Serve, Support, Simplify 

Report of the President’s Commission on Care 

For America’s Returning Wounded Warriors 

July 2007 

Subcommittee Reports & Survey Findings 
 

2
 

3

Table of Contents 

Work of the Commission 5

Commissioners’ Biographical Profiles 7

Subcommittee Reports 9

A System that Serves 

 The Continuum of Care 11

 Post-Traumatic Stress Disorder & 

Traumatic Brain Injury 

35

 Rehabilitation 53

A System that Supports 

 Family Support 69

 Education, Training, & Employment 81

A Simpler System 

 Disability Evaluation & 

Compensation 

93

 Information Systems 117

Key Survey Findings 145
 

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5

The Work of the Commission 

President George W. Bush established the President’s Commission on Care for 

America’s Returning Wounded Warriors by executive order (EO 13426, March 8, 2007). 

Section 3 of the order specifies: 

The mission of the Commission shall be to: 

(a) examine the effectiveness of returning wounded service members’ 

transition from deployment in support of the Global War on Terror to 

successful return to productive military service or civilian society, and 

recommend needed improvements; 

(b) evaluate the coordination, management, and adequacy of the delivery 

of health care, disability, traumatic injury, education, employment, and 

other benefits and services to returning wounded Global War on Terror 

service members by Federal agencies as well as by the private sector, and 

recommend ways to ensure that programs provide high-quality services; 

(c) (i) analyze the effectiveness of existing outreach to service members 

regarding such benefits and services, and service members’ level of 

awareness of and ability to access these benefits and services, and (ii) 

identify ways to reduce barriers to and gaps in these benefits and services; 

and 

(d) consult with foundations, veterans service organizations, non-profit 

groups, faith-based organizations, and others as appropriate, in performing 

the Commission’s functions under subsections (a) through (c) of this 

section. 

Our report is rooted in the work done by the Commission, plus the work of the several 

other Task Forces and Commissions that in recent months have been examining similar 

issues. This Commission heard testimony at seven public meetings and conducted 23 site 

visits to military bases, VA hospitals and treatment centers across the country. We heard 

from experts on providing physical and mental health care, navigating health care and 

disability evaluation and compensation systems, members of Congress and their staff, 

and most importantly, service men and women, their families, and the health care 

professionals charged with their care. The Commission also conducted its own 

nationwide survey of more than 1700 injured service men and women, and findings from 

this June 2007 survey are noted throughout the main report and the Subcommittee 

reports. 

Given the short timeframe of the Commission and the desire of Commission members to 

reach as many service men and women and their families as possible, a public website 
 

6

was established with a special “Share Your Story” feature at www.pccww.gov. From 

April 14th through July 9th, the Commission received 473 “Share Your Story” e-mails. 

Individuals also could contact the Commission by mail (P.O. Box 12588, Arlington VA 

22219-2588) or toll-free telephone number (1-877-588-2035), where detailed messages 

could be recorded. Commission staff reviewed every in-person, electronic, written, and 

telephonic submission. As of July 9th, the Commission received and responded to 502 

pieces of correspondence and 414 phone calls. 

Site Visits 

The Commission visited the following facilities: 

California 

 Camp Pendleton (San Diego) 

 Balboa Naval Medical Center 

(San Diego) 

 San Diego VA Medical Center 

Florida 

 Miami VA Medical Center 

 Ryder Trauma Center 

 James A. Haley VA Medical 

Center (Tampa) 

Illinois 

 North Chicago VA/Great Lakes 

Naval Hospital 

 Rehabilitation Institute of 

Chicago 

Maryland 

 National Naval Medical Center 

Minnesota 

 National Guard “Beyond the 

Yellow Ribbon” Program 

Nevada 

 Southern Nevada VA Medical 

Center 

New Jersey 

 New Jersey VA Medical Center 

– Lyons Campus 

New York 

 Bronx VA Medical Center 

North Carolina 

 Camp Lejeune 

 Womack Army Medical Center 

(Fort Bragg) 

Texas 

 Brooke Army Medical Center 

(Fort Sam Houston) 

 Wilford Hall Medical Center 

(Lackland Air Force Base) 

 Audie Murphy VA Medical 

Center (San Antonio) 

Virginia 

 Hunter Holmes McGuire VA 

Polytrauma Rehabilitation 

Center (Richmond) 

 Fort Belvoir 

Washington, DC 

 National Rehabilitation Hospital 

 Walter Reed Army Medical 

Center 

 Washington Navy Yard 
 

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Commissioners’ Biographical Profiles 

President Bush named nine members to the President’s Commission on Care for 

America’s Returning Wounded Warriors, including two co-chairs. Each 

Commission member brought unique personal and professional experience to the 

work of the Commission. The following are brief biographical profiles of our 

Commission members: 

Co-Chairs

Bob Dole: Senator Bob Dole was elected to Congress from his home state of Kansas in 

1960 and to the U.S. Senate in 1968. He resigned from the Senate in 1996. His personal 

history of service includes active duty in World War II, during which he was gravely 

wounded and received for heroic achievement two Purple Hearts and a Bronze Star with 

Oak Leaf Cluster. 

Donna Shalala: In 1993, President Clinton appointed Donna Shalala Secretary of Health 

and Human Services (HHS), where she served for eight years, becoming the longest 

serving HHS Secretary in U.S. history. She has served as President of the University of 

Miami since June 1, 2001. 

Commissioners 

Edward A. Eckenhoff: Edward A. Eckenhoff is Founder, President, and CEO of the 

National Rehabilitation Hospital and a Member of the District of Columbia Hospital 

Association Board of Directors. As the leader of one of the largest medical rehabilitation 

providers in the Washington-Baltimore area, he is an innovator in the field of 

rehabilitation medicine. Earlier in his career, he served as Vice President and 

Administrator at the Rehabilitation Institute of Chicago. He received his bachelor's 

degree from Transylvania University in Kentucky and his master's degree in Health Care 

Administration from the Washington University School of Medicine. 

Tammy Edwards: Tammy Edwards is a strong advocate for families of wounded service 

members. In 2005, her husband, U.S. Army Staff Sergeant Christopher Edwards, was 

severely burned in Iraq when a 500-pound bomb exploded under his vehicle. Since her 

husband's injury, Tammy has provided support for family members of wounded veterans 

in her community of Cibolo, Texas. She received her bachelor's and master's degrees 

from Florida State University. 

Kenneth Fisher: Kenneth Fisher is Senior Partner of Fisher Brothers and Chairman and 

CEO of Fisher House Foundation, a not-for-profit organization that constructs "comfort 
 

8

homes" for families of hospitalized military personnel and veterans. Fisher Houses serve 

8,500 families every year. Mr. Fisher has more than 26 years of experience in the real 

estate industry and attended Ithaca College. 

C. Martin Harris: C. Martin Harris is Chief Information Officer and Chairman of the 

Information Technology Division at the Cleveland Clinic. He has been a practicing 

physician since 1987. He has served on government and private sector commissions that 

have addressed health care interoperability issues, including the Congressional 

Commission on Systemic Interoperability and as Chairman of the Healthcare Information 

and Management Systems Society’s National Health Information Infrastructure Task 

Force. Dr. Harris received his MBA from the Wharton School of Business and his MD 

from the University of Pennsylvania School of Medicine. 

Marc Giammatteo: Marc Giammatteo is a student at Harvard Business School, a 

graduate of the U.S. Military Academy at West Point, and a former Captain in the U.S. 

Army. In 2004, his leg was severely injured during a rocket propelled grenade attack in 

Iraq. He has undergone more than 30 surgeries at Walter Reed Army Medical Center. 

From 2004 to 2007, he served as an Unofficial Patient Advocate at Walter Reed. He is a 

recipient of the Bronze Star and Purple Heart. 

Jose Ramos: Jose Ramos is a student at George Mason University, where he is pursuing 

a major in International Studies and minor in Islamic Studies and Arabic. While serving 

as a Hospital Corpsman 3rd Class in the U.S. Navy, he treated soldiers who were injured 

during unconventional warfare in Iraq. In 2004, during his second tour of duty in Iraq, he 

lost his arm during combat. He also served one tour of duty in Afghanistan. 

Gail Wilensky: Gail Wilensky is an Economist and Senior Fellow at Project HOPE, an 

international health education foundation. She also serves as Co-Chair of the Task Force 

on Future Health Care at the U.S. Department of Defense. Earlier in her career, she 

served as the Chair of the 2003 President's Task Force to Improve Health Care Delivery 

for Our Nation's Veterans and Chair of the Medicare Payment Advisory Commission. 

She also directed Medicare and Medicaid programs at the U.S. Department of the Health 

and Human Services. Dr. Wilensky received her bachelor's, master's, and doctoral 

degrees from the University of Michigan. 
 

9

Subcommittee Reports 
 

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11

THE CONTINUUM OF CARE

 

THE CHALLENGE

Advances in military medicine, rapid evacuation, and improved protective gear 

have increased survival of our injured service members compared to previous conflicts 

and wars. Care from the point of injury through medical evacuation is demonstrably firstclass. Service members can arrive in the continental United States within 36 hours after 

sustaining very serious and complex injuries. 

 

Although the military health system is responding admirably to the rapidly 

increasing number and complexity of injuries, evidence has arisen of gaps in care, lack of 

accountability, and bureaucratic mazes. Fragmentation in the health and social services 

systems creates frequent confusion and uncertainty. 

 

Processes for access to care, case management, coordination of services, and 

inpatient to outpatient transitions lack clear and common definition. Further, these 

processes have not evolved to meet the changes in health care needs. Successful 

transition from inpatient to outpatient status requires attentive coordination and 

management of care, focusing on the service member’s readiness to begin the journey 

from the inpatient environment to life in the community. 

 

BACKGROUND

 

Military medicine has contributed greatly to improvements in care and 

management of the severely wounded. From the concept of triage—the system for 

prioritizing injuries for treatment, which began in World War I—to rapid transportation 

of the wounded to sites for definitive care, the advances and lessons learned during times 

of war have created and improved the system of trauma care for both U.S. service 

members and civilians. During World War II, for example, the process for storing blood 

was put to the test in the field by the British Red Cross. In Korea, MASH units were 

developed and used as forward surgical units to improve care for the wounded, and 

helicopter ambulances created the first formal air evacuation system. In Vietnam, the air 

evacuation system was advanced to the point where injured service members were 

transported from the point of injury to definitive care within two hours, compared with 12 

to 48 hours in World War I. 

The current wars in Iraq and Afghanistan have also seen great strides in the 

development of trauma medicine. Advances in body armor and hemorrhage control 

techniques have dramatically reduced mortality rates and limited the severity of many 

injuries. 

 
 

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According to a recent report, the proportion of combat casualties—active-duty 

service members who have to leave the theater because of a medical condition, including 

injury, illness, or non-combat injury[1]—who are killed in action fell from 20 percent in 

World War II to 13.8 percent in Afghanistan and Iraq. This decrease in the number dying 

instantly from their wounds is a measure of the effectiveness of early care and evacuation 

in the face of more deadly weapons.[2] Another way of measuring this effectiveness is 

the case fatality rate, which is the percentage of killed and wounded who die from 

injuries, either immediately (killed in action) or after a lapse of time (died of wounds). 

The case fatality rate has fallen from 19.1 percent in World War II to 10.1 percent in Iraq 

and Afghanistan. [3] 

 

Case Fatality Rate = killed in action + died of wounds x 100 

 killed in action + wounded in action 

 

% Killed in Action = killed in action x 100 

 killed in action + (wounded in action – return to duty) 

 

 

OVERVIEW

The military readiness mission of the military health system is twofold: 1) to 

maintain the health of America’s fighting force and 2) to care for those service members 

who are ill or injured. Casualty planning for each war builds on the lessons learned from 

previous wars and conflicts. Allocation of medical resources for any war is based on the 

number of deployed troops. 

For the current wars in Iraq and Afghanistan, the general plan for access to 

medical care for our service members encompasses five levels: 

 

Level I : Medic (Army or Air Force)/Corpsman (Marine) 

 Battalion Aid Station (Army) /Regimental Aid Station (Marine) 

Level II : Forward Surgical Team (Army) / Forward Resuscitative Surgical 

 System (Marine) 

Level III : Combat Support Hospital/Air Force Theater Hospital/Naval Hospital 

 Ship 

Level IV : Landstuhl Regional Medical Center, Germany 

Level V : Continent of the United States 

All service members are first-aid trained in order to assist a wounded comrade. 

When a service member is injured during combat, he or she is trained to self-apply a 

tourniquet if necessary. A medic (Army) or corpsman (Navy) assists if immediate 

lifesaving measures are required, and with evacuation. The injured service member is 

transported to the next appropriate level of care, depending on the type and severity of the 

wounds. 

 
 

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For some, this means being air evacuated to Landstuhl Regional Medical Center 

in Germany, where they receive additional care and stabilization. As of June 30, 2007, 

37,851 individuals had arrived at Landstuhl from Iraq and Afghanistan, and 23,270 of 

these returned to duty within 72 hours.[5] Not all of these service members were injured 

in combat, and not all actually required hospitalization at Landstuhl. (From the 

beginning of Operation Iraqi Freedom until May 15, 2003, 1,236 patients were evacuated 

to Landstuhl, only 620 required inpatient admission; 256 of these had been injured in 

battle. [6]) 

Service members with any injury or illness which requires additional expertise, or 

which will prevent their returning to their military duties, are generally air evacuated to 

medical treatment facilities in the United States.[7] Prior to evacuation, physicians at 

Landstuhl determine the optimal medical treatment facility to refer the patient, given the 

individual’s injuries or medical needs. Receiving physicians at stateside military 

treatment facilities are provided with a summary of the medical condition for which the 

patient was referred. 

 

On arrival in the United States, injured service members are taken to the 

appropriate medical treatment facility where they are examined and placed into inpatient 

or outpatient status. After recovery, some return to duty. Others begin the process of 

evaluation to determine whether or not they are medically fit to continue in their military 

job. Service members found unfit are then evaluated for separation or medical 

retirement from the military. (The details of this process are fully discussed in the 

Subcommittee Report on Disability.) 

 

Most veterans file for a disability rating from the VA, and all those who were 

deployed to Iraq and Afghanistan are eligible for two years of free medical care in the 

VA health system. To continue receiving health care from the VA, they must enroll. 

Many veterans are also eligible for other benefits, such as vocational rehabilitation or 

education benefits through the Montgomery GI Bill. Various federal and state programs 

also provide support and assistance with employment. These aspects of veteran benefits 

are detailed in the Subcommittee Report on Education, Training, and Employment. 

 

On February 18, 2007, the Washington Post began publication of a series 

focusing on deficient conditions in Building 18, an outpatient unit, located on the campus 

of Walter Reed Army Medical Center. That and subsequent events led to the creation of 

a task force and an inter-agency review, along with a host of corrective actions on the 

part of the military and VA. Congress has held hearings, and hundreds of bills have been 

proposed to address the perceived problems. 

PREVIOUS REPORTS AND RECOMMENDATIONS

Previous Commission and Task Force reports have examined care and services 

that injured service members receive. A common theme among these reports is the need 

for coordinated care, with a mechanism to assist service members as they transition from 
 

14

inpatient to outpatient care and services. The following specific recommendations were 

made: 

• The Task Force on Returning Global War on Terror Heroes (March 

2007) recommended development of a system for co-management and 

case management for returning service members to ease the transition 

from DoD to VA care. Specific recommendations from this report 

included: 

• Standardization of VA Liaison Agreements across all military 

treatment facilities 

• Enhancement of electronic health records to facilitate complete 

reporting of medical information between DoD and VA. 

• A 2007 report by the Government Accountability Office (GAO) on 

challenges encountered by injured service members during their recovery 

process concluded that transition of care for the seriously injured, and 

DoD and VA’s efforts to provide rehabilitation services as soon as 

possible after the injury, constituted the greatest areas of challenge. This 

has resulted in streamlining of processes between DoD, VA, Department 

of Labor, and other federal agencies to develop measures to ensure better 

outcomes.[8] 

 

• The Independent Review Group (April 2007) criticized shortcomings in 

the areas of continuum of care, leadership, and policy in regard to care of 

injured service members. The report specifically recommended: 

o Developing a tri-service policy for case management services 

o Assigning every returning service member assigned a primary care 

manager and a case manager as the basic unit of support 

• Creating a standard for qualifications and initial and recurring 

training for all case managers. 

• In a 2006 report, the GAO observed that many outreach efforts were 

underway between DoD and the VA to provide seamless transition of care 

for Iraq and Afghanistan service members and veterans. It concluded that 

efforts to get information to service members and veterans about VA 

health care services were successful. Results of these efforts included 

memoranda of agreement between DoD and VA health care facilities for 

transfer of injured service members, and initiatives to improve the 

electronic exchange of information between DoD and the VA. [9] 

• In a report to Congress in 2006, the Transition Assistance and Disabled 

Transition Assistance Programs (TAP and DTAP) were the focus. Work 

done in this area has led to the restructuring of the TAP program to 

include a web-based portal for information, increases in TAP briefings 
 

15

done jointly between DoD and the VA, and measures to enhance the 

existing TAP program.[10] 

 

WHAT THE COMMISSION FOUND

Introduction 

The Commission learned a great deal about the care and benefits provided to 

America’s military personnel and veterans. The Commission learned that, on the whole, 

we are a generous and giving Nation when it comes to providing for our service members 

and veterans. Benefits include health care for veterans through the VA health care 

system and for retirees through the military health system and through civilian providers 

through TRICARE. In addition, we pay retirement and disability benefits, and provide 

for education, adaptive equipment, employment hiring preferences, and more. The total 

cost of these benefits was well over $127 billion in 2006.[11] 

 

The Commission was not charged with determining if this amount is sufficient. 

Instead, the Commission was charged with determining if the benefits and services 

provided to our wounded service members are effective in maximizing their potential for 

a productive life—either by returning to full military service or transitioning to civilian 

life. This is a big challenge. 

 

The Commission recognized that it could not tackle every problem in the care of 

injured service members within its four-month time frame and determined to focus on the 

disability system for the military and the VA, rehabilitation, education/training and 

employment, families, post-traumatic stress disorder and traumatic brain injury, and 

information transfer. Each of these areas is discussed in the subcommittee reports that 

follow. The remainder of this Subcommittee Report discusses coordination and delivery 

of care and benefits to our injured service members. 

 

Transition: Becoming a Patient 

 

 From the time of injury, service members progress through a series of recovery 

transitions. The first occurs at the front lines, when the service member is injured and 

becomes a patient. Experience in the field has documented that the greatest threat to life 

is the immediate blood loss associated with the injury. [12] ,[13] In response, the combat 

health support system has provided more first responder training and has positioned 

advanced trauma management capabilities closer to the front lines.[14] As a result, if an 

injured service member arrives at any level of theater medical care, he or she has a 97.5 

percent chance of surviving.[15] 

 

The process of getting injured services members the care they need while 

remaining in a combat zone is excellent. The Army, Marines, Air Force, and Navy have 

each created a system of combat care and evacuation that quickly moves the injured 

individual through the various levels of care and back to military treatment facilities in 
 

16

the United States. It is not uncommon for an injured service member to arrive at a 

stateside military treatment facility within 36 hours after injury. [16] 

 

 The Commission found no area of concern regarding in-theater care and 

evacuation of injured service members. 

 

Transition: Evacuation & Triage 

A later transition involves the decision to evacuate an active-duty service member 

to the United States, typically from Landstuhl Regional Medical Center in Germany 

(Table 1). This decision is based on a determination that the patient’s condition is so 

serious that returning to duty is not feasible or that additional resources are required to 

care for the individual. The physicians at Landstuhl first match the patient’s needs with a 

referral hospital that can provide the necessary services. The referral hospital is notified, 

and arrangements are made for transfer. The air evacuation manifest, containing specific 

information about the patient, is sent to the referring hospital prior to the patient’s 

arrival. 

 Upon arrival at the destination facility, the patient is triaged to either inpatient or 

outpatient status. Within 24 hours, outpatients are usually seen in a clinic, where an 

evaluation is completed and referrals are made for needed services. Inpatients receive 

further stabilization for their injuries and additional procedures before being discharged 

to outpatient status or transferred to another hospital. 

In general, patients with traumatic amputations are cared for at Walter Reed Army 

Medical Center, Brooke Army Medical Center, and Naval Medical Center San Diego. 

Burn patients are admitted directly to the burn unit at Brooke Army Medical Center. 

Patients with spinal cord injuries are stabilized and then transferred to a VA spinal cord 

center. Patients with penetrating head injuries are primarily cared for at National Naval 

Medical Center, Bethesda, Maryland. Service members with multiple injuries are 

stabilized at one of the military treatment facilities and may, afterwards, be transferred to 

one of four VA Polytrauma Rehabilitation Facilities. 

 

As of July 23, 2007, 911 service members experienced an amputation from 

injuries sustained in Iraq or Afghanistan. Of these, 644 have been for the loss of an arm, 

leg , han d, or foot, including those individuals with multiple amputations. 

Approximately 76 percent of these have been cared for at Walter Reed Army Medical 

Center. 

Accounting for all patients with traumatic brain injury is more difficult (see 

Subcommittee Report on Post-Traumatic Stress Disorder and Traumatic Brain Injury). 

As of March 2007, 2,726 service members had been reported to the Defense Veterans 

Brain Injury Center with the diagnosis of traumatic brain injury. Of these, 2,094 were 

classified as mild and 255 as moderate. Another 192 had severe traumatic brain injuries 

and 171 had penetrating brain injuries. 
 

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 Ninety-one service members had been treated for spinal cord injuries in the VA, 

as of June 8, 2007. Brooke Army Medical Center’s burn unit reports receiving 598 

service members evacuated from Iraq and Afghanistan with burns as of June 30, 2007. 

Fifty-three service members have received blind rehabilitation services from the VA as of 

April 3, 2007. 

 

 The Commission found no area of great concern with the inpatient treatment of 

patients evacuated from Landstuhl. The medical care at Walter Reed Army Medical 

Center, Brooke Army Medical Center, National Naval Medical Center at Bethesda, Naval 

Medical Center San Diego, and other military treatment facilities is compassionate and 

complete. The specialized services and programs for amputations and burns, in 

particular, are world-class. 

 

 Transition: Inpatient to Outpatient 

Transitioning from an inpatient to outpatient setting can be difficult for 

patients—in or out of the military. Being an outpatient places the burden to follow 

through with instructions and plans for recovery directly on the patient and family. This 

may be an easier task for those with relatively minor injuries. 

Patients with complex and chronic problems are less likely to do well without 

additional guidance and attention. The Commission heard concerns that care in the 

outpatient setting was less well coordinated, difficult to access, and fragmented. Some 

injured service members reported waiting two to three weeks between appointments for 

specialty services, consistent with the access standard for all military patients. In 

addition, access to support and administrative services is challenging. Outpatient care 

can be further complicated by the structure, rules, and regulations required by the 

military. 

Transition to VA: Medical Hold & Holdover 

 In the Army, medical hold is a term used to describe the duty status of active-duty 

service members who are unable to perform in their duty capacity.[17] Medical holdover

is the term used for the duty status of Army reservists who need medical care at any time 

during their mobilization or who experienced a medical condition in the line of duty.[18] 

The Air Force has a similar concept for airmen, called patient squadrons, although an 

airman who can work at any duty is returned to his unit. The Navy and Marines also use 

the terms medical hold and medical holdover. Service members who require more than 

30 days for recovery prior to returning to duty are placed in medical hold/medical 

holdover/patient squadrons. 

 

These administrative terms are used to maintain command and control of service 

members during outpatient recovery or treatment. The ability to reassign an individual to 

medical hold also enables commanders to maintain unit strength by filling the position. 
 

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For those whose medical condition precludes a return to their military duties, the 

evaluation process for separation or medical retirement begins. Medical hold is not 

intended to be permanent or a means to maintain active-duty status. 

 

 Currently in the Army, there are 1,530 active duty and 2,069 reservists on medical 

hold or medical holdover. The average length of time spent in medical hold or medical 

holdover is 174 days, with many spending 122 days.[19] 

Durations are similar for the Air Force, where the average length of time is 222 

days, and, for sailors and Marines, the average time spent in medical hold is 130 

days. There have been instances, however, when service members have spent more than 

years in medical hold.[20]

 

 Although the Army’s Office of the Surgeon General was unable to provide the 

number of soldiers in medical hold or holdover status since 2001, it did provide data on 

soldiers in medical hold and holdover status at each military treatment facility (Table 2). 

The highest number of soldiers in medical hold or holdover status continues to be at 

Walter Reed Army Medical Center, followed closely by Fort Sam Houston. While 

soldiers in medical hold or holdover status at other military treatment facilities may 

actually be recovering at home, those recovering at Walter Reed present a housing issue. 

Walter Reed is not co-located with an active troop command center, such as Fort Bragg , 

and therefore housing for outpatients is limited. 

 

Many long lengths of stay in medical hold and holdover status are the result of 

injury complexity and the natural progression of recovery. Other delays, however, 

appear to result from suboptimal care coordination and planning, long waits for 

outpatient appointments, lack of accountability for soldiers’ whereabouts, and service 

members’ desire to remain on active duty for as long as possible, in order to receive 

active-duty pay and benefits. 

 

 Recently, the Army Medical Department implemented the Army Medical Action 

Plan to address problems at Walter Reed.[22] The plan includes development of Warrior 

Transition Units. These units are intended to replace medical hold and holdover with a 

formal military unit structure and will be located at every medical treatment facility 

where at least 35 soldiers qualify. A primary care provider, case manager, and squad 

leader are assigned to each recovering soldier. The plan also calls for expedited access 

for outpatient appointments and appropriate diagnostic tests. 

 

 The Wounded Warrior Regiment, established in April 2007, is the comparable 

Marine Corps program. This is a centralized unit with command and control of all 

wounded and ill Marines. Some of these Marines live in Wounded Warrior barracks; 

others live on or off base with their families. Medical case management is provided by 

the closest naval medical center, and coordination between the regiment and the medical 

team is facilitated with biweekly meetings. The Regiment commands two Wounded 

Warrior Battalions; East at Camp Lejeune, North Carolina, and West at Camp Pendleton, 

California. 
 

19

 

The Navy and Air Force also have similar programs. Safe Harbor (Navy) assists 

injured sailors with access to existing support resources, while encouraging them to 

remain in the Navy. While the Palace HART (Air Force) program works to retain 

combat-injured service members on active duty, provides benefits counseling, and 

facilitates civilian employment for those medically separated. 

These programs are commendable and will assist service members while reducing 

medical hold and holdover excesses. But, they are not sufficient to solve the fundamental 

problem of transitioning service members through a complex and, at times, convoluted 

process. 

 

Transition: From Active Duty to Veteran 

 

Prior to 2000, access to VA health care was only possible after leaving the 

military. Today, however, many active-duty services members are treated for their 

injuries in VA Polytrauma Rehabilitation Centers and Spinal Cord Centers. Furthermore, 

they may be transferred back to a military treatment facility for additional care. These 

transitions and transfers can be challenging. Few service members or their families know 

how to navigate the VA system. 

To help resolve some of these problems, in January 2005, the VA established the 

Office of Seamless Transition. This Office provides oversight and assistance for 

military-VA facility patient transitions.[23] The VA provides social work liaisons in ten of 

the major military hospitals. These liaisons serve as part of the health care team, and 

facilitate transfer to a VA facility when the team thinks it is in the patient’s best interest. 

When a service member is transferred to a VA facility, he or she is assigned a case 

manager to assist with care and help educate the patient and the family. 

 

Transitioning to the VA after leaving the military can be difficult as well. For 

veterans who served in Iraq and Afghanistan, two years of health care is provided in the 

VA health care system without the need to enroll. Veterans who believe they have 

service-related or service-aggravated conditions must apply for VA disability benefits. 

Under a new VA program, Benefits Delivery at Discharge, injured service members can 

file for VA claims if they are within 180 days of military discharge. This program is 

working quite well and appears to be achieving the goal of providing injured service 

members with disability income by the time they leave the hospital. 

 

A host of programs and benefits assist veterans at the federal, state, and 

community levels. Identifying these programs and benefits, the requirements for 

eligibility, and the forms needed to apply can be complicated and difficult to access, even 

for those posted on the Internet. Sometimes there appears to be too much information 

provided and, at others, not enough. A contemporary, interactive personalized online 

resource is needed for service members and veterans to access this information. (This 

concept is more fully discussed in the Subcommittee Report on Information Systems.) 
 

20

Managing Transitions 

Optimally, case management assists and guides patients in a collaborative 

process, using a defined plan to meet the individual’s health needs.[24] It can include 

both clinical and non-clinical components. The concept is an important one— 

coordination of care. Unfortunately, in the military health care system, every process and 

point of health care delivery now “does” case management. Consistency is further 

weakened by differences among the Services in requirements for case management 

positions, training, certification, and case load ratios. 

 

At a recent Military Health System Case Management Summit, at least 16 areas 

were identified as providing case management services at 11 types of facilities (Table 3). 

An injured service member hospitalized at one military treatment facility and discharged 

to outpatient status may have as many as 15 case managers—all at the same facility. 

Patients requiring more complex care get more case managers; patients going between 

DoD and VA facilities for care get even more. The individual’s health needs may be met, 

but it appears that much of the time case managers are managing the patient through a set 

of services or episodes of care instead of coordinating service. The end result for the 

service member and his or her family is confusion and redundancy in a system that was 

intended to coordinate care. No one is in charge. 

 

Survey and Survey Results 

 

The Commission conducted a telephone survey of 1,730 current and former 

service members who sustained injuries in Iraq and Afghanistan that necessitated their 

medical evacuation to the United States. In general, these are young people 

inexperienced in navigating any health system, who find themselves thrust into a highly 

complex one (Table 4). Most were satisfied with their inpatient care (Figure 1). To a 

lesser degree, they were generally satisfied with rehabilitative care and outpatient care. 

We asked respondents whether they could easily find a doctor or other provider, 

and most could do so (Figure 2). When asked whether they had a medical provider to 

coordinate their care, only half of active duty said they did, and a fifth of reserve 

component or separated/retired said they had such a person. 

 

ACTION STEPS 

 

Integrated care management offers a better approach than fragmented case

management for managing and assisting injured service members and their families in 

navigating difficult and cumbersome systems of care and benefits. Integrated care 

management provides patients with the right care and benefits at the right time in the 

right place by leveraging all resources appropriate to the needs. For injured service 

members—particularly the severely injured—integrated care management would build 
 

21

bridges across health care services in a single facility and across health care services and 

benefits provided by DoD and VA. 

Integrated care management begins with a comprehensive, patient-centered 

evaluation by a multidisciplinary team of physicians, nurses, allied health care 

professionals, mental health professionals, rehabilitation and vocational rehabilitation 

specialists, and social workers, as needed, completed as early in the acute care phase of a 

service member’s recovery as possible. This evaluation guides the development of a 

comprehensive, but flexible, recovery plan. 

Components of the recovery plan include: 

 Identifying the patient’s goals for rehabilitation and outpatient care, taking 

into account plans for returning to military duty or transitioning to civilian 

life, including identification of any education, training, or employment needs 

 Specifying all resources needed to meet these goals 

 Setting milestones and estimates of time for recovery 

 Identifying the most appropriate facilities to meet the needs for rehabilitation 

and clinical care 

 Evaluating the needs of the family and providing the necessary resources for 

support. 

In our vision, the recovery plan is managed by a Recovery Coordinator. These 

highly skilled and cross-trained individuals work with existing case managers and other 

personnel involved in the various aspects of care needed by the patient to recover. In 

addition, the Recovery Coordinator arranges for any support program services required 

and serves as the patient’s advocate. The Recovery Coordinator must be able to operate 

across Departments to access the best that each has to offer in helping an injured service 

member to reach his or her maximum potential. The Recovery Coordinator will need to 

be knowledgeable not only about health care, but about benefits provided at the local, 

state, and federal levels, particularly the broad range of services provided by the VA. 

This will not be an easy task and will require a certain type of individual with 

extraordinary skills. We have developed a job description that includes a listing of the 

capabilities we expect these individuals will need (Appendix). We believe that, to be 

effective, these individuals should become part of the Commissioned Corps in the Public 

Health Service of the Department of Health and Human Services. This new unit’s 

commander would report directly to the U.S. Surgeon General. 

We thought long and hard about placing the Recovery Coordinators outside of the 

two Departments. In the end we believe that this is necessary. Placing these individuals 

in either Department is unlikely to work in the manner we have described. We do not 

suggest creating another agency or office, but propose using an existing, well respected 

source of strength—the U.S. Public Health Service’s Commissioned Corps. 

 
 

22

To make sure that this approach works, we believe the Surgeon General (Public 

Health Service [PHS], Department of Health and Human Services) should sit on the 

current Strategic Operating Committee and hold a permanent place on the Joint Executive 

Committee. The PHS Surgeon General should work with the service Surgeons General 

and the Under Secretaries for VA Health and Benefits to quickly develop a memorandum 

of understanding that would provide the authority and access needed to implement this 

strategy. 

The Recovery Coordinators can immediately be recruited from individuals 

currently working in the Commissioned Corps, DoD, and VA. A training course also 

must be immediately developed jointly with the DoD and VA, under direction of the 

Surgeon General. We believe that our approach will ultimately reduce the current 

number of case managers and VA health and benefits liaisons. This adjustment should 

take place over time, with evaluation, and as experience is gained with the Recovery 

Coordinator concept. 

 

The effectiveness of the Recovery Coordinators—their annual performance 

reviews—should be conducted by the Unit Commander, Hospital Commanders, VA 

Hospital Chiefs of Staff, patients, and families. The case load for each Recovery 

Coordinator should not be mandated, but must be flexible to meet the needs of patients. 

Because patients tend to improve with time, a Recovery Coordinator may manage up to 

20 or so patients, depending on their combined needs and time required. Most important, 

these individuals must have the authority to tap all resources necessary to implement 

each patient’s Recovery Plan. Everyone, regardless of Department affiliation, rank, or 

seniority, must cooperate. 

 

Recovery Coordinators will need timely access to medical and benefits 

information in order to properly coordinate services. This will not require any new 

information systems, but improved access to existing electronic resources. As the 

information technology in each Department continues to evolve, the information needs of 

the Recovery Coordinators must be considered and incorporated. An important 

component is the proposed “My eBenefits” web portal (discussed in the Subcommittee 

Report on Information Systems). This would serve as an integrated care management 

tool and allow instant communication between Recovery Coordinator and patient, 

assisting in the overall coordination of care and benefits. 

The Commission believes that many current injured and recovering service 

members, as well as those arriving daily from Iraq and Afghanistan, will benefit from this 

approach. 
 

23

Table 1. DESTINATIONS FOR MEDICAL EVACUATIONS FROM 

IRAQ AND AFGHANISTAN, January 2005 – March 2007. 

Destination Facility Name Number Percent

Walter Reed Army Medical Center, Washington D.C. 2236 18

Eisenhower Army Medical Center, Ft. Gordon 1015 8

Darnall Army Medical Center, Ft. Hood 903 7

National Naval Medical Center, Bethesda 801 7

Brooke Army Medical Center, Ft. Sam Houston 766 6

Womack Army Medical Center, Ft. Bragg 671 6

Naval Hospital Camp Lejeune, North Carolina 435 4

Madigan Army Medical Center Ft. Lewis 379 3

Blanchfield Army Community Hospital, Ft. Campbell 357 3

Naval Hospital Camp Pendleton, California 348 3

All other facilities combined 4177 35

Total 12,088 100 

Source: USTRANSCOM TRAC2ES, January 2005 to March 2007 

Table 2. NUMBER OF SERVICE MEMBERS ON MEDICAL HOLD OR 

HOLDOVER STATUS, BY SITE, JULY 2007. 

Walter Reed AMC 628 Tripler 68

Ft. Sam Houston 512 Ft. Eustis 38

Ft. Hood 184 Ft. Buchanan 66

Ft. Bragg 306 West Point 25

Ft. Lewis 269 Ft. Dix 103

Ft. Gordon 252 Ft. Sill 48

Ft. Bliss 163 Ft. Polk 94

Ft. Knox 219 Ft. Leonard Wood 5

Ft. Benning 96 Ft. Richardson 34

Ft. Carson 67 Ft. Irwin 16

Ft. Campbell 73 Ft. Jackson 6

Ft. Drum 162 Ft. Belvoir 10

Ft. Stewart 73 Ft. Leavenworth 3

Ft. Riley 40 Camp Shelby 39

TOTAL: 3599 
 

24

Table 3. Range of Case Management Services MT F Military Clinics Base CMD Co.

HoldMed CentersAD/RCVAMCClinicsVA ProgramsDay ProgramsTrans  CentersRehabState 

Nurse CM √ √ √ √ √ √ √ √ √

SW CM √ √ √ √ √ √ √ √ √

Clergy √ √ √ √ √ √ √ √ √

PEBLO √ √ √ √ √ √ √ √

SSL √ √ √ √ √ √ √

Service F SCP √ √ √ √ √ √

VA STL √ √ √ √ √ √

VA OEF/OIF PM √ √ √ √ √ √ √ 

VA Poly CM √ √ √

VA Vet Centers √ √ √ √ √ √

VA Women’s VPM √ √ √ √ √ √ √ √ 

VA TPA √ √

VA VIST, SCI CM √ √ √ √ √ √ √

VBO and VSO √ √ √ √ √ √ √ √ √ √

CBO √ √ √ √ √ √ √ √ √

Others √ √ √ √ √ √ √ √ √ √

 LEGEND:

MTF – Military Treatment Facility

Co CMD – Company Command

Med Hold – Medical Hold Facilities

AD/RC Centers – Active Duty and Reserve Component Service Centers

VAMC – VA Medical Centers

VA Clinics – VA Community Based Outpatient Clinics

Day Programs – Structured Day Programs

Trans Programs – Independent Living Programs

State Rehab Centers – State Rehabilitation Centers

CM – Case Manager

SW – Social Worker

SSL – Service Support Liaison

Service FSC – Service Family Support Center Personnel

VA STL – VA Seamless Transition Liaisons

VA OEF/OIF PM – VA OEF/OIF Program Managers

VA Poly CM – VA Polytrauma Case Managers

VA Vet Centers – VA Community Based Vet Centers

VA Women’s VPM – VA Women’s Veteran Program Manager

VA TPA – VA Transition Patient Advocates

VA VIST, SCI CM – VA VIST, SCI Case Managers

VBO and VSO – Veterans Benefits Organizations and Veterans Service Organizations

CBO – Community Based Organizations

 
 

25

Table 4. DEMOGRAPHIC CHARACTERISTICS OF RESPONDENTS, PCCWW 

SURVEY 

 

Characteristic

Active Duty 

Component (%)

Guard/Reserve 

Components (%)

Age 

 18-24 42 16 

 25-34 41 30 

 35+ 17 54 

Military rank 

 Junior enlisted 52 36 

 Senior enlisted 39 57 

 Officer 9 7 

Male 94 92 

 

 
 

26

Figure 1. INJURED SERVICE MEMBERS’ SATISFACTION WITH MEDICAL 

CARE, PCCWW SURVEY 

0%

20%

40%

60%

80%

Very/somewhat

satisfied

Not satisfied or

dissatisfied

Very/somewhat

dissatisfied

Very/somewhat

satisfied

Not satisfied or

dissatisfied

Very/somewhat

dissatisfied

Inpatient care Rehabilitative care Non-rehab outpatient care

% Active duty % Guard/reserve

Figure 2. INJURED SERVICE MEMBERS’ ACCESS TO MEDICAL 

PROVIDERS AND CARE COORDINATORS, PCCWW SURVEY 

 

0%

20%

40%

60%

80%

Can find providers near them Have a medical professional

who coordinates their care

Active Duty Demobilized Guard/Reserve Separated/Retired
 

27

Figure 3. 

Soldier Care Delivery Flow from Combat to Recovery 

Walter Reed

(Extremity) 

Bethesda Naval 

(Brain Injury Trauma) 

San Antonio, 

BAMC 

(Burns) 

DOD or VA Facility 

77 Possible 

(Injuries other than 

Extremity, BIT or Burns) 

Combat 

Zone

Needs-Based Plans: 

Patient Profile Driven 

1) Wounded soldier 

receives emergency care 

followed by evacuation to 

military hospital in 

Germany. 

2) Stabilized soldier 

triaged to stateside 

facility based on 

injuries and treatment 

needs. 

3) Soldier completes 

facility-based (acute) 

treatment. 

5) Plans are tailored to the 

individual, and are 

implemented by a 

customized team of 

specialists 

4) Soldier receives 

comprehensive 

evaluation and care 

plans. 

Comprehensive

Evaluation 

Comprehensive

Clinical Plan 

6) The outcome objective 

is to return the wounded 

warrior to the most optimal 

level of personal capability 

Implementation of 

Comprehensive 

Plans 

Case Manager 

VA Physician 

Service Physician 

Benefits Spec. 

Rehab Spec. 

Career Spec. 

Service Admin. 

Comprehensive

Rehab Plan 

Comprehensive

Career Plan 

Theater 

Hospita

Injur

Outcomes 

Return to Optimal 

Personal Capability 
 

28

Endnotes 

[1] Holcomb JB, Stansbury LG, Champion HR, Wade C, Bellamy RF. Understanding Combat Casualty 

Care Statistics. J Trauma. 2006;60:397-401. 

[2] ibid. 

[3] Force Health Protection and Readiness Programs, TRICARE Management Activity, Office of the 

Assistant Secretary of Defense (Health Affairs), July 23, 2007. 

[4] http://www.defenselink.mil/news/newsarticle.aspx?id=45404. Accessed July 19, 2007. 

[5] Personal communication, Defense Manpower Data Center. 

[6] Johnson B, Carmack D, Neary M, et al. Operation Iraqi Freedom: The Landstuhl Regional Medical 

Center Experience. J of Foot and Ankle Surgery 44:177-183, 2005. 

[7] Personal communication, Defense Manpower Data Center. 

[8] U.S., Government Accountability Office, GAO-07-589T. DoD and VA Health Care: Challenges 

Encountered by Injured Servicemembers during their recovery process. March 2007. 

[9] U.S., Government Accountability Office, GAO-06-794R. VA and DoD Healthcare: Efforts to Provide 

Seamless Transition of Care for OEF and OIF Servicemembers and Veterans, June 2006. 

[10] Report to Congress, 4 May 06 Transition Assistance and Disabled Transition Assistance Programs 

(TAP/DTAP).

[11] In 2006, the annual budget for the Department of Veterans Affairs was $70.8 billion. That same year, 

the annual budget for retired military personnel and survivors was $40.5 billion and the cost for retiree 

health care approximately $16 billion. 

[12] Heydorn WH, Basic and advanced combat casualty care: a military problem. Military Medicine 155: 

229-231, 1990. 

[13] Chambers LW, Rhee P, Baker BC, et al. Initial experience of US Marine Corps forward resuscitative 

surgical system during operation Iraqi Freedom. Arch Surg 140:26-32, 2005. 

[14] Strawder GS. The “golden hour” standard: transforming combat health support. JFQ 41: 60-67, 2006. 

[15] Defense Medical Data Center, Force Health Protection and Readiness Programs. 

[16] Montgomery SP, Swiecki CW, and Shriver CD. The evaluation of casualties from Operation Iraqi 

Freedom on return to the continental United States from March to June 2003. J Am Coll Surg 205:7-13, 

2005. 

[17] Army Regulation 40-400. 

[18] Definition from Annex S (Glossary of Terms) to EXORD 118-07 [Healing Warriors]). [19] Army medical hold data from Col Michael J Carion, OTSG, 9 July 2007. 

[20] Personal communication, Carol J. Thompson, Assistant Deputy (Health Policy) Force Management 

Integration (SAF/MRM). 

[21] Montgomery SP, op. cit. 

[22] Independent Review Group. Rebuilding the Trust: Report on Rehabilitative Care and Administrative 

Processes at Walter Reed Army Medical Center and National Naval Medical Center, April 2007. 

[23] U.S., Government Accountability Office, GAO-06-794R. Transition of Care for OEF and OIF 

Servicemembers, 2006. 

[24] Case Management Society of America. Available at: http:www.cmsa.org.

 
 

29

Appendix to 

Subcommittee Report on Continuum of Care 

Interagency Recovery Coordinator 

Position Description & Qualifications 

JOB SUMMARY: 

The Interagency Recovery Coordinator (IRC) must be a member of the Commissioned 

Corps of the United States Public Health Service (USPHS) and will serve as the 

executive-level coordinator for the delivery of health care and benefits to severely 

injured, ill and wounded service members and their families. The IRC is responsible for 

the implementation and oversight of a full recovery plan, working with existing DoD and 

VA case managers to provide the optimal services that meet the individual needs of each 

severely injured, ill or wounded service member. The IRC must be cross trained by the 

DoD and VA in all existing programs, rules and regulations pertaining to their mission. 

MAJOR DUTIES: 

The IRC has overall responsibility for coordinating medical, administrative and 

supporting operations across the spectrum of patient care services and benefits between 

the DoD, VA and private sector. The individual, in collaboration with others, 

implements a three part recovery plan that consists of acute care, rehabilitative care, 

outpatient care, and benefits and services. This plan is designed to assist service 

members in achieving their maximum potential. 

The individual will exercise executive-level authority to coordinate the necessary services 

and programs in order to implement a patient’s full recovery plan. The individual must 

possess excellent communication skills in order to work with Federal, State, local, 

nonprofit and private sector organizations in implementing recovery plans. In addition, 

the individual must have excellent judgment, initiative, and drive. 

SUPERVISORY CONTROLS: 

The Coordinator reports directly to and is rated by the CEO of the supported DoD or VA 

facility; a senior member of the USPHS, as designated by the United States Surgeon 

General, will review and approve the performance appraisal in accordance with Health & 

Human Service Instruction 430-4. 

TECHNICAL QUALIFICATION: 

Knowledge of health care and benefits systems and the ability to manage and direct a 

health care recovery program for seriously wounded or injured patients are essential. 
 

30

Individuals with personal knowledge and experience in DoD or VA health care services 

or benefit programs are considered ideal candidates. 

QUALIFICATIONS REQUIRED: 

As a basic requirement for entry for this position, applicants must provide evidence of 

leadership experience indicative of senior level management capability, familiarity with 

clinical care, and skills and abilities related to the Technical Qualifications and Executive 

Core Qualifications listed below. Typically, experience of this nature will have been 

gained at or above the GS-13 or 0-5 grade level in the federal service or its equivalent in 

the private sector. 

EDUCATION REQUIREMENTS:

Master’s of Public Health or Master of Social Work or Master of Science in Nursing or

Social Science Ph.D. or Master’s of Health Care Administration 

Incumbent will have a minimum of 10 years’ documented experience in a health care 

and/or benefits environment. 

U.S. citizen 

Background Investigation: This position is a sensitive position and the tentative selectee 

must undergo and successfully complete a background investigation as a condition of 

placement/retention in the position. A Secret security clearance is required. 

HOW YOU WILL BE EVALUATED: 

Please provide a narrative, not to exceed three (3) pages for each Technical 

Qualification (TQ) below:

TQ-1: Expert knowledge of and ability to plan, coordinate and participate in developing 

and implementing policies and procedures for a variety of complex health care and/or 

benefits delivery systems. 

TQ-2: Specialized experience with highly sensitive and potentially controversial 

management and administrative matters that affect the planning, delivery, and evaluation 

of health care/benefits. 

You will also be evaluated on the following Executive Core Qualifications. Please 

provide a narrative not to exceed two pages per ECQ and not more than 10 pages in 

total: 

ECQ 1 - LEADING CHANGE . This core qualification involves the ability to bring 
 

31

about strategic change, both within and outside the organization, to meet patient life 

recovery goals. Inherent to this ECQ is the ability to establish a patient/family focused 

plan recovery plan and to implement it in a continuously changing environment. 

Leadership Competencies: 

1. Creativity and Innovation

Develops new insights into situations; questions conventional approaches; 

encourages new ideas and innovations. 

2. External Awareness

Understands and keeps up-to-date on local, national, and international policies 

and trends that affect the DoD and the VA and shape stakeholders' views; is 

aware of the organization's impact on the external environment. 

3. Flexibility

Is open to change and new information; rapidly adapts to new information, 

changing conditions, or unexpected obstacles. 

4. Resilience

Deals effectively with pressure; remains optimistic and persistent, even under 

adversity. Recovers quickly from setbacks. 

5. Strategic Thinking

Formulates objectives and priorities, and implements plans consistent with the 

long-term interests of the patient. Capitalizes on opportunities and manages risks.

6. Vision

Takes a long-term view and builds a shared vision with others; acts as a catalyst 

for organizational change. Influences others to translate vision into action. 

ECQ 2 - LEADING PEOPLE. This core qualification involves the ability to lead people 

toward meeting the goal of promoting a rapid recovery for the injured with a return to 

military or civilian life. Inherent to this ECQ is the ability to provide an inclusive 

workplace that fosters the development of others, facilitates cooperation and teamwork, 

and supports constructive resolution of conflicts. 

Leadership Competencies: 

1. Conflict Management - Encourages creative tension and differences of opinions. 

Anticipates and takes steps to prevent counter-productive confrontations. 

Manages and resolves conflicts and disagreements in a constructive manner. 

2. Leveraging Diversity - Fosters an inclusive workplace where diversity and 

individual differences are valued and leveraged to achieve the vision and mission 
 

32

of the organization. 

3. Developing Others - Develops the ability of others to perform and contribute to 

the organization by providing ongoing feedback and by providing opportunities to 

learn through formal and informal methods. 

4. Team Building -Inspires and fosters team commitment, spirit, pride, and trust. 

Facilitates cooperation and motivates team members to accomplish group goals. 

ECQ 3 - RESULTS DRIVEN. This core qualification involves the ability to meet 

recovery plan goals and objectives. Inherent to this ECQ is the ability to make decisions 

that produce high-quality results by applying technical knowledge, analyzing problems, 

and calculating risks. 

Leadership Competencies: 

1. Accountability – Primarily accountable to the patient, but takes into account the 

control systems and rules of the respective departments. Holds self and others 

accountable for measurable high-quality, timely, and cost-effective results. 

Determines objectives, sets priorities, and facilitates work. Accepts responsibility 

for mistakes. 

2. Customer Service - Anticipates and meets the needs of patients and families. 

Delivers timely and strategic counseling and support; is committed to continuous 

improvement. 

3. Decisiveness - Makes well-informed, effective, and timely decisions, even when 

data are limited or solutions produce unpleasant consequences; perceives the 

impact and implications of decisions. 

4. Entrepreneurship - Positions the patient for future success by identifying new 

opportunities; contributes to DoD and VA processes and policies by developing 

or improving products or services. 

5. Problem Solving - Identifies and analyzes problems; weighs relevance and 

accuracy of information; generates and evaluates alternative solutions; makes 

recommendations. 

6. Technical Credibility - Understands and appropriately applies principles, 

procedures, requirements, regulations, and policies related to specialized 

expertise. 

ECQ 4 - BUSINESS ACUMEN. This core qualification involves the ability to 

contribute to the management of human, financial, and information resources 

strategically. 
 

33

Leadership Competencies: 

1. Technology Management

Keeps up-to-date on technological developments. Makes effective use of 

technology to achieve results. Ensures access to and security of technology 

systems. 

ECQ 5 – SEAMLESS TRANSITIONS. This core qualification involves the ability to 

guide Service Members and Veterans within and across Departments and to bring 

together Federal agencies, State and local governments, nonprofit and private sector 

organizations, foreign governments, or international organizations to achieve recovery 

goals. 

Leadership Competencies: 

1. Partnering

Develops networks and builds alliances; collaborates across boundaries to build 

strategic relationships and achieve common goals. 

2. Political Savvy

Identifies the internal and external politics that impact the work of the 

Departments. Perceives organizational and political reality and acts accordingly. 

3. Influencing/Negotiating

Persuades others; builds consensus through give and take; gains cooperation from 

others to obtain information and accomplish goals. 

Fundamental Competencies These competencies are the foundation for success in each 

of the Executive Core Qualifications. 

Competencies: 

1. Interpersonal Skills

Treats others with courtesy, sensitivity, and respect. Considers and responds 

appropriately to the needs and feelings of different people in different situations. 

2. Oral Communication

Makes clear and convincing oral presentations. Listens effectively; clarifies 

information as needed. 

3. Integrity/Honesty

Behaves in an honest, fair, and ethical manner. Shows consistency in words and 

actions. Models high standards of ethics. 

4. Written Communication
 

34

Writes in a clear, concise, organized, and convincing manner for the intended 

audience. 

5. Continual Learning

Assesses and recognizes own strengths and weaknesses; pursues selfdevelopment. 

6. Public Service Motivation

Shows a commitment to serve the public. Ensures that actions meet public needs; 

aligns organizational objectives and practices with public interests. 
 

35

POST-TRAUMATIC STRESS DISORDER & TRAUMATIC BRAIN 

INJURY 

THE CHALLENGE 

 Post-traumatic stress disorder (PTSD) and traumatic brain injury (TBI) can be 

serious problems for service members returning from the conflicts in Iraq and 

Afghanistan. PTSD is an anxiety disorder that can develop after exposure to a terrifying 

event or ordeal in which grave physical harm occurred or was threatened. TBI can occur 

when a sudden trauma causes damage to the brain, such as when the head violently hits 

or is hit by an object, or when the head is exposed to significant external forces including 

those that may be generated from an explosive blast. PTSD and TBI are sometimes 

referred to as “invisible injuries” because outwardly the individual’s appearance is just as 

it was before the injury or onset of symptoms. Although they are distinct disorders, a 

number of service members have both PTSD and TBI. Diagnostic confusion between the 

two disorders can result because both can result from the same trauma and some 

symptoms of PTSD overlap those of TBI. Although service members with more severe 

PTSD or TBI are generally diagnosed and treated, many mild cases go unrecognized by 

the service member, commanding officers, family, friends, and health care providers, and 

so are left untreated. Even in cases with significant additional physical trauma, the 

presence of TBI and/or PTSD may be initially overlooked as the immediate focus is on 

the more readily identifiable, “visible” injuries. 

BACKGROUND 

Although PTSD and TBI are relatively common medical conditions of the Iraq 

and Afghanistan wars, both conditions have been recognized for decades, and much is 

known about their causes, diagnosis, and treatment. 

PTSD Overview 

Reactions to a traumatic event depend on, among other things, details of the 

situation and the specific individual's personality, level of resiliency, and past 

experiences. Many symptoms of anxiety are considered normal responses in the 

immediate aftermath of a traumatic event. Fortunately, for most individuals, emotional 

and behavioral reactions to a stressful event—stress responses—resolve over time.1

 

However, when symptoms like frequent flashbacks or nightmares, withdrawal, or 

 

1

 Although approximately 60% of men and 50% of women in the general population experience the type of 

traumatic event that may lead to PTSD, only about 8% of the men and 20 % of women develop PTSD. 

National Center for Post Traumatic Stress Disorder Fact Sheet “How Common is PTSD?” 

http://www.ncptsd.va.gov/ncmain/ncdocs/fact_shts/fs_how_common_is_ptsd.html 
 

36

difficulty controlling anger last longer than 30 days and impair the individual’s day-today functioning, the individual should be evaluated for PTSD. 

At present, there is no test that reliably shows whether a person does or does not 

have PTSD. Instead, the diagnosis is based mainly on a detailed clinical interview by a 

qualified mental health2 professional. Because symptoms can emerge or change long 

after the traumatic event, it can be useful to educate individuals exposed to trauma 

regarding what is considered a healthy versus unhealthy response, in addition to what 

resources are available should they require them in the future. 

 The course of PTSD is variable. The National Co-Morbidity Survey, a large 

nationally representative mental health survey, found that individuals who receive 

treatment for PTSD typically experience symptoms for about three years, whereas those 

who do not receive treatment experience symptoms for about 5 years.3

 However, for 

many individuals PTSD is a chronic condition characterized by periods of symptom 

improvement and worsening. Additionally, the initial onset of PTSD symptoms can occur 

days, weeks or even years after the traumatic event is experienced. The National CoMorbidity Survey also demonstrated that men who experience combat trauma are more 

likely to have chronic or delayed onset of PTSD symptoms.4 

The goal of treatment for PTSD is to reduce symptoms and return the affected 

individual to optimal functioning. The choice of treatment is based on many variables, 

including the patient’s other health problems, the home and social environment, 

therapists’ skills, and potential side effects. Four-fifths of people diagnosed with PTSD 

also have a major depressive disorder, or some other psychiatric condition, such as 

substance abuse.5 Treatment approaches for PTSD, therefore, must also include 

interventions for these other conditions. Evidence-based treatment for PTSD typically 

includes one or more of the following: 

• Cognitive behavioral therapies, 

• Exposure therapies, 

• Targeted anxiety therapies, 

• Drug therapy. 

 

2

 For ease, the term “mental health” is utilized in an all-inclusive manner in this report, at times referring to 

disorders or services that could alternatively be accurately described using the terms “behavioral health” or 

“psychological health.” 

3

 “Evidence Relevant to Compensation Awards for PTSD; A Report to the Institute of Medicine” 

Presentation by Matthew J. Friedman, MD, PhD, Executive Director of VA National Center for Post 

Traumatic Stress Disorder. Information from the National Co-Morbidity Survey, a large scale survey used 

to establish benchmarks for the prevalence of mental health disorders in the U.S. 4 Ibid. 5

 Institute of Medicine, PTSD Compensation and Military Service, May 2007. Committee on Veterans’ 

Compensation for Posttraumatic Stress Disorder. The National Academies Press, Washington, DC. 
 

37

PTSD and DoD/VA 

Exposure to traumatic events, such as terrorist attacks, natural disasters, motor 

vehicle accidents, and violent personal crimes including sexual assaults can lead to 

PTSD. For service members, the realities of war may result in combat stress reactions 

which, in turn, can develop into acute stress disorder and ultimately, PTSD: 

• The current conflicts involve intense urban fighting, often against civilian 

combatants, and many service members see or experience acts of terrorism.6

• A study of four Marine and Army infantry units found that nearly all unit 

members had been shot at or exposed to small arms fire. Eighty-five percent had 

known someone who was killed or seriously injured, and half had handled or 

uncovered human remains.7

• Five hundred thousand service members have been deployed multiple times. 

Service members who have been deployed multiple times or for longer periods 

are more likely to experience more symptoms of acute stress disorder.8

A 2006 study found that in the year following their deployment, 35 percent of 

Iraq veterans used mental health services.9 Best estimates are that PTSD occurs in 

approximately 6 to 11% of veterans serving in Operation Enduring Freedom and in 

approximately 12 to 20 % of Operation Iraqi Freedom veterans.10 These rates are lower 

than the rates for the Vietnam War, after which 30% of veterans experienced PTSD. The 

reason for the difference is not entirely clear. The lower OEF/OIF rate may reflect earlier 

identification and treatment of symptoms and preventative efforts before and during 

deployment. However, it is still early in the recovery process for veterans of this war, 

and those with delayed symptoms may not have sought care yet. Clearly though, not 

everyone experiencing a traumatic event develops symptoms of PTSD, and not everyone 

who is symptomatic develops PTSD. 

Recent DoD efforts to mitigate PTSD have centered on prevention and early 

intervention. Prevention efforts identify and enhance factors that help protect individuals 

from developing PTSD if they experience a traumatic event. According to former Army 

 

6

 Litz, BT. "The Mental Health Impact of the Wars in Afghanistan and Iraq: What Can We Expect?" 

(Information for Professionals), Department of Veterans Affairs, National Center for post-traumatic stress 

disorder, available at 

[http://www.ncptsd.va.gov/ncmain/ncdocs/fact_shts/fs_iraq_afghanistan_lay_audien.html?opm=1&rr=rr14

0&srt=d&echorr=true] 7

 Hoge, CW, Castro, CA, Messer, SC, et al. "Combat Duty in Iraq and Afghanistan, Mental Health 

Problems, and Barriers to Care." New England Journal of Medicine 351: 13-22, 2004. 8

 Mental Health Advisory Team IV Operation Iraqi Freedom 05-07 Final Report, November 2006. 

(www.armymedicine.army.mil) 9

 Hoge, CW, Auchterlonie, JL, and CS Milliken. "Mental Health Problems, Use of Mental Health Services, 

and Attrition From Military Service After Returning from Deployment to Iraq and Afghanistan." Journal 

of the American Medical Association 295: 1023-32, 2006. 10 National Center for PTSD Fact Sheet, “How common is PTSD?” 

(http://www.ncptsd.va.gov/ncmain/ncdocs/fact_shts/fs_how_common_is_ptsd.html) 
 

38

Surgeon General Kevin C. Kiley, "the Army has found that soldiers who undergo the 

most intense, realistic training before deploying to combat tend to experience the fewest 

associated mental health problems."11 By using live ammunition and having realistic, 

harsh, extended in-field exercises away from families, the Army prepares soldiers for the 

realities of battle. The Army also employs "battlemind training,"12 which trains leaders 

how to mitigate risk and build resilience in their soldiers, and trains deploying soldiers in 

potential emotional responses to combat. However, even with the best training and 

prevention methods, many service members with multiple or extremely stressful 

deployments to combat zones require additional assistance to prevent PTSD. 

The objective of early intervention techniques is to identify individuals at risk for 

developing PTSD and equip them with coping strategies to prevent the condition from 

occurring and to make any case that does emerge as manageable as possible. To this end, 

the Army deploys mental health teams along with operational units to bring early 

intervention techniques to the battlefield. Similarly, the Marine Corps’ Operational 

Stress Control and Readiness (OSCAR) program embeds mental health professionals in 

combat units to enhance access to mental health care and build resilience. Another 

objective of embedding these providers with operational units is to break down the 

stigma associated with mental health problems. 

Brief screening questions for PTSD and other mental health issues are included on 

the standard form for post-deployment health assessment, which is administered prior to 

the service member’s return from deployment, along with the post-deployment health 

reassessment, which takes place 3 to 6 months after return in order to detect delayed or 

previously unacknowledged symptoms. Upon departure from theater, many service 

members may choose not to report symptoms they assume will require further evaluation 

and delay their return to family or limit their military activities. To illustrate, in the postdeployment health assessment, only 5 percent of active-duty service members and 6 

percent of reservists report symptoms consistent with PTSD. But, in the reassessment, 

fully 27 percent of active-duty members and 42 percent of reservists note mental health 

concerns.13 The increased reporting of mental health concerns on the reassessment also 

may reflect adjustments inherent in homecoming. Administering the reassessment is 

difficult, though, due to repeat deployments and other factors. Although initially not 

consistently provided to Reservists, the post-deployment health reassessment is now 

offered, with VA assistance, to all active and reserve service members. 

Once identified through screening, self-referral, medical referral, or another way, 

individuals still on active duty can obtain mental health services in settings ranging from 

medical centers with research and training programs to small-scale community clinics to 

 

11Miles, D. Army "Providing 'Unprecedented' Mental-Health Support to Troops." American Forces Press 

Service, July 2006.

12 Battlemind website [www.battlemind.org]. 

13 Statement of Michael E. Kilpatrick, MD, Deputy Director, Force Health Protection and Readiness 

Programs, Department of Defense, to House Committee on Oversight on Government Reform Hearing on 

Mental Health Concerns of May 24, 2007. 
 

39

rugged deployed settings. DoD mental health professionals include uniformed and 

civilian psychologists, psychiatrists, social workers, psychiatric nurses, and mental health 

technicians. 

The difficulties with PTSD care in the military reflect larger problems that exist in 

military mental health care, as well as in the civilian mental health care community14. A 

widespread reluctance to disclose symptoms, due to the stigma of mental health 

problems, delays treatment and may lead to worse outcomes of care. Clinical approaches 

and structures vary across and even within the same organization, producing 

inconsistencies in care. Gaps in care occur and are in part due to significant personnel 

shortages. To improve services, some practitioners and organizations have developed 

innovative programs that could serve as models for broader use.15 Today, DoD resources 

include: 

• The Deployment Health Clinical Center that performs deployment-related 

health research, develops deployment-related health education and training 

programs for conditions including PTSD, and offers an intensive 3-week 

day treatment program for patients with PTSD at Walter Reed Army 

Medical Center 

• The Center for Deployment Psychology, which trains military and civilian 

providers treating mental health conditions of returning combat veterans 

• U.S. Army Center for Health Promotion and Preventative Medicine, which 

produces combat and operational stress research and education materials 

• Walter Reed Army Institute of Research, whose research has resulted in 

the implementation of military programs such as “Battlemind.” 

Recognizing the fragmentation and duplication of mental health efforts among 

different agencies, the Army established the Proponency Office for Behavioral Health in 

March 2007 to assist in coordinating and integrating efforts within their jurisdiction. 

VA is a recognized leader in the treatment of combat-related PTSD, with an 

extensive network of specialized inpatient, outpatient, day hospital, and residential 

treatment programs, some of which are directed at underserved populations, minorities, 

or women. VA excellence in PTSD clinical care and research was sparked by the 

National Vietnam Veterans Readjustment Study which examined the psychological 

effects of war on combatants, published in 1988.16 Today, VA resources include: 

 

14 “Each State faces individual legislative, financial, and social constraints and uses different opportunities 

in its efforts to transform the mental health delivery system. Yet, they all confront similar challenges: 

shrinking resources, increasing needs, and a desire to provide the most effective treatments and services.” 

U.S. Department of Health and Human Services “Trends in Mental Health System Transformation: 2005” 

page 3. www.samhsa.gov 15 For example, to assist in combating stigma and improving access to mental health care many individual 

military facilities have integrated qualified mental health providers into primary care settings, a strategy 

that many states have supported and the VA has recently implemented. Ibid reference 14 for state details. 16 Testimony of Terence M. Keane, PhD, Director, Behavioral Sciences Division, National Center for PostTraumatic Stress Disorder, VA Boston Healthcare System, to Presidential Commission on Care for 

America’s Returning Wounded Warriors on May 24, 2007. 
 

40

• The National Center for Posttraumatic Stress Disorder, consisting of seven VA 

academic centers of excellence located throughout the country 

• Ten Mental Illness Research, Education, and Clinical Centers, one of which 

specifically focuses on the post-deployment needs of Iraq and Afghanistan war 

veterans 

• 209 Vet Center clinics that provide community-based mental health services.17, 18

VA provides routine screening for PTSD, substance abuse, depression, and sexual 

trauma. Of the more than 225,000 Iraq and Afghanistan war veterans who sought care at 

a VA facility through December 2006, 17 percent reported concerns indicating possible 

PTSD.19 

TBI Overview 

A traumatic brain injury occurs when a blow or jolt to the head is significant 

enough to change the person’s normal level of neurological functioning, often producing 

an immediate change in consciousness, orientation, awareness, or recall of events 

surrounding the injury. The consequences of TBI can be temporary or permanent, and 

many factors combine to result in highly individualized injuries. An array of physical, 

cognitive, emotional, and behavioral problems may result from TBI, such as sleep 

disturbances, headaches, sensitivity to light and noise, decreased attention and poor 

frustration tolerance. 

When a traumatic injury to the head results in an object entering the brain, it is 

labeled a penetrating brain injury. In contrast, a closed head injury occurs with blunt 

force trauma. Closed brain injuries are typically classified as mild, moderate, or severe, 

depending on the length of time the individual lost consciousness and the level of posttraumatic amnesia. Penetrating head injuries are not further classified by level of 

severity. Most TBI cases are mild closed brain injuries, with good prospects for 

recovery.20 In one study, 89 percent of TBI patients injured in terrorist attacks in Israel 

returned to independent living.21 

Mild TBI can be difficult to identify. Some patients have other, more “visible” 

injuries; radiological brain scans often fail to identify a problem; and frequently the 

 

17 Department of Veteran’s Affairs Fact Sheet (2006). “Veterans with Post Traumatic Stress Disorder 

(PTSD)”, Washington D.C. 

18 Statement of Antoinette Zeiss, PhD, Deputy Chief Consultant, Office of Mental Health Services, 

Department of Veterans Affairs, for House Committee on Oversight and Government Reform on May 24, 

2007. 

19 Overall, 37 percent had possible mental health conditions. Other high frequency mental health diagnoses 

included non-dependent abuse of drugs (33,099) and depressive disorders (27,023). Ibid reference 18. 

20 Langlois, J., Rutland-Brown, W. and Thomas, K. “Traumatic Brain Injury in the United States: 

Emergency Visits, Hospitalizations, and Deaths.” Atlanta (GA): Centers for Disease Control and 

Prevention, National Center for Injury Prevention and Control; 2006. 

21 Schwartz, I, Tsenter, J, Schochina, M, et al. "Rehabilitation Outcomes of Terror Victims with Multiple 

Traumas." Archives of Physical Medicine and Rehabilitation 88: 440-448, 2007. 
 

41

patient attributes the subtle changes in thinking and feeling to something else. To aid in 

diagnosis and document recovery, neuropsychological tests are used with all severity of 

brain injuries in order to examine cognitive functioning, including attention, processing 

speed, memory, problem solving, language, visual perception, and testing effort. Tests 

are also given that evaluate emotional and behavioral symptoms, such as depression, 

anxiety, aggression, and motivation. 

 

TBI and DoD/VA 

The four most common causes of traumatic brain injury for service members in 

Iraq and Afghanistan are blast exposure, motor vehicle accident, falls, and gunshot 

wounds.22 Consistent with civilian population findings, the majority of these traumatic 

brain injuries are identified as mild, closed head injuries. However, it is important to note 

that a person who has previously experienced even a mild traumatic brain injury may be 

at risk for greater impairment from subsequent TBIs. 

It is not known how many service members have suffered a mild TBI that went 

undiagnosed. Recently, over 35,000 otherwise healthy service members returning from 

deployment were screened for TBI and approximately 10-20% screened positive for 

having experienced a mild TBI while deployed.23 The majority of this group was no 

longer symptomatic at the time of screening. 

Most individuals with mild TBI recover completely within a few months, 

although a minority may experience more persistent symptoms.24 A primary component 

of current evidence-based treatments for mild TBI is psycho-educational counseling for 

the patient and family members.25 Mild TBI cases are identified in theatre through the 

use of recently established clinical practice guidelines. These individuals are not typically 

evacuated out of the combat theatre; rather the Defense Veteran Brain Injury Center 

recommends that these individuals receive rest, education and symptomatic treatment of 

their complaints (for example, pain medicine for headaches) as close to their units as 

possible. Mild to moderate TBI cases identified after returning from deployment may be 

managed by local military, VA, TRICARE network providers, or some combination 

thereof depending on the geographic location and capabilities of their local military 

medical facility. 

In 2007, TBI screening questions were added to the post-deployment health 

assessment and reassessment questionnaires in order to identify individuals who may 

 

22 “Traumatic Brain Injury in Returning Warfighters,” Presentation by Dr. Louis French, Defense Veterans 

Brain Injury Center, to the President's Commission on America's Returning Wounded Warriors, May 4, 

2007. 

23 Zoroya, G. Army Times Lawmakers may halve brain injury funding August 21, 2006. 

24 Schatz, P. & Barth, J. “Assessment of Severity of TBI and Functional Outcome Measurement:” 

http://nanonline.org/nandistance/mtbi/modules/outcome/outcome.html. 25 Ponsford, J, Willmott, C, Rothwell, A, et al. "Impact of early intervention on outcome following mild 

head injury in adults." J Neurol Neurosurg Psychiatry 73: 330-332, 2002. 
 

42

have experienced a mild TBI in theatre, but never sought or received care.26 In addition, 

the VA has designed an electronic prompt to remind health professionals to screen Iraq 

and Afghanistan veterans for TBI on their first VA health care visit. 

Compared to previous wars, the proportion of injured service members surviving 

serious brain injury has increased greatly due to state-of-the-art care. Penetrating 

traumatic brain injuries in OIF/OEF are treated early using American Association of 

Neurological Surgeons guidelines for severe and penetrating TBI. Moderate to severe 

closed traumatic brain injuries are also typically identified early and evacuated for care. 

The multi-site Defense and Veterans Brain Injury Center also plays a major role 

in identifying and evaluating moderate to severe TBI patients at selected DoD hospitals. 

Many of the moderate to severe TBI patients are then referred to VA Polytrauma 

Rehabilitation Centers for neurobehavioral rehabilitation. 

The goal of TBI treatment is to maximize functioning and provide techniques for 

managing any remaining cognitive deficits. Prompt identification and treatment enhance 

the chances of recovery. In relatively serious cases, treatment usually includes medical 

stabilization in the acute-care hospital, followed by rehabilitative care by a multidisciplinary team of providers in diverse settings: 

• Acute-care hospitals 

• Post-acute care units 

• Rehabilitation hospitals 

• Outpatient rehabilitation departments 

• Day treatment centers 

• Transitional treatment facilities 

• Home. 

The scope, duration, and intensity of rehabilitation vary markedly, depending on 

individual patient needs. Certain permanently disabled patients may require significant 

supervision and care, in nursing or assisted care facilities or at home with family 

caregivers or hired attendants. 

PREVIOUS RECOMMENDATIONS AND FINDINGS 

 

Over the past few years many task forces have focused on PTSD, and TBI is 

beginning to receive the same level of attention. Summarized findings from several of 

the most recent of these studies are presented here. 

 

 Although the VA formally disagreed with the findings, the Government 

Accountability Office (GAO) asserted27 in 2005 that the VA had failed to implement 

 

26 Winkenwerder, W. Traumatic Brain Injury: Questions for the Post-Deployment Health Assessment 

Memorandum of March 8, 2007. 
 

43

many 2004 recommendations of VA’s own congressionally mandated Special Committee 

on PTSD, including the following: 

• Provide increased access to PTSD services through VA community-based clinics 

and Vet Centers 

• Develop effective dual treatment for veterans with both PTSD and substance 

abuse problems, and a dual rehabilitation approach to PTSD and coexisting 

conditions 

• Improve the continuum of care, supported by electronic health records that follow 

veterans across VA's system of care 

• Expand treatment to include family assessment and treatment services. 

Additionally, in 2006, the GAO called on DoD to investigate differences across 

the Services in referral rates for PTSD treatment following positive screening on post 

deployment health assessment evaluations.28

 In April 2007, the Presidential Task Force on Returning Global War on Terror 

Heroes made two recommendations on PTSD and TBI: 

• DoD and VA should train clinicians in PTSD and TBI, and ensure that patients 

are referred to facilities with appropriate multi-disciplinary teams 

• VA staff should attend PDHA events to provide information about VA health care 

and benefits, enroll eligible veterans, and schedule outpatient appointments. 

After noting inconsistencies in early TBI diagnosis and treatment in DoD in April 

2007, the Independent Review Group recommended a more structured approach, 

including: 

• Development of functional and cognitive measures for all new service members, 

as a baseline for evaluating any future changes in the member’s condition 

• Inclusion of functional and cognitive screening in the post-deployment health 

assessment and post-deployment health reassessment 

• Documentation of all exposures to blast in service members’ health records 

• Development of a clinical practice guideline for TBI 

• Coding guidelines for TBI to facilitate standard documentation in medical 

records, research, and education 

• Cognitive remediation for service members who experience a decrease in 

cognitive ability at any point during their service 

• Establishment of a DoD/VA center of excellence in PTSD and TBI for research, 

training, and patient care 

• Improvement in mental health staffing through changes in compensation and 

recruiting. 

 27 U.S., Government Accountability Office, GAO-05-287, VA Health Care: VA Should Expedite the 

Implementation of Recommendations Needed to Improve Post-Traumatic Stress Disorder Services, 

February 2005. 

28 U.S., Government Accountability Office, GAO-06-397, DoD Needs to Identify the Factors Its Providers 

Use to Make Mental Health Evaluation Referrals for Servicemembers. 
 

44

In May 2007, the Institute of Medicine (IOM) issued a report, for the Veterans 

Disability Benefits Commission, on VA’s practices in evaluating and compensating 

veterans for PTSD.29 The IOM panel recommended that VA should: 

• Develop a new method for evaluating how well PTSD patients are functioning, 

and, while the form is being developed, use the PTSD rating criteria of the 

Diagnostic and Statistical Manual of Mental Disorders 

• Develop training programs for clinicians who evaluate patients for PTSD and for 

personnel who administer PTSD claims 

• In light of the recurring and relapsing nature of the condition, consider a 

minimum level of benefits for all veterans with service-connected PTSD, 

regardless of their initial health status 

• Use experienced mental health professionals to evaluate all new applicants for 

VA benefits for PTSD 

• Establish a database and research program to improve evaluation in the future, 

paying special attention to female and minority veterans 

• Adopt an integrated benefits approach for achieving maximum mental 

functioning, using case managers. 

The congressionally mandated DoD Mental Health Task Force released an 

extensive report in June 200730. The Task Force found that the stigma about mental 

health problems remains pervasive in the military and often prevents service members 

from seeking needed care. It further found significant gaps in the continuum of care, due 

mostly to shortages of mental health professionals, as well as quality-of-care deficits 

involving inadequate monitoring and insufficient use of evidence-based treatment. In 

addition, it found that TRICARE mental health benefits are hindered by fragmented rules 

and policies, inadequate oversight, and insufficient reimbursement. The Task Force 

recommended that DoD: 

• Build a culture of support for psychological health and dispel stigma 

o Establish visible leadership and advocacy for psychological health 

o Embed training about psychological health throughout military life 

o Revise military policies to reflect up-to-date knowledge about mental 

health 

o Make professional mental health services easily accessible 

o Make psychological assessments an effective, efficient, and normal part of 

military life. 

• Ensure that service members and their families receive a full continuum of 

excellent care 

o Make prevention, early intervention, and treatment universally available to 

service members and their families 

 

29 Institute of Medicine, PTSD Compensation and Military Service, May 2007. Committee on Veterans’ 

Compensation for Posttraumatic Stress Disorder. The National Academies Press, Washington, DC.

30 An Achievable Vision: Report of the Department of Defense Task Force on Mental Health, June 2007. 
 

45

o Ensure an adequate number of uniformed providers and other staff in 

military treatment facilities and a robust network of TRICARE providers 

o Maintain continuity of care across transitions to new assignments and out 

of service 

o Use evidence-based treatments. 

WHAT THE COMMISSION LEARNED 

The Commission’s survey of injured service members sought to determine 

whether medical providers were screening for traumatic brain injury and deploymentrelated mental health conditions in injured, medically evacuated patients (Figure 1). 

Nearly 70 percent of those surveyed reported having been asked if they experienced a 

blast or event causing blow or jolt to the head and almost 60 percent said that they 

reported such an event to a medical provider. Recognizing that not all individuals were 

appropriately screened for TBI risk factors, the DoD has added screening questions to the 

post deployment health assessment forms, and the major military hospitals have 

implemented universal screening of all injured, medically evacuated patients. 

In assessing the screening of mental health issues, the survey results indicate that 

close to 80 percent of respondents reported having been asked about mood changes, 

nervousness or hopelessness; about 20 percent of these individuals said that they were 

asked about these symptoms at every clinic visit. A majority of respondents said that 

they reported these symptoms to a medical provider. 

Figure 1Percent of Injured Service Members Reporting Screening for and 

Symptoms of PTSD and TBI, PCCWW Survey 

69%

58%

77%

62%

0%

20%

40%

60%

80%

Asked about blast or

other event

Reported blast or

other event

Asked about mental

health symptoms

Reported mental

health symptoms

Through site visits, meetings and reviews of programs, studies, and earlier 

reports, the Commission has identified key issues in PTSD and TBI workforce 

requirements, quality of care, disability evaluation, family support, and research. 
 

46

Workforce Requirements 

Evidence consistently supports the DoD Mental Health Task Force’s conclusion 

that “the Military Health System lacks the fiscal resources and fully-trained personnel to 

fulfill its mission to support psychological health in peacetime or fulfill the enhanced 

requirements imposed during times of conflict.”31 DoD methods for determining the 

number of providers required do not allow for the large prevention and education mission 

needed in military mental health. Recently, even when positions are authorized, filling 

them with qualified professionals has been difficult: 

• The number of uniformed mental health professionals has significantly decreased, 

and those remaining on active duty are frequently deployed to theatre. For 

example, attrition of Army psychologists increased 55 percent between 2004 and 

2006, whereas the authorizations for psychologists increased 11 percent between 

2005 and 2007.32

• The current strategy of using temporary contract positions to replace deployed 

mental health professionals is problematic in part because it is difficult to attract 

experienced professionals to positions that are only 12 months in length. 

• Government Service (GS) civilian positions are filled through cumbersome hiring 

practices33 and provide inadequate salaries, especially in rural locations and for 

subspecialists.34 

VA also faces challenges in filling mental health positions, especially in rural 

communities where some community-based outpatient clinics have no mental health 

professionals at all. The mental health component of VA’s new Quality Enhancement 

Research Initiative, along with the expansion of telehealth services that link community 

facilities to experts in distant locations, may alleviate some of these needs. 

Quality of Care 

Treatment approaches for PTSD and TBI continue to evolve, but knowledge 

generated through research and clinical experience is not systematically disseminated to 

all DoD and VA providers of care. One survey conducted found that 90 percent of DoD 

providers had received no training on, or even were unaware of, a joint DoD/VA clinical 

 

31Ibid. 32 Statement of Bruce Crow, Army Psychology Consultant to the Surgeon General, to the President's 

Commission on America's Returning Wounded Warriors, May 3, 2007. 

33 Among other things, those hiring permanent GS non-physician mental health specialists do not have 

direct hire authority, resulting in extended delays in hiring - on average 83 days for social workers and 87 

days for psychologists. Ibid. 34 For example, a 2005 Salary Survey of Neuropsychologists (The TCN/AACN 2005 Salary Survey, 

Professional Practices, Beliefs, and Incomes of U.S. Neuropsychologists, The Clinical Neuropsychologist, 

20: 325–364, 2006) identifies the median salary of a Neuropsychologist practicing in Maryland as 

$102,000. At that same time, the GS Locality Pay table for Maryland identified the salary range of a GS-13 

employee (the advertised level for a GS Neuropsychologist) at $74,782 to $97,213. 
 

47

practice guideline for PTSD.35 DoD mental health providers tend not to be fully 

informed about what services are available through VA, and vice-versa. 

Joint DoD/VA clinical practice guidelines exist for the diagnosis and treatment of 

PTSD, although as just mentioned, awareness and use of these guidelines may be limited. 

Clinical practice guidelines were also identified for the in-theatre care of TBI;36 however 

there is some question about the consistency with which these are utilized. American 

Association of Neurological Surgeons’ guidelines on the acute management of severe and 

penetrating TBI are utilized in theatre. The Commission found no universal or joint 

clinical practice guidelines in use for the management of mild or moderate TBI patients 

following return from deployment. DoD facilities that were visited frequently had 

individual practices and policies regarding the identification, treatment and management 

of TBI patients, however these varied from site to site. At the time of this report, joint 

clinical management guidelines for symptomatic mild TBI were being developed and the 

DoD and VA planning group described below was meeting to develop clinical practice 

guidelines for the primary care management of TBI. 

On the TBI front specifically, the Armed Forces Epidemiological Board 

concluded that DoD “lacks a system-wide approach for proper identification, 

management, and surveillance” of TBI patients.37 Providers and case managers have 

varying levels of training and incomplete knowledge in the recognition and management 

of TBI. Confronting the same problem in recent years, the VA developed a web based 

independent study course in TBI symptom identification, evaluation and treatment. VA 

providers in primary care, mental health, spinal cord injury, and rehabilitation care are 

required to participate in this training. 

Commission members observed during site visits that appropriate educational 

counseling is not consistently provided to patients with mild TBI. Some symptomatic 

TBI patients may go without formally coordinated care and referral. 

DoD and VA recently have developed initiatives to remedy poor information 

dissemination and training regarding PTSD and TBI, including: 

• A requirement that all Army social workers attend combat and operational 

stress training classes38 

 

35 "The Future of Mental Health Care in DoD: Carpe Diem." Presentation by CDR Mark Russell to DoD 

Mental Health Task Force in San Diego, Calif., 19 Oct 06. 36 Defense and Veterans Brain Injury Center (DVBIC) Working Group on the Acute Management of Mild 

Traumatic Brain Injury in Military Operational Settings Clinical Practice Guideline and Recommendations; 

Joint Theater Trauma System (JTTS) Clinical Practice Guidelines for In-Theatre Management of Mild 

Traumatic Brain Injury (Concussion), Updated Aug 06; Guidelines for Field Management of CombatRelated Head Trauma, 2005.

37 Armed Forces Epidemiological Board. Memorandum dated August 11, 2006, on Traumatic Brain Injury 

in Military Service Members 2006-02 to The Honorable William Winkenwerder, Jr., MD. 38 Department of the Army Executive Order 118-07, “Healing Warriors.” 
 

48

• Collaborative efforts allowing DoD mental health providers to attend VA 

training sessions in PTSD and to take the VA’s independent study course in 

TBI 

• A DoD/VA consolidation initiative on TBI, in which a multidisciplinary 

group of DoD, VA, and Defense and Veterans Brain Injury Center experts 

are developing a common definition of TBI, a standard curriculum for 

provider and patient/family training, and model programs for long-term care, 

disability assessment, research, testing, and treatment. 

Disability Evaluation 

The IOM panel has convincingly argued that VA’s system of evaluating and 

rating individual veterans’ PTSD status is seriously inadequate. Similar shortcomings 

may be present in the DoD disability system. Not only might current evaluations miss 

true cases, but also some healthy service members may be able to intentionally report 

non-existent symptoms in order to receive compensation. 

Recently, a concern was raised that DoD, and the Army specifically, may be 

discharging large numbers OIF/OEF veterans with PTSD under a personality disorder 

diagnosis in order to save money.39 A discharge for a personality disorder is an 

administrative action that is different from a medical discharge. In investigating this 

allegation the Commission found that 

• As Figure 2 demonstrates, the annual number of personality disorder 

discharges in the DoD has dropped since the late 1990’s and has remained 

relatively stable since the beginning of the Global War on Terrorism.40 

• While the raw number of Army personality disorder discharges has 

increased, the Army’s total number of discharges is quite comparable to 

the other Services despite having a far larger troop contingency. 

• The number of Army personality discharges over the past 10 years 

represents only between approximately 1 to 1.5 percent of total Army 

discharges per year. 

• 88 percent of the total DoD personality disorder discharges from 2001-

2006 and 78 percent of total Army personality disorder discharges from 

that same time frame had never been deployed in Operations Iraqi or 

Enduring Freedom.41

These facts do not support the assertion that the Army or DoD is supporting a 

large scale effort to use the administrative personality disorder discharge for OIF/OEF 

veterans suffering from PTSD in order to save money. Further, Army policy requires that 

 

39 Kors, Joshua. “How Specialist Town Lost His Benefits.” The Nation, April 9, 2007. Available at 

http://www.thenation.com/doc/20070409/kors. 40 Defense Manpower Data Center (DMDC). Personality Disorder Separations by Service and Component 

by Fiscal Year, FY 97-07, prepared July 16, 2007 Active component data used. 

41 Op. cit., reference 39. 
 

49

a psychiatrist or doctoral-level clinical psychologist establish the diagnosis of a 

personality disorder prior to administrative discharge. Any large scale effort to save 

money using the personality disorder discharge instead of a medical discharge for PTSD 

would require large numbers of these licensed professionals to act unethically, something 

we found no evidence to support.42 

Figure 2–Number of Service Members Discharged with a Diagnosis of Personality 

Disorder, Total and by Service, 1997-2006 

Personality Disorder Separations

0

1,000

2,000

3,000

4,000

5,000

6,000

Fiscal Year 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 Number of Separations

Total Army Navy Air Force Marine Corps

% of Total 

Separations 2.4 2.3 2.1 2.3 2.1 2.4 2.3 1.7 2.0 2.2

Within the DoD and VA, TBI disability evaluation and rating similarly is 

inconsistent, due to the absence of clear criteria and standardized training for raters. 

Unlike PTSD, TBI involves well-validated neuropsychological assessment methods to 

confirm symptoms, aid in diagnosis, and quantify cognitive impairments. The use of 

recent neuropsychological assessment by qualified professionals and well-trained raters 

may improve disability determinations, particularly in cases where a decline in 

functioning is subtle or brain abnormality is not readily observable; however the use of 

neuropsychological testing is frequently non-specific and non-prescriptive. 

Family Support 

The Commission has repeatedly heard about dedicated family members whose 

financial, family, and professional sacrifices allowed them to participate in their loved 

one's TBI care. Some patients with severe TBI may need family members or others to 

 

42 Individual instances of service members feeling pressured by commanders, practitioners or peers to 

accept administrative discharges were beyond the purview of this Commission, however, the Government 

Accountability Office has been commissioned to investigate this matter further. 
 

50

provide care for an extended period. Families are often thrust into an intensive long-term 

caregiving role for which they are ill-prepared and are offered limited respite care options 

for occasional relief. Although caregiver education is crucial, the Commission found 

only very limited caregiver educational training opportunities. 

For PTSD, family members need to be educated about symptom identification and 

management in order to provide support and better understand their service member’s 

symptoms. This education may help keep the family intact and provide a supportive 

environment for recovery. Currently DoD and VA provide limited mental health services 

for family members in their own facilities. Family members of active-duty personnel 

typically use TRICARE network providers, while almost all family members of veterans 

must use other third-party insurers to receive community-based care. The limitations of 

TRICARE mental health care benefits described in the DoD Mental Health Task Force 

report were voiced repeatedly to this Commission. 

Recent Research on PTSD 

Over the past ten years, research into the mental and biological foundations of 

PTSD has rapidly progressed and scientists and practitioners now frequently focus their 

efforts on prevention in addition to treatment efficacy. Examples of prevention include 

everything from identifying and enhancing cognitive, emotional and social protective 

factors, to a current NIMH study exploring medications believed to target underlying 

causes of PTSD in order to prevent the development of the disorder. Within DoD there 

has been interest in large scale testing of all service members’ “hardiness” or “resiliency” 

in order to predict vulnerability to PTSD. However research has not been completed to 

establish the predictive validity of any specific testing instrument for this purpose; 

policies have not been developed to determine what decisions will be based on the 

findings; and the potential ethical misuse of such findings has not been adequately 

addressed. Notably, previous attempts to use personality variables to screen out 

individuals presumed at risk for becoming psychiatric casualties resulted in “the 

elimination of nine out of ten who would have succeeded in order to eliminate the one out 

of ten who would not succeed in the military.”43

Research into primary prevention and early intervention in TBI is also ongoing in 

the military and includes among other things, the use of personnel sensors to monitor 

blast exposure. There are also interesting developments in evaluating cognition in 

deploying troops. Mandatory and universal pre-deployment cognitive testing for use as a 

baseline comparison post deployment is a very popular recommendation at the time of 

report. The use of pre-injury cognitive baselines is typically quite beneficial in 

determining declines in cognitive functioning following an identified brain injury. 

However, ongoing research demonstrates that the impact of war-zone deployment on 

cognitive performance needs to be further examined before testing results are 

 

43 Glass, A. & Jones, F. “Psychiatry in the U.S. Army: Lessons for Community Psychiatry” Monograph, 

Uniformed Services University of the Health Sciences, (2005). 
 

51

implemented for purposes that may include the identification of mild TBI post 

deployment. For example, a major study that conducted cognitive testing both before and 

after deployment found that deployment alone (independent of head injury, depressive 

symptoms, or stress) was associated with changes in some measures of attention, learning 

and memory in the post-deployment evaluation.44 The Defense Veteran’s Brain Injury 

Center currently has targeted pilot studies further examining the utility of pre-deployment 

baseline testing, including the effectiveness of neurocognitive instruments that may be 

used for such. 

 

It was clear to the Commission that DoD needed to direct research and policy 

development efforts toward identifying the utility of mandatory, large scale service entry 

or pre-deployment cognitive and/or personality testing for the purposes described above. 

While universal testing to predict risk for PTSD or establish a cognitive baseline appears 

meritorious in concept, science and military policy development at this time do not 

support large scale implementation of such. 

Difficulties in preventing TBI and PTSD, and in determining the utility of 

interventions directed at both are not unique to the DoD and VA, but the two departments 

are in a unique position to address these issues through research. 

ACTION STEPS 

 

DoD and VA should make a maximum effort, visibly backed by leadership, to 

improve the diagnosis and care for these significant combat injuries, while fostering a 

culture that promotes mental health care. 

Action Step: DoD should establish a TBI “network of excellence” utilizing and 

expanding upon existing DoD, VA, and private sector resources. A lead office should 

coordinate policy, research, education, clinical guidelines, and foster intercommunication 

among the network of clinical programs. Clinical coordination should promote seamless 

transitions as patients move from one setting to another. Areas of immediate focus for 

the lead office should include: 

• Comprehensive training programs in TBI designed to educate military leaders, 

VA and DoD medical personnel, family members, and caregivers 

• The distribution of existing TBI clinical practice guidelines to all involved 

providers; where no guidelines exist in the continuum of care for TBI, DoD and 

VA should work together with other national experts to develop them 

• Development of a state-of-the-art quality improvement program to assure services 

consistently meet the highest standards. 

 

44 Vasterling, J, Proctor, S., Amoroso, P., et al. Neuropsychological outcomes of army personnel following 

deployment to the Iraq war. JAMA, 2006: 296(6):519-29. 
 

52

Action Step: DoD and VA must move rapidly to resolve shortages in the mental health 

workforce that serves injured service members and veterans. DoD personnel 

requirements must allow for the practitioners needed for prevention and education 

missions, in addition to the expected long term demand that may arise from chronic or 

delayed onset symptoms of PTSD. 

Action Step: Any service member or veteran who has deployed to Afghanistan, Iraq, 

and other theaters in the current war and presents with PTSD symptoms should be 

eligible at anytime, without restriction within the VA to receive an expedited initial 

evaluation by a qualified VA mental health provider. If determined to have combat 

related PTSD symptoms, the veteran should have access to VA PTSD care regardless of 

eligibility category. 
 

53

REHABILITATION 

PROBLEM STATEMENT 

The rehabilitation needs of injured service members are currently met through an 

array of military, Department of Veterans Affairs (VA), and private-sector health 

facilities. Many of these facilities are state-of-the-art centers of excellence. Some 

facilities specialize in a particular injury, whereas others have the capability to care for a 

full spectrum of injuries. 

The process of rehabilitation requires time, a complex array of services, and 

multiple levels of care, depending on the patient’s needs and abilities. By marshaling the 

expertise in the nation’s best rehabilitation facilities, injured service members can be 

restored to the highest possible level of functioning and independence. 

Within the Department of Defense (DoD) and VA, the resources required to 

develop specialized centers limit their number, so that severely injured service members 

and veterans often are treated far from home. To expand geographic access and assure 

excellence, a comprehensive system of rehabilitation for our injured service members is 

needed that taps into the private sector as well as the public sector. 

BACKGROUND 

The Role of Rehabilitation 

 

Through a series of individually designed interventions, rehabilitation restores the 

skills—lost through illness or injury—which an individual needs in order to function at 

the highest possible level. Rehabilitation programs and services improve the patient’s 

functional recovery, health care outcome, and quality of life, and include the family in 

the scope of support. 

Components of rehabilitation include: 

 Preventing additional impairments or disabilities 

 Protecting uninjured or uninvolved body systems 

 Improving functional capacity lost from injury 

 Promoting use of adaptive equipment and technology 

 Enhancing patient and family adjustment through education, and 

 Removing barriers from the patient’s environment. 

Rehabilitation programs are intensive, individualized, and coordinated programs 

designed to achieve total optimal functioning after a major event, such as severe 

traumatic brain injury or amputation. (This report focuses on rehabilitation programs 

related to injury recovery, although civilian and military rehabilitation facilities also treat 
 

54

other conditions, such as stroke and joint replacement.) Rehabilitation services involve 

physical therapy or occupational therapy after relatively minor injuries and include, for 

example, an exercise protocol following a sprains and strength training after a fracture 

has healed. 

For most injured patients, rehabilitation should begin as early as the patient’s 

medical condition allows and progresses through a carefully orchestrated sequence of 

inpatient and outpatient services provided by a team of rehabilitation specialists. For our 

injured service members, rehabilitation services are available from military, the VA, and 

private sector sources. The goal is to achieve optimal physical, psychological, social, and 

vocational functioning. 

Rehabilitation in the Military 

 Even preparing for war and maintaining the peace is a hazardous occupation. In 

the peacetime year of 1994, for example, 4,500 soldiers were disabled, 20,000 were 

hospitalized, and 400,000 took sick call because of injuries.45 In peacetime, injuries 

sustained by service members range from minor (such as the result of a fall during a 

training fitness run) to severe (such as the result of a helicopter crash). Most of the time, 

particularly for those serving in the Army, hospitalizations are for musculoskeletal 

problems related to training and athletic activities.46 

These peacetime needs establish the ongoing baseline requirements for 

rehabilitation in the military. To meet baseline needs, most military treatment facilities 

provide a consistent level of rehabilitation services, either in the facility itself or through 

referral to other military treatment facilities, the VA, or the private sector. 

In wartime, both the number of injured service members and the complexity of their 

injuries increase, creating occasional peak needs for rehabilitation. 

The military’s major rehabilitation programs were developed around specific, 

high-incidence injuries and are scattered across the country (Figures 1 and 2). 

Burns 

The vast majority of service members with major burns are transported to the 

burn unit at Brooke Army Medical Center in San Antonio, Texas, for acute care. The 

unit contains 16 intensive care unit beds, 24 step-down beds, and an outpatient clinic, and 

is accredited by the American Burn Association. Burn rehabilitation begins during the 

acute care phase and continues after the patient is discharged to a rehabilitation facility, 

usually Brooke’s burn rehabilitation center. Complete burn rehabilitation can take from 

two to four years. 

 

45 Amoroso PJ, NS Bell, SP Baker, & L. Senier. “Understanding injuries in the military environment.” In 

Injury Control Part I. U.S. Army Research Institute of Environmental Medicine, 1999. 

46 Smith GS, AL Dannenberg, & PJ Amoroso. “Hospitalization due to injuries in the military: evaluation of 

current data and recommendations on their use for injury prevention,” Am J Prev Med 18: 41-53, 2000. 
 

55

Brooke Army Medical Center’s burn unit reports receiving 598 service members 

evacuated from Iraq and Afghanistan with burns as of June 30, 2007. 

Amputation 

Service members with traumatic amputations are generally taken to Walter Reed 

Army Medical Center, in Washington, DC, for both acute care and rehabilitation. With 

the opening of the Center for the Intrepid at Brooke Army Medical Center and a new 

amputee rehabilitation center at Naval Medical Center San Diego, in California, capacity 

and capability to care for service members with amputations have been greatly expanded. 

As of 7/23/2007, 911 service members had an amputation from injuries sustained 

in Iraq or Afghanistan. Of these, 644 have been for the loss of an arm, leg, had, or foot, 

including those individuals with multiple amputations. Approximately 76% of these have 

been cared for at Walter Reed Army Medical Center; the rest were cared for at Brooke 

Army Medical Center. 

Traumatic Brain Injury 

Most traumatic brain injuries (TBI) are mild and improve with time (see the 

Subcommittee Report on Post-Traumatic Stress Disorder and Traumatic Brain Injury). 

Most patients only need education about their injury, which can be furnished in a military 

outpatient clinic or by TRICARE47 network providers. Other patients, with moderate to 

severe TBI, receive some inpatient rehabilitation services during their acute medical 

stabilization in military treatment facilities. After stabilization, most of these patients are 

transferred to VA Polytrauma Rehabilitation Centers or to specialty private-sector 

facilities for inpatient or outpatient rehabilitation programs. 

Accounting for all patients with traumatic brain injury is more difficult (see 

subcommittee report on Post Traumatic Stress Disorder and Traumatic Brain Injury). As 

of March 2007, 2,726 service members had been reported to the Defense Veterans Brain 

Injury Center with the diagnosis of traumatic brain injury. Of these, 2,094 were 

classified as mild and 255 as moderate. Another 192 had severe traumatic brain injuries 

and 171 had penetrating brain injuries. 

Spinal Cord Injury and Blindness 

Acute hospital care for spinal cord injuries is generally provided at Walter Reed. 

After stabilization, these patients are transferred to specialized VA spinal cord 

rehabilitation facilities. The military does not provide specialized vision rehabilitation 

care. 

Ninety one service members had been treated for spinal cord injuries as of June 8, 

2007, in the VA. Fifty-three service members have received blind rehabilitation services 

from the VA as of April 3, 2007. 

 

47 TRICARE is DoD’s health care program for members of the uniformed services, their families, and 

survivors, as well as some retired military personnel. 
 

56

Community Based Care 

 In 2004, the Army created eight Community Based Health Care Organizations to 

provide case management—coordinating rehabilitation and other health care needs—for 

injured National Guard and Reserve members who return home. Care is arranged with 

military, VA, and (through TRICARE) private-sector facilities throughout the United 

States. The Army plans to expand Community Based Health Care Organizations to cover 

members on active duty. 

Rehabilitation at VA 

The VA has developed rehabilitation capability and capacity with a specific focus 

on certain types of injuries and on the needs of veterans. VA rehabilitation programs and 

services—on which the military also relies—are typically organized in “hub-and-spoke” 

systems with a few highly specialized research, treatment, and training centers linked to a 

larger number of less specialized treatment facilities throughout the country (Figures 1 

and 2). This arrangement maximizes efficiency and helps the patient gradually achieve 

reintegration into the community. 

All VA rehabilitation facilities are accredited by the Commission on 

Accreditation of Rehabilitation Facilities (CARF). Accreditation means that these 

facilities meet national standards of care and that the quality and effectiveness of 

programs and services are monitored by an independent entity. 

Polytrauma Rehabilitation Network 

In 1991, the VA, with funding support from DoD, designated three VA facilities 

as TBI centers for active-duty service members, with a fourth center added in 1993. 

Under 2004 legislation requiring the VA to expand the centers so they could treat multiinjured service members,48 the centers were renamed “Polytrauma Rehabilitation 

Centers.” 

The Polytrauma Rehabilitation Centers are located in Palo Alto, California, 

Richmond, Virginia, Tampa, Florida, and Minneapolis, Minnesota. Admission criteria 

are: 

 Must be active duty or a veteran discharged from military service under other 

than dishonorable circumstances 

 Medically stable 

 Have sustained multiple physical, cognitive, and/or emotional injuries 

secondary to trauma 

 Not require one-to-one staffing for medical or behavioral reasons 

 Not require a ventilator to breathe 

 Have the potential to benefit from rehabilitation OR need an initial, 

comprehensive rehabilitation evaluation and care plan. 

 

48 Veterans Health Programs Improvement Act of 2004, P.L. 108-422; Consolidated Appropriations Act 

for 2005, P.L. 108-447. 
 

57

In addition to the four inpatient Polytrauma Rehabilitation Centers, with a total 

bed capacity of 48, the VA developed a rehabilitation network to address the ongoing 

needs of multi-injured service members and veterans: 

 23 Polytrauma Network sites provide both inpatient and outpatient 

rehabilitation care 

 72 Polytrauma Support Clinic Teams are distributed in VA facilities across the 

country to assist veterans and service members with rehabilitation needs close 

to their home communities 

 A Polytrauma Telehealth Network provides additional support for patients 

throughout the system, by using communications technologies to involve 

experts from distant locations in the patient’s care. 

Amputations 

Once separated from active duty, amputee patients can receive care at one of 76 

VA facilities with amputation outpatient rehabilitation clinics. The VA also has 58 VA 

prosthetic labs and contracts with local prosthetists for ongoing care close to veterans’ 

homes. 

Spinal Cord Injury 

The VA supports 23 regional Spinal Cord Injury Centers, with 150 acute 

rehabilitation beds, dedicated to the acute care and rehabilitation needs of spinal cord 

injury patients. These centers provide a multi-disciplinary team approach to the care of 

approximately 400 spinal cord injured veterans and active-duty service members each 

year. After patients leave these centers, their medical needs are cared for by specifically 

trained primary care physicians at 135 VA medical centers. 

Blind Care and Rehabilitation

The VA has made a substantial investment in the care of veterans who are 

visually impaired: 

• 10 blind inpatient rehabilitation centers located at VA facilities provide 

training in orientation and mobility, independent living, and computer 

access 

• Day outpatient rehabilitation programs are available through the Visual 

Impairment Services Outpatient Rehabilitation Program for veterans with 

low vision who can live independently but need additional training in 

specific skills, such as orientation and mobility 

• Four VICTORS (Visual Impairment Centers To Optimize Remaining 

Sight) provide diagnosis, evaluation, and training for patients with low 

vision 

• Blind Rehabilitation Outpatient Specialists provide training to visually 

impaired veterans in diverse settings, including nursing homes, assisted 

living facilities, Walter Reed Army Medical Center, and National Naval 

Medical Center
 

58

• Visual impairment service teams and coordinators, placed at several VA 

medical centers and outpatient clinics, identify, evaluate, and provide 

direct services and case management to veterans adjusting to vision loss. 

Private Sector Rehabilitation 

Private-sector rehabilitation programs and services are provided to injured service 

members in a variety of ways and locations, depending on the needs and capabilities of 

the patient. According to the Centers for Medicare and Medicaid Services, there now are 

224 free-standing inpatient rehabilitation hospitals—where the most intensive 

rehabilitation programs are based—and 1,010 inpatient rehabilitation units within acute 

care hospitals. 

Patients in private-sector inpatient programs engage in a series of daily activities, 

such as occupational and physical therapy and speech and language recovery, usually for 

three to six hours per day, five to seven days per week. For patients whose conditions 

allow them to stay at home, day rehabilitation programs typically provide at least two 

different types of therapy for three hours per day, five days per week. Many patients 

participate in day programs, as a next step toward independence, after being discharged 

from inpatient settings. Another post-hospitalization option, residential programs, are 

similar to day rehabilitation programs but provide additional, limited assistance with 

activities of daily living. 

Other settings include: 

 Moderately intensive rehabilitation programs in outpatient departments for 

one to two hours per day, three days per week 

 Low to moderately intensive rehabilitation programs at home or in skilled 

nursing facilities 

 Limited rehabilitation services during an acute hospitalization, such as 

assistance with early mobilization, ambulation aids (crutches, walkers, etc.), 

and training. 

The choice of setting depends on several factors: 

 the patient’s diagnosis 

 ability to recover 

 other diseases or conditions 

 level of functioning prior to the illness or injury 

 support systems 

 mental status 

 ability to tolerate the intensive nature of the program. 

For each level of rehabilitation, health insurers enforce specific criteria for 

demonstrating positive progress toward goals and time benchmarks for program 

completion (such as 45 days for spinal cord injury recovery at an inpatient rehabilitation 

facility). 
 

59

The Commission on Accreditation of Rehabilitation Facilities (CARF) currently 

accredits civilian facilities (Figure 3). 

PREVIOUS RECOMMENDATIONS AND REPORT FINDINGS 

Previous Commission and Task Force reports examining injured service 

members’ needs have not addressed rehabilitation specifically. However, several reports 

did issue broad recommendations that would affect rehabilitation in important ways. A 

common theme emerging from these reports is the need for greater collaboration and 

resource-sharing between the military and VA to improve access to high-quality care and 

allow patients to be treated closer to home. Previous commissions and their key 

recommendations are: 

 The Congressional Commission on Service Members and Veterans 

Assistance (1999) recommended a review of the geographic structure of the 

DoD and VA health systems. The Commission observed that “both systems 

have beneficiaries who could more conveniently obtain care at facilities 

operated by the other system.” 

 The Independent Review Group (April 2007) criticized the unavailability of 

technologically advanced follow-up care for amputees in the VA (a breakdown 

in the transition from inpatient to outpatient status). It cited the need for more 

extensive training for case managers and a need to develop practice guidelines 

and research on TBI. Specifically, the report recommended: 

o Creating a DoD-VA partnership to provide ongoing amputee treatment 

and prosthetic services 

o Providing greater access to private-sector health facilities and stronger 

incentives for private providers to participate in TRICARE 

o Reviewing post-service care for reservists and considering expansion 

of the Army’s Community Based Health Care Organization network. 

 The President’s Task Force to Improve Healthcare Delivery for Our 

Nation’s Veterans (2003) recommended: 

o Identifying and correcting staff shortages 

o Creating consistent clinical scopes of practice for non-physician 

practitioners 

o Creating an interface between VA and DoD systems for credentialing 

individual and institutional providers. 

 In support of warriors returning home for outpatient rehabilitation, the Task 

Force on Returning Global War on Terror Heroes (April 2007) 

recommended that Adapted Housing and Special Home Adaptation Grant 

claims be expedited. 

 A 2004 report by the Government Accountability Office (GAO) on outpatient 

rehabilitation services for blind veterans concluded that the VA’s outpatient 

care capacity was inadequate and recommended that inpatient and outpatient 
 

60

services be made more widely available to legally blind veterans.49 The VA 

has responded by expanding blind rehabilitation centers across the country. 

 In a 2007 report, GAO observed that allowing injured service members to 

receive early rehabilitation at VA facilities should be coordinated with DoD’s 

evaluation of whether they could become fit to return to duty.50 

WHAT THE COMMISSION LEARNED 

 The Commission has learned that access to high-quality, comprehensive 

rehabilitation programs and services should be part of the recovery plan of every injured 

service member, to provide the opportunity to reach one’s full potential. 

The Effectiveness of Rehabilitation 

 Rehabilitation is essential to the recovery of injured individuals.51 Although 

randomized clinical trials demonstrating the effectiveness of rehabilitation are seldom 

conducted, because that would deprive patients of basic and standard care, many studies 

document that rehabilitation improves health care outcomes. Examples for TBI, 

amputation, and burns follow. 

 For TBI, rehabilitation—along with clinical pathways and early consultation—

improves efficiency, optimizes outpatient care, and decreases hospital lengths of stay. 

Patients with severe TBI experience fewer complications and spend less time in the 

hospital if they are given clearly defined goals and a structured progression of 

rehabilitation services.52,53 Early consultation with a physiatrist (physical medicine 

specialist) and prompt referral to rehabilitation programs apparently improve functional 

outcomes for these patients.54 Similarly, patients with moderate to severe TBI recover 

their personal independence faster when they are provided with more intensive 

 

49 U.S., Government Accountability Office. VA HEALTH CARE: More Outpatient Rehabilitation Services 

for Blind Veterans Could Better Meet Their Needs. GAO-04-996T, July 22, 2004. 50 U.S., Government Accountability Office. Challenges Encountered by Injured Servicemembers During 

Their Recovery Process. GAO-07-589T, March 5, 2007. 51 Mock C, Lormand JD, Goosen J, et al. Guidelines for essential trauma care. Geneva, World Health 

Organization, 2004. 

52 Vitaz TW McIlvoy L, Raque GH, et al. Development and implementation of a clinical pathway for 

severe traumatic brain injury. J of Trauma 51:369-375, 2001. 53 Wagner AK, Fabio T, Azfonte RD, et al. Physical medicine and rehabilitation consultation: relationships 

with acute functional outcome, length of stay, and discharge planning after traumatic brain injury. Am J 

Phys Med Rehabil 82: 526-536, 2003. 54 Ibid. 
 

61

treatment,55,56 and comprehensive, integrated outpatient rehabilitation programs improve 

these patients’ functioning even if provided one year after the acute injury.57 

 For amputations, prosthetics has changed dramatically over the years.58 

Accompanying the development of sophisticated artificial limbs was the rise of structured 

rehabilitation programs to return amputees to functional independence.59 A coordinated, 

multi-disciplinary approach to prosthetic rehabilitation reduces the length of time patients 

spend in the hospital and decreases the amount of physical therapy needed in the 

outpatient setting.60 Structured programs that include vocational rehabilitation, 

community reintegration, and sports activities improve the quality of life for these 

individuals.61 

 

 Burn patients face significant rehabilitation challenges. Serious burns often 

require multiple operations and generate chronic pain and psychological problems.62 

Moreover, burned service members frequently have other injuries and are at risk for 

PTSD.63 A comprehensive multidisciplinary approach to burn rehabilitation is, therefore, 

critical.64 Providing burn care in a burn center with a rehabilitation unit decreases 

lengths of stay and more rapidly restores function to the patient.65 Because of the 

intensive nature of the care required, along with the resources needed, burn care in the 

United States is provided through a regional approach. 

Optimal Rehabilitation Staffing 

 Staffing for rehabilitation programs and services varies by type of facility, such as 

(as categorized by the World Health Organization’s 2004 “Guidelines for Essential 

Trauma Care”) basic (clinic), general practice (non-specialty hospital), specialist hospital, 

 

55 Shiel A, Burn JPS, Henry D, et al. The effects of increased rehabilitation therapy after brain injury: 

results of a prospective controlled trial. Clinical Rehabilitation 15:501-514, 2001. 56 Zhu XL, Poon WS, Chan CH, & Chan SH. Does intensive rehabilitation improve the functional outcome 

of patients with traumatic brain injury? Interim result of a randomized controlled trial. British Jounal of 

Neurosurgery 15:464-473, 2001. 57 High WM, Roebuck-Spencer T, Sander AM, et al. Early versus later admission to postacute 

rehabilitation: impact on functional outcome after traumatic brain injury. Arch Phys Med Rehabil 87: 334-

342, 2006. 

58 Eldar R & Jelic M. The association of rehabilitation and war. Disability and Rehab 25: 1019-1023, 2003. 

59 Pezzin LE, Dillingham TR, & MacKenzie EJ. Rehabilitation and the Long-Term Outcomes of Persons 

with Trauma-related Amputations. Arch Phys Med Rehabil 81: 292-300, 2000. 60 Kent R & Fyfe, Neil. Effectiveness of rehabilitation following amputation. Clinical Rehab 13: S43-S50, 

1999. 

61 Pasquina PF, Bryant PR, Huang ME, et al. Advances in Amputee Care. Arch Phys Med Rehabil 87I: 

S34-S43, 2001. 

62 Esselman, PC, Thombs, BD, Magyar-Russell, G, & Fauerbach, JA. Burn Rehabilitation: state of the 

science. Am J Phys Med Rehab 85: 383-413, 2006. 63 Ibid. 64 Jonsson, CE, et al. Rehabilitative, psychiatric, functional and aesthetic problems in patients treated for 

burn injuries--A Preliminary follow-up study. Act Chir Plast 39:3-8, 1997. 65 DeSanti, L, et al. Development of a burn rehabilitation unit: Impact on burn center length of stay and 

functional outcome. J Burn Care Rehabil 19: 414-419, 1998. 
 

62

and tertiary care facility for extremity injuries. In order to determine the types of staffing 

available, the Commission obtained data from selected military treatment facilities where 

a majority of injured service members are taken when evacuated and compared these 

staffing levels with WHO standards (Table 1). 

 Community hospitals provide primary and general acute care with a limited 

number of specialty providers. Tertiary referral hospitals, by contrast, have a 

concentration of specialists and few primary care providers. Medical centers have a mix 

of primary care and specialty care, but neither as many specialists as tertiary hospitals nor 

as many primary care providers as community hospitals. 

 

 Most tertiary referral military hospitals generally meet WHO standards, but only 

two—Walter Reed and Brooke Army Medical Centers—have rehabilitation nurses on 

staff. Staffing at military treatment facilities is always vulnerable to deployment and the 

routine base rotational life of military personnel. While every attempt is made to “back 

fill” these positions, periods of staff unavailability occur throughout DoD, not only for 

rehabilitation staff, but also for general medical staff. 

 Matching rehabilitation needs with capability and capacity at each facility should 

be a priority. For those injuries with specialized needs, plans need to be in place for 

obtaining rehabilitation services elsewhere, including in the private sector. 

Optimal Rehabilitation Programs and Services 

 Only three facilities have specialized rehabilitation programs for upper and lower 

extremity amputations (Walter Reed Army Medical Center, Brooke Army Medical 

Center, and Naval Medical Center, San Diego). Five facilities have had programs for 

mild TBI, and two have specialized rehabilitation programs for moderate TBI. There are 

no programs in the military for rehabilitation for severe TBI. Brooke is the only facility 

with specialized burn rehabilitation. 

 In responding to the Commission’s data request, only Walter Reed expressed the 

belief that it had facilities meeting a strict definition of both inpatient and outpatient 

rehabilitation units and services. Most of the other facilities reported that services were 

obtained by referral to military specialty hospitals, TRICARE network providers (Figure 

4), or through the VA. 

 Recently, the Army Surgeon General created an office of Rehabilitative Care 

Proponency. Working in coordination with other DoD, federal, and community 

rehabilitation authorities, this office will identify the rehabilitation capabilities of the 

Army’s military treatment facilities and recommend improvements. This initiative is 

specific to the Army, and thought does not appear to have been given to a DoD-wide 

activity. 
 

63

Challenges for War-Related Injury Rehabilitation 

 

The military has state-of -the-art amputee and burn centers; the VA maintains 

special expertise in spinal cord injuries and blindness; and both treat TBI patients 

depending on the level of severity. It is clear, however, that no unified rehabilitation 

strategy exists between the two departments or with private-sector providers, particularly 

during this peak need for additional rehabilitation services and programs. The lack of 

strategic planning results in uneven availability of community-based rehabilitation, 

unused capacity in some costly specialized facilities, and stretched capacity in other 

facilities. The recently established Army’s Rehabilitative Care Proponency Office should 

be able to determine needs and create opportunities to coordinate the best rehabilitation 

care, but the extent to which the other Services are conducting similar efforts is unknown. 

A contemporary rehabilitation system would adjust resources according to the 

volume of patients and the severity of their injuries and needs. This would prevent 

congestion, excessively low patient volumes, and gaps in care. Research shows that, for 

other types of highly specialized care, the number of patients treated at a facility is related 

to better outcomes.66, 67 In some specialty fields, this research has led to patient care 

guidelines that incorporate minimum patient volume standards.68 In rehabilitation, too, it 

is difficult to justify the ongoing expense of equipment and a skilled multidisciplinary 

team, if that team is not fully utilized, and of course, that team will become less skilled 

over time. 

 

The military faces a special challenge in planning for successive generations of 

war injuries. Once war ends, specialized military rehabilitation facilities and programs 

may lose the patient volume necessary to sustain excellence. The burn center at Brooke 

has met this challenge by serving as the sole treatment site for all military beneficiaries 

with severe burns and by treating other patients from around the world. This model can 

be adapted to other specialized care facilities, such as Walter Reed’s amputee center. An 

alternative strategy would be to rely on leading VA or private-sector facilities, providing 

support to ensure that the particular expertise needed to treat service members is 

sustained through research and training. 

Most private sector and all VA rehabilitation facilities are accredited by CARF. 

Military rehabilitation facilities do not participate in CARF accreditation. (An Army 

spokesperson explained to the Commission that military hospitals primarily provide acute 

rehabilitation services and so do not require specialized accreditation.) In light of the 

 

66 DiSario, JA. Hospital volume and ERCP outcomes: the writing is on the wall. Gastrointestinal 

Endoscopy 64: 348-350, 2006. 

67 Harmon JW, Tang DG, Gordon TA, et al. Hospital volume can serve as a surrogate for surgeon volume 

for achieving excellent outcomes in colorectal resection. Ann Surg 230: 404-411, 2000. 

68 Birkmeyer JD, Finlayson EV, Birkmeyer CM. Volume standards for high risk surgical procedures: 

potential benefits of the Leapfrog initiative. Surgery 130:415-422, 2001. 
 

64

expansion in inpatient and outpatient rehabilitation programs and services, several large 

Army and Navy medical centers reasonably would seek and obtain CARF accreditation 

to assure that they meet the highest standards. 

Using Community-Based Rehabilitation 

Specialized military and VA centers for rehabilitating seriously injured service 

members and veterans provide technologically advanced treatment, and research at these 

facilities has led to improvements in prosthetics, burn care, and other rehabilitation 

services. Yet prolonged stays at these centers keep some patients from returning to their 

homes and may require their families to relocate for extended periods. These long stays 

may also delay community reintegration and social, vocational, and psychological 

adjustment needed for optimal recovery.69

 Some patients, particularly National Guard 

and reserve members, may prefer to receive their care at private-sector rehabilitation 

facilities closer to their homes. 

In general, very little is understood about long-term outcomes of care in different 

settings,70 although some evidence suggests that early vocational rehabilitation and 

medical rehabilitation care close to the patient’s home improve long-term recovery.71 In 

any event, patients should be transferred to other facilities if the type of rehabilitation 

available is consistent with their recovery plan. 

ACTION STEPS 

 The military should maintain a level of rehabilitation services and programs in 

keeping with the need to maintain America’s fighting force. 

 The military should develop a strategy to adjust peak demands for rehabilitation 

services and programs utilizing military, VA, and private sector sources. 

 The military should develop a plan for utilization and maintenance of specialty 

rehabilitation centers and programs. 

 The military should assess the specific staffing needs of each rehabilitation programs 

to assure adequacy. 

 The VA should maintain an inventory of contemporary prosthetics consistent with 

those supplied by the military.

 

69 U.S., Government Accountability Office (GAO), DoD and VA Health Care: Challenges Encountered by 

Injured Servicemembers during Their Recovery Process. GAO 07-606T, March 2007; GAO , Vocational 

Rehabilitation: More DOD and VA Collaboration Needed to Expedite Services for Seriously Injured 

Servicemembers, GAO 05-167, January 2005. 70 Dillingham, TR. Musculoskeletal Rehabilitation: Current Understandings and Future Directions. Am J of 

Phys Med Rehab 86: S19-S28, 2007. 71The two GAO reports cited above recommend early intervention to maximize work potential and 

rehabilitation needs. 
 

65

Table 1: STAFFING AT MILITARY TREATMENT FACILITIES 

Services Community Hospitals Medical Centers Tertiary Referral Hospitals 

*WHOIACH LNCH BACH PNCH *WHOCDAMCEAMCWAM*WHOMCWRACNNMCBAMDNMCSC MAMNMCP 

Physical Medicine 

and Rehabilitation 

Physician 

I D D 

Rehabilitation 

Nurses 

I D D 

Physical 

Therapists 

I D D 

Occupational 

Therapists 

I D D 

Speech 

Pathologists 

I D D 

Neuropsychology/ 

Psychological 

counseling 

I/E D/

E 

 D/

E 

 

Vocational 

Therapists 

 

Prosthetists I D E 

Orthotists 

• E = essential, D = desirable, I = ideal 

• Stars indicate staff in that hospital; 

• Filled boxes indicate that the service at that facility and by 

referral to TRICARE, VA or military specialty hospitals 

• Open circles indicate that the service is available by 

referral to TRICARE, VA or to military specialty hospitals 

• Open boxes indicate emerging capability at this military 

hospital 

• WHO = World Health Organization 

• WRAMC = Walter Reed Army Medical Center 

• NNMC = National Naval Medical Center 

• BAMC = Brooke Army Medical Center 

• MAMC = Madigan Army Medical Center 

• NMCP = Naval Medical Center Portsmouth 

• NMCSD = Naval Medical Center San Diego 

• DAMC = Darnall Army Medical Center 

• EAMC = Eisenhower Army Medical Center 

• WAMC = Womack Army Medical Center 

• IACH = Ireland Army Community Hospital 

• LNHC-LeJune = Naval Hospital Community 

Hospital – Lejeune 

• BACH = Blanchfield Army Community Hospital 

• PNCH=Naval Community Hospital - Pendleton 
 

66

Figures 1 and 2. DOD AND VA ACUTE AND POST-ACUTE 

REHABILITATION LOCATIONS 

VA/DOD Post-Acute 

Rehabilitation Locations

SOURCE: DOD and Veteran's Health Administration

Albuquerque Augusta

Baltimore

Boston

Chicago Cleveland

Dallas

Denver Indianapolis

Little Rock

Los Angeles

Miami

Milwaukee

New York City

Oklahoma City

Philadelphia

Portland

Salt Lake City

San Diego

Seattle

Tucson

Bay Pines

Bronx

Butler

Detroit

Hines

Houston

Knoxville

Loma Linda

Long Beach

Lyons

Montgomery

Northpoint

St Louis

Syracuse

Wilkes-Barre

San Juan

Keesler

AFB Lackland

AFB

Ft Bliss

FT Lewis

Travis AFB

Andrews AFB

Washington

Wright-Paterson

AFB

Ft Gordon

Scott AFB

Ft Cambell

Naval Medical Center

Portsmouth

Ft Bragg

Tripler Army 

MedicalCenter

DOD/VA Major Acute 

Rehabilitation Locations

SOURCE: DOD and Veteran's Health Administration

Minneapolis

Richmond

National Naval Medical

Tampa

Palo Alto

Brooke Army

Medical Center

Naval Medical

Center Balboa

Walter Reed

Army Medical Center
 

67

Figure 3. DISTRIBUTION OF COMMISSION ON ACCREDITATION 

OF REHABILITATION ACCREDITED FACILITIES 

Figure 4. DENSITY OF TRICARE NETWORK REHABILITATION 

FACILITIES 

Number of Military, VA, and TRICARE

Rehabilitation Facilities by State

TX

▲ ▲

▲

▲

▲

▲

▲▲

▲= Major Military & VA 

Rehabilitation Facilities AK

MT

WY

DE

ID

NH

PR

DC

HI

RI

VT

CT

ME

MN

WI

IN

SD

NM

MD

NE

OR

NC

ND

UT

WA

MS

NV

SC

IA

KY

WV

NJ

MI

MO

MA

IL

VA

OH

OK

AR

KS

CO

AL

NY

LA

GA

AZ

TN

PA

FL

CA

0

1 to 22

22 to 44

44 to 66

66 to 88

Number of Accredited 

Rehabilitation Facilities by State

ID

AK

VT

WY

AL

DE

DC

RI

KS

WV

ME

NM

NH

PR

ND

SD

AZ

NV

OR

CO

MS

AR

MT

HI

UT

OK

SC

NE

VA

MA

LA

TN

GA

MD

IA

KY

WA

WI

CT

IN

NC

NJ

MN

NY

MO

CA

PA

IL

OH

FL

MI

TX

0

1 to 13

14 to 26

27 to 70

71 to 291
 

68
 

69

FAMILY SUPPORT 

THE CHALLENGE 

Families are a vital aspect of injured service members’ concerns, attitude, 

treatment, recovery, and ongoing state of health and social connections. During the 

current conflict, the military and other organizations have made great strides in 

integrating families into the programs and services available to injured service members. 

Nevertheless, family members often are left confused and needing assistance as 

they navigate the complicated military and veterans systems. Families would benefit 

from—and deserve—greater and more systematic involvement in information-sharing, 

care of injured service members, and the shaping of programs and policies. 

BACKGROUND 

Initial Support 

 

Families of injured service members usually learn of the injury in a telephone call 

placed to the next of kin, as designated by the member before deployment, by either a 

military casualty affairs staff member or the unit commander in the field. Family 

members quickly receive information about travel, lodging, and support at the treating 

medical facility. If the injury falls into defined serious or very serious categories, 

Invitational Travel Orders can be issued for up to three family members, usually for 14 

days and sometimes for 30 days (or even longer, under the Service Secretary’s order). 

Travel orders provide: 

• Travel expenses 

• Lodging 

• Local transportation expenses 

• Daily allowance. 

 An official of the Service meets family members at the airport and drives them to 

the local finance office—to receive a five- to 15-day advance—and then to their lodging 

and the hospital. If the hospital has a Family Assistance Center, it is the first stop. As 

soon as possible thereafter, the family is escorted to meet the charge nurse at the hospital 

and then to the bedside. 

When the service member is discharged from the hospital, a Non-Medical 

Attendant Order can be issued if the attending physician believes that having a family 

member in attendance will aid in the patient’s recovery. These orders cover 

transportation and meals and are usually issued in 14-day increments to only one family 
 

70

member, although additional family members may receive them in extraordinary 

circumstances. 

All families need support at some point, but some families need more services 

than others and for much longer periods of time. In cases where recovery will take a long 

time—for example, severe burn cases—the military Service may decide to move the 

family permanently. Moving the family facilitates normal family interactions, which 

may be especially important if there are children, but uproots families from their 

community. To fill the resulting gap, an abundance of military and community support 

organizations—including more than a thousand non-profit organizations—play a vital 

role in family support. 

 Family members’ bedside lengths of stay range from one day to six months, with 

an average of 45 days. Most injured service members recover quickly and return to duty. 

Others take longer to recover, but eventually return to full functioning. A small number 

of the most severely injured never fully recover and remain dependent on family 

members for care-giving and economic support. 

 Walter Reed and Brooke Army Medical Centers have Soldier and Family 

Assistance Centers, where family members are connected on-site with a host of programs 

and referral services. The Army recently directed all its medical facilities to develop a 

capability to open such Centers if needed, while the other Services offer family support in 

other ways. Additionally, DoD and VA treatment facilities offer family members: 

• Education about the service member’s specific injuries and the physical, 

psychological, and social functioning changes that will result in both the short and 

long term 

• Training for family members who will need to be caregivers 

• Counseling to deal with their emotional reactions and adjustments. 

 Fisher Houses—which provide a “home away from home” for families of injured 

and wounded service members, at no charge—are located near all military medical 

centers as well as several VA medical centers and military community hospitals on large 

bases. In this private-public partnership, the private Fisher House Foundation raises 

funds, constructs the houses, and provides programs and other support services to family 

members, while the Department of Defense (DoD) or Department of Veterans Affairs 

(VA) operates and maintains the house. Currently, 38 Fisher Houses house 8,500 

families per year. The foundation now plans to construct 22 more houses, mostly at VA 

medical facilities. 

Ongoing Support 

 Each Service has a program to help seriously wounded and injured service 

members and their families: 

• Army Wounded Warrior Program 

• Navy Casualty and Safe Harbor Program 

• Marines Wounded Warrior Regiment 
 

71

• Air Force Palace HART (Helping Airmen Recover Together) Program. 

These wounded warrior programs help in many ways: 

• furnishing advice and assistance during treatment, recovery, and reentry to 

military or civilian life 

• cutting through bureaucratic red tape 

• providing referrals to public and private agencies 

• facilitating job searches 

• helping to remedy communication problems affecting families and injured 

service members 

• identifying needed changes in policies or procedures. 

In addition, DoD’s Military OneSource program gives assistance around the clock 

to service and family members and is accessible electronically and by telephone. This 

program provides information and referrals for support services ranging from child day 

care to elder care, from education to employment, from financial to legal aid, and from 

housing to relocation. It also can arrange up to six counseling sessions for service or 

family members experiencing problems. Military OneSource’s partners include VA, the 

Departments of Labor and Education, veterans service organizations, state agencies, and 

non-profit organizations. 

 Military OneSource also manages the Military Severely Injured Center. In close 

collaboration with the Services’ wounded warrior programs, the Center helps injured 

service members and their families with: 

• Financial planning 

• Education, training, and job placement 

• Information on VA benefits and other entitlements 

• Home, transportation, and workplace accommodations for disabilities 

• Personal, couples, and family issues counseling 

• Personal mobility and functioning. 

 After leaving the hospital, some service members need personal caregiver 

services, sometimes for a long time or even permanently. VA provides two kinds of 

support: 

• An aid and attendance allowance ranges from $1,851 to $2,757 per month for 

veterans living at home who are blind, need routine assistance with activities of 

daily living, or have at least two significant impairments. This allowance pays for 

nursing assistants or other aides; the higher amounts cover licensed health 

professionals who provide services directly or supervise the aides. (Most 

beneficiaries of this allowance are rated as 100 percent disabled and a veteran 

with a spouse and two children receive monthly disability compensation ranging 

from $2,781 to as much as $7,380 if severely impaired.) 

• Respite care is available for up to 30 days a year for all disabled veterans. 

Respite care provides care-giving services while family caregivers take a break 

from their daily burden. 
 

72

DoD provides no explicit benefits for care-giving. Aid/attendance and respite 

care are not available to injured service members on active duty—even though the 

TRICARE Extended Health Care Option provides these benefits to service members 

whose children or other dependents have special needs. A few states provide benefits to 

disabled adults who need care-giving (in most states, this benefit is only for the elderly), 

and some charitable organizations offer respite care to military families. 

While the service member is on active duty, spouses and dependents receive 

comprehensive health benefits through TRICARE. This coverage continues after a 

medical retirement from service—but, for regular service members who receive a 

medical separation (with a DoD disability rating of zero to 20 percent) and for 

demobilized reservists, this extension lasts only 180 days.72 

PREVIOUS RECOMMENDATIONS AND REPORT FINDINGS 

Prior to this year, family issues received little attention in the multitude of task 

force and commission reports published. However, recent reports have cited areas in 

need of attention. 

The Independent Review Group is the only recent task force that made specific 

recommendations for family support. These called on DoD to: 

• Inform family members about the support they are entitled to, and assign 

individuals to assist with travel, lodging, and other support 

• Consider permanently moving families of wounded, ill, and seriously injured 

service members who need long-term rehabilitative care in outpatient settings. 

Moves should be considered on a case-by-case basis with consideration given to 

the needs of the family. 

The DoD Task Force on Mental Health included services for family members in 

its extensive review of the military’s mental health system. The task force concluded: 

• Families receive inadequate education about psychological health 

• The military health system lacks the resources and personnel needed to provide 

adequate mental health service to family members 

• Coordination among the many DoD organizations that provide psychological care 

is lacking. 

The Army’s Wounded Warrior Program sponsors regular symposia twice a 

year for severely injured service members and their family members. The top issues 

identified by participants at the last two meetings included several recommendations for 

improving family support: 

 

72 For more details about medical retirement, separation, and TRICARE benefits, see the Subcommittee 

Report on Disability Evaluation and Compensation. Separated individuals may purchase up to 18 months 

of additional coverage; the cost for a family is about $8,000 per year. 
 

73

• Provide support groups, led by trained social workers, and counseling for family 

members at military treatment facilities, and inform families about the groups 

when they first arrive 

• Provide a stipend for caregivers until the soldier returns to duty or VA benefits 

begin 

• Before the service member’s discharge from the hospital, train family caregivers 

and provide them with specific instructions and medical supplies and equipment 

• Develop a package of materials for families about the notification process, the 

importance of powers of attorney, and mental health issues. 

WHAT THE COMMISSION LEARNED 

 

Families are integral to the care and recovery process. They contribute critical 

emotional and practical support to recovering service members, sometimes for life. 

Patient-centered care, as advocated by the Commission, integrates families along the 

continuum of care and provides them with information and support. 

 Typically, a family’s first concern is to get to the bedside, and the Services appear 

to have developed effective procedures for meeting this fairly basic need. Once the 

family’s immediate needs for travel and temporary lodging are satisfied, it requires more 

individualized support, depending on the service member’s medical condition and the 

family’s own situation. Beyond issues involving in bringing the family to the injured 

service member, information gathered through the Commission’s site visits and DoD and 

VA expert consultations revealed issues in four other areas: 

• Information and administrative help 

• Financial support during the recovery phase 

• Health care for the family 

• Special needs for family caregivers. 

Bringing Families to Injured Service Members 

Most injured service members, especially active-duty personnel, have had family 

members join them soon after they are medically evacuated to the United States (Figure 

1). In almost all cases, these family members have traveled at government expense, and 

two-thirds were provided housing. Only one-third were issued Non-Medical Attendant 

Orders after the service member left the hospital, however. 
 

74

Figure 1─Percentage of Returning Injured Service Members with Families in 

Attendance, PCCWW Survey 

0%

10%

20%

30%

40%

50%

60%

70%

Came to bedside Travel orders Provided housing Attendant orders

Active duty

Reserve/Guard

Over the past five years, the Services have fine-tuned their policies and practices 

for bringing family members to the bedside. The level of support is impressive. Travel 

arrangements are made quickly, and family members are escorted upon arrival and then 

prepared for their initial bedside encounter. 

 Family members who will stay for an extended period of time deserve 

comfortable and safe temporary lodging. The Fisher Houses and certain other facilities 

meet this need. When a military medical center’s capacity for temporary housing is 

exceeded, local officials are usually able to arrange off-base housing in hotels until the 

family can be moved to the base. 

 Large bases with military medical centers have extensive services for families, 

including commissaries, child care, and recreational facilities. Military spouses have 

immediate and permanent access to these services, and parents and other relatives usually 

can obtain temporary access to them. 

Information and Administrative Help for Families 

In conversations with many injured service members and their families at 

different stages along the continuum of care, the Commission heard a recurring theme of 

confusion and frustration in navigating the medical and benefits systems. Some families 

described receiving very limited or inconsistent information about the anticipated course 

of treatment and recovery—and recovery is families’ overriding concern—and how that 

course would affect eligibility for, and appropriateness of, specific services and benefits. 

Many family members’ knowledge of the military is quite limited, and they could 

use a “crash course” in the many administrative processes and service programs relevant 

to their situation. The Army’s Soldier and Family Assistance Centers and the Services’ 
 

75

wounded warrior programs—developed during the current conflict—help meet this need. 

VA also has expanded the number and locations of liaison staff at military treatment 

facilities. These VA staff members inform patients and families about VA benefits and 

facilitate the transition to civilian life and VA care. 

As the Subcommittee Report on the Continuum of Care describes, a host of “case 

managers,” assigned at various stages of the treatment and recovery process, help patients 

and families navigate the complex system of care and benefits. Some patients and 

families are fortunate to find a single person at each stage of the process—such as a 

medical case manager or hospital social worker—to serve as a single coordinator. 

Once a service member (including National Guard and reserve personnel) leaves 

the military, the flow of information and support tends to become more fragmented. 

Various websites, supported by the wounded warrior programs and other sponsors, try to 

make information readily available to this dispersed population. These websites contain 

a wealth of information, but navigating them to get answers to specific questions can be 

difficult. 

 The Commission’s survey asked injured service members whether their families 

received all the information they needed and wanted. Three-fourths of active-duty 

personnel, and slightly lower proportions of National Guard members and reservists, said 

their families were well-informed (Figure 2). (Note that this is second-hand information 

related by the service member, and some family members might have responded 

differently.) This finding suggests that information was a problem for a substantial 

minority of families. 

 

Figure 2─Percentage of Families Who Received All the Information They Needed, 

PCCWW Survey 

0%

20%

40%

60%

80%

Active Duty Guard/Reserve
 

76

Family Financial Support During Recovery 

 

While the injured service member remains on active duty, military income and 

benefits continue, which provides some stability to the family. But, almost one in five 

respondents to the PCCWW Survey reported that family members gave up a job to help 

care for them after they were injured (Figure 3). Sixty percent of the medically 

evacuated service members who were surveyed were married and 42 percent had children 

living with them. Supporting the family when the injury is severe and the recovery is 

long can be a challenge. 

For families of the most seriously injured, the income from these jobs can be 

replaced, temporarily, by the Traumatic Servicemembers Group Life Insurance program. 

This program, which most service members join, pays up to $100,000 for injuries 

involving loss of limb, eyesight, hearing, burns, and severe traumatic brain injuries (TBI) 

that impede the ability to perform activities of daily living. In the first nine months after 

the program began in December 2005, roughly 400 claims were paid, assisting about half 

of combat-injured patients evacuated to a DoD medical center. Payment is lump-sum 

(averaging $52,000) except for service members with TBI, who receive $25,000 per 

month while they are unable to perform activities of daily living. The program does not 

provide benefits to individuals who can perform such daily living activities as bathing 

and dressing but are unable to work, prepare meals, or perform other functions necessary 

to live independently 

Figure 3─Percent of Service Members with a Family Member Who Gave Up a Job, 

PCCWW Survey 

0%

5%

10%

15%

20%

25%

Active Duty Guard/Reserve

Recalling that some family members average 45 days on travel orders and some 

stay for up to six months, returning to the same job may not be possible. The Family 
 

77

Medical Leave Act protects employment for up to 12 weeks, which covers the average 

leave but not the long leaves necessitated by the most serious injuries.73 

Returning to work can be especially problematic for spouses and parents of 

injured service members who are permanently dependent on attendant care. When 

employer taxes and agency overhead are taken into account, the VA aid and attendance 

allowance barely covers the costs of full-time attendant care.74 Family members who 

assume the caregiver role themselves—and manage to qualify for payment through the 

VA allowance, which isn’t always easy—may earn less in this “job” than they would 

otherwise. Families are financially strapped whether they hire caregivers or serve as 

caregivers themselves. 

 Many charitable organizations have stepped up to assist families—starting as 

early as April 2003 with the American Red Cross, Walter Reed Army Community 

Service, Fisher House Foundation, and United Services Organization (USO). Today the 

number of organizations serving inured service members and their families exceeds 

1,000. Families benefit enormously from this philanthropy (Figure 4), but a key problem 

for families is that no centralized clearing-house lists all these organizations, many of 

which are local. The DoD-approved “America Supports You” and Military OneSource 

websites, for example, list only those organizations that register with the website. 

Figure 4─Percent of Families Helped by Non-Profit Groups, 

PCCWW Survey 

0%

10%

20%

30%

Charity Veterans group Church group Community

group

Active duty

Reserve/Guard

 

73 The Family Medical Leave Act requires reinstatement in a comparable position for immediate family 

members only (spouses and parents) who work for a public employer or private employer with 50 or more 

employees. Up to 12 weeks are authorized each year. 

74 See Small, VD. “What is a Fair Wage When Provided by Family or Friend?” The Case Manager 17: 63-

66, 2006. 
 

78

 Caregivers often experience considerable financial, physical, and emotional 

stress. Studies of caregivers consistently show high levels of psychological stress and 

unmet service needs. Multi-faceted programs that tailor benefits and services to family 

needs are the most effective.75 

Health Care for Families 

While injured service members are receiving acute care and rehabilitation, their 

families—spouses, children, parents, and others—also need unencumbered access to 

health care. Military treatment facilities care only for TRICARE beneficiaries, including 

active-duty and retired families, and are not authorized to provide non-emergency 

services such as prescription refill orders or primary care to others. 

A clear area of family need is psychological services directed, in part, at healing 

the family unit. Family members bear the brunt of daily care for long periods of 

rehabilitation and recovery, while their own emotional stability and well-being, along 

with those of the injured service member, are placed at great risk. Ideally, these family 

members could obtain psychological services at the military medical facility, where they 

could be coordinated with other health services; referral to community providers in the 

TRICARE network is a less desirable alternative. But, the shortage of mental health 

professionals throughout the military, coupled with the deployment of many mental 

health professionals to theaters of operations, prevents the military facilities from being 

able to offer such services to family members routinely. 

For health care generally, TRICARE provides a comprehensive health benefit at 

no cost to active-duty personnel (including activated reservists) for themselves and their 

dependents. This is helpful, because few spouses of active-duty personnel have their own 

health insurance. That makes the loss of TRICARE coverage significant, though, when 

the injured service member separates from the military, especially if recovery will be a 

long haul. The Subcommittee Report on Disability Evaluation and Compensation 

discusses offering TRICARE to all service members whose injuries lead to their leaving 

military service. This change would fill an important gap in support for a number of 

families. 

Overall Satisfaction with Family Support 

 The PCCWW survey asked injured service members how satisfied they were 

overall with the support provided to their families. Sixty percent were very or somewhat 

satisfied and only 27 percent were very or somewhat dissatisfied (top panel of Figure 5). 

 

75 U.S., Department of Health and Human Services, National Institutes of Health. “Caring for the 

Caregivers: The Hidden Victims of Long-Term Illness.” News in Health, August 2006. Available at 

http://www.newsinhealth.nih.gov/pdf/NIHNiH%20August06.pdf. 
 

79

This figure is for all evacuated service members. We expected that the results 

might differ for the more seriously injured, whose families need more support. Using 

whether the military issued non-medical attendant orders to flag seriously injured service 

members, we find noticeably higher satisfaction levels in this group (bottom panel of 

Figure 5). 

Figure 5Satisfaction with Support for Families, 

PCCWW Survey 

All Evacuees

Very 

satisfied, 

39%

Satisfied, 

21%

Neutral, 

14%

Very 

dissatisfied

, 19%

Dissatisfie

d, 8%

Evacuees with Attendant Orders

Very 

satisfied, 

54%

Satisfied, 

22%

Neutral, 

6%

Dissatisfie

d, 4%

Very 

dissatisfied

, 13%
 

80

ACTION STEPS 

 Complementing action steps presented in other subcommittee reports—such as 

including family members in discussions about the recovery plan, having a single 

Recovery Coordinator, and extending TRICARE coverage to all service members who 

leave the military because of a combat-related injury—the following measures would 

help support families of injured service members now and in the future: 

Action Step: DoD should establish a standby plan for family support of injured service 

members in future conflicts, drawing on the experiences and model programs developed 

during this conflict. 

Action Step: Congress should make injured service members eligible for the TRICARE 

respite care and aid and attendance services benefits through the Extended Care Health 

Option. 

Action Step (suggested): DoD and VA should standardize, and assure universal access 

to, family services early in the treatment process. This package should include education 

about the service member’s injuries and expected progress, caregiver training, and 

counseling and psychological services. 

Action Step: DoD and VA, in regularly evaluating their programs for injured service 

members, should routinely consider the interests of families and solicit family members’ 

comments, suggestions, and feedback on proposed changes. 

Action Step: Congress should amend the Family Medical Leave Act to allow up to six 

months’ leave for a family member of a service member who has a combat-related injury 

and meets the other eligibility requirements in the law. 
 

81

EDUCATION, TRAINING, AND EMPLOYMENT 

THE CHALLENGE 

The Department of Veterans Affairs (DVA), Department of Labor (DOL), 

Department of Defense (DoD), state, private, faith based, community based, and other 

organizations are providing employment services to assist veterans with disabilities 

returning from the war to become suitably employed. VA and DoD along with the other 

organizations, work together to assist veterans with disabilities obtain suitable 

employment for veterans. Each organization provides employment, education and 

training services through different venues. The primary function of these organizations is 

to assist in providing the veteran with the tools necessary to return to work, attain selfsufficiency, and participate in family and community life. 

BACKGROUND 

Education and Training Services 

Employment is the dominant concern for most veterans making their transition to 

civilian life. A veteran with a suitable job is in a position to face the challenges that 

come with beginning a new life. The VA’s Vocational Rehabilitation and Employment 

program provides education, training, and employment services to disabled veterans who 

have an employment handicap—defined by VA as “an impairment of a veteran's ability 

to prepare for, obtain or retain employment consistent with his or her abilities, aptitudes 

and interests.” To apply for the program, veterans must have at least a 10% disability 

rating to receive the comprehensive evaluation that determines the presence of an 

employment handicap. If the veteran’s disability rating is right at 10%, the employment 

handicap has to be serious. The many services offered in this program and other DoD 

and VA programs are summarized in Table 1. 

While recovering on active duty, injured service members whose condition 

permits it could begin an educational program under DoD’s tuition assistance program. 

However, it is unclear how many could or would want to do this. 

The objective of vocational rehabilitation services is to prepare veterans for 

suitable employment that is consistent with their aptitudes, interests, and abilities. 

Services—such as vocational assessment, labor market surveys, developing alternative 

work plans, retraining, and assistance with job-seeking skills—focus primarily on helping 

individuals with disabilities enter a different job or career. For severely disabled veterans 

for whom employment is not an option, the program focuses on enhancing their ability to 

live more independently in their home and/or community. 
 

82

Table 1DoD and DoD Education, Training, and Employment Benefits 

Benefit Type Eligibility Criteria Services/Benefits 

Tuition Assistance 

(DoD) 

Active Duty • Up to $4500/ year 

Computer/ Electronics 

Accommodation 

Program (DoD) 

Service members with injuries 

that have caused: 

• Dexterity impairment 

• Vision/hearing loss 

• Cognitive injury 

• Assistive technology 

and services for: 

• Active duty during 

medical recovery 

• Veterans in a federal job 

Vocationaleducational 

counseling (VA) 

• Eligible for a VA education 

program: e.g., 

o Montgomery GI Bill 

o Reservists Education 

Program 

• If active duty, within 6 

months of separation 

• Interest and aptitude 

testing 

• Setting occupational 

goal 

• Locating appropriate 

educational or training 

program 

Vocational 

rehabilitation and 

employment (VA) 

• Honorable or other than 

dishonorable discharge; 

• Service-connected disability 

at least 20%; 

• Comprehensive evaluation 

shows employment handicap 

• Period of eligibility is 12 

years 

• Full tuition in approved 

training programs 

• Subsistence allowance 

(e.g., $508/mo if single, 

$799 for a family of 4) 

• Employment assistance 

• Independent living 

assistance 

Educational assistance 

for veterans not 

eligible for the 

services above 

(DoD/VA) 

Montgomery GI Bill 

• High school degree 

• Active Duty: 2-3 yrs service, 

honorable discharge, 

$100/mo while serving 

• Selected Reserve: 6 year 

obligation, in good standing 

with a reserve unit 

Reserve Educational Assistance 

Program 

• Reserve component members 

with 90+ days on active duty 

after 9/11/2001 

• Monthly benefit varies 

by benefits program, 

type of educational 

program, attendance 

level (standard benefit 

for full-time college is 

$1,075/mo.) 

• 36 months over 10 years 

after discharge 

• Some recruiting 

contracts include higher 

benefits 

Dependents’ 

educational assistance 

(VA) 

• Dependent of service 

member or veteran who is 

permanently and totally 

disabled due to a servicerelated condition 

• Up to $860/month for 

48 months 
 

83

Finally, the VA program also provides education and training for spouses and 

dependents of service members who are permanently and totally disabled. This benefit 

recognizes that most of these veterans cannot work, making their family members’ 

earnings especially important. 

Research has shown that vocational rehabilitation and employment services 

should be provided as early as possible after the onset of the disability to significantly 

impact the service members’ return to work.76 

In collaboration with DoD, VA has several policies that expedite entry into its 

programs: 

• VA places a vocational rehabilitation counselor at eight military medical 

centers77 to advise assist those service members who need to prepare for 

civilian life. The counselor can arrange through the Coming Home to Work 

program for service members qualified for vocational rehabilitation and facing 

separation to work in a government office, gain on-the-job training, and be 

considered for post-service employment 

• Since 1992, DoD and VA have collaborated to offer the Disabled Transition 

Assistance Program, an expanded version of an educational program offered 

to all service members when they leave the military. 

• DoD provides VA with data on all OIF/OEF veterans who have been 

discharged from service. VA identifies those with pending claims and these 

claims receive expedited processing. 

• Veterans who are newly separated, disabled, or burdened with a barrier to 

employment have priority for receiving vocational and employment services. 

Employment Services 

An array of employment services and employer incentives has been developed to 

promote employment opportunities for veterans in general and disabled veterans in 

particular. Federal and state hiring gives veterans preference. Disabled veterans qualify 

for 10 extra points on the federal civil service examination. For scientific and 

professional positions at GS-9 or higher, candidates are rank-ordered by points including 

preference points. For other positions, veterans with a disability rating of 10% or higher 

are listed above all other candidates for the position. In general, a veteran may not be 

passed over for a non-veteran without good reason. Disabled veterans also may be 

appointed without competition through a Veterans Recruitment Appointment. Finally, 

 

76 GAO-05-167, Vocational Rehabilitation: More VA and DoD Collaboration Needed to Expedite Services 

for Seriously Injured Servicemembers, January 2005; GAO-96-133, SSA Disability: Return-to-Work 

Strategies from Other Systems May Improve Federal Programs, July 1996; Michigan Bureau of Disability 

Workers’ Compensation, Report of The Task Force on Vocational Rehabilitation in Workers' 

Compensation. 

77 Walter Reed Army Medical Center; National Naval Medical Center at Bethesda, Brooke Army Medical 

Center, Naval Medical Center San Diego, Eisenhower Medical Center (Fort Gordon, Georgia), Evans 

Army Community Hospital (Fort Carson, Colorado), Darnall Army Community Hospital (Fort Hood, 

Texas), and Madigan Army Medical Center (Fort Lewis, Washington). 
 

84

federal agencies are required by law to establish a separate affirmative action program for 

disabled veterans to promote their “maximum of employment and job advancement 

opportunities.”78 In fiscal year 2005, 92,642 disabled veterans were employed in nonpostal federal jobs—an 18% increase since 2001. An additional 63,456 disabled veterans 

were employed in postal jobs. Reflecting an overall decline in postal employment, this 

number was down 18% since 2001.79 

The Department of Labor’s Veterans Employment and Training provides funding 

through grants to the states ($225 million in fiscal year 2006) to hire staff to assist 

veterans in finding employment: 

• Disabled Veterans Outreach Program specialists work from VA facilities, state or 

local veterans service offices, or nonprofit agencies. They act as case managers 

for veterans with a serious employment handicap and work with DoD and VA, 

employers in the veteran’s community, Veterans Service Organizations, and 

others to identify appropriate training and employment opportunities. They also 

follow up with veterans who find jobs and their employers to assist in job 

retention. 

• Local Veteran Employment Representatives are state employees who work in 

local state employment offices and assist veterans with all the employment 

services provided by these offices. 

The grants carry a requirement to give “special disabled veterans”80 preference in 

referrals to potential employers. 

The Workforce Investment Act of 1998 authorized a network of community OneStop Career Centers around the country. The Department of Labor coordinates with 

other federal agencies, state and local employment boards, and other public and 

community-based organizations to operate offices where people can receive or be 

referred to all the qualified education, training, and employment services in the area. 

There are currently 3500 Centers and an online portal (Career One Stop). Combined, 62 

percent of service members, including those in transition, entered employment and most 

retained it. 

 

78 Section 4214 of Title 38, United States Code. 

79 U.S. Office of Personnel Management, Report to the Congress: The Employment of Veterans in the 

Federal Government: FY 2005, November 2006. 

80 Special Disabled Veteran - A Veteran (see definition above) entitled to disability compensation (or who 

but for the receipt of military retired pay would be entitled to compensation) under laws administered by 

the U.S. Department of Veterans’ Affairs for a disability: 

• Rated at 30 percent or more; or 

• Rated at 10 or 20 percent in the case of a veteran who has been determined by the U.S. 

Department of Veterans’ Affairs to have a serious employment handicap under Chapter 31, 

Training and Rehabilitation for Veterans with Service Connected Disabilities; or 

• A person who was discharged or released from active duty because of a service connected 

disability. 
 

85

Employers have incentives to hire veterans from the VA’s Vocational 

Rehabilitation and Employment Program, who are eligible for special incentives in 

addition to incentives that apply to all veterans. Incentives offered by VA include: 

• VA On-the Job Training Program: VA supplements entry wages for disabled 

veterans hired through the Vocational Rehabilitation and Employment program. 

The employer pays an apprentice wage and VA increases the wage to the 

journeyman level. The employer is eligible for the federal Work Opportunity Tax 

Credit (see below). 

• VA Special Employer Incentive Program: Employers who hire veterans judged 

to have extraordinary obstacles to employment are reimbursed for up to 50% of 

the veteran’s pay for up to six months and also qualify for the federal Work 

Opportunity Tax Credit. 

• VA Non-Paid Work Experience Program: This program places veterans in 

local, state, or federal government agencies to gain particular skills and, 

hopefully, obtain a permanent position in the agency. VA pays the veteran its 

standard monthly subsistence allowance for trainees. 

Other federal incentives include: 

• Architectural / Transportation Tax Deduction: Businesses can deduct up to 

$15,000 per year to make facilities or work vehicles more accessible and usable 

by disabled persons. 

• Disabled Access Credit: Small businesses that incur expenses to provide access 

to persons with disabilities can take a tax credit of 50% of costs per year above 

$250 and up to $5125. The expenses must be necessary for compliance with the 

Americans with Disabilities Act. 

• Veterans Job Training Act: VA provides training costs incurred by employers 

who hire long-term unemployed veterans. This program currently applies only to 

veterans from the Korean and Vietnam eras; it will likely be extended to veterans 

of the current war when the time comes. 

• Work Opportunity Tax Credit: One-time tax credit of up to $2400 for 

businesses that hire individuals with disabilities who have completed or are in the 

process of completing rehabilitative services, including the VA’s. 

Federal contractors must comply with several veteran hiring provisions. 

Contractors and subcontractors must list all job openings with state employment offices, 

file an annual report on veteran employment, and have an affirmative action plan that 

addresses disabled veteran hiring. 

To raise employer and veteran awareness of these programs and incentives for 

veteran employment, the Jobs for Veterans Act in 2002 established the President’s 

National Hire Veterans Committee within the Department of Labor. The committee 

brings together representatives from private employers, organized labor, and service 

organizations with officials from the Small Business Administration, Office of Personal 

Management, United States Postal Service, VA, DoD, and Department of Labor; most of 

the members are veterans themselves. 
 

86

Roughly half of service members injured in Iraq and Afghanistan are reservists, 

most of whom took leave from a civilian job when they were called to active duty and 

deployed. The Uniform Services Employment and Reemployment Rights Act 

(USERRA) requires that civilian employers rehire reservists after they return from 

deployment in the same or comparable position and precludes employment 

discrimination based on military service, particularly in the Guard and Reserve. The 

National Committee for Employer Support of the Guard and Reserve, operated within the 

Office of the Secretary of Defense, educates Reserve component members and civilian 

employers about the provisions of USERRA and assists in the resolution of conflicts 

arising from an employee's military commitment. 

PREVIOUS RECOMMENDATIONS AND REPORT FINDINGS 

The 1999 report of the Congressional Commission on Servicemembers and 

Veterans Transition Assistance reviewed the many programs and services that assist 

service members making the transition to civilian life. Among the Commission’s 

recommendations was one that has not so far been implemented:

• DOL, DoD, and VA should establish a customized, separate Veterans and 

Servicemembers Internet Site (VASIS) on the Department of Labor’s web site.81 

In 2004, the VA Task Force on Vocational Rehabilitation and Employment

was convened to analyze and assess the VA’s Vocational Rehabilitation and Employment 

program. It concluded that “over the past decade, the Veterans Benefits Administration 

(VBA) has reduced its focus on the ultimate VA mission of returning veterans with 

service-connected disabilities to the workforce and the preeminent role of vocational 

rehabilitation in achieving that goal.” The task force recommended reorganization and 

increased staffing to support the following actions: 

• Streamline eligibility and entitlement for those veterans in most critical need, 

• Replace the current vocational rehabilitation and employment process with a fivetrack employment-driven service delivery process, 

• Expand counseling benefits to provide VR&E services to service members before 

they leave military service and veterans, 

• Improve the capacity of the information technology systems and 

• Develop online systems for job placement instead of relying on other agencies’ 

systems, 

• Improve intra-and interagency coordination within VA and with DoD, the 

Department of Labor, and the states, 

• Implement a long-term research and program evaluation agenda to assess the life 

cycle outcomes of the vocational rehabilitation program. 

 

81 This targeted web site would be similar to MonsterTRAK, which assists college students and recent 

alumni as they transition from school to the job market. The website includes job listings, a resume 

database, statistics about the jobs being offered and accepted, job fair and campus interview schedules, and 

a network of mentors. The President's National Hire Veterans Committee maintains a web site with links 

to existing employment resources (www.HireVetsFirst.gov) but it is not the full-service site envisioned in 

the 1999 report. 
 

87

A 2005 Government Accountability Office (GAO) report on DoD reviewed 

VA’s ability to expedite vocational rehabilitation and employment services for seriously 

injured service members.82 The report notes that the recovery process differs 

substantially across patients with similar injuries and, for many, prospects for return to 

duty may be uncertain for some time. Under these circumstances, determining when to 

approach injured service members about these VA services is not straightforward. GAO 

recommended that: 

• VA and DoD should reach an agreement about providing information that VA 

needs to promote the recovery and return to work of seriously injured service 

members, 

• The need for VA to develop policies and procedures for regional offices to 

maintain contact with seriously injured service members who do not initially 

apply for vocational rehabilitation and employment services. 

In light of the GAO recommendations, VA and DoD signed an agreement in June 2005 to 

lay the groundwork for sharing data and improving their assistance to seriously injured 

service members, including reservists, as they transition to civilian life. 

The 2007 Presidential Task Force on Returning Global War on Terror 

Heroes made the following employment related recommendations: 

• Increase attendance at TAP and DTAP Sessions. 

• Department of Education staff participate in Department of Labor-sponsored job 

fairs 

• Integrate the “Hire Vets First” Campaign into existing job and career fairs. 

• Improve civilian workforce credentialing and certification. 

• Train active duty, Guard and Reserve personnel on the Uniformed Services 

Employment and Reemployment Rights Act (USERRA) 

• Develop a financial education module for transitioning service members on the 

benefits 

• Increasing Employment Within The Federal, State, Private and Faith Based 

Sectors 

WHAT THE COMMISSION LEARNED 

Other studies find that disabled veterans are slightly less likely to be working than 

their non-disabled counterparts and, among workers, disabled veterans earn somewhat 

less. Almost all of these differences are concentrated among veterans with a VA 

disability rating above 50%.83 These veterans make up more than one-third of the 

Vocational Rehabilitation and Employment program’s caseload—about the same fraction 

that are under age 30 

 

82 U.S., Government Accountability Office, GAO-05-167. Vocational Rehabilitation: More VA and DoD 

Collaboration Needed to Expedite Services for Seriously Injured Servicemembers, January 2005. 83 Buddin, Richard J. and Kanika Kapur. An Analysis of Military Disability Compensation, MG-369-OSD, 

RAND Corporation, 2005; U.S., Bureau of Labor Statistics, Employment Situation of Veterans: August 

2005, news release, May 26, 2006; U.S., Bureau of Labor Statistics, Employment Situation of Veterans 

Summary, USDL 06-897, 2006.
 

88

The survey fielded for this Commission also found relatively high employment 

rates even for those who were medically evacuated to the U.S. and subsequently left 

active service (Figure 1). The employment and school attendance rates were similar for 

veterans in their first and second years post-service. 

Figure 1Employment and School Attendance for OIF/OEF Veterans and 

Demobilized Reservists, PCCWW Survey 

31%

59%

13%

14%

19%

7% 37%

20%

0%

20%

40%

60%

80%

100%

Medically

retired/separated

Demobilized reservists

Not working

or in school

Attending

School

Working and

in school

Working

The VA Task Force on Vocational Rehabilitation and Employment found that VA 

data on program participants could not support an evaluation of program outcomes over 

time. Studies of other vocational education programs have found that they can 

substantially improve employment outcomes in the first few years.84 For men with 

musculoskeletal and mental health disabilities, a $1 investment by the public in federally 

subsidized state vocational rehabilitation has been estimated to return $3 in (discounted) 

future earnings.

Each year, about 65,000 veterans apply for the VA’s Vocational Rehabilitation 

and Employment program (Figure 2). Historically, most applicants were seeking the 

program’s generous education and training benefits—more generous than the benefits 

available through the GI Bill. All program participants must be judged to have an 

employment handicap, but for many participants their goal is to improve their 

employment opportunities and earnings. As the 2004 Task Force on Veterans Vocational 

Rehabilitation and Employment observed, many more veterans apply for the program 

than are accepted and dropouts are relatively common over the course of a program that 

traditionally averaged three or more years to complete. The task force anticipated that its 

five-track employment program, individually tailored to the veteran’s goals, would 

 

84 Jellinek HM and Harvey RF. “Vocational/Educational Services in a Medical Rehabilitation Facility: 

Outcomes in Spinal Cord and Brain Injured Patients.” Archives of Physical Medicine and Rehabilitation 

63, 87-88, 1982. Dean, DH, RC Dolan, RM Schmidt. “Evaluating the Vocation Rehabilitation Program 

Using Longitudinal Data: Evidence for a Quasiexperimental Research Design” Evaluation Review 23, 162-

89, 1999. 
 

89

decrease the dropout rate. VA data for fiscal year 2006 show that about half of the 

applicants qualify for the program and fewer than 40% of qualified veterans complete the 

program. These statistics differ little from the statistics quoted in the task force report for 

2003. 

Figure 2Vocational Rehabilitation and Employment Program Statistics, 

Fiscal Year 2006 

12,117

23,445

31,502

63,228

0 10,000 20,000 30,000 40,000 50,000 60,000 70,000

Completed program

Received rehab plan

Qualified

Applied

Number of veterans

↓ 50%

↓ 26%

↓ 48%

 

Three-quarters of the disabled veterans who complete the Vocational 

Rehabilitation and Employment Program are on a job track rather than an independent 

living track. Over 90 percent found jobs, most in the private sector (Figure 3) where their 

monthly pay averaged almost $3000 (Figure 4). The most lucrative jobs were in the 

federal government, where 12% found a position. 

The earnings for veterans who complete vocational rehabilitation appear to 

compare favorably with earnings achieved through the state vocational rehabilitation 

programs that serve the general population with disabilities.85 However, earnings for the 

state programs were measured three years after completion, whereas the VA data are 

initial earnings. Both employment and earnings outcomes have been shown to slip over 

time and disabled workers may find that their ability to perform their jobs is limited.86 

VA does not routinely track vocational rehabilitation participants over time to evaluate 

program outcomes and identify factors associated with success. Therefore, it is difficult 

 

85 Hayward, BJ and H Schmidt-Davis, Longitudinal Study of the VocationalRehabilitation Services 

Program, Final Report: VR Services and Outcomes, RTI International, May 2003. 86 Butler, RJ, WG Johnson, and ML Baldwin, “Managing Work Disability: Why First Return to Works is 

Not a Measure of Success,” Industrial and Labor Relations Review, 48:3, April, 1995. MacKenzie EJ, MJ 

Bosse, JF Kellam, et al. “Early Predictors of Long-Term Work Disability after Major Limb Trauma. 

Journal of Trauma 61, 688-94, 2006. Pezzin, LP, TR Dillingham, and EJ MacKenzie. “Rehabilitation and 

the Long-Term Outcomes of Persons with Traum-Related Amputations.” Archives of Physical Medicine 

and Rehabilitation 81, 292-300, 2000. 
 

90

to assess the patchwork of programs and hiring incentives described earlier. We cannot 

determine whether these programs are allowing disabled veterans to reach their full 

potential after they return to civilian life. 

Figure 3Sector Where Veterans with Disabilities Found Employment, FY 2006 

NonProfit 

Org's

7%

State & 

Local 

Govt

18%

VA

5% Federal 

Govt

12%

SelfEmploye

d

1%

Private 

Sector 

57%

Figure 4Average Monthly Pay Offered to Veterans with Disabilities 

by Sector, FY 2006 

$2,580

$3,419

$2,044

$2,960

$2,740

$2,940

$0 $1,000 $2,000 $3,000 $4,000

Non-Profit Org's

Federal Govt

Self-Employed

Private Sector 

State & Local Govt

VA

Although not definitive, the evidence points to the effectiveness of vocational 

rehabilitation in improving employment opportunities for the disabled and the benefits of 

early intervention. VA’s Vocational Rehabilitation and Employment program appears to 

have good results with those veterans who are eligible for and complete the program. 

However, of the 65,000 veterans who apply for the program each year, at most 10,000 of 

all ages complete the employment track in the program each year (another 2,000 or more 

complete the independent living track). Including a vocational rehabilitation plan in the 

recovery plan outlined by this Commission’s Subcommittee on the Continuum of Care 
 

91

may lead to more injured service members benefiting from the VA’s program. This 

could be accomplished by expanding the Coming Home to Work program that provides 

vocational evaluation and assistance to injured service members in eight military 

treatment facilities. Some other disability systems in the U.S. and overseas require 

participation in vocational rehabilitation, where it is likely to be beneficial, for continued 

receipt of disability compensation.87 This would be a dramatic departure in policy for 

disabled veterans, however. 

On the surface, it appears likely that expanding eligibility for the program and 

improving the completion rate would be highly cost-effective, substantially improve 

long-term outcomes for injured service members, and decrease the substantial lifetime 

earnings losses experience by the most severely disabled veterans. More systematic 

collection of information on the life course of disabled veterans and the employers who 

hire them will be needed to develop the most effective strategy for vocational 

rehabilitation and employment. 

ACTION STEPS 

The Commission believes that the public investment in education, training, and 

employment services for injured service members should be increased and incentives 

should be provided to encourage veterans to complete their education and training 

programs. Veterans who have been injured in service to their country should be given the 

education or training they need for the most complete life recovery possible and help 

finding a job. 

Action Step: VA should intervene early to plan for and provide education, training, and 

employment services for injured service members. 

• The recovery plan for seriously injured service members should include an initial 

vocational rehabilitation plan based on a vocational evaluation by a VA counselor 

as early as the member’s medical condition allows. 

• Vocational services should begin as early as possible, whether or not the service 

member is still on active duty and be closely coordinated with the state 

employment and veteran agencies where the service member will live. 

• VA vocational staffing and location must be adequate to support early 

intervention. 

Action Step: VA should make the following modifications in its Vocational 

Rehabilitation and Education program to improve completion rates: 

• Extend the maximum number of months for a veteran who attends part-time (up 

to 72 months), with approval of their Recovery Coordinators and vocational 

counselor 

• In addition to providing financial support for participants through transition pay 

(as described in the Subcommittee Report on Disability Evaluation and 

 

87 U.S., General Accounting Office, GAO-01-153. SSA Disability: Other Programs May Provide Lessons 

for Improving Return-to-Work Efforts, January 2004. 
 

92

Compensation), pay a retention bonus equal to 10 percent of annual transition pay 

for completion of the first and second years and 5 percent for completion of the 

third year. 

Action Step: VA should institute a quality improvement program for vocation 

rehabilitation involving systematic collection of data on employment and earnings of 

disabled veterans over time and employer hiring practices. Through regular program 

evaluation and well-designed experimental interventions, VA should evaluate its methods 

for identifying candidates for vocational rehabilitation and employment services, 

retaining them in the programs, and providing incentives for employers to hire them. 
 

93

DISABILITY EVALUATION & COMPENSATION 

THE CHALLENGE 

The current disability evaluation and compensation systems within the 

Departments of Defense and Veterans Affairs were developed after World War II. Their 

methods for rating the level of an injured service member’s disability need to be updated. 

DoD’s disability evaluation process appears to have multiple objectives and can be overly 

complicated; VA’s system compensates for the inability to earn what a non-disabled 

veteran earns. The two systems provide different amounts of compensation for the same 

injury, based on their different approaches to rating disabilities. The procedures for 

obtaining benefits have, over many years, become overly bureaucratic, hard to navigate, 

and confusing for some. Injured service members who received excellent medical care 

on the battlefield and in the acute care hospital setting sometimes find themselves in a 

maze of disability policies and procedures. 

BACKGROUND 

 A service member who is injured and cannot continue in military service 

navigates the military disability system and then the VA disability system. Each system 

rates the member’s disability level and each has a disability compensation package. Most 

service members can receive disability compensation from only one department. This 

section first describes the military and VA evaluation (rating) systems and then the 

compensation systems. 

DoD’s Physical Disability Evaluation System 

The Secretaries of each branch of the military have the authority to develop 

systems to assess whether service members are capable of carrying out the activities of 

their military occupation (Figure 1). Service members deemed “unfit” to carry out these 

activities are given a disability rating from zero to 100 percent (in 10 percent increments), 

based on the condition or conditions that make them unfit for duty. They are then 

discharged from the military into one of three categories: 

• Medical separation: 0-20% rating 

• Temporary disability retirement: 30-100% rating, but level of impairment may 

change 

• Permanent disability retirement: 30-100% rating and level of impairment is 

stable. 

The Department calculates the disability compensation that members will receive based 

upon either years of service or percent disability rating; the final rating is permanent. 

 The disability evaluation process generally begins at a military treatment facility, 

after medical personnel determine that a service member has received the maximum 
 

94

benefit from medical care for his or her injuries. At that point, the member undergoes a 

complete physical examination, the results of which are summarized in a written report to 

a Medical Evaluation Board, which typically includes at least two physicians from the 

military treatment facility. The Board receives additional information from the service 

member’s commanding officer, addressing his or her ability to perform assigned duties, 

and, if necessary, evidence that the injury was not due to the member’s own misconduct. 

The report from the medical examination conducted when the member entered service is 

included in the package, if it is available. If the member fails to meet general medical 

standards for continuing in service, the Medical Evaluation Board refers the case to the 

Physical Evaluation Board. 

 This Board determines the member’s specific fitness for continued military 

service. The standard for determining fitness is whether the medical condition precludes 

the member from reasonably performing the duties of his or her military occupation and 

rank.88 For those found unfit, the Board further determines whether the member qualifies 

for medical separation or retirement and, if so, assigns a disability rating based on the 

Veterans’ Affairs Schedule for Rating Disabilities. Only the medical conditions 

affecting fitness are rated. Membership on the Physical Evaluation Board varies by 

service, but generally includes a physician and two line officers or civilian equivalents. 

The initial Board review is considered informal. Service members who do not concur 

with its findings may request reconsideration and submit new medical information or 

additional supporting evidence. If found unfit, they may demand a formal Physical 

Evaluation Board hearing and, if found unfit again, may petition the Secretary of their 

Service for relief. 

Physical Evaluation Board Liaison Officers are available at all military 

treatment facilities to counsel service members on their legal rights and benefits during 

each step of the disability evaluation process. These liaison officers inform service 

members of the Physical Evaluation Board’s findings and help them complete an 

“election of options” form, indicating whether they accept the Board’s findings. The 

liaison officer then notifies the Board as to how members have decided to proceed. 

Liaison officers receive annual training, but at present that training is not standardized, 

and there is no certification program. 

 88 DoDD 1332.18 states: “The sole standard to be used in making determinations of unfitness due 

to physical disability shall be unfitness to perform the duties of the member's office, 

grade, rank or rating because of disease or injury.” The Directive also specifies the requirements for 

medical separation and retirement. For members with less than eight years of service, the medical 

condition must have arisen during service after 30 days or in the line of duty during the first 30 days. If 

they have more than eight years’ active service, they are eligible for disability compensation, even if the 

disabling condition existed prior to service. Conditions must be permanent and not the result of misconduct 

or neglect. 
 

95

Figure 1─DoD Disability Evaluation System 

Note: Modified from Commission presentation, Mr. William Carr, Principal Director, Military Personnel 

Programs, April 14, 2007. 

MEB

*Informal / Formal PEB 

Process:

Formal PEB

Conducted with 

member, legal 

counsel, witnesses

Informal PEB

Conducted without 

member’s presence

Dispositions:

Is the member 

fit for duty?

Is the 

disability 

compensable?

What is the 

disability rating 

(injury/conditions 

severity)?

Based on:

•Medical evidence

•Injury / condition

•Duty performance 

(commander advice; 

performance 

records)

Based on:

•Line of duty 

determination

•For condition 

existing prior to 

service—whether 

member has at least 

8 years of active 

duty service

Based on:

•Medical evidence

•VA “Schedule for 

Rating Disabilities”

•DoD rating policy 

(clarifying detail)

Yes

Return 

to 

duty

Yes 

(Fit)

Placed on the Temporary 

Disability Retired List 

(medically reevaluated at 18 

months)

Placed on Permanent 

Disability Retirement 

(Separated with monthly 

disability retirement benefits)

Separated with lump sum 

disability severance

Separated without benefits

Disability 

is stable

No

< 20 

years

No

Yes

= 20 

years

No 

(Unfit)

40 Days—Standard

0-

20%

30% or 

higher

Member’s 

years of 

active 

duty or 

equivalent 

service

Member may 

elect Formal 

PEB after 

unfitness 

determination

Necessitates 

Formal PEB 

Proceedings*

M

E

B

Member 

with 

medically 

limiting 

injury/ 

condition

Does the 

member 

meet 

retention 

standard?

Based on:

•Medical evidence

•DoD Instruction 

Guidance

•Service Regulations

No

Return 

to 

duty

Yes

P

E

B

Optimum 

healthcare 

reached at 

Medical 

Treatment 

Facility

Continue 

Medical 

Treatment

Yes

No

Wound/

injury

Normally Not To Exceed 

One Year 30 Days—Standard

Dictation of 

Final 

Medical 

Narrative 

Summary

Medical Evaluation Board (MEB)

Physical Evaluation Board (PEB)
 

96

VA’s Disability Claims Process

When a veteran files a VA disability claim, the VA’s disability evaluation system 

is set in motion (Figure 2). VA is required by statute to obtain evidence supporting the 

claim, and claimants may need to undergo a physical examination. VA’s rating decision 

determines whether a claimed disability is service-connected, its severity, and its 

effective date. VA rates service-connected medical conditions that are service connected, 

as well as conditions that might have been aggravated by military service. Unlike DoD’s 

rating, VA’s rating is not permanent and may be adjusted over time as a veteran’s 

condition improves or worsens. 

Approximately 80 percent of all service members who go through DoD’s Physical 

Disability Evaluation System also file a VA claim. VA claims may be filed any time after 

discharge. Claims by veterans of Iraq and Afghanistan are given top priority for 

processing, and VA is meeting its goal to complete these claims within 100 days. 

Veterans who have a single-disability rating of 60 percent or more, or a combineddisability rating of 70 percent or more, and who are unable to work receive compensation 

at the 100 percent level. Over the past decade, the number of veterans rated 

unemployable has more than tripled.89

Figure 2─VA Disability Evaluation System 

 89 U.S., Government Accountability Office. Veterans’ Disability Benefits: VA Should Improve Its 

Management of Individual Unemployability Benefits by Strengthening Criteria, Guidance, and Procedures. 

GAO-06-309, May 30, 2006. Available at http://www.gao.gov/new.items/d06309. 

Disability 

rating

Based on:

•Medical evidence

•Service record

Member 

may elect 

to appeal

Are medical 

conditions 

serviceconnected?

Claim

Denied

Yes

No

Claim 

Application

Goal is 100 days
 

97

 A joint VA/DoD initiative, the Benefits Delivery at Discharge Program, helps 

medically separating or retiring service members file for VA service-connected disability 

compensation up to 180 days before they are discharged. The program is intended to 

provide a smooth transition into the VA health care system and enable prompt receipt of 

VA disability compensation. About half of the service members who might be eligible 

for the program file their claims this way, according to VA. 

 

 VA and DoD agreed in November 2004 on specific criteria to establish a single 

medical examination at the time of separation from the military. This cooperative 

examination was intended to improve the quality of service, provide a single portal for 

establishing eligibility for all benefits to which the veteran is entitled, and enhance the 

efficiency of the claims process. Local agreements between military installations and VA 

facilities to implement the single medical examination have been signed at almost all 

locations, but we could find no data to show how many separating service members 

complete DoD and VA disability processing with a single medical examination. 

Volume of Cases and Timeliness 

The volume of disability cases handled by DoD’s Physical Evaluation Board 

system increased 55 percent across all Services between 2001 and 2005 (Figure 3) and 

then dropped in 2006. The Army has had the largest gain, driven by an almost seven-fold 

increase in cases for members of the Guard and Reserve Components. 

DoD standards call for the Medical Evaluation Board and the Physical Evaluation 

Board to be completed in 70 days. But, in fiscal year 2005, the Army process exceeded 

90 days for 26 percent of active-duty personnel and 52 percent of Guard/Reserve 

members.90

Figure 3─Number of Cases in the Physical Evaluation Board System, 2001-2006 

0

5,000

10,000

15,000

20,000

25,000

2001 2002 2003 2004 2005 2006

Reserves

Active

Duty

 90 U.S., Government Accountability Office. Military Disability System: Improved Oversight 

Needed to Ensure Consistent and Timely Outcomes for Reserve and Active Duty Service Members. GAO06-362, March 31, 2006. Available at http://www.gao.gov/new.items/d06362. 
 

98

In 2006, 806,000 VA claims were filed (Figure 4); only about one-fourth of these 

were first time or new claims. Between 2001 and 2003, the number of VA claims 

pending decreased 40 percent, and the number of claims pending for more than six 

months decreased by almost three-fourths. This progress, however, was stopped by a 

2003 court decision which required that VA allow a year for veterans to submit all claim 

related information before reaching a final determination.91 

Figure 4─Number of Cases in the VA Disability Claims System, 2001-2006 

0

100,000

200,000

300,000

400,000

500,000

2001 2002 2003 2004 2005 2006

Pending 

over 6 mo.

Pending

under 6 mo.

The growing VA claims workload has caused the average number of days 

required to process a claim to reach 180. Veterans who appeal their decisions can expect 

to lengthen the process by, on average, another 657 days92—well over two years. The 

Benefits Delivery at Discharge, described earlier, has been effective in expediting VA 

claim processing; in fiscal year 2006, it took an average of only 68 days to complete a 

claim under this program. Since the member is still on active duty, the ready availability 

of complete medical information facilitates claims review. 

VA Schedule for Rating Disabilities 

The current VA Schedule for Rating Disabilities is the latest in a long list of 

disability rating schedules dating back to 1921. A 1945 revision is the basis for today’s 

schedule. DoD and VA both use this schedule to evaluate disabilities resulting from 

diseases or injuries incurred in, or aggravated by, military service. The schedule lists 

more than 700 disabilities in 15 body systems and provides evaluation criteria for each. 

The schedule’s rating outcomes range between zero and 100 percent, at 10-point 

increments, depending on severity. 

 In 1988, the General Accounting Office (later the Government Accountability 

Office) reported that there had been no comprehensive review of the disability rating 

 91 Paralyzed Veterans of America et al. v. Secretary of Veterans Affairs, U.S. Court of Appeals for 

the Federal Circuit, 02-7007,-7008,-7009,-7010, decided September 22, 2003. 

92 U.S., Government Accountability Office. “Processing of Claims Continues to Present 

Challenges.” Testimony before President’s Commission on Care for America’s Returning Wounded 

Warriors, March 13, 2007. 
 

99

schedule since 1945, and that the schedule contained outdated terminology, ambiguous 

classifications, and criteria that threaten consistency in ratings.93 GAO recommended 

that VA thoroughly review the schedule and establish a process for systematic review and 

updating. VA followed up on the recommendation, and over the past 20 years, ratings for 

12 of 15 body systems have been revised. The three unrevised body systems account for 

a disproportionate number of claims, however. 

HOW DISABILITIES ARE COMPENSATED 

DoD Disability Compensation 

A service member’s disability rating determines whether he or she receives 

lifelong disability retirement payments or a lump-sum disability severance payment. 

Service members with a zero, 10 or 20 percent disability rating and less than 20 years’ 

service receive a lump-sum payment upon separation from the military. The payment 

equals twice the number of years served multiplied by monthly base pay at separation. 

Those with combined disability ratings of at least 30 percent or who have at least 20 

years of service, regardless of the percentage rating, receive disability retirement 

compensation. The monthly benefit is the higher of two calculations, where the base pay 

amount used is an average over 36 months prior to discharge: 

 Disability rating % multiplied by monthly base pay, or

 Years of service (up to 12) times 2.5% times monthly base pay. 

 Disability retirement pay is capped at 75 percent of base pay.94 DoD also 

provides a lifetime TRICARE benefit to veterans with disabilities rated at 30 percent or 

higher or who have at least 20 years of service, regardless of the disability rating 

percentage. DoD disability pay is taxable unless the medical condition is combat-related. 

Table 1 provides approximate disability pay for enlisted personnel and officers at 

different levels of experience and with different medical conditions. The examples are 

the same ones used in a recent GAO report comparing disability compensation for 

military personnel with disability compensation for public safety officers across the 

nation.95 The table assumes only one unfitting medical condition in each case; many of 

the most serious injured personnel would have more than one condition that would be 

rated. The values are only approximate because the table uses the current level of base 

pay for calculating disability retirement pay. In reality, the calculation would be based on 

base pay over the past 36 months. Nevertheless, the table provides a reasonable picture 

of how disability pay changes across medical conditions and personnel with different 

ranks and years of service. Since all the calculations are based on monthly base pay, 

 93 U.S., Government Accounting Office. Veterans’ Benefits: Need to Update Medical Criteria 

Used in VA’s Disability Rating Schedule. HRD-89-28, December 29, 1988. Available at 

http://www.gao.gov/cgi-bin/getrpt?. 94 While on the temporary disability retirement list, discharged personnel receive an amount equal to their 

disability rating times base pay, with a minimum of 50 percent. 

95 U.S., Government Accountability Office. Disability Benefits: Benefit Amounts for Military 

Personnel and Civilian Public Safety Officers Vary by Program Provisions and Individual Circumstances. 

GAO-06-4, April 7, 2006. Available at http://www.gao.gov/new.items/d064. 
 

100

officers receive more than enlisted personnel and senior personnel receive more than 

junior personnel. 

Table 1─Monthly DoD Disability Compensation for Selected Cases 

Medical 

Condition 

Years of 

Service 

Enlisted 

Rank 

Enlisted 

Compensation 

Officer 

Rank 

Officer 

Compensation 

1 E-2 $2,900* O-1 $4,900* 

6 E-5 $27,900* O-3 $55,200* 

12 E-6 $72,000* O-4 $141,200* 

Tinnitus—10% 

rating 

22 E-9 $3,000 O-5 $4,400 

1 E-2 $ 580 O-1 $ 990 

6 E-5 $ 930 O-3 $1,840 

12 E-6 $1,200 O-4 $2,350 

Amputation below 

knee—40% rating 

22 E-9 $3,000 O-5 $4,400 

1 E-2 $1,090 O-1 $1,850 

6 E-5 $1,740 O-3 $3,450 

12 E-6 $2,250 O-4 $4,410 

Quadriplegia—100% 

rating 

22 E-9 $3,800 O-5 $5,530 

* Amounts shown in blue are lump-sum severance payments; these service members get no monthly pay 

 check. 

VA Disability Compensation 

Veterans given a VA disability rating of 10 percent or higher can receive monthly 

compensation from the Department of Veterans Affairs. The base amount of the payment 

depends on the percent rating and family status—whether the veteran has a spouse and 

dependents, including parents, and the ages of any children. Congress authorizes the 

payment amounts annually. VA disability compensation is tax free. The basic 

compensation rates for single veterans and veterans with a spouse and two children 

amounts are plotted in Figure 5. Compensation increases with disability level, with a 

sharp increase from the 90 percent to the 100 percent level. The added amounts for 

dependents are very modest. 

 VA also increases the amount provided to veterans with specific impairments 

through a schedule of Special Monthly Compensation payments. These may add only a 

modest amount to the basic compensation level, but the most severely impaired veterans 

can receive almost $7500/month. 
 

101

Figure 5─ Monthly VA Basic Disability Compensation 

$-

$500

$1,000

$1,500

$2,000

$2,500

$3,000

10 20 30 40 50 60 70 80 90 100

Veteran

alone

Veteran w/

spouse &

2 children

 Table 2 shows VA compensation for the same cases used in Table 1 (showing 

DoD compensation). VA varies its compensation with disability rating level and the 

number of family dependents, but not with military experience or rank, as DoD does. 

Table 2– Monthly VA Disability Compensation for Selected Cases 

Medical 

Condition Dependents 

Basic 

Amount 

Total with Special 

Monthly Compensation 

Tinnitus—10% 

rating 

Anya $ 115 $ 115 

None $ 501 $ 590 

Spouse $ 556 $ 645 

Amputation 

below knee—

40% rating Spouse, 2 

children 

$ 625 $ 714 

None $2471 $6164 

Spouse $2610 $6303 

Quadriplegia—

100% rating 

Spouse, 2 

children 

$2781 $6474 

a

Compensation for veterans with disabilities rated at 10% or 20% do not include additional 

 amounts for dependents. 

The law pertaining to VA disability programs specifies that VA’s disability 

ratings should be based on “average impairments of earning capacity resulting from such 

injuries in civil occupations,”96 implying that VA compensation should replace lost 

earnings capacity. 

 

96 Title 38, U.S.C., Section 1155. 
 

102

A recent study loss compared survey data on labor force participation and 

earnings of military retirees with and without a service-connected disability.97 Military 

retirees with disabilities rated 50 to 90 percent are less likely to work and work fewer 

hours than nondisabled retirees. Disabled retirees rated at 100 percent work even less. 

Conversely, the research shows very little difference in labor force participation or hours 

for those with lower disability levels. Generally, full-time work yields relatively 

comparable earnings for disabled and nondisabled retirees. Earnings are lower for 

individuals at higher disability ratings primarily because of their lower labor force 

participation rates. Finally, the research showed that VA disability compensation failed 

to make up for the modest earnings loss at lower disability ratings and more than made up 

for earnings loss at higher disability ratings, after accounting for the tax exemption. 

Various other benefits VA provides—for example, vocational rehabilitation, 

retraining, and job counseling—are designed to increase disabled veterans’ ability to 

function and work. These various benefits have different eligibility requirements. For 

health care, a veteran’s disability rating determines the priority group he or she falls into 

and thereby affects eligibility for enrollment, priority for care, and out-of-pocket costs. 

Coordination of DoD & VA Disability Payments 

All veterans can apply for VA disability pay. Most veterans who are medically 

separated or retired cannot receive disability pay from both VA and DoD. They must 

offset one pay with the other. Veterans who receive the lump-sum severance payment do 

not receive a VA check until VA pays back the DoD severance pay. For example, an 

enlisted member who separated after a year with only a 10 percent disability rating would 

not receive any VA disability pay for about the first two years. An ex-officer with 12 

years of service would have to wait more than ten years before seeing a VA check; this 

veteran might not bother to file a VA claim. 

Individuals who are medically retired receive the higher of the two payments. 

Disabled veterans who have completed 20 years of military service and who have 

received at least a 50 percent VA disability rating are eligible for both DoD and VA 

disability pay—this is called “concurrent receipt.” 

 Figure 6 illustrates how the two disability compensation systems compare for 

veterans who were medically retired—in the examples we use, amputees and 

quadriplegics. In the charts, the higher of the two payments is outlined in black. Except 

for junior enlisted personnel, DoD disability pay is higher for amputees, whereas Special 

Monthly Compensation for quadriplegics raises their VA disability pay significantly 

above their DoD pay. Recall that personnel who reach 20 years of service, have a DoD 

disability rating at or above 50 percent, and are wounded or injured in the line of duty 

receive both checks. In the cases shown in Figure 4, only the quadriplegics are eligible 

for concurrent receipt and they receive a combined annual income of well over $100,000 

 

97 Buddin, R and K Kapur, An Analysis of Military Disability Compensation, Santa Monica, CA: RAND, 

2005. 
 

103

(tax-free). Stepping over the eligibility thresholds for concurrent receipt (50 percent DoD 

rating and 20 years of service) is worth a considerable amount of money. 

Figure 6─Comparison of DoD and VA Disability Compensation for Selected Single 

Medical Conditions 

PREVIOUS RECOMMENDATIONS AND REPORT FINDINGS 

The Commission drew on a wealth of information from numerous reports on the 

veterans’ disability system, going back to the 1956 report by the President’s Commission 

on Veterans’ Pensions, chaired by General of the Army (Ret.) Omar N. Bradley. Over the 

years, recommendations similar to those of the Bradley Commission have been made 

repeatedly. 

Amputation -- Enlisted

0

1000

2000

3000

4000

5000

6000

1 6 12 22

Years of service

Monthly income

DoD

VA

Amputation -- Officer

0

1000

2000

3000

4000

5000

6000

1 6 12 22

Years of service

Monthly income

Quadriplegia -- Enlisted

0

1000

2000

3000

4000

5000

6000

7000

1 6 12 22

Years of service

Monthly income

DoD

VA

Quadriplegia -- Officer

0

1000

2000

3000

4000

5000

6000

7000

1 6 12 22

Years of service

Monthly income
 

104

In 1956, the Bradley Commission concluded that there was “no clear 

national philosophy of veterans’ benefits.” That Commission’s report contains the 

first clearest statement of goals for veterans’ disability benefits programs: 

 “Veterans’ benefits are one means by which society attempts to ameliorate the 

human tragedy of war and distribute its burdens....It is clearly a national desire—

and fully within our national economic capacity—to do justice by those who were 

injured or disabled as a consequence of their military service.” (page 10) 

 “The Government’s obligation is to help veterans overcome special, significant 

handicaps incurred as a consequence of their military service. The objective 

should be to return veterans as nearly as possible to the status they would have 

achieved had they not been in military service.” (page 4) 

 “The rehabilitation of disabled veterans and their reintegration into useful 

economic and social life should be our primary objective.”98 (page 11) 

More recent reports on the military and veterans disability systems have focused 

on the pressing need for improvement in the system’s processes for assessing disabilities, 

assigning ratings, and determining compensation. Within the DoD disability system, 

reports issued in spring 2007 by the Army Inspector General and the Independent Review 

Group (IRG) note that the Services’ disability evaluation systems vary significantly in the 

way they are implemented. The Independent Review Group also found that the various 

processes are unnecessarily cumbersome and adversarial. It recommended a complete 

overhaul to create a single DoD-wide Physical Evaluation Board and a common guideline 

for DoD and VA ratings. 

Similarly, the 2003 President’s Task Force to Improve Health Care Delivery for 

Our Nation’s Veterans specifically recommended a single discharge examination to 

document conditions that might indicate a compensable condition99 and make the 

transition from DoD to VA more seamless. The Task Force on Returning Global War on 

Terror Heroes went a step further and recommended “a joint DoD/VA process for 

disability benefit determinations by establishing a cooperative Medical and Physical 

Evaluation Board process within the military service branches and VA.”100 

The National Defense Authorization Act for 2004 established the Veterans 

Disability Benefits Commission and directed it to report on (1) eligibility for disability 

benefits, and other assistance for veterans and (2) the rates of compensation, including 

the “appropriateness of a schedule for rating disabilities based on average impairment of 

earning capacity.” The Commission is scheduled to send its report to Congress in 

October 2007. Although we did not have the benefit of this report, the findings and 

recommendations of an Institute of Medicine study conducted for the Commission 

 

98 The Americans with Disabilities Act of 1990 established similar national goals for all individuals with 

disabilities: “To assure equality of opportunity, full participation, independent living, and economic selfsufficiency.” 42 U.S.C. sec. 12101(a)(8), P.L. 101-336. 99 U.S., President’s Task Force to Improve Health Care Delivery for Our Nation’s Veterans. Final Report. 

May 2003, pp. 29-30 

100 U.S., Task Force on Returning Global War on Terror Heroes. Final Report. March 2007, p. 4. 
 

105

provided valuable information and recommendations. The study’s findings and 

recommendations can be summarized as follows:101

 Consistent with current models of disability, the veterans’ disability 

compensation program should expand its purpose to compensate for “work 

disability, loss of ability to engage in usual life activities other than work, and 

loss in quality of life.” 

 The VA Rating Schedule is out of date and rates impairments with little or no 

assessment of a veteran’s ability to work, engage in other daily activities, or 

enjoy quality of life. “VA should immediately update the current Rating 

Schedule...and devise a system for keeping it up to date.” The study 

recommended adopting a new classification system using standard diagnostic 

coding systems and either incorporating functional limitation criteria in the 

schedule or developing a separate mechanism to support compensation for 

non-work disability. 

 Numerous recommendations were directed at improving the implementation 

of the rating schedule, including better training, access to medical expertise 

during the rating process, and regular monitoring of consistency in ratings. 

 VA should undertake a program of research on the ability of the schedule to 

predict earnings loss, methods for measuring functional limitation and quality 

of life, and the outcomes achieved by the services provided to disabled 

veterans. 

WHAT THE COMMISSION LEARNED 

Current anecdotal evidence of problems in the care of injured service members 

focuses heavily on the disability systems of DoD and VA. They and their family 

members describe a lengthy, hard-to-understand, and difficult-to-navigate process of 

assessing the individual’s extent of disability. Delays in obtaining a VA disability rating 

can delay receipt of services and benefits. To many, the disability rating systems appear 

inherently unfair, because of inconsistencies in ratings granted between the different 

services, the services and VA, and for active-duty versus Reserve or National Guard 

service members. 

From the Service perspective, injured service members unable to perform their 

duties—but maintained on active-duty status while hospitalized or in rehabilitation—

reduce the effectiveness of their units. Given the rapid redeployment turn-around seen in 

this war, units with injured service members may not be able to replace those members 

and thus must return to battle shorthanded. The recent formation of an Army Wounded 

Warrior Regiment, complete with command structure, will allow injured members to be 

“reassigned,” and their units to replace them. 

An additional complicating factor is the need for certain service members to 

remain on active-duty status in order to receive necessary medical and rehabilitation care. 

This has led to an increase in the amount of time service members spend in medical hold 

 

101 Institute of Medicine. A 21st Century System for Evaluating Veterans for Disability Benefits. 

Washington, DC: National Academy Press, 2007. 
 

106

or medical holdover status, bringing some members closer to 20 years of service. The 

incentive is to stay until the 20-year mark in order to qualify for full retirement benefits—

particularly if the disability rating is less than 30 percent. For others with less time in 

service, the incentive is to appeal their disability rating to achieve 30 percent or higher in 

order to also qualify for full retirement benefits. 

Earlier studies also have concluded that the disability process needs improvement. 

These studies, as well as media reports and information gathered during the 

Commission’s meetings and site visits, raised concerns in the following four areas: 

 Inadequate and outdated rating schedule 

 Inconsistent evaluation processes and ratings outcomes 

 Long delays in making determinations and 

 Compensation formulas with unclear objectives. 

Adequacy of Rating Schedule 

As stated earlier, in the current DoD/VA disability systems, the disability rating 

service members and veterans receive determines the health care services, vocational 

rehabilitation, and other benefits they are eligible for as they recover, become 

rehabilitated, and adjust to any remaining impairments throughout their lives. The ratings 

also determine how much they will receive in disability compensation and whether this 

compensation is one-time-only or lifelong and whether it is tax-exempt. 

It has taken 20 years to revise and update 12 of the 15 chapters in the VA 

disability rating schedule. The slow progress has important implications for service 

members injured in Iraq and Afghanistan because many of them experience injuries, such 

as traumatic brain injury and post-traumatic stress disorder, for which the ratings 

schedule is especially inadequate. The evolving nature of warfare and advances in 

trauma care change the “signature conditions” associated with new conflicts, and a more 

rapid and responsive updating and revision of any rating schedule must be a priority. 

In its several reports on disability, the Institute of Medicine has stressed the 

importance of a new concept for rating disability.102 When the Rating Schedule was 

initially developed, the degree of disability was measured by the degree of impairment. 

A more comprehensive rating system would: 

 Consider disability as the product of a dynamic interaction among a person’s 

health status, environment, and personal context

 Recognize that disability affects more aspects of a person’s life than the ability 

to work and limits all kinds of activity and participation in community and 

family life and 

 Measure the person’s ability to function directly instead of inferring it from 

physical impairments.

VA’s rating system, which focuses on limitations or loss of specific bodily parts or 

functions, does not map well to the more complex understanding of disability that has 

 

102 The most recent report in the series is Institute of Medicine. The Future of Disability in America. 

Washington, DC: National Academies Press, 2007. 
 

107

developed over the past few decades. In particular, it does not directly measure

functional losses relevant to ability to work or participate in other activities. 

Consistency of Evaluation Process and Rating Outcomes 

Although DoD and VA both use the VA Schedule for Rating Disabilities, the two 

departments often base their overall ratings on a different set of medical conditions. DoD 

assigns disability ratings for service-limiting medical conditions only, whereas VA 

ratings take into account all medical conditions incurred during or aggravated by 

military service. For this reason, VA’s combined disability ratings for all medical 

conditions are often higher than DoD’s. 

For the same medical condition, the ratings should be consistent across and within 

the departments, because they use the same rating schedule. However, a Center for 

Naval Analyses comparison of DoD and VA ratings for about 65,000 veterans showed 

that VA ratings within a year or two of discharge are 20 to 40 percentage points higher 

than DoD ratings for the same individuals.103 The higher VA ratings result primarily 

from the rating of more medical conditions, not higher ratings for individual conditions. 

Within DoD, the Army’s Physical Evaluation Board has granted substantially more zero 

percent ratings (30 percent of all ratings) than have the other Services’ boards (which 

average 4 to 5 percent).104 Similar rating inconsistencies have been found across the 57 

regional offices where VA claims are processed.105

The Physical Evaluation Board procedures described above for active-duty 

personnel are supposed to be the same for Reserve Component members. However, 

some of the rules may affect reservists differently, and the process may not unfold in the 

same way. Indeed, Government Accountability Office (GAO) reports from 2005 and 

2006 analyzed Army data and found differences in the handling of Army active-duty and 

Reserve Component cases, including: 

 Reservists declared unfit by a Physical Evaluation Board were less likely to 

receive permanent disability retirement or lump-sum disability severance pay; 

 Reservist cases take longer to resolve and 

 The process for extending a reservist’s period of active duty, so that he or she 

may receive medical treatment, is “convoluted and poorly defined,” according 

to the GAO, resulting in some reservists’ being inappropriately dropped from 

active duty and consequent gaps in pay and benefits.106

 103 Commission on Veterans Disability Benefits. Statement Of James Terry Scott, Ltg Usa (Ret) 

before the United States Senate Joint Hearing of the Armed Services and Veterans’ Affairs Committees on 

April 12, 2007. 104 This comparison was part of ongoing research for the Veterans Disability Benefits Commission 

and involved service members who had medical separations or retirements from 2000 to 2004. 105 U.S., Government Accountability Office. Veterans’ Benefits: Further Changes in VBA’s Field 

Office Structure Could Help Improve Disability Claims Processing. GAO-06-149, December 9, 2005. 

Available at http://gao.gov/new.items/d06149. 106 U.S., Government Accountability Office. Military Disability Evaluation: Ensuring 

Consistent and Timely Outcomes for Reserve and Active Duty Service Members. GAO-06-561T, April 6, 

2006. Available at http://www.gao.gov/new.items/d06561t. U.S., Government Accountability Office. 
 

108

These differences for reservists are compounded by differences in the application 

of policy between active and reserve personnel. For example, DoD will consider medical 

conditions that existed before military service only after eight years of service. Part-time 

reservists do not accumulate eight years’ service for many years. 

As expected, the Commission’s survey shows relatively high DoD disability 

ratings for injured service members who are medically evacuated to the United States 

(Figure 7). Three-fourths of those who have completed the ratings process qualified for 

medical retirement and two-fifths received a rating above 50 percent. Nevertheless, 60 

percent thought their DoD rating should be higher and, even thought their VA was 

substantially higher (Figure 8), almost as many thought it should be higher, too. 

Figure 7─ DoD Disability Ratings Reported in PCCWW Survey 

0%

10%

20%

30%

40%

50%

60%

0-20% 30-40% 50-90% 100%

Disability rating

Percent of 

respondents

Figure 8─ Comparison of DoD and VA Disability Ratings for Separated/Retired 

Survey Respondents 

0%

10%

20%

30%

40%

50%

60%

DoD ratings VA ratings

Disability rating

Percent of 

respondents

0-20%

30-40%

50-90%

100%

 Military Pay: Gaps in Pay and Benefits Create Financial Hardships for Injured Army National Guard and 

Reserve Soldiers. GAO-05-322T, February 17, 2005. Available at http://www.gao.gov/new.items/d05322t. 
 

109

Long Processing Delays 

 Survey respondents who completed the DoD and VA disability processes reported 

their estimates of the length of time each process took (Figure 9). One-third reported that 

they received an answer from the DoD process within the 10-week standard; at the high 

end, 14 percent said their medical and physical evaluation board process took more than 

40 weeks. The VA disability process took a similar amount of time. 

Lost or incomplete paperwork likely added to the DoD and VA processing times; 

40 to 50 percent of service members reported that they had to resubmit paperwork. Twothirds said they were kept informed of progress during this time, but one-third said they 

were not kept informed. 

Figure 9─Length of Time to Complete DoD and VA Disability Processes, 

PCCWW Survey 

0%

10%

20%

30%

40%

Up to 10

weeks

11-20

weeks

21-40

weeks

Over 40

weeks

Percent of 

respondents

DoD

VA

Compensation Structure

The objectives of the two Departments’ disability compensation systems are 

unclear. The Commission identified four potential rationales for offering disabled 

veterans a compensation benefit, which this paper will discuss in turn: 

1. Military personnel found unfit for duty lose the option to complete a 20-year 

career and thereby earn substantial retirement benefits 

2. Civilian employment opportunities may be more limited, possibly leading to 

lower earnings and the loss of preferred occupations 

3. The disabled veteran potentially suffers other quality-of-life losses—including 

disfigurement, inability to participate in favorite activities, and social problems 

4. Transition to civilian life and employment takes some time, especially if the 

veteran takes full advantage of the VA’s education, training, and job search 

programs. 

Annuity Pay for Loss of Military Retirement Opportunity. Service members 

who are separated or retired because of disability lose the opportunity to qualify for 

generous retirement benefits after a 20- to 30-year military career. These benefits can be 
 

110

thought of as “deferred earnings” that vest only after 20 years of service.107 This is called 

cliff vesting because there is no retirement benefit at all before the service member 

reaches 20 years and a large benefit at 20 years. Most injured service members who must 

leave the military do not reach the cliff at 20 years of service. A reasonable objective of 

DoD’s disability compensation system would be give them a retirement benefit in the 

form of annuity pay scaled to the years of service they did provide. Indeed, the DoD 

compensation formula for medical retirees mirrors in part the formula of retirement pay 

for qualifying individuals. 

Figure 10─ Percent of Enlisted and Officer Personnel Who Remain 

in Service 

0%

20%

40%

60%

80%

100%

1

Percent of 

respondents

Enlisted

Officers 30%

13%

5 10 15 20 25 30

Years of service

 Source: Defense Manpower Data Center continuation rates for 2006. 

The loss of benefit is higher the greater the likelihood that the service member 

would have stayed for 20 years. The vast majority of service members do not plan on a 

military career and return to civilian life after four to eight years of service (Figure 10). 

After the eighth year of service, however, most members who intend to leave have done 

so, and those remaining are likely to be committed to a military career. Since most career 

personnel retire promptly when they become eligible to do so, at 20 years of service, the 

value of military retirement pay and benefits appears to be an important reason to stay in 

service to that point. A service member who is medically discharged after reaching the 

eight year “career stage” does lose significant lifetime income by not qualifying for 

retirement. 

 107Any change in military retirement would call for a change in military disability pay. The 

military retirement system has been a subject of policy debate for some years. The current system largely 

drives the tenure profile shown in Figure D-4. It provides no benefit for service members who leave before 

20 years of service and offers little incentive to stay in service after 20 years. The most recent retirement 

reform proposal was in 2006, when the Defense Advisory Committee on Military Compensation 

recommended full vesting at 10 years of service in an annuity beginning at age 60. If this proposal were 

adopted, and if the goal were to replace the retirement benefit for injured service members, then military 

disability compensation would be needed only for personnel in their first 10 years of service. 
 

111

 The retirement benefit lost when the career is cut short depends on rank (enlisted 

personnel earn less than officers) and years of service (members in higher years of 

service are more likely to reach retirement), but not on the level of disability. The current 

policy (which substantially increases disability compensation at 20 years in service or 30 

percent or higher disability ratings) creates incentives to reach these thresholds. 

A new compensation system that provides all medically discharged service 

members annuity pay, scaled to their years of service, would eliminate the thresholds in 

the current system. Different formulas could be used to calculate the annuity pay, 

including for example: 

 The formula currently used to calculate regular retirement pay, which is 2.5% 

multiplied by the years of service and base pay. 

 A formula that calculates the actuarially fair value of retirement pay accrued 

at each year of service, based on the formula now used to compute the accrual 

cost of retirement pay for current service. 

Table 3 presents monthly estimates of DoD annuity pay for injured service members in a 

new system, applying the first method to the cases we used earlier for Tables 1 and 2. 

Table 3─Estimated Monthly Pay under a DoD Disability Retirement Pay System 

Years of Service Enlisted Pay Officer Pay 

1 $ 36 $ 62 

6 $ 349 $ 690 

12 $ 900 $1,765 

22 $3,800 $5,530 

Table 4 shows how total DoD and VA pay would be affected by the change to a 

DoD compensation system. If, as the Institute of Medicine has recommended, VA 

disability pay is restructured with a substantially revised rating schedule and 

compensation for quality of life loss, there would be a further change. Unlike Figure 6, 

the comparison in Table 4 incorporates the higher VA disability rating for amputees to 

account for other service-connected medical conditions. Under the current VA disability 

compensation scheme and adding a DoD annuity payment, all of the cases would gain 

under the new DoD system. 

An increasingly valuable benefit is lifetime TRICARE coverage for retired 

service members and dependents. However, the current policy of offering TRICARE 

only to those whose disability is rated at 30 percent or more appears arbitrary. Providing 

TRICARE to all medically discharged members whose injuries are determined to be 

combat related would ensure access to needed health care services for them and their 

families. 

Work Disability Pay for Loss of Civilian Earnings Capacity. Congress has 

directed that the VA disability compensation system should replace lost civilian earnings. 
 

112

It is not easy to know what those earnings might have been. More important, disability 

pay can reduce an individual’s incentive to work or to invest in additional education and 

training, and warnings about these disincentives have been repeatedly cited, going back 

to the Bradley Commission.108 Too generous compensation interfere with the goal of 

returning disabled veterans to as near-normal life as possible—a goal that this 

Commission strongly endorses. 

Table 4─Effect of DoD Disability Retirement Pay Change on Total Disability 

Compensation for Selected Cases 

Completed Enlisted Officer 

years of 

service 

Current 

System 

New 

System 

Current 

System 

New 

System 

Amputation

1 $1,165 $ 1,201 $1,165 $1,227 

6 $1,220 $ 1,569 $1,840 $1,910 

12 $1,289 $2,189 $2,350 $3.054 

22 $4,514 $4,514 $6,244 $6,244 

Quadriplegia

1 $ 6,164 $ 6,200 $ 6,164 $ 6,226 

6 $ 6,303 $ 6,652 $ 6,303 $ 6,993 

12 $ 6,474 $ 7,374 $ 6,474 $ 8,239 

22 $10,274 $10,274 $12,004 $12,004 

Preliminary research results show that, on average, veterans with a disability 

rating below 50 percent suffer little earnings loss. This is an average finding and, at each 

disability rating level, some veterans do make less than they would have without the 

injury. Others who take advantage of the education and training benefits may earn more 

than they would have. New models for replacing earnings loss associated with disability 

are being developed and tested by a number of state workers compensation programs.109 

For example, one new approach replaces the average earnings loss for those who earn 

less than comparable non-disabled workers but phases out disability pay out for those 

who earn more. Regardless of the approach used, keeping work disability pay at modest 

levels for those who should be able to work will support incentives for work. 

Quality of Life Pay. Aside from earnings, the disabled veteran potentially 

suffers a wide array of “quality of life” losses—including the inability to participate in 

favorite activities, social problems related to disfigurement or cognitive difficulties, and 

 108 Research has shown that workers compensation or disability pay tends to decrease 

employment, functioning, and quality of life. See, for example: Duggan M, R Rosenheck, Federal Policy 

and the Rise in Disability Enrollment: Evidence for the VA's Disability Compensation Program, NBER 

Working Paper No. 12323, 2006 and Atlas SJ, Y Chang , RB Keller, et al. “The Impact of Disability 

Compensation on Long-Term Treatment Outcomes of Patients with Sciatica due to A Lumbar Disc 

Herniation,” Spine 31: 3061-9, 2006. 

109 Barth, PS. “Compensating Workers for Permanent Partial Disabilities” Social Security Bulletin 

65:16-23, 2003/2004. 
 

113

the need to spend a great deal of time performing activities of daily living. VA’s monthly 

payment add-ons for specific impairments—primarily anatomical losses110 —arguably 

compensate for some functional limitations not related to work (such as loss of 

reproductive organs), but basing compensation on the specific loss and whether the 

veteran has suffered multiple losses is not a good measure of quality of life loss. 

 A different approach to quality of life loss would be more consistent with the 

concept of disability advocated by the World Health Organization and the Institute of 

Medicine. This system would consider the effects of medical conditions on a broad array 

of outcomes: activities of independent living, recreational and community activities, and 

personal relationships. Measures of these outcomes are available that could be used as 

the basis for quality of life pay for veterans and the Canadian and Australian veterans 

disability system include quality of life payments.111 

Transitional Income Gap. The current DoD-VA compensation system does not 

guarantee an uninterrupted income as service members with disabling injuries transition 

from active duty to veteran status. Even if VA disability pay begins immediately after 

discharge, all but the most severely disabled veterans experience a decrease in income 

until the veteran completes rehabilitation, acquires any further education and training, 

and finds a job.112 A stipend during rehabilitation, education and training, and a 

reasonable period for job search would support the veteran and family during this critical 

recovery and reentry period. The Subcommittee Report on Education, Training, and 

Employment emphasizes the importance of providing a stipend to encourage and support 

veterans to invest in education and training to enhance their employment prospects and, 

for the most disabled, their independent living skills. A similar stipend for a few months 

would allow veterans who do not pursue education and training to search for a job with 

help from the VA and other federal and state agencies. 

Figure 11 shows how the four types of compensation would be synchronized to 

support the service member and family during the transition to civilian life and work. All 

medically discharged service members would receive the following three pay streams: 

1. Annuity pay, beginning at discharge and continuing throughout the 

individual’s life 

2. Quality of life disability pay, also paid from discharge to death 

3. Work disability pay, with two components: 

a. Transition pay while the veteran looks for a civilian job or participates 

in an intensive medical or vocational rehabilitation program, as called 

 110 The anatomical losses include: loss, or loss of use, of a hand, foot, reproductive organ, both 

buttocks; immobility of a joint or paralysis; loss of sight of an eye; deafness of both ears; inability to 

communicate by speech; loss of a percentage of tissue from a single breast, or both breasts, from 

mastectomy or radiation treatment. 111 Institute of Medicine. A 21st Century System for Evaluating Veterans for Disability Benefits. 

Washington, DC: National Academy Press, 2007. 112 Testimony by William Carr, Principal Director of Military Personnel Policy, Office of the Secretary of 

Defense before the Commission on April 14, 2007 indicated that the average medically discharged service 

member has experienced an annual income drop from $38,000 to $18,000 during the transition to civilian 

employment. 
 

114

for in their recovery plan113; those who immediately look for a civilian 

job would receive transition pay for only three months. 

b. Work disability pay, if needed to replace an earnings loss, to begin 

when the transition pay ends; veterans who receive this pay but are 

able to work would need to reapply for this pay and be reevaluated on 

a fixed schedule (such as every five years). 

Figure 11. A Streamlined DoD/VA Retirement and Disability Compensation System 

At any point in time, disabled veterans would receive three types of payments:

 Point of Discharge Point of Retirement 

 d d

 Throughout “working years,” veterans would receive . . . 

After 

retirement . . . 

1. DoD’s Military 

Annuity 

Payments $ amount based on rank and years of military service

2. VA Quality of 

Life Disability 

Payments $ amount based on impacts on quality of life 

3. Transition 

payments* 

4. Followed by . . . 5. Followed by . 

. . 

fEITHER Long-term living 

expense support 

while in school/VRE 

Earnings loss payments when 

employment begins** 

Social 

Security 

fOR 3 

months 

Earnings loss payments when employment begins 

** 

Social 

Security 

*To help veterans become established and move into work or, if unable to work, to enable independent 

living. 

**These payments would contribute to veterans’ earnings for Social Security eligibility; the amount would 

be recalculated periodically as veterans’ condition or earnings change. 

If carefully designed, the compensation package could provide incentives for veterans to 

make the investment in recovery and education that will enable them to lead productive 

and active lives. In this way, VA’s resources can be redirected over time to education 

and training investments that make income support for most disabled veterans 

unnecessary. The Bradley Commission endorsed this strategy 50 years ago, stating: 

Timely assistance on a temporary basis to help wartime veterans become self-sufficient 

and productive members of society is an effective alternative to the backward-looking, 

less constructive ‘old soldiers’ pensions. Education and training and related readjustment 

benefits are now recognized as the best way of discharging the Government's obligation 

to the non-disabled. 

 

113 The recovery plan is described in the Subcommittee Report on the Continuum of Care. 
 

115

ACTION STEPS 

The President’s Commission supports a major restructuring of disability benefits 

that is tailored to the unique needs of individual service members injured in the line of 

duty and provides the incentives and services necessary to bring disabled individuals 

back into the mainstream of American life. The restructuring should also substantially 

simplify the disability program and the processes for evaluating disability and 

determining fitness for continued military service. 

Action: Congress should clarify the objectives for DoD and VA disability systems to 

reflect the goal of returning injured service members to optimal functioning in American 

society. 

Action: Create a clear and timely disability evaluation process that: 

 Uses a single medical examination to provide baseline data at the time of military 

discharge for the initial disability rating 

 Allows the different Services to continue to determine fitness to serve 

 Applies a single baseline disability rating for all service-connected conditions at 

the time of discharge from the military 

 Updates the disability rating schedule to reflect injuries sustained in modern 

warfare and modern concepts of the impact of disability on multiple domains of a 

veteran’s life and 

 Keeps the rating schedule current as warfare, rehabilitation technology, and 

medical care changes 

Action: Redesign disability compensation, based on clarified objectives and clearly 

differentiating the responsibilities of DoD and VA for separate components of a 

coordinated system. 

 DoD would compensate injured service members for the loss of a military career, 

with an annuity payment commensurate with time served 

 VA would provide transition pay while veterans adjust to civilian life or 

participate in the Vocational Rehabilitation and Employment program. 

 VA would base subsequent compensation on diminished civilian earnings capacity 

and quality of life. 

VA compensation rates would be regularly updated based on frequent evaluation of 

earnings and quality of life of disabled veterans. 
 

116
 

117

INFORMATION SYSTEMS 

THE CHALLENGE 

The medical system required to meet the long-term care and rehabilitation needs 

of America’s injured service members has become highly complex. The treatment path 

stretches from the battlefield to acute and post-acute inpatient/outpatient care to the 

service members’ transition back into military duty and/or civilian life. Vital medical 

information is captured during the acute phase of this process. However, integration of 

the information systems necessary to make information available for the comprehensive 

care and recovery planning needed to return injured individuals to the fullest possible 

state of health and personal independence has yet to occur. This situation has been 

recognized for some years and must change. 

Electronic information systems are not an end in themselves, but a means to an 

end. The ideal health care outcome is well-managed, high-quality patient care in 

efficiently run facilities by staff who can obtain the information they need, when they 

need it, and easily enter important new information. A smoothly functioning benefits 

process needs to be coordinated with the health care process to ensure that injured service 

members and their families are supported throughout recovery. The movement towards 

information interoperability that is under way in some critical systems must be 

accelerated and expanded to include other information needed day-to-day. Simply put, 

our nation’s service men and women would be underserved if we failed to take this 

opportunity to improve IT systems at the Department of Defense and Department of 

Veterans Affairs to create, manage, and transmit vital data that make navigating the 

system of care and benefits easier, more efficient, and more effective. 

BACKGROUND 

Information Is Essential for Patient-Focused Integrated Care & Services 

Given the complexity of the medical and rehabilitative services required to care 

for seriously injured military personnel, it is necessary to carefully coordinate the 

expertise of multiple medical, rehabilitative, and benefits specialists in multiple facilities 

over an extended period of time. This commission has recommended that care delivery 

be guided by comprehensive, patient-centric recovery plans, developed by the patient’s 

multi-disciplinary care team, with a Recovery Coordinator responsible for seeing that the 

plan is implemented.114 To develop and implement the recovery plan, every Department 

of Defense (DoD) and Department of Veterans Affairs (VA) physician, allied health 

professional, and benefits specialist involved in the treatment, rehabilitation, and support 

 

114 See the Subcommittee Report on the Continuum of Care. 
 

118

of an injured service member should have immediate access to the relevant medical and 

administrative information for that individual 

The recovery plan program will expand both the quantity and the types of 

information that the DoD and VA need to share. For example, acute rehabilitation for 

amputees is provided by DoD, but vocational rehabilitation services are a VA 

responsibility. All caregivers involved in this example will require immediate access to 

timely information on a patient’s status, service use, and outcomes to create an effective 

individualized treatment, rehabilitation, health promotion, retraining, and reemployment 

or independent living plan. Our present challenge centers on integrating DoD and VA 

information systems that were originally designed to focus on specific components of the 

care or administrative process and do not readily exchange the information necessary to 

support a recovery plan. 

Current IT Systems Supporting DoD Patient Care 

Over the years, information systems have been developed to support specific 

health care processes of the various military services. As a result, segregated data are 

often collected in many systems that each support a portion of the overall patient care 

process. The information needed for care of injured service members currently resides in 

the following systems: 

 Electronic Health Record. AHLTA115, the DoD’s electronic health record, is 

available wherever the military delivers health care services, around the world. 

At present, the electronic record includes outpatient encounters and laboratory 

and radiology reports; it does not yet include inpatient medical records, but 

does include discharge summaries from inpatient hospitalizations. 

 Electronic Health Record-Theater Version. Military medical personnel in 

Iraq and Afghanistan have access to a theater version of AHLTA, AHLTAT.116 The implementation of AHLTA-T began in 2003 with a fully integrated 

outpatient record and, as of May 2007, the theater data are globally available 

for inpatient encounters, pharmacy, laboratory, and radiology reports through a 

central theater data repository. Providers outside the theater—at Landstuhl 

Regional Medical Center in Ramstein, Germany, and in the United States—

can access information from this repository through a web-based application. 

 Joint Theater Trauma Record. This system was developed during the 

current conflict to collect theater battle-trauma patient data across all levels 

of care. 

 Patient Movement and Patient Tracking. The TRANSCOM Regulating 

and Command and Control Evacuation System (TRAC2ES) provides in-transit 

visibility on patients as they are evacuated from a theater hospital to Landstuhl 

and U.S. facilities. The Joint Patient Tracking Application (JPTA), deployed 

 

115 AHLTA - Armed Forces Health Longitudinal Technology Application. 116 AHLTA-T outpatient encounters are transmitted through a theater data repository (Theater Medical Data 

Store, or TMDS) to the AHLTA Central Data Repository and are viewable in TMDS and AHLTA. 

Inpatient and ancillary encounters are transmitted to TMDS and are viewable through the TMDS webbased application. 
 

119

in January 2004, locates patients within military medical treatment facilities, 

captures diagnoses, and documents patient treatment notes. DoD grants VA 

providers access to the patient tracking database via the Veteran Tracking 

Application. 

AHLTA resides on networked computers and, because there are separate 

networks for the different military services, problems occur. Even if the system operates 

as designed at individual military treatment facilities, the network infrastructures can 

impede access to information across facilities. For example, Brooke Army Medical 

Center frequently cannot obtain ready access to the Air Force network to retrieve 

AHLTA records at the Wilford Hall Medical Center, 18 miles away, even though these 

two large medical centers treat some of the same patients. As a result, clinicians do not 

have access to critical patient information and have become increasingly distrustful of the 

IT community’s ability to provide reliable support to patient care.117

Current IT Systems Supporting DoD Benefits & Disability Processes 

A comprehensive, patient-centric recovery plan would integrate planning for the 

care of seriously injured service members with their benefits and post-recovery activities. 

A fully interoperable electronic health record system would provide much of the 

information needed. However, a relevant picture for each patient is fully achieved when 

clinical and administrative systems are integrated. Within DoD, the key administrative 

systems are: 

 Personnel and Pay Systems. The military services have maintained their 

own independent personnel systems. Next year, the new Defense Integrated 

Military Human Resources System will begin to replace these separate 

systems with a single, integrated system for active duty and reserve component 

personnel. 

 Disability Systems. Service disability information systems also are standalone, and, in many cases, are using outdated applications to document the 

medical and physical evaluation processes. 

The complexity of moving wounded and injured patients from point of injury to 

medical facilities throughout the continuum of care is measured by the myriad of Jointand Service- sponsored systems available (Figure 1). However, despite the number of 

systems deployed to support this process, there are gaps in available information. 

Although seriously-injured patients are receiving excellent direct care from health care 

providers in theater, patients can be invisible to the system during certain phases of 

evacuation. In addition, health care providers and administrators are often required to 

enter the same information in several different systems, while information users must 

access multiple sources in order to piece together a full picture. 

 

117 Commission staff site visit to Brook Army Medical Center, San Antonio, TX – June 4, 2007. In 2006-

2007, DoD expert teams concluded that the current IT network environment is unsustainable and seriously 

detrimental to patient care. 
 

120

Current IT Systems Supporting VA Health Care 

The majority of VA’s IT systems involve multiple sub-systems that have been 

designed to address specific needs, not to work together in an efficient, coordinated way. 

In general, VA employees who work in one functional area can see some data from 

another area, but cannot exchange data from one system to another. Information 

provided by external sources—DoD, other federal agencies, such as the Internal Revenue 

Service or the Social Security Administration, or the private sector—that may be of value 

for care or benefits is rarely available across organizational functions to serve common 

needs. Figure 2 depicts the existing systems that support the VA’s medical and other 

benefits programs. 

Developed in the early 1980’s, VistA, VA’s electronic medical record system was 

one of the first such systems. It was revolutionary in its ability to support the clinical 

decision making process, but it has become rapidly outdated and is increasingly difficult 

to maintain. VistA currently consists of 128 stand-alone systems118 that generally run the 

same software, but different institutions use different formats and include different 

content, which makes system data difficult to meaningfully integrate and compare. 

Records for patients usually treated at one facility are viewable by providers at other 

facilities. However, because the data are not standardized, VistA is not fully 

interoperable across VHA facilities and can not be used for clinical decision support 

systems. (Such systems automatically produce clinical reminders or notify providers 

when there is a potential drug/drug or drug/allergy interaction, for example.) 

 VA has a long-range plan to update VistA. Like AHLTA, patient data will be 

stored in a single repository where providers can access and contribute information. The 

plan involves data standardization and the replacement or re-engineering of the majority 

of the existing VistA components by 2014. This future system, VistA 2.0, is intended to 

provide all of the necessary information to support the provision of health care 

throughout the VA. 

Current IT Systems for Administering VA Benefits & Disability Processes 

VA also uses a grouping of stand-alone electronic systems to support each of its 

major service areas: compensation and benefits, education, loan guarantees, vocational 

rehabilitation and employment, and insurance. Modifications and upgrades to these 

systems have been ongoing for several years and have undergone a degree of critical 

scrutiny from several oversight bodies. The information systems share information and 

computer applications on only a limited basis. Although there has been some degree of 

re-engineering, for the most part the systems are antiquated, difficult to maintain, and not 

easily updated when there are changes to the benefits provided to eligible veterans and 

family members. Additionally integration between these systems and VistA is limited, 

 

118 Testimony of Dr. Steven H. Rappaport at the Commissions public hearing in Washington, DC – May 

16, 2007. 
 

121

which complicates the consistent provision of benefits or health services. For example, 

claims for benefits decisions are maintained in multiple places in both benefits and health 

systems and are not synchronized when the authoritative sources are changed. This can 

lead to incorrect benefits determinations, mistakenly billing the veteran for care or 

services that they are entitled to without charge, and general frustration for the veteran 

and users of these systems. 

Current Status of DoD-VA Interoperability: Exchanging Information on Health, 

Benefits, Disability, & Support Programs 

The Center for Information Technology at the National Institutes of Health has 

defined four levels of data interoperability:119

 Level 1: Non-electronic data—paper and phone calls 

 Level 2: Machine transportable data—unindexed documents, fax, and email 

 Level 3: Machine organizable data—indexed documents and images 

 Level 4: Machine interpretable data—transfer of data from one system to 

another without need for further translation or interpretation. 

Calls for DoD-VA data interoperability typically envision exchanges at level 4, whereas 

much of the current data exchange is at level 3 or below. If the data being exchanged are 

comprehensive and timely, level 3 exchange can be highly effective as a step toward the 

much more difficult level 4 exchange. 

The missions of DoD and VA are closely intertwined when it comes to the 

delivery of health care, benefits, and other support services. In addition to its mission to 

support health care and benefits for disabled veterans, the VA is required to maintain and 

document additional inpatient capacity during times of war. Today, the VA provides 

injured or ill service members with: 

 Complex medical care at VA Polytrauma Rehabilitation Centers; 

 Physical therapy and rehabilitation care; 

 Treatment for combat-related Post-Traumatic Stress Disorder (PTSD); 

Post–deployment, the VA, in conjunction with the military health system may be heavily 

involved in assessing and tracking conditions related to service members’ environmental 

exposures, such as Gulf War Syndrome, or other delayed-onset illnesses, such as 

undetected PTSD. 

VA disability determination requires accurate and timely information from DoD, 

confirming military service and describing the claimant’s medical condition. The 

automated sharing of this information has been a long-standing initiative of the two 

Departments and has received a significant amount of attention from multiple 

administrations and legislative bodies. 

 

119 http://www.nahit.org/cms/index.php?option=com_content&task=view&id=220&Itemid=115, accessed 

July 19, 2007. 
 

122

Interoperability of Health Care Information 

Figure 3 depicts the current and planned health information flows between the 

departments. Prior to combat operations in Afghanistan and Iraq, the focus was on the 

unidirectional exchange of information from DoD to VA, in order to help the VA 

understand the care that veterans had received within the military. As efforts progressed, 

a bi-directional exchange seemed more desirable, to include information about, for 

example, patients’ allergies, lab and radiology results, and pharmacy data. In support of 

the complex medical needs of service members transferring to VA Polytrauma 

Rehabilitation Centers, scans of patients’ radiology and medical records are now being 

transferred to the VA’s integrated imaging system. At present, the information 

exchanged between the two Departments is fully viewable within the VA system while 

the DoD uses a web-based application to view information passed back from the VA. 

 The Clinical Health Data Repository interface, currently being tested in several 

locations, supports the interchange of data elements in real time rather than via the 

movement of batches of data at regular intervals. This system leverages the DoD’s 

Clinical Data Repository and VA’s Health Data Repository–the standardized, 

authoritative source for the exchange of clinical data within each Department. The 

interface will extend this capability to support exchange between the Departments and 

guarantee that providers can have the most current patient data available at the point of 

care.

Electronic information exchange began in 2001 and progressed slowly through 

2004, but the pace of progress has increased steadily beginning in 2005. The full 

timeline and critical milestones supporting the exchange of medical information between 

the two departments is reflected in Figure 4. External reviews have determined that DoD 

and VA have made progress in improving the interoperability of their electronic health 

record systems (level 3) but are far from having comprehensive electronic medical 

records (level 4).120 

Interoperability of Benefits & Support Services 

The flow of administrative and benefits data between the two Departments is 

more rudimentary. The current data exchange consists of 31 separate data feeds from 

DoD’s Defense Manpower Data Center to various VA entities and 11 feeds from VA to 

DoD. In 2003, as part of an Electronic Government (e-Gov) initiative, the Departments 

began the process of combining these feeds into a single incoming and outgoing data 

stream. Progress has been made in identifying the business needs for the data and the 

nature of the information each Department needs. Systems in both Departments are 

being modified and brought on-line to leverage the new data. 

 

120 U.S., Government Accountability Office. Information Technology: VA and DoD Are Making Progress 

in Sharing Medical Information, but are Far from Comprehensive Electronic Medical Records. GAO-07-

852T. Testimony, May 8, 2007.
 

123

To support VA’s outreach efforts to service members and veterans and to support 

the provision of VA health care for two years post-deployment, the interfaces were 

recently upgraded to include information on activations and de-mobilization of reservists. 

Additionally, as part of the efforts to support the educational benefits program, data were 

added to the bi-directional exchange of information provided between VA and DoD. The 

Departments are currently discussing plans for further improvements to support 

administrative and benefits processes, with emphasis on improving e-benefits systems.

The Future Direction of DoD & VA Health & Benefits IT Systems: What’s In the 

Works... 

DoD and VA plan to build data repositories that contain information based on industry or 

other agreed-upon standards. Figure 5 presents a schematic view of what the Departments 

are trying to achieve. In summary, they believe that: 

• The repository concept will allow for information to be easily exchanged or 

accessed to meet the health care and benefits needs of any service member or 

veteran. 

• Timely and relevant information will be available from any of the repositories to 

support care or administrative decisions. 

As reflected by the data sources in grey, we observed that little has been done to support 

the availability of Military Disability and Finance and VA benefits and ratings 

information. 

Figure 5─Overview of DoD/VA Information Exchange Efforts

Military

Health

VA

Health

Military

Personnel

Military

Disability

Military

Finance

VA

Benefits

Information 

Exchange

&

Interoperability

Legend:

Active Improvement Efforts

Future Efforts
 

124

PREVIOUS TASK FORCE RECOMMENDATIONS AND REPORT 

FINDINGS 

This Commission reviewed numerous reports and task force recommendations 

that addressed the information systems in the DoD, VA, and private sector and how well 

they support health care delivery to injured service members and veterans. A common 

theme among these reports, going back to 2001, is the need for interoperability between 

the DoD and VA medical information systems. In 1996, the Presidential Advisory 

Committee on Gulf War Veterans’ Illnesses121 reported on the many deficiencies in the 

two Departments’ capabilities for handling service members’ health information. In 

November 1997, the President called for the Departments to start developing a 

“comprehensive, lifelong medical record for each service member,” and in 1998 issued a 

directive requiring them to develop a “computer-based patient record system that will 

accurately and efficiently exchange information.” 

According to the GAO’s most recent congressional testimony regarding the 

departments’ progress toward information-sharing, 

“To achieve this goal, significant work remains to be done, including agreeing to 

standards for the remaining categories of medical information, populating the data 

repositories with all this information, completing the development of their modernized 

systems, and transitioning from the legacy systems. Consequently, it is essential for the 

departments to develop a comprehensive plan to guide this effort to completion, in line 

with our earlier recommendations.”122 

In this testimony, GAO summarized several of its recurring recommendations and 

findings regarding VA and DoD’s efforts to create a comprehensive electronic medical 

record: 

 VA and DoD need a comprehensive strategy for implementing a 

comprehensive medical record; 

 Progress has been made exchanging clinical information but a comprehensive 

medical record would better achieve the departments’ long-term goal of 

comprehensive, seamless exchange of health information; 

 Program delays and target date slippage in the implementation of elements of 

a comprehensive approach have been impeding the exchange of information 

between the organizations, delaying accomplishment of the long-term 

objectives; 

 It is not clear how short-term initiatives to share health information between 

existing systems fit into the overall strategy; 

 In some areas VA and DoD still need to agree on the information standards 

needed to facilitate the transfer of information between Departments; 

 VA and DoD must address data quality and availability challenges. For 

example, VA still has to convert its electronic records into the interoperable 

 

121 Presidential Advisory Committee on Gulf War Veterans’ Illnesses. Final Report. Washington, DC: U.S. 

Government Printing Office, December 1996. 122 U.S., Government Accountability Office. Information Technology: VA and DoD Are Making Progress 

in Sharing Medical Information, but are Far from Comprehensive Electronic Medical Records. GAO-07-

852T. Testimony, May 8, 2007 
 

125

format appropriate for a repository. DoD, in addition to converting current 

records from its systems supporting each [military] service, must also address 

medical records that are not automated. 

 The influx and complex medical needs of service members injured in Iraq and 

Afghanistan has intensified the stress on the two Departments’ ability to exchange 

clinical and administrative information. Recent GAO reviews have underscored the need 

for more rapid progress in information-sharing, in order to streamline delivery of benefits 

and services. Specific types of information that need to be shared efficiently include: 

 Clinical information necessary to help determine the level of services that will 

be needed once a patient is transferred to a VA Polytrauma Rehabilitation 

Center123 

 True interoperability of medical records for active duty service members 

treated in VA facilities; 

 Appropriate and necessary DoD medical and personnel information 

electronically viewable for VA benefits determination; 

 Routine transmittal to VA of health information on service members likely to 

be discharged from the military due to their medical condition; 

 Post-Deployment Health Reassessment Program (PHDRA) data to VA124

The 2007 report of the Task Force on Returning Global War on Terror Heroes has 

provided several short, mid, and long-term recommendations related to the use of 

information technology to address gaps in services provided to injured service members. 

Several of these recommendations support of the two Departments’ ongoing plans to 

improve clinical information exchange and interoperability. However, the Task Force 

identified immediate goals to address issues related to tracking service members and 

signature injuries and illnesses: 

 The provision of increased access by VA and DoD staff to available 

information systems to assure continuity of care and coordinated patient handoff. 

 The increased use of interfaces that allow scanned records (medical images 

and inpatient records) to be exchanged between DoD and VA. 

 The creation of data markers, clinical reminders and databases to track current 

combat veterans’ identification, and patients with traumatic brain injuries, 

embedded fragments, and polytrauma. 

 Improvements to the VA’s Electronic Benefits Claims Enrollment processes 

and IT systems. 

The DoD Task Force on Mental Health also supported the need for the exchange 

of all relevant medical records between DoD and VA. It also recommended faster 

development of a mental health module in AHLTA. 

 

123 U.S., Government Accountability Office, DOD and VA Health Care: Challenges Encountered by 

Injured Service members During Their Recovery Process. GAO-07-606T. Testimony, March 8, 2007. 

124 U.S., Government Accountability Office. Computer-Based Patient Records: A and DOD Have Made 

Progress, but Much Work Remains to Fully Share Medical Information. GAO-05-105IT. Testimony, 

September 28, 2005 
 

126

The thread throughout all of these reviews and recommendations is that process 

improvements to support the needs of returning service members must be supported by 

improved information systems. 

WHAT THE PRESIDENT’S COMMISSION LEARNED

Based on the Commission’s recommendation to create a comprehensive patientcentric recovery plan, the first step in implementing this vision is to take a hard look at 

the Departments’ processes, and improving them as needed. The information system can 

then be designed to reflect best organizational practices. 

This Commission is recommending the development of a recovery plan for each 

seriously injured service member transitioning between the in-patient (hospital) and outpatient (ambulatory) care environments. The recovery plan is fundamental to retaining a 

patient-focused care philosophy through an injured service member’s complete path 

towards recovery. For the recovery plan to function effectively, every health-care 

professional and service provider involved in the treatment, rehabilitation, reintegration, 

and support of injured service members must have immediate access to the medical and 

appropriate personnel and benefits information. 

The recovery planning model would expand both the quantity and the types of 

information that the two Departments would need to share. The services provided by the 

multi-disciplinary teams reside in both Departments—for example, acute rehabilitation 

for amputees is provided by DoD, but vocational rehabilitation services are a VA 

responsibility. Therefore, the seriously injured service members whose care and recovery 

will be complex will have provider teams that include DoD and VA staff and require 

coordinated administrative actions. The recovery plan will guide post-acute treatment, 

rehabilitation, health promotion, retraining, and reemployment. Service members will be 

periodically reevaluated, and their plans updated, as their medical condition, functioning, 

and circumstances dictate. Timely information on service members’ status, service use, 

and outcomes will enable the Recovery Coordinator, the care team, and service providers 

to design and implement the recovery plan and maximize the patient’s health and life 

outcomes. 

Capability of Current DoD/VA IT Systems to Support Patient Care 

Through testimonies to the Commission during public meetings and opportunities 

to review the information systems during site visits,125 the Commission learned that 

existing information systems within DoD and VA focus on specific components of the 

care process and have not been built to support activities that cross organizational 

boundaries. As clinical and administrative processes have been modified to support the 

seamless transition of the injured service member, the pace of information system 

development has lagged. Today’s information systems are not appropriately aligned to 

 

125 Testimony of Dr. Paul Tibbits at the Commissions public hearing in San Diego, CA – May 24, 2007. 
 

127

efficiently support the proposed recovery plan process or effective case management.126

Examples and observations include: 

 The systems have been built to support episodic care and not care based on a 

long-term treatment plan. The DoD health care model is focused on capturing 

treatment information and being able to pass it along to the next location 

where the service member is cared for. The VA’s system has traditionally 

been designed to support care provided within VA medical facilities and other 

clinical settings. Neither system has been designed to support care across 

multiple specialties and administrative processes. 

 We observed that the existing systems do not support fully the tracking, and 

health information needs of injured service members who are moving between 

the DoD and VA medical facilities. 

The impact of these weaknesses is particularly evident for polytrauma cases that 

receive acute care in the military hospital, then are transferred to a VA Polytrauma 

Rehabilitation Center, and eventually may return to the military health system. To 

address the shortfall in the availability of electronic clinical data, DoD and VA health 

providers have established informal standards for what should be included in the paper 

record that accompanies the patient being transferred. Acute-care information that may be 

missing is obtained through phone calls and fax requests.127 VA staff then review the 

available paper-based information and scan indexed information into VistA Imaging—an 

interface that allows providers to view scanned records. Though manually intensive, the 

scanning of information into VistA Imaging will make the image available to all other 

VA facilities; referring to the definition presented above, this process increases 

interoperability of information for polytrauma patients from level 1 to level 3. The same 

level of interoperability is not achieved for all injured service members, however. 

In an effort to provide an electronic view of the military’s patient record, DoD has 

begun scanning inpatient medical records and transferring this information to VA’s 

Polytrauma Rehabilitation Centers. As an interim solution, until a standardized data 

exchange methodology can be determined, VA staff then manually imports this file into 

VistA Imaging. However, the Commission observed that, since the full record is 

contained in a single file which is quite voluminous and difficult to search, it may not 

meet the needs of the providers and are ignored. This is a time-consuming manual 

process that, if it works at all, works only because of the small number of patients being 

transferred between the two organizations. 

The commission staff also observed that while the information that is currently 

interoperable at higher levels—such as pharmacy, allergy and laboratory information—

may be of some use, other information—such as progress notes, radiology reports, 

discharge summaries—are not readily available, even though it would be of tremendous 

value in determining past treatment received or the established care plan. The VA has 

 

126 Testimony of Dr. Lynda Davis at the Commissions public hearing in San Diego, CA – May 24, 2007 127 Only a portion of the outpatient data that is available electronically in AHLTA or VistA electronically is 

currently exchanged. The paper record that accompanies patients transferred to VA facilities primarily 

contains inpatient and acute care information from the referring military facility. 
 

128

modified VistA to support the tracking of service members who have symptoms of 

traumatic brain injury and post-traumatic stress disorder. Automated clinical reminders 

in VistA notify clinicians and other health care providers when specific treatment 

protocols should be consulted. Because a similar automated clinical decision support 

system does not exist within AHLTA, reminders are generated manually, based on 

protocols used during the post-deployment health reassessment process. 

The DoD and VA’s existing interoperability strategy was determined after 

Operation Desert Storm, and was a logical one. Its focus was on environmental disease 

surveillance, managed care for TRICARE beneficiaries and exchange of information 

when service members moved to veteran status. DoD gave priority to the development of 

an electronic outpatient medical record system because at the time, it had no automated 

record of ambulatory care in military treatment facilities. Also, there were relatively few 

traumatic injuries requiring coordinated care by the VA and DoD. 

Regardless of the interoperability approach that is taken, the migration of data 

between complex information systems must start with the standardization of the 

information to be shared. There is little point in exchanging data if the receiving system 

is incapable of using it efficiently. Figures 3 and 4 (referenced above) illustrates a 

strategy that sequences the exchange of data from component systems—such as 

pharmacy and radiology—based on the amount of work needed to make them 

interoperable at levels 3 or 4. DoD and VA are partly through the implementation of this 

strategy, with only some component systems currently interoperable. 

Care for injured service members would have been better supported by a different 

strategy that made all the information needed by clinicians available at the highest level 

of interoperability possible in the short run and subsequently worked towards a higher 

level of interoperability through a component-cased strategy. DoD and VA have 

recognized the current need to support the care of injured service members and developed 

short-term solutions. Examples include the exchange of data from the Joint Patient 

Tracking Application to a Veterans Tracking Application and the manual process for 

scanning more complete medical records for polytrauma patients. A more complete 

solution would identify the information needed for the current conflicts’ most complex 

and common medical conditions, including polytrauma, traumatic brain injuries, 

amputations, and post-traumatic stress disorder. The information necessary to care for 

these patients can be determined by the providers who care for them. Where highly 

structured data are necessary and available, the Departments can determine the best route 

to be taken to achieve level 4 interoperability. In the interim, providers could use nonstructured data, such as text-based progress notes documenting previous care, information 

can be made interoperable at level 3. 

Capability of Current DoD/VA IT Systems to Support Non-Clinical Services 

Over the years the major focus of information exchange between DoD and VA has been 

on the movement of clinical data. In retrospect, the Departments are finding gaps in 

supporting case management, disability evaluation, benefits determination, and other 
 

129

administrative processes that support the seamless transition of patients between DoD 

and VA. Based on discussions with officials in both Departments, the Commission 

learned that: 

 The DoD disability evaluation process is highly paper-intensive and requires 

extensive case files to support the workings of the evaluation boards. 

Currently, little automation supports this process. 

 The official report of separation from active duty or from 90 days or more of 

active service by reservists (DD Form 214) is required before the VA can 

initiate its disability rating process. VA raters view an image of this form 

through a web interface, interpret the information they need, and manually 

enter it in the information system they use. The DD 214 is scheduled to be 

automated as part of the new Defense Integrated Military Human Resources 

System (DIMHRS) within the next 12 months. 

 As we described earlier, DoD’s Joint Patient Tracking System and VA’s 

Veteran Tracking System were developed during the current conflict to fill the 

information void on patient movement from theater to the VA.128 The VA 

uses this information to initiate timely contact with returning service members 

and initiate the disability claims process as soon as possible 

With the prevalence of case management and the increased emphasis on seamless 

transition between DoD and VA, users often resort to manual processes to exchange 

information. During the Commission’s site visits, users often expressed their frustration 

with the slowness of the systems or with needing to sign into multiple systems, each 

having only a portion of the information they need. Interim solutions are coming on line 

to replace or augment these manual processes, but there is the risk that further standalone solutions are being created because a more comprehensive approach has not been 

identified. 

DoD and VA have developed several websites to give service members and 

veterans access to their personal health information, disability evaluation and benefits, 

and a host of government and private support programs. We reviewed numerous web 

sites that may be useful to service members and their families. However, in some cases 

these web sites do not appear to be well coordinated. Similar information concerning 

disability benefits, services, military retirement, and so on, was noted on several different 

sites. Without a coordinated effort to update similar sites’ information, they will soon be 

out of sync and the accuracy of their information will be compromised. We observed that 

there is no single authoritative web site that can serve as the starting point for injured 

service members and families.129 The existing web sites typically focus on linking 

individuals seeking information to other websites. The wealth of linked information can 

make it difficult for users to find the specific information they need. A more effective 

approach would tailor sites to the user’s interests and needs (as many commercial web 

sites now do) and would be interactive, giving the user tools to update information, make 

 

128 Commission staff meeting with DoD/VA representatives re: Joint Patient Tracking Application/Veteran 

Tracking Application, June 5, 2007. 

129 Web sites reviewed: www.va.gov, www.dod.gov, www.myhealth.va.gov, www.myarmybenefits.com 
 

130

appointments, and so on. This would require access to authoritative clinical and nonclinical information systems and more sophisticated software. 

Drawing information from DoD and VA information systems, an interactive web portal, 

such as the prototype “My eBenefits” pages appended to this report, could provide 

tailored information to each service member and veteran, specific to their situation, and 

enable them to make appointments, do financial planning, maintain confidential personal 

health records, and apply for various benefits programs. Today, in order to find such 

information, armed service members and veterans must navigate a disparate, confusing, 

and cumbersome array of websites. First-rate content exists online for service members 

and their families; however, the presentation and organization of this information simply 

have not evolved to meet the needs and expectations of the next generation of service 

members. 

 

A one-stop “information shop,” such as the prototype “My eBenefits,” would be a 

consumer-friendly, interactive, evolving, fully customizable and personalized information 

portal. It would host almost every type of data important to a patient’s Recovery Plan. It 

also would include tailored, up-to-date information on federal and state benefits, inpatient and out-patient care, disability evaluation and application status, local and 

national resources from veterans service organizations and community organizations, 

area employment opportunities, doctors’ names and contact information, news, and the 

ability to connect easily with other armed service members and veterans. 

Capability of Proposed Future DoD/VA IT System Designs to Meet 

Recommendations of the President’s Commission 

A number of appropriate information strategies are being implemented to meet 

the immediate needs of injured service members. DoD’s AHLTA is becoming the 

standard system to support health care from theater to military treatment facilities in the 

United States, and the VA has plans for a next generation of VistA. Both systems are 

being designed around clinical and administrative data repositories, which will give 

providers throughout both Departments access to their patients’ health information. 

Initiatives such as the Clinical Health Data Repository, which supports the real-time 

exchange of data between DoD and VA, are significant advances and need rapid 

implementation. Yet, the health information systems provide only some of the 

information needed to manage the needs of injured service members.

System redesigns should emphasize leveraging single, authoritative data sources 

rather than duplicating information across multiple systems, which may threaten data 

integrity and confidentiality. When independent systems maintain separate copies of 

similar data elements, the ability to control changes in the data and data integrity 

becomes nearly impossible.130 Inaccurate information can jeopardize patient safety. 

Maintaining confidentiality and privacy becomes more difficult. 

 

130 Commission staff meeting with DoD/VA representatives re: Joint Patient Tracking Application/Veteran 

Tracking Application, June 5, 2007: JPTA collects data about patient care, but does not connect to 
 

131

Interoperable systems based on a repository concept are developed with 

standardized data elements, definitions, and formats, in order to facilitate information 

exchange. For example, critical data fields, such as names, dates and times, and 

laboratory results must look the same across systems. 

Efforts are under way to determine whether the two Departments could run the 

same inpatient information system. However, given DoD’s requirement to provide 

medical support to deployment forces in austere environments, it is not always practical 

for the Departments to deploy the same information system. Where this is the case, DoD 

and VA have been able to develop a strategy to exchange data at the level of 

interoperability necessary. These two approaches can live together to produce an DoDVA information system that is interoperable, functions well for users, and supports 

ongoing care and program requirements. 

Achieving interoperability even at the highest level does not require adoption of 

the same computer systems or operation of the same software. Nor does all information 

present in the electronic health or administrative databases need to be exchanged in order 

to support health care or administrative action. While universal system interoperability 

may be an important and appropriate goal, the tasks involved are so varied and complex 

that it will take years to complete them. Meanwhile, DoD and VA have the ability to 

achieve a practical level of interoperability in the near term.

ACTION STEPS 

The primary concern of this Commission is to ensure that each and every service 

member injured in the performance of their duty receives all the ongoing healthcare 

services and benefits they require to achieve and enjoy the greatest possible quality of 

life. Reaching this objective will be facilitated by the following DoD and VA 

information systems and process modifications: 

Action Step: Within 12 months, DoD and VA should make all essential health, 

administrative, and benefits data are made immediately available in viewable form to any 

clinician, allied health professional, or program administrator who needs it. 

Action Step: DoD and VA should also develop information support for the recovery 

plan and its implementation by the recovery coordinator, health care and rehabilitation 

teams, and benefits administrators. This should include a tool that the recovery 

coordinator will use in coordinating the development and implementation of the recovery 

plan and in monitoring patient outcomes 

 AHLTA. This creates confusion among providers, and requires them to view separate systems to piece 

together a puzzle of patient care documentation. 
 

132

Action Step: DoD should create an interactive web site for injured service members, 

personalized according to their individual needs. A design for the website is included at 

the end of this subcommittee report. 

Action Step: Without delaying the accomplishment of the first two steps, DoD and VA 

should expedite the work presently underway to create a fully interoperable information 

system that will meet the long-term clinical and administrative needs of all injured 

service members over time. 

Action Step: DoD and VA need to report their progress on all steps to higher authority 

using a detailed scorecard with measures of exact status of information interoperability at 

each type of medical facility by essential health, administrative, and benefits categories. 

A template for the scorecard follows. 
 

133
 

134

Figure 1: Source: DoD Capability Area Management, Joint Logistics Test Case to 

Improve Patient Tracking Visibility Throughout the Medical Continuum. DRAFT Patient Movement by Service and Taxonomy of Care Theater Hospital (CSH, EMEDS, FLT HOS, MRO, MRCO, AELT) JTFSGTransport to MASF Transport to MASF Transport to MASF Definitive Care (CONUS, SVC SG, OCONUS MTF)MTF Forward Resuscitative (FST, STP, FRSS, EMEDS) Enroute Care (AE, CCATT) First Responder (Medic, Corpsman) Regulating Authority Facility? Point of Injury Evac? 9 Line Request MRO Prepare/ Send PMR MRO Prepare/ Send PMR TRICARE MTF AIREVAC Port of Debarkation /FCC Approve? G A

Y

Request

Lift Bed

Deny

Suspend

Delay

G A MTF

T/JPMRC

Process/

Validate

PMR

CASF/

MASF G A

T/GPMRC

DOW RTD

DOW RTD

Evac?

DOW

Evac?

RTD

MRCO

Prepare/

Send PMR

CASEVAC

Regulating

Authority

AELT/

ASF

NDMS VA

CASEVAC/GA SOCCATT

C-130 AA/GA

AA/GA

FRSS

SHIP

STP

MEDEVAC/G A

EMEDS

CSH

Hos

Ship

Surg Co

EMEDS

FST AA/GA AA/GA

AA

FLTHOS

N

Y

N

Y

N

Y

N

DCIPS - Dem o, Service/Civ, Location, Status(VSI, SI)

JMeW s - C2

CHCS Cache

DTAS - W IA Database

TRAC2ES

Dem o/Clinical

Status

PEB/MEB

Process

TRAC2ES PMR

MODS

TRAC2ES

Flight

Manifest

USMC LNO Det

Location, Status

JPTA

TRAC2ES PMR

TRAC2ES

Dem o/Clinical

Status

*JPTA - Dem o, Transportation, Treatm ent, Disposition, Location

TRAC2ES

Dem o/Clinical

Status

AHLTA-T - Demo, Med/Dent Status

SAMS - Demo, Med/Dent Status

Aviation Bde

AAR

USMC IIPT - Dem o, Location, Status

BMIST (AHLTA-M) - Dem o, Med/Dent Status

DFAS-IN Army W IA DB

W W AS - Dem o, MEB/PEB Data, Duty Status, Clinical Status

PARRTS

DJMS-AC

DJMS-RC

(Finance)

MEDEVAC 9

Line Request

DCIPS

GEMS - Demo, Med/Dent Status

USMC LNO Det

Location, Status

USMC LNO Det

Location, Status

Service Casualty Management Joint Casualty

Management

Patient

Movement

& Tracking

Medical

Information

(EHR)

AA

Patient Visibility Interface

to Personnel

Accountability Systems NSIPS DIMHRS VA All AFdB Q Continuum ITAPD Army eMILPO - Demo, Location, Status

TACMedCS
 

135

Figure 2: Source: Provided to commission staff by the VA Office of Information & 

Technology – Enterprise Architecture Department, June 7, 2007
 

136

Figure 3, Source: Testimony of Dr. Paul Tibbits at the Commissions public hearing in 

San Diego, CA – May 24, 2007 

5/15/2007

VA

All VA Medical Facilities

• 53.9 million lab results• 8.9 million radiology reports• 54.4 million pharmacy records• 56 million standard ambulatory data records• 1.7 million consultation reports• 1.6 deployment-related health assessments• 2.2 million correlated patients, including 

919,000 patients not in FHIE repository

• 15,200 average weekly FHIE/BHIE queries 

2nd Qtr FY 2007

Health Information Sharing

DoD

Data on Separated Service Members

• Outpatient pharmacy data, lab & radiology results• Inpatient laboratory & radiology results• Allergy data• Consult reports• Admission, disposition, transfer data• Standard ambulatory data record elements (including 

diagnosis and treating physician)

• Pre-/post-deployment health assessments• Post-deployment health reassessments

Data on OIF/OEF Polytrauma Patients

• Radiology images• Scanned medical records

Currently transferred from Walter Reed AMC and Bethesda (NNMC), expanding to include Brooke AMC

Data on Shared Patients & Veterans Receiving Care from VA

• Current 

– Outpatient pharmacy data, lab & radiology results– Inpatient laboratory & radiology results– Allergy data– Discharge summaries (6 sites, expanding to 13)

• Planned (short- / mid-term enhancements)

– Encounters/clinical notes & problem lists (1Q FY08)– Vital signs & scanned/imported documents & images 

(3Q FY08)

– Family history, social history, other history, & 

questionnaires/forms (4Q FY08 / 1Q FY09)

– Inpatient consultations & operative reports (4Q FY07)– Theater data: inpatient/outpatient pharmacy data, 

radiology results, lab results, discharge summaries/ operative notes, outpatient provider notes 

VA Polytrauma Centers

Currently transferred to Tampa VA Polytrauma Center, expanding to include all 4 VA Polytrauma Centers (adding Richmond, Minneapolis, and Palo Alto)

Live data flow beginning March 2007

One-way transfer of health data initiated at time of decision to transfer patient

Federal Health Information Exchange

Live data flow beginning 2002; data from 1989 forward

One-way, monthly transfer of health data

Currently 15 medical centers, 18 hospitals, and 190+ clinics, expanding to include all DoD medical facilities in June 2007 

Bidirectional Health Information Exchange

Live data flow beginning 2004; data from 1989 forward

Health data on more than 3.8 million Service membersTwo-way, on-demand view of health data available in real-time
 

137

Figure 4 DoD/VA Health Information Sharing Timeline: Sources: Testimony of Dr. 

Paul Tibbits at the Commissions public hearing in San Diego, CA – May 24, 2007 
 

138

APPENDIXES TO 

Subcommittee Report on Information Systems 

Figure: Current Websites for Military Personnel & Veterans 
 

139

Figure: A comprehensive site home page: My e-Benefits 
 

140

Figure: A personalized My e-Benefits Page 
 

141

Abbreviations and Acronyms used in the charts in the 

Information Systems Subcommittee Report 

Abbreviation/Acronym Definition 

AA Air Ambulance 

AAR After Action Report 

AE Aeromedical Evacuation 

AELT Aeromedical Evacuation Liaison Team 

AHLTA Armed Forces Health Longitudinal 

Technology Application 

AIREVAC Aero-Medical Evacuation 

All AFdB All Air Force Data Bases 

Army eMILPO Army Electronic Military Personnel Office 

ASF Aerial Staging Facility 

BMIST Battlefield Medical Information System 

Telemedicine 

CASEVAC Casualty Evacuation 

CASF Contingency Aeromedical Staging Facility 

CCATT Critical Care Air Transport Team 

CHCS Composite Health Care System 

CONUS Continental United States 

CSH Combat Support Hospital 

C2 Command and Control 

DFAS – IN Defense Finance and Accounting Service - 

Indianapolis 

DCIPS Defense Casualty Information Processing 

System 
 

142

DENT Dental 

DIMHRS Defense Integrated Military Human Resources 

System 

DJMS Defense Joint Military System 

DOW Died of Wounds 

DTAS Deployed Theater Accountability System 

EMEDS Expeditionary Medical Support 

EVAC Evacuation 

FCC Flight Clinical Coordinator 

FLT HOS Fleet Hospital 

FRSS Forward Resuscitative Surgical System 

FST Forward Surgical Team 

GA Ground Ambulance 

GEMS Global Expeditionary Medical System 

GPMRC Global Patient Movements Requirement 

Center 

JMeWS Joint Medical Work Station 

JPTA Joint Patient Tracking Application 

MASF Mobile Staging Facility 

MEB Medical Evaluation Board 

MED Medical 

MEDEVAC Medical Evacuation 

MODS Medical Operational Data System 

MRCO Medical Regulating Officer 

MRO Medical Readiness Officer 
 

143

MTF Medical Treatment Facility 

NDMS National Disaster Medical System 

PARRTS Patient Accounting and Reporting Real-Time 

Tracking System 

PEB Physical Evaluation Report 

PMR Patient Movement Request 

RTD Return to Duty 

SAMS Shipboard Automated Medical System 

SI Seriously Injured 

STP Site Treatment Plan 

SURG CO Surgical Company 

SVC SG Servicing Surgeon General 

T/JPMRC Theater Joint Patient Movement Requirements 

Center 

TACMedCS Tactical Medical Coordination System 

TRAC2ES US Transportation Command Regulating and 

Command and Control Evacuation System 

VA Department of Veterans Affairs 

VSI Very Seriously Injured 

USMC II PT United States Marine Corps Injured/Ill Patient 

Tracking 

WIA DB Wounded in Action Data Base 

WWAS World Wide Airfield Summaries 
 

144
 

145

Key Survey Findings 
 

146
 

147

President’ Commission on Care for America’s Returning Wounded 

Warriors (PCCWW) National Survey on Health Care Experiences of 

Service Members Injured in Iraq and Afghanistan 

 The President’s Commission on Care for America’s Returning Wounded Warriors 

released today preliminary results of a nationwide telephone survey it conducted to help 

assess the health care experiences of service members injured in Iraq and Afghanistan. 

 The Commission survey was conducted from June 7 to June 19, 2007. 

Participants were military members and veterans who had undergone medical treatment 

for wounds sustained in Iraq and Afghanistan that led to medical evacuation to the United 

States. 1,730 interviews were completed. 

 The following are preliminary results from the Commission survey for the 

following three segments of the survey population: 

 Active Duty 

 National Guard/Reserve members serving on active duty or with home units 

 Active duty and National Guard/Reserve members who have left the military, 

most of them with a medical separation or retirement. 

The Injured 

 The typical active duty service member injured in Iraq and Afghanistan is young. 

In the survey, 40% are under the age of 25. Guard/Reserve veterans are older—

only 16% are under 25 and one of three are from the junior ranks. 

 Both active and Guard/Reserve have modest levels of education, with 10 to 15% 

having some college. 

 Overall, 60% are married. 

Care System 

 These young service members need help navigating the complex medical and 

disability systems, but many have not had a single coordinator. While on active 

duty, half of respondents said they had a professional to help coordinate care. 

After leaving the military, just one in five said they had a coordinator. 

Disability System 

The survey confirms that the disability evaluation system is source of concern. 
 

148

 Just over 40% fully understood the disability evaluation system and another 30% 

mostly understood the system. 

 Help is available for injured veterans moving through the disability evaluation 

process—two-thirds said they had help. Nevertheless, under 40% were satisfied 

with the disability system. 

 The survey includes 500 medically separated/retired injured veterans who left 

service in the past two years. Most of them—60% in the Reserve and Guard and 

85% of veterans—reported their injuries limit the work they can do. They appear 

to be overcoming their limits, as 80% of Guard/Reserve and 63% of veterans are 

either working or in school. 

Family

 Two third of injured active duty service members had family come for an 

extended period to be with them in their recovery; slightly less for Guard and 

Reserve. Most family members who came were provided housing through Fisher 

Houses and other local accommodations. 

 One in five family members gave up a job in order to stay with their injured 

family member. 

 Family members often act as care coordinators and care takers. Most respondents 

said family members got the information needed to support this role. 

 Non-profit organizations play an important role in family support. 40% of survey 

respondents said their families receive help from at least one of these groups. 

Post-Traumatic Stress Disorder and Traumatic Brain Injury 

 The survey confirms the significance of post traumatic stress disorder (PTSD) and 

traumatic brain injury (TBI) in this conflict. Over 40% of respondents said they 

reported systems of PTSD or other mental health problems to a health care 

professional. Sixty percent experienced a blast or other event that could be severe 

enough to cause brain injury. 

 DoD and VA have stepped up screening for these conditions. Almost threefourths of respondents report being asked questions about PTSD and TBI 

symptoms. 

Information Technology 

 Most of the time, the role of information technology is invisible to the service 

member. They often notice when information is not available. A common 

complaint is lost paperwork. For example, 40% of survey respondents had to 

resubmit paperwork during the disability evaluation process.