Background

VA offers a broad array of disability benefits and health care through its  Veterans Benefits Administration (VBA) and its Veterans Health  Administration (VHA), respectively. VBA provides benefits and services  such as disability compensation and VR&E to veterans through its 57  regional offices. The VR&E program is designed to ensure that veterans  with disabilities find meaningful work and achieve maximum  independence in daily living. VR&E services include vocational counseling,  evaluation, and training that can include payment for tuition and other  expenses for education, as well as job placement assistance.
VHA manages one of the largest health care systems in the United States  and provides PTSD services in its medical facilities, community settings,  and Vet Centers. VA is a world leader in PTSD treatment and offers PTSD  services to veterans. PTSD can result from having experienced an  extremely stressful event such as the threat of death or serious injury, as  happens in military combat, and is the most prevalent mental disorder  resulting from combat.
Servicemembers injured in Afghanistan and Iraq are surviving injuries that  would have been fatal in past conflicts, due, in part, to advanced  protective equipment and medical treatment. However, the severity of  their injuries can result in a lengthy transition involving rehabilitation and  complex assessments of their ability to function. Many also sustain  psychological injuries. Mental health experts predict that because of the  intensity of warfare in Afghanistan and Iraq 15 percent or more of the  servicemembers returning from these conflicts will develop PTSD.

	VA Has Taken Steps to Provide Services to Seriously Injured Servicemembers as a High Priority

In our January 2005 report on VA’s efforts to expedite VR&E services for  seriously injured servicemembers returning from Afghanistan and Iraq, we  noted that VA instructed its VBA regional offices, in a September 2003  letter, to provide priority consideration and assistance for all VA services,  including health care, to these servicemembers. VA specifically instructed  regional offices to focus on servicemembers whose disabilities will  definitely or are likely to result in military separation. Because most  seriously injured servicemembers are initially treated at major MTFs, VA  has deployed staff to the sites where the majority of the seriously injured  are treated. These staff have included VA social workers and disability  compensation benefit counselors. VA has placed social workers and  benefit counselors at Walter Reed and Brooke Army Medical Centers and  at several other MTFs. In addition to these staff, VA has provided a  vocational rehabilitation counselor to work with hospitalized patients at  Walter Reed Army Medical Center, where the largest number of seriously  injured servicemembers has been treated.
To identify and monitor those whose injuries may result in a need for VA  disability and health services, VA has asked DOD to share data about  seriously injured servicemembers. VA has been working with DOD to  develop a formal agreement on what specific information to share. VA  requested personal identifying information, medical information, and  DOD’s injury classification for each listed servicemember. VA also  requested monthly lists of servicemembers being evaluated for medical  separation from military service. VA officials said that systematic  information from DOD would provide them with a way to more reliably  identify and monitor seriously injured servicemembers. As of the end of  2004, a formal agreement with DOD was still pending.
In the absence of a formal arrangement for DOD data on seriously injured  servicemembers, VA has relied on its regional offices to obtain information  about them. In its September 2003 letter, VA asked the regional offices to  coordinate with staff at MTFs and VA medical centers in their areas to  ascertain the identities, medical conditions, and military status of the  seriously injured.
In regard to psychological injuries, our September 2004 report noted that  mental health experts have recognized the importance of early  identification and treatment of PTSD. VA and DOD jointly developed a  clinical practice guideline for identifying and treating individuals with  PTSD. The guideline includes a four-question screening tool to identify  servicemembers and veterans who may be at risk for PTSD. VA uses these  questions to screen all veterans who visit VA for health care, including  those previously deployed to Afghanistan and Iraq. The screening  questions are:  Have you ever had any experience that was so frightening, horrible, or  upsetting that, in the past month, you    have had any nightmares about it or thought about it when you did not  want to?  tried hard not to think about it or went out of your way to avoid situations  that remind you of it?    were constantly on guard, watchful, or easily startled?  felt numb or detached from others, activities, or your surroundings?
DOD is also using these four questions in its post-deployment health  assessment questionnaire (form DD 2796) to identify servicemembers at  risk for PTSD. DOD requires the questionnaire be completed by all  servicemembers, including Reserve and National Guard members,  returning from a combat theater and is planning to conduct follow-up  screenings within 6 months after return.

	VA Faces Significant Challenges in Providing Services to the Seriously Injured

VA faces significant challenges in providing services to servicemembers  who have sustained serious physical and psychological injuries. For  example, in providing VR&E services, individual differences and  uncertainties in the recovery process make it inherently difficult to  determine when a seriously injured servicemember will be most receptive  to assistance. The nature of the recovery process is highly individualized  and depends to a large extent on the individual’s medical condition and  personal readiness. Consequently, VA professionals exercise judgment to  determine when to contact the seriously injured and when to begin  services.
In our January 2005 report on VA’s efforts to expedite VR&E services to  seriously injured servicemembers, we noted that many need time to  recover and adjust to the prospect that they may be unable to remain in  the military and will need to prepare instead for civilian employment. Yet  we found that VA has no policy for maintaining contact with those  servicemembers who may not apply for VR&E services prior to discharge  from the hospital.  As a result, several regional offices reported that they  do not stay in contact with these individuals, while others use various  ways to maintain contact.
VA is also challenged by DOD’s concern that outreach about VA benefits  could work at cross purposes to military retention goals. In our January  2005 report, we stated that DOD expressed concern about the timing of  VA’s outreach to servicemembers whose discharge from military service is  not yet certain. To expedite VR&E services, VA’s outreach process may  overlap with the military’s process for evaluating servicemembers who  may be able to return to duty. According to DOD officials, it may be  premature for VA to begin working with injured servicemembers who may  eventually return to active duty. With advances in medicine and prosthetic  devices, many serious injuries no longer result in work-related  impairments. Army officials who track injured servicemembers told us  that many seriously injured servicemembers overcome their injuries and  return to active duty.
Further, VA is challenged by the lack of access to systematic data  regarding seriously injured servicemembers. In the absence of a formal  information-sharing agreement with DOD, VA does not have systematic  access to DOD data about the population who may need its services.  Specifically, VA cannot reliably identify all seriously injured  servicemembers or know with certainty when they are medically  stabilized, when they are undergoing evaluation for a medical discharge,  or when they are actually medically discharged from the military. VA has  instead had to rely on ad hoc regional office arrangements at the local  level to identify and obtain specific data about seriously injured  servicemembers. While regional office staff generally expressed  confidence that the information sources they developed enabled them to  identify most seriously injured servicemembers, they have no official data  source from DOD with which to confirm the completeness and reliability  of their data nor can they provide reasonable assurance that some  seriously injured servicemembers have not been overlooked. In addition,  informal data-sharing relationships could break down with changes in  personnel at either the MTF or the regional office.
In our review of 12 regional offices, we found that they have developed  different information sources resulting in varying levels of information.  The nature of the local relationships between VA staff and military staff at  MTFs was a key factor in the completeness and reliability of the  information the military provided. For example, the MTF staff at one  regional office provided VA staff with only the names of new patients and  no indication of the severity of their condition or the theater from which  they were returning. Another regional office reported receiving lists of  servicemembers for whom the Army had initiated a medical separation in  addition to lists of patients with information on the severity of their  injuries. Some regional offices were able to capitalize on long-standing  informal relationships. For example, the VA coordinator responsible for  identifying and monitoring the seriously injured at one regional office had  served as an Army nurse at the local MTF and was provided all pertinent  information. In contrast, staff at another regional office reported that local  military staff did not until recently provide them with any information on  seriously injured servicemembers admitted to the MTF.
DOD officials expressed their concerns about the type of information to be  shared and when the information would be shared. DOD noted that it  needed to comply with legal privacy rules on sharing individual patient  information. DOD officials told us that information could be made  available to VA upon separation from military service, that is, when a  servicemember enters the separation process. However, prior to  separation, information can only be provided under certain circumstances,  such as when a patient’s authorization is obtained.
Based on our review of VA’s efforts to expedite VR&E services to seriously  injured servicemembers, we recommended that VA and DOD collaborate  to reach an agreement for VA to have access to information that both  agencies agree is needed to promote recovery and return to work for  seriously injured servicemembers. We also recommended that VA develop  policy and procedures for regional offices to maintain contact with  seriously injured servicemembers who do not initially apply for VR&E  services. VA and DOD generally concurred with our recommendations. VA  also told us that its follow-up policies and procedures include sending  veterans information on VR&E benefits upon notification of disability  compensation award and 60 days later. However, we believe a more  individualized approach, such as maintaining personal contact, could  better ensure the opportunity for veterans to participate in the program  when they are ready.
In dealing with psychological injuries such as PTSD, VA also faces  challenges in providing services. Specifically, the inherent uncertainty of  the onset of PTSD symptoms poses a challenge because symptoms may be  delayed for years after the stressful event. Symptoms include insomnia,  intense anxiety, nightmares about the event, and difficulties coping with  work, family, and social relationships. Although there is no cure for PTSD,  experts believe that early identification and treatment of PTSD symptoms  may lessen the severity of the condition and improve the overall quality of  life for servicemembers and veterans. If left untreated it can lead to  substance abuse, severe depression, and suicide.
Another challenge VA faces in dealing with veterans with PTSD is the lack  of accurate data on its workload for PTSD. Inaccurate data limit VA’s  ability to estimate its capacity for treating additional veterans and to plan  for an increased demand for these services. For example, we noted in our  September 2004 report that VA publishes two reports that include  information on veterans receiving PTSD services at its medical facilities.  However, neither report includes all the veterans receiving PTSD services.  We found that veterans may be double counted in these two reports,  counted in only one report, or omitted from both reports. Moreover, the  VA Office of Inspector General found that the data in VA’s annual capacity  report, which includes information on veterans receiving PTSD services,  are not accurate. Thus, VA does not have an accurate count of the number  of veterans being treated for PTSD.
In our September 2004 report, we recommended that VA determine the  total number of veterans receiving PTSD services and provide facility- specific information to VA medical centers. VA concurred with our  recommendation and later provided us with information on the number of  Operation Enduring Freedom and Operation Iraqi Freedom veterans that  has accessed VA services in its medical centers, as well as its Vet Centers.  However, VA acknowledged that estimating workload demand and  resource readiness remains limited. VA stated that the provision of basic  post-deployment health data from DOD to VA would better enable VA to  provide health care to individual veterans and help VA to better  understand and plan for the health problems of servicemembers returning  from Afghanistan and Iraq. In February 2005, we reported on  recommendations made by VA’s Special Committee on PTSD; some of the  recommendations were long-standing. We recommended that VA prioritize  implementation of those recommendations that would improve PTSD  services. VA disagreed with our recommendation and stated the report  failed to address the many efforts undertaken by the agency to improve  the care delivered to veterans with PTSD. We believe our report  appropriately raised questions about VA’s capacity to meet veterans’ needs  for PTSD services. We noted that, given VA’s outreach efforts, expanded  access to VA health care for many new combat veterans, and the large  number of servicemembers returning from Afghanistan and Iraq who may  seek PTSD services, it is critical that VA’s PTSD services be available  when servicemembers return from military combat.

	Concluding Observations

VA has taken steps to help the nation’s newest generation of veterans who  returned from Afghanistan and Iraq seriously injured move forward with  their lives, particularly those who return from combat with disabling  physical injuries. While physical injuries may be more apparent,  psychological injuries, although not visible, are also debilitating. VA has  made seriously injured servicemembers and veterans a priority, but faces  challenges in providing services to both the physically and psychologically  injured. For example, VA must be mindful to balance effective outreach  with an approach that could be viewed as intrusive. Moreover, overcoming  these challenges requires VA and DOD to work more closely to identify  those who need services and to share data about them so that seriously  injured servicemembers and veterans receive the care they need.
Mr. Chairman, this concludes my prepared remarks. I will be happy to  answer any questions that you or Members of the Committee might have.

	Contact and Acknowledgments

For further information, please contact Cynthia A. Bascetta at (202) 512- 7101. Also contributing to this statement were Irene Chu, Linda Diggs,  Martha A. Fisher, Lori Fritz, and Janet Overton.

Related GAO Products

VA Health Care: VA Should Expedite the Implementation of  Recommendations Needed to Improve Post-Traumatic Stress Disorder  Services. GAO-05-287. Washington, D.C.: February 14, 2005.
Vocational Rehabilitation: More VA and DOD Collaboration Needed to  Expedite Services for Seriously Injured Servicemembers. GAO-05-167.  Washington, D.C.: January 14, 2005.
VA and Defense Health Care: More Information Needed to Determine if  VA Can Meet an Increase in Demand for Post-Traumatic Stress Disorder  Services. GAO-04-1069. Washington, D.C.: September 20, 2004.
VA Vocational Rehabilitation and Employment Program: GAO  Comments on Key Task Force Findings and Recommendations. GAO-04- 853. Washington, D.C.: June 15, 2004.
Defense Health Care: DOD Needs to Improve Force Health Protection and  Surveillance Processes. GAO-04-158T. Washington, D.C.: October 16, 2003.
Defense Health Care: Quality Assurance Process Needed to Improve  Force Health Protection and Surveillance. GAO-03-1041. Washington,  D.C.: September 19, 2003.
VA Benefits: Fundamental Changes to VA’s Disability Criteria Need  Careful Consideration. GAO-03-1172T. Washington, D.C.: September 23,  2003.
High-Risk Series: An Update. GAO-03-119. Washington, D.C.: January 1,  2003.
Major Management Challenges and Program Risks: Department of  Veterans Affairs. GAO-03-110. Washington, D.C.: January 2003.
SSA and VA Disability Programs: Re-Examination of Disability  Criteria Needed to Help Ensure Program Integrity. GAO-02-597.  Washington, D.C.: August 9, 2002.
Military and Veterans’ Benefits: Observations on the Transition  Assistance Program. GAO-02-914T. Washington, D.C.: July 18, 2002.
Disabled Veterans’ Care: Better Data and More Accountability Needed to  Adequately Assess Care. GAO/HEHS-00-57. Washington, D.C.: April 21,  2000.
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Summary:
Why GAO Did This Study

More than 10,000 U.S. military servicemembers, including members of the National Guard and Reserve, have been injured in the conflicts in Afghanistan and Iraq. Those with serious physical and psychological injuries are initially treated at the Department of Defense's (DOD) major military treatment facilities (MTF). The Department of Veterans Affairs (VA) has made provision of services to these servicemembers a high priority. This testimony focuses on the steps VA has taken and the challenges it faces in providing services to the seriously injured and highlights findings from three recent GAO reports that addressed VA's efforts to provide services to the seriously injured. These services include vocational rehabilitation and employment (VR&E) and health care for those with post-traumatic stress disorder (PTSD).

What GAO Found

VA has taken steps to provide services as a high priority to seriously injured servicemembers returning from Afghanistan and Iraq. To identify and monitor those who may require VA's services, VA and DOD are working on a formal agreement to share data about servicemembers with serious injuries. Meanwhile, VA has relied on its regional offices to coordinate with staff at MTFs and VA medical centers to learn the identities, medical conditions, and military status of seriously injured servicemembers. For servicemembers with PTSD, VA has taken steps to improve care including developing with DOD a clinical practice guideline for identifying and treating individuals with PTSD. The guideline contains a four-question screening tool, which both VA and DOD use to identify those who may be at risk for PTSD. VA faces significant challenges in providing services to seriously injured servicemembers. For example, the individualized nature of recovery makes it difficult to determine when a seriously injured servicemember will be ready for vocational rehabilitation, and DOD has expressed concern that VA's outreach to servicemembers could affect retention for those whose discharge from military service is uncertain. VA is also challenged by the lack of access to DOD data; although VA staff have developed ad hoc arrangements, such informal agreements can break down. Regarding PTSD, inaccurate data limit VA's ability to estimate its capacity for treating additional veterans and to plan for an increased demand for these services.