Army Health Care
Progress Made in Staffing and Monitoring Units that Provide Outpatient Case Management, but Additional Steps Needed Gao ID: GAO-09-357 April 20, 2009In February 2007, a series of Washington Post articles disclosed problems at Walter Reed Army Medical Center, particularly with the management of servicemembers receiving outpatient care. In response, the Army established Warrior Transition Units (WTU) for servicemembers requiring complex case management. Each servicemember in a WTU is assigned to a Triad of Care--a primary care manager, a nurse case manager, and a squad leader--who provide case management services to ensure continuity of care. The Army established staff-to-servicemember ratios for each Triad of Care position. This report examines (1) the Army's ongoing efforts to staff WTU Triad of Care positions and (2) how the Army monitors the recovery process of WTU servicemembers. GAO reviewed WTU policies, analyzed Army staffing and monitoring data, interviewed Army officials, and visited five selected WTUs.
The Army has taken several steps to help ensure that WTUs are staffed appropriately. First, the Army developed policies aimed at reducing WTU staffing shortfalls, including a policy requiring the reassignment of other personnel on an installation to fill open WTU positions. Second, in October 2008, the Army revised its WTU staffing model, including the staff-to-servicemember ratios for two of its Triad of Care positions, because an Army study determined that the existing ratios were not adequate to provide an appropriate level of care to servicemembers in WTUs. The Army has made considerable progress in meeting the new ratios, and as of January 2009, the Triad of Care positions at most WTUs were fully staffed. However, staffing ratios for the WTU at Walter Reed Army Medical Center were not revised, even though the Army recognizes that servicemembers treated at this facility have more complex health care needs than servicemembers at other WTUs. Walter Reed might require a different staffing model, for example, one that decreases the number of servicemembers assigned to staff members, but the Army does not plan to conduct an assessment of Walter Reed's staffing model. Third, the Army modified its WTU placement and exit criteria for full-time servicemembers, excluding Army Reserve and National Guard servicemembers who comprise about one-third of the WTU population. These changes are intended to help ensure that only those who need complex case management are in WTUs. Those with less serious health care needs can be reassigned to other units on the installation to continue their recovery. As the Army expected, the WTU population of full-time servicemembers declined by about 1,500 in the 4 months after implementation of the new criteria. To monitor the recovery process of WTU servicemembers, the Army has implemented transition plans for individual servicemembers as well as various upward feedback mechanisms to identify concerns and gauge satisfaction. In January 2008, the Army issued a policy establishing Comprehensive Transition Plans, which can be used to monitor and coordinate servicemembers' care. To help ensure consistent implementation of these plans among its WTUs, the Army is developing a new policy that includes the systematic collection of performance measures across WTUs. However, despite Army officials' repeated assurances to GAO that this policy was forthcoming, it had not been finalized as of February 27, 2009. The Army's feedback mechanisms include its Warrior Transition Unit Program Satisfaction Survey, which collects information from servicemembers in WTUs on a number of issues, including the primary care manager and nurse case manager. However, the survey's response rates for the WTUs have been low (13 to 35 percent) and the Army has not determined whether the results obtained from the respondents are representative of all WTU servicemembers. An Army official told GAO that the Army does not plan to conduct analyses to determine whether the survey results are representative, because it is satisfied with the response rates. In GAO's view, the response rates are too low for the Army to reliably report satisfaction of servicemembers in WTUs.
RecommendationsOur recommendations from this work are listed below with a Contact for more information. Status will change from "In process" to "Open," "Closed - implemented," or "Closed - not implemented" based on our follow up work.
Director: Team: Phone:GAO-09-357, Army Health Care: Progress Made in Staffing and Monitoring Units that Provide Outpatient Case Management, but Additional Steps Needed
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Report to Congressional Requesters:
United States Government Accountability Office:
GAO:
April 2009:
Army Health Care:
Progress Made in Staffing and Monitoring Units that Provide Outpatient
Case Management, but Additional Steps Needed:
GAO-09-357:
GAO Highlights:
Highlights of GAO-09-357, a report to congressional requesters.
Why GAO Did This Study:
In February 2007, a series of Washington Post articles disclosed
problems at Walter Reed Army Medical Center, particularly with the
management of servicemembers receiving outpatient care. In response,
the Army established Warrior Transition Units (WTU) for servicemembers
requiring complex case management. Each servicemember in a WTU is
assigned to a Triad of Care”a primary care manager, a nurse case
manager, and a squad leader”who provide case management services to
ensure continuity of care. The Army established staff-to-servicemember
ratios for each Triad of Care position. This report examines (1) the
Army‘s ongoing efforts to staff WTU Triad of Care positions and (2) how
the Army monitors the recovery process of WTU servicemembers. GAO
reviewed WTU policies, analyzed Army staffing and monitoring data,
interviewed Army officials, and visited five selected WTUs.
What GAO Found:
The Army has taken several steps to help ensure that WTUs are staffed
appropriately. First, the Army developed policies aimed at reducing WTU
staffing shortfalls, including a policy requiring the reassignment of
other personnel on an installation to fill open WTU positions. Second,
in October 2008, the Army revised its WTU staffing model, including the
staff-to-servicemember ratios for two of its Triad of Care positions,
because an Army study determined that the existing ratios were not
adequate to provide an appropriate level of care to servicemembers in
WTUs. The Army has made considerable progress in meeting the new
ratios, and as of January 2009, the Triad of Care positions at most
WTUs were fully staffed. However, staffing ratios for the WTU at Walter
Reed Army Medical Center were not revised, even though the Army
recognizes that servicemembers treated at this facility have more
complex health care needs than servicemembers at other WTUs. Walter
Reed might require a different staffing model, for example, one that
decreases the number of servicemembers assigned to staff members, but
the Army does not plan to conduct an assessment of Walter Reed‘s
staffing model. Third, the Army modified its WTU placement and exit
criteria for full-time servicemembers, excluding Army Reserve and
National Guard servicemembers who comprise about one-third of the WTU
population. These changes are intended to help ensure that only those
who need complex case management are in WTUs. Those with less serious
health care needs can be reassigned to other units on the installation
to continue their recovery. As the Army expected, the WTU population of
full-time servicemembers declined by about 1,500 in the 4 months after
implementation of the new criteria.
To monitor the recovery process of WTU servicemembers, the Army has
implemented transition plans for individual servicemembers as well as
various upward feedback mechanisms to identify concerns and gauge
satisfaction. In January 2008, the Army issued a policy establishing
Comprehensive Transition Plans, which can be used to monitor and
coordinate servicemembers‘ care. To help ensure consistent
implementation of these plans among its WTUs, the Army is developing a
new policy that includes the systematic collection of performance
measures across WTUs. However, despite Army officials‘ repeated
assurances to GAO that this policy was forthcoming, it had not been
finalized as of February 27, 2009. The Army‘s feedback mechanisms
include its Warrior Transition Unit Program Satisfaction Survey, which
collects information from servicemembers in WTUs on a number of issues,
including the primary care manager and nurse case manager. However, the
survey‘s response rates for the WTUs have been low (13 to 35 percent)
and the Army has not determined whether the results obtained from the
respondents are representative of all WTU servicemembers. An Army
official told GAO that the Army does not plan to conduct analyses to
determine whether the survey results are representative, because it is
satisfied with the response rates. In GAO‘s view, the response rates
are too low for the Army to reliably report satisfaction of
servicemembers in WTUs.
What GAO Recommends:
GAO recommends that the Army (1) examine the staffing model of the
Walter Reed WTU, (2) expedite efforts to implement policy related to
servicemembers‘ transition plans, and (3) ensure that the results from
its WTU satisfaction survey are representative of all servicemembers in
WTUs. While DOD concurred with GAO‘s recommendations, its comments on
actions planned and taken did not fully address recommendations on the
Walter Reed staffing model and the WTU satisfaction survey.
To view the full product, including the scope and methodology, click on
[hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-09-357]. For more
information, contact Randall B. Williamson at (202) 512-7114 or
williamsonr@gao.gov.
[End of section]
Contents:
Letter:
Background:
The Army Issued Additional WTU Policies to Reduce Staffing Shortfalls,
Modify Its Staffing Model, and Revise Servicemember Entry and Exit
Criteria:
The Army Uses Various Mechanisms to Monitor WTU Servicemembers'
Recovery, but Its Feedback Mechanisms May Not Provide Complete
Information:
Conclusions:
Recommendations for Executive Action:
Agency Comments and Our Evaluation:
Appendix I: Scope and Methodology:
Appendix II: Comments from the Department of Defense:
Appendix III: GAO Contact and Staff Acknowledgments:
Table:
Table 1: Selected Army-wide Upward Feedback Mechanisms:
Figures:
Figure 1: Location of WTUs at Army Installations within the United
States:
Figure 2: Description of Triad of Care Positions:
Figure 3: Original and Revised Staff-to-Servicemember Ratios for the
WTU Triad of Care:
Abbreviations:
DOD: Department of Defense:
MTF: military treatment facility:
OEF: Operation Enduring Freedom:
OIF: Operation Iraqi Freedom:
WTU: Warrior Transition Unit:
[End of section]
United States Government Accountability Office: Washington, DC 20548:
April 20, 2009:
Congressional Requesters:
Approximately 24,000 Army servicemembers have been wounded in action in
Operations Enduring Freedom (OEF) and Iraqi Freedom (OIF), as of
December 2008.[Footnote 1] Due to improved battlefield medicine, those
who might have died in past conflicts are now surviving, many with
multiple serious injuries that require extensive outpatient
rehabilitation, such as amputations, burns, and traumatic brain
injuries. Seriously injured servicemembers are usually transported to
military treatment facilities (MTF) in the United States, with most
treated at Walter Reed Army Medical Center or the National Naval
Medical Center.[Footnote 2] In February 2007, a series of Washington
Post articles disclosed serious deficiencies at Walter Reed,
particularly with the management of servicemembers who had been
released from the hospital and were receiving care and other services
as outpatients. Specifically, the articles reported that some
servicemembers remained in outpatient status for months and sometimes
years without a clear understanding about their plans of care or the
future of their military service. Furthermore, several review groups
were tasked with investigating the reported problems.[Footnote 3] The
groups identified, among other things, numerous problems with the
Army's management of servicemembers in an outpatient status, including
inadequate case management, which helps ensure continuity of care by
guiding a person's care from one service, provider, or agency to
another. For example, one review group found inadequate coordination of
care for some patients who visited numerous therapists, specialists,
and other providers and received differing treatment plans and multiple
medications.
In response to the deficiencies reported by the media, the Army took
several actions, most notably initiating the development of the Army
Medical Action Plan in March 2007. (This plan is currently referred to
as the Warrior Care & Transition Program.) The Army used this plan to
implement changes in the management of outpatient care for
servicemembers returning from OEF and OIF as well as for other
servicemembers receiving outpatient care at Army facilities. One key
component of the plan was the establishment of a new type of Army unit
for servicemembers that provides complex outpatient case management
services--the Warrior Transition Unit (WTU). In June 2007, the Army
began implementing WTUs, and as of January 2009 the Army had
established WTUs at 33 MTFs located at military installations across
the United States and at 3 MTFs overseas. Each servicemember in a unit
is assigned to a team of three key staff referred to as the Triad of
Care--a primary care manager, a nurse case manager, and a squad leader.
The primary care manager is usually a physician who provides oversight
of the servicemember's medical care; the nurse case manager is a
registered nurse who coordinates and monitors options and services to
meet the servicemember's health care needs; and the squad leader is a
noncommissioned officer who provides direct oversight of the
servicemembers, ensuring they attend medical and administrative
appointments. The Triad of Care is collectively responsible for
providing case management services to ensure continuity of care. In
order to determine the staffing levels for the Triad of Care positions,
the Army established specific staff-to-servicemember ratios, basing
staffing needs on the number of WTU servicemembers, which almost
tripled in the first year at the 33 U.S.-based WTUs--from about 3,500
in June 2007 to about 10,300 in June 2008.
In September 2007, we reported preliminary observations on the Army's
initial efforts to establish the WTUs and staff the Triad of Care
positions.[Footnote 4] Subsequently, in February 2008, we provided a
status update on the Army's efforts to staff the Triad of Care
positions in its WTUs.[Footnote 5] We found that although the Army had
made considerable progress implementing the WTUs, about a third of the
units had less than 90 percent of staff needed to meet the staff-to-
servicemember ratios that the Army had established for the Triad of
Care positions. We also noted that an emerging challenge for the Army
was gathering reliable and objective data to monitor the performance of
WTUs and to determine how well the units were meeting servicemembers'
recovery needs. This report updates our previous work and focuses on
the progress that the Army has made in implementing the WTUs.
Specifically, for this report, we examined (1) the Army's ongoing
efforts related to staffing WTU Triad of Care positions and (2) how the
Army is monitoring the recovery process of servicemembers in WTUs.
To conduct our work, we obtained documentation from and interviewed
officials with the Army's Office of the Surgeon General, Medical
Command,[Footnote 6] Warrior Care and Transition Office,[Footnote 7]
Manpower Analysis Agency, and Office of the Inspector General. In
addition, we visited five selected WTU locations--Forts Benning and
Gordon (Georgia), Fort Lewis (Washington), Fort Sam Houston (Texas),
and Walter Reed Army Medical Center (Washington, D.C.)--to obtain
information from Army officials about their efforts to staff the WTUs
and about their local mechanisms for monitoring servicemembers'
recovery process. We selected these sites because they represent
different regional Medical Commands and they vary in the number of
servicemembers placed in the WTU.
To assess the Army's ongoing efforts related to staffing the WTU Triad
of Care positions, we analyzed the Army's Triad of Care staffing data
and WTU servicemember population data--on which staffing needs are
based--for the 33 WTUs that have been established within the United
States. Our analysis did not include the WTUs that have been
established overseas. We also reviewed Army policies, including staff-
to-servicemember ratios and WTU entry and exit criteria. We did not
verify the accuracy of the Army's staffing and population data;
however, we interviewed agency officials knowledgeable about the data,
and we determined that they were sufficiently reliable for the purposes
of this report. We also did not evaluate the appropriateness of the
Triad of Care ratios for meeting the staffing needs of the WTUs. To
determine how the Army is monitoring the recovery process of WTU
servicemembers, we reviewed Army policies, documents, and data on
selected monitoring efforts that the Army has underway, including
efforts to develop transition plans for individual servicemembers and
to obtain feedback from servicemembers and their families. We reviewed
Army data on the number of servicemembers who had been in a WTU for at
least 30 days and who had transition plans as of January 6, 2009. For
the Warrior Transition Unit Program Satisfaction Survey, we reviewed
the Army's survey questionnaire, protocol, and results for the period
July 2007 through September 2008, which were the most recently
available data at the time of our review. We assessed the reliability
of the transition plan and survey data by reviewing related
documentation or speaking with knowledgeable agency officials and
determined the data to be sufficiently reliable for our purposes.
We conducted this performance audit from June 2007 through April 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. Additional information about
our scope and methodology is provided in appendix I.
Background:
In June 2007, the Army began establishing WTUs at United States
military installations with MTFs that were providing medical care to 35
or more eligible servicemembers. As of January 2009, the Army was
operating 33 of these WTUs. (See fig. 1.) The Army has also established
WTUs at locations in Germany--Bavaria, Heidelberg, and Landstuhl.
[Footnote 8] For servicemembers with less complex medical needs, the
Army uses its existing network of community-based health care
organizations, which it now refers to as community-based WTUs. The
community-based WTUs allow servicemembers to live at home and receive
medical care while remaining on active duty.[Footnote 9]
Figure 1: Location of WTUs at Army Installations within the United
States:
[Refer to PDF for image: map of the United States]
WTU Locations:
Fort Rucker, Alabama;
Redstone Arsenal, Alabama;
Fort Wainwright, Alaska;
Fort Richardson, Alaska;
Fort Huachuca, Arizona;
Fort Irwin, California;
Balboa, California[A];
Fort Carson, Colorado;
Walter Reed, Washington, DC;
Fort Benning, Georgia;
Fort Gordon, Georgia;
Fort Stewart, Georgia;
Tripler, Hawaii;
Fort Leavenworth, Kansas;
Fort Riley, Kansas;
Fort Campbell, Kentucky;
Fort Knox, Kentucky;
Fort Polk, Louisiana;
Fort Meade, Maryland;
Fort Leonard Wood, Missouri;
Fort Dix, New Jersey;
Fort Drum, New York;
West Point, New York;
Fort Bragg, North Carolina;
Fort Sill, Oklahoma;
Fort Jackson, South Carolina;
Fort Bliss, Texas;
For Hood, Texas;
Fort Sam Houston, Texas;
Fort Belvoir, Virginia;
Fort Eustis, Virginia;
Fort Lee, Virginia;
Fort Lewis, Washington.
Source: GAO analysis of Army data.
Note: The Army also established WTUs in Germany--Bavaria, Heidelberg,
and Landstuhl--and community-based WTUs in Alabama, Arkansas,
California, Florida, Illinois, Massachusetts, Puerto Rico, Utah, and
Virginia.
[A] The Army established a WTU at Balboa Naval Medical Center because
it was sending seriously injured servicemembers to this facility for
trauma care and it had a sufficient number of servicemembers to
establish a WTU at this location.
[End of figure]
A servicemember was eligible for placement in a WTU if he or she
required more than 6 months of medical treatment and required complex
case management. Army guidance specifies that the mission of
servicemembers assigned to a WTU is to heal and transition--return to
duty or to civilian life--and while WTU servicemembers may have work
assignments in the unit, this work may not take precedent over the
servicemembers' treatment. WTUs have a defined staffing structure that
includes leadership positions of commanders and platoon sergeants, as
well as administrative staff, such as human resources and financial
management specialists. Within each unit, the servicemember is assigned
to a team of three key staff--the Triad of Care--who provide case
management services to ensure continuity of care. (See fig. 2.):
Figure 2: Description of Triad of Care Positions:
[Refer to PDF for image: illustration/table]
Triad of Care position: Primary care manager; Description: Provides
primary oversight and continuity of health care and ensures the quality
of the servicemembers‘ care; usually a physician.
Triad of Care position: Nurse case manager; Description: Plans,
implements, coordinates, monitors, and evaluates options and services
to meet the servicemembers‘ health care needs; a registered nurse.
Triad of Care position: Squad leader; Description: Links the
servicemember to the chain of command, builds a relationship with the
servicemember, and works alongside the other parts of the Triad of Care–
primary care manager and nurse case manager–to ensure the servicemember
attends medical and administrative appointments and the needs of the
servicemember and his or her family are met; a noncommissioned officer.
Source: GAO and Army officials.
[End of figure]
Servicemembers in the WTUs vary by the type of medical condition for
which they are receiving care and include Army active component,
Reserve, and National Guard servicemembers.[Footnote 10] Active
component servicemembers comprise about two-thirds of the WTU
population, and active duty Reserve and National Guard servicemembers
collectively comprise about one-third.[Footnote 11] As of December 1,
2008, about 60 percent of servicemembers in WTUs had been wounded in
combat or had incurred a noncombat injury or illness during OEF or OIF,
which may have resulted in burns, amputations, or other types of
conditions. The remaining servicemembers in the units included those
who may have been referred to the WTU for completion of the disability
evaluation process; those who incurred a noncombat injury, such as
during a training exercise; and those who incurred a noncombat illness
such as cancer that required complex case management.
The Army Issued Additional WTU Policies to Reduce Staffing Shortfalls,
Modify Its Staffing Model, and Revise Servicemember Entry and Exit
Criteria:
The Army has issued additional WTU policies aimed at reducing staffing
shortfalls, modifying the staffing model, and revising servicemember
entry and exit criteria. To reduce staffing shortfalls, the Army issued
policies designed to ensure that WTUs achieve and maintain staffing at
required staff-to-servicemember ratios. The Army also implemented a
revised WTU staffing model that includes new staff-to-servicemember
ratios for two of the three Triad of Care positions. In addition, the
Army issued policies to revise its criteria for servicemembers entering
and leaving WTUs--a policy that affects population size and staffing
needs.
New WTU Staffing Policies Helped Reduce WTU Triad of Care Staffing
Shortfalls:
Although the Army had increased the number of staff being assigned to
the WTUs, staffing shortfalls continued through June 2008. When we last
reported on the Army's progress in staffing the WTUs in February 2008,
the Army had established a goal of having at least 90 percent of Triad
of Care staff positions filled to meet the staff-to-servicemember
ratios that it had established for its WTUs. These ratios were 1:200
for primary care managers; 1:18 for nurse case managers at Army medical
centers that normally see servicemembers with more acute conditions and
1:36 for other types of Army medical treatment facilities; and 1:12 for
squad leaders. At that time, the Army had 1,141 Triad of Care staff for
its WTUs, and 11 WTUs had less than 90 percent of needed staff for one
or more Triad of Care positions--representing a total shortfall of 64
staff. As of June 25, 2008, WTU Triad of Care staff had increased to
1,328, but because the size of the WTU servicemember population
continued to grow and increase staffing needs, 21 WTUs were not meeting
this goal and had staffing shortfalls in 108 Triad of Care positions.
However, it is important to note that WTU staffing shortfalls represent
a specific point in time. WTU staffing needs may vary daily based on
both the number of servicemembers entering and exiting the WTUs and
with fluctuations in the number of Triad of Care staff, who may deploy
or otherwise be reassigned or leave.
To address challenges in fully staffing the WTUs, including Triad of
Care positions, the Army issued new policies in July 2008 for staffing
the WTUs. The Army's new policies included a requirement that local
leadership--WTU commanders, MTF commanders, and senior installation
commanders--fill 100 percent of WTU staff shortages, including those
related to the Triad of Care, by July 14, 2008. For example, commanders
were directed to fill the positions using personnel present on the
installation, such as physicians and nurses who work in the MTFs, and
to ensure continued 100 percent staffing from July 14, 2008, forward.
As of August 2008, after the implementation of these new staffing
policies, Army data indicated that Triad of Care staffing shortfalls
had been reduced considerably, and the Army had generally met its goal
of 100 percent staffing of its WTUs, with only a few exceptions. As of
August 25, 2008, four WTUs had staffing shortfalls in four Triad of
Care positions total--Balboa was missing one nurse case manager, Fort
Belvoir was missing one squad leader, and Fort Drum and Fort Irwin were
each missing one primary care manager.
The Army Implemented a New WTU Staffing Model in Response to Study
Findings, but Walter Reed Was Excluded from This Study:
On October 16, 2008, the Army implemented revisions to its WTU staffing
model, including changes to two of its Triad of Care staff-to-
servicemember ratios. (See fig. 3.) These policy changes were based on
a study initiated by the Army in February 2008 that found that some of
the existing staff-to-servicemember ratios were not adequate for
providing an appropriate level of care to servicemembers in WTUs.
[Footnote 12] The study team recommended changes to the Triad of Care
staffing ratios for nurse case managers and squad leaders. The team
also recommended realigning existing medical and administrative support
staff in the WTU to provide direct assistance to the nurse case manager
and hiring new staff to support the primary care manager.
Figure 3: Original and Revised Staff-to-Servicemember Ratios for the
WTU Triad of Care:
[See PDF for image: illustration]
WTU Triad of Care, Original ratios:
Squad leader: 1:12;
Primary care manager: 1:200;
Nurse care manager: 1:18 or 1:36[B].
WTU Triad of Care, Revised ratios[A]:
Squad leader: 1:10;
Primary care manager: 1:200;
Nurse care manager: 1:20.
Source: GAO analysis of Army documentation.
[A] The revised ratios were the result of a study initiated by the
United States Army Manpower Analysis Agency in February 2008 that found
that some of the existing staff-to-servicemember ratios were not
adequate for providing an appropriate level of care to servicemembers
in WTUs. The revised ratios apply to all WTUs, except Walter Reed Army
Medical Center, which continues to operate under its original staff-to-
servicemember ratios--1:200 for primary care managers, 1:18 for nurse
case managers, and 1:12 for squad leaders.
[B] The 1:18 ratio is for nurse case managers at medical centers that
normally see servicemembers with more acute medical conditions. An
exception is Fort Hood, which operated at a 1:25 ratio because the
health care needs of its servicemember population were not as acute as
for other WTUs at medical centers. Additionally, the 1:36 ratio is for
nurse case managers at other types of Army MTFs.
[End of figure]
The Army applied the revised ratios to all the WTUs except Walter Reed
Army Medical Center. Army officials told us that the study team
excluded Walter Reed from its review because the population receiving
care at Walter Reed has more complex medical needs than the population
at other WTUs. As a result, Walter Reed is continuing to operate under
its original staff-to-servicemember ratios--1:200 for primary care
managers, 1:18 for nurse case managers, and 1:12 for squad leaders.
Despite the servicemember population at Walter Reed having more complex
medical needs, these ratios are not much different than the revised
ratios established for other WTUs. According to WTU officials from
Walter Reed, Triad of Care staff who work with servicemembers with more
complex medical needs generally require higher staff-to-servicemember
ratios, but an assessment of acuity--the complexity of servicemembers'
needs--is necessary for determining the exact ratios that would be
appropriate for Triad of Care positions at this location. Army
officials told us that the Army currently does not have a plan for
conducting a study of Walter Reed's staffing model because this
facility is scheduled to close in 2011 under Base Realignment and
Closure 2005.[Footnote 13] According to Army officials, the WTU at
Walter Reed will be moved to the newly established Walter Reed National
Military Medical Center in Bethesda, Maryland. The WTU servicemember
population from Walter Reed will be dispersed among the WTU at the new
medical center and the WTUs at Fort Belvoir and Fort Meade.
Nonetheless, the Army had made considerable progress in meeting the new
WTU staff-to-servicemember ratios for the Triad of Care positions. On
January 12, 2009, 4 of the 32 WTUs in the United States (excluding
Walter Reed Army Medical Center) had a total shortfall of seven Triad
of Care positions--three primary care managers and four squad leaders.
Walter Reed, which continued to operate under its original Triad of
Care staff-to-servicemember ratios, did not have any shortfalls.
Revised WTU Servicemember Entry and Exit Criteria Have Decreased WTU
Population Growth, Which Determines Staffing Needs:
In July 2008, the Army also implemented policies revising WTU
servicemember entry and exit criteria to increase emphasis on
servicemembers needing complex case management. The revised policies
stated that feedback from WTU officials, MTF commanders, and other
senior officials indicated that many servicemembers in WTUs did not
need the complex case management that the units provided. For example,
officials from one WTU we visited told us that the WTUs included
servicemembers who had conditions that were not complex, such as a
broken leg, or who were waiting to finish the Army's disability
evaluation process and no longer had medical appointments.[Footnote 14]
Army officials indicated that the growth of the WTU population--
partially due to the inclusion of servicemembers who did not need
complex case management--had impeded its ability to achieve and
maintain staff for its Triad of Care positions in accordance with its
staff-to-servicemember ratios.
The Army's July 2008 policies modified WTU entry and exit criteria
specifically for active component servicemembers. These revised
criteria do not apply to Reserve and National Guard servicemembers, who
comprise about one-third of the WTU population. Army policy indicates
that Reserve and National Guard servicemembers are generally eligible
for placement in a WTU if they need health care for conditions
identified, incurred, or aggravated while on active duty, and they will
remain in the WTU until their medical condition is resolved and they
are eligible to be released from active duty or they complete the
Army's disability evaluation process. According to an Army official,
the Army is also exploring ways to apply the revised entry and exit
criteria to Reserve and National Guard servicemembers and is planning
to issue a corresponding policy in March 2009.
The Army's revised WTU entry criteria for active component
servicemembers are intended to help ensure that only those who need
complex case management are placed in the WTU. For example, according
to the original criteria, a servicemember was eligible for placement in
a WTU if he or she had complex medical needs requiring more than 6
months of treatment and did not include an assessment of the
servicemember's ability to perform his or her duties. The revised
criteria state that an active component servicemember is eligible for
placement in a WTU if he or she has complex medical conditions that
require case management and will not be able to train for or contribute
to the mission of a unit for more than 6 months.
The WTU exit criteria, which had not been explicitly articulated in the
original WTU policy, now allow local leadership greater flexibility in
reassigning active component servicemembers to other units on the
installation. Previously, an active component servicemember would
remain in a WTU until he or she was able to return to duty and
completed his or her medical treatment or was discharged from the Army,
even if the servicemember's medical care could be managed outside a
WTU. The exit criteria state that an active component servicemember who
is expected to return to duty may be reassigned to a unit on the
installation before being found medically fit to return to duty if
certain conditions are met. In particular, the servicemember may be
reassigned if the servicemember's remaining medical needs can be
managed outside a WTU and if the servicemember's reassignment has been
approved by the Triad of Care and by leadership of the WTU, MTF, and
installation.
Along with its policies establishing the revised entry and exit
criteria, the Army required the Warrior Care and Transition Office to
assess the effectiveness of the revised entry and exit criteria in
ensuring that only those servicemembers needing complex case management
are in the WTUs and to monitor the effects of the revised criteria.
Specifically, the Warrior Care and Transition Office was tasked with
developing measures for assessing the criteria's effectiveness.
According to Army officials, the Warrior Care and Transition Office has
not developed any additional measures to determine the effectiveness of
the revised entry and exit criteria, but instead is relying on existing
measures. For example, the number of servicemembers in WTUs decreased
after implementation of the criteria, as the Army anticipated.
Specifically, Army data show that the active component population of
the WTUs has declined each month since the new entry and exit criteria
went into effect, from about 8,400 in July 2008 to about 6,900 in
November 2008.[Footnote 15] Army officials also said that length of
stay can be used to assess the entry and exit criteria because
servicemembers requiring complex care would be expected to have longer
lengths of stay in the WTU.
The policy with the revised entry and exit criteria also includes a
provision for the Army Inspector General to assess the criteria as part
of a broader provision to conduct a follow-up inspection of the Army's
disability evaluation process and WTUs. An official within the Army's
Office of the Inspector General told us that this inspection is
included in its proposed long-range inspection plan for fiscal years
2009 and 2010, which is pending approval by the Secretary of the Army.
The Army Uses Various Mechanisms to Monitor WTU Servicemembers'
Recovery, but Its Feedback Mechanisms May Not Provide Complete
Information:
To monitor the recovery process of WTU servicemembers, the Army uses
individual transition plans and various upward feedback mechanisms, but
its feedback mechanisms may not provide complete information on the
performance of WTUs. The Army's feedback mechanisms, which include a
telephone hotline and a satisfaction survey, provide a way for
servicemembers and their families to raise concerns about WTU-related
issues. However, while this may provide helpful and important
information to Army leadership, the concerns raised through these
mechanisms are not necessarily representative of the concerns of all
WTU servicemembers and their families.
The Army Is Implementing Plans for Monitoring the Recovery of
Individual Servicemembers:
To facilitate servicemembers' recovery, the Army has developed a
process for coordinating and monitoring the care that servicemembers
receive while in a WTU. In January 2008, the Army issued a policy
establishing Comprehensive Transition Plans for WTU servicemembers.
[Footnote 16] A plan includes a servicemember's medical conditions and
vocational training needs, as well as his or her expectations and goals
for the recovery process. The Army requires that a servicemember's
transition plan be developed within 30 days of his or her placement
into the WTU by WTU leadership and Triad of Care staff with input from
the servicemember and his or her family. The WTU and MTF commanders are
responsible for ensuring that the transition plan is developed.
Army policy requires that the Triad of Care monitor the servicemember's
transition plan weekly. For example, officials told us that meetings,
which may include staff in addition to the Triad of Care, are held to
determine whether the goals documented in the servicemember's
transition plan are being met and to modify the plan as necessary.
Additionally, according to an Army official, conducting periodic formal
evaluations of the transition plan is required to determine whether the
servicemember should (1) return to duty, (2) continue rehabilitation,
or (3) be referred to the Army disability evaluation process. An
official said that these formal evaluations occur at least every 3
months, but can occur more often based on the servicemember's
transition plan.
In addition to actions already underway, the Army is developing
additional policy to assist WTUs in developing the Comprehensive
Transition Plans, which could help ensure that the plans are
implemented consistently across WTUs and that the transition needs of
all servicemembers in the WTUs are regularly assessed. According to the
Army, this additional policy will include guidance on setting goals
with servicemembers and their families. It will also include
performance measures that will allow the Army to more systematically
monitor the extent to which WTUs have developed transition plans for
its servicemembers. For example, according to the Army, the performance
measures will include the number of servicemembers in WTUs for more
than 30 days who do not have a transition plan. The policy will require
that the performance measures be reported at least monthly. During a 6-
month period over the course of our review, Army officials had provided
us with various dates for which they had expected that this policy
would be finalized, but this had not yet occurred as of February 27,
2009.
Related to one of these performance measures, the Army has begun
reporting data on the number of servicemembers in WTUs for more than 30
days who had a transition plan. Our analysis of these data shows that
as of January 6, 2009, 94 percent of all servicemembers in WTUs across
the United States had transition plans. Specifically, between 84 and
100 percent of servicemembers at 32 of 33 WTUs had transition plans. At
the remaining WTU, 73 percent of servicemembers had transition plans.
Officials from this WTU said that, because of the rapid growth in the
WTU servicemember population, there were insufficient staff in some
positions involved in developing the transition plan, such as social
workers. As a result, officials were first developing transition plans
for servicemembers who had the greatest need. Additionally, officials
said that some servicemembers did not need transition plans because
they were in the process of leaving the WTU.
The Army Obtains Information on Servicemembers' Concerns through
Various Upward Feedback Mechanisms, but This Information May Not Be
Representative of All WTU Servicemembers:
Using various upward feedback mechanisms, the Army has obtained
information about different aspects of its WTUs, including the Triad of
Care. (See table 1.) For example, the Army requires each of its WTUs to
hold monthly Town Hall meetings to serve as a forum for WTU
servicemembers and their family members to voice their concerns
directly to WTU and installation leadership. Additionally, after the
media reported deficiencies at Walter Reed Army Medical Center, the
Army established two other feedback mechanisms--the Wounded Soldier and
Family Hotline and the Ombudsman Program--which are also available to
servicemembers receiving care at the MTF who are not part of the WTU
and their families. Through both of these mechanisms, Army personnel
are available to address servicemembers' concerns about medical and
nonmedical issues, including transportation, financial, legal, and
housing concerns. The Army collects and analyzes data from these
feedback mechanisms to identify trends and potential problem areas.
While this may provide helpful and important information to Army
leadership about the performance of the WTUs, the concerns raised
through these mechanisms are not necessarily representative of all
concerns of WTU servicemembers and their families because they are
dependent upon the initiative taken by individuals and because they may
include concerns from servicemembers not in WTUs.
Table 1: Selected Army-wide Upward Feedback Mechanisms:
Monitoring type: Town Hall Meeting;
Date established: June 2007;
Description: Provides a venue for servicemembers and their families to
ask questions and raise concerns to WTU leadership. The Army requires
each WTU to conduct these meetings monthly.
Monitoring type: Wounded Soldier and Family Hotline;
Date established: March 2007;
Description: Offers wounded and injured servicemembers and their
families a way to elevate medical and nonmedical issues, which are
forwarded to the appropriate Army officials for resolution. As of
November 30, 2008, the hotline had received 16,724 calls.
Monitoring type: Ombudsman Program;
Date established: April 2007;
Description: Places soldier and family advocates at Army MTFs. They are
available to assist servicemembers and their families with both medical
and nonmedical issues by serving as a liaison to the Army's Medical
Command and the MTF.[A] As of November 30, 2008, the Army had a total
of 56 ombudsmen. For the period January 2008 through November 2008,
1,130 issues related to the WTUs or case management services were
reported to ombudsmen.
Monitoring type: Warrior Transition Unit Program Satisfaction Survey;
Date established: June 2007[B];
Description: Surveys WTU servicemembers to determine satisfaction with
their primary care manager and nurse case manager, access to medical
care, and other medical and nonmedical issues. The survey is
administered to servicemembers on certain anniversary dates--30, 120,
280, and 410 days after entry in the WTU.
Source: GAO based on review of Army documentation and interviews with
Army officials.
[A] The Army does not have an ombudsman at Fort Leavenworth, KS; Fort
Meade, MD; Fort Rucker, AL; or Redstone Arsenal, AL. An ombudsman at
the nearest MTF supports these locations.
[B] Prior to June 2007, the Army implemented this survey under a
different name for National Guard and Reserve servicemembers. In June
2007, the Army expanded the population surveyed to include active
component servicemembers, added questions about the WTUs, and changed
the name of the survey.
[End of table]
In addition, the Army obtains feedback on WTUs through its Warrior
Transition Unit Program Satisfaction Survey, which solicits feedback on
the performance of WTUs, including the WTUs in Germany and the
community-based WTUs. This survey is designed to assess servicemembers'
satisfaction with various aspects of WTUs, including the primary care
manager and nurse case manager.[Footnote 17] The Army began
administering this survey in June 2007 to servicemembers who had been
placed in WTUs. The Army mails the survey to WTU servicemembers on the
30-, 120-, 280-, and 410-day anniversaries of their placement into the
WTU. In February 2008, the Army began following up by telephone with
servicemembers who did not respond 30 days after the surveys were
mailed.
Although the Army has used this survey to report relatively high
satisfaction rates among WTU servicemembers, including servicemembers
at WTUs in Germany and community-based WTUs, the survey results may not
be representative of all WTU servicemembers. During the period July
2007 through September 2008, the Army's data showed that for WTUs at
military installations, the percentage of servicemembers satisfied
ranged between approximately 60 and 80 percent, and for the community-
based WTUs, between approximately 80 and 90 percent. However, the
overall monthly response rates for WTU respondents ranged between 13
and 35 percent for the period June 2007 through September 2008, which
was the most current data available at the time of our review. Such a
low response rate decreases the likelihood that the survey results
accurately reflect the views and characteristics of the target
population.
Despite low response rates, the Army has not conducted additional
analyses to determine whether its survey results are representative of
the entire WTU servicemember population. According to Office of
Management and Budget guidelines, best practices to ensure that survey
results are representative of the target population include conducting
a nonresponse analysis for surveys with a response rate lower than 80
percent.[Footnote 18] Although the Army was not required to seek the
Office of Management and Budget's approval for the Warrior Transition
Unit Program Satisfaction Survey, these are generally accepted best
practices and are relevant for the purposes of assessing whether the
survey results are representative of all WTU servicemembers. A
nonresponse analysis may be completed on more than one occasion,
depending on how frequently the survey is administered. A nonresponse
analysis can be used to determine if the responses from nonresponding
servicemembers would be the same as the responses from responding
servicemembers. Therefore, this analysis could help the Army determine
whether its WTU satisfaction survey results are representative of all
WTU servicemembers. An Army official told us that the Army does not
plan to conduct nonresponse analyses because it is satisfied with the
response rates that it has been receiving since it began following up
with servicemembers by telephone in February 2008. For the period
February 2008 through September 2008, WTU response rates for both mail
and telephone respondents, including WTUs in Germany and community-
based WTUs, have ranged between 26 and 35 percent. In addition, this
official told us that beginning in Spring 2009 the Army no longer plans
to conduct this survey by mail, but will conduct this survey solely by
telephone, and expects response rates to further increase once this
occurs.
Nonetheless, the Army has used its survey results to monitor trends and
identify areas for improvement. For example, the Army conducted
additional analyses of nine WTUs, which are among the largest WTUs. For
one of these WTUs, the Army reported that additional analyses indicated
that factors contributing to low satisfaction included decreased
satisfaction about pain control and financial issues. The analyses also
showed that servicemembers in this WTU for more than 280 days were the
most dissatisfied.
While Army leadership may use the Warrior Transition Unit Program
Satisfaction Survey results to identify areas for improvement, Army
officials at some locations we visited said that low response rates and
lack of specific information limits the usefulness of the survey at the
local level. Consequently, some WTUs have undertaken local efforts to
collect information about servicemembers' satisfaction. Army officials
at three of the WTUs we visited told us that they have independently
conducted local satisfaction surveys to obtain specific information
from their servicemembers. These local efforts have focused on gauging
satisfaction in several areas, including, for example, satisfaction
with nurse case managers, primary care managers, and squad leaders. The
local surveys do not replace the Army-wide satisfaction survey, and
Army officials reported that they have been able to use them to improve
services at individual WTUs. For example, at one location we visited,
officials administered a satisfaction survey in January 2008 and August
2008 that focused on the nurse case managers. These results showed
that, while servicemembers were generally satisfied with their nurse
case managers, a few servicemembers commented that their nurse case
manager's caseload was too large. In response to the survey results,
the WTU has worked to balance the caseload among the nurse case
managers so that no case manager has an excessive number of WTU
servicemembers.
Conclusions:
After problems at Walter Reed Army Medical Center were disclosed in
early 2007, the Army dedicated significant resources and attention to
improving outpatient care for servicemembers through the establishment
of the WTUs. Initially, the Army faced challenges fully staffing the
units to serve an increasing population, but revisions to WTU policies
substantially reduced staffing shortfalls and appeared to manage
population growth for active component servicemembers. As of January
2009, almost all of the Triad of Care positions in the WTUs were fully
staffed. In addition, the number of active component servicemembers in
WTUs decreased within the first 4 months of implementing the revised
entry and exit criteria. Sustained attention to staffing levels and the
implementation of the revised WTU entry and exit criteria will be
important for maintaining these gains and helping to ensure that
servicemembers are getting the care that they need.
The Army demonstrated its dedication to caring for its WTU
servicemembers by studying and revising its staffing model, including
staff-to-servicemember ratios for selected positions, to help ensure
the WTUs were providing an appropriate level of care. However, a
lingering concern--in light of the study's findings not applying to the
WTU at Walter Reed Army Medical Center--is that the Army does not have
a plan to conduct a similar study for this WTU. The population
receiving care at Walter Reed has more complex health care needs than
the population at other WTUs, and might also require, for example,
higher staff-to-servicemember ratios. Without an assessment of the
current staffing model that considers this complexity, the Army cannot
be assured that it is providing an appropriate level of care to
servicemembers at Walter Reed. This evaluation could help the Army
determine the appropriate staffing model for the population at Walter
Reed and ensure that previously reported problems with coordination of
care and treatment for this population do not recur. Furthermore, an
assessment of Walter Reed's staffing model could help the Army make
staffing decisions in preparation for the transfer of seriously injured
servicemembers to other facilities once Walter Reed closes in 2011.
Continued monitoring of the Army's WTUs, including servicemembers'
recovery process, will be important for ensuring that these units are
meeting servicemembers' needs. The Army's Comprehensive Transition
Plans appear to be a significant step towards ensuring that
servicemembers are receiving the care they need by regularly assessing
their progress. However, the Army has not finalized policy that would
allow it to systematically determine whether WTUs are consistently
developing these plans. The Army has also established various upward
feedback mechanisms that help inform Army leadership about issues WTU
servicemembers are facing, but they do not provide information on the
overall effectiveness of the WTUs. The Army's Warrior Transition Unit
Program Satisfaction Survey could potentially be used to collect
information representative of the WTU population. However, the survey
has had low response rates, and the Army has not performed additional
analysis to determine whether these results are representative of all
WTU servicemembers. Although the Army's plan to conduct the
satisfaction survey solely by telephone may increase response rates,
nonresponse analyses may still be warranted because the response rates
may remain well below 80 percent--the level where generally accepted
best practices call for nonresponse analyses to ensure that survey
results are representative. Without representative information, the
Army cannot reliably report servicemembers' satisfaction with the WTUs,
and without such data Army officials could potentially be unaware of
serious deficiencies like those that were identified at Walter Reed in
2007.
Recommendations for Executive Action:
We recommend that the Secretary of Defense direct the Secretary of the
Army to take the following three actions:
* To help ensure that the WTU at Walter Reed Army Medical Center is
providing an appropriate level of care to servicemembers and help the
Army make future staffing decisions for the WTUs that will be caring
for this population once Walter Reed closes, the Army should examine
Walter Reed's WTU staffing model, including its Triad of Care staff-to-
servicemember ratios, in light of the complexity of the health care
needs of servicemembers placed in this WTU.
* To help ensure that the Comprehensive Transition Plans are
implemented consistently across WTUs and that the Army has performance
data for monitoring the implementation of the transition plans, the
Army should expedite efforts to finalize and implement its policy for
guiding the development of the Comprehensive Transition Plans.
* To determine whether the results of the Warrior Transition Unit
Program Satisfaction Survey can be used to assess the effectiveness of
the WTUs, the Army should take steps to determine whether the results
are representative of all servicemembers in WTUs, such as by conducting
nonresponse analyses, and should take additional steps if necessary to
obtain results that are representative.
Agency Comments and Our Evaluation:
In commenting on a draft of this report, DOD stated that it concurred
with our findings and recommendations. (DOD's comments are reprinted in
appendix II.) However, DOD's description of the actions that it has
taken and those that it plans to take to respond to the recommendations
did not fully address two of the recommendations.
* In response to our recommendation to examine the WTU staffing model
at Walter Reed Army Medical Center, DOD indicated that the Army has
multiple planning efforts and studies underway to prepare for the
closing of Walter Reed. For example, it indicated that the Center for
Army Analysis is determining the capacity and capabilities of Fort
Meade, Fort Belvoir, and the new Walter Reed National Military Medical
Center to determine how best to provide the appropriate level of care
and services to these WTU servicemembers. DOD also indicated that
Walter Reed has sufficient resources to provide appropriate care until
the new Walter Reed is completed. Specifically, DOD commented that
Walter Reed's staffing has met or in certain areas exceeded that of
other WTUs--for example, nurse case managers have dedicated supervisory
assistance available to them at all times and the Walter Reed nurse
case manager staff-to-servicemember ratio is 1:18, compared to 1:20 at
other WTUs. In describing the Army's efforts and studies, however, DOD
did not indicate how, if at all, they would be examining the WTU
staffing model at Walter Reed, including the Triad of Care staff-to-
servicemember ratios. Furthermore, although Walter Reed may have
additional resources and its nurse case managers may operate under a
slightly higher ratio, the population receiving care at Walter Reed has
more complex health care needs than the population at other WTUs. We
continue to believe that without an assessment of the current staffing
model that considers this complexity, the Army cannot be assured that
it is providing an appropriate level of care to servicemembers at
Walter Reed. Furthermore, we continue to believe that such an
assessment can help the Army make future staffing decisions for the
WTUs that will be caring for this WTU population once Walter Reed
closes. As such, it is imperative that DOD take all actions necessary
to examine the WTU staffing model at Walter Reed.
* With respect to our recommendation for the Army to take steps to
determine whether the results of the Warrior Transition Unit Program
Satisfaction Survey are representative of all servicemembers in WTUs,
DOD's response does not indicate that the Army will be taking the
actions that we recommended. DOD indicated that the Army's change to
telephone surveys has greatly increased response rates and a
nonresponse analysis is currently not required. However, DOD did not
indicate its most recent response rates. Although DOD indicated that
the Army would reevaluate the need for a nonresponse analysis by
September 1, 2009, unless the change to telephone surveys has resulted
in a response rate that is 80 percent or higher, we believe that taking
steps to determine whether the results are representative of all
servicemembers in WTUs is warranted. Without such data, we continue to
believe that the Army cannot reliably report servicemembers'
satisfaction with the WTUs and that Army leadership could potentially
be unaware of serious deficiencies in some of its WTUs.
With regard to our recommendation for the Army to finalize and
implement its policy for guiding the development of Comprehensive
Transition Plans, DOD responded that the policy was signed on March 10,
2009. DOD also indicated that staff associated with the Army's
Organizational Inspection Program are assisting with the implementation
of the plans and will validate compliance with the new policy.
We are sending copies of this report to the Secretary of Defense,
relevant congressional committees, and other interested parties. The
report also is available at no charge on GAO's Web site at [hyperlink,
http://www.gao.gov].
If you or your staff members have any questions about this report,
please contact me at (202) 512-7114 or williamsonr@gao.gov. Contact
points for our Offices of Congressional Relations and Public Affairs
may be found on the last page of this report. Key contributors to this
report are listed in appendix III.
Signed by:
Randall B. Williamson:
Director, Health Care:
List of Requesters:
The Honorable Steve Buyer:
Ranking Member:
Committee on Veterans' Affairs:
House of Representatives:
The Honorable John Hall:
Chairman:
Subcommittee on Disability Assistance and Memorial Affairs:
Committee on Veterans' Affairs:
House of Representatives:
The Honorable Harry Mitchell:
Chairman:
Subcommittee on Oversight and Investigations:
Committee on Veterans' Affairs:
House of Representatives:
The Honorable John F. Tierney:
Chairman:
Subcommittee on National Security and Foreign Affairs:
Committee on Oversight and Government Reform:
House of Representatives:
The Honorable Kirsten Gillibrand:
United States Senate:
The Honorable Jason Altmire:
House of Representatives:
The Honorable Michael Arcuri:
House of Representatives:
The Honorable Bruce Braley:
House of Representatives:
The Honorable Christopher Carney:
House of Representatives:
The Honorable Kathy Castor:
House of Representatives:
The Honorable Yvette Clarke:
House of Representatives:
The Honorable Steve Cohen:
House of Representatives:
The Honorable Joe Courtney:
House of Representatives:
The Honorable Joe Donnelly:
House of Representatives:
The Honorable Keith Ellison:
House of Representatives:
The Honorable Brad Ellsworth:
House of Representatives:
The Honorable Gabrielle Giffords:
House of Representatives:
The Honorable Phil Hare:
House of Representatives:
The Honorable Baron Hill:
House of Representatives:
The Honorable Mazie Hirono:
House of Representatives:
The Honorable Paul Hodes:
House of Representatives:
The Honorable Hank Johnson:
House of Representatives:
The Honorable Steve Kagen, M.D.
House of Representatives:
The Honorable Ron Klein:
House of Representatives:
The Honorable David Loebsack:
House of Representatives:
The Honorable Jerry McNerney:
House of Representatives:
The Honorable Chris Murphy:
House of Representatives:
The Honorable Patrick J. Murphy:
House of Representatives:
The Honorable Ed Perlmutter:
House of Representatives:
The Honorable Ciro D. Rodriguez:
House of Representatives:
The Honorable John Sarbanes:
House of Representatives:
The Honorable Joe Sestak:
House of Representatives:
The Honorable Carol Shea-Porter:
House of Representatives:
The Honorable Heath Shuler:
House of Representatives:
The Honorable Albio Sires:
House of Representatives:
The Honorable Zach Space:
House of Representatives:
The Honorable Betty Sutton:
House of Representatives:
The Honorable Timothy Walz:
House of Representatives:
The Honorable Peter Welch:
House of Representatives:
The Honorable Charles Wilson:
House of Representatives:
The Honorable John Yarmuth:
House of Representatives:
[End of section]
Appendix I: Scope and Methodology:
Overall, to evaluate the Army's efforts to staff and monitor its
Warrior Transition Units (WTU), we obtained documentation from and
interviewed officials with the Army's Office of the Surgeon General,
Medical Command, Warrior Care and Transition Office, Manpower Analysis
Agency, and Office of the Inspector General. To gain an understanding
of staffing and monitoring activities at individual WTUs, we visited
five WTU locations--Forts Benning and Gordon (Georgia), Fort Lewis
(Washington), Fort Sam Houston (Texas), and Walter Reed Army Medical
Center (Washington, D.C.). We selected these locations because they
represent different Army regional Medical Commands and they vary in the
number of servicemembers placed in the WTU. Because we did not visit a
representative sample of WTUs, the results from these visits cannot be
generalized to other WTUs. At each location, we met with WTU command
staff, nurse case managers or primary care managers, and servicemembers
placed in the WTU to gain their perspectives on case management
services being provided through the WTU. We also met with officials
representing the Army's regional Medical Command to discuss case
management services, including staffing and monitoring.[Footnote 19]
Lastly, we met with officials representing the Case Management Society
of America to obtain their perspectives on the Army's WTUs and efforts
to monitor healthcare provided to servicemembers.
More specifically, to assess the Army's ongoing efforts to staff its
WTU Triad of Care positions--primary care managers, nurse case
managers, and squad leaders--we obtained and reviewed the Army Warrior
Care & Transition Program,[Footnote 20] which established policies for
implementing the WTUs. We also reviewed additional staffing policies
that the Army established in July 2008. These policies included
additional requirements for staffing the WTUs and a new WTU staffing
model that included revised WTU staff-to-servicemember ratios. To
determine the extent to which the Army was meeting its staff-to-
servicemember ratios for its Triad of Care positions, we analyzed Army
staffing and servicemember population data for the 33 WTUs that were
established at MTFs located at Army installations within the United
States. We did not verify the accuracy of these data. We did, however,
speak with Army officials regarding the reliability of the data and
determined them to be sufficiently reliable for the purposes of our
review. We also did not evaluate the appropriateness of the Triad of
Care ratios for meeting the staffing needs of the WTUs.
To determine how the Army is monitoring the recovery process of
servicemembers in WTUs, we reviewed the Army's policy and guidance
regarding the implementation of its Comprehensive Transition Plans. We
also spoke with an Army official about a draft policy related to the
documentation of the transition plans that would include performance
measures to track compliance. To determine the extent to which the 33
WTUs within the United States had plans for individual servicemembers,
we analyzed the Army's biweekly data on the number of servicemembers
who had been in the WTU for at least 30 days who had a transition plan.
We did not verify the accuracy of these data. We did, however, speak
with an Army official regarding the reliability of the data and
determined them to be sufficiently reliable for the purposes of our
review. We also reviewed protocols and procedures for selected upward
feedback mechanisms. The Army uses a number of mechanisms for obtaining
feedback from servicemembers and their families to address WTU-related
issues, but we did not review every mechanism. We focused on the Town
Hall Meeting, Wounded Soldier and Family Hotline, the Ombudsman
Program, and the Warrior Transition Unit Program Satisfaction Survey.
We focused on these mechanisms because they were implemented shortly
after the media reported deficiencies at Walter Reed Army Medical
Center and because they provide WTU servicemembers and their families
with methods for sharing their experiences and concerns about health
care and case management with Army leadership. For the Army's Warrior
Transition Unit Program Satisfaction Survey, which is used to assess
servicemembers' satisfaction across all WTUs, we reviewed the survey
questionnaire, protocol, and results for the period July 2007 through
September 2008, which were the most recent data available at the time
of our review. We reviewed and analyzed Army data on the number of
surveys mailed monthly and corresponding response rates for all of the
WTUs, including the overseas and community-based WTUs. We assessed the
reliability of these data by reviewing related documentation and
speaking with knowledgeable agency officials and determined the data to
be sufficiently reliable for our purposes. We also reviewed the Office
of Management and Budget Standards and Guidelines for Statistical
Surveys (September 2006) to identify standards for statistical surveys
conducted by federal agencies, including best practices for ensuring
that survey results are representative of the target population.
Although the Army is not required to seek Office of Management and
Budget approval to conduct its satisfaction survey, these guidelines
are relevant for assessing whether survey results are representative.
Lastly, three WTUs we visited administered local surveys and we
obtained and reviewed their survey questionnaires and corresponding
results, when available. However, we did not review the survey
methodology for those WTUs that administered a local survey. Further,
because these local surveys collected data that were specific to these
WTUs, the survey results cannot be generalized to all WTUs.
We conducted this performance audit from June 2007 to April 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: Comments from the Department of Defense:
The Assistant Secretary Of Defense: Health Affairs:
1200 Defense Pentagon:
Washington, DC 20301-1200:
March 27, 2009:
Mr. Randall B. Williamson:
2009 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-09-357, "Army Health
Care: Progress Made in Staffing and Monitoring Units that Provide
Outpatient Case Management, but Additional Steps Needed," dated
February 27, 2009 (GAO Code 290635)."
Thank you for the opportunity to review and comment on the draft
report. Overall. I concur with the report's findings and conclusions.
Responses to the draft report's recommendations are attached. Since the
recommendations specifically concerned the Army and the health care
provided to wounded warriors, they were provided to the Office of the
Army Surgeon General for review and development of responses. My staff
and the Army functional points of contact worked collegially to develop
the responses which have been approved by the Army Surgeon General.
Again, thank you for the opportunity to provide these comments. My
points of contact for additional information are Lieutenant Colonel
Glenda Mitchell (Functional) at (703) 681-6717,
glenda.mitchell@tma.osd.mil and Mr. Gunther Zimmerman (Audit Liaison)
at (703) 681-4360, gunther.zimmerman@tma.osd.mil.
Sincerely,
Signed by:
S. Ward Casscells, M.D.
Enclosures: As stated:
GAO Draft Report - Dated February 27, 2009: GAO Code 290635/GAO-09-357:
Army Health Care: Progress Made in Staffing and Monitoring Units that
Provide Outpatient Case Management, but Additional Steps Needed.
Department Of Defense Comments To The Recommendations:
Recommendation 1: The GAO recommends that the Secretary of Defense
direct the Secretary of the Army to examine Walter Reed's Warrior
Transition Unit (WTU) staffing model, including its Triad of Care staff-
to-Service member ratios, in light of the complexity of the health care
needs of Service members placed in this WTU to help ensure that the WTU
at Walter Reed Army Medical Center is providing an appropriate level of
care to Service members and help the Army make future staffing
decisions for the WTUs that will be caring for this population once
Walter Reed closes.
DOD Response: Concur. Multiple planning efforts or studies are underway
in order to prepare for the eventual closing of Walter Reed Army
Medical Center (WRAMC). Among these, the Center for Army Analysis is
determining the capacity and capabilities of Fort Meade, Fort Belvoir
and the new Walter Reed to determine how best to provide the
appropriate level of care and services to these Warriors in Transition.
This study should be completed by June 30, 2009. In conjunction with
this study, the Warrior Care and Transition Office and the North
Atlantic Regional Medical Command are in the process of planning how to
best provide the appropriate level of care and services to soldiers in
the National Capital Region. Additionally, the Army Medical Command
monitors the access to care standards at Walter Reed, as well as every
other Warrior Transition Unit, to determine the appropriate level of
care is given to each Warrior in Transition. The Wounded Warrior Act of
2008 required that WRAMC remain resourced sufficiently to provide
appropriate care until the new Walter Reed Military National Medical
Center is completed. This is being accomplished. Since the inception of
the Warrior Transition Unit (WTU) concept, staffing at the WRAMC unit
has met or in certain areas exceeded that of other WTUs. This is seen
in the establishment of this unit as a Brigade element with a Colonel
as Commander, to include the same or greater care and command and
control support than, for example, exists at the Company size WTU
level. As a result, the Nurse Case Managers (assigned at a lower Nurse
Case Manager to Warrior in Transition ratio of 1:18 than the 1:20 ratio
of other WTUs) and other medical and care professionals have dedicated
supervisory assistance available to them at all times. Additionally,
the WRAMC WTU also has the support of a dedicated Warrior Transition
Unit of providers focused entirely on Warrior in Transition care, and
the Military Advanced Training Center (MATC), a state-of-the-art
therapy and rehabilitation center equipped with state of the art
capabilities and a dedicated staff of therapists and other
professionals totally focused on the rehabilitation of Warriors in
Transition. These additional resources over and above those of other
WTUs, coupled with the demonstrated excellence and satisfaction found
in the care received at this premier medical center is considered
indicative that the care and treatment model currently in use is
appropriate and effective. The OSD Transition Policy and Care
Coordination (TPCC) Office has recommended the Army consider adding at
least one Recovery Care Coordinator (RCCs) to the WTU at WRAMC. The
Army RCCs are currently placed under the AW2 program to assist
recovering service members who meet that program criteria. In
discussions with Army leadership, the TPCC Director recommended the
Army consider either expanding the scope of the AW2 program criteria or
placing RCCs in the WTUs, in order to better serve the Army population
of recovering service members who do not meet the AW2 program criteria.
The Army is considering this recommendation.
Recommendation 2: The GAO recommends that the Secretary of Defense
direct the Secretary of the Army to expedite efforts to finalize and
implement its policy for guiding the development of the Comprehensive
Transition Plans to help ensure that the Comprehensive Transition Plans
are implemented consistently across WTUs and that the Army has
performance data for monitoring the implementation of the transition
plans.
DOD Response: Concur. The Comprehensive Transition Policy (CTP) was
signed on March 10, 2009 by Lieutenant General Eric B. Schoomaker,
M.D., PhD, The Surgeon General of the United States Army and Commander,
U.S. Army Medical Command. Currently, the CTP annexes and working
documents along with the goal setting training is on the Warrior in
Transition Program website for Warrior in Transition Unit Commanders to
utilize. The Organizational Inspection Program (OIP) includes
measurable tasks and standards which support the CTP. In addition, the
Subject Matter Experts on the OIP Team conduct staff assistance
regarding CTP implementation. The OIPs will validate compliance with
policy as set forth in the CTP until more aggressive implementation and
training can be conducted. The Warrior Care and Transition Office will
publish draft doctrine for the CTP within 60 days of March 10, 2009.
That draft will then go to the field for staffing and recommended
improvements with a target date for approved doctrine of July 1, 2009.
The OSD Transition Policy and Care Coordination Office (TPCC) Director
has recommended to Army leadership that to comply with the NDAA 08
requirements for each recovering service member to have a Comprehensive
Recovery Plan (CRP), the Army consider combining the requirements of
the CRP into the Army CTP. Uniform standards have been developed and
agreed to by the Services for the creation of a CRP. The Recovery Care
Coordinators will assist in the development of the recovery plan and
provide oversight of its implementation.
Recommendation 3: The GAO recommends that the Secretary of Defense
direct the Secretary of the Army to take steps to determine whether the
results arc representative of all Service members in WTUs, such as by
conducting nonresponse analyses, and take additional steps if necessary
to obtain results that are representative to determine whether the
results of the Warrior Transition Unit Program Satisfaction Survey can
be used to assess the effectiveness of the WTUs.
DOD Response: Concur. The Army has numerous metrics that allow
transparency into the Warrior Care and Transition Program. The use of
independent surveys is one means by which the Army gains an indication
of soldier satisfaction. Additionally, the Commander of the Walter Reed
Warrior in Transition Unit conducts his own satisfaction survey, the
results of which correlate well with those obtained using the Synovate
instrument. Soldiers are satisfied with the program. As part of an
ongoing effort to improve the quality of responses received to the
Synovate instrument, the previous hard-copy survey was recently
replaced by telephonic surveys. This has greatly increased the
percentage of respondents, yet the overall satisfaction expressed in
these surveys has not wavered. As the change to telephonic surveys has
resulted in an increased response rate, we believe a nonresponse
analysis is not required at this time. However, we will re-evaluate the
need for a nonresponse analysis not later than September 1, 2009.
[End of section]
Appendix III: GAO Contact and Staff Acknowledgments:
GAO Contact:
Randall B. Williamson at (202) 512-7114 or williamsonr@gao.gov:
Staff Acknowledgments:
In addition to the contact named above, Bonnie Anderson, Assistant
Director; Janina Austin; Susannah Bloch; Christopher Langford; Lisa
Motley; Jessica C. Smith; C. Jenna Sondhelm; and Suzanne Worth made
major contributions to this report.
[End of section]
Footnotes:
[1] The data include active component, Reserve, and National Guard
servicemembers wounded in action from October 7, 2001, through December
27, 2008. OEF, which began in October 2001, supports combat operations
in Afghanistan and other locations, and OIF, which began in March 2003,
supports combat operations in Iraq and other locations.
[2] Seriously injured servicemembers are also transported to Brooke
Army Medical Center in San Antonio, Texas and Balboa Naval Medical
Center in San Diego, California.
[3] Independent Review Group, Rebuilding the Trust: Report on
Rehabilitative Care and Administrative Processes at Walter Reed Army
Medical Center and National Naval Medical Center (Arlington, Va., April
2007); Task Force on Returning Global War on Terror Heroes, Report to
the President (April 2007); and President's Commission on Care for
America's Returning Wounded Warriors, Serve, Support, Simplify (July
2007).
[4] GAO, DOD and VA: Preliminary Observations on Efforts to Improve
Health Care and Disability Evaluations for Returning Servicemembers,
[hyperlink, http://www.gao.gov/products/GAO-07-1256T] (Washington,
D.C.: Sept. 26, 2007).
[5] GAO, DOD and VA: Preliminary Observations on Efforts to Improve
Care Management and Disability Evaluations for Servicemembers,
[hyperlink, http://www.gao.gov/products/GAO-08-514T] (Washington, D.C.:
Feb. 27, 2008).
[6] The Army's Office of the Surgeon General and Medical Command are
separate entities with different duties and powers--the Office of the
Surgeon General provides medical expertise to the Army and the Medical
Command controls hospitals and other medical facilities. To reduce
duplication and improve communication, the staff of the two entities
are blended into a single staff and they report to one person, who is
both the Army Surgeon General and the commander of the Army's Medical
Command.
[7] The Army's Warrior Care and Transition Office is responsible for
providing strategic direction and for developing and assessing plans,
policies, and resources for programs dedicated to caring for wounded,
ill, and injured servicemembers and their families.
[8] Initially, most seriously injured servicemembers from OEF and OIF
are evacuated to Landstuhl Regional Medical center in Germany for
treatment.
[9] The community-based WTUs are located in eight states (Alabama,
Arkansas, California, Florida, Illinois, Massachusetts, Utah, and
Virginia) and Puerto Rico. As of December 1, 2008, the Army was serving
about 1,400 servicemembers in community-based WTUs.
[10] Active component refers to full-time active duty servicemembers.
Reserve and National Guard servicemembers are called to active duty in
response to a national emergency, and many were employed in civilian
occupations before they were called to active duty.
[11] This includes all WTUs, including those in Germany and the
community-based WTUs.
[12] The study was conducted by the United States Army Manpower
Analysis Agency, a subordinate office of the Assistant Secretary of the
Army's Manpower and Reserve Affairs.
[13] Base Realignment and Closure is a congressionally authorized
process for the Department of Defense (DOD) to reorganize its base
structure to more efficiently and effectively support forces and
increase operational readiness. Base Realignment and Closure 2005 was
authorized by the National Defense Authorization Act for Fiscal Year
2002, Pub. L. No. 107-107, tit. XXX, 115 Stat. 1012, 1342-53 (2001).
[14] The Army's disability evaluation process includes identifying
medical conditions that could render a servicemember unfit for duty.
[15] These data include servicemembers at all WTUs, including WTUs in
Germany and community-based WTUs.
[16] Comprehensive Transition Plans were initially referred to as
Comprehensive Care Plans.
[17] In general, agency surveys must be approved by the Office of
Management and Budget. See 44 U.S.C. § 3507. However, DOD has authority
to conduct surveys of servicemembers and their families to determine
the effectiveness of federal programs relating to military families and
the need for new programs without seeking approval from the Office of
Management and Budget. See 10 U.S.C. § 1782; DOD 8910.1-M, Department
of Defense Procedures for Management of Information Requirements § C3.7
(June 1998). Accordingly, the Army did not seek Office of Management
and Budget approval for the Warrior Transition Unit Program
Satisfaction Survey.
[18] See Office of Management and Budget Standards and Guidelines for
Statistical Surveys (September 2006), which documents the professional
principles and practices that federal agencies are required to adhere
to and the level of quality and effort expected in statistical
activities. For questionnaire surveys, regardless of the mode of
administration--mail or telephone--a nonresponse analysis may be
conducted by randomly selecting a sample of the nonrespondents and
surveying them to obtain answers to key survey questions.
[19] The Army regional Medical Commands are located in six geographic
locations, including the United States, Europe, and the Pacific. These
commands oversee the daily operations of the military treatment
facilities (MTF) within their respective regions.
[20] This plan was previously called the Army Medical Action Plan.
[End of section]
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