions. [hyperlink, http://www.gao.gov/products/GAO-09-374]. Washington, D.C.: April 23, 2009. Military Operations: DOD Needs to Address Contract Oversight and Quality Assurance Issues for Contracts Used to Support Contingency Operations. [hyperlink, http://www.gao.gov/products/GAO-08-1087]. Washington, D.C.: September 26, 2008. DOD Systems Modernization: Maintaining Effective Communication Is Needed to Help Ensure the Army's Successful Deployment of the Defense Integrated Military Human Resources System. [hyperlink, http://www.gao.gov/products/GAO-08-927R]. Washington, D.C.: September 8, 2008. Defense Health Care: Oversight of Military Services' Post-Deployment Health Reassessment Completion Rates Is Limited. [hyperlink, http://www.gao.gov/products/GAO-08-1025R]. Washington, D.C.: September 4, 2008. Electronic Health Records: DOD and VA Have Increased Their Sharing of Health Information, but More Work Remains. [hyperlink, http://www.gao.gov/products/GAO-08-954]. Washington, D.C.: July 28, 2008. VA and DOD Health Care: Administration of DOD's Post-Deployment Health Reassessment to National Guard and Reserve Servicemembers and VA's Interaction with DOD. [hyperlink, http://www.gao.gov/products/GAO-08-181R]. Washington, D.C.: January 25, 2008. Defense Health Care: Comprehensive Oversight Framework Needed to Help Ensure Effective Implementation of a Deployment Health Quality Assurance Program. [hyperlink, http://www.gao.gov/products/GAO-07-831]. Washington, D.C.: June 22, 2007. Military Personnel: DMDC Data on Officers' Commissioning Programs is Insufficiently Reliable and Needs to be Corrected. [hyperlink, http://www.gao.gov/products/GAO-07-372R]. Washington, D.C.: March 8, 2007. Military Personnel: Actions Needed to Strengthen Management of Imminent Danger Pay and Combat Zone Tax Relief Benefits. [hyperlink, http://www.gao.gov/products/GAO-06-1011]. Washington, D.C.: September 28, 2006. Post-Traumatic Stress Disorder: DOD Needs to Identify the Factors its Providers Use to Make Mental Health Evaluation Referrals for Servicemembers. [hyperlink, http://www.gao.gov/products/GAO-06-397]. Washington, D.C.: May 11, 2006. Military Pay: Inadequate Controls for Stopping Overpayments of Hostile Fire and Hardship Duty Pay to Over 200 Sick or Injured Army National Guard and Army Reserve Soldiers Assigned to Fort Bragg. [hyperlink, http://www.gao.gov/products/GAO-06-384R]. Washington, D.C.: April 27, 2006. Contract Management: Opportunities to Improve Surveillance on Department of Defense Service Contracts. [hyperlink, http://www.gao.gov/products/GAO-05-274]. Washington, D.C.: March 17, 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. [hyperlink, http://www.gao.gov/products/GAO-04-1069]. Washington, D.C.: September 20, 2004. Military Pay: Army Reserve Soldiers Mobilized to Active Duty Experienced Significant Pay Problems. [hyperlink, http://www.gao.gov/products/GAO-04-911]. Washington, D.C.: August 20, 2004. Defense Health Care: Quality Assurance Process Needed to Improve Force Health Protection and Surveillance. [hyperlink, http://www.gao.gov/products/GAO-03-1041]. Washington, D.C.: September 19, 2003. [End of section] FOOTNOTES: [1] After the terrorist attacks of September 11, 2001, the President announced a Global War on Terrorism, now known as the Overseas Contingency Operations which includes operations in Iraq and Afghanistan. [2] Assistant Secretary of Defense for Health Affairs Memorandum, "Post- Deployment Health Reassessment," (Mar. 10, 2005). The post-deployment health reassessment (PDHRA) is administered on Department of Defense (DOD) form DD 2900. [3] The other assessments are the pre-deployment health assessment, which is administered before deployment, and the post-deployment health assessment, which is administered about the time servicemembers return from deployment. [4] C.S. Milliken, J.L. Auchterlonie, and C.W. Hoge, "Longitudinal Assessment of Mental Health Problems Among Active and Reserve Component Soldiers Returning from the Iraq War," Journal of the American Medical Association, vol. 298, no. 18 (2007). [5] Milliken, Auchterlonie, and Hoge, "Longitudinal Assessment of Mental Health Problems Among Active and Reserve Component Soldiers Returning from the Iraq War," 2141. [6] DOD's Reserve components include servicemembers in the Army and Air National Guard, as well as the Army, Air Force, Navy, and Marine Corps Reserves. As of May 2008, Reserve component servicemembers made up almost 28 percent of those deployed to Iraq and Afghanistan. [7] Although Logistics Health, Inc. (LHI) administers the PDHRA to Reserve component servicemembers, the military services are responsible for identifying and notifying servicemembers to whom the PDHRA requirement applies. [8] Military service officials stated that they do not have requirements related to the PDHRA once servicemembers are separated from military service. For the purposes of our review, the term "separated servicemembers" includes active component, Reserve, and National Guard servicemembers who, following return from deployment, have separated from military service and have no further military service obligation. [9] DOD's central repository is the Armed Forces Health Surveillance Center's (AFHSC), formerly known as the Army Medical Surveillance Activity, Defense Medical Surveillance System. AFHSC is supported by the U.S. Army Center for Health Promotion and Preventive Medicine and performs comprehensive medical surveillance and reporting of rates of diseases and injuries among DOD servicemembers. [10] GAO, Defense Health Care: Oversight of Military Services' Post- Deployment Health Reassessment Completion Rates Is Limited, [hyperlink, http://www.gao.gov/products/GAO-08-1025R] (Washington, D.C.: Sept. 4, 2008). [11] S. Rep. No. 110-77, at 360 (2007). [12] DOD Defense Manpower Data Center (DMDC) data indicate that our population of interest returned from deployment between January 1, 2007, and May 31, 2008. Given this timeframe, the last date on which servicemembers in our population could have filled out the PDHRA questionnaire within 180 days after their return from deployment, as required by DOD policy, was approximately November 30, 2008. However, servicemembers may have filled out the questionnaire after the 90-to 180-day reassessment period had elapsed. [13] We considered servicemembers to have a PDHRA questionnaire if one could be identified in DOD's central repository, regardless of whether servicemembers filled out the entire questionnaire or only the demographic section. [14] The Coast Guard was excluded from our review because it is under the direction of the Department of Homeland Security and represents a very small portion of servicemembers deployed to Iraq and Afghanistan. [15] DOD also contracts with LHI for the provision of other health services to Reserve component servicemembers. [16] See GAO, Standards for Internal Control in the Federal Government, GAO/AIMD-00-21.3.1 (Washington, D.C.: November 1999). Internal control standards provide the overall framework for establishing and maintaining internal controls in the federal government. We reviewed the consistency of DOD's monitoring with a subset of these internal control standards, the monitoring and control activities standards. [17] In order to assess how DOD monitors the administration of the PDHRA to Reserve component servicemembers, we reviewed how DOD monitors LHI's administration of the PDHRA. We did not evaluate the sufficiency or appropriateness of the methods used by DOD to monitor LHI's compliance with the terms of the contract generally. [18] Assistant Secretary of Defense for Health Affairs Memorandum, "Post-Deployment Health Reassessment," (Mar. 10, 2005), and Department of Defense Instruction 6490.03, "Deployment Health," (Aug. 11, 2006). [19] For active and Reserve component servicemembers who are frequent deployers--those who deploy for greater than 30 days more than once during any 365-day period--the military services maintain policies stating that these servicemembers will only have to fill out one PDHRA questionnaire in any 365-day period. The Army implemented a frequent deployer policy in May 2008, the Air Force in February 2006, and the Navy--whose medical policies also apply to the Marine Corps--in January 2009. However, a post-deployment health assessment is still administered to these servicemembers about the time they return from each deployment. [20] Servicemembers whose deployments are primarily aboard ships and do not include onshore operations are exempt from filling out the PDHRA questionnaire. [21] Due to challenges of administering the PDHRA to separated servicemembers, DOD's PDHRA program manager stated that DOD encouraged the military services to administer the PDHRA as part of the separation process. [22] The Air Force does not require a review by a health care provider if the servicemember declines to fill out the medical section of the PDHRA questionnaire. In addition, for active component Air Force and Air Force Reserve servicemembers who fill out the PDHRA questionnaire, but do not respond positively to certain questions, the PDHRA questionnaire is electronically closed out and forwarded to DOD's central repository without a health care provider's review. [23] According to DOD's former PDHRA program manager, the Air Force declination rate is less than 5 percent. [24] LHI operates two call centers 24 hours a day, 7 days a week: one in La Crosse, Wisconsin and one in Detroit, Michigan. LHI's call centers have the same phone number, so when servicemembers call in to the number, they are directed to one of the two call centers. [25] In certain circumstances, LHI may, through its call centers, administer the PDHRA questionnaire to remotely located active component servicemembers, such as remotely located military service recruiters, who are unable to attend PDHRA on-site events at military installations. [26] Servicemembers who are administered the PDHRA questionnaire before they separate from the military fill out the questionnaire either online or with LHI staff, along with their active or Reserve component counterparts. [27] Consistent with DOD policy, the four military services' health care providers include physicians, physician assistants, nurse practitioners, independent duty corpsmen (an enlisted person that has been trained to give first aid and basic medical treatment, especially in combat situations), and independent duty medical technicians (an enlisted person who receives advanced training to provide treatment and administer medication). LHI PDHRA health care providers include physicians, physician assistants, nurse practitioners, and licensed clinical social workers, according to LHI staff. [28] Assistant Secretary of Defense for Health Affairs Memorandum, "Post-Deployment Health Reassessment," (Mar. 10, 2005). [29] As stated previously, the Air Force does not require a review by a health care provider if the servicemember declines to fill out the medical section of the PDHRA questionnaire. In addition, for active component Air Force and Air Force Reserve servicemembers who fill out the PDHRA questionnaire, but do not respond positively to certain questions, the PDHRA questionnaire is electronically closed out and forwarded to DOD's central repository without a health care provider's review. [30] Other information could include both verbal and nonverbal information servicemembers offer during the discussion with the health care provider. [31] Vet Centers are run by the Department of Veterans Affairs and offer mental health services, including readjustment counseling, to all veterans who served in any combat zone. [32] According to a DOD official, during PDHRA on-site events, LHI provides a similar service to ensure servicemembers who have been issued a referral for a further evaluation have the information needed to obtain an appointment. [33] LHI does not perform a 30-day follow-up on servicemembers who receive non-medical referrals, such as a referral to Military OneSource or to a chaplain. Military OneSource is a free resource that provides a wide variety of support and educational resources to servicemembers and their families, available 24 hours a day, 7 days a week. [34] DOD policy also requires that a copy be placed in each servicemember's medical record. [35] The quality assurance program was required by the National Defense Authorization Act for Fiscal Year 1998, Pub. L. No. 105-85, 765(a)(1), 111 Stat. 1629, 1826 (1997) (codified as amended at 10 U.S.C. 1074f(d)). Although DOD's program predates the PDHRA, DOD uses the quality assurance program to monitor compliance with PDHRA requirements. The quality assurance program is overseen by the Office of the Assistant Secretary of Defense for Health Affairs. [36] DOD receives quarterly reports from each of the military services containing information on the number of servicemembers who returned from deployment and the number of PDHRA questionnaires filled out. The Army and Marine Corps use data from the central repository in their quarterly reports to report the number of PDHRA questionnaires filled out. [37] Our previous report discussed DOD's deployment health quality assurance program, but at that time, the program largely focused on active component servicemembers. [38] DOD's Reserve components began using LHI for PDHRA services through pilot programs on the following dates: the Army Reserve and Army National Guard, November 2005; Air National Guard, February 2006; Marine Corps Reserve, March 2006; Navy Reserve, May 2006; and the Air Force Reserve, August 2008. The Air Force Reserve had been using its own resources to administer the PDHRA prior to August 2008. [39] DOD's contract with LHI is a 1-year contract with four 1-year option periods and a 2-month transition period. The dollar amount invoiced for the PDHRA portion of the contract for fiscal year 2008 was $9,438,137. For fiscal year 2009 through May 15, 2009, the invoiced amount for the PDHRA portion of the contract was $6,136,134. [40] DOD's Reserve Health Readiness Program (RHRP) office is staffed by a contracting officer's representative, who is responsible for verifying that LHI complies with contractual standards for all provided health services and for managing the RHRP program, and with other staff who work for the contracting officer's representative to monitor specific aspects of the RHRP program. The RHRP office is ultimately overseen by the Office of the Assistant Secretary of Defense for Health Affairs. [41] DOD policy states that the PDHRA should be administered to servicemembers 90 to 180 days following their return from a deployment of greater than 30 days, to a location outside the continental United States without permanent military treatment facilities, such as Iraq or Afghanistan. [42] While the majority of the roughly 319,000 servicemembers in our population of interest were required to fill out the questionnaire, our population includes about 19,000 servicemembers who, according to DOD DMDC data, had separated from military service between January 1, 2007, and May 31, 2008. As stated earlier, although DOD initially required the military services to contact servicemembers who separated before or during the reassessment period to offer them the opportunity to fill out the PDHRA questionnaire, implementation of this policy posed challenges. Once servicemembers have separated from military service, they cannot be required to fill out the PDHRA questionnaire. Instead, the military services implemented, or plan to implement, policies to administer the PDHRA to servicemembers as part of the separation process from the military. However, the Army was the only service that had this practice in effect for servicemembers who returned from deployment between January 1, 2007, and May 31, 2008. If the 19,000 servicemembers in our population separated prior to or during the reassessment period, they may not have been required to fill out the questionnaire. Because we do not know the extent to which these 19,000 servicemembers in our population of interest separated before or during the reassessment period, we include separated servicemembers in our analysis as part of the military service and component with which they were affiliated at the end of their deployment. If we had excluded these separated servicemembers from our analysis, as of April 15, 2009, DOD's central repository would have contained PDHRA questionnaires for 78 percent of servicemembers in our population of interest, rather than 77 percent. [43] DOD DMDC data indicate that our population of interest returned from deployment between January 1, 2007, and May 31, 2008. Given this time frame, the last date on which servicemembers in our population could have filled out the PDHRA questionnaire within 180 days after their return from deployment, as required by DOD policy, was approximately November 30, 2008. However, servicemembers may have filled out the questionnaire after the 90-to 180-day reassessment period had elapsed. [44] The Air National Guard had the lowest percentage of servicemembers--about 800 of 9,000--without a questionnaire in the central repository, while the Air Force Reserve had the highest percentage of servicemembers--about 2,000 of 3,000--without a questionnaire. [45] We received data in May 2009 from the Air Force, and in June 2009 from the Army and Navy. As the Navy manages PDHRA data for the Marine Corps, the Navy data also included data for Marine Corps servicemembers. [46] The 7,000 questionnaires found in the military services' databases, but not in the central repository, were filled out by servicemembers prior to April 15, 2009--the date we first queried DOD's central repository. [47] The military services could not definitively tell us why these PDHRA questionnaires could be identified in the military services databases, but not in DOD's central repository. Some officials speculated that the questionnaires might not have been incorporated into DOD's central repository because they did not meet data rules. Questionnaires must meet data rules, such as the dates of deployment being filled out on the questionnaire, before the questionnaires are incorporated into DOD's central repository. [48] For more information on the extent to which the approximately 7,000 questionnaires identified in the military services databases could later be identified in the central repository as of September 4, 2009, see appendix III. [49] If we had excluded separated servicemembers from our analysis, as of September 4, 2009, DOD's central repository would have contained PDHRA questionnaires for 79 percent of servicemembers in our population of interest. [50] Of these 72,000 servicemembers without a PDHRA questionnaire in DOD's central repository, about 9,000 separated from military service between January 1, 2007, and May 31, 2008. About 10,000, or 53 percent of the 19,000 separated servicemembers in our original population of interest, had a PDHRA questionnaire in DOD's central repository. [51] Air Force officials also told us that a small subset of servicemembers in our population of interest may not have been required to fill out a PDHRA questionnaire for this deployment because of their status as frequent deployers (servicemembers who deploy for greater than 30 days more than once during a 365-day period only need to fill out one PDHRA questionnaire in any 365-day period). Although Air Force officials could not quantify the size of this population, they told us it is a small subset of the servicemembers who should fill out a PDHRA questionnaire. In addition, Army officials told us that a small population of Army servicemembers does not have a PDHRA questionnaire either in the Army database or in the central repository. The officials explained that out of concerns of being tracked, Army Special Forces can comply with Army PDHRA requirements by filling out a hard copy PDHRA questionnaire, blacking out all of their demographic information, and storing a copy of the questionnaire in their physical medical records. [52] DOD requires LHI to submit some reports on a monthly basis and some on a weekly basis. [53] The RHRP office also receives reports on other performance standards, such as a report detailing LHI's compliance with a standard that requires LHI to enter 95 percent of servicemembers' PDHRA information into the military services' databases within 5 days of administering the PDHRA. [54] The RHRP office provides the military services copies of LHI's periodic reports on the number of servicemembers administered the PDHRA and referred for a further evaluation. According to an RHRP official, the military services can compare information in the reports with the services' own data. Accordingly, the RHRP office relies, in part, on feedback from the military services to monitor and check the accuracy of the information presented in the reports. An RHRP official also compares weekly and monthly reports to check the consistency of the information presented in the reports. [55] LHI maintains its own quality assurance program to internally monitor the services being provided to servicemembers. The RHRP office's inspections have also involved reviews of LHI's internal quality assurance efforts related to the administration of PDHRA. [56] [hyperlink, http://www.gao.gov/products/GAO/AIMD-00-21.3.1]. [57] Potential problems that have not been resolved are generally carried over to the following week's agenda. [58] The RHRP office was asked to provide documentation related to a sample of potential problems we selected. [59] The RHRP office's documentation for 9 of the 15 potential problems that we reviewed did not clearly describe the potential problem. In addition, for 13 of the 15 potential problems, documentation did not allow us to understand the actions taken to address the problems and the problems' resolutions. Documentation did, however, allow us to understand the nature of the actions taken to address the problems and the problems' resolution for the other 2 of the 15 potential problems. [60] The RHRP office did not have e-mail correspondence for 6 of the 15 potential problems. [61] LHI is required to seek emergency care for Reserve component servicemembers indicating serious mental health concerns. [62] The RHRP official recalled that in this situation the LHI health care provider had determined the Reserve component servicemember's suicidal ideations--thoughts of harming or killing oneself, the severity of which can be determined by an assessment of these thoughts-- were not serious in nature and that the servicemember had no plans for self harm. This official also said the servicemember had been offered a referral to obtain a further evaluation and had refused the referral. However, the health care provider did not document this on the servicemember's PDHRA questionnaire, so anyone reviewing this questionnaire would assume, in error, that the servicemember should have been referred for immediate care. [63] The Department of Defense's (DOD) Reserve components include servicemembers in the Army and Air National Guard, as well as the Army, Air Force, Navy, and Marine Corps Reserves. The Coast Guard was excluded from our review because it is under the direction of the Department of Homeland Security and represents a very small portion of servicemembers deployed to Iraq and Afghanistan. [64] The Armed Forces Health Surveillance Center (AFHSC), formerly known as the Army Medical Surveillance Activity, is supported by the U.S. Army Center for Health Promotion and Preventive Medicine and performs comprehensive medical surveillance and reporting of rates of diseases and injuries among DOD servicemembers. [65] After the terrorist attacks of September 11, 2001, the President announced a Global War on Terrorism, now known as the Overseas Contingency Operations. Ongoing military and diplomatic operations overseas, especially in Iraq and Afghanistan, constitute a key part of the Overseas Contingency Operations. [66] While the majority of servicemembers in our population were required to fill out the questionnaire, our population also includes separated servicemembers--servicemembers who, following return from deployment, separated from military service and have no further military service obligation. Servicemembers are required to fill out the PDHRA questionnaire 90 to 180 days following their return from deployment. Although DOD initially required the military services to contact servicemembers who separated before or during the reassessment period to offer them the opportunity to fill out the PDHRA questionnaire, implementation of this policy posed challenges. Once servicemembers have separated from military service, they cannot be required to fill out the PDHRA questionnaire. Instead, the military services implemented policies to administer the PDHRA to servicemembers as part of the separation process from the military. However, the Army was the only service that had this practice in effect for servicemembers who returned from deployment between January 1, 2007, and May 31, 2008. If the servicemembers in our population separated prior to or during the reassessment period, they may not have been required to fill out the questionnaire. Because we do not know the extent to which servicemembers in our population separated before or during the reassessment period, we include separated servicemembers in our analysis as part of the military service and component with which they were affiliated at the end of their deployment. [67] We considered servicemembers to have a PDHRA questionnaire if one could be identified in DOD's central repository, regardless of whether servicemembers filled out the entire questionnaire or only the demographic section. [68] DOD's contract with LHI also includes the provision of other health services for Reserve component servicemembers, such as immunizations, physical examinations, and dental examinations and X- rays. [69] See GAO, Standards for Internal Control in the Federal Government, [hyperlink, http://www.gao.gov/products/GAO/AIMD-00-21.3.1] (Washington, D.C.: November 1999). We used the criteria in these standards, which provide the overall framework for establishing and maintaining internal control in the federal government. We reviewed the consistency of DOD's monitoring with a subset of these internal control standards, the monitoring and control activities standards. [70] In order to assess how DOD ensures that program objectives are being met, we reviewed how DOD monitors LHI's administration of the PDHRA to Reserve component servicemembers. We did not evaluate the sufficiency or appropriateness of the methods used by DOD to monitor LHI's compliance with the terms of the contract. [71] While the majority of servicemembers in our population of interest were required to fill out the questionnaire, our population includes about 19,000 servicemembers who, according to DOD Defense Manpower Data Center (DMDC) data, had separated from military service between January 1, 2007, and May 31, 2008. Although DOD initially required the military services to contact servicemembers who separated before or during the reassessment period to offer them the opportunity to fill out the PDHRA questionnaire, implementation of this policy posed challenges. Once servicemembers have separated from military service, they cannot be required to fill out the PDHRA questionnaire. Instead, the military services implemented, or plan to implement, policies to administer the PDHRA to servicemembers as part of the separation process from the military. However, the Army was the only service that had this practice in effect for servicemembers who returned from deployment between January 1, 2007, and May 31, 2008. If the 19,000 servicemembers in our population separated prior to or during the reassessment period, they may not have been required to fill out the questionnaire. Because we do not know the extent to which these 19,000 servicemembers in our population of interest separated before or during the reassessment period, we include separated servicemembers in our analysis as part of the military service and component with which they were affiliated at the end of their deployment. If we had excluded these separated servicemembers from our analysis, as of April 15, 2009, DOD's central repository would have been missing PDHRA questionnaires for 22 percent of servicemembers in our population of interest, rather than 23 percent. [72] We received data in May 2009 from the Air Force, and in June 2009 from the Army and Navy. As the Navy manages post-deployment health reassessment data for the Marine Corps, the Navy data also included data for Marine Corps servicemembers. [73] The roughly 7,000 questionnaires found in the military services' databases, but not in the central repository, were filled out prior to April 15, 2009--the date we first queried DOD's central repository. [74] The Department of Defense's (DOD) Reserve components include servicemembers in the Army and Air National Guard, as well as the Army, Air Force, Navy, and Marine Corps Reserves. [75] See GAO, Standards for Internal Control in the Federal Government, [hyperlink, http://www.gao.gov/products/GAO/AIMD-00-21.3.1] (Washington, D.C.: November 1999). We used the criteria in these standards, which provide the overall framework for establishing and maintaining internal control in the federal government. We reviewed the consistency of DOD's monitoring with a subset of these internal control standards, the monitoring and control activities standards. [End of section] GAO's Mission: The Government Accountability Office, the audit, evaluation and 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. 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