Federal Recovery Coordination Program
Enrollment, Staffing, and Care Coordination Pose Significant Challenges
Gao ID: GAO-11-572T May 13, 2011
This testimony discusses the challenges facing the Federal Recovery Coordination Program (FRCP)--a program that was jointly developed by the Departments of Defense (DOD) and Veterans Affairs (VA) following critical media reports of deficiencies in the provision of outpatient services at Walter Reed Army Medical Center. This program was established to assist "severely wounded, ill, and injured" Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) servicemembers, veterans, and their families with access to care, services, and benefits. Specifically, the program's population was to include individuals who had suffered traumatic brain injuries, amputations, burns, spinal cord injuries, visual impairment, and post-traumatic stress disorder. From January 2008--when FRCP enrollment began--to May 2011, the FRCP has provided services to a total of 1,665 servicemembers and veterans; of these, 734 are currently active enrollees. As the first care coordination program developed collaboratively by DOD and VA, the FRCP is more comprehensive in scope than clinical or nonclinical case management programs. It uses Federal Recovery Coordinators (FRC) who are either senior-level registered nurses or licensed social workers to monitor and coordinate both the clinical and nonclinical services needed by program enrollees by serving as a link between case managers of multiple programs. Unlike case managers, FRCs have planning, coordination, monitoring, and problem-resolution responsibilities that encompass both health services and benefits provided through DOD, VA, other federal agencies, states, and the private sector. The FRCs' primary responsibility is to work with each enrollee along with his or her family and clinical team to develop a Federal Individual Recovery Plan, which sets individualized goals for recovery and is intended to guide the enrollee through the continuum of care. 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. The FRCP is administered by VA, and FRCs are VA employees. Since beginning operation in January 2008, the FRCP has grown considerably but experienced turmoil in its early stages, including turnover of staff and management. At present, there are 22 FRCs who have been located at various military treatment facilities, VA medical centers, and the headquarters of two military wounded warrior programs. 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. This testimony is based on our March 2011 report, which examined several FRCP implementation issues: (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.
In summary, we found that while the FRCP has overcome some early setbacks, it currently faces challenges related to the enrollment of potentially eligible individuals, determination of FRC staffing needs and placement, and the FRCP's ability to coordinate care for enrollees. (1) Challenges in identifying potentially eligible individuals. 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. (2) Challenges in determining staffing needs and placement decisions. 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 it 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 these processes 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. (3) Challenges in coordinating with other VA and DOD programs and supporting FRCs. A key challenge facing the FRCP concerns the coordination of services by the large number of DOD and VA programs that support wounded servicemembers and veterans. Although these programs vary in terms of the severity of the injuries among the servicemembers and veterans they serve and the specific types of services they coordinate, many programs have similar functions and are involved in similar types of activities.
GAO-11-572T, Federal Recovery Coordination Program: Enrollment, Staffing, and Care Coordination Pose Significant Challenges
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United States Government Accountability Office:
GAO:
Testimony:
Before the Subcommittee on Health, Committee on Veterans' Affairs,
House of Representatives:
For Release on Delivery:
Expected at 10:00 a.m. EDT:
Friday, May 13, 2011:
Federal Recovery Coordination Program:
Enrollment, Staffing, and Care Coordination Pose Significant
Challenges:
Statement of Randall B. Williamson:
Director, Health Care:
GAO-11-572T:
Chairwoman Buerkle, Ranking Member Michaud, and Members of the
Subcommittee:
I am pleased to be here today as you discuss the challenges facing the
Federal Recovery Coordination Program (FRCP)--a program that was
jointly developed by the Departments of Defense (DOD) and Veterans
Affairs (VA) following critical media reports of deficiencies in the
provision of outpatient services at Walter Reed Army Medical Center.
This program was established to assist "severely wounded, ill, and
injured" Operation Enduring Freedom (OEF) and Operation Iraqi Freedom
(OIF) servicemembers, veterans, and their families with access to
care, services, and benefits.[Footnote 1] Specifically, the program's
population was to include individuals who had suffered traumatic brain
injuries, amputations, burns, spinal cord injuries, visual impairment,
and post-traumatic stress disorder. From January 2008--when FRCP
enrollment began--to May 2011, the FRCP has provided services to a
total of 1,665 servicemembers and veterans; of these, 734 are
currently active enrollees.
As the first care coordination program[Footnote 2] developed
collaboratively by DOD and VA, the FRCP is more comprehensive in scope
than clinical or nonclinical case management programs. It uses Federal
Recovery Coordinators (FRC) who are either senior-level registered
nurses or licensed social workers to monitor and coordinate both the
clinical and nonclinical services needed by program enrollees by
serving as a link between case managers of multiple programs. Unlike
case managers, FRCs have planning, coordination, monitoring, and
problem-resolution responsibilities that encompass both health
services and benefits provided through DOD, VA, other federal
agencies, states, and the private sector.
The FRCs' primary responsibility is to work with each enrollee along
with his or her family and clinical team to develop a Federal
Individual Recovery Plan, which sets individualized goals for recovery
and is intended to guide the enrollee through the continuum of care.
[Footnote 3] 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.
The FRCP is administered by VA, and FRCs are VA employees. Since
beginning operation in January 2008, the FRCP has grown considerably
but experienced turmoil in its early stages, including turnover of
staff and management. At present, there are 22 FRCs who have been
located at various military treatment facilities, VA medical centers,
and the headquarters of two military wounded warrior programs. 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.
My testimony is based on our March 2011 report,[Footnote 4] which
examined several FRCP implementation issues: (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.
To obtain information about these challenges, 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, including leadership officials from each
military service's wounded warrior program; and medical facility
directors and staff at DOD and VA medical facilities. 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.[Footnote 5]
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, which enabled us to analyze
responses to specific interview topics for a large number of
interviews. 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.[Footnote 6]
We conducted the performance audit for our report from September 2009
through March 2011 and updated certain data elements in May 2011 for
this testimony, in accordance with generally accepted government
auditing standards. These 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.
In summary, we found that while the FRCP has overcome some early
setbacks, it currently faces challenges related to the enrollment of
potentially eligible individuals, determination of FRC staffing needs
and placement, and the FRCP's ability to coordinate care for enrollees.
* Challenges in identifying potentially eligible individuals. 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.
* Challenges in determining staffing needs and placement decisions.
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 it 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 these processes 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.
* Challenges in coordinating with other VA and DOD programs and
supporting FRCs. A key challenge facing the FRCP concerns the
coordination of services by the large number of DOD and VA programs
that support wounded servicemembers and veterans. Although these
programs vary in terms of the severity of the injuries among the
servicemembers and veterans they serve and the specific types of
services they coordinate, many programs have similar functions and are
involved in similar types of activities. Table 1 illustrates the key
characteristics of major DOD and VA programs and the activities in
which they are involved.
Table 1: Characteristics of Major Department of Defense (DOD) and
Department of Veterans Affairs (VA) Programs for Seriously and
Severely Wounded Servicemembers and Veterans:
Program name: VA/DOD Federal Recovery Coordination Program (FRCP);
Program characteristics:
Program description: Joint DOD/VA initiative that coordinates clinical
and nonclinical services and benefits across federal, state, and
private entities for recovering servicemembers, veterans, and their
families;
Severity of enrollees' injuries[A]: Severe;
Title of care coordinator or case manager: Federal Recovery
Coordinator (FRC);
Type of services provided:
Lifetime follow-up: [Check];
Clinical: [Check];
Non-clinical: [Check];
Recovery plan: [Check].
Program name: DOD Recovery Coordination Program;
Program characteristics:
Program description: DOD program that coordinates nonclinical services
and benefits for recovering servicemembers;
Severity of enrollees' injuries[A]: Serious;
Title of care coordinator or case manager: Recovery Care Coordinator;
Type of services provided:
Lifetime follow-up: [Check];
Clinical: [Empty];
Non-clinical: [Check];
Recovery plan: [Check].
Program name: Army Warrior Transition Units;
Program characteristics:
Program description: Army unit that provides complex outpatient case
management for servicemembers requiring more than 6 months of medical
treatment;
Severity of enrollees' injuries[A]: Serious to severe;
Title of care coordinator or case manager: Triad of nurse case
manager, squad leader, and physician;
Type of services provided:
Lifetime follow-up: [Empty];
Clinical: [Check];
Non-clinical: [Check];
Recovery plan: [Check].
Program name: Military wounded warrior programs[B];
Program characteristics:
Program description: Programs operated by the military services that
help manage servicemembers' recovery process, including 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;
Severity of enrollees' injuries[A]: Serious to severe;
Title of care coordinator or case manager: Case manager or Advocate
(title varies by service);
Type of services provided:
Lifetime follow-up: [Check];
Clinical: [Empty];
Non-clinical: [Check];
Recovery plan: [Check].
Program name: VA OEF/OIF Care Management Program[C];
Program characteristics:
Program description: VA program that facilitates the transition of
care from military to VA medical facilities and the coordination of
clinical and nonclinical services for OEF/OIF servicemembers and
veterans;
Severity of enrollees' injuries[A]: Mild to severe;
Title of care coordinator or case manager: Case manager, Transition
Patient Advocate[D];
Type of services provided:
Lifetime follow-up: [Check];
Clinical: [Check];
Non-clinical: [Check];
Recovery plan: [Check].
Program name: VA Spinal Cord Injury and Disorders Program;
Program characteristics:
Program description: VA system of care that provides a coordinated
continuum of services for servicemembers and veterans with spinal cord
injuries;
Severity of enrollees' injuries[A]: Mild to severe;
Title of care coordinator or case manager: Nurse, social worker;
Type of services provided:
Lifetime follow-up: [Check];
Clinical: [Check];
Non-clinical: [Check];
Recovery plan: [Check].
Program name: VA Polytrauma System of Care;
Program characteristics:
Program description: VA system of specialized facilities that provides
comprehensive, individually tailored rehabilitation to servicemembers
and veterans with multiple injuries;
Severity of enrollees' injuries[A]: Serious to severe;
Title of care coordinator or case manager: Social work and nurse case
managers;
Type of services provided:
Lifetime follow-up: [Check];
Clinical: [Check];
Non-clinical: [Check];
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] FRCs placed at the headquarters of Special Operations Command's
Care Coalition and Navy Safe Harbor coordinate clinical and
nonclinical care for enrollees in these two programs and for other
FRCP enrollees.
[C] OEF/OIF refers to Operation Enduring Freedom and Operation Iraqi
Freedom.
[D] An OEF/OIF care manager supervises the case managers and
transition patient advocates and may also maintain a caseload of
wounded veterans.
[End of table]
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. However, limitations on information sharing among the
programs has resulted in duplication of services and enrollee
confusion, prompting two military wounded warrior programs to cease
making referrals to the FRCP. Specifically, the FRCP could not share
certain enrollee data maintained on its information system with staff
of non-VA programs because VA had not completed public disclosure
actions necessary to enable the sharing of this information. 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 as information
about enrollees cannot be easily transferred among these systems.
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.
Finally, FRCs identified several types of logistical problems that
have affected their ability to carry out their responsibilities. These
issues center around (1) provision of equipment such as computers,
printers, landline telephones, and BlackBerrys; (2) technology support
such as equipment maintenance, software upgrades, and systems
security; and (3) private workspace at medical facilities.
Overall, as the first joint care coordination program for DOD and VA,
the FRCP represents a new patient support paradigm 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.
As a result of our examination of the FRCP, we recommended that the
Secretary of Veterans Affairs direct the Executive Director of the
FRCP to take actions to establish adequate internal controls regarding
FRCs' enrollment decisions, to complete development of the workload
assessment tool for FRCs' caseloads, and to document procedures to
strengthen FRC staffing and placement decisions. In their comments on
our report, DOD stated that it continues to increase its collaboration
with VA, and VA generally agreed with our conclusions and concurred
with our recommendations to the Secretary.
Chairwoman Buerkle, Ranking Member Michaud, and Members of the
Subcommittee, this completes my prepared statement. I would be pleased
to respond to any questions you or other members of the subcommittee
may have.
Contacts and Acknowledgments:
For further information about this testimony, please contact Randall
B. Williamson 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 testimony. Individuals who made key
contributions to this testimony include Bonnie Anderson, Assistant
Director; Frederick Caison; Elizabeth Conklin; Deitra Lee; and Lisa
Motley.
[End of section]
Footnotes:
[1] 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.
[2] 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.
[3] The continuum of care consists of three phases: acute medical
treatment and stabilization, rehabilitation, and reintegration--either
a return to active duty or to the civilian community as a veteran.
[4] GAO, DOD and VA Health Care: Federal Recovery Coordination Program
Continues to Expand but Faces Significant Challenges, [hyperlink,
http://www.gao.gov/products/GAO-11-250] (Washington, D.C.: Mar. 23,
2011).
[5] 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. At the end of calendar year 2010, following the completion
of our site visits, the FRCP placed two FRCs at the VA medical center
in Richmond.
[6] The FRCP Handbook was finalized on April 1, 2011.
[End of section]
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