Recovering Servicemembers
DOD and VA Have Jointly Developed the Majority of Required Policies but Challenges Remain Gao ID: GAO-09-728 July 8, 2009The 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 Wounded, Ill, and Injured 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 jointly developing and implementing the policies. This report focuses on the joint development of the policies. Implementation of the policies will be addressed in future reports. Specifically, this report provides information on (1) the progress DOD and VA have made in jointly developing the comprehensive policies required by the NDAA 2008 and (2) the challenges DOD and VA are encountering in the joint development 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 April 2009, 60 of the 76 policy requirements GAO identified have been completed and the remaining 16 policy requirements are in progress. DOD and VA have completed all of the policy development requirements for medical and physical 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 memorandum that was developed in consultation with VA. DOD officials reported that more information will be provided in a subsequent policy instruction, which is to be issued in August 2009. VA also plans to issue related policy guidance in the fourth quarter of 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 well 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 roles and responsibilities. GAO provided a draft of this report to DOD and VA for comment. VA provided technical comments, which GAO incorporated as appropriate. DOD and VA did not provide other comments.
GAO-09-728, Recovering Servicemembers: DOD and VA Have Jointly Developed the Majority of Required Policies but Challenges Remain
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Report to Congressional Committees:
United States Government Accountability Office:
GAO:
July 2009:
Recovering Servicemembers:
DOD and VA Have Jointly Developed the Majority of Required Policies but
Challenges Remain:
GAO-09-728:
GAO Highlights:
Highlights of GAO-09-728, a report to congressional committees.
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 Wounded,
Ill, and Injured 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 jointly developing and implementing the policies. This report
focuses on the joint development of the policies. Implementation of the
policies will be addressed in future reports.
Specifically, this report provides information on (1) the progress DOD
and VA have made in jointly developing the comprehensive policies
required by the NDAA 2008 and (2) the challenges DOD and VA are
encountering in the joint development 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 policy requirements GAO identified have
been completed and the remaining 16 policy requirements are in
progress. DOD and VA have completed all of the policy development
requirements for medical and physical 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 memorandum that
was developed in consultation with VA. DOD officials reported that more
information will be provided in a subsequent policy instruction, which
is to be issued in August 2009. VA also plans to issue related policy
guidance in the fourth quarter of 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 well 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 roles and responsibilities.
GAO provided a draft of this report to DOD and VA for comment. VA
provided technical comments, which GAO incorporated as appropriate. DOD
and VA did not provide other comments.
View [hyperlink, http://www.gao.gov/products/GAO-09-728] or key
components. For more information, contact Randall B. Williamson at
(202) 512-7114 or williamsonr@gao.gov.
[End of section]
Contents:
Letter:
Background:
DOD 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:
DOD and VA Officials Experienced Challenges during Joint Development of
Required Policies:
Agency Comments and Our Evaluation:
Appendix I: Summary of Selected Requirements from the National Defense
Authorization Act for Fiscal Year 2008:
Appendix II: GAO Contact and Staff Acknowledgments:
Tables:
Table 1: Overview of the Senior Oversight Committee's Lines of Action
(LOA):
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:
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:
Table 4: Status of Requirements to Address the Care and Management of
Recovering Servicemembers, as of April 2009:
Table 5: Status of Requirements to Address the Medical Evaluation and
Disability Evaluation of Recovering Servicemembers, as of April 2009:
Table 6: Status of Requirement to Address the Standards for Return-to-
Duty Decisions, as of April 2009:
Table 7: Status of Requirements to Address the Transition of Recovering
Servicemembers, 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:
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:
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:
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:
Abbreviations:
DOD: Department of Defense
DTM: Directive-Type Memorandum
IPO: Interagency Program Office
LOA: Lines of Action
NDAA 2008: National Defense Authorization Act for Fiscal Year 2008
OEF: Operation Enduring Freedom
OIF: Operation Iraqi Freedom
PTSD: post-traumatic stress disorder
SOC: Wounded, Ill, and Injured Senior Oversight Committee
TBI: traumatic brain injury
VA: Department of Veterans Affairs:
[End of section]
United States Government Accountability Office:
Washington, DC 20548:
July 8, 2009:
Congressional Committees:
Over 1.6 million U.S. troops have deployed in Operation Enduring
Freedom (OEF) and Operation Iraqi Freedom (OIF) since October 2001.
[Footnote 1],[Footnote 2] In May 2009, the Department of Defense (DOD)
reported that over 34,000 servicemembers have been wounded in action
since the onset of these conflicts.[Footnote 3] 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 the Department of Veterans Affairs
(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 4]
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.[Footnote 5] 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. SOC officials
sign and issue interim policy guidance, which is then developed by DOD
and VA into finalized policies. Although DOD and VA consider the SOC's
policies to be official, in this report we refer to them as interim
because they must still be finalized and implemented by DOD and VA.
The National Defense Authorization Act for Fiscal Year 2008 (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.[Footnote 6] 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 that we report on the
progress DOD and VA make in developing and implementing the
comprehensive policy.[Footnote 7] This report 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. Implementation of the policies
will be addressed in a series of future reports.
Specifically, we assessed (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 of these policies. We testified on these issues on April
29, 2009, before the Personnel Subcommittee of the Senate Armed
Services Committee.[Footnote 8]
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 9] (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 10] 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 addressed 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 or the extent to which these policies
have been implemented. To identify the challenges DOD and VA
encountered in jointly developing 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 knowledgeable DOD and VA officials.
The NDAA 2008 also requires us to certify whether we had timely access
to sufficient information to make informed judgments on the matters
covered by our report. We were provided sufficient information in a
timely manner to assess DOD and VA's progress in jointly developing
policies as well as the challenges DOD and VA are encountering in
developing policies.
We conducted our work from May 2008 through July 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
in this product.
Background:
Over the past 8 years, DOD has designated over 34,000 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 11]
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 12] VA will
pay monthly compensation and the veteran will be eligible to receive a
higher priority status for health care benefits enrollment.
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 the transition 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. In addition, two
previously-established review groups were already examining related
issues. 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 13]
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 14]
Table 1: Overview of the Senior Oversight Committee's Lines of Action
(LOA):
LOA: LOA 1: Disability Evaluation System;
Responsibilities: Addresses efforts to reform the DOD and VA disability
evaluation systems.
LOA: LOA 2: Traumatic Brain Injury (TBI)/Post Traumatic Stress Disorder
(PTSD);
Responsibilities: Addresses issues related to TBI/PTSD.
LOA: LOA 3: Case Management;
Responsibilities: Addresses care, management, and transition of
recovering servicemembers from recovery to rehabilitation and
reintegration.
LOA: LOA 4: DOD/VA Data Sharing;
Responsibilities: Addresses issues regarding the electronic exchange of
DOD and VA health records.
LOA: LOA 5: Facilities;
Responsibilities: Addresses issues relating to military and VA medical
facilities.
LOA: 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.[A].
LOA: LOA 7: Legislation and Public Affairs; Responsibilities: Addresses
legal and other issues for policy development.
LOA: LOA 8: Personnel, Pay, and Financial Support;
Responsibilities: Addresses compensation and benefit issues.
Source: GAO analysis of Senior Oversight Committee (SOC) documents and
interviews with SOC officials.
[A] As of February 2008, LOA 6 completed its responsibilities with the
issuance of a report of its recommendations to improve the support and
care for recovering servicemembers and veterans.
[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 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, and 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 public resource for recovering servicemembers,
veterans, and their families.[Footnote 15] In addition, the SOC
supported the development of several programs to improve the care,
management, and transition of 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
to be used by a medical evaluation board to document medical conditions
that may limit a servicemember's ability to serve in the military, a
single source disability rating 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. These servicemembers are highly unlikely to be able to
return to duty and may 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 overseeing the development of 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
16],[Footnote 17] 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 Senior Oversight
Committee.
[End of table]
DOD and VA Have Completed More Than Two-Thirds of the Requirements for
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 nonmedical 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 nonmedical 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: [Empty].
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: In progress.
Source: GAO analysis of information from the Senior Oversight
Committee.
[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. 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 are
unlikely to return to active duty in less than 180 days. 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 August 2009.[Footnote 18] 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 during the fourth
quarter of 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 Senior Oversight
Committee.
[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 a DOD 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 19]
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 20]
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 Senior Oversight
Committee.
[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 resulting from 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: 6. 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 Senior Oversight
Committee.
[A] NDAA 2008, section 1614(a), 1614(b)(1)-(9), (14).
[B] NDAA 2008, section 1614(b)(10)-(13), (15).
[C] NDAA 2008, section 1614(b)(16).
[D] NDAA 2008, section 1614(b)(17).
[E] NDAA 2008, section 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--which 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 the
fourth quarter of 2009.
DOD and VA Officials Experienced Challenges during Joint Development 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, 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. A provision for caregiver benefits based
on the SOC's proposal was included in the NDAA 2010 bill that was
introduced in May 2009.[Footnote 21]
* 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 were not uniformly defined.
Consequently, standardized definitions were important 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 April 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
22] 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 address the privacy rights of patients who receive medical
services from VA while serving in the military, and to protect 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.
Changes to the SOC's Staff and Scope of Responsibilities Could Pose
Future Challenges to Joint Policy Development:
The SOC has experienced turnover in leadership, reconfiguration in its
organizational structure at DOD, and changes affecting policy
development responsibilities. These changes could pose future
challenges to DOD's and VA's efforts to develop joint policy.
The SOC has experienced leadership changes caused by the turnover in
presidential administrations as well as turnover in some of its key
staff. For example, the outgoing deputy secretaries of DOD and VA, who
previously chaired the SOC, left their positions in January 2009 with
the change in administration, and new deputy secretaries were not
confirmed until February and April 2009. In their absence, the
Secretaries of VA and DOD co-chaired a SOC meeting as a short-term
measure. 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 memorandum, 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 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 23]
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. It is not clear how the IPO will ensure
effective coordination with the SOC's LOAs for overseeing the
development of information technology applications for the disability
evaluation system pilot and the individual recovery plans for the
Federal Recovery Coordination Program. Given that information
technology 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
negatively affect the development of improved policies for recovering
servicemembers.
Agency Comments and Our Evaluation:
We provided a draft of this report to DOD and VA for comment. VA
provided technical comments, which we incorporated as appropriate. DOD
and VA did not provide other comments.
We are sending copies of this report to the Secretaries of the
Departments of Defense and Veterans Affairs, congressional committees,
and other interested parties. The report is also available at no charge
on GAO's Web site at [hyperlink, http://www.gao.gov].
If you or your staff have questions about this report, please contact
me at (202) 512-7114 or at williamsonr@gao.gov. Contact points for our
Offices of Congressional Relations and Public Affairs may be found on
the last page of this report. GAO staff who made major contributions to
this report are listed in appendix II.
Signed by:
Randall B. Williamson:
Director, DOD and VA Health Care:
List of Committees:
The Honorable Carl Levin:
Chairman:
The Honorable John McCain:
Ranking Member:
Committee on Armed Services:
United States Senate:
The Honorable Daniel Akaka:
Chairman:
The Honorable Richard Burr:
Ranking Member:
Committee on Veterans' Affairs:
United States Senate:
The Honorable Daniel Inouye:
Chairman:
The Honorable Thad Cochran:
Ranking Member:
Subcommittee on Defense:
Committee on Appropriations:
United States Senate:
The Honorable Tim Johnson:
Chairman:
The Honorable Kay Bailey Hutchinson:
Ranking Member:
Subcommittee on Military Construction, Veterans' Affairs, and Related
Agencies:
Committee on Appropriations:
United States Senate:
The Honorable Ike Skelton:
Chairman:
The Honorable Howard McKeon:
Ranking Member:
Committee on Armed Services:
House of Representatives:
The Honorable Bob Filner:
Chairman:
The Honorable Steve Buyer:
Ranking Member:
Committee on Veterans Affairs:
House of Representatives:
The Honorable John P. Murtha:
Chairman:
The Honorable C. W. Bill Young:
Ranking Member:
Subcommittee on Defense:
Committee on Appropriations:
House of Representatives:
The Honorable Chet Edwards:
Chairman:
The Honorable Zach Wamp:
Ranking Member:
Subcommittee on Military Construction, Veterans Affairs, and Related
Agencies:
Committee on Appropriations:
House of Representatives:
[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
National Defense Authorization Act for Fiscal Year 2008 (NDAA 2008), we
identified 76 requirements in these sections and grouped related
requirements into 14 logical categories.[Footnote 24] Tables 8 through
11 enumerate the requirements in each of GAO's categories and provide
the status of DOD's 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: In
progress.
8. Standards and procedures for integrated medical care and management
of recovering servicemembers during transition; Status: 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[A]; 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[B];
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.
Key:
Complete:
In progress:
[A] Pub. L. No. 104-191, 110 Stat. 1936.
[B] 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 Contact and Staff Acknowledgments:
GAO Contact:
Randall B. Williamson, (202) 512-7114 or williamsonr@gao.gov:
Acknowledgments:
In addition to the contact named above, Bonnie Anderson, Assistant
Director; Susannah Bloch; Catina Bradley; April Brantley; Frederick
Caison; Lisa Motley; and Elise Pressma made major contributions to this
report.
[End of section]
Footnotes:
[1] 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).
[2] 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.
[3] DOD, 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 May 14, 2009).
[4] GAO, DOD and VA Health Care: Challenges Encountered by Injured
Servicemembers during Their Recovery Process, GAO-07-589T (Washington,
D.C.: Mar. 5, 2007) and DOD and VA Health Care: Challenges Encountered
by Injured Servicemembers during Their Recovery Process, GAO-07-606T
(Washington, D.C.: Mar. 8, 2007).
[5] For this report, hereafter, we refer to the Wounded, Ill, and
Injured Senior Oversight Committee as the Senior Oversight Committee.
[6] Pub. L. No. 110-181, 122 Stat. 3.
[7] Pub. L. No. 110-181, § 1615(d), 122 Stat. 3, 447.
[8] GAO, Recovering Servicemembers: DOD and VA Have Made Progress to
Jointly Develop Required Polices but Additional Challenges Remain, GAO-
09-540T (Washington, D.C.: Apr. 29, 2009).
[9] 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.
[10] Completed policy guidance also included interim policy guidance
signed by the SOC.
[11] These servicemembers may also receive care at Balboa Naval
Hospital in San Diego, California, or at Brooke Army Medical Center in
San Antonio, Texas.
[12] VA determines the degree to which veterans are disabled in 10
percent increments on a scale of 0 to 100 percent.
[13] 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).
[14] Duncan Hunter National Defense Authorization Act for Fiscal Year
2009, Pub. L. No. 110-417, § 726, 122 Stat. 4356, 4509 (2008).
[15] See [hyperlink, http://www.nationalresourcedirectory.org].
[16] Pub. L. No. 110-181, § 1635, 122 Stat. 3, 460-63.
[17] Interoperability is the ability of two or more systems or
components to exchange information and to use the information that has
been exchanged.
[18] 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.
[19] 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).
[20] The NDAA 2008 directed the Secretary of Defense to respond to this
policy requirement. VA does not participate in return-to-duty
decisions.
[21] S. 1033, 111th Cong. § 701 (2009).
[22] Department of Defense Task Force on Mental Health (2007).
[23] The Joint Executive Council is responsible for addressing
strategic issues affecting both departments and developing a joint DOD/
VA strategic plan.
[24] 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]
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