DOD and VA Health Care
Action Needed to Strengthen Integration across Care Coordination and Case Management Programs Gao ID: GAO-12-129T October 6, 2011In a May 2011 testimony before this subcommittee (GAO-11-572T), based on a March 2011 report (GAO-11-250), GAO highlighted challenges for the Federal Recovery Coordination Program (FRCP), developed by the Departments of Defense (DOD) and Veterans Affairs (VA) to assist some of the most severely wounded, ill, and injured servicemembers, veterans, and their families. Specifically, GAO reported on challenges in FRCP enrollment, staffing needs, caseloads, and placement locations. GAO also cited challenges faced by the FRCP when coordinating with other VA and DOD programs, including DOD's Recovery Coordination Program (RCP), which can result in duplication of effort and enrollee confusion. In this statement, GAO examines the status of DOD and VA's efforts to (1) implement GAO's March 2011 recommendations and (2) identify and analyze potential options to functionally integrate the FRCP and RCP. This statement is based on GAO's March 2011 report and updated information obtained in September 2011.
VA has made progress addressing each of the recommendations from GAO's March 2011 report on program management issues related to enrollment decisions, caseloads, and program staffing needs and placement decisions for the Federal Recovery Coordinators (FRC) the FRCP uses to coordinate care. These recommendations were directed to the Secretary of VA because VA maintains administrative control of the program, and DOD and VA were asked to provide a response to this subcommittee about how the departments could jointly implement these recommendations. DOD has provided limited assistance to VA with the implementation of GAO's recommendation about enrollment through an e-mail communication about referrals to the FRCP to the commanders of the military services' wounded warrior programs. Despite this effort, however, VA officials stated that they have not noticed any change in referral numbers or patterns from DOD since the e-mail was sent. DOD and VA have made little progress reaching agreement on options to better integrate the FRCP and RCP, although they have made a number of attempts to address this issue. Most recently, DOD and VA experienced difficulty jointly providing potential options for integrating these programs in response to this subcommittee's May 26, 2011, request to the deputy secretaries, who co-chair the DOD and VA Wounded, Ill, and Injured Senior Oversight Committee (Senior Oversight Committee). On September 12, 2011--almost 3 months after the subcommittee requested a response--the co-chairs of the Senior Oversight Committee issued a joint letter that stated that the departments are considering several options to maximize care coordination resources. However, these options have not been finalized and were not specifically identified or outlined in the letter. The two departments have made prior attempts to jointly develop options for improved collaboration and potential integration of the FRCP and RCP, but despite the identification of various options, no final decisions to revamp, merge, or eliminate programs have been agreed upon. This lack of progress illustrates DOD's and VA's continued difficulty in collaborating to resolve duplication and overlap between care coordination programs. Furthermore, as we have previously reported, there are numerous programs in addition to the FRCP and RCP that provide similar services to recovering servicemembers and veterans-- many of whom are enrolled in more than one program and therefore have multiple care coordinators and case managers. We found that inadequate information exchange and poor coordination between these programs has resulted in not only redundancy, but confusion and frustration for enrollees, particularly when care coordinators and case managers duplicate or contradict one another's efforts. Consequently, the intended purpose of these programs--to better manage and facilitate care and services--may actually have the opposite effect. We recommend that the Secretaries of DOD and VA direct the Senior Oversight Committee to expeditiously develop and implement a plan to strengthen functional integration across all DOD and VA care coordination and case management programs, including the FRCP and RCP, to reduce redundancy and overlap. We obtained oral comments on the content of this statement from both DOD and VA officials, and we incorporated their comments as appropriate.
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: Debra A. Draper Team: Government Accountability Office: Health Care Phone: (202)512-3000GAO-12-129T, DOD and VA Health Care: Action Needed to Strengthen Integration across Care Coordination and Case Management Programs
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United States Government Accountability Office:
GAO:
Testimony:
Before the Subcommittee on Health, Committee on Veterans' Affairs,
House of Representatives:
For Release on Delivery:
Expected at 8:30 a.m. EDT:
Thursday, October 6, 2011:
DOD and VA Health Care:
Action Needed to Strengthen Integration across Care Coordination and
Case Management Programs:
Statement of Debra A. Draper:
Director, Health Care:
GAO-12-129T:
GAO Highlights:
Highlights of GAO-12-129T, a testimony before the Subcommittee on
Health, Committee on Veterans‘ Affairs, House of Representatives.
Why GAO Did This Study:
In a May 2011 testimony before this subcommittee (GAO-11-572T), based
on a March 2011 report (GAO-11-250), GAO highlighted challenges for
the Federal Recovery Coordination Program (FRCP), developed by the
Departments of Defense (DOD) and Veterans Affairs (VA) to assist some
of the most severely wounded, ill, and injured servicemembers,
veterans, and their families. Specifically, GAO reported on challenges
in FRCP enrollment, staffing needs, caseloads, and placement
locations. GAO also cited challenges faced by the FRCP when
coordinating with other VA and DOD programs, including DOD‘s Recovery
Coordination Program (RCP), which can result in duplication of effort
and enrollee confusion.
In this statement, GAO examines the status of DOD and VA‘s efforts to
(1) implement GAO‘s March 2011 recommendations and (2) identify and
analyze potential options to functionally integrate the FRCP and RCP.
This statement is based on GAO‘s March 2011 report and updated
information obtained in September 2011.
What GAO Found:
VA has made progress addressing each of the recommendations from GAO‘s
March 2011 report on program management issues related to enrollment
decisions, caseloads, and program staffing needs and placement
decisions for the Federal Recovery Coordinators (FRC) the FRCP uses to
coordinate care. These recommendations were directed to the Secretary
of VA because VA maintains administrative control of the program, and
DOD and VA were asked to provide a response to this subcommittee about
how the departments could jointly implement these recommendations. DOD
has provided limited assistance to VA with the implementation of GAO‘s
recommendation about enrollment through an e-mail communication about
referrals to the FRCP to the commanders of the military services‘
wounded warrior programs. Despite this effort, however, VA officials
stated that they have not noticed any change in referral numbers or
patterns from DOD since the e-mail was sent.
DOD and VA have made little progress reaching agreement on options to
better integrate the FRCP and RCP, although they have made a number of
attempts to address this issue. Most recently, DOD and VA experienced
difficulty jointly providing potential options for integrating these
programs in response to this subcommittee‘s May 26, 2011, request to
the deputy secretaries, who co-chair the DOD and VA Wounded, Ill, and
Injured Senior Oversight Committee (Senior Oversight Committee). On
September 12, 2011”almost 3 months after the subcommittee requested a
response”the co-chairs of the Senior Oversight Committee issued a
joint letter that stated that the departments are considering several
options to maximize care coordination resources. However, these
options have not been finalized and were not specifically identified
or outlined in the letter. The two departments have made prior
attempts to jointly develop options for improved collaboration and
potential integration of the FRCP and RCP, but despite the
identification of various options, no final decisions to revamp,
merge, or eliminate programs have been agreed upon. This lack of
progress illustrates DOD‘s and VA‘s continued difficulty in
collaborating to resolve duplication and overlap between care
coordination programs. Furthermore, as we have previously reported,
there are numerous programs in addition to the FRCP and RCP that
provide similar services to recovering servicemembers and veterans”
many of whom are enrolled in more than one program and therefore have
multiple care coordinators and case managers. We found that inadequate
information exchange and poor coordination between these programs has
resulted in not only redundancy, but confusion and frustration for
enrollees, particularly when care coordinators and case managers
duplicate or contradict one another‘s efforts. Consequently, the
intended purpose of these programs”to better manage and facilitate
care and services”may actually have the opposite effect.
What GAO Recommends:
We recommend that the Secretaries of DOD and VA direct the Senior
Oversight Committee to expeditiously develop and implement a plan to
strengthen functional integration across all DOD and VA care
coordination and case management programs, including the FRCP and RCP,
to reduce redundancy and overlap. We obtained oral comments on the
content of this statement from both DOD and VA officials, and we
incorporated their comments as appropriate.
View [hyperlink, http://www.gao.gov/products/GAO-12-129T]. For more
information, contact Debra A. Draper at (202) 512-7114 or
draperd@gao.gov.
[End of section]
Chairwoman Buerkle, Ranking Member Michaud, and Members of the
Subcommittee:
I am pleased to be here today as you discuss the actions taken by the
Departments of Defense (DOD) and Veterans Affairs (VA) to address
issues of concern that were raised during your May 13, 2011, hearing on
the Federal Recovery Coordination Program (FRCP). Our statement for
that hearing,[Footnote 1] based on our March 2011 report,[Footnote 2]
outlined several implementation issues for the FRCP, which was jointly
implemented by DOD and VA to assist some of the most severely wounded,
ill, and injured servicemembers, veterans, and their families with
access to care, services, and benefits. Specifically, we reported on
challenges faced by FRCP leadership when identifying potentially
eligible individuals for program enrollment and determining staffing
needs and placement locations. We also cited challenges faced by the
FRCP when coordinating with other VA and DOD care coordination[Footnote
3] and case management[Footnote 4] programs that support wounded
servicemembers, veterans, and their families, including DOD's Recovery
Coordination Program (RCP). Specifically, we reported that poor
coordination among these programs can result in duplication of effort
and enrollee confusion because these programs often provide similar
services and individuals may be enrolled in more than one program.
Based on the concerns raised during the May 2011 hearing, your
subcommittee requested that DOD and VA provide a detailed response on
how they plan to jointly implement the recommendations to improve FRCP
management that were outlined in our report. You also requested that
the two departments analyze potential options for integrating the FRCP
and RCP under a single administrative umbrella to reduce redundancy and
to better fulfill the goal of establishing a seamless transition for
wounded servicemembers and their families. Although a response was
requested by June 20, 2011, the departments had not responded by
September 2, 2011, when this subcommittee announced that it intended to
hold an oversight hearing on continuing concerns about the care
coordination issues of the FRCP and RCP.
Our review of DOD's and VA's care coordination and case management
programs, including the FRCP and RCP, is part of a body of ongoing work
that is focused on the continuity of care for recovering servicemembers
and veterans. My testimony today addresses the status of DOD and VA's
efforts to (1) implement the recommendations to improve FRCP management
from our March 2011 report and (2) identify and analyze potential
options to integrate the FRCP and the RCP as requested by this
subcommittee.
We conducted the original performance audit for our 2011 report from
September 2009 through March 2011 and obtained updated data and
additional information in September 2011 for this testimony.
Specifically, to obtain information on the status of the
recommendations contained in our March 2011 report, we reviewed
documentation provided by VA and interviewed the Acting Executive
Director for the FRCP. Although our recommendations were directed to
VA, which administers the program, we also obtained information from
DOD officials that described to what extent they have worked with VA to
implement them based on your request for the departments to work
together. To obtain information regarding the status of DOD and VA's
efforts aimed at identifying and analyzing options for integrating or
otherwise revamping the FRCP and RCP, we conducted interviews with DOD
and VA officials and reviewed documents provided by both departments.
We also obtained updated information about DOD's and VA's care
coordination and case management programs by reviewing program
documentation and by interviewing DOD and VA program officials.
We conducted our work for this testimony 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.
Background:
The FRCP was jointly developed by DOD and VA following critical media
reports of deficiencies in the provision and coordination of outpatient
services at Walter Reed Army Medical Center. It was established to
assist severely wounded, ill, and injured Operation Enduring Freedom
(OEF) and Operation Iraqi Freedom (OIF) servicemembers,[Footnote 5]
veterans, and their families with access to care, services, and
benefits provided through DOD, VA, other federal agencies, states, and
the private sector. The FRCP is intended to serve individuals who are
highly unlikely to return to active duty and most likely will be
separated from the military, including those who have suffered
traumatic brain injuries, amputations, burns, spinal cord injuries,
visual impairment, and post-traumatic stress disorder. From January
2008--when FRCP enrollment began--to September 12, 2011, the FRCP has
provided services to a total of 1,827 servicemembers and veterans;
[Footnote 6] of these, 777 are currently active enrollees. [Footnote 7]
As the first care coordination program developed collaboratively by DOD
and VA, the FRCP uses Federal Recovery Coordinators (FRC) to monitor
and coordinate both the clinical and nonclinical services needed by
program enrollees; FRCs are intended to accomplish this by serving as
the single point of contact among case managers of DOD, VA, and other
governmental and private care coordination and case management
programs. As of September 12, 2011, there were 21 FRCs located at
various military treatment facilities and VA medical centers. Although
the program was jointly created by DOD and VA, it is administered by
VA, and FRCs are VA employees.
Separately, the RCP was established in response to the National Defense
Authorization Act for Fiscal Year 2008 to improve the care, management,
and transition of recovering servicemembers. It is a DOD-specific
program that uses Recovery Care Coordinators (RCC) to provide
nonclinical care coordination to both seriously and severely wounded,
ill, and injured servicemembers. Servicemembers who are severely
wounded, ill, and injured and who will most likely be medically
separated from the military, also are to be assigned an FRC. While the
program is centrally coordinated by DOD's Office of Wounded Warrior
Care and Transition Policy, it has been implemented separately by each
of the military services, which have integrated RCCs[Footnote 8] within
their existing wounded warrior programs.[Footnote 9] According to DOD's
Office of Wounded Warrior Care and Transition Policy, in September
2011, there were 162 RCCs and over 170 Army Advocates[Footnote 10] who
worked in more than 100 locations, including military treatment
facilities and VA medical centers. As of September 2011, these RCCs
have assisted approximately 14,000 recovering servicemembers and their
families and sometimes continue this assistance for those
servicemembers who separate from active duty.[Footnote 11]
The FRCP and RCP are two of at least a dozen DOD and VA programs that
provide care coordination and case management services to recovering
servicemembers, veterans, and their families, as we have previously
reported.[Footnote 12] Although these programs may vary in terms of the
severity of injuries or illnesses among the population they serve, or
in the types of services they provide, many, including the FRCP and
RCP, provide similar services. (See table 1.)
Table 1: Characteristics of Selected Department of Defense (DOD) and
Department of Veterans Affairs (VA) Care Coordination and Case
Management Programs for Seriously and Severely Wounded, Ill, and
Injured Servicemembers, Veterans, and Their Families:
Program: VA/DOD Federal Recovery Coordination Program (FRCP);
Severity of enrollees' injuries[A]: Severe;
Title of care coordinator or case manager: Federal Recovery
Coordinator (FRC);
Type of services provided:
Clinical: [Check];
Nonclinical: [Check];
Recovery plan: [Check].
Program: DOD Recovery Coordination Program (RCP);
Severity of enrollees' injuries[A]: Serious;
Title of care coordinator or case manager: Recovery Care Coordinator;
Type of services provided:
Clinical: [Empty];
Nonclinical: [Check];
Recovery plan: [Check].
Program: Army Warrior Transition Units;
Severity of enrollees' injuries[A]: Serious to severe;
Title of care coordinator or case manager: Nurse case manager, squad
leader, physician (one of each is assigned);
Clinical: [Check];
Nonclinical: [Check];
Recovery plan: [Check].
Program: Military wounded warrior programs[B,C];
Severity of enrollees' injuries[A]: Serious to severe;
Title of care coordinator or case manager: Case manager or Advocate
(title varies by service);
Type of services provided:
Clinical: [Empty];
Nonclinical: [Check];
Recovery plan: [Check].
Program: VA OEF/OIF Care Management Program[D];
Severity of enrollees' injuries[A]: Mild to severe;
Title of care coordinator or case manager: Case manager, Transition
Patient Advocate[E];
Type of services provided:
Clinical: [Check];
Nonclinical: [Check];
Recovery plan: [Check].
Program: VA Spinal Cord Injury and Disorders Program;
Severity of enrollees' injuries[A]: Mild to severe;
Title of care coordinator or case manager: Nurse, social worker;
Type of services provided:
Clinical: [Check];
Nonclinical: [Check];
Recovery plan: [Check].
Program: VA Polytrauma System of Care;
Severity of enrollees' injuries[A]: Serious to severe;
Title of care coordinator or case manager: Social work and nurse case
managers;
Type of services provided:
Clinical: [Check];
Nonclinical: [Check];
Recovery plan: [Check].
Source: GAO analysis of DOD and VA program information.
Notes: The characteristics listed in this table are general
characteristics of each program; individual circumstances may affect
the enrollees served and services provided by specific programs.
[A] For the purposes of this table, we have categorized the severity of
enrollees' injuries according to the injury categories established by
the DOD and VA Wounded, Ill, and Injured Senior Oversight Committee.
Servicemembers with mild wounds, illness, or injury are expected to
return to duty in less than 180 days; those with serious wounds,
illness, or injury are unlikely to return to duty in less than 180 days
and possibly may be medically separated from the military; and those
who are severely wounded, ill, or injured are highly unlikely to return
to duty and are also likely to medically separate from the military.
These categories are not necessarily used by the programs themselves.
[B] The military wounded warrior programs are the Army Wounded Warrior
Program, Marine Wounded Warrior Regiment, Navy Safe Harbor, Air Force
Warrior and Survivor Care Program, Army Reserve Wounded Warrior
Component, and Special Operations Command's Care Coalition.
[C] An FRC placed at the Special Operations Command's Care Coalition
headquarters coordinates clinical and nonclinical care for Care
Coalition and other FRCP enrollees.
[D] OEF/OIF refers to Operation Enduring Freedom and Operation Iraqi
Freedom, respectively. Since September 1, 2010, OIF is referred to as
Operation New Dawn.
[E] An OEF/OIF care manager supervises the case managers and transition
patient advocates and may also maintain a caseload of wounded veterans.
[End of table]
VA Has Made Progress in Addressing Our Recommendations to Improve FRCP
Management Processes, and DOD Has Provided Limited Assistance:
VA has recently made progress addressing the recommendations from our
March 2011 report, and although our recommendations were directed to
VA, DOD has provided limited assistance for one of the recommendations.
We previously reported that the FRCP would benefit from more definitive
management processes to strengthen program oversight and decision
making, and that program leadership could no longer rely on the
informal management processes it had developed to oversee and manage
key aspects of the program. Because VA maintains administrative control
of the program, we recommended that the Secretary of VA direct the FRCP
to take actions to address management issues related to FRC enrollment
decisions, FRCs' caseloads, and program staffing needs and placement
decisions. VA concurred with all of our recommendations and its
progress in addressing them is outlined below:
* FRC enrollment decisions. To ensure that referred servicemembers and
veterans who need FRC services are enrolled in the program, we
recommended that the FRCP establish adequate internal controls
regarding enrollment decisions by requiring FRCs to record the factors
they consider in making enrollment decisions, to develop and implement
a methodology and protocols for assessing the appropriateness of
enrollment decisions, and to refine the methodology as needed.
In May 2011, VA reported that the FRCP had fully implemented an interim
solution, which requires that FRCs present each enrollment decision to
FRCP management for review and approval. The discussion between the FRC
and management and the final decisions are documented in the program's
data management system. As of September 2011, VA reported that the FRCP
continues to review and refine the enrollment process and establish
document protocols.
* FRC caseloads. In an effort to improve the management of FRCs'
caseloads, we recommended that the FRCP complete the development of a
workload assessment tool, which would enable the program to assess the
complexity of services needed by enrollees and the amount of time
required to provide services.
As of September 2011, the FRCP has implemented a workload intensity
tool within the program's data management system, and FRCs began using
it for all new referrals in September 2011. According to the Acting
Executive Director for the FRCP, the FRCP will be monitoring the
effectiveness of the workload intensity tool and will be making
modifications to it as needed.
* Staffing needs and placement decisions. We recommended that the FRCP
clearly define and document the decision-making process for determining
when VA should hire FRCs, how many it should hire, and that the FRCP
develop and document a clear rationale for FRC placement.
In September 2011, VA reported that the FRCP has documented the formula
that the program currently uses to determine the number of FRC
positions required. In addition, the FRCP is developing a systematic
analysis to better inform decisions about the future placement of FRCs.
This analysis considers referrals received by the program, client
location upon reintegration into the community, and requests from
programs or facilities for placing FRCs at particular locations.
According to the Acting Executive Director for the FRCP, the FRCP will
report updated information about staffing and placement processes
annually in its business operation planning document.
Although our recommendations to improve the management of the FRCP were
directed to the Secretary of VA, both DOD and VA were asked to provide
a response to this subcommittee about how the departments could jointly
implement the recommendations. DOD has provided limited assistance to
VA with the implementation of our recommendation regarding enrollment.
Specifically, according to DOD and VA officials, an e-mail
communication was sent on June 30, 2011, to the commanders of the
military services' wounded warrior programs stating that they should
refer all severely wounded, ill, and injured servicemembers who could
benefit from the services of an FRC to the program for evaluation.
Despite this effort, VA officials stated that they have not noticed any
change in referral numbers or patterns from DOD since the e-mail was
sent.
DOD and VA Have Made Little Progress Reaching Agreement on Options to
Better Integrate Care Coordination Programs:
DOD and VA have made little progress reaching agreement on options to
better integrate the FRCP and RCP, although they have made a number of
attempts to address this issue. Most recently, DOD and VA experienced
difficulty jointly providing potential options for integrating these
programs in response to this subcommittee's May 26, 2011, request to
the deputy secretaries, who co-chair the DOD and VA Wounded, Ill, and
Injured Senior Oversight Committee (Senior Oversight
Committee).[Footnote 13] The subcommittee requested that the co-chairs
provide a written response to the subcommittee by June 20, 2011. In the
absence of such a response, on August 19, 2011, the subcommittee
contacted the Secretaries of DOD and VA and requested that they
facilitate moving this matter forward.
On September 12, 2011, the co-chairs of the Senior Oversight Committee
issued a joint letter that stated that the departments are considering
several options to maximize care coordination resources. However, these
options have not been finalized and were not specifically identified or
outlined in the letter. According to DOD and VA officials, the
development of this response involved a back-and-forth between the
departments because of disagreement over its contents. Although
officials of both departments collaborated on the development of the
letter, changes were made during the review process that resulted in
the delay of its release to the subcommittee. According to DOD and VA
officials, after VA had signed the letter and sent it to DOD for review
and signature, DOD officials unilaterally modified the wording, to
which VA officials objected. Officials from both departments told us
that the resulting impasse caused considerable delay in finalizing the
letter and was resolved only after DOD agreed to withdraw its changes.
Issuance of the letter followed notification by the subcommittee that
it would hold a hearing on the FRCP and RCP care coordination issue in
September 2011.
The two departments have made prior attempts to jointly develop options
for improved collaboration and potential integration of the FRCP and
RCP. Despite these efforts, no final decisions to revamp, merge, or
eliminate programs have been agreed upon. For example:
* Beginning in December 2010, the Senior Oversight Committee directed
its care management work group[Footnote 14] to conduct an inventory of
DOD and VA case managers and perform a feasibility study of
recommendations on the governance, roles, and mission of DOD and VA
care coordination. According to DOD and VA officials, this information
was requested for the purpose of formulating options for improving DOD
and VA care coordination. DOD officials stated that following
compilation of this information, no action was taken by the committee,
and care coordination was subsequently removed from the Senior
Oversight Committee's agenda as other issues, such as budget
reductions, were given higher priority. Recently, care coordination has
again been placed on the committee's agenda for a meeting scheduled in
October 2011.
* In March 2011, the DOD Office of Wounded Warrior Care and Transition
Policy sponsored a summit that included a review of DOD and VA care
coordination issues. This effort resulted in the development of five
recommendations to improve collaboration between the FRCP and RCP,
including a more standardized methodology for making referrals to the
FRCP, and two recommendations to redefine the FRCP and the RCP.
However, there was no joint response to these recommendations and no
agreement appears to have been reached to jointly implement them.
Although DOD officials contend that they have taken action on many of
these recommendations within DOD's care coordination program, VA
maintains that no substantive action has been taken to jointly
implement them. The degree of disagreement that exists between DOD and
VA on implementing these recommendations may be illustrated by the
continued disagreement between the departments about when the FRC
should engage with a seriously wounded, ill, and injured servicemember.
In discussing one of the outcomes of this coordination summit, DOD
officials asserted that the FRCP should become engaged with the
servicemember during rehabilitation after medical treatment has been
finished. In contrast, VA maintains that the point of engagement should
be in the early stage of medical treatment to build rapport and trust
with their clients and their clients' families throughout their course
of care.
In July 2011, a task force consisting of staff representing different
VA programs, including the FRCP, began meeting independently of DOD to
examine more broadly the range of services VA provides to the wounded,
ill, and injured veterans it serves. VA officials said that this task
force was formed to provide a critical examination of how VA's care
coordination and case management programs are meeting the needs of this
population. However, a VA official stated that this is an ongoing
effort, and that the task force has not yet identified any options or
recommendations related to its review. While the task force has not yet
shared information about its efforts with DOD, a VA official told us
that it is planning to make a presentation of its efforts to the Senior
Oversight Committee at a meeting scheduled in October 2011.
The lack of progress to date in reaching agreement on options to better
integrate the FRCP and the RCP illustrates DOD's and VA's continued
difficulty in collaborating to resolve care coordination program
duplication and overlap. We currently have work underway to further
study this issue and identify the key impediments that continue to
affect recovering servicemembers and veterans during the course of
their care. Additionally, as we have previously reported, there are
numerous programs in addition to the FRCP and RCP that provide similar
services to recovering servicemembers and veterans--many of whom are
enrolled in more than one program and therefore have multiple care
coordinators and case managers. For example, as of September 12, 2011,
75 percent of active FRCP enrollees also were enrolled in DOD's wounded
warrior programs. According to one FRC, his enrollees have, on average,
eight case managers who are affiliated with different programs. We
found that inadequate information exchange and poor coordination
between these programs has resulted in not only redundancy, but
confusion and frustration for enrollees, particularly when care
coordinators and case managers duplicate or contradict one another's
efforts. For example, an FRC told us that in one instance there were
five case managers working on the same life insurance issue for an
individual. In another example, an FRC and RCC were not aware the other
was involved in coordinating care for the same servicemember and had
unknowingly established conflicting recovery goals for this individual.
In this case, a servicemember with multiple amputations was advised by
his FRC to separate from the military in order to receive needed
services from VA, whereas his RCC set a goal of remaining on active
duty. These conflicting goals caused considerable confusion for this
servicemember and his family.
Conclusions:
Numerous programs, including the FRCP and RCP, have been established or
modified to improve care coordination and case management for
recovering servicemembers, veterans, and their families--individuals
who because of the severity of their injuries and illnesses could
particularly benefit from these services. While well intended, the
proliferation of these programs, which often provide similar services,
has resulted not only in inefficiencies, but also confusion for those
being served. Consequently, the intended purpose of these programs--to
better manage and facilitate care and services--may actually have the
opposite effect. Particularly disconcerting is the continued lack of
progress by DOD and VA to more effectively align and integrate their
care coordination and case management programs across the departments.
This concern is heightened further as the number of enrollees served by
these programs continues to grow. Without interdepartmental
coordination and action to better coordinate these programs, problems
with duplication and overlap will persist, and perhaps worsen.
Moreover, the confusion this creates for recovering servicemembers,
veterans, and their families may hamper their recovery.
Recommendation for Executive Action:
To improve the effectiveness, efficiency, and efficacy of services for
recovering servicemembers, veterans, and their families, we recommend
that the Secretaries of DOD and VA direct the Senior Oversight
Committee to expeditiously develop and implement a plan to strengthen
functional integration across all DOD and VA care coordination and case
management programs that serve this population, including the FRCP and
RCP, to reduce redundancy and overlap.
Agency Comments:
We obtained oral comments on the content of this statement from both
DOD and VA officials. These officials provided additional information
and technical comments, which we incorporated as appropriate.
Chairwoman Buerkle, Ranking Member Michaud, and Members of the
Subcommittee, this completes my prepared statement. I would be pleased
to respond to any questions that you may have at this time.
GAO Contact and Staff Acknowledgments:
If you or your staff have any questions about this testimony, please
contact me at (202) 512-7114 or draperd@gao.gov. Contact points for our
Offices of Congressional Relations and Public Affairs may be found on
the last page of this statement. Individuals who made key contributions
to this testimony include Bonnie Anderson, Assistant Director; Jennie
Apter; Frederick Caison; Deitra Lee; Mariel Lifshitz; and Elise
Pressma.
[End of section]
Footnotes:
[1] GAO, Federal Recovery Coordination Program: Enrollment, Staffing,
and Care Coordination Pose Significant Challenges, GAO-11-572T
(Washington, D.C.: May 13, 2011).
[2] GAO, DOD and VA Health Care: Federal Recovery Coordination Program
Continues to Expand but Faces Significant Challenges, GAO-11-250
(Washington, D.C.: Mar. 23, 2011).
[3] According to the National Coalition on Care Coordination, care
coordination is a client-centered, assessment-based interdisciplinary
approach to integrating health care and social support services in
which an individual's needs and preferences are assessed, a
comprehensive care plan is developed, and services are managed and
monitored by an identified care coordinator.
[4] According to the Case Management Society of America, case
management is defined as a collaborative process of assessment,
planning, facilitation, and advocacy for options and services to meet
an individual's health needs through communication and available
resources to promote quality, cost-effective outcomes.
[5] 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. Since September
1, 2010, OIF is referred to as Operation New Dawn.
[6] In addition to active enrollees in the FRCP, the 1,827
servicemembers and veterans served includes individuals who were
evaluated for the program but were not enrolled (in which case the FRCs
provided temporary assistance to the individual, redirected the
individual to another program, or both) and enrollees who were
deactivated from the program because they could not be contacted, no
longer required FRCP services, or had died.
[7] FRCP enrollment has continued to grow. In September 2010, for
example, the FRCP had 607 active enrollees and had provided services to
a total of 1,268 servicemembers and veterans.
[8] RCCs are assigned to and supervised by each of the military
services' wounded warrior programs.
[9] The military wounded warrior programs are the Army Wounded Warrior
Program, Marine Wounded Warrior Regiment, Navy Safe Harbor, Air Force
Warrior and Survivor Care Program, Army Reserve Wounded Warrior
Component, and Special Operations Command's Care Coalition.
[10] The Army's Wounded Warrior Program refers to its nonclinical care
coordinators as "Advocates."
[11] According to a DOD official, the number of servicemembers in the
RCP program has steadily increased over time as conflicts continue and
people take longer to transition out of the military.
[12] GAO-11-250.
[13] In May 2007, DOD and VA established the Senior Oversight Committee
to address problems 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.
[14] The Senior Oversight Committee is supported by several internal
work groups devoted to specific issues, such as DOD and VA care
coordination and case management. Participants in the committee's care
management work group include officials from the FRCP and the RCP.
[End of section]
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