DOD and VA Health Care
Federal Recovery Coordination Program Continues to Expand but Faces Significant Challenges Gao ID: GAO-11-250 March 23, 2011In 2007, following reports of poor case management for outpatients at Walter Reed Army Medical Center, the Departments of Defense (DOD) and Veterans Affairs (VA) jointly developed the Federal Recovery Coordination Program (FRCP) to coordinate the clinical and nonclinical services needed by severely wounded, ill, and injured servicemembers and veterans. The FRCP, which continues to expand, is administered by VA, and the care coordinators, called Federal Recovery Coordinators (FRC), are VA employees. This report examines (1) whether servicemembers and veterans who need FRCP services are being identified and enrolled in the program, (2) staffing challenges confronting the FRCP, and (3) challenges facing the FRCP in its efforts to coordinate care for enrollees. GAO reviewed FRCP policies and procedures and conducted over 170 interviews of FRCP officials, FRCs, headquarters officials and staff of DOD and VA case management programs, and staff at medical facilities where FRCs are located.
It is unclear whether all individuals who could benefit from the FRCP's care coordination services are being identified and enrolled in the program. Because neither DOD nor VA medical and benefits information systems classify servicemembers and veterans as "severely wounded, ill, and injured," FRCs cannot readily identify potential enrollees using existing data sources. Instead, the program must rely on referrals to identify eligible individuals. Once these individuals are identified, FRCs must evaluate them and make their enrollment determinations--a process that involves considerable judgment by FRCs because of broad criteria. However, FRCP leadership does not systematically review FRCs' enrollment decisions, and as a result, program officials cannot ensure that referred individuals who could benefit from the program are enrolled and, conversely, that the individuals who are not enrolled are referred to other programs. The FRCP faces challenges in determining staffing needs, including managing FRCs' caseloads and deciding when VA should hire additional FRCs and where to place them. According to the FRCP Executive Director, appropriately balanced caseloads (size and mix) are difficult to determine because there are no comparable criteria against which to base caseloads for this program because of its unique care coordination activities. The program has taken other steps to manage FRCs' caseloads, including the use of an informal FRC-to-enrollee ratio. Because these methods have some limitations, the FRCP is developing a customized workload assessment tool to help balance the size and mix of FRCs' caseloads but has not determined when this tool will be completed. In addition, the FRCP has not clearly defined or documented the processes for making staffing decisions in FRCP policies or procedures. As a result, it is difficult to determine how staffing decisions are made, or how this process could be sustained during a change in leadership. Finally, the FRCP's basis for placing FRCs at DOD and VA facilities has changed over time, and the program lacks a clear and consistent rationale for making these decisions, which would help ensure that FRCs are located where they could provide maximum benefit to current and potential enrollees. A key challenge facing the FRCP concerns limitations on sharing information needed to coordinate services for enrollees, who may be enrolled in multiple DOD and VA case management programs. These limitations are often blamed for duplication of services and enrollee confusion, prompting two military wounded warrior programs to cease making referrals to the FRCP. One such limitation existed because VA had not completed public disclosure actions necessary to enable the sharing of information from the FRCP's information system. In January 2011, VA completed the process needed to resolve this issue. In addition, incompatibility among information systems used by different case management programs limits data sharing. Although the ultimate solution to information system incompatibility is beyond the capacity of the FRCP to resolve, the program has initiated an effort to improve information exchange. GAO recommends that VA direct the FRCP Executive Director to establish systematic oversight of enrollment decisions, complete development of a workload assessment tool, document staffing decisions, and develop and document a rationale for FRC placement. GAO received comments from DOD and VA; VA concurred with GAO's recommendations.
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: Randall B. Williamson Team: Government Accountability Office: Health Care Phone: (206) 287-4860GAO-11-250, DOD and VA Health Care: Federal Recovery Coordination Program Continues to Expand but Faces Significant Challenges
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United States Government Accountability Office:
GAO:
Report to Congressional Requesters:
March 2011:
DOD and VA Health Care:
Federal Recovery Coordination Program Continues to Expand but Faces
Significant Challenges:
GAO-11-250:
GAO Highlights:
Highlights of GAO-11-250, a report to congressional requesters.
Why GAO Did This Study:
In 2007, following reports of poor case management for outpatients at
Walter Reed Army Medical Center, the Departments of Defense (DOD) and
Veterans Affairs (VA) jointly developed the Federal Recovery
Coordination Program (FRCP) to coordinate the clinical and nonclinical
services needed by severely wounded, ill, and injured servicemembers
and veterans. The FRCP, which continues to expand, is administered by
VA, and the care coordinators, called Federal Recovery Coordinators
(FRC), are VA employees. This report examines (1) whether
servicemembers and veterans who need FRCP services are being
identified and enrolled in the program, (2) staffing challenges
confronting the FRCP, and (3) challenges facing the FRCP in its
efforts to coordinate care for enrollees. GAO reviewed FRCP policies
and procedures and conducted over 170 interviews of FRCP officials,
FRCs, headquarters officials and staff of DOD and VA case management
programs, and staff at medical facilities where FRCs are located.
What GAO Found:
It is unclear whether all individuals who could benefit from the FRCP‘
s care coordination services are being identified and enrolled in the
program. Because neither DOD nor VA medical and benefits information
systems classify servicemembers and veterans as ’severely wounded,
ill, and injured,“ FRCs cannot readily identify potential enrollees
using existing data sources. Instead, the program must rely on
referrals to identify eligible individuals. Once these individuals are
identified, FRCs must evaluate them and make their enrollment
determinations”a process that involves considerable judgment by FRCs
because of broad criteria. However, FRCP leadership does not
systematically review FRCs‘ enrollment decisions, and as a result,
program officials cannot ensure that referred individuals who could
benefit from the program are enrolled and, conversely, that the
individuals who are not enrolled are referred to other programs.
The FRCP faces challenges in determining staffing needs, including
managing FRCs‘ caseloads and deciding when VA should hire additional
FRCs and where to place them. According to the FRCP Executive
Director, appropriately balanced caseloads (size and mix) are
difficult to determine because there are no comparable criteria
against which to base caseloads for this program because of its unique
care coordination activities. The program has taken other steps to
manage FRCs‘ caseloads, including the use of an informal FRC-to-
enrollee ratio. Because these methods have some limitations, the FRCP
is developing a customized workload assessment tool to help balance
the size and mix of FRCs‘ caseloads but has not determined when this
tool will be completed. In addition, the FRCP has not clearly defined
or documented the processes for making staffing decisions in FRCP
policies or procedures. As a result, it is difficult to determine how
staffing decisions are made, or how this process could be sustained
during a change in leadership. Finally, the FRCP‘s basis for placing
FRCs at DOD and VA facilities has changed over time, and the program
lacks a clear and consistent rationale for making these decisions,
which would help ensure that FRCs are located where they could provide
maximum benefit to current and potential enrollees.
A key challenge facing the FRCP concerns limitations on sharing
information needed to coordinate services for enrollees, who may be
enrolled in multiple DOD and VA case management programs. These
limitations are often blamed for duplication of services and enrollee
confusion, prompting two military wounded warrior programs to cease
making referrals to the FRCP. One such limitation existed because VA
had not completed public disclosure actions necessary to enable the
sharing of information from the FRCP‘s information system. In January
2011, VA completed the process needed to resolve this issue. In
addition, incompatibility among information systems used by different
case management programs limits data sharing. Although the ultimate
solution to information system incompatibility is beyond the capacity
of the FRCP to resolve, the program has initiated an effort to improve
information exchange.
What GAO Recommends:
GAO recommends that VA direct the FRCP Executive Director to establish
systematic oversight of enrollment decisions, complete development of
a workload assessment tool, document staffing decisions, and develop
and document a rationale for FRC placement. GAO received comments from
DOD and VA; VA concurred with GAO‘s recommendations.
View [hyperlink, http://www.gao.gov/products/GAO-11-250] or key
components. For more information, contact Randall B. Williamson at
(202) 512-7114 or williamsonr@gao.gov.
[End of section]
Contents:
Letter:
Background:
Problems Identifying Potential Enrollees and Reviewing Enrollment
Decisions Make It Unclear Whether Those Needing FRCP Services Are
Enrolled:
The FRCP Faces Challenges in Determining Staffing Needs and Has Not
Clearly Defined or Documented Its Processes for Managing FRCs'
Caseloads, Making Staffing Decisions, and Placing FRCs:
The FRCP Faces Challenges That Limit Its Ability to Coordinate Care
but Is Taking Steps to Address Them:
Conclusions:
Recommendations for Executive Action:
Agency Comments and Our Evaluation:
Appendix I: The Use of Software to Analyze Testimonial Evidence:
Appendix II: Comments from the Department of Defense:
Appendix III: Comments from the Department of Veterans Affairs:
Appendix IV: GAO Contact and Staff Acknowledgments:
Tables:
Table 1: Demographic Information of Federal Recovery Coordination
Program (FRCP) Enrollees as a Percentage of FRCP Enrollment, September
2010:
Table 2: Description of Selected Federal Recovery Coordinator (FRC)
Activities:
Table 3: Diagnoses of Federal Recovery Coordination Program (FRCP)
Enrollees, September 2010:
Table 4: Characteristics of Major Department of Defense (DOD) and
Department of Veterans Affairs (VA) Programs for Seriously and
Severely Wounded Servicemembers and Veterans:
Figure:
Figure 1: Location and Number of Federal Recovery Coordinators (FRC),
September 2010:
Abbreviations:
DOD: Department of Defense:
FRC: Federal Recovery Coordinator:
FRCP: Federal Recovery Coordination Program:
OEF: Operation Enduring Freedom:
OIF: Operation Iraqi Freedom:
VA: Department of Veterans Affairs:
[End of section]
United States Government Accountability Office:
Washington, DC 20548:
March 23, 2011:
Congressional Requesters:
In 2007, in response to critical media reports of deficiencies in the
provision of outpatient services at Walter Reed Army Medical Center,
various review groups investigated the challenges that the Departments
of Defense (DOD) and Veterans Affairs (VA) faced in providing care to
recovering servicemembers. The review groups cited common areas of
concern, including case management, which helps ensure continuity of
care by coordinating services from multiple providers and guiding
transitions between providers or agencies or back to the civilian
community. One of these review groups, the President's Commission on
Care for America's Returning Wounded Warriors--commonly referred to as
the Dole-Shalala Commission--issued a report[Footnote 1] that noted
that while the military services did provide case management, some
servicemembers were being assigned multiple case managers, having no
single person to monitor and coordinate their activities, which often
resulted in confusion, redundancy, and delay. To address these
shortcomings, the commission recommended strengthening the continuity
of care for recovering servicemembers through the use of
individualized recovery plans that would be developed and monitored by
skilled recovery coordinators who would have the ability to operate
across departments. In response, the joint DOD and VA Wounded, Ill,
and Injured Senior Oversight Committee (Senior Oversight Committee)
developed the Federal Recovery Coordination Program (FRCP) to assist
severely wounded Operation Enduring Freedom (OEF) and Operation Iraqi
Freedom (OIF) servicemembers, veterans, and their families with access
to care, services, and benefits.[Footnote 2] The FRCP was envisioned
to serve severely wounded, ill, or injured servicemembers and
veterans,[Footnote 3] including those who had suffered traumatic brain
injuries, amputations, burns, spinal cord injuries, visual impairment,
and post-traumatic stress disorder. (In this report, we use "severely
wounded" to denote severely wounded, ill, and injured servicemembers
and veterans, as appropriate.) According to VA officials, the number
of severely wounded servicemembers in the OEF/OIF conflicts is not
known with certainty because "severely wounded" is not a categorical
designation used by DOD or VA medical or benefits programs. Estimates
of the size of the severely wounded population vary, depending on
definitions and methodology.
Although the FRCP is the first care coordination program jointly
developed by DOD and VA, it is but one of several recently introduced
or revised programs intended to improve the continuity of care for
wounded servicemembers and veterans. Other programs include the
wounded warrior programs operated by the military services;[Footnote
4] VA's OEF/OIF Care Management Program; and DOD's Recovery
Coordination Program, which is separately implemented and managed by
each military service. However, the FRCP was intended to complement
rather than duplicate the efforts of clinical and nonclinical case
management programs in both DOD and VA through the use of senior-level
coordinators called Federal Recovery Coordinators (FRC). Unlike case
managers, FRCs are intended to be care coordinators whose planning,
coordination, monitoring, and problem-resolution activities encompass
both health services and benefits provided through DOD, VA, other
federal agencies, states, and the private sector. Care coordination
programs[Footnote 5] are typically more comprehensive in scope than
clinical or nonclinical case management programs, and care
coordinators, such as FRCs, may serve as a link between multiple case
managers. The FRCs strive to work with each enrollee to create a
comprehensive Federal Individual Recovery Plan to identify his or her
goals and subsequently to coordinate and monitor the clinical and
nonclinical services needed to achieve the enrollee's goals--
interacting with the enrollee for a lifetime if necessary. The FRCP is
administered by VA, and the FRCs are VA employees.
An evaluation of the FRCP during the program's initial implementation
phase identified a number of challenges facing the program, including
the determination of appropriate staffing levels for FRCs.[Footnote 6]
This evaluation noted that staffing levels were difficult to
determine, given the absence of a widely accepted estimate of the size
of the severely wounded population. In addition, the FRCs'
unprecedented care coordination role and work activities meant that it
was not known how many FRCs would be required to address the needs of
enrollees. This evaluation also noted that the program should consider
future FRC placement in response to the expected increase in the
number of enrollees, who could be located in different parts of the
country.
Since beginning operation in January 2008, the FRCP has grown
considerably, but the program experienced turmoil in its early stages.
At the time of the program's introduction, eight FRCs were placed at
three military treatment facilities--Walter Reed Army Medical Center,
National Naval Medical Center, and Brooke Army Medical Center.
However, within the first 7 months of its implementation, six of the
original eight FRCs left the program, VA moved oversight of the
program directly under the VA Secretary, and the FRCP Executive
Director was replaced in July 2008. Under the new Executive Director,
the FRCP enlarged its staff, increased the number of enrollees, and
expanded the number of locations where FRCs are assigned. As of
September 2010, the program employed 20 FRCs, who were serving about
600 servicemembers and veterans. These FRCs were located at six
military treatment facilities, three VA medical centers, and the
headquarters of one military service's wounded warrior program. While
the FRCs are physically located at certain facilities, their enrollees
are scattered throughout the country and may not be receiving care at
the facility where their assigned FRC is located.
Our review of the FRCP is one in a series of engagements focused on
the continuity of care for recovering servicemembers and veterans,
which resulted from requests from multiple congressional requesters.
In light of continued concerns about DOD's and VA's efforts to support
servicemembers and veterans, this report examines (1) whether
servicemembers and veterans who need FRCP services are being
identified and enrolled in the program, (2) staffing challenges
confronting the FRCP, and (3) the challenges facing the FRCP in its
efforts to coordinate care for severely wounded servicemembers and
veterans.
To address these objectives, we conducted more than 170 interviews of
the following groups: FRCs; FRCP leadership, which includes the
Executive Director, the Deputy Director for Health, and the Deputy
Director for Benefits; leadership officials with DOD and VA case
management programs (collectively referred to as program officials),
including leadership officials from each military service's wounded
warrior program; and medical facility directors and staff at DOD and
VA medical facilities (referred to as medical facility staff). We
interviewed the FRCs individually to learn about challenges they have
encountered, using comprehensive interviews of the 15 FRCs who were
working in the FRCP in or before December 2009 and limited interviews
of the 5 FRCs who were hired in January 2010. To develop an
understanding about how clinical and nonclinical officials and staff
interact with the FRCs, we conducted site visits and telephone
interviews with program officials at DOD and VA headquarters and
medical facility staff at the DOD and VA medical facilities where FRCs
are located. These facilities included Walter Reed Army Medical
Center; National Naval Medical Center; Brooke Army Medical Center;
Naval Medical Center-San Diego; Naval Hospital Camp Pendleton;
Eisenhower Army Medical Center; and the VA medical centers in Houston,
Texas; Providence, Rhode Island; and Tampa, Florida. In addition, we
visited three VA medical centers with which FRCs have significant
interaction--the facilities in Richmond, Virginia; Augusta, Georgia;
and San Diego, California. We performed content analysis of the
qualitative information obtained from the FRCs, DOD and VA program
officials, and medical facility staff by grouping their responses by
topic and then identifying response patterns. Content analysis of
qualitative information obtained from DOD and VA program officials and
medical facility staff was conducted using a software
package,[Footnote 7] which enabled us to analyze responses to specific
interview topics for a large number of interviews. (See app. I for a
discussion of how we used the software package.) However, the results
from our site visits and interviews cannot be generalized because
while all DOD and VA facilities could potentially interact with FRCs,
our review focused on facilities where FRCs are located as well as
some facilities where FRCs have significant interaction. In addition,
we obtained and reviewed documentation related to the FRCP, including
VA's October 2009 handbook on care management of OEF and OIF Veterans;
the FRCP Standard Operating Procedures; the FRCP fiscal year 2010
operating plan; and draft FRCP procedures, such as the VA handbook on
the FRCP.
We conducted this performance audit from September 2009 through March
2011 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:
Servicemembers wounded in recent conflicts are surviving injuries that
would have been fatal in past conflicts, in part because of advanced
protective equipment and medical treatment. However, the severity of
their injuries can result in a lengthy transition from patient status
back to active duty or to veteran status. Most severely wounded
servicemembers from the conflicts in Iraq and Afghanistan initially
are evacuated to Landstuhl Regional Medical Center in Germany for
treatment. From there, they are usually transported to military
treatment facilities in the United States, with most of the severely
wounded admitted to Walter Reed Army Medical Center, the National
Naval Medical Center, or Brooke Army Medical Center.
Acute medical treatment and stabilization is the first of three phases
in the "continuum of care" experienced by severely wounded
servicemembers. The second phase of the continuum is rehabilitation at
a DOD, VA, or civilian facility. (The recovery needs of some
servicemembers receiving rehabilitation may require their return to a
medical center for acute medical care, such as surgical procedures.)
The third phase of the continuum is reintegration--either return to
active duty or to the civilian community as a veteran, where they may
receive health care from DOD, VA, or civilian providers.
FRCP Enrollees:
From January 2008--when FRCP enrollment began--through September 2010,
the FRCP provided services to a total of 1,268 servicemembers and
veterans.[Footnote 8] As of September 2010, the program had 607 active
enrollees, ranging in age from 19 to 61 years, with a median age of 27
years. About half of the enrollees were or had been married. Fifty-
eight percent had designated another person as his or her primary
caregiver, and 38 percent had delegated legal authority to another
person. (See table 1 for additional demographic information about
current FRCP enrollees.)
Table 1: Demographic Information of Federal Recovery Coordination
Program (FRCP) Enrollees as a Percentage of FRCP Enrollment, September
2010:
Enrollee's branch of service:
Army; 56 percent;
Marines; 29 percent;
Navy; 9 percent;
Air Force; 6 percent;
Coast Guard; Less than 1 percent.
Duty status:
Active duty; 57 percent;
Veteran; 43 percent.
Gender:
Male; 94 percent;
Female; 6 percent.
Treatment status:
Outpatient; 77 percent;
Inpatient; 23 percent.
Source: GAO analysis of FRCP data.
Note: Totals may not equal 100 percent because of rounding.
[End of table]
FRC Activities:
FRCs are senior-level registered nurses and licensed social workers
whose principal role is to coordinate services with case managers
rather than provide services directly to enrollees. FRCs are expected
to serve as the single point of contact for the enrollees and their
families and to assist the enrollees in a number of ways. FRCP care
coordination guidelines identify FRC activities, which are outlined in
table 2.
Table 2: Description of Selected Federal Recovery Coordinator (FRC)
Activities:
Activity: Referral;
Description: Receiving notification of or identifying potential
Federal Recovery Coordination Program (FRCP) enrollees and contacting
them.
Activity: Evaluation;
Description: Conducting an evaluation of need and whether the
servicemember or veteran meets FRCP eligibility criteria;
individuals who are referred to but not enrolled into the FRCP may be
counseled about alternative sources of support ("redirected") or
provided with short-term services to address a specific issue (an
"assist").
Activity: Enrollment;
Description: Determining that a servicemember or veteran meets
eligibility criteria and would benefit from care coordination, and
enrolling that individual in the FRCP.
Activity: Creation of Federal Individual Recovery Plan;
Description: Developing an individualized plan for each FRCP enrollee.
Activity: Documentation;
Description: Entering enrollee information and Federal Individual
Recovery Plan into the FRCP data management system, known as the
Veterans Tracking Application;
FRCs use the Veterans Tracking Application to record subsequent
actions taken on an enrollee's behalf.
Activity: Communication;
Description: Contacting enrollee or family at least every 30 days,
unless otherwise negotiated.
Activity: Coordination;
Description: Identifying, communicating with, and coordinating with
providers and case managers from federal, state, local, and private
organizations, based on the needs of enrollees.
Activity: Monitoring;
Description: Monitoring the enrollee and goal achievement as contained
in the Federal Individual Recovery Plan;
modifying the Federal Individual Recovery Plan over time in response
to enrollee's changing needs.
Activity: Deactivation;
Description: Changing enrollment status to "inactive" in the event
that an enrollee dies, no longer needs or desires assistance, or is
nonresponsive to FRC communications;
otherwise, care coordination may continue over an enrollee's lifetime.
Source: FRCP handbook (in draft).
[End of table]
According to FRCP policy, the FRC's primary responsibility is to
develop and monitor progress of each enrollee as detailed in that
person's Federal Individual Recovery Plan, which is created and
implemented by the FRC with input from the enrollee and his or her
family and clinical team. This plan is to be a comprehensive, client-
centered plan that sets individualized goals for recovery and is
intended to guide and support the enrollee through the continuum of
care. FRCs update Federal Individual Recovery Plans to reflect
changing conditions or enrollee goals.
Based on their diagnoses and other factors, enrollees are likely to
require a complex array of clinical and nonclinical services from
multiple providers and facilities. (See table 3.) In providing care
coordination services, the FRC may engage with an enrollee's health
care providers, other care coordinators, and case managers, such as
those with the military services' wounded warrior programs. As care
coordinators, FRCs are generally not expected to directly provide the
services needed by enrollees. However, FRCs may provide services
directly to enrollees in certain situations, such as when they cannot
determine whether a case manager has taken care of an issue for an
FRCP enrollee, when asked to resolve complex problems, or when making
complicated arrangements, for example, identifying and arranging
admission to a substance abuse treatment program for a veteran who was
beginning to develop violent behaviors and had refused to complete a
VA drug rehabilitation treatment program.
Table 3: Diagnoses of Federal Recovery Coordination Program (FRCP)
Enrollees, September 2010:
Diagnoses: Traumatic brain injury;
Percentage of enrollees: 54%.
Diagnoses: Psychological diagnosis;
Percentage of enrollees: 43%.
Diagnoses: Orthopedic injury;
Percentage of enrollees: 25%.
Diagnoses: Amputation;
Percentage of enrollees: 20%.
Diagnoses: Spinal cord injury;
Percentage of enrollees: 19%.
Diagnoses: Vision loss;
Percentage of enrollees: 15%.
Diagnoses: Medical diagnosis[A];
Percentage of enrollees: 13%.
Diagnoses: Burn;
Percentage of enrollees: 9%.
Diagnoses: Chest injury;
Percentage of enrollees: 9%.
Diagnoses: Hearing loss;
Percentage of enrollees: 9%.
Diagnoses: Intra-abdominal injury;
Percentage of enrollees: 9%.
Diagnoses: Other[B];
Percentage of enrollees: 25%.
Source: GAO analysis of FRCP data.
Note: These diagnoses may not represent each enrollee's primary
medical diagnosis. Additionally, approximately 70 percent of FRCP
enrollees have more than one diagnosis.
[A] "Medical diagnosis" includes diagnoses such as stroke, heart
attack, and cancer.
[B] "Other" includes diagnoses not otherwise covered in the table,
such as anoxic brain injury and inhalation injury.
[End of table]
Problems Identifying Potential Enrollees and Reviewing Enrollment
Decisions Make It Unclear Whether Those Needing FRCP Services Are
Enrolled:
It is unclear whether all of the eligible "severely wounded, ill, and
injured" servicemembers and veterans who could benefit from the FRCP
are being enrolled in the program. The FRCP cannot readily identify
these individuals because the "severely wounded, ill, and injured"
classification is not captured in existing data sources. Additionally,
the program's broad eligibility criteria cannot be used systematically
to identify potentially eligible servicemembers and veterans. Instead,
the FRCP must rely on referrals from others to identify these
individuals, although the program has also taken steps to identify
potential enrollees through the FRCs' efforts at medical facilities
and through a "look back" initiative to identify eligible veterans who
were wounded prior to program implementation. In addition, the FRCs
must exercise judgment in applying the program's criteria for
enrollment determinations, and FRCP leadership does not systematically
review these decisions to ensure that these criteria are applied
appropriately so that referred individuals who could benefit from the
program are enrolled, and that individuals who could be served by less
intensive services are referred to other programs.
The FRCP's Potential Enrollee Population Cannot Be Readily Identified
from Existing Data Sources, but the FRCP Has Taken a Number of Steps
to Identify Potentially Eligible Individuals:
FRCP officials have experienced difficulties in identifying the
potentially eligible population of "severely wounded, ill, or injured"
servicemembers and veterans, and as a result, it is unclear whether
all of these individuals who could benefit from care coordination
services are enrolled in the program. The Senior Oversight Committee,
which created the FRCP, developed a three-level care categorization
system to differentiate the population of wounded servicemembers and
veterans for different programs based on the severity of their
conditions. In this system,
* Category 1 servicemembers are those with mild wounds, illnesses, or
injuries who are expected to return to duty in less than 180 days;
* Category 2 servicemembers are those with serious wounds, illnesses,
or injuries who are unlikely to return to duty in less than 180 days
and possibly may be medically separated from the military; and:
* Category 3 servicemembers are severely wounded, ill, or injured
individuals whose medical conditions are highly likely to prevent
their return to duty and also likely to result in medical separation
from the military.
Individuals who fall under category 3 may be considered for enrollment
into the FRCP, while individuals falling under categories 1 or 2 may
qualify for other types of programs. However, according to the FRCP
Executive Director, these are administrative categories that are not
captured in existing VA or DOD medical or benefits data systems or
included in medical or benefits records. As a result, the FRCP cannot
use this classification to systematically identify the population of
potentially eligible severely wounded servicemembers and veterans
using available data sources. In addition, the FRCP Executive Director
and FRCs told us that the broad eligibility criteria developed for the
FRCP must be used on a case-by-case basis to identify potentially
eligible individuals for the program because these criteria require
some judgment. Therefore, the criteria cannot be used systematically
to identify the program's potentially eligible population. These
criteria include both specific medical diagnoses and requirements that
are somewhat subjective, such as whether an individual may benefit
from a recovery plan. To decide whether potential enrollees may
benefit from a recovery plan, FRCs reported that they evaluate the
complexity of a situation by examining issues such as future medical
needs, family dynamics, and any financial or legal problems--
information that is not readily available in any one data source.
As a result, to identify potentially eligible individuals, the FRCP
relies on referrals from others, including program officials and
medical facility staff. Sources of referrals include, for example,
wounded warrior program staff, Recovery Care Coordinators, and
clinical treatment teams. Of the program officials and medical
facility staff we spoke with who discussed referrals, more than half
(25 of 47) had made a referral to the program. However, more than half
(15 of 27) of the program officials and medical facility staff we
interviewed who responded to questions on eligibility also felt that
the FRCP eligibility criteria were unclear.[Footnote 9] In addition to
relying on referrals, the FRCs also take steps to identify potential
enrollees. Some FRCs stated that they review their facility's list of
incoming severely wounded servicemembers and attend weekly
multidisciplinary team meetings where hospital officials and medical
staff discuss severely wounded patients' cases.
In an attempt to ensure that eligible veterans who were wounded prior
to the program's inception are enrolled in the program, the FRCP
conducted a "look back" initiative in May 2010. Because no single data
source contains sufficient information, the FRCP Executive Director
told us that she combined five DOD and VA data sets and used multiple
"proxy" factors to narrow the data from 40,000 veterans' records to
the final list of potentially eligible veterans. For example, the
Veterans Benefits Administration's 100 percent disability compensation
list and medical diagnostic codes were used to help identify this
population. Based on this analysis, the FRCP Executive Director
reported that the program contacted approximately 300 potential
enrollees to determine whether they could benefit from an FRC's
assistance. As a result, 35 of those severely wounded veterans will be
further evaluated for potential enrollment.
According to the FRCP Executive Director, this analysis was
prioritized to focus on severely wounded veterans who were most likely
to need FRC assistance. The Executive Director told us that, as a
result, the list was not comprehensive--for example, the program did
not contact veterans who were already enrolled in VA's OEF/OIF Care
Management Program under the assumption that they were already
receiving adequate case management. Additionally, the FRCP Executive
Director told us that identifying 35 veterans indicated that the FRCP
is not reaching all potentially eligible veterans through its normal
referral process or that information about the program is not reaching
severely wounded veterans. The FRCP Executive Director added that once
it is complete, this effort will be assessed to determine whether
another "look back" is needed, but as of February 2011, leadership
officials had not yet determined whether they would conduct a
subsequent "look back."
Enrollment Decisions Require FRC Judgment, and FRCP Leadership Does
Not Systematically Review These Decisions to Ensure That Referred
Individuals Who Could Benefit Are Enrolled:
Following the identification of potentially eligible servicemembers
and veterans, FRCs use a more thorough application of the program's
eligibility criteria to evaluate these individuals for enrollment. The
eligibility criteria are broad and require FRCs to exercise judgment
with their enrollment decisions. However, FRCP leadership does not
systematically review these decisions to ensure that referred
individuals who could benefit from the program are enrolled while
those requiring less intensive services are referred to other programs.
Eligibility criteria for the program--developed by the Senior
Oversight Committee--specify that enrollees:
* be receiving acute care in a military treatment facility;
* be diagnosed or referred for one or more of the following: spinal
cord injury, burns, amputation, visual impairment, traumatic brain
injury, or post-traumatic stress disorder;
* be considered at risk for psychosocial complication; or:
* may benefit from a recovery plan.
Because some of these criteria are subjective, particularly whether an
individual is at risk for psychosocial complications or would benefit
from a recovery plan, the FRCs must use their judgment when deciding
whether an individual should be enrolled in the program. According to
the FRCP Executive Director, the program's criteria are intended to
provide guidance for the FRCs, giving them the flexibility to enroll
severely wounded servicemembers and veterans, rather than being
restrictive. The Executive Director added that FRCs strive to enroll
severely wounded servicemembers and veterans in cases where having an
FRC can add value to existing case management efforts.
To evaluate servicemembers and veterans for program eligibility, FRCs
must make subjective assessments of the impact their care coordination
efforts could have on potential enrollees. This involves FRCs making
assessments of the severity of potential enrollees' medical conditions
to determine future medical needs--such as rehabilitation--and
nonmedical issues--such as caregiver status. FRCs obtain information
from a number of sources, including DOD and VA medical records, as
well as records from private sector providers. They may also discuss
potential enrollees' situations with members of multidisciplinary
teams providing medical treatment, family members, and the potential
enrollees. At the end of the evaluation period, the FRC will consider
a potential enrollee's need for care coordination based on the
collected information and determine whether the individual should be
enrolled in the program, provided temporary assistance, or referred to
another program.
While it is necessary for FRCs to use their judgment in making
enrollment decisions, the FRCP does not systematically review the
factors and reasons for enrolling, providing temporary assistance, or
referring potentially eligible servicemembers and veterans to other
programs. Systematic review could involve the use of a defined
protocol for the review of eligibility decisions made by FRCs.
According to federal internal control standards,[Footnote 10] agencies
should establish ongoing internal control activities to provide
reasonable assurance that decisions are consistent with applicable
criteria--in this case, criteria designed to ensure that those in need
of care coordination services are enrolled in the program. While the
FRCs indicate in their data management system--the Veterans Tracking
Application--whether they decided to enroll an individual, FRCP
leadership told us they do not require that the FRCs record the
factors they considered to support this decision. Additionally, FRCP
leadership told us that while they closely review all enrollment
decisions made by new FRCs, they do not perform similar reviews of
decisions made by more experienced FRCs. Instead, FRCP leadership and
experienced FRCs discuss the FRCs' recommended actions on newly
referred individuals as part of weekly telephone conversations.
However, FRCP officials acknowledged that these discussions with the
FRCs may not be comprehensive and that there is no section in the
Veterans Tracking Application dedicated to recording these
discussions. Without specific documentation of the factors the FRCs
considered when making their enrollment decisions and absent internal
controls and systematic oversight of much of the enrollment process,
it is difficult to determine whether severely wounded servicemembers
and veterans who are referred and could benefit from the program are
actually enrolled and severely wounded servicemembers and veterans who
could be served by less intensive services are referred to other
programs. Additionally, this issue could become even more problematic
as the program's enrollment continues to increase and FRCP leadership
has to review more enrollment decisions.
The FRCP Faces Challenges in Determining Staffing Needs and Has Not
Clearly Defined or Documented Its Processes for Managing FRCs'
Caseloads, Making Staffing Decisions, and Placing FRCs:
Several challenges confront the FRCP in determining staffing needs for
the program, including how to manage FRCs' caseloads, deciding when VA
should hire FRCs, and determining where to place them in the field to
best serve current and potential enrollees. The FRCP has not
established a formal caseload size for FRCs because there are no
comparable criteria upon which to determine caseload size because of
the program's unique care coordination activities. Also, while
establishing an appropriate caseload size for FRCs may help FRCP
leadership determine how many FRCs VA should hire, it remains
difficult for FRCP leadership to determine when VA should hire FRCs.
Finally, the FRCP lacks a clear and consistent rationale for making
decisions about where to place FRCs in the field.
FRCs Have Expressed Concerns about Heavy Caseloads, and the FRCP Is
Developing a Workload Assessment Tool That Should Help Address This
Concern:
The FRCs we spoke with expressed concerns about the high number of
enrollees assigned to them and cited the need for improved caseload
management. Specifically, 11 of the 15 FRCs we interviewed[Footnote
11] identified inadequate caseload management as a concern. Eight of
these FRCs expressed concerns about the large number of cases assigned
to them. As of September 30, 2010, FRCs' caseloads ranged from 25 to
48, with two-thirds of the FRCs (10 of 15) having caseloads that
exceeded the informal target ratio of 1 FRC for every 30 enrollees
established by the FRCP Executive Director to manage FRC caseloads.
Some FRCs told us that the large number of cases required them to work
long hours and sometimes forced them to limit the amount of time that
they could devote to an enrollee. In addition, more than half of the
FRCs (8 of 15) expressed concerns that FRCP leadership does not
adequately account for the services required by existing enrollees in
their caseloads when assigning new cases. For example, one FRC told us
that the types of cases assigned to her were stressful. She indicated
that she had been assigned two enrollees with terminal conditions
because she was skilled at managing the issues related to these types
of cases, but she is now reluctant to take another terminally ill
enrollee because it is emotionally draining to deal with end-of-life
issues. However, an FRCP leadership official told us that FRCs have
the flexibility to forward a referral to the FRCP central office for
assignment to another FRC as a means of managing their existing
caseloads.
According to the FRCP Executive Director, an appropriate caseload is
difficult to determine because care coordination is a new type of
function, and there are no comparable criteria against which to
measure and base caseload size for this program because of its unique
activities. Additionally, the FRCs' caseloads are dynamic in that the
needs of each enrollee differ and may change over time. For example,
out of a caseload of 30 clients, 5 may need intensive crisis
management, while the remaining 25 enrollees may only need periodic
contact or limited services. However, as noted by FRCP leadership and
some FRCs, the needs of these enrollees, and consequently, the time
required of an FRC, may change as enrollees move through different
stages of the continuum of care.
As a means of managing FRCs' caseloads, the FRCP Executive Director
cited two actions in particular that FRCP leadership uses to assess
and manage FRC caseloads.
* FRCP leadership uses an informal FRC-to-enrollee target ratio of 1
to 30 (with a targeted range of 25 to 35 enrollees per FRC), which is
based on the FRCP Executive Director's experience in managing the
program over time.
* Weekly telephone calls with each FRC are used by FRCP leadership to
discuss issues related to their assigned cases and to gauge workload
burden.
The FRCP Executive Director told us that the program is developing a
customized workload assessment tool to help balance FRCs' caseloads--
in other words, to ensure that an FRC's caseload mix is manageable.
The objective of the workload assessment tool is to identify specific
enrollee characteristics, such as medical diagnosis, and to correlate
each characteristic with the amount of time an FRC would be required
to spend on addressing issues related to it. One method being
considered is the assignment of a point value to each identified
enrollee characteristic. Adding up the number of points for the
characteristics of all enrollees in an FRC's caseload would provide an
estimate of that FRC's workload burden. However, according to the FRCP
Executive Director, the development of such a tool has been difficult,
primarily because the enrollee characteristics that existing workload
assessment tools use to determine how much time it takes to address an
issue are not relevant to the care coordination activities that FRCs
perform. As a result, program leadership continues to consider
different methods of assessing FRCs' workloads, including measurement
tools that have already been validated for other purposes, to identify
a method that could potentially be relevant for the program. The FRCP
Executive Director is uncertain how long it will take to develop a
workload assessment tool and has not established timelines to complete
this effort. Without a workload assessment tool, the program does not
have the data it needs to develop a more comprehensive caseload
management strategy and to better determine appropriate caseload size
for FRCs.
FRCP Staffing Decisions Are Based on Ongoing Program Monitoring
Efforts, but This Process Has Not Been Clearly Defined or Documented:
While establishing appropriate FRC caseloads should help FRCP
leadership better determine how many FRCs VA should hire, determining
when VA should hire FRCs has been another staffing challenge.
Currently, the FRCP Executive Director's decisions about when VA
should hire FRCs are based on various ongoing monitoring efforts. The
FRCP Executive Director told us that staffing decisions regarding FRCs
are difficult to make because the FRCP cannot predict the number of
potentially eligible servicemembers and veterans, which is affected by
the OEF/OIF conflicts. In the absence of being able to project the
number of potentially eligible servicemembers and veterans, the FRCP
Executive Director said she uses other methods to predict future
trends and guide the staffing process. One method involves monitoring
FRCs' workloads as an indicator that workload levels are increasing
and new FRCs are needed. In this regard, the FRCP Executive Director
told us that FRCP leadership conducts weekly telephone calls with each
FRC to discuss issues related to their caseloads. The FRCP Executive
Director told us that another method she uses to predict staffing
needs is through the analysis of the number of new referrals and
enrollment rates in the program, which she uses to create a quarterly
report that highlights the projected number of FRCs that the program
may need. For example, the average number of new referrals grew from
25 a month in 2008 to 35 a month in 2009. VA hired five FRCs in
January 2010 in part because of this increase in the number of
referrals and the expected resulting increase in the number of
enrolled servicemembers and veterans. The FRCP Executive Director told
us that the referral data collected in 2010 show that the number of
new referrals continued to increase and averaged 50 a month, which
indicates a continuing need for more FRCs. According to the FRCP
Executive Director, she routinely shares this information with the
Secretary of Veterans Affairs as advance notice that a request for
additional FRCs may be forthcoming because it takes about 6 months for
VA to hire a new FRC. The FRCP Executive Director told us that the
program's ongoing monitoring efforts are the most logical approach for
determining when and how many FRCs VA should hire in the absence of
knowing the number of potentially eligible servicemembers and veterans.
While these methods appear to be reasonable given the lack of overall
data on the numbers of severely wounded servicemembers and veterans,
the staffing process is not well documented. Internal control
standards applicable to all federal agencies state that an agency
should effectively communicate its policies and procedures by
providing clear documentation that is readily available for
examination. Consistent with this internal control standard, we would
expect the FRCP to have documented procedures outlining its process
for making staffing decisions. FRCP leadership documented staffing
projections for fiscal year 2010 in the program's annual operating
plan, citing that ongoing analysis of referrals and enrollment rates
was important in making those projections. However, the process used
by program leadership--specifically how the referral and enrollment
data are used in making staffing decisions--has not been clearly
defined or documented in the operating plan or any of the other
program policies or procedures. By documenting this information, the
FRCP would have greater assurance that the process developed by the
current leadership will be maintained during management changes.
The FRCP Lacks a Clear and Consistent Rationale for Making FRC
Placement Decisions:
Deciding where to place FRCs to best serve current and potential
enrollees' needs is another key staffing issue, despite the fact that
FRCs often coordinate services for enrollees who are located
throughout the country and may not be receiving care at the facility
where their assigned FRC is located. The FRCP's basis for making
decisions about where to place FRCs has varied over time, and the
program currently lacks a clear and consistent rationale for making
FRC placement decisions. As of September 2010, 20 FRCs were located at
10 facilities. (See figure 1.)
Figure 1: Location and Number of Federal Recovery Coordinators (FRC),
September 2010:
[Refer to PDF for image: illustrated U.S. map]
Locations of the following are depicted on the map:
Military treatment facility:
Brooke Army Medical Center, Texas (4 FRCs);
Dwight D. Eisenhower Army Medical Center (2 FRCs);
National Naval Medical Center, Maryland (3 FRCs);
Naval Hospital Camp Pendleton, California (1 FRC);
Naval Medical Center San Diego, California (3 FRCs);
Walter Reed Army Medical Center, District of Columbia (3 FRCs)
VA medical center:
Michael E. DeBakey VA Medical Center, Texas (1 FRC);
Providence VA Medical Center, Rhode Island (1 FRC);
Tampa Polytrauma Rehabilitation Center, Florida (1 FRC).
Wounded warrior program:
U.S. Special Operations Command, Florida (1 FRC).
Source: GAO, based on Federal Recovery Coordination Program data.
[End of figure]
When the FRCP began operating in 2008, eight FRCs were placed at the
three military treatment facilities where the majority of severely
wounded servicemembers were receiving treatment. According to the FRCP
Executive Director, the placement of FRCs at military treatment
facilities helped with the identification of servicemembers who could
benefit from FRCP services. In addition, some FRCs told us that being
located at the military treatment facilities allowed them to develop
relationships with the enrollees, their families, and the case
managers who would be providing direct services to the enrollees.
However, as the program expanded, placement of some FRCs was not based
on a rationale or an analysis of where FRCs could provide the maximum
benefit to severely wounded servicemembers and veterans. For example,
some DOD and VA officials we spoke with expressed concerns about the
FRCP's placement decisions, particularly the placement of FRCs at
facilities that do not treat a large population of severely wounded
servicemembers or veterans. DOD officials told us that it was not
clear why there were FRCs assigned to a military treatment facility
that typically does not treat severely wounded servicemembers.
Similarly, a VA medical center official stated that it was unclear why
FRCs were initially placed at two VA medical centers that had few FRCP
enrollees being treated there, rather than at VA medical centers where
a significant number of severely wounded veterans may be receiving
treatment. There was no official FRCP documentation that explained the
basis for these decisions, which were made by FRCP officials who are
no longer with the program.
After the FRCP leadership changed in July 2008, decisions to place
FRCs have been based on several factors. According to the FRCP
Executive Director, some placement decisions focused on ensuring that
enough FRCs were in place to meet the demands of the FRCP workload by
replacing FRCs who had left the program and by adding FRCs at
facilities where only one FRC was located. She explained that where
possible, it is helpful to have at least two FRCs at each facility so
that there can be backup support, particularly for administrative
purposes such as coverage, when an FRC is on leave. However, the FRCP
Executive Director told us that more recently--from March 2010 through
September 2010--FRC placement decisions have primarily been based on
requests or recommendations from DOD and VA officials. For example, in
June 2010, the FRCP relocated an FRC to a military wounded warrior
program headquarters facility in response to a request from the
program's director. FRCP officials have also decided to place some new
FRCs at two VA medical centers where servicemembers and veterans with
polytrauma injuries receive care, based on recommendations from DOD
and VA officials.
The FRCP Executive Director explained that the FRCP had not
established a systematic rationale for FRC placement because the
program initially lacked the data upon which to base these
determinations. Additionally, she told us that every placement of an
FRC at a VA or DOD facility is a negotiation and depends on the
facility's ability to accommodate an FRC, including the provision of
work space and equipment. However, she told us that she and other FRCP
leadership officials have begun to think about how to improve the
FRCP's process for deciding where to place FRCs. In August 2010, the
FRCP Executive Director explained that a planned update of the
Veterans Tracking Application would collect additional information
that would allow FRCP officials to identify the location of
individuals who refer potential enrollees.[Footnote 12] She
anticipates being able to use these data to identify the locations and
facilities where the most referrals are being made. According to the
FRCP Executive Director, this information along with other factors,
such as placement recommendations from DOD and VA officials, could be
used in making future placement decisions. However, as of December
2010, she had not established a specific time frame for this effort.
Developing a clear and consistent rationale for placing FRCs, which
includes a systematic analysis of program data, should help ensure
that FRCs are located where they could provide the maximum benefit to
current and potential enrollees.
The FRCP Faces Challenges That Limit Its Ability to Coordinate Care
but Is Taking Steps to Address Them:
FRCs and others identified challenges that can limit the FRCP's
efforts to coordinate the services needed by severely wounded
servicemembers and veterans. One challenge involves limitations on the
FRCP's ability to share information with the large number of programs
that provide care coordination and case management services to wounded
servicemembers and veterans. These limitations--which are the result
of restrictions on the disclosure of enrollee information and data
systems' incompatibility--have sometimes resulted in confusion and the
duplication of services for enrollees. Efforts by the FRCP to improve
information sharing are ongoing. Another challenge is that FRCs often
have difficulty obtaining resources from the facilities at which they
are located--such as telephones, computers, and private office space--
that they need to perform their care coordination activities,
including communicating with enrollees across the country. This can
affect the quality of services to enrollees, and the FRCP is working
to resolve these logistical issues.
Coordination among the FRCP and DOD and VA Case Management Programs Is
Impeded by Limitations on Their Ability to Share Information, and
Efforts to Address These Limitations Are Ongoing:
Coordination among DOD and VA programs that provide care coordination
and case management is difficult because of the large number of such
programs that exist to address the needs of wounded servicemembers and
veterans and the limitations in the ability of these programs to share
information. Although these programs vary in terms of the severity of
the injuries among the servicemembers or veterans they serve and the
specific types of services they coordinate, many programs have similar
functions. (See table 4.)
Table 4: Characteristics of Major Department of Defense (DOD) and
Department of Veterans Affairs (VA) Programs for Seriously and
Severely Wounded Servicemembers and Veterans:
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);
Involvement in the continuum of care: Acute care: [Check];
Involvement in the continuum of care: Rehab: [Check];
Involvement in the continuum of care: Reintegration: [Check];
Involvement in the continuum of care: Lifetime follow-up: [Check];
Type of services provided: Clinical: [Check];
Type of services provided: Nonclinical: [Check];
Type of services provided: Recovery plan: [Check].
Program: DOD Recovery Coordination Program;
Severity of enrollees' injuries[A]: Serious;
Title of care coordinator or case manager: Recovery Care Coordinator;
Involvement in the continuum of care: Acute care: [Check];
Involvement in the continuum of care: Rehab: [Check];
Involvement in the continuum of care: Reintegration: [Check];
Involvement in the continuum of care: Lifetime follow-up: [Check];
Type of services provided: Clinical: [Empty];
Type of services provided: Nonclinical: [Check];
Type of services provided: Recovery plan: [Check].
Program: Army Warrior Transition Units;
Severity of enrollees' injuries[A]: Serious to severe;
Title of care coordinator or case manager: Triad of nurse case
manager, squad leader, and physician;
Involvement in the continuum of care: Acute care: [Check];
Involvement in the continuum of care: Rehab: [Check];
Involvement in the continuum of care: Reintegration: [Check];
Involvement in the continuum of care: Lifetime follow-up: [Empty];
Type of services provided: Clinical: [Check];
Type of services provided: Nonclinical: [Check];
Type of services provided: 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);
Involvement in the continuum of care: Acute care: [Check];
Involvement in the continuum of care: Rehab: [Check];
Involvement in the continuum of care: Reintegration: [Check];
Involvement in the continuum of care: Lifetime follow-up: [Empty];
Type of services provided: Clinical: [Check];
Type of services provided: Nonclinical: [Check];
Type of services provided: 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];
Involvement in the continuum of care: Acute care: [F];
Involvement in the continuum of care: Rehab: [Check];
Involvement in the continuum of care: Reintegration: [Check];
Involvement in the continuum of care: Lifetime follow-up: [Check];
Type of services provided: Clinical: [Check];
Type of services provided: Nonclinical: [Check];
Type of services provided: 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;
Involvement in the continuum of care: Acute care: [Check];
Involvement in the continuum of care: Rehab: [Check];
Involvement in the continuum of care: Reintegration: [Check];
Involvement in the continuum of care: Lifetime follow-up: [Check];
Type of services provided: Clinical: [Check];
Type of services provided: Nonclinical: [Check];
Type of services provided: 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;
Involvement in the continuum of care: Acute care: [F];
Involvement in the continuum of care: Rehab: [Check];
Involvement in the continuum of care: Reintegration: [Check];
Involvement in the continuum of care: Lifetime follow-up: [Check];
Type of services provided: Clinical: [Check];
Type of services provided: Nonclinical: [Check];
Type of services provided: Recovery plan: [Check].
Source: GAO analysis of DOD and VA program information.
Note: 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 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, and Special Operations Command's
Care Coalition.
[C] An FRC placed at 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.
[E] An OEF/OIF care manager supervises the case managers and
transition patient advocates and may also maintain a caseload of
wounded veterans.
[F] According to VA, in some instances, patients are transferred to VA
medical facilities while still in the acute phase of the care
continuum and may receive services from VA care management or
polytrauma program staff.
[End of table]
Many recovering servicemembers and veterans are enrolled in more than
one program. For example, in September 2010, approximately 84 percent
of FRCP enrollees were also enrolled in a military service wounded
warrior program. According to one FRC, his enrollees have, on average,
eight case managers who are affiliated with different programs.
Individuals enrolled in multiple programs may have recovery plans or
goals that have been developed by different programs. Moreover, some
case managers of other programs consider themselves to be the single
point of contact for their enrollees, even those enrolled in the FRCP.
Because the majority of FRCP enrollees are enrolled in more than one
program, there is a high likelihood that without adequate information
exchange and coordination, FRCs and case managers could duplicate one
another's efforts, confuse enrollees and families, waste resources, or
mistakenly believe that someone else has taken care of a task for an
enrollee. The extent of overlap and the lack of information sharing by
the FRCP have prompted some programs to limit FRCs' involvement with
servicemembers when they are receiving initial medical treatment at a
military treatment facility. At two of the military treatment
facilities we visited, for example, a military program serving wounded
servicemembers delays referrals to the FRCP until a servicemember
approaches the point when he or she is preparing to transition to
another facility or VA.
Information Disclosure Requirements Limited the FRCP's Information
Sharing with DOD's Wounded Warrior Programs:
Prior to January 2011, VA had not completed public disclosure actions
necessary to enable the sharing of information from the Veterans
Tracking Application, the information system used by the FRCP that
contains each enrollee's personal information and Federal Individual
Recovery Plan. As a result, VA management had advised the FRCP that
the program could not provide staff of non-VA programs (such as those
affiliated with DOD) with its enrollees' personally identifiable
information, such as names, addresses, Social Security numbers, and
details of Federal Individual Recovery Plans.[Footnote 13]
Specifically, VA had not completed the System of Records Notification
process for the Veterans Tracking Application, a process required by
the Privacy Act of 1974[Footnote 14] that requires federal agencies to
publish in the Federal Register a notice of the existence, purpose,
and routine uses of every "system of records" that contains
information that may be linked to individuals.[Footnote 15]
Although this limitation did not prevent FRCs from performing their
care coordination responsibilities, it has been a source of
frustration for others. Specifically, officials of several of DOD's
wounded warrior programs contend that the inability to receive
enrollment information from the FRCP has caused difficulties. The
director of one program, for example, told us that not having the
names of servicemembers enrolled in the FRCP resulted in a situation
in which an FRC and a wounded warrior program Recovery Care
Coordinator were not aware that 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 Recovery Care Coordinator set a goal of remaining on
active duty.[Footnote 16] These conflicting goals caused considerable
confusion for this servicemember and his family. Furthermore,
leadership officials of two of the military services' wounded warrior
programs told us that they have instructed their staff not to make
referrals to the FRCP to avoid confusion and potential duplication of
activities, citing issues associated with information sharing.
In August 2010, prompted by the FRCP, VA initiated the public-
disclosure process to facilitate information sharing. In December
2010, VA published a notice in the Federal Register that describes the
compilation of information in the Veterans Tracking Application and
routine uses of that information.[Footnote 17] VA received no comments
on the notice during the public comment period, which ended on January
10, 2011. The new system of records became effective on that date and
the FRCP was able to share certain enrollee information, such as the
names of enrollees, with DOD programs.
DOD and VA Data System Incompatibility Impedes Information Sharing
among the FRCP and DOD's Wounded Warrior Programs:
Another factor that limits information sharing is the inability of the
information systems used by the FRCP, the DOD Recovery Coordination
Program, and the five military services' wounded warrior programs to
exchange information directly with one another. As a result, FRCs
cannot readily access information from data systems used by case
management programs about their enrollees and information about an
individual cannot be easily transferred among systems. To help address
this issue, the FRCP has spearheaded an effort, known as the
Information Sharing Initiative, to identify an approach for the direct
exchange of information between DOD and VA care coordination and case
management information systems in the future. The FRCP Executive
Director explained that this initiative primarily includes identifying
the data that need to be exchanged as well as identifying the data
systems where these data originate and subsequently developing a
technical solution to electronically exchange this information.
Further, she noted that the Information Sharing Initiative is a
grassroots effort and that work on the initiative has been performed
by DOD and VA employees in addition to their normal duties, making a
completion date difficult to estimate. An official from the
Interagency Program Office, which oversees major information
technology initiatives jointly undertaken by DOD and VA, said that the
Information Sharing Initiative was a well-considered initial step but
notes that the ultimate goal of direct information exchange among
programs' information systems faces daunting challenges, such as
resolving conflicting DOD and VA policies pertaining to information
exchange. We have previously reported on DOD's and VA's efforts to
electronically exchange health care information, including the
departments' progress toward increasing their capabilities to share
medical and nonmedical history and physical exam data.[Footnote 18] We
have found that despite the departments' progress, their efforts to
meet clinicians' evolving needs to exchange health information and to
create a single lifetime electronic record for each servicemember,
which is intended to streamline the transition of electronic records
between the two departments, are ongoing.
Recognizing that these limitations on information sharing exist, the
FRCP is also taking steps to emphasize FRCs' principal role of
coordinating with case managers rather than providing services to
enrollees themselves, which should help prevent unintentional
duplication of effort. Because FRCs may provide a direct service in
some instances, proper information sharing is necessary so that staff
from multiple programs may not unknowingly perform the same task for
an enrollee. 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. According to the FRCP Executive Director, the Federal
Individual Recovery Plan process has been improved to encourage
coordination by FRCs and also to reinforce their primary role as care
coordinators. To accomplish these objectives, in January 2011 the FRCP
upgraded the Veterans Tracking Application, in which Federal
Individual Recovery Plans are maintained, by adding a record of the
names of the case managers who are responsible for completing
activities linked to enrollees' planning goals. In addition, the
Veterans Tracking Application began displaying indicators to inform
each FRC about the completion status of every goal-related activity
planned for each enrollee, based on the completion dates that the FRCs
put into the system. The FRCP Executive Director believes that such an
indicator system, when linked to the names of the case managers who
are responsible for completing the activities, will reinforce the
FRCs' care coordination role by encouraging them to actively follow up
with others on the status of individual tasks rather than taking on
these tasks themselves.
FRCs Face Difficulties in Obtaining Access to Equipment, Technology
Support, and Work Space at Their Medical Facilities, but FRCP
Leadership Is Taking Steps to Remedy These Issues:
FRCs and others identified several types of logistical problems that
have affected the FRCs' ability to carry out their responsibilities in
dealing with FRCP enrollees and coordinating with wounded warrior
programs. These issues center around three specific areas: provision
of equipment (such as computers, printers, landline telephones, and
BlackBerrys), technology support (such as equipment maintenance,
software upgrades, and systems security), and private work space at
the medical facilities.
* Provision of equipment. Most of the FRCs' work is done using
computers, accessing data management systems, and communicating with
enrollees and DOD and VA facility staff by e-mail and phone. However,
about half of the FRCs told us that they have been hindered in their
ability to perform their care coordination responsibilities by the
lack of appropriate technology resources at the facilities at which
they work. Some FRCs expressed frustration with delays in obtaining
appropriate computer or communications equipment when they first
reported to their facilities, and this experience was echoed by nearly
all of the FRCs hired in January 2010. For example, one FRC said she
waited more than 6 weeks at the facility to receive a DOD computer and
landline telephone. Another FRC reported that he has found that e-mail
is an effective mode of communication with enrollees with traumatic
brain injuries because he can provide detailed instructions to them,
but when he was hired he did not receive a DOD computer and a landline
telephone with long-distance calling capability for 8 months.
Consequently, he had to resort to mailing letters and brochures to
current and potential enrollees.
* Technology support. In addition to the lack of equipment, some FRCs
cited the lack of technology support as a factor that hindered their
care coordination activities. Technological support includes functions
such as connectivity to information systems, installing security
systems, and equipment upgrading and repair. An FRCP deputy director
told us that the lack of such support is often experienced by new
FRCs, but it is also an ongoing issue for many, especially after a
facility computer system is upgraded and the FRCs' equipment becomes
incompatible. Additionally, several FRCs have had difficulty with
their BlackBerrys, either because the facility was unable to install a
security patch needed to access e-mails or because poor reception made
the device unusable. Some FRCs also reported their inability to access
DOD medical records (although this issue is beyond the scope of a
single program to address)--for example, FRCs located at VA medical
centers must ask FRCs at military treatment facilities to access
enrollees' DOD records and then fax them to the FRCs at the VA medical
centers. Finally, FRCP officials noted that equipment repair has been
a problem for some FRCs--one FRC told us that she had to use a
malfunctioning laptop computer issued to her by the local VA medical
center for 8 months.
* Work space. Some FRCs noted that they had been assigned work space
at the facility that was unsuitable for conducting sensitive
conversations with enrollees, family members, and coworkers. At a
major medical center, we observed that FRCs were located in tightly
spaced cubicles that allowed nearby staff to easily overhear their
conversations. A recently transferred FRC told us that when she
arrived at her new medical center, she found that she had no office
and had been located in an open room that serves as the call center
for triage nurses. Lacking the privacy needed to make confidential
calls to her enrollees, this FRC resorted to making sensitive phone
calls from her car in the parking lot. At another treatment facility,
an FRC who shared an office with staff from another program had to
take phone calls with enrollees in the stairwell in order to have
privacy. Finally, two recently hired FRCs were not only placed in the
same office but also had to share the same desk.
The provision of equipment, technology support, and work space is
covered by memoranda of agreement between the FRCP and the DOD and VA
facilities where FRCs are located. However, an FRCP deputy director
told us that obtaining compliance with the memoranda of agreement at
some facilities is an ongoing challenge and that equipment maintenance
and systems upgrades are persistent issues for all FRCs. In some
instances, after FRCs had made repeated requests for needed resources
without result, the FRCP Executive Director intervened with medical
center officials or through the Senior Oversight Committee to obtain a
resolution. A leadership official for a wounded warrior program told
us that some military medical centers have difficulty satisfying
requests for equipment and space from programs such as the FRCP
because these facilities house and support various DOD and VA support
programs and all make requests for resources. This official pointed
out that at one military treatment facility, a military case manager
was relocated in order to make an office available to an FRC. An FRCP
deputy director added that given the frequent turnover of military
staff, medical center officials are sometimes unaware that their
facility is responsible for providing resources and services to FRCs.
FRCP officials reviewed existing memoranda of agreement between the
FRCP and DOD and VA medical facilities to determine where improvements
could be made to ensure that the FRCs have the tools and privacy
required to do their work. The program has developed three new
templates for memoranda of agreement that will be used when FRCs are
located in new settings: one each for military treatment facilities,
VA medical centers where servicemembers and veterans with polytrauma
injuries receive care, and military wounded warrior programs. These
new memoranda are more detailed than the previous versions, and they
identify who is responsible for providing specific resources and
services. The FRCP is using the revised agreements in its negotiations
for logistical support for newly placed FRCs at two VA medical centers
and with the Special Operations Command wounded warrior program.
Following implementation of the new memoranda of agreement, the FRCP
plans to revise existing agreements to make them consistent with the
newer versions, but no specific timetable has been established to
complete these revisions.
Conclusions:
Since its inception, the FRCP has increased the number of enrollees,
enlarged its staff considerably, and expanded the number of locations
where FRCs are assigned. However, the program faces significant
challenges as it matures. As the first joint care coordination program
for DOD and VA, the FRCP represents a new paradigm in patient support
for the departments. Because of its unprecedented nature, the program
cannot refer to preexisting data or policies and procedures to manage
the program, and as a result, FRCP leadership had to develop
management processes as the program was being implemented and has
largely relied on informal processes to oversee and manage key aspects
of the program. However, now that the program has been operating for
several years and continues to grow, it has become apparent that the
program would benefit from more definitive management processes to
strengthen program oversight and decision making.
While the program has overcome some early setbacks and has established
processes related to enrollment and staffing, these processes are not
clearly documented or systematic. Because enrollment decisions are not
well documented or systematically reviewed by FRCP leadership, it is
unclear whether referred servicemembers and veterans who need FRC
services are being enrolled in the program. Additionally, as the
number of individuals enrolled in the program steadily increases, it
will be important for the FRCP to appropriately balance FRCs' workload
to ensure that enrollees receive the services they need and to prevent
FRC burnout. While program leadership recognizes this issue and is
developing a customized workload tool, there is no firm timeline for
the completion of this effort. The FRCP also needs clearly documented
processes and criteria for guiding staffing and placement decisions.
Without this, it will be difficult to provide continuity to subsequent
program leadership and to place FRCs where they would best serve the
needs of current and future enrollees.
Some of the daunting challenges facing FRCs and the program are beyond
the capability of the program's leadership to resolve. The exchange of
information among DOD and VA data systems, in particular, has been a
long-standing issue and will require interdepartmental action.
Similarly, the duplication of effort resulting from the proliferation
and overlap of DOD and VA programs that support recovering
servicemembers and veterans can best be resolved through
interdepartmental coordination and action.
Recommendations for Executive Action:
We recommend that the Secretary of Veterans Affairs direct the
Executive Director of the FRCP to take four actions:
1. Ensure that referred servicemembers and veterans who need FRC
services are enrolled in the program by establishing adequate internal
controls regarding the FRCs' enrollment decisions. To accomplish this,
the FRCP leadership should:
* require FRCs to record in the Veterans Tracking Application the
factors they consider in making an enrollment decision,
* develop and implement a methodology and protocol for assessing the
appropriateness of enrollment decisions, and:
* refine the methodology as needed.
2. Complete development of the FRCP's workload assessment tool that
will enable the program to assess the complexity of services needed by
enrollees and the amount of time required to provide services to
improve the management of FRCs' caseloads.
3. Clearly define and document the FRCP's decision-making process for
determining when and how many FRCs VA should hire to ensure that
subsequent FRCP leadership can understand the methods currently used
to make staffing decisions.
4. Develop and document a clear rationale for the placement of FRCs,
which should include a systematic analysis of data, such as referral
locations, to ensure that future FRC placement decisions are strategic
in providing maximum benefit for the program's population.
Agency Comments and Our Evaluation:
DOD and VA each provided comments on a draft of this report. In its
comments, DOD stated that it continues to work with VA to fully
integrate their efforts and to increase collaboration between the two
departments. (DOD's comments are reprinted in appendix II.) In its
comments, VA stated that it generally agrees with GAO's conclusions
and concurs with our recommendations to the Secretary. (VA's comments
are reprinted in appendix III.) VA's responses to each of our
recommendations are as follows:
* To ensure that referred servicemembers and veterans who need FRC
services are enrolled in the program, VA indicated that the FRCP will
document decisions and factors used to assess a potential enrollee's
eligibility for the program. In addition, the program will establish
clear documentation requirements according to a defined protocol
within the program's data management system.
* To complete the development of the FRCP's workload assessment tool,
VA indicated that the FRCP will continue field-testing a new
assessment tool, which will require at least a year to complete.
* To document the decision-making process for determining when and how
many FRCs VA should hire, VA stated that the FRCP will clearly
document the current process used for making staffing decisions. In
addition, the staffing processes and plans will be updated annually in
the FRCP business operation planning document.
* To develop and document a clear rationale for the placement of FRCs,
VA indicated that the FRCP will develop an FRC placement strategy
based upon a systematic analysis of data over the next 6 months. This
process will be documented and updated annually in the FRCP business
operation planning document.
VA provided an additional comment regarding the progress made toward
the exchange of data between VA and DOD's wounded warrior information
systems. VA stated that it anticipates that an initial set of data
will be available for exchange between VA and DOD by the end of fiscal
year 2011. The departments plan to expand the exchange of data to
support improved collaboration on care plans in fiscal year 2012.
We are sending copies of this report to the Secretary of Defense and
the Secretary of Veterans Affairs and other interested parties. The
report also is available at no charge on the GAO Web site at
[hyperlink, http://www.gao.gov].
If you or your staff members have any questions about this report,
please contact me at (202) 512-7114 or williamsonr@gao.gov. Contact
points for our Offices of Congressional Relations and Public Affairs
may be found on the last page of this report. Key contributors to this
report are listed in appendix IV.
Signed by:
Randall B. Williamson:
Director, Health Care:
List of Requesters:
The Honorable John F. Tierney:
Ranking Member:
Subcommittee on National Security, Homeland Defense and Foreign
Operations:
Committee on Oversight and Government Reform:
House of Representatives:
The Honorable Kirsten Gillibrand:
United States Senate:
The Honorable Jason Altmire:
House of Representatives:
The Honorable Bruce Braley:
House of Representatives:
The Honorable Kathy Castor:
House of Representatives:
The Honorable Yvette Clarke:
House of Representatives:
The Honorable Steve Cohen:
House of Representatives:
The Honorable Joe Courtney:
House of Representatives:
The Honorable Joe Donnelly:
House of Representatives:
The Honorable Keith Ellison:
House of Representatives:
The Honorable Gabrielle Giffords:
House of Representatives:
The Honorable Mazie Hirono:
House of Representatives:
The Honorable Hank Johnson:
House of Representatives:
The Honorable David Loebsack:
House of Representatives:
The Honorable Jerry McNerney:
House of Representatives:
The Honorable Chris Murphy:
House of Representatives:
The Honorable Ed Perlmutter:
House of Representatives:
The Honorable John Sarbanes:
House of Representatives:
The Honorable Heath Shuler:
House of Representatives:
The Honorable Albio Sires:
House of Representatives:
The Honorable Betty Sutton:
House of Representatives:
The Honorable Tim Walz:
House of Representatives:
The Honorable Peter Welch:
House of Representatives:
The Honorable John Yarmuth:
House of Representatives:
[End of section]
Appendix I: The Use of Software to Analyze Testimonial Evidence:
To conduct a content analysis of our interviews with program officials
and medical facility staff, we used a qualitative data analysis
software package. The software facilitated our analysis of over 150 of
the 170 interviews we conducted and helped us to identify and quantify
interviewees' responses on various topics. The program's coding
capabilities allowed us to group our interviewees' responses into
categories. It also provided a centralized location where all of our
documents could be reviewed and analyzed.
We took a number of steps to ensure that our analysis was
methodologically sound. First, we defined categories to organize the
views of the Department of Defense and the Department of Veterans
Affairs program officials and medical facility staff by specific
topics, including the Federal Recovery Coordination Program's (FRCP)
eligibility criteria, the interviewees' interactions with the Federal
Recovery Coordinators (FRC), overlap and duplication of activities
among the FRCP and the case management programs with which the FRCs
interacted, knowledge of the FRC role, and challenges faced by the
FRCs. These categories were chosen based on themes we heard during our
interviews with the program officials and medical facility staff. We
conducted an intercoder reliability check to ensure the accuracy of
the category definitions. To do this, two analysts coded a sample of
15 interviews into the categories. A methodologist compared the
analyses to determine where inconsistencies occurred and, as a result,
what categories needed more specific definitions.
Once the category definitions were finalized, the same two analysts
divided the categories among them and coded their categories for all
of the interview documents. When the coding was completed, both
analysts reviewed every code made by the other analyst and indicated
whether they agreed or disagreed with the code. Changes were then made
accordingly. We subsequently analyzed the interviewees' responses
based on the defined categories. This analysis allowed us to quantify
interviewees' responses within each category.
[End of section]
Appendix II: Comments from the Department of Defense:
Office Of The Under Secretary Of Defense:
Personnel And Readiness:
4000 Defense Pentagon:
Washington, D.C. 20301-4000:
March 4, 2011:
Mr. Randall Williamson:
Director, Health Care:
U.S. Government Accountability Office:
441 G Street, NW:
Washington, DC 20548:
Dear Mr. Williamson:
This is the Department of Defense (DoD) response to the Government
Accountability Office (GAO) Draft Report, GAO 11-250, "DOD and VA Care
Healthcare: Federal Recovery Coordination Program Continues to Expand,
but Faces Significant Challenges," dated February 2, 2011 (GAO Code
290804).
While there were no specific recommendations with regards to DoD, GAO
requested that comments be provided. The following comments are
provided by the Department: DoD and VA continue to work together to
fully integrate their efforts and to increase collaboration between
the two departments. To that end, a Joint DoD/VA Committee has been
formed to study how to combine or integrate recovery care coordination
efforts for wounded, ill, and injured Service members, Veterans and
their families.
The Department appreciates the opportunity to review and comment on
the draft report.
Sincerely,
Signed by:
John R. Campbell:
Deputy Assistant Secretary of Defense for Wounded Warrior Care and
Transition Policy:
[End of section]
Appendix III: Comments from the Department of Veterans Affairs:
Department Of Veterans Affairs:
Washington DC 20420:
March 7, 2011:
Mr. Randall B. Williamson:
Director, Health Care:
U.S. Government Accountability Office:
441 G Street, NW:
Washington, DC 20548:
Dear Mr. Williamson:
The Department of Veterans Affairs (VA) has reviewed the Government
Accountability Office's (GAO) draft report, "DOD and VA Health Care:
Federal Recovery Coordination Program Continues to Expand, but Faces
Significant Challenges" (GAO-11-250) and generally agrees with GAO's
conclusions and concurs with GAO's recommendations to the Department.
The enclosure specifically addresses GAO's recommendations and
provides additional and technical comments to the report. VA
appreciates the opportunity to comment on your draft report.
Sincerely,
Signed by:
John R. Gingrich:
Chief of Staff:
Enclosure:
[End of letter]
Enclosure:
Department of Veterans Affairs (VA) Comments to Government
Accountability Office (GAO) Draft Report DOD and VA Health Care:
Federal Recovery Coordination Program (FRCP) Continues to Expand, but
Faces Significant Challenges (GAO-11-250):
GAO Recommendation: We recommend that the Secretary of VA direct the
Executive Director of the FRC to take four actions:
Recommendation 1: ensure that referred servicemembers and veterans who
need FRC services are enrolled in the program by establishing adequate
internal controls regarding the FRCs' enrollment decisions. To
accomplish this, the FRCP leadership should:
* Require FRCs to record in the Veteran's Tracking Application the
factors they consider in making an enrollment decision; and;
* Develop and implement a methodology and protocol for assessing the
appropriateness of enrollment decisions; and;
* Refine the methodology as needed.
VA Response: Concur. As pointed out by GAO, evaluation of potential
FRCP clients is based on an assessment of the individual's medical and
non-medical needs and requirements in order to recover, rehabilitate,
and reintegrate to the maximum extent possible. A key feature of this
process is the clinical experience of the FRCs and their clinical
judgment of whether or not an individual would benefit from care
coordination.
While many of these decisions are discussed routinely with management,
improved documentation of the decision factors is required. FRCP will
establish clear documentation requirements, according to a defined
protocol, within the program's data management system as a permanent
solution. The defined protocol will be developed in concert with the
service intensity measurement tool (GAO Recommendation 2 below). In
the short-term, the program will implement an immediate requirement
that all FRCs discuss each enrollment decision with management.
It is the highest priority of FRCP to ensure that all severely
wounded, ill and injured Servicemembers and Veterans who would benefit
from care coordination are enrolled. While the program will ensure
that adequate internal controls exist for enrolling individuals into
FRCP, the program cannot ensure that all potentially eligible
individuals are referred to FRCP. FRCP, as currently structured, is a
voluntary referral program and, as such, relies on the identification
and referral of those who might benefit from FRCP services by others
(case managers, Command, Wounded Warrior Programs, etc.). The terms
"catastrophic" and "severely", often used to describe the wounded, ill
or injured population who should be referred to FRCP, are
administrative in nature and whose meaning is left to interpretation.
To date, the program has relied on outreach activities and
demonstrated outcomes to inform the referral process.
Recommendation 2: complete development of its workload assessment tool
that will enable the program to assess the complexity of services
needed by enrollees and the amount of time required to provide
services to improve the management of FRCs' caseloads.
VA Response: Concur. Determining the right caseload for each FRC is a
strategic goal for FRCP. Because care coordination is a relatively new
concept, particularly as implemented across and within Federal
agencies, no clear guidelines or intensity measurement tools exist to
accurately determine caseloads. This is a labor intensive task that
requires tool development and testing, along with validity and
reliability assessments. FRCP is in the process of field testing a new
service intensity measurement tool that will likely need refinement
and additional testing. We believe that this iterative process will
require at least a year to complete.
Recommendation 3: clearly define and document the FRCP's decision-making
process for determining when and how many FRCs VA should hire to
ensure that subsequent FRCP leadership can understand the methods
currently used to make hiring decision.
VA Response: Concur. FRCP will more clearly document the current
process used for staffing decisions. The process will be revised when
the service intensity measurement tool is in place. Staffing processes
and plans will be updated annually in the FRCP business operation
planning document.
Recommendation 4: develop and document a clear rationale for the
placement of FRCs, which should include a systematic analysis of data,
such as referral locations, to ensure that future FRC placement
decisions are strategic in providing maximum benefit for the program's
population.
VA Response: Concur. FRCP will develop a FRC placement strategy based
upon a systematic analysis of data over the next six months. This
process will be documented and updated annually in the FRCP business
operation planning document.
Additional Comment:
Since the time of this report, significant progress has been made
toward a live exchange of data between VA and DoD wounded warrior
information systems as part of the Information Sharing Initiative.
Leveraging existing VA-DoD data exchange mechanisms, it is anticipated
that an initial set of data around the case/care managers assigned to
an individual Servicemember or Veteran will be available for exchange
by the end of Fiscal 2011. It is anticipated that this mechanism will
provide the ability to accommodate IT systems that are not directly
compatible. Additional data to support improved collaboration on care
plans is planned for exchange in Fiscal 2012.
[End of section]
Appendix IV: GAO Contact and Staff Acknowledgments:
GAO Contact:
Randall B. Williamson, (202) 512-7114 or williamsonr@gao.gov:
Staff Acknowledgments:
In addition to the contact named above, Bonnie Anderson, Assistant
Director; Susannah Bloch; Frederick Caison; Elizabeth Conklin; Cynthia
Gilbert; Deitra Lee; Lisa Motley; Kristina Martin; Steven Putansu; and
Suzanne Worth made key contributions to this report.
[End of section]
Footnotes:
[1] President's Commission on Care for America's Returning Wounded
Warriors, Serve, Support, Simplify (July 2007).
[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. Since
September 1, 2010, OIF is referred to as Operation New Dawn.
[3] The FRCP defines severely wounded, ill, and injured individuals as
those who, because of their physiological or psychological disease or
condition, or a mental disorder, require ongoing medical care, exhibit
impaired ability to function independently in their community, are
vulnerable and whose personal safety is highly at risk, and require
informal and formal support for maintenance of health and safety.
[4] 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, and Special Operations Command's
Care Coalition.
[5] 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.
[6] Booz Allen Hamilton, Federal Recovery Coordination Program, Draft
Program Evaluation Report for Phase I: November 2007 - April 2008
(McLean, Va.: 2008).
[7] We used a data analysis computer software package designed to
organize and analyze complex nonnumerical or unstructured data.
[8] In addition to active enrollees in the FRCP, this number 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.
[9] The denominators for these numbers are different because not all
of the program officials and medical facility staff we interviewed
responded to every question.
[10] GAO, Standards for Internal Control in the Federal Government,
[hyperlink, http://www.gao.gov/products/GAO/AIMD-00-21.3.1]
(Washington, D.C.: November 1999).
[11] This information was obtained from comprehensive interviews with
the 15 FRCs who were working in the FRCP in or before December 2009.
[12] In January 2011, the Veterans Tracking Application was
successfully upgraded to be able to collect location information,
according to an FRCP official.
[13] FRCs would be able to provide this information to staff of non-VA
programs if they obtain the enrollees' written permission. However,
FRCP officials stated that because it is not feasible to obtain such
permission from each enrollee for logistical reasons, this procedure
has not been introduced.
[14] See 5 U.S.C. § 552a(e)(4).
[15] The Privacy Act defines a "system of records" as a group of any
records under the control of any federal agency from which information
is retrieved by the name of the individual or by some identifying
number, symbol, or personal identifier assigned to the individual. 5
U.S.C. § 552a(a)(5). A "routine use" is a disclosure of a record for a
purpose that is compatible with the purpose for which it was
collected. 5 U.S.C. § 552a(a)(7).
[16] With the assistance of prosthetic devices, some amputees are able
to return to active duty status.
[17] 75 Fed. Reg. 76,784 (Dec. 9, 2010).
[18] For additional information, see GAO, Electronic Health Records:
DOD and VA Interoperability Efforts Are Ongoing; Program Office Needs
to Implement Recommended Improvements, [hyperlink,
http://www.gao.gov/products/GAO-10-332] (Washington, D.C.: Jan. 28,
2010), and Electronic Health Records: DOD and VA Efforts to Achieve
Full Interoperability Are Ongoing; Program Office Management Needs
Improvement, [hyperlink, http://www.gao.gov/products/GAO-09-775]
(Washington, D.C.: July 28, 2009).
[End of section]
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