Recovering Servicemembers

DOD and VA Have Made Progress to Jointly Develop Required Policies but Additional Challenges Remain Gao ID: GAO-09-540T April 29, 2009

The National Defense Authorization Act for Fiscal Year 2008 (NDAA 2008) requires the Departments of Defense (DOD) and Veterans Affairs (VA) to jointly develop and implement comprehensive policies on the care, management, and transition of recovering servicemembers. The Senior Oversight Committee (SOC)--jointly chaired by DOD and VA leadership--has assumed responsibility for these policies. The NDAA 2008 also requires GAO to report on the progress DOD and VA make in developing and implementing the policies. This statement provides preliminary information on (1) the progress DOD and VA have made in jointly developing the comprehensive policies required in the NDAA 2008 and (2) the challenges DOD and VA are encountering in the joint development and initial implementation of these policies. GAO determined the current status of policy development by assessing the status reported by SOC officials and analyzing supporting documentation. To identify challenges, GAO interviewed the Acting Under Secretary of Defense for Personnel and Readiness, the Executive Director and Chief of Staff of the SOC, the departmental co-leads for most of the SOC work groups, the Acting Director of DOD's Office of Transition Policy and Care Coordination, and other knowledgeable officials.

DOD and VA have made substantial progress in jointly developing policies required by sections 1611 through 1614 of the NDAA 2008 in the areas of (1) care and management, (2) medical and disability evaluation, (3) return to active duty, and (4) transition of care and services received from DOD to VA. Overall, GAO's analysis showed that as of March 2009, 60 of the 76 requirements GAO identified have been completed and the remaining 16 requirements are in progress. DOD and VA have completed all of the policy development requirements for medical and disability evaluations, including issuing a report on the feasibility and advisability of consolidating the DOD and VA disability evaluation systems, although the pilot for this approach is still ongoing. DOD has also completed establishing standards for returning recovering servicemembers to active duty. More than two-thirds of the policy development requirements have been completed for the remaining two policy areas--care and management and the transition of recovering servicemembers from DOD to VA. Most of these requirements were addressed in a January 2009 DOD Directive-Type Memorandum that was developed in consultation with VA. DOD officials reported that more information will be provided in a subsequent policy instruction, which will be issued in June 2009. VA also plans to issue related policy guidance in June 2009. DOD and VA officials told GAO that they have experienced numerous challenges as they worked to jointly develop policies to improve the care, management, and transition of recovering servicemembers. According to officials, these challenges contributed to the length of time required to issue policy guidance, and in some cases the challenges have not yet been completely resolved. For example, the SOC must still standardize key terminology relevant to policy issues affecting recovering servicemembers. DOD and VA agreement on key definitions for what constitutes "mental health," for instance, is important for developing policies that define the scope, eligibility, and service levels for recovering servicemembers. Recent changes affecting the SOC may also pose future challenges to policy development. Some officials have expressed concern that DOD's recent changes to staff supporting the SOC have disrupted the unity of command because SOC staff now report to three different officials within DOD and VA. However, it is too soon to determine how DOD's staffing changes will work. Additionally, according to DOD and VA officials, the SOC's scope of responsibilities appears to be in flux. While the SOC will remain responsible for policy matters for recovering servicemembers, a number of policy issues may now be directed to the DOD and VA Joint Executive Council. Despite this uncertainty, DOD and VA officials told GAO that the SOC's work groups continue to carry out their responsibilities. GAO shared the information contained in this statement with DOD and VA officials, and they agreed with the information GAO presented.



GAO-09-540T, Recovering Servicemembers: DOD and VA Have Made Progress to Jointly Develop Required Policies by Additional Challenges Remain This is the accessible text file for GAO report number GAO-09-540T entitled 'Recovering Servicemembers: DOD and VA Have Made Progress to Jointly Develop Required Policies but Additional Challenges Remain' which was released on April 29, 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. Testimony: Before the Personnel Subcommittee of the Committee on Armed Services, U.S. Senate: United States Government Accountability Office: GAO: For Release on Delivery: Expected at 2:30 p.m. EDT: Wednesday, April 29, 2009: Recovering Servicemembers: DOD and VA Have Made Progress to Jointly Develop Required Policies but Additional Challenges Remain: Statement of Randall B. Williamson: Director, DOD and VA Health Care: Statement of Daniel Bertoni: Director, Education, Workforce, and Income Security: Statement of Valerie C. Melvin: Director, Information Management and Human Capital Issues: GAO-09-540T: GAO Highlights: Highlights of GAO-09-540T, a testimony before the Personnel Subcommittee of the Committee on Armed Services, U.S. Senate. Why GAO Did This Study: The National Defense Authorization Act for Fiscal Year 2008 (NDAA 2008) requires the Departments of Defense (DOD) and Veterans Affairs (VA) to jointly develop and implement comprehensive policies on the care, management, and transition of recovering servicemembers. The Senior Oversight Committee (SOC)”jointly chaired by DOD and VA leadership”has assumed responsibility for these policies. The NDAA 2008 also requires GAO to report on the progress DOD and VA make in developing and implementing the policies. This statement provides preliminary information on (1) the progress DOD and VA have made in jointly developing the comprehensive policies required in the NDAA 2008 and (2) the challenges DOD and VA are encountering in the joint development and initial implementation of these policies. GAO determined the current status of policy development by assessing the status reported by SOC officials and analyzing supporting documentation. To identify challenges, GAO interviewed the Acting Under Secretary of Defense for Personnel and Readiness, the Executive Director and Chief of Staff of the SOC, the departmental co-leads for most of the SOC work groups, the Acting Director of DOD‘s Office of Transition Policy and Care Coordination, and other knowledgeable officials. What GAO Found: DOD and VA have made substantial progress in jointly developing policies required by sections 1611 through 1614 of the NDAA 2008 in the areas of (1) care and management, (2) medical and disability evaluation, (3) return to active duty, and (4) transition of care and services received from DOD to VA. Overall, GAO‘s analysis showed that as of April 2009, 60 of the 76 requirements GAO identified have been completed and the remaining 16 requirements are in progress. DOD and VA have completed all of the policy development requirements for medical and disability evaluations, including issuing a report on the feasibility and advisability of consolidating the DOD and VA disability evaluation systems, although the pilot for this approach is still ongoing. DOD has also completed establishing standards for returning recovering servicemembers to active duty. More than two-thirds of the policy development requirements have been completed for the remaining two policy areas”care and management and the transition of recovering servicemembers from DOD to VA. Most of these requirements were addressed in a January 2009 DOD Directive-Type Memorandum that was developed in consultation with VA. DOD officials reported that more information will be provided in a subsequent policy instruction, which will be issued in June 2009. VA also plans to issue related policy guidance in June 2009. DOD and VA officials told GAO that they have experienced numerous challenges as they worked to jointly develop policies to improve the care, management, and transition of recovering servicemembers. According to officials, these challenges contributed to the length of time required to issue policy guidance, and in some cases the challenges have not yet been completely resolved. For example, the SOC must still standardize key terminology relevant to policy issues affecting recovering servicemembers. DOD and VA agreement on key definitions for what constitutes ’mental health,“ for instance, is important for developing policies that define the scope, eligibility, and service levels for recovering servicemembers. Recent changes affecting the SOC may also pose future challenges to policy development. Some officials have expressed concern that DOD‘s recent changes to staff supporting the SOC have disrupted the unity of command because SOC staff now report to three different officials within DOD and VA. However, it is too soon to determine how DOD‘s staffing changes will work. Additionally, according to DOD and VA officials, the SOC‘s scope of responsibilities appears to be in flux. While the SOC will remain responsible for policy matters for recovering servicemembers, a number of policy issues may now be directed to the DOD and VA Joint Executive Council. Despite this uncertainty, DOD and VA officials told GAO that the SOC‘s work groups continue to carry out their responsibilities. GAO shared the information contained in this statement with DOD and VA officials, and they agreed with the information GAO presented. View [hyperlink, http://www.gao.gov/products/GAO-09-540T] or key components. For more information, contact Randall B. Williamson at (202) 512-7114 or williamsonr@gao.gov, Daniel Bertoni at (202) 512-7215 or bertonid@gao.gov, or Valerie C. Melvin at (202) 512-6304 or melvinv@gao.gov. [End of section] Mr. Chairman and Members of the Subcommittee: We are pleased to be here today as you examine issues related to meeting the critical needs of recovering servicemembers by reviewing the progress made by the Department of Defense (DOD) and the Department of Veterans Affairs (VA) in jointly developing policies mandated by the National Defense Authorization Act for Fiscal Year 2008 (NDAA 2008). [Footnote 1] Over 1.6 million U.S. troops have deployed in Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) since October 2001. [Footnote 2],[Footnote 3] In February 2009, DOD reported that over 33,000 servicemembers have been wounded in action since the onset of these conflicts.[Footnote 4] Because of improved battlefield medicine, those who might have died in past conflicts are now surviving, many with multiple serious injuries such as amputations, traumatic brain injury (TBI), and post-traumatic stress disorder (PTSD). Beyond adjusting to their injuries, recovering servicemembers may face additional challenges, including difficulties managing their outpatient recovery process, difficulties navigating the military's disability evaluation system, and problems transitioning between care provided by DOD and care provided by VA. Questions were raised in the media and by Congress about whether DOD and VA are prepared to meet the needs of the increasing number of recovering servicemembers and veterans. In February 2007, a series of Washington Post articles disclosed deficiencies in the provision of outpatient services at Walter Reed Army Medical Center, including poor living conditions at Walter Reed, a confusing disability evaluation system, and servicemembers remaining in outpatient status for months and sometimes years without a clear understanding about their plan of care or the future of their military service. Various review groups investigated the challenges that DOD and VA faced in providing care to recovering servicemembers and made a number of recommendations to address the problems they identified. Shortly after the media disclosures, we testified about the challenges facing recovering servicemembers during their recovery process.[Footnote 5] In May 2007, DOD and VA established the Wounded, Ill, and Injured Senior Oversight Committee (SOC) to address the problems that had been identified with the care of recovering servicemembers. The committee is co-chaired by the Deputy Secretaries of DOD and VA and includes military service Secretaries and other high-ranking officials within both departments. One of the SOC's primary responsibilities is to oversee the development of policies in response to the recommendations of the review groups that studied the issues associated with recovering servicemembers' health care and benefits. Generally, senior officials from the SOC sign and issue interim policy guidance, which is then vetted through DOD's and VA's internal processes to be finalized as department policies. The NDAA 2008, which was enacted in January 2008, requires DOD and VA, to the extent feasible, to jointly develop and implement a comprehensive policy on improvements to the care, management, and transition of recovering servicemembers. Specifically, section 1611(a) of the NDAA 2008 directs DOD and VA to cover four key areas--(1) care and management, (2) medical evaluation and disability evaluation, (3) the return of servicemembers to active duty, and (4) the transition of recovering servicemembers from DOD to VA. Because of the related ongoing work of the SOC, it assumed responsibility for addressing these requirements. The NDAA 2008 also requires GAO to report on the progress DOD and VA make in developing and implementing the comprehensive policy.[Footnote 6] Our work is focused on the status of the development of the comprehensive policy, which includes the development of multiple policies that are further enumerated in sections 1611 through 1614 of the law. In my testimony today, I will discuss our preliminary findings on (1) the progress DOD and VA have made in jointly developing comprehensive policies for recovering servicemembers in the areas of care and management, medical and disability evaluation, return to active duty, and transition from care and services received from DOD to VA as required by sections 1611 through 1614 of the NDAA 2008 and (2) the challenges DOD and VA are encountering in the joint development and initial implementation of these policies. To assess the extent to which DOD and VA have made progress in developing the required policies, we asked SOC representatives to report on the status of policy development for the 76 individual requirements that we identified in sections 1611 through 1614 of the NDAA 2008, which we grouped into 14 categories.[Footnote 7] (See app. I for a summary of these requirements and categories.) We also asked the SOC representatives to provide documentation to substantiate the status of each requirement, and we verified the reported status of each requirement by reviewing this documentation. We determined whether each of the requirements (1) had been completed, (2) was in progress, or (3) had not been acted upon. We considered a requirement to have been "completed" if a document had been signed and approved by DOD, VA, or both, at the SOC level, that contained standards, guidelines, or procedures that addressed the requirement, even if DOD, VA, or both plan to issue additional policies on the subject.[Footnote 8] We considered a requirement to be "in progress" if documentation demonstrated that work had been initiated to develop standards, guidelines, or procedures that addressed the requirement. We considered a requirement not to have been acted upon if no action had been taken to develop standards, guidelines, or procedures that address the requirement. We based our review in part on the interim policy documents signed by DOD and VA officials working through the SOC. In some cases, interim policy documents were signed by officials of both departments, and in other cases, the documents were signed by officials of one department, depending upon the requirement. Interim policy documents could be in the form of memoranda of agreement, memoranda of understanding, directives, decision-or directive-type memoranda, instructions or policy memoranda, or other guidelines or forms of guidance. In addition, we conducted follow-up interviews with DOD and VA officials when we needed clarification on the reported progress or additional documentation. We did not, however, evaluate the quality of the policy documents we reviewed. To identify the challenges DOD and VA encountered in jointly developing and initially implementing the required policies, we interviewed officials from both departments to obtain an account of their experiences in the policy development process. In conducting our work, we interviewed the Acting Under Secretary of Defense for Personnel and Readiness, the Executive Director and Chief of Staff of the SOC, the departmental co-leads for most of the SOC work groups, the Acting Director of DOD's Office of Transition Policy and Care Coordination, and other relevant DOD and VA officials. We shared the information contained in this statement with DOD and VA officials, and they agreed with the information we presented. We conducted our work from May 2008 through April 2009 in accordance with all sections of GAO's Quality Assurance Framework that are relevant to our objectives. The framework requires that we plan and perform the engagement to obtain sufficient and appropriate evidence to meet our stated objectives and to discuss any limitations in our work. We believe that the information and data obtained, and the analysis conducted, provide a reasonable basis for any findings and conclusions. Background: Over the past 8 years, DOD has designated over 33,000 servicemembers involved in OEF and OIF as wounded in action. The severity of injuries can result in a lengthy process for a patient to either return to duty or to transition to veteran status. The most seriously injured servicemembers from these conflicts usually receive care at Walter Reed Army Medical Center or the National Naval Medical Center.[Footnote 9] According to DOD officials, once they are stabilized and discharged from the hospital, servicemembers may relocate closer to their homes or military bases and be treated as outpatients by the closest military or VA facility. Recovering servicemembers potentially navigate two different disability evaluation systems that serve different purposes. DOD's system serves a personnel management purpose by identifying servicemembers who are no longer medically fit for duty. If a servicemember is found unfit because of medical conditions incurred in the line of duty, the servicemember is assigned a disability rating and can be discharged from duty. This disability rating, along with years of service and other factors, determines subsequent disability and health care benefits from DOD. Under VA's system, disability ratings help determine the level of disability compensation a veteran receives and priority status for enrollment for health care benefits. To determine eligibility for disability compensation, VA evaluates all claimed medical conditions, whether they were evaluated previously by the military service's evaluation process or not. If VA finds that a veteran has one or more service-connected disabilities that together result in a final rating of at least 10 percent,[Footnote 10] VA will pay monthly compensation and the veteran will be eligible to receive medical care from VA. Efforts to Address the Care and Benefits for Recovering Servicemembers: Efforts have been taken to address the deficiencies reported at Walter Reed related to the care provided and transitioning of recovering servicemembers. After the press reports about Walter Reed, several high- level review groups were established to study the care and benefits provided to recovering servicemembers by DOD and VA. The studies produced from all of these groups, released from April 2007 through June 2008, contained over 400 recommendations covering a broad range of topics, including case management, disability evaluation systems, data sharing between the departments, and the need to better understand and diagnose TBI and PTSD.[Footnote 11] In May 2007, DOD and VA established the SOC as a temporary, 1-year committee with the responsibility for addressing recommendations from these reports. To conduct its work, the SOC established eight work groups called lines of action (LOA). Each LOA is co-chaired by representatives from DOD and VA and has representation from each military service. LOAs are responsible for specific issues, such as disability evaluation systems and case management. (See table 1 for an overview of the LOAs.) The committee was originally intended to expire May 2008 but it was extended to January 2009. Then, the NDAA 2009 extended the SOC through December 2009.[Footnote 12] Table 1: Overview of the Senior Oversight Committee's LOAs: LOAs: LOA 1: Disability Evaluation System; Responsibilities: Addresses efforts to reform the DOD and VA disability evaluation systems. LOAs: LOA 2: Traumatic Brain Injury (TBI)/Post Traumatic Stress Disorder (PTSD); Responsibilities: Addresses issues related to TBI/PTSD. LOAs: LOA 3: Case Management; Responsibilities: Addresses care, management, and transition of recovering servicemembers from recovery to rehabilitation and reintegration. LOAs: LOA 4: DOD/VA Data Sharing; Responsibilities: Addresses issues regarding the electronic exchange of DOD and VA health records. LOAs: LOA 5: Facilities; Responsibilities: Address issues relating to military and VA medical facilities. LOAs: LOA 6: Clean Sheet Review; Responsibilities: Develops recommendations to improve care and benefits without the constraints of existing laws, regulations, organizational roles, personnel constraints or budgets. LOAs: LOA 7: Legislation and Public Affairs; Responsibilities: Addresses legal and other issues for policy development. LOAs: LOA 8: Personnel, Pay, and Financial Support; Responsibilities: Addresses compensation and benefit issues. Source: GAO analysis of SOC documents and interviews with SOC officials. [End of table] In addition to addressing the published recommendations, the SOC assumed responsibility for addressing the policy development and reporting requirements contained in the NDAA 2008. Section 1611(a) of the NDAA 2008 directs DOD and VA, to the extent feasible, to develop and implement a comprehensive policy covering four areas--(1) care and management, (2) medical evaluation and disability evaluation, (3) the return of servicemembers to active duty, and (4) the transition of recovering servicemembers from DOD to VA. The specific requirements for each of these four areas are further enumerated in sections 1611 through 1614 of the law and would include the development of multiple policies. Table 2 summarizes the requirements for the jointly developed policies. Table 2: Summary of the NDAA 2008 Requirements to Jointly Develop Comprehensive Policy for Improving Care and Management, Medical and Disability Evaluation, Return-to-Duty Decisions, and Transition of Recovering Servicemembers in Sections 1611 through 1614: Key areas of policy development: Care and management of recovering servicemembers (section 1611); Summary of requirement: Requires DOD and VA to develop policies to address several aspects of access to health care and other assistance, including the training of health care professionals, waiting times, patient tracking, and family support. Key areas of policy development: Medical evaluation and disability evaluation of recovering servicemembers (section 1612); Summary of requirement: Requires DOD to develop policies for improved medical evaluations, DOD and VA to develop policies for improved disability evaluations and report to Congress on the feasibility and advisability of consolidating their disability evaluation systems. Key areas of policy development: Return of servicemembers who have recovered to active duty (section 1613); Summary of requirement: Requires DOD to establish standards for determinations by the military departments on the return of recovering servicemembers to active duty. Key areas of policy development: Transition of recovering servicemembers from receipt of care and services through DOD to receipt of care and services through VA (section 1614); Summary of requirement: Requires DOD and VA to jointly develop and implement procedures and standards for the transition of servicemembers from health care and treatment provided through DOD to care, treatment, and rehabilitation provided through VA. Source: GAO analysis of sections 1611 through 1614 of the NDAA 2008. [End of table] Selected Initiatives of the SOC: Since its inception, the SOC has completed many initiatives, such as establishing the Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury and creating a National Resource Directory, which is an online resource for recovering servicemembers, veterans, and their families. In addition, the SOC has undertaken initiatives specifically related to the requirements contained in sections 1611 through 1614 of the NDAA 2008. Specifically, the SOC supported the development of several programs to improve the care and management of benefits to recovering servicemembers, including the disability evaluation system pilot and the Federal Recovery Coordination Program. These programs are currently in pilot or beginning phases: * Disability evaluation system pilot: DOD and VA are piloting a joint disability evaluation system to improve the timeliness and resource use of their separate disability evaluation systems. Key features of the pilot include a single physical examination conducted to VA standards by the medical evaluation board that documents medical conditions that may limit a servicemember's ability to serve in the military, disability ratings prepared by VA for use by both DOD and VA in determining disability benefits, and additional outreach and nonclinical case management provided by VA staff at the DOD pilot locations to explain VA results and processes to servicemembers. DOD and VA anticipate a final report on the pilot in August 2009. * Federal Recovery Coordination Program: In 2007, DOD and VA established the Federal Recovery Coordination Program in response to the report by the President's Commission on Care for America's Returning Wounded Warriors, commonly referred to as the Dole-Shalala Commission. The commission's report highlighted the need for better coordination of care and additional support for families. The Federal Recovery Coordination Program serves the most severely injured or ill servicemembers, or those who are catastrophically injured. These servicemembers are highly unlikely to be able to return to duty and will have to adjust to permanent disabling conditions. The program was created to provide uniform and seamless care, management, and transition of recovering servicemembers and their families by assigning recovering servicemembers to coordinators who manage the development and implementation of a recovery plan. Each servicemember enrolled in the Federal Recovery Coordination Program has a Federal Individual Recovery Plan, which tracks care, management, and transition through recovery, rehabilitation, and reintegration. Although the Federal Recovery Coordination Program is operated as a joint DOD and VA program, VA is responsible for the administrative duties and program personnel are employees of the agency. Beyond these specific initiatives, the SOC took responsibility for issues related to electronic health records through the work of LOA 4, the SOC's work group focused on DOD and VA data sharing. This LOA also addressed issues more generally focused on joint DOD and VA data needs, including developing components for the disability evaluation system pilot and the individual recovery plans for the Federal Recovery Coordination Program. LOA 4's progress on these issues was monitored and overseen by the SOC. The NDAA 2008 established an interagency program office (IPO) to serve as a single point of accountability for both departments in the development and implementation of interoperable electronic health records.[Footnote 13],[Footnote 14] Subsequently, management oversight of many of LOA 4's responsibilities were transferred to the IPO. Also, the IPO's scope of responsibility was broadened to include personnel and benefits data sharing between DOD and VA. DOD and VA Have Completed the Majority of the Requirements to Jointly Develop Policies on Care and Management, Medical and Disability Evaluation, Return to Active Duty, and the Transition from DOD to VA: As of April 2009, DOD and VA have completed 60 of the 76 requirements we identified for jointly developing policies for recovering servicemembers on (1) care and management, (2) medical and disability evaluation, (3) return to active duty, and (4) servicemember transition from DOD to VA. The two departments have completed all requirements for developing policy for two of the policy areas--medical and disability evaluation and return to active duty. Of the 16 requirements that are in progress, 10 are related to care and management and 6 are related to servicemembers transitioning from DOD to VA. (See table 3.) Table 3: Summary of Status of DOD and VA Progress to Jointly Develop Policy for Improving Care and Management, Medical and Disability Evaluation, Return-to-Duty Decisions, and Transition of Recovering Servicemembers Required by the NDAA 2008 Sections 1611 through 1614, as of April 2009: Policy area: 1. Care and management of recovering servicemembers (section 1611); Number of requirements: 38; Requirements completed: 28; Requirements in progress: 10; Overall status: In progress. Policy area: 2. Medical evaluation and disability evaluation of recovering servicemembers (section 1612); Number of requirements: 18; Requirements completed: 18; Requirements in progress: 0; Overall status: Complete. Policy area: 3. Return of servicemembers who have recovered to active duty (section 1613); Number of requirements: 1; Requirements completed: 1; Requirements in progress: 0; Overall status: Complete. Policy area: 4. Transition of recovering servicemembers from receipt of care and services through DOD to receipt of care and services through VA (section 1614); Number of requirements: 19; Requirements completed: 13; Requirements in progress: 6; Overall status: In progress. Policy area: Overall progress; Number of requirements: 76; Requirements completed: 60 (79 percent); Requirements in progress: 16 (21 percent); Overall status: In progress. Source: GAO analysis of information from the SOC. [End of table] DOD and VA Have Completed More Than Two-Thirds of the Requirements Regarding the Care and Management of Recovering Servicemembers: We found that more than two-thirds of the requirements for DOD's and VA's joint policy development to improve the care and management of recovering servicemembers have been completed while the remaining requirements are in progress. (See table 4.) We identified 38 requirements for this policy area and grouped them into five categories. Although 28 of the 38 requirements had been completed, one category--improving access to medical and other health care services-- had most of its requirements in progress. Table 4: Status of Requirements to Address the Care and Management of Recovering Servicemembers, as of April 2009: Categories of requirements for care and management: 1. Develop policy for training and skills of health care professionals, recovery care coordinators, medical care case managers, and non-medical care managers[A]; Number of requirements: 2; Requirements completed: 2; Requirements in progress: 0; Overall status: Complete. Categories of requirements for care and management: 2. Develop policy for recovery plans for recovering servicemembers and the training, duties, support, and supervision of recovery care coordinators, medical care case managers, and non-medical care managers[B]; Number of requirements: 20; Requirements completed: 19; Requirements in progress: 1; Overall status: In progress. Categories of requirements for care and management: 3. Develop policy for improved access to medical and other health care services[C]; Number of requirements: 10; Requirements completed: 1; Requirements in progress: 9; Overall status: In progress. Categories of requirements for care and management: 4. Develop policy for improved outreach and services for family members of recovering servicemembers[D]; Number of requirements: 5; Requirements completed: 5; Requirements in progress: 0; Overall status: Complete. Categories of requirements for care and management: 5. Apply policy to recovering servicemembers on the temporary disability retired list as determined by DOD[E]; Number of requirements: 1; Requirements completed: 1; Requirements in progress: 0; Overall status: Complete. Categories of requirements for care and management: Overall progress; Number of requirements: 38; Requirements completed: 28 (74 percent); Requirements in progress: 10 (26 percent); Overall status: Complete. Source: GAO analysis of information from the SOC. [A] NDAA 2008, Section 1611(d). [B] NDAA 2008, Section 1611(e)(1) - (4). [C] NDAA 2008, Section 1611(e)(5) - (11). [D] NDAA 2008, Section 1611(f)(g). [E] NDAA 2008, Section 1611(h). [End of table] Most of the completed requirements were addressed in DOD's January 2009 Directive-Type Memorandum (DTM), which was developed in consultation with VA.[Footnote 15] This DTM, entitled Recovery Coordination Program: Improvements to the Care, Management, and Transition of Recovering Service Members, establishes interim policy for the improvements to the care, management, and transition of recovering servicemembers in response to sections 1611 and 1614 of the NDAA 2008. In consultation with VA, DOD created the Recovery Coordination Program in response to the NDAA 2008 requirements. This program, which was launched in November 2008, extended the same comprehensive coordination and transition support provided under the Federal Recovery Coordination Program to servicemembers who were less severely injured or ill, yet who still were unlikely to return to duty and continue their careers in the military. This program follows the same structured process as the Federal Recovery Coordination Program. However, DOD oversees this program and the coordinators are DOD employees. DOD's January 2009 DTM includes information on the scope and program elements of the Recovery Coordination Program as well as on the roles and responsibilities of the recovery care coordinators, federal recovery coordinators, and medical care case managers and non-medical care managers. According to DOD officials, DOD took the lead in developing policy to address the requirements for care and management because it interpreted most of the requirements to refer to active duty servicemembers. According to DOD and VA officials, the January 2009 DTM serves as the interim policy for care, management, and transition until the completion of DOD's comprehensive policy instruction, which is estimated to be completed by June 2009.[Footnote 16] This policy instruction will contain more detailed information on the policies outlined in the DTM. A VA official told us that VA also plans to issue related policy guidance as part of a VA handbook in June 2009. The VA official noted that the final form of the policy document would correspond with DOD's instruction. DOD and VA Have Completed All of the Requirements for Developing Policy on the Medical Evaluation and Disability Evaluation of Recovering Servicemembers: DOD and VA have completed all of the requirements for developing policy to improve the medical and physical disability evaluation of recovering servicemembers. (See table 5.) We identified 18 requirements for this policy area and grouped them into three categories: (1) policy for improved medical evaluations, (2) policy for improved physical disability evaluations, and (3) reporting on the feasibility and advisability of consolidating DOD and VA disability evaluation systems. Table 5: Status of Requirements to Address the Medical Evaluation and Disability Evaluation of Recovering Servicemembers, as of April 2009: Categories of requirements for medical and disability evaluations: 1. Develop policy for improved medical evaluations[A]; Number of requirements: 8; Requirements completed: 8; Requirements in progress: 0; Overall status: Complete. Categories of requirements for medical and disability evaluations: 2. Develop policy for improved physical disability evaluations[B]; Number of requirements: 8; Requirements completed: 8; Requirements in progress: 0; Overall status: Complete. Categories of requirements for medical and disability evaluations: 3. Report on feasibility and advisability of consolidating DOD and VA disability evaluation systems[C]; Number of requirements: 2; Requirements completed: 2; Requirements in progress: 0; Overall status: Complete. Categories of requirements for medical and disability evaluations: Overall progress; Number of requirements: 18; Requirements completed: 18 (100 percent); Requirements in progress: 0; Overall status: Complete. Source: GAO analysis of information from the SOC. [A] NDAA 2008, Section 1612(a). [B] NDAA 2008, Section 1612(b). [C] NDAA 2008, Section 1612(c). [End of table] DOD issued a series of memoranda that addressed the first two categories starting in May 2007. These memoranda, some of which were developed in collaboration with VA, contained policies and implementing guidance to improve DOD's existing disability evaluation system. To address the third category in this policy area, DOD and VA have issued a report to Congress that describes the organizing framework for consolidating the two departments' disability evaluation systems and states that the departments are hopeful that consolidation would be feasible and advisable even though the evaluation of this approach through the disability evaluation system pilot is still ongoing. According to an agency official, further assessment of the feasibility and advisability of consolidation will be conducted. DOD and VA anticipate issuing a final report on the pilot in August 2009. However, as we reported in September 2008, it was unclear what specific criteria DOD and VA will use to evaluate the success of the pilot, and when sufficient data will be available to complete such an evaluation. [Footnote 17] DOD Has Completed Establishing Standards for Determining the Return of Recovering Servicemembers to Active Duty: DOD has completed the requirement for establishing standards for determining the return of recovering servicemembers to active duty. (See table 6.)[Footnote 18] Table 6: Status of Requirement to Address the Standards for Return-to- Duty Decisions, as of April 2009: Requirement for return-to-duty decisions: 1. Establish standards for return-to-duty decisions[A]; Number of requirements: 1; Requirements completed: 1; Requirements in progress: 0; Overall status: Complete. Requirement for return-to-duty decisions: Overall progress; Number of requirements: 1; Requirements completed: 1 (100 percent); Requirements in progress: 0; Overall status: Complete. Source: GAO analysis of information from the SOC. [A] NDAA 2008, Section 1613. [End of table] On March 13, 2008, DOD issued a DTM amending its existing policy on retirement or separation due to a physical disability. The revised policy states that the disability evaluation system will be the mechanism for determining both retirement or separation and return to active duty because of a physical disability. An additional revision to the existing DOD policy allows DOD to consider requests for permanent limited active duty or reserve status for servicemembers who have been determined to be unfit because of a physical disability. Previously, DOD could consider such cases only as exceptions to the general policy. According to a DOD official, it is too early to tell whether the revisions will have an effect on retirement rates or return-to-duty rates. DOD annually assesses the disability evaluation system and tracks retirement and return to duty rates. However, because of the length of time a servicemember takes to move through the disability evaluation system--sometimes over a year--it will take a while before changes due to the policy revisions register in the annual assessment of the disability evaluation system. Over Two-Thirds of the Requirements for Improving the Transition of Recovering Servicemembers from DOD to VA Have Been Completed: DOD and VA have completed more than two-thirds of the requirements for developing procedures, processes, or standards for improving the transition of recovering servicemembers. (See table 7.) We identified 19 requirements for this policy area, and we grouped them into five categories. We found that 13 of the 19 policy requirements have been completed, including all of the requirements for two of the categories- -the development of a process for a joint separation and evaluation physical examination and development of procedures for surveys and other mechanisms to measure patient and family satisfaction with services for recovering servicemembers. The remaining three categories contain requirements that are still in progress. Table 7: Status of Requirements to Address the Transition of Recovering Servicemembers, as of April 2009: Categories of requirements for improved transition: 1. Develop procedures, processes, and standards for care coordination, benefits, and service transition[A]; Number of requirements: 11; Requirements completed: 7; Requirements in progress: 4; Overall status: In progress. Categories of requirements for improved transition: 2. Develop procedures and processes for information sharing of military service and health records[B]; Number of requirements: 5; Requirements completed: 4; Requirements in progress: 1; Overall status: In progress. Categories of requirements for improved transition: 3. Develop a process for a joint separation and evaluation physical examination[C]; Number of requirements: 1; Requirements completed: 1; Requirements in progress: 0; Overall status: Complete. Categories of requirements for improved transition: 4. Develop procedures for surveys and other mechanisms to measure patient and family satisfaction with services for recovering servicemembers[D]; Number of requirements: 1; Requirements completed: 1; Requirements in progress: 0; Overall status: Complete. Categories of requirements for improved transition: 5. Develop procedures to ensure the participation of recovering servicemembers of the National Guard or Reserve in the Benefits Delivery at Discharge Program[E, F]; Number of requirements: 1; Requirements completed: 0; Requirements in progress: 1; Overall status: In progress. Categories of requirements for improved transition: Overall progress; Number of requirements: 19; Requirements completed: 13 (68 percent); Requirements in progress: 6 (32 percent); Overall status: In progress. Source: GAO analysis of information from the SOC. [A] NDAA 2008, 1614(a), 1614(b)(1)-(9), (14). [B] NDAA 2008, 1614(b)(10)-(13), (15). [C] NDAA 2008, 1614(b)(16). [D] NDAA 2008, 1614(b)(17). [E] NDAA 2008, 1614(b)(18). [F] Through the Benefits Delivery at Discharge program, DOD and VA have made efforts to streamline access to veterans' disability benefits by allowing some servicemembers to file a claim and obtain a single comprehensive exam prior to discharge. [End of table] Most of the requirements for improving the transition from DOD to VA were addressed in DOD's January 2009 DTM--Recovery Coordination Program: Improvements to the Care, Management, and Transition of Recovering Service Members--that establishes interim policy for the care, management, and transition of recovering servicemembers through the Recovery Coordination Program. However, we found that DOD's DTM includes limited detail related to the procedures, processes, and standards for transition of recovering servicemembers. As a result, we could not always directly link the interim policy in the DTM to the specific requirements contained in section 1614 of the NDAA 2008. DOD and VA officials noted that they will be further developing the procedures, processes, and standards for the transition of recovering servicemembers in a subsequent comprehensive policy instruction, which is estimated to be completed by June 2009. A VA official reported that VA plans to separately issue policy guidance addressing the requirements for transitioning servicemembers from DOD to VA in June 2009. DOD and VA Officials Experienced Challenges during Joint Development and Initial Implementation of Required Policies: DOD and VA officials told us that they experienced numerous challenges as they worked to jointly develop policies to improve the care, management, and transition of recovering servicemembers. According to officials, these challenges contributed to the length of time required to issue policy guidance, and in some cases the challenges have not yet been completely resolved. In addition, challenges have arisen during the initial implementation of some of the NDAA 2008 policies. Finally, recent changes to the SOC staff, including DOD's organizational changes for staff supporting the SOC, could pose challenges to the development of policy affecting recovering servicemembers. Various Challenges Arose during Policy Development: DOD and VA officials encountered numerous challenges during the course of jointly developing policies to improve the care, management, and transition of recovering servicemembers, as required by sections 1611 through 1614 of the NDAA 2008, in addition to responding to other requirements of the law. Many of these challenges have been addressed, but some have yet to be completely resolved. DOD and VA officials cited the following examples of issues for which policy development was particularly challenging. * Increased support for family caregivers. The NDAA 2008 includes a number of provisions to strengthen support for families of recovering servicemembers, including those who become caregivers. However, DOD and VA officials on a SOC work group stated that before they could develop policy to increase support for such families, they had to obtain concrete evidence of their needs. Officials explained that while they did have anecdotal information about the impact on families who provide care to recovering servicemembers, they lacked the systematic data needed for sound policy decisions--such as frequency of job loss and the economic value of family-provided medical services. A work group official told us that their proposals for increasing support to family caregivers were rejected twice by the SOC, due in part to the lack of systematic data on what would be needed. The work group then contracted with researchers to obtain substantiating evidence, a study that required 18 months to complete. In January 2009, the SOC approved the work group's third proposal and family caregiver legislation is being prepared, with anticipated implementation of new benefits for caregivers in fiscal year 2010. * Establishing standard definitions for operational terms. One of the important tasks facing the SOC was the need to standardize key terminology relevant to policy issues affecting recovering servicemembers. DOD took the lead in working with its military services and VA officials to identify and define key terms. DOD and VA officials told us that many of the key terms found in existing DOD and VA policy, the reports from the review groups, and the NDAA 2008, as well as those used by the different military services are not uniformly defined. Consequently, standardized definitions are needed to promote agreement on issues such as: - identifying the recovering servicemembers who are subject to NDAA 2008 requirements, - identifying categories of servicemembers who would receive services from the different classes of case managers or be eligible for certain benefits, - managing aspects of the disability evaluation process, and: - establishing criteria to guide research. In some cases, standardized definitions were critical to policy development. The importance of agreement on key terms is illustrated by an issue encountered by the SOC's work group responsible for family support policy. In this case, before policy could be developed for furnishing additional support to family members that provide medical care to recovering servicemembers, the definition of "family" had to be agreed upon. DOD and VA officials said that they considered two options: to define the term narrowly to include a servicemember's spouse, parents, and children, or to use broader definitions that included distant relatives and unrelated individuals with a connection to the servicemember. These two definitions would result in significantly different numbers of family members eligible to receive additional support services. DOD and VA officials decided to use a broader definition to determine who would be eligible for support. Of the 41 key definitions identified for reconciliation, DOD and VA had concurred on 33 as of March 2009 and these 33 standardized definitions are now being used. Disagreement remains over the remaining definitions, including the definition of "mental health." A DOD official stated that given the uncertainty associated with the organizational and procedural changes recently introduced to the SOC (which are discussed below), obtaining concurrence on the remaining definitions has been given lower priority. * Improving TBI and PTSD screening and treatment. Requirements related to screening and treatment for TBI and PTSD were embedded in several sections of the NDAA 2008, including section 1611, and were also discussed extensively in a task force report on mental health.[Footnote 19] DOD and VA officials told us that policy development for these issues was difficult. For example, during development of improved TBI and PTSD treatment policy, policymakers often lacked sufficient scientific information needed to help achieve consensus on policy decisions. Also, members of the SOC work group told us that they disagreed on appropriate models for screening and treatment and struggled to reorient the military services to patient-focused treatment. A senior DOD official stated that the adoption of patient- focused models is particularly difficult for the military services because, historically, the needs of the military have been given precedence over the needs of individual servicemembers. To address these challenges, the SOC oversaw the creation of the Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury--a partnership between DOD and VA. While policies continue to be developed on these issues, TBI and PTSD policy remains a challenge for DOD and VA. However, DOD officials told us that the centers of excellence have made progress with reducing knowledge gaps in psychological health and TBI treatment, identifying best practices, and establishing clinical standards of care. * Release of psychological health treatment records to DOD by VA health care providers who treat members of the National Guard and Reserves. Section 1614 of the NDAA 2008 requires the departments to improve medical and support services provided to members of the National Guard and Reserves. In pursuing these objectives, VA faced challenges related to the release of medical information to DOD on reservists and National Guard servicemembers who have received treatment for PTSD or other mental health conditions from VA. DOD requests medical information from VA to help make command decisions about the reactivation of servicemembers, but VA practitioners face an ethical dilemma if the disclosure of medical treatment could compromise servicemembers' medical conditions, particularly for those at risk of suicide. The challenge of sharing and protecting sensitive medical information on servicemembers who obtain treatment at VA was reviewed by the Blue Ribbon Work Group on Suicide Prevention convened in 2008 at the behest of the Secretary of Veterans Affairs. DOD and VA are continuing their efforts to develop policy to clarify the privacy rights of patients who receive medical services from VA while serving in the military, and also for protecting the confidential records of VA patients who may also be treated by the military's health care system. The need to resolve this challenge assumes even greater importance in light of DOD's and VA's increasing capability to exchange medical records electronically, which will expand DOD's ability to access records of servicemembers who have received medical treatment from VA. Future Challenges Could Impede the Joint Implementation of Policy Initiatives: In addition to challenges encountered during the joint development of policy for recovering servicemembers, additional challenges have arisen as DOD and VA have begun implementing NDAA 2008 policy initiatives. * Medical examinations conducted as part of the DOD/VA disability evaluation system pilot. In 2007, DOD and VA jointly began to develop policy to improve the disability evaluation process for recovering servicemembers and began pilot testing these new procedures in the disability system. One significant innovation of the disability evaluation system pilot is the use of a single physical examination for multiple purposes, such as for both disability determinations and disability benefits from both departments. In our review of the disability evaluation system pilot, we reported that DOD and VA had tracked challenges that arose during implementation of the pilot but had not yet resolved all of them.[Footnote 20] For example, one unresolved issue was uncertainty about who will conduct the single physical examination when a VA medical center is not located nearby. Another challenge that could emerge in the future is linked to VA's announcement in November 2008 that it would cease providing physical reexaminations for recovering servicemembers placed on the Temporary Disability Retired List (TDRL).[Footnote 21] However, VA made an exception to its decision and will continue to provide reexaminations for TDRL servicemembers participating in the disability evaluation system pilot. In March 2009, VA officials told us that they were developing a policy to clarify this issue. * Electronic health information sharing between DOD and VA. The two departments have been working for over a decade to share electronic health information and have continued to make progress toward increased information sharing through ongoing initiatives and activities. However, the departments continue to face challenges in managing the activities required to achieve this goal. As we previously reported, [Footnote 22] the departments' plans to further increase their electronic sharing capabilities do not consistently identify results- oriented performance measures, which are essential for assessing progress toward the delivery of that capability.[Footnote 23] Further challenging the departments is the need to complete all necessary activities to fully set up their IPO, including hiring a permanent Director and Deputy Director. Defining results-oriented performance goals in its plans and ensuring that they are met is an important responsibility of this office. Until these challenges are fully addressed, the departments and their stakeholders may lack the comprehensive understanding that they need to effectively manage their progress toward achieving increased sharing of information between the departments. Moreover, not fully addressing these challenges increases the risk that DOD and VA may not develop and implement comprehensive policies to improve the care, management, and transition of recovering servicemembers and veterans. Changes to the SOC's Staff and Scope of Policy Development Responsibilities Could Pose Future Challenges: Recent changes to staff and working relationships within the SOC could pose future challenges to DOD's and VA's efforts to develop joint policy. Since December 2008, the SOC has experienced turnover in leadership and changes in policy development responsibilities. The SOC is undergoing leadership changes caused by the turnover in presidential administrations as well as turnover in some of its key staff. For example, the DOD and VA deputy secretaries who previously co-chaired the SOC departed in January 2009. As a short-term measure, the Secretaries of VA and DOD have co-chaired a SOC meeting. DOD also introduced other staffing changes to replace personnel who had been temporarily detailed to the SOC and needed to return to their primary duties. DOD had relied on temporarily-assigned staff to meet SOC staffing needs because the SOC was originally envisioned as a short- term effort. In a December 2008 memo, DOD outlined the realignment of its SOC staff. This included the transition of responsibilities from detailed, temporary SOC staff and executives to permanent staff in existing DOD offices that managed similar issues. For example, the functions of LOA 7 (Legislation and Public Affairs) will now be overseen by the Assistant Secretary of Defense for Legislative Affairs, the Assistant Secretary of Defense for Public Affairs, and the DOD General Counsel. DOD also established two new organizational structures--the Office of Transition Policy and Care Coordination and an Executive Secretariat office. The Office of Transition Policy and Care Coordination oversees transition support for all servicemembers and serves as the permanent entity for issues being addressed by LOA 1 (Disability Evaluation System), LOA 3 (Case Management), and LOA 8 (Personnel, Pay, and Financial Support). The Executive Secretariat office is responsible for performance planning, performance management, and SOC support functions. According to DOD officials, the new offices were created to establish permanent organizations that address a specific set of issues and to enhance accountability for policy development and implementation as these offices report directly to the Office of the Under Secretary of Defense for Personnel and Readiness. Currently, many of the positions in these new offices, including the director positions, are staffed by officials in an acting capacity or are unfilled. DOD's changes to the SOC are important because of the potential effects these changes could have on the development of policy for recovering servicemembers. However, officials in both DOD and VA have mixed reactions about the consequences of these changes. Some DOD officials consider the organizational changes to the SOC to be positive developments that will enhance the SOC's effectiveness. They point out that the SOC's temporary staffing situation needed to be addressed, and also that the two new offices were created to support the SOC and provide focus on the implementation of key policy initiatives developed by the SOC--primarily the disability evaluation system pilot and the new case management programs. In contrast, others are concerned by DOD's changes, stating that the new organizations disrupt the unity of command that once characterized the SOC's management because personnel within the SOC organization now report to three different officials within DOD and VA. However, it is too soon to determine how well DOD's new structure will work in conjunction with the SOC. DOD and VA officials we spoke with told us that the SOC's work groups continue to carry out their roles and responsibilities. Finally, according to DOD and VA officials, the roles and scope of responsibilities of both the SOC and the DOD and VA Joint Executive Council appear to be in flux and may evolve further still.[Footnote 24] According to DOD and VA officials, changes to the oversight responsibilities of the SOC and the Joint Executive Council are causing confusion. While the SOC will remain responsible for policy matters directly related to recovering servicemembers, a number of policy issues may now be directed to the Joint Executive Council, including issues that the SOC had previously addressed. For example, management oversight of many of LOA 4's responsibilities (DOD and VA Data Sharing) has transitioned from the SOC to the IPO, which reports primarily to the Joint Executive Council. LOA 4 continues to be responsible for developing a component for the disability evaluation system pilot[Footnote 25] and the individual recovery plans for the Federal Recovery Coordination Program. It is not clear how the IPO will ensure effective coordination with the SOC's LOAs for the development of IT applications for these initiatives. Given that IT support for two key SOC initiatives is identified in the joint DOD/VA Information Interoperability Plan, if the IPO and the SOC do not effectively coordinate with one another, the result may impact negatively on the development of improved policies for recovering servicemembers. Mr. Chairman, this completes our prepared remarks. We would be happy to respond to any questions you or other members of the Subcommittee may have at this time. Contacts and Acknowledgments: For further information about this testimony, please contact Randall B. Williamson at (202) 512-7114 or williamsonr@gao.gov, Daniel Bertoni at (202) 512-7215 or bertonid@gao.gov, or Valerie C. Melvin at (202) 512- 6304 or melvinv@gao.gov. Contact points for our Offices of Congressional Relations and Public Affairs may be found on the last page of this testimony. GAO staff who made key contributions to this testimony are listed in appendix II. [End of section] Appendix I: Summary of Selected Requirements from the National Defense Authorization Act for Fiscal Year 2008: To summarize the status of the Departments' of Defense (DOD) and Veterans Affairs (VA) efforts to jointly develop policies for each of the four policy areas outlined in sections 1611 through 1614 of the NDAA 2008, we identified 76 requirements in these sections and grouped related requirements into 14 logical categories.[Footnote 26] Tables 8 through 11 enumerate the requirements in each of GAO's categories and provide the status of DOD and VA's efforts to develop policy related to each requirement, as of April 2009. Table 8: Requirements to Address the Care and Management of Recovering Servicemembers, as Outlined in Section 1611(a)(2)(A), with Specific Requirements Enumerated in Section 1611: GAO category: Develop policy for training and skills of health care professionals, recovery care coordinators, medical care case managers, and non-medical care managers; Number of NDAA 2008 requirements in category: 2 requirements; Summary of NDAA 2008 requirements: 1611(d): Policy shall provide for uniform standards among the military departments for training and skills of health care professionals, recovery care coordinators, medical care case managers, and non-medical care managers, including tracking notifications made by them. The policy shall: 1. Ensure that health care professionals, recovery care coordinators, medical care case managers, and non-medical care managers are able to detect and report early warning signs of post traumatic stress disorder or suicidal or homicidal thoughts or behaviors in recovering servicemembers; Status: Complete. 2. Include a mechanism or system to track the number of notifications made by recovery care coordinators, medical care case managers, and non- medical care managers to health care professionals regarding post traumatic stress disorder or suicidal behaviors in recovering servicemembers; Status: Complete. GAO category: Develop policy for recovery plans for recovering servicemembers and the training, duties, support, and supervision of recovery care coordinators, medical care case managers, and non-medical care managers; Number of NDAA 2008 requirements in category: 20 requirements; Summary of NDAA 2008 requirements: 1611(e)(1)-(4): To improve the care, management, and transition of recovering servicemembers, the policy shall: 1. Provide for uniform standards and procedures among the military services for the development of a comprehensive recovery plan for each recovering servicemember; Status: Complete. For recovery care coordinators: 2. Provide for a uniform program for the assignment of recovery care coordinators to recovering servicemembers; Status: Complete. 3. Include specified duties assigned to recovery care coordinators; Status: Complete. 4. Specify the maximum number of cases of recovering servicemembers assigned to a recovery care coordinator; Status: In progress. 5. Specify standard training requirements for recovery care coordinators; Status: Complete. 6. Include mechanisms to ensure recovery care coordinators have necessary resources; Status: Complete. 7. Specify requirements for supervision of recovery care coordinators; Status: Complete. For medical care case managers: 8. Provide for a uniform program for the assignment of medical care case managers; Status: Complete. 9. Include specified duties assigned to medical care case managers; Status: Complete. 10. Specify the maximum number of cases of recovering servicemembers assigned to a medical care case manager; Status: Complete. 11. Specify standard training requirements for medical care case managers; Status: Complete. 12. Include mechanisms to ensure that medical care case managers have necessary resources; Status: [Complete]. 13. Specify requirements for supervision of medical care case managers; Status: Complete. For non-medical care managers: 14. Provide for a uniform program for the assignment of non-medical care managers to recovering servicemembers; Status: Complete. 15. Include specified duties assigned to non-medical care managers; Status: Complete. 16. Specify duration of non-medical care managers' duties; Status: Complete. 17. Specify the maximum number of cases of recovering servicemembers assigned to a non-medical care manager; Status: Complete. 18. Specify standard training requirements for non-medical care managers; Status: Complete. 19. Include mechanisms to ensure that non-medical care managers have necessary resources; Status: Complete. 20. Specify requirements for supervision of non-medical care managers; Status: Complete. GAO category: Develop policy for improved access to medical and other health care services; Number of NDAA 2008 requirements in category: 10 requirements; Summary of NDAA 2008 requirements: 1611(e)(5)-(11): Policy shall provide for: 1. Appropriate minimum standards for access to non-urgent medical care and other health care services by recovering servicemembers in certain settings; Status: In progress. 2. Maximum waiting times for follow-up, specialty, diagnostic, and surgical care; Status: In progress. 3. Recovering servicemember's ability to waive access standards; Status: In progress. 4. Assignment of recovering servicemembers to locations of care; Status: In progress. 5. Reassignment of recovering servicemembers from deficient medical or medical support facilities; Status: In progress. 6. Availability of transportation and subsistence when obtaining medical care and services; Status: In progress. 7. Assignment of recovering servicemembers to work and duty compatible with their medical conditions; Status: In progress. 8. Access to educational and vocational training and rehabilitation; Status: Complete. 9. Tracking the location of recovering servicemembers and their compliance with appointments; Status: In progress. 10. Referral of recovering servicemembers to VA and other providers; Status: In progress. GAO category: Develop policy for improved outreach and services for family members of recovering servicemembers; Number of NDAA 2008 requirements in category: 5 requirements; Summary of NDAA 2008 requirements: 1611(f) and (g): Policy shall provide or include: 1. Providing support for family members not eligible under section 1672; Status: Complete. 2. Providing advice and training to family members for providing care to recovering servicemembers; Status: Complete. 3. Measuring family members' satisfaction with quality of health care provided to recovering servicemembers; Status: Complete. 4. Procedures for applying for job placement services by family members; Status: Complete. 5. Procedures and mechanisms for outreach to recovering servicemembers and family members to inform them of policies on medical care, management and transition of recovering servicemembers, and responsibilities of recovering servicemembers and families; Status: Complete. GAO category: Apply policy to recovering servicemembers on the Temporary Disability Retired List as determined by DOD; Number of NDAA 2008 requirements in category: 1 requirement; Summary of NDAA 2008 requirements: 1611(h): 1. Policy required by this section shall apply to recovering servicemembers placed on the temporary disability retired list as determined by DOD; Status: Complete. Source: GAO analysis of section 1611 of the NDAA 2008. [End of table] Table 9: Requirements to Address the Medical and Disability Evaluations of Recovering Servicemembers, as Outlined in Section 1611(a)(2)(B), with Specific Requirements Enumerated in Section 1612: GAO category: Develop policy for improved medical evaluations; Number of NDAA 2008 requirements in category: 8 requirements; Summary of NDAA 2008 requirements: 1612(a): 1. The Secretary of Defense shall develop policy to improve processes, procedures, and standards for medical evaluations of recovering servicemembers; Status: Complete. Policy improvements to medical evaluations shall include and address: 2. Uniform application of medical evaluation policy throughout the military departments to recovering servicemembers in the regular components of the Armed Forces, National Guard, and Reserves; Status: Complete. 3. Standard criteria and definitions for determining maximum medical benefit from treatment for recovering servicemembers; Status: Complete. 4. Standard timelines for fitness-for-duty determinations, specialty care consultations, preparation of medical documents, and appeals of medical evaluation determinations; Status: Complete. 5. Procedures to ensure assignment of a physician or health care professional to a recovering servicemember, if requested, who is independent of the medical evaluation board and provides appropriate advice; Status: Complete. 6. Standards for qualifications and training of medical evaluation board personnel; Status: Complete. 7. Standards for the maximum number of recovering servicemember cases pending before a medical evaluation board, and procedures to expand on medical evaluation board if warranted; Status: Complete. 8. Standards for information provided to recovering servicemembers and their families regarding their rights and responsibilities in the medical evaluation board process; Status: Complete. GAO category: Develop policy for improved physical disability evaluations; Number of NDAA 2008 requirements in category: 8 requirements; Summary of NDAA 2008 requirements: 1612(b): 1. The DOD and VA Secretaries shall develop policy to improve processes, procedures, and standards for physical disability evaluations of recovering servicemembers by DOD and VA; Status: Complete. Policy to improve physical disability evaluations shall include: 2. A clearly-defined DOD and VA process for physical disability determinations for recovering servicemembers; Status: Complete. 3. To the extent feasible, procedures to eliminate unacceptable discrepancies and improve consistency among disability ratings assigned by DOD and VA to recovering servicemembers of the Armed Forces, National Guard, and Reserves in the use by each military department of the VA disability rating schedule; Status: Complete. 4. Uniform timelines for appeals of disability determinations of recovering servicemembers; Status: Complete. 5. Uniform standards for qualifications and training of physical disability evaluation board personnel; Status: Complete. 6. Uniform standards for the maximum number of recovering servicemember cases pending before a physical disability evaluation board, and procedures to expand board; Status: Complete. 7. Uniform standards and procedures for providing legal counsel to recovering servicemembers undergoing physical disability evaluation; Status: Complete. 8. Uniform standards on the roles and responsibilities of non-medical care managers and judge advocates, and the maximum number of recovering servicemembers assigned to judge advocates at any one time; Status: Complete. GAO category: Report on feasibility and advisability of consolidating DOD and VA disability evaluation processes; Number of NDAA 2008 requirements in category: 2 requirements; Summary of NDAA 2008 requirements: 1612(c): The DOD and VA Secretaries shall report on: 1. The feasibility and advisability of consolidating the DOD and VA disability evaluation systems; Status: Complete. 2. Recommendations for options for consolidating the DOD and VA disability evaluation systems, and recommendations for mechanisms to evaluate and assess progress made in consolidating the DOD and VA disability evaluation systems, if consolidation is considered feasible and advisable; Status: Complete. Source: GAO analysis of section 1612 of the NDAA 2008. [End of table] Table 10: Requirement to Address Standards for Return-to-Duty Decisions, as Outlined in Section 1611(a)(2)(C), with Specific Requirements Enumerated in Section 1613: GAO category: Establish standards for return-to-duty decisions; Number of NDAA 2008 requirements in category: 1 requirement; Summary of NDAA 2008 requirements: 1613: 1. The DOD Secretary shall establish standards for determinations by the military departments on the return of recovering servicemembers to active duty; Status: Complete. Source: GAO analysis of section 1613 of the NDAA 2008. [End of table] Table 11: Requirements to Address the Transition of Recovering Servicemembers, as Outlined in Section 1611(a)(2)(D), with Specific Requirements Enumerated in Section 1614: GAO category: Develop procedures, processes, and standards for care coordination, benefits, and service transition; Number of NDAA 2008 requirements in category: 11 requirements; Summary of NDAA 2008 requirements: 1614(a), (b)(1)-(9), (14): 1. The DOD and VA Secretaries shall jointly develop uniform processes, procedures, and standards for the transition of recovering servicemembers from DOD care to VA care and rehabilitation; Status: In progress. Processes, procedures, and standards shall include: 2. Uniform patient-focused procedures; Status: In progress. 3. Procedures for identifying and tracking recovering servicemembers during transition, and coordinating and managing their care; Status: Complete. 4. Procedures for notifying VA of recovering servicemembers commencing the medical and the physical disability determination processes; Status: Complete. 5. Procedures and timelines for enrollment of recovering servicemembers for health care, education, rehabilitation, and other benefits; Status: Complete. 6. Procedures for ensuring recovering servicemembers' access to vocational, educational, and rehabilitation benefits during transition; Status: Complete. 7. Standards for optimal location of DOD and VA liaison and case management personnel at DOD treatment and other facilities; Status: Complete. 8. Standards and procedures for integrated medical care and management of recovering servicemembers during transition; Complete. 9. Standards for preparation of detailed, written plans for transitioning recovering servicemembers from DOD treatment to VA treatment and rehabilitation; Status: Complete. 10 Procedures to ensure that each recovering servicemember being retired or separated receives a written transition plan prior to retirement or separation; Status: Complete. 11. Procedures to ensure that the VA Secretary duly considers statements submitted by recovering servicemembers regarding the transition; Status: In progress. GAO category: Develop procedures and processes for information sharing of military service and health records; Number of NDAA 2008 requirements in category: 5 requirements; Summary of NDAA 2008 requirements: 1614(b)(10)-(13), (15): The DOD and VA Secretaries shall jointly develop uniform processes, procedures, and standards for: 1. Transmittal of necessary records and information of each recovering servicemember being retired or separated from DOD to VA, including military service and medical records, information for entitlement to transitional health care or benefits, and request for assistance in application for VA health benefits, compensation, or vocational rehabilitation; Status: In progress. 2. Obtaining authorization by recovering servicemember or legal representative for transmittal of medical records from DOD to VA in accordance with the Health Insurance Portability and Accountability Act of 1996; Status: Complete. 3. Transmittal of address and contact information to recovering servicemember's state veterans' agency; Status: Complete. 4. Arranging a meeting between the recovering servicemember, his/her family members, and DOD and VA representatives to discuss the transfer of records to VA prior to such transfer with at least 30 days notice; Status: Complete. 5. Providing for VA's access to military health records of recovering servicemembers receiving or who anticipate receiving treatment in VA facilities; Status: Complete. GAO category: Develop a process for a joint separation and evaluation physical examination; Number of NDAA 2008 requirements in category: 1 requirement; Summary of NDAA 2008 requirements: Subsection 1614(b)(16): 1. The DOD and VA Secretaries shall jointly develop uniform processes, procedures, and standards for a joint physical examination that meets DOD requirements for separation and VA requirements for disability evaluations; Status: Complete. GAO category: Develop procedures for surveys and other mechanisms to measure patient and family satisfaction with services for recovering servicemembers; Number of NDAA 2008 requirements in category: 1 requirement; Summary of NDAA 2008 requirements: Subsection 1614(b)(17): 1. The DOD and VA Secretaries shall jointly develop uniform processes, procedures, and standards for surveys and other mechanisms to measure recovering servicemember and family satisfaction with DOD and VA care and services for recovering servicemembers, and to promote oversight of such care and services; Status: Complete. GAO category: Develop procedures to ensure the participation of recovering servicemembers of the National Guard or Reserve in the Benefits Delivery at Discharge Program[A]; Number of NDAA 2008 requirements in category: 1 requirement; Summary of NDAA 2008 requirements: Subsection 1614(b)(18): 1. The DOD and VA Secretaries shall jointly develop uniform processes, procedures, and standards for ensuring that recovering servicemembers of the National Guard or Reserve participate in the Benefits Delivery at Discharge Program; Status: In progress. Source: GAO analysis of section 1614 of the NDAA 2008. [A] Through the Benefits Delivery at Discharge Program, DOD and VA have made efforts to streamline access to veterans' disability benefits by allowing some servicemembers to file a claim and obtain a single comprehensive exam prior to discharge. [End of table] [End of section] Appendix II: GAO Contacts and Staff Acknowledgments: GAO Contacts: Randall B. Williamson (202) 512-7114 or williamsonr@gao.gov: Daniel Bertoni (202) 512-7215 or bertonid@gao.gov: Valerie C. Melvin (202) 512-6304 or melvinv@gao.gov: Acknowledgments: In addition to the contacts named above, Bonnie Anderson, Assistant Director; Mark Bird, Assistant Director; Susannah Bloch; Catina Bradley; April Brantley; Frederick Caison; Joel Green; Lisa Motley; Elise Pressma; J. Michael Resser; Regina Santucci; Kelly Shaw; Eric Trout; and Gregory Whitney made key contributions to this testimony. [End of section] Footnotes: [1] Pub. L. No. 110-181, 122 Stat. 3. [2] Terri Tanielian and Lisa H. Jaycox, Invisible Wounds of War, Psychological and Cognitive Injuries, Their Consequences, and Services to Assist Recovery (Santa Monica, Calif.: RAND Corporation, 2008). [3] 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. [4] Department of Defense, Operation Iraqi Freedom (OIF) U.S. Casualty Status, Operation Enduring Freedom (OEF) U.S. Casualty Status. [hyperlink, http://www.defenselink.mil/news/casualty.pdf]. (accessed Feb. 19, 2009). [5] GAO, DOD and VA Health Care: Challenges Encountered by Injured Servicemembers during Their Recovery Process, [hyperlink, http://www.gao.gov/products/GAO-07-589T] (Washington, D.C.: Mar. 5, 2007) and DOD and VA Health Care: Challenges Encountered by Injured Servicemembers during Their Recovery Process, [hyperlink, http://www.gao.gov/products/GAO-07-606T] (Washington, D.C.: Mar. 8, 2007). [6] Pub. L. No. 110-181, 1615(d), 122 Stat. 3, 447. [7] We defined an individual requirement as a provision within sections 1611 through 1614 related to the policy required by 1611(a) that directs DOD, VA, or both to take a specific action or to include a specific criterion in their policy. The SOC's legal counsel reviewed these requirements and our groupings, and agreed with our approach. [8] Completed policy guidance also included interim policy guidance signed by the SOC. [9] These servicemembers may also receive care at Balboa Naval Hospital in San Diego, California or at Brooke Army Medical Center in San Antonio, Texas. [10] VA determines the degree to which veterans are disabled in 10 percent increments on a scale of 0 to 100 percent. [11] The reports are as follows: Independent Review Group, Rebuilding the Trust: Report on Rehabilitative Care and Administrative Processes at Walter Reed Army Medical Center and National Naval Medical Center (April 2007); Task Force on Returning Global War on Terror Heroes, Report to the President (April 2007); Department of Defense Task Force on Mental Health, An Achievable Vision: Report of the Department of Defense Task Force on Mental Health (June 2007); President's Commission on Care for America's Returning Wounded Warriors, Serve, Support, Simplify (July 2007); Veterans' Disability Benefits Commission, Honoring the Call to Duty: Veterans' Disability Benefits in the 21st Century (October 2007); and Inspectors General, Department of Defense, Department of Veterans Affairs, DOD/VA Care Transition Process for Service Members Injured in OIF/OEF (June 2008). [12] Duncan Hunter National Defense Authorization Act for Fiscal Year 2009, Pub. L. No. 110-417, 726, 122 Stat. 4356, 4509 (2008). [13] Pub. L. No. 110-181, 1635, 122 Stat. 3, 460-63. [14] Interoperability is the ability of two or more systems or components to exchange information and to use the information that has been exchanged. [15] DOD and VA will also be issuing a joint directive regarding the policies. [16] DOD issues directive-type memoranda to address time-sensitive actions that affect current policies or that will be developed into new DOD policies. A directive-type memoranda establishes temporary policy and provides DOD the direction to implement the policy when time constraints prevent publishing a new policy or a change to an existing DOD policy. [17] GAO, Military Disability System: Increased Supports for Servicemembers and Better Pilot Planning Could Improve the Disability Evaluation Process, [hyperlink, http://www.gao.gov/products/GAO-08-1137] (Washington, D.C.: Sept. 24, 2008). [18] The NDAA 2008 directed the Secretary of Defense to respond to this policy requirement. VA does not participate in return-to-duty decisions. [19] Department of Defense Task Force on Mental Health (2007). [20] See [hyperlink, http://www.gao.gov/products/GAO-08-1137]. [21] Recovering servicemembers may be placed on the TDRL if they are found to be medically unfit for duty and have service-related illnesses or injuries that are not stable enough for assignment of a permanent disability rating. Assignment to the TDRL temporarily retires and provides servicemembers with disability benefits for up to 5 years while they wait for their disabling medical conditions to stabilize. A TDRL retiree must undergo periodic medical reexaminations and evaluations every 18 months. See 10 U.S.C. 1202, 1210. [22] GAO, Electronic Health Records: DOD's and VA's Sharing of Information Could Benefit from Improved Management, [hyperlink, http://www.gao.gov/products/GAO-09-268] (Washington, D.C.: Jan. 28, 2009). [23] These plans are the November 2007 VA/DOD Joint Executive Council Strategic Plan for Fiscal Years 2008-2010 (known as the VA/DOD Joint Strategic Plan) and the September 2008 DOD/VA Information Interoperability Plan (Version 1.0). [24] The Joint Executive Council is responsible for addressing strategic issues affecting both departments and developing a joint DOD/ VA strategic plan. [25] LOA 4 is developing a tracking system for the disability evaluation system pilot that tracks information about servicemembers such as the assignment of a physical evaluation board liaison officer and timeframes for completing the disability evaluation processes. [26] We defined an individual requirement as a provision within sections 1611 through 1614 related to the policy required by 1611(a) that directs DOD, VA, or both to take a specific action or to include a specific criterion in their policy. The SOC's legal counsel reviewed these requirements and our groupings, and agreed with our approach. [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. GAO's commitment to good government is reflected in its core values of accountability, integrity, and reliability. 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