United States General Accounting Office

GAO Report to the Chairman, Committee on

Veterans’ Affairs, U.S. Senate

July 1996 READJUSTMENT

COUNSELING SERVICE

Vet Centers Address

Multiple Client Problems,

but Improvement Is

Needed

G O A

years

1921 - 1996

GAO/HEHS-96-113

GAO United States

General Accounting Office

Washington, D.C. 20548

Health, Education, and

Human Services Division

B-266316 

July 17, 1996

The Honorable Alan K. Simpson

Chairman, Committee on Veterans’ Affairs

United States Senate

Dear Senator Simpson:

The Department of Veterans Affairs (VA), through its Readjustment

Counseling Service (RCS), operates 205 community-based facilities known

as Vet Centers to help certain veterans make a successful transition from

military to civilian life. This readjustment counseling program, initially

established by the Congress in 1979 to assist Vietnam era veterans, has

been expanded to cover veterans who served in all areas of military

conflict since Vietnam, including Lebanon, Grenada, Panama, the Persian

Gulf, and Somalia. Vet Centers also serve family members and significant

others to the extent necessary to help veterans. Services provided by Vet

Centers range from assistance with basic needs and benefits to therapeutic

counseling for drug and alcohol abuse, sexual trauma, and post-traumatic

stress disorder (PTSD).1

RCS is part of VA’s Veterans Health Administration (VHA) and is subject to its

budget and administrative review. However, within VHA, which also

manages VA medical centers, RCS has its own organizational structure,

manages its own resources, and evaluates its own program.

This report responds to your request for information about RCS’ Vet Center

program to assist in the Committee’s evaluation of the appropriateness of

the organizational structure of RCS and the effectiveness of its programs. It

addresses the following areas:

• Who are the individuals that Vet Centers serve and what services are

provided?

• How accurate is RCS’ workload reporting system, and does it ensure that

services reported are actually delivered?

• How adequate is VA’s methodology to determine whether Vet Center

services are appropriate and effective?

• Should RCS maintain an organizational structure within VHA that is separate

from medical centers?

1

PTSD is a condition caused by severely stressful or traumatic events such as military combat and may

be chronic. Its symptoms include intense reliving of events, anxiety, sleep disturbance, depression, and

social isolation.

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In 1987, we reported on various aspects of VA’s readjustment counseling

program and made recommendations for improvement in some program

areas.2

 Our report included observations on the accuracy of RCS’ database,

the need for RCS to better monitor Vet Center activities by making regional

office site visits as required, and the need to better evaluate the quality of

Vet Center care. This report recognizes RCS’ efforts in these areas and

identifies the need for further improvements.

In performing this review, we visited RCS’ central office in Washington,

D.C., four of RCS’ seven regional offices,3

 and five Vet Centers.4 At these

locations we reviewed documentation, discussed program activities with

officials, and at three of the Vet Centers we met with veterans to obtain

their views on the program. We also obtained workload activity data for

fiscal years 1993 through 1995 from 39 randomly selected Vet Centers that

helped to describe clients and services provided. We also met with

officials of several veteran service organizations to obtain their views on

the program. We performed our work between June 1995 and April 1996 in

accordance with generally accepted government auditing standards. (See

app. I for a detailed description of our scope and methodology.)

Results in Brief Vet Center counselors reported visiting with approximately 138,000

veterans during fiscal year 1995, 84,000 of whom were new to Vet Centers.

Most veterans do not establish long-term relationships with Vet Center

counselors; however, those who do represent a core group who use

services over extended periods for serious psychological problems such as

PTSD. Other veterans usually visit Vet Center counselors only once or twice

for social concerns such as employment or benefit needs.

Although Vet Centers track their number of visits with clients, RCS’

workload measurement system overcounts some activities and

undercounts others. Also, the system does not track staff resources used

during client visits and cannot distinguish between client visits requiring

minimal staff time and visits that require extended periods of staff effort.

2

Vietnam Veterans: A Profile of VA’s Readjustment Counseling Program (GAO/HRD-87-63, Aug. 26,

1987).

3

The RCS regional offices we visited are in Bay Pines, Florida; Hines, Illinois; Denver, Colorado; and

Providence, Rhode Island.

4

The Vet Centers we visited are in Cheyenne, Wyoming; Chicago, Illinois; Norwich, Connecticut;

Tampa, Florida; and White River Junction, Vermont.

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RCS has taken steps to help ensure that the services provided by Vet Center

staff are appropriate. These steps include recurring consultation and

records reviews by supervisory and clinical professionals within and

external to Vet Centers, annual clinical reviews by RCS regional officials,

and increased RCS emphasis on the credentials of its staff. However,

problems exist with documenting client records, and RCS has not

developed a systematic approach for measuring the effectiveness of Vet

Center services in meeting clients’ psychological needs.

VA is currently implementing a new health care services management

structure known as the Veterans Integrated Service Networks (VISN) to

coordinate and integrate health care resources within 22 local service

networks. The VISN structure recognizes Vet Centers as a resource within

each local network but continues RCS’ organizational independence within

VHA. Our work suggests that, at this time, RCS’ independence is consistent

with its mission of providing both social and psychological readjustment

counseling services to veterans and the developing nature of the VISN

structure. However, as VA completes implementation of the VISN structure

for its health care services, reconsideration of RCS’ organizational structure

may be warranted.

Background Under the Veterans’ Health Care Amendments of 1979 (P.L. 96-22), the

Congress authorized a temporary program of readjustment counseling

services for Vietnam era veterans who served from August 5, 1964, to

May 7, 1975, to assist them in the transition to postwar civilian life. At that

time it was recognized that a veteran suffering from a “readjustment

problem” might exhibit “a low-grade motivational or behavioral

impairment” that interfered with interpersonal relationships, job or

educational performance, or overall ability to cope with daily life. This

condition, in combination with other symptoms, was later termed

post-traumatic stress disorder (PTSD). At that time VA medical centers did

not have special programs in place to treat these problems. Veterans who

did go to VA medical centers for treatment were usually admitted to the

general psychiatric service where these problems were not well

understood.

PTSD is caused by severely stressful or traumatic events such as military

combat, seeing people die, or incarceration as a prisoner of war. PTSD

symptoms include intense reliving of the event in memory or dreams,

anxiety, sleep disturbance, depression, social isolation, and an incapacity

for intimate relations with others. PTSD may not be curable and can be a

Page 3 GAO/HEHS-96-113 Vet Center Program
B-266316 

chronic condition with symptoms that are stress-induced and effects that

may increase with a person’s age.

The readjustment counseling program was authorized as a

community-based program separate from VA medical centers at least

partially on the premise that many Vietnam era veterans were so

distrustful and suspicious of government institutions that they would not

come to VA’s inpatient hospitals to seek care. It was also believed that

providing mental health services in outpatient facilities would help to

remove the stigma often associated with so-called “mental illness.” The

guiding principle was that readjustment services should be provided on an

outpatient basis, regardless of the veteran’s income, and that unnecessary

barriers to care should be removed. In addition, requests for counseling

should be speedily honored with a minimum of red tape.5

 In passing the

authorizing legislation, the Congress recognized that Vet Centers would

provide services to address not only psychological problems, but also

other aspects of readjustment. Over the intervening 17 years, the Congress

has expanded the program to include veterans who participated in all

post-Vietnam military conflicts. The Congress also made the Vet Center

program permanent and specifically authorized VA, supported by Vet

Centers, to provide counseling to veterans who experienced sexual trauma

while on active duty.

As currently configured, the Director of RCS reports to the Under Secretary

for Health and is responsible for overall program oversight and direction.

The Director is assisted in many management responsibilities by staff in

seven regional offices.6

 Each regional office is headed by a regional

manager who is responsible for monitoring Vet Center services, hiring and

training Vet Center staff, enhancing relations with other VA facilities, and

assessing program performance.

Two clinical field managers are responsible for monitoring the quality of

clinical services provided by Vet Centers. One, based in Bay Pines, Florida,

is responsible for all Vet Centers in the East and the other, in Denver, is

responsible for western Vet Centers.

To meet clients’ needs, Vet Centers provide easy, “hassle free” access to a

variety of services, including individual, group, and family counseling;

5

Veterans’ Health Care Amendments of 1979, Report of the Committee on Veterans’ Affairs, United

States Senate, Report No. 96-100, pp. 27-31.

6

RCS regional offices are in Baltimore, Maryland; Bay Pines, Florida; Benicia, California; Dallas, Texas;

Denver, Colorado; Hines, Illinois; and Providence, Rhode Island.

Page 4 GAO/HEHS-96-113 Vet Center Program
B-266316 

referrals to other VA and community resources; and outreach activities to

identify veterans needing assistance. Vet Centers are also authorized to

provide services to family members and significant others to the extent

necessary to help veterans who are being treated by program staff. In

assisting clients, counselors draw from an array of psychosocial services.

Social services address problems such as basic needs, unemployment, and

veterans benefits. Social services include coordinating with community

providers for basic services, state representatives of Disabled Veteran

Outreach Programs who work to match veterans with employment

opportunities, and VA benefit offices who attempt to assist veterans with

the benefits to which they are entitled. Psychological services address

issues such as PTSD, drug and alcohol abuse, and sexual trauma. Vet Center

staff may either directly provide the psychological care needed or refer the

veterans to other sources of treatment. For example, veterans who need

medications or inpatient care for PTSD are generally referred to VA medical

centers.

During the first 16 years of the program, approximately 1.2 million

veterans had about 7.3 million visits with Vet Center counselors. RCS

currently operates 205 Vet Centers at an estimated fiscal year 1996 cost of

about $64 million.7

 Vet Centers are generally located in community

storefront facilities and staffed with counselors who are often veterans

themselves. In general, each Vet Center has three to six staff members,

including a team leader,8

 counselor(s), and an office manager. Ten of the

205 Vet Centers are also known as Veterans Resource Centers and may be

staffed with as many as six counselors. Some Vet Centers contract with

private mental health professionals in locations that are distant from the

Vet Center or other VA providers. These contractors provide therapeutic

services to veterans with psychological problems, such as PTSD.

Although located apart from established VA facilities, each Vet Center is

administratively assigned to a VA support facility (usually a VA medical

center) that provides services such as purchasing supplies, paying bills,

and maintaining the payroll.

7

See app. II for a list of all Vet Center locations.

8

The team leader directly supervises and oversees the performance of Vet Center staff in the provision

of outreach, counseling, and referral services. Duties include selecting and evaluating staff,

administering the budget, collaborating with staff in the supporting VA medical facility, and providing

direct clinical services.

Page 5 GAO/HEHS-96-113 Vet Center Program
B-266316 

Currently many medical centers have their own inpatient and outpatient

programs specifically to address PTSD-related problems. In some cases,

veterans need inpatient care to address debilitating symptoms while

others may need medications to treat symptoms but only on an outpatient

basis. Today there are 61 inpatient and 93 outpatient specialized medical

center programs for veterans who are diagnosed as having PTSD.

Over the life of the Vet Center program, questions have been raised about

the continued need for readjustment counseling services, whether,

organizationally, RCS should be more closely connected with VA medical

centers, and what program management improvements could be made. A

number of studies have addressed these questions, including our 1987

report on the readjustment counseling program. These studies have

consistently recommended the continuation of readjustment counseling

services and RCS’ organizational independence within VHA. (See the

bibliography for a list of major studies and reports related to RCS’ Vet

Center program and the diagnosis and treatment of PTSD.)

Many Veterans Are

Served, but Few

Require Extended Vet

Center Services

Approximately 138,000 veterans visited with Vet Center staff during fiscal

year 1995,9

 of which about 84,000 were new veterans to the program.10

(See app. III for RCS’ fiscal year 1995 Service Activity Reporting System

(SARS) data.) Most veterans do not remain in contact with counselors over

extended periods. Nevertheless, veterans who have more serious

psychological problems, such as PTSD, represent a core group who visit

with Vet Center staff, on average, more often than veterans with social

concerns such as the need for employment or veterans’ benefits.

While RCS reports that a large number of veterans are seen each year, most

do not establish long-term relationships with Vet Center counselors. RCS

reported that nearly 283,000 new veteran clients visited Vet Centers during

fiscal years 1993 through 1995. Of these veterans, we estimate based on

our sample11 that 59 percent had only one visit with Vet Center staff,

80 percent had three or fewer visits, and 90 percent had seven or fewer

staff visits during the 3-year period. The remaining 10 percent of Vet

9

For the purpose of our analysis, Vet Center visits include face-to-face and substantive telephone

contacts between Vet Center counselors and clients.

10A veteran who has never had an open/active record at a particular Vet Center is defined by RCS as a

“new veteran.”

11With RCS assistance, we obtained workload measurement data from a sample of 39 Vet Centers for

fiscal years 1993 through 1995. The data from these centers provide a national estimate based on the

sample.

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B-266316 

Center clients visited eight or more times.12 The 17 counselors and team

leaders we met with at five Vet Centers each had an average clinical

caseload of about 26 clients.

New veterans with psychological problems such as PTSD and sub-PTSD13

were seen more often by Vet Center counselors. For example, veterans

with PTSD averaged 5 visits and those with sub-PTSD averaged 4.3 Vet

Center staff visits during fiscal year 1995. Over a 3-year period, veterans

with these problems averaged 9.4 and 6.4 Vet Center staff visits,

respectively. Conversely, veterans who had social concerns, such as

employment and VA benefit needs, averaged 1.9 and 1.5 visits during fiscal

years 1993 through 1995.14

A relatively small percentage or core group of veterans are long-term users

of the Vet Center program. For example, of the veterans who first visited

with a Vet Center counselor before fiscal year 1993, 20 percent were seen

13 or more times through fiscal year 1995; 10 percent had 32 or more visits

in that period. In addition, during our visits with 50 clients (veterans and

family members) at three Vet Centers, some of the veterans and spouses

commented that the Vet Center staff were responsible for saving these

veterans’ lives and they very much needed the Vet Center program. These

veterans also stated that they preferred to obtain services at Vet Centers

rather than VA medical centers. As a result, many of these veterans now,

and in the foreseeable future, are likely to continue to use the counseling

services provided by this community-based program.

Family members and significant others constitute about 8 percent of the

total number of visits. We found that these clients, on average, have fewer

visits with Vet Center counselors than veterans in all areas, except for

marriage and family problems, where significant other and family member

visits with Vet Center staff exceeded those of veterans over our 3-year

period of review. Table 1 shows the average and median number of visits

by new veterans and family and significant others by problem areas

addressed for fiscal year 1995. Table 2 shows data for the 3-year study

period, fiscal years 1993 through 1995.

12In our sample, the highest number of visits was 236.

13Sub-PTSD is a clinical diagnosis for someone found to have been exposed to a traumatic event but

who fails to meet all of the criteria to support a diagnosis of PTSD.

14Vet Center staff are responsible for reporting the problems addressed during each client’s visits, and

counselors can report up to three problems per visit. For each subsequent client visit, Vet Center staff

record problems in the same manner except that the problems addressed may be different, with the

exception of PTSD. Once a veteran is identified with PTSD, it is automatically counted as one of the

problems addressed in all future contacts.

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Table 1: FY 1995 Visits by New

Veterans and Family and Significant

Others, by Problem Addressed

New veterans Family and significant others

Problem addressed

Average

visits Median visits

Average

visits Median visits

Sexual trauma 6.7 3.0 2.8 2.0

PTSD 5.0 2.0 2.7 1.0

Sub-PTSD 4.3 2.0 2.7 1.0

Marital/family 3.1 1.0 2.8 1.0

Psych/other 3.0 1.0 1.9 1.0

Legal 2.4 1.0 1.3 1.0

Drug/alcohol 2.4 1.0 1.3 1.0

Homeless 1.8 1.0 1.0 1.0

Employment 1.6 1.0 1.1 1.0

Basic needs 1.6 1.0 1.1 1.0

Other 1.5 1.0 1.1 1.0

Medical 1.4 1.0 1.2 1.0

Benefits 1.3 1.0 1.2 1.0

Source: GAO analysis of SARS data.

Table 2: FY 1993-95 Visits by New

Veterans and Family and Significant

Others, by Problem Addressed

New veterans Family and significant others

Problem addressed

Average

visits Median visits

Average

visits Median visits

Sexual trauma 11.2 4.0 4.8 2.0

PTSD 9.4 3.0 4.1 1.0

Sub-PTSD 6.4 2.0 3.6 1.0

Marital/family 4.5 2.0 4.8 2.0

Psych/other 3.8 1.0 2.8 1.0

Drug/alcohol 3.0 1.0 1.5 1.0

Homeless 2.5 1.0 1.1 1.0

Legal 2.2 1.0 1.4 1.0

Other 2.1 1.0 1.2 1.0

Employment 1.9 1.0 1.2 1.0

Basic needs 1.7 1.0 1.2 1.0

Medical 1.6 1.0 1.4 1.0

Benefits 1.5 1.0 1.3 1.0

Source: GAO analysis of SARS data.

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B-266316 

We found two reasons that partially explain why most veterans do not

continue to use Vet Centers after a few visits. First, many veterans have

social concerns that can be addressed in three or fewer visits with staff.

These visits might include helping clients with basic needs, legal problems,

employment matters, and homelessness issues. Vet Center staff may draw

on their own resources to assist with these problems or may refer clients

to other VA and non-VA programs, thus limiting the number of visits needed.

Second, RCS restricts veterans from World War II, the Korean War, and

noncombat veterans from conflicts other than Vietnam to three visits with

Vet Center counselors. In fiscal year 1995, RCS reported that almost

one-fourth of the new veteran clients were from these eras.

Vet Center Workload

Reporting System

Needs Improvement

SARS is RCS’ primary means for collecting productivity data from its Vet

Centers. In our review of 40 records in four Vet Centers, we found that

data on client visits were, for the most part, accurately entered in the SARS

database. However, refinements are needed to make the information more

useful. SARS, as currently designed, produces data that emphasize the

quantitative rather than the qualitative aspects of the Vet Center program.

For example, it does not accurately describe Vet Center operations or

distinguish between client visits requiring minimal staff time and visits that

require extended periods of staff effort. As a result, the core group of

veterans who use the largest portion of Vet Centers’ staff resources are not

readily identifiable, and managers and supervisors may lack information

needed to oversee the program and monitor staff activities.

Client Visits Are Generally

Recorded Accurately in

RCS’ Workload Reporting

System

Client visits were accurately recorded at three of the four Vet Centers

where we compared our sample of client records with information in the

SARS database. All Vet Center staff are required to maintain handwritten

daily activity log sheets that record each of their client contacts

throughout the day. These daily activity logs are the original documents

from which SARS data are entered. To test the accuracy of the SARS

database, we compared the SARS data, daily activity logs, and 40 client

records to determine whether information about client visits was

consistent among the three sources. We found the information was

correctly recorded at three of the four Vet Centers we visited and, in total,

was accurate in 95 percent (38 of 40) of the cases. At one Vet Center, the

client visits were shown in the progress notes in two of the client records

we reviewed but not in the daily logs or SARS.

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B-266316 

Workload System Does Not

Adequately Report Staff

Activities

The workload reporting system does not provide adequate information

about the activities conducted by Vet Center staff. For example, when

reporting activities in SARS, staff in some Vet Centers count meetings they

conduct with active duty personnel in the Transitional Assistance Program

(TAP).15 These meetings may include 10 to 100 people, each of whom may

be counted in SARS as an individual client visit.

Our analysis of the data from 39 Vet Centers showed that visits with active

duty personnel accounted for more than 21 percent of the outreach visits

performed in 5 of the 39 Vet Centers during fiscal year 1995. Moreover, in

three of the five Vet Centers, active duty personnel accounted for over

two-thirds of the total number of outreach visits.

While contacting military personnel who are about to be separated from

active duty is a legitimate Vet Center outreach activity, recording group

meetings as individual client visits makes them appear to be the same as

visits that involve extended counseling. This method of counting and

recording Vet Center visits inflates productivity data.

Vet Center staff also told us that several services and activities they

provide or participate in are not recorded in the workload reporting

system. We were told, for example, that staff help clients through crisis

situations, such as suicidal periods, provide assistance with support

groups for family members of active duty personnel who have been

deployed for an overseas mission, and participate in community events

during holidays such as Veterans Day. These and similar types of actions

are not recorded in the workload reporting system, which contributes to

understating the activities performed by Vet Center staff.

Furthermore, the workload reporting system does not collect information

to determine how Vet Center staff resources are used. Through fiscal year

1992, time spent with clients was recorded by Vet Center staff; however,

this information is no longer included in SARS. The time spent by

counselors to help clients can vary dramatically. In some instances,

counselors may spend 15 minutes and make only one or two phone calls to

provide the assistance their clients need. In other situations, counselors

may spend all day helping clients cope with serious situations and more

complex issues. Without information on how time is spent, supervisors

cannot (1) readily identify the core group of clients who use the largest

portion of staff resources, (2) measure how staff allocate their time over a

15TAP was established to provide active duty personnel nearing separation from military service with

employment and training information. Vet Center counselors meet with them to describe the services

eligible veterans can get from the centers.

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given period, or (3) determine whether the time spent with certain clients

is appropriate.

Processes and

Staffing in Place, but

Documentation of

Records and Program

Effectiveness Need to

Be Addressed

RCS has taken steps to ensure that Vet Center services are appropriate, but

problems exist with documenting client records and demonstrating, on a

systematic basis, that these services are effective. Activities to ensure that

the services provided by Vet Center staff are appropriate include recurring

consultation and records reviews by supervisory and clinical professionals

within and external to Vet Centers, annual clinical reviews by RCS regional

officials, and increased RCS emphasis on the credentials of its staff.

However, some clients’ records are not well documented, and RCS has not

developed a systematic approach for demonstrating that the Vet Center

program is effective, on a continuing basis, in meeting the psychological

needs of its clients.

Processes in Place to

Review the

Appropriateness of Vet

Center Services

Since our 1987 report, RCS has instituted processes to ensure that services

provided to its clients are appropriate. RCS has established standards for

Vet Center clinical records and case reviews by supervisory and clinical

staff. During the required evaluations, Vet Center team leaders, regional

office staff, and clinical coordinators review current client cases to

determine whether (1) records are adequately documented, (2) treatment

plans are being followed and progress made toward the treatment goals,

and (3) treatment services are appropriate. Table 3 summarizes these

activities.

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Table 3: Summary of Activities to

Ensure the Appropriateness of Vet

Center Services

Activity Performed by Description

Clinical reviews of

client records

Vet Center staff Monthly reviews of client records are

performed by team leaders with clinical

backgrounds and/or the clinical

coordinator on staff at each Vet Center

to evaluate case documentation,

appropriateness of care, and progress

toward treatment goals.

Site reviews Regional office staff Annual clinical reviews are conducted

at all Vet Centers. A sample of client

records is reviewed for documentation

and appropriateness of care.

External clinical 

reviews

VA medical center or

contract staff

All Vet Centers are required to undergo

at least 4 hours of monthly external

clinical consultation. The sessions

review the assessment and treatment

planning for all active cases.

Crisis intervention Vet Center staff Vet Centers have plans that describe

the appropriate method for addressing

crisis situations such as suicide threats.

The plans aim to reduce the (1)

likelihood of a crisis at a Vet Center and

(2) severity of a crisis when it occurs.

Staff seek to identify clients at risk of

dangerous behaviors to provide them

with the means of handling their

situations.

Mortality and morbidity

(M&M) reviews

Regional office and

Vet Center staff

M&M reviews are conducted on all

suicide cases and serious suicide

attempts to, among other things,

determine (1) if care was appropriate

and adequate, (2) if other steps and

interventions might have altered the

outcome, and (3) whether Vet Center

practices are adequate.

Increased Emphasis Given

to Vet Center Staff

Credentials

Over time, RCS has enhanced the credentials of the Vet Center staff in

order to meet the psychological counseling needs of veterans suffering

with clinically diagnosed PTSD and sub-PTSD. Originally, Vet Centers were to

serve as outreach, entry, and treatment points for Vietnam veterans, many

of whom were unwilling to use mainstream VA programs. However, the Vet

Centers soon became the preferred location for some Vietnam era

veterans to obtain psychological treatment services.

To meet the clinical needs of clients suffering with psychological

readjustment problems, RCS strengthened the educational backgrounds of

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B-266316 

key staff. For example, as of January 1996, RCS reported that 87 percent

(179 of 205) of its Vet Center team leaders had master’s or doctorate

degrees. In 17 of 18 Vet Centers with team leaders holding bachelor’s

degrees or less, other staff members had master’s or doctorate degrees. In

seven of eight Vet Centers without team leaders, other staff members also

had master’s or doctorate degrees. The other two Vet Centers were staffed

with personnel who held less than a bachelor’s degree. At these two Vet

Centers, we were told that the clinical coordinator from another Vet

Center and the PTSD clinical team at a nearby VA medical center provide

clinical consultation. See table 4 for a summary of the educational levels of

Vet Center team leaders.

Table 4: Summary of Vet Center Team

Leader Educational Backgrounds As of January 1996

Vet Center team leader educational

backgrounds Number Percentagea

Doctorate degree 26 12.7

Master’s degree 153 74.6

Bachelor’s degree 13 6.3

Less than bachelor’s degree 5 2.4

Vacant position 8 3.9

aBecause of rounding, column does not equal 100 percent.

Source: RCS Staffing List for January 28, 1996.

Vet Center staff receive in-service training to further their professional

development and, in 1995, RCS conducted its first national team leader

training conference.

Documentation of Clients’

Records Continues to Be a

Problem

In 1987, we reported that about one-third of the client files we reviewed

inadequately documented the reasons for the clients’ visits and the

assistance given them. Although RCS has increased its monitoring of Vet

Centers, the documentation of clients’ records continues to be a problem.

As previously mentioned, RCS’ regional office staff conduct annual clinical

reviews of Vet Centers within their regions. To monitor RCS’

self-assessment of the quality of services and the results of treatment Vet

Centers provided to veterans, we reviewed the fiscal year 1995 results

from clinical site visits in the four regions we visited.16

16The four regions have a total of 119 Vet Centers under their jurisdiction, of which 117 had clinical site

visits during fiscal year 1995. The 117 Vet Centers included in our analysis of four regions represent

57 percent of the program’s centers.

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Regional officials reported various Vet Center deficiencies in record

keeping and other required activities. Record keeping problems included

inadequate documentation of treatment plans, military histories, and

progress notes. Forms that would have provided client information were

sometimes missing from files, incomplete, or needed updating. For

example, one region found 35 percent of its Vet Centers had deficiencies

with the military history forms. In the four regions, RCS regional officials

reported deficiencies in client treatment plans at 38 percent of the Vet

Centers.

Other problems regional staff cited during Vet Center visits were

associated with activities such as team leader record reviews and

counselor follow-up of clients. For example, 26 percent of the team

leaders in the four regions were not providing appropriate clinical reviews

or supervision as RCS policy requires. Moreover, 19 percent of the Vet

Centers were not documenting follow-up contacts with clients. See table 5

for a summary of the deficiencies reported by RCS regional officials in the

four regions we visited during their fiscal year 1995 reviews.

Table 5: Summary of Vet Center

Deficiencies Reported by Four

Regions

Fiscal year 1995

Deficiency cited

Number of Vet

Centers with

deficiency

Percentage with

deficiencies

Treatment plans 45 38

Military history 30 26

Team leader file reviews or supervision 30 26

Progress notes 27 23

Follow-up contact 22 19

Psychosocial assessment 19 16

Health history 17 15

Closing summaries 16 14

Source: RCS regional office clinical site visit reports.

Our own review of client records revealed findings similar to those of the

regional staffs. In a sample of 90 client records, we found that in 26

(29 percent), forms such as problem lists and military histories were

missing or incomplete.

While RCS has procedures in place for determining whether clients

received appropriate care, records are often not well documented and

Page 14 GAO/HEHS-96-113 Vet Center Program
B-266316 

clinical record reviews are not always performed. Missing or incomplete

clinical file information prevents an adequate assessment of the nature and

quality of services rendered to veterans. The RCS director acknowledged

that documentation within client records is a problem, and he has initiated

actions to improve record keeping practices, such as standardizing client

treatment files.

Systematic Approach

Needed to Evaluate

Psychological Services

RCS does not have a systematic approach to demonstrate whether the Vet

Center program is effective, on a continuing basis, in meeting the

psychological needs of its clients. Although PTSD may not be curable,

improved record keeping would allow program officials to examine the

progress made as a result of treatment services. In 1987, we concluded

that RCS had little assurance that its centers were providing quality care

because clinical record keeping practices and file review procedures were

inadequate. Also, in May 1991, VA’s Deputy Assistant Secretary for Program

Coordination and Evaluation recommended, among other things, that RCS

and the Mental Health and Behavioral Sciences Service establish a joint

program evaluation and research component to include mechanisms for

developing ongoing outcome data to measure the effectiveness of all PTSD

programs.17

RCS officials acknowledge that outcome measures have not been

developed for the Vet Center program but said they have relied on other

ways of determining how well centers are serving their clients. For

example, clinicians review records to determine whether clients are

receiving appropriate care and making progress toward their treatment

goals. Other methods, such as surveys of client satisfaction with Vet

Center services, stability in clients’ work lives, and improved family

relationships are used by RCS officials as outcome measures in evaluating

the effectiveness of the program.

RCS has been associated with two efforts that addressed the effectiveness

of Vet Centers. In 1991, it undertook a study with the National Center for

PTSD of 1,006 Persian Gulf war zone veterans to evaluate the prevalence of

PTSD over time. They found that veterans who obtained psychological

treatment at Vet Centers upon their return from the Persian Gulf showed

lower levels of PTSD after approximately 6 months than those who were

17Department of Veterans Affairs, A Program Evaluation of the Department of Veterans Affairs Post

Traumatic Stress Disorder (PTSD) Programs, report no. 1990-04 (Washington, D.C.: Office of the

Deputy Assistant Secretary for Program Coordination and Evaluation, May 1991).

Page 15 GAO/HEHS-96-113 Vet Center Program
B-266316 

not immediately treated.18 PTSD prevalence among veterans who sought

psychological treatment from Vet Centers decreased from 26.9 to

19.4 percent. On the other hand, the prevalence of PTSD symptoms among

veterans who used Vet Centers but did not seek psychological counseling

increased from 7.8 to 9.8 percent. RCS officials concluded, among other

things, that the Vet Center treatment model of providing outreach, social

and economic services, and psychological counseling for PTSD is

appropriate for the needs of returning war veterans.

In May 1995, RCS reported the results of a nationwide customer satisfaction

survey it conducted of a random sample of 1,112 veterans who used the

Vet Centers during fiscal years 1988 and 1991. On the basis of a 30-percent

response rate, RCS found that 90 percent of these clients indicated they

would recommend the Vet Center program to other veterans. RCS officials

also reported that clients who visited Vet Centers more often were more

likely to benefit from the services provided. For example, of those

surveyed, the clients who made between 25 to 49 visits reported that they

derived the most benefit from Vet Center services.

RCS’ actions and evaluation efforts do not, however, clearly demonstrate

the overall effectiveness of Vet Centers in meeting the psychological needs

of their clients. While assessments of the quality of the care clients receive

are made during internal and external clinical reviews, these reviews are

limited to a sample of current clients and do not measure progress on a

program basis. A systematic approach is needed for measuring outcomes

and evaluating the extent to which Vet Centers are effective, on a

continuing basis, in treating their clients, but RCS has not developed one.

Without a systematic evaluation approach, RCS lacks the information

necessary to demonstrate that its psychological services are effective.

Current RCS

Organizational

Independence Within

VHA Does Not

Conflict With

Assigned

Responsibilities

In meeting their readjustment counseling responsibilities as defined by

authorizing legislation, Vet Centers provide both social and psychological

services to veterans. Although the psychiatric treatment in Vet Centers is

similar to the outpatient PTSD care provided by some medical centers, the

two types of facilities generally focus on different clients and missions.

The health care management structure VA is currently implementing

maintains RCS’ organizational independence within VHA. Our work suggests

that RCS independence, at this time, is consistent with its mission of

providing both social and psychological readjustment counseling services

18These results relate to the PTSD levels in the 226 veterans who were tracked over a 6-month period.

Page 16 GAO/HEHS-96-113 Vet Center Program
B-266316 

to veterans and the developing nature of VHA’s VISN structure. Once the VISN

structure has been fully implemented, reconsideration of RCS’

organizational structure may be warranted.

Attitudes Have Changed

Since Vet Center Program

Was Established

The alienation and hostility Vietnam era veterans felt toward the VA system

at the end of the war have diminished for many to the point that they are

now more likely to seek clinical care at VA medical centers. While many

veterans would rather obtain the therapeutic services they need from Vet

Center staff, reluctance to use the VA system is often related to the

bureaucracy veterans encounter or expect to encounter when visiting a VA

medical center.

Some Vet Center counselors with whom we met estimated that the

segment of all Vietnam era veterans who are still unwilling to seek help

from medical centers ranges from 10 to 35 percent. More favorable veteran

attitudes toward VA medical center care relate to, in part, the time that has

passed since the war ended and improvements in medical center staff

understanding and treatment of PTSD.

During our discussions with veterans at three of the five Vet Centers we

visited, many told us that they prefer to receive their care in the Vet Center

rather than the medical center. However, a number of them indicated that

they were using or had used medical center services as well. These

veterans, many of whom were long-term clients of the Vet Centers, were

not averse to using medical center services when needed.

RCS staff told us that over the past several years, referrals of veterans to

medical centers for PTSD care have increased. Some staff stated that they

have been instrumental in easing veterans’ resistance to seeking medical

center care. In some cases, clients are referred for inpatient care or for

medication that the Vet Center staff do not prescribe. We were told that

Vet Center staff not only refer veterans to medical centers but may, if

necessary, take the veterans there.

Vet Centers and Medical

Centers Generally Serve

Different Clients and

Missions

Many medical centers support their own inpatient and outpatient

programs to specifically address PTSD-related problems. In some cases,

veterans need inpatient care to address debilitating symptoms, while

others may need medications to treat symptoms but only on an outpatient

basis. Today, there are 61 inpatient and 93 outpatient specialized medical

center programs designed to meet the needs of veterans diagnosed as

Page 17 GAO/HEHS-96-113 Vet Center Program
B-266316 

having PTSD. In contrast, Vet Centers do not provide inpatient care or

medical prescriptions but do provide services that medical centers cannot

or do not provide.

When compared with medical centers, Vet Centers serve different roles,

purposes, and benefits by

• being located in small, community-based storefront facilities;

• providing care to all veterans who served during the authorized eras of

conflict without regard to their income (generally, to receive free medical

center services for non-service-connected illness, veterans must have

incomes below a specified amount);

• providing counseling to veterans’ family members and significant others to

assist with the veterans’ readjustment (medical centers seldom include

others in veterans’ treatment);

• providing counseling for social and economic needs such as employment

and VA benefits, which is generally not provided by medical centers;

• performing outreach activities to identify veterans who could benefit from

Vet Center or other VA services (medical centers perform little or no

outreach);

• establishing close ties with local service providers and linking veterans

with the services they need;

• hiring a staff of team leaders and counselors of whom about 60 percent are

veterans of Vietnam and later conflicts; and

• if needed, working with veterans for longer periods than medical centers

generally do.

Some medical centers do provide services that Vet Centers cannot by

• providing psychological services for veterans from World War II and the

Korean War, which Vet Centers are not authorized to serve on an extended

basis;

• dealing with veterans severely affected by psychological problems who are

more appropriately cared for in medical centers; and

• developing specialized outpatient programs that provide medication for

veterans with PTSD, if needed.

Vet Center and medical center services also differ in their treatment

settings, staff expertise, and emphasis. Medical centers focus primarily on

psychological issues while Vet Centers address social as well as

psychological issues. As a result, some veterans are more likely to contact

Page 18 GAO/HEHS-96-113 Vet Center Program
B-266316 

and be successfully treated in Vet Centers, while others are more likely to

contact and be treated in medical centers.

How Does RCS Fit Into

VA’s Vision for

Restructuring Its Health

Care System?

VHA is implementing a new plan for managing its health care resources.

Recognizing that major changes are occurring in the health care

environment, VHA intends to increase ambulatory care access points,

emphasize primary care, decentralize decision-making, and integrate VA’s

delivery assets to provide an interdependent, interlocking system of care.

Vet Centers will be an indirect part of that interlocking system.

In 1995, VA operated 159 medical centers, 375 ambulatory clinics, 133

nursing homes, 39 domiciliaries, and 205 Vet Centers. VHA’s plan calls for

these providers to be reorganized into a community-based system founded

on the concept of coordinating and integrating all health delivery assets

into 22 Veterans Integrated Service Networks (VISN). Under VHA’s plan, the

geographic area each VISN serves is defined by patient referral patterns; the

number of beneficiaries in each area; facilities needed to support and

provide primary, secondary, and tertiary care; and, to a lesser extent,

political jurisdictional boundaries such as state borders. While hospitals

will remain an important, albeit less central, component of each network,

the integration of ambulatory, acute, and extended care services will be

emphasized to provide a coordinated continuum of care.

Under VHA’s VISN plan, RCS will remain independent within VHA, and RCS Vet

Center coordinators will act as the link with, but will not report to, VISN

directors. VHA’s Deputy Under Secretary for Health told us that RCS will

retain its independence under the plan primarily for three reasons. First,

VHA’s top officials believed RCS had done a good job of serving its clients in

the past, and they did not want to draw it into the difficulties of

implementing a major medical program reorganization. Second, Vet

Centers offer a unique approach to client care in that they are

community-based, they act as access points for many veterans seeking VA

services, and they perform outreach to the veteran population. Finally,

these officials believed that in a number of locations, good interaction and

coordination occurs between Vet Center and medical center staff and they

did not want to interrupt it. The Deputy Under Secretary stated that as the

VISN structure is implemented and as network services become more

integrated, VHA may need to reassess RCS’ organizational relationship

within that structure.

Page 19 GAO/HEHS-96-113 Vet Center Program
B-266316 

Once the VISN structure is in place, VA can reassess the role and

relationship Vet Centers have with other VA health care providers and how

Vet Centers can best be integrated into VA’s continuum of care to serve the

greatest number of veterans with the health care resources currently

available. For example, in some communities, the Vet Center represents

the only nearby access point veterans have to VA personnel and the care

and services available through the VA system. Forty-one Vet Centers are

more than 30 miles from a VA medical center or VA outpatient clinic and 27

of these are more than 50 miles from such facilities. For veterans in those

communities, the Vet Centers not only provide psychosocial services but

also act as access and referral points for needed medical center services.

In other communities, Vet Centers are close to VA medical centers; 133 are

within 10 miles of a VA medical center or an outpatient clinic. Future

consideration of Vet Center locations and their relationship with other VA

providers might best take place within the context of each VISN’s

geographic area.

RCS’ continued independence is consistent with recommendations made by

past studies. In its January 1986 report, the Vet Center Planning

Committee concluded that of the five options considered for RCS’ future

organizational structure, the one that would maintain RCS’ organizational

independence was the most appropriate. Two more recent studies—the

May 1991 VA program evaluation of PTSD programs and the April 1995

biannual report of the Advisory Committee on the Readjustment of

Vietnam and Other War Veterans—also concluded that RCS’ current

independent organizational structure should be maintained.19

Conclusions Vet Centers continue to provide a range of services to a large number of

veterans and their significant others. We found three program areas,

however, that need improvement. First, the workload reporting system,

SARS, focuses only on quantitative, not qualitative, aspects of the Vet

Center program. Hence, although SARS reports productivity data, it

provides insufficient information about actual Vet Center activities and the

resources used to perform them. Second, the documentation in client case

files is not always sufficient to ensure that veterans are receiving the care

they need and that an adequate assessment of the appropriateness and

quality of services rendered can be made. And third, RCS lacks a method of

demonstrating that its treatment services are effective in meeting the

psychological needs of Vet Center clients.

19For complete citations, please see the bibliography.

Page 20 GAO/HEHS-96-113 Vet Center Program
B-266316 

VA’s current restructuring of medical services under the VISN concept

maintains RCS’ independence within VHA. We believe that continuing RCS’

organizational independence is consistent with its mission of providing

both social and psychological services to veterans and the developing

nature of VHA’s VISN structure. Once the VISN structure has been

implemented, however, reconsideration of RCS’ organizational position

may be warranted.

Recommendations We recommend that the Secretary of the Department of Veterans Affairs

direct RCS to

• make changes to the Service Activity Reporting System so that it will more

accurately reflect Vet Center activity and staff resources used;

• require Vet Center counselors to properly document the care provided to

veterans and that when documentation problems are identified, take

corrective action; and

• develop a method for demonstrating, on a continuing basis, the

effectiveness of the Vet Center program.

Agency Comments

and Our Evaluation

In a letter dated May 28, 1996, VA’s Under Secretary for Health expressed

satisfaction with our generally positive conclusions about RCS’ operations

and concurred with our three recommendations, with qualifications. VHA

agreed that limitations of the existing workload reporting system, SARS, are

responsible for significant underreporting of actual RCS activities but did

not agree that overreporting of activities is an issue since it assumed that

our conclusions were based on evidence from only one Vet Center. It

indicated that reporting group contacts made under the Transition

Assistance Program as though they were individual visits is not a serious

problem and stated that the generalization of our findings in this area to

other centers was misleading.

Our discussion of Vet Centers’ overreporting as a result of the way TAP

contacts are recorded was based on data obtained from a number of Vet

Centers. We added information to the report to clarify the basis for our

conclusions. We are encouraged by RCS’ stated efforts to upgrade the SARS

information collection capability to more fairly and accurately report Vet

Center staff activity and believe that this may address the overreporting

problem that we identified during our review.

Page 21 GAO/HEHS-96-113 Vet Center Program
B-266316 

VHA stated that established processes are already in place to meet the

intent of our recommendation that counselors be required to properly

document the care provided to veterans and that when problems are

identified, corrective action be taken. VHA cited the standards established

by RCS for clinical record keeping and the processes in place for quality

and chart reviews. Our report does not take issue with the standards and

processes in place. Our concern rests with the high level of

noncompliance identified during RCS regional office clinical site visits, the

level of noncompliance identified in the sample of cases we reviewed, and

similar file documentation problems we noted in our 1987 report on RCS.

We believe that continued documentation problems of the magnitude we

identified point to the need for stronger action than proposed in VHA’s

comments. VHA’s statements that “monitoring of compliance with these

policies and processes will continue to be an ongoing activity” and “The

RCS program office will . . . continue to stress the importance of complete

documentation” do not indicate a recognition of the need for compliance

that we believe is called for in this area. We believe that RCS must initiate a

concerted effort to educate counselors on the importance of full case

documentation and to ensure that when documentation problems are

identified, effective action is taken to correct deficiencies. Not doing so

leaves in question the quality of care Vet Center clients are receiving.

VHA also offered several technical comments on our draft report that we

incorporated into the final report, as appropriate. The text of VHA’s

comments is in appendix IV.

Page 22 GAO/HEHS-96-113 Vet Center Program
B-266316 

Copies of this report are being sent to the Secretary of Veterans Affairs,

other congressional committees, and interested parties. Copies will be

made available to others upon request.

Please call me at (202) 512-7101 if you have any questions or need

additional assistance. Other GAO contacts and contributors to this report

are listed in appendix V.

Sincerely yours,

David P. Baine

Director, Federal Health Care

 Delivery and Quality Issues

Page 23 GAO/HEHS-96-113 Vet Center Program
Contents

Letter 1

Appendix I 

Scope and

Methodology

26

Appendix II 

RCS’ 205 Vet Centers

by Location

30

Appendix III 

Readjustment

Counseling Service

Fiscal Year 1995 SARS

Data

31

Appendix IV 

Comments From the

Department of

Veterans’ Affairs

33

Appendix V 

GAO Contacts and

Staff

Acknowledgments

40

Bibliography 41

Tables Table 1: FY 1995 Visits by New Veterans and Family and

Significant Others, by Problem Addressed

8

Table 2: FY 1993-95 Visits by New Veterans and Family and

Significant Others, by Problem Addressed

8

Table 3: Summary of Activities to Ensure the Appropriateness of

Vet Center Services

12

Page 24 GAO/HEHS-96-113 Vet Center Program
Contents

Table 4: Summary of Vet Center Team Leader Educational

Backgrounds

13

Table 5: Summary of Vet Center Deficiencies Reported by Four

Regions

14

Table I.1: Sampling Errors for Average FY 1995 Visits by New

Veterans and Family and Significant Others, by Problem

Addressed

28

Table I.2: Sampling Errors for Average FY 1993-95 Visits by New

Veterans and Family and Significant Others, by Problem

Addressed

28

Figure Figure II.1: Vet Center Locations 30

Abbreviations

M&M mortality and morbidity

PTSD post-traumatic stress disorder

RCS Readjustment Counseling Service

SARS Service Activity Reporting System

TAP Transition Assistance Program

VA Department of Veterans Affairs

VHA Veterans Health Administration

VISN Veterans Integrated Service Network

Page 25 GAO/HEHS-96-113 Vet Center Program
Appendix I 

Scope and Methodology

In performing our review of the Readjustment Counseling Service’s (RCS)

Vet Center program, we (1) interviewed officials from VHA’s and RCS’

central office in Washington, D.C., and RCS’ regional offices in Bay Pines,

Florida; Hines, Illinois; Denver, Colorado; and Providence, Rhode Island;

(2) reviewed studies, reports, and program information from RCS’ central

office and the RCS regional offices we visited as well as documents from

several advisory councils and committees; (3) visited Vet Centers in

Cheyenne, Wyoming; Chicago, Illinois; Norwich, Connecticut; Tampa,

Florida; and White River Junction, Vermont; (4) analyzed workload

reporting system data for a sample of 39 Vet Centers for fiscal years 1993

through 1995; and (5) talked with officials of VA’s National Center for

Post-Traumatic Stress Disorder (PTSD) in White River Junction, Vermont,

and four veteran service organizations.

At the four RCS regional offices, we discussed the Vet Center program and

reviewed documentation on regional efforts to evaluate the care provided

by the centers. In Providence, we also met with RCS’ National Data

Coordinator to discuss the Service Activity Reporting System (SARS) and to

collect program data from it. In Bay Pines and Denver we met with RCS’

clinical field managers to discuss their role in monitoring and improving

the quality of clinical services Vet Centers provide in their areas of

responsibility.

The five Vet Centers we visited were selected because they are

geographically and operationally diverse. For example, the White River

Junction Vet Center is in a rural area close to a medical center. The Vet

Center in Norwich is about 50 miles from the closest VA medical center and

has a military base in its catchment area. The Tampa and Chicago Vet

Centers are in large urban areas and both are close to VA medical centers.

Chicago is unique within the five in that it is a Veterans Resource

Center—a Vet Center with expanded employment and alcohol/drug abuse

services and staffing. The Cheyenne Vet Center is close to a VA medical

center and did not, at the time of our visit, have a full-time team leader.

While the White River Junction and Norwich Vet Centers are

geographically similar, the others serve distinctly different geographic

areas. At each Vet Center we met with the team leader and counselors to

get their views about the program. We reviewed activities, observed Vet

Center operations, and in three Vet Centers we met with veterans and

significant others to obtain their views. We also obtained workload data

from each center and, in four centers, reviewed a sample of case files to

evaluate case documentation and the accuracy of SARS data compared with

data in case files.

Page 26 GAO/HEHS-96-113 Vet Center Program
Appendix I 

Scope and Methodology

We met with officials of VA’s National Center for Post-Traumatic Stress

Disorder in White River Junction to discuss the treatment of PTSD in VA

medical centers and Vet Centers and the current methods of evaluating

treatment outcomes. We also met with officials of four veteran service

organizations—The American Legion, Vietnam Veterans of America, Inc.,

Veterans of Foreign Wars, and Disabled American Veterans—to obtain

their views on the program.

We reviewed a number of studies and reports on readjustment counseling

services and the diagnosis and treatment of PTSD in VA programs, prepared

by several organizations, advisory councils, and committees, including our

1987 report on the readjustment counseling program.20

As part of our review of RCS’ workload reporting system—SARS—we

requested activity data for 40 randomly selected Vet Centers for fiscal

years 1993 through 1995. The 40 were selected from the universe of 205

Vet Centers, minus three21 that were new in 1995 and did not have many

cases in their data system and five22 that are not located in the continental

United States and, according to an RCS official, are not typical of other Vet

Centers. This resulted in a sample universe of 197 Vet Centers. We

obtained data from 39 of the 40 Vet Centers. One center was unable to

provide information as a result of a computer problem. The data include

information on all clients who visited the 39 Vet Centers during fiscal years

1993, 1994, and 1995. We analyzed the data from the 39 Vet Centers to

describe the clients served, the number of visits clients made, and the type

of problems addressed.

The statistics we cite are estimates relating to all 197 Vet Centers

contained in our sampling universe. Our sampling errors for the estimates

were calculated at the 95-percent confidence level. This means that in 95

out of 100 instances, the sampling procedure we used would produce a

confidence interval23 containing the population value we are estimating.

20Vietnam Veterans: A Profile of VA’s Readjustment Counseling Program (GAO/HRD-87-63, Aug. 26,

1987).

21The three new Vet Centers that opened in 1995 were Raleigh, North Carolina; Bellingham,

Washington; and Yakima Valley, Washington.

22These five Vet Centers are in Agana, Guam; Arecibo, Puerto Rico; Ponce, Puerto Rico; St. Croix,

Virgin Islands; and St. Thomas, Virgin Islands.

23“Confidence interval” is another term for the range defined by our estimate, plus or minus the

sampling error.

Page 27 GAO/HEHS-96-113 Vet Center Program
Appendix I 

Scope and Methodology

The sampling errors for estimates of the average number of visits used in

this report are given in tables I.1 and I.2 and in subsequent paragraphs.

Table I.1: Sampling Errors for Average

FY 1995 Visits by New Veterans and

Family and Significant Others, by

Problem Addressed

New veterans Family and significant others

Problem addressed

Average

visits

95% sampling

error (±)

Average

visits

95% sampling

error (±)

Sexual trauma 6.7 1.7 2.8 0.6

PTSD 5.0 0.7 2.7 0.6

Sub-PTSD 4.3 0.8 2.7 1.0

Marital/family 3.1 0.4 2.8 0.6

Psych/other 3.0 0.5 1.9 0.3

Legal 2.4 1.0 1.3 0.4

Drug/alcohol 2.4 0.4 1.3 0.1

Homeless 1.8 0.5 1.0 0.0

Employment 1.6 0.2 1.1 0.1

Basic needs 1.6 0.3 1.1 0.2

Other 1.5 0.3 1.1 0.1

Medical 1.4 0.1 1.2 0.2

Benefits 1.3 0.1 1.2 0.1

Table I.2: Sampling Errors for Average

FY 1993-95 Visits by New Veterans and

Family and Significant Others, by

Problem Addressed

New veterans Family and significant others

Problem addressed

Average

visits

95% sampling

error (±)

Average

visits

95% sampling

error (±)

Sexual trauma 11.2 2.1 4.8 1.2

PTSD 9.4 1.3 4.1 0.8

Sub-PTSD 6.4 1.1 3.6 1.0

Marital/family 4.5 0.5 4.8 0.8

Psych/other 3.8 0.6 2.8 0.6

Drug/alcohol 3.0 0.4 1.5 0.1

Homeless 2.5 1.2 1.1 0.1

Legal 2.2 0.4 1.4 0.3

Other 2.1 0.5 1.2 0.1

Employment 1.9 0.3 1.2 0.2

Basic needs 1.7 0.2 1.2 0.2

Medical 1.6 0.2 1.4 0.2

Benefits 1.5 0.1 1.3 0.1

Our estimates and corresponding sampling errors for the number of visits

made by new veterans during fiscal years 1993 through 1995 are as

Page 28 GAO/HEHS-96-113 Vet Center Program
Appendix I 

Scope and Methodology

follows: 59 percent had only one visit with Vet Center staff ± 4 percent,

80 percent had three or fewer visits ± 2 percent, and 90 percent had seven

or fewer visits during the 3-year period ± 1 percent. The remaining

10 percent of Vet Center clients visited eight or more times ± 1 percent.

For the core group of veterans who are long-term users of the Vet Center

program, our sampling errors were as follows: 20 percent ± 3 percent of

the veterans who first visited a Vet Center prior to fiscal year 1993 had 13

or more visits and of these 10 percent ± 2 percent had 32 or more visits

through fiscal year 1995.

Page 29 GAO/HEHS-96-113 Vet Center Program
Appendix II 

RCS’ 205 Vet Centers by Location

Figure II.1: Vet Center Locations

Alabama

Alaska

Arizona

Arkansas

California

Colorado

Connecticut

Delaware

Birmingham

Mobile

Anchorage

Fairbanks

Kenai

Wasilla

Phoenix

Prescott

Tucson

Little Rock

Anaheim

Burlingame

Chico

Concord

East Los Angeles

Eureka

Fresno

Los Angeles (2)

Marina

North Bay

Oakland

Riverside

Sacramento

San Diego

San Francisco

San Jose

Santa Barbara

Sepulveda

Upland

Vista

Boulder

Colorado Springs

Denver

Hartford

New Haven

Norwich

Wilmington

District of

Columbia

Florida

Georgia

Guam

Hawaii

Idaho

Illinois

Indiana

Iowa

Washington

Fort Lauderdale

Jacksonville

Miami

Orlando

Palm Beach

Pensacola

Sarasota

St. Petersburg

Tallahassee

Tampa

Atlanta

Savannah

Agana

Hilo

Honolulu

Kauai

Kailua-Kona

Maui

Boise

Pocatello

Chicago

Chicago Heights

East St. Louis

Evanston

Moline

Oak Park

Peoria

Springfield

Evansville

Fort Wayne

Gary

Indianapolis

Cedar Rapids

Des Moines

Sioux City

Kansas

Kentucky

Louisiana

Maine

Maryland

Massachusetts

Michigan

Minnesota

Mississippi

Missouri

Wichita

Lexington

Louisville

New Orleans

Shreveport

Bangor

Caribou

Lewiston

Portland

Sanford

Baltimore

Elkton

Silver Spring

Boston

Brockton

Lowell

New Bedford

Springfield

Worcester

Grand Rapids

Lincoln Park

Oak Park

Duluth

St. Paul

Biloxi

Jackson

Kansas City

St. Louis

Montana

Nebraska

Nevada

New Hampshire

New Jersey

New Mexico

New York

North Carolina

North Dakota

Billings

Missoula

Lincoln

Omaha

Las Vegas

Reno

Manchester

Jersey City

Newark

Trenton

Ventnor

Albuquerque

Farmington

Santa Fe

Albany

Buffalo

Harlem

Long Island

New York (Bronx)

New York (Brooklyn)

New York (Queens)

New York

(Manhattan)

New York (Staten

Island)

Rochester

Syracuse

White Plains

Charlotte

Fayetteville

Greensboro

Greenville

Raleigh

Fargo

Minot

Ohio

Oklahoma

Oregon

Pennsylvania

Puerto Rico

Rhode Island

South Carolina

South Dakota

Tennessee

Texas

Cincinnati

Cleveland

Cleveland Heights

Columbus

Dayton

Oklahoma City

Tulsa

Eugene

Grants Pass

Portland

Salem

Erie

Harrisburg

McKeesport

Philadelphia (2)

Pittsburgh

Scranton

Arecibo

Ponce

San Juan

Cranston

Columbia

Charleston

Greenville

Rapid City

Sioux Falls

Chattanooga

Johnson City

Knoxville

Memphis

Amarillo

Austin

Corpus Christi

Dallas

El Paso

Fort Worth

Houston (2)

Laredo

Lubbock

McAllen

Midland

San Antonio

Provo

Salt Lake City

South Burlington

White River Junction

St. Croix

St. Thomas

Norfolk

Richmond

Roanoke

Springfield

Bellingham

Seattle

Spokane

Tacoma

Yakima Valley

Beckley

Charleston

Huntington

Martinsburg

Morgantown

Princeton

Wheeling

Madison

Milwaukee

Casper

Cheyenne

Utah

Vermont

Virgin Islands

Virginia

Washington

West Virginia

Wisconsin

Wyoming

Page 30 GAO/HEHS-96-113 Vet Center Program
Appendix III 

Readjustment Counseling Service Fiscal

Year 1995 SARS Data

Veterans seen first time this fiscal year 138,393

New veteran clients

Vietnam theater 28,363

Vietnam non-theater 21,809

Persian Gulf 10,692

Lebanon 534

Grenada 309

Panama 418

Somalia 1,047

Korean theater 1,634

World War II theater 1,469

Other 17,978

Total 84,253

Non-time defined visits

Veteran 587,116

Significant others 53,729

Total 640,845

Visits by location

In center 488,293

Out of center 123,728

Phone 37,351

Client sessions by type

Individual 383,674

Group 209,842

Family 22,001

Hours of outreach/education 114,432

Hours of consultation/supervision 128,511

Problem areas treated

PTSD 279,323

Sub-PTSD 63,955

Drug/alcohol 84,020

Marital/family 85,633

Psychological, other 111,404

Employment 66,500

Benefits 81,769

Basic needs 20,564

Medical 19,150

Legal 7,908

(continued)

Page 31 GAO/HEHS-96-113 Vet Center Program
Appendix III 

Readjustment Counseling Service Fiscal

Year 1995 SARS Data

Homeless 14,425

Other 25,163

Women veteran-sexual trauma 29,004

Total 888,818

Source: Service Activity Report for Period Ending September 30, 1995, Readjustment Counseling

Service, VA.

Page 32 GAO/HEHS-96-113 Vet Center Program
Appendix IV 

Comments From the Department of

Veterans’ Affairs

Page 33 GAO/HEHS-96-113 Vet Center Program
Appendix IV 

Comments From the Department of

Veterans’ Affairs

Page 34 GAO/HEHS-96-113 Vet Center Program
Appendix IV 

Comments From the Department of

Veterans’ Affairs

Page 35 GAO/HEHS-96-113 Vet Center Program
Appendix IV 

Comments From the Department of

Veterans’ Affairs

Page 36 GAO/HEHS-96-113 Vet Center Program
Appendix IV 

Comments From the Department of

Veterans’ Affairs

Page 37 GAO/HEHS-96-113 Vet Center Program
Appendix IV 

Comments From the Department of

Veterans’ Affairs

Page 38 GAO/HEHS-96-113 Vet Center Program
Appendix IV 

Comments From the Department of

Veterans’ Affairs

Page 39 GAO/HEHS-96-113 Vet Center Program
Appendix V 

GAO Contacts and Staff Acknowledgments

GAO Contacts George Poindexter, Assistant Director, (202) 512-7213

Stuart Fleishman, Senior Evaluator, (202) 512-7173

Timothy Hall, Senior Evaluator, (202) 512-7192

Acknowledgments James A. Carlan, Assistant Director

Rich LaMore, Senior Evaluator

Art Merriam, Evaluator

Leonard Hamilton, Evaluator

Joan Vogel, Data Specialist

Page 40 GAO/HEHS-96-113 Vet Center Program
Bibliography

Readjustment

Counseling Service

Advisory Committee on the Readjustment of Vietnam and Other War

Veterans. Biannual Report of the Advisory Committee on the

Readjustment of Vietnam and Other War Veterans, 1993-94. Washington,

D.C.: VA, Apr. 20, 1995.

Department of Veterans Affairs. Client Satisfaction Follow-up Project,

Final Report. Washington, D.C.: VA, Readjustment Counseling Service,

Client Satisfaction Questionnaire Committee, May 1995.

_____. Advisory Committee on the Readjustment of Vietnam and Other

War Veterans, Summary Report 1992. Washington, D.C.: VA, Office of

Readjustment Counseling Service, Feb. 1993.

_____. Report of the Vet Center Planning Committee. Washington, D.C.: VA,

Vet Center Planning Committee, Jan. 8, 1986.

U.S. General Accounting Office. Vietnam Veterans: A Profile of VA’s

Readjustment Counseling Program. GAO/HRD-87-63, Aug. 26, 1987.

Post-Traumatic Stress

Disorder

Department of Veterans Affairs. Treatment of Posttraumatic Stress

Disorder in the Department of Veterans Affairs: Fiscal Year 1995 Service

Delivery and Performance. West Haven, Conn.: Northeast Program

Evaluation Center, Feb. 6, 1996.

_____. The Long Journey Home IV: The Fourth Progress Report on the

Specialized PTSD Programs. West Haven, Conn.: Northeast Program

Evaluation Center, July 1, 1995.

_____. The National Center for Post-Traumatic Stress Disorder, 5th Annual

Report, Fiscal Year 1994. White River Junction, Vt.: VA, National Center for

Post-Traumatic Stress Disorder, no date.

_____. 9th Report of the Special Committee on Post-traumatic Stress

Disorder. Washington, D.C.: VA, Special Committee on Post-traumatic

Stress Disorder, Dec. 31, 1993.

_____. Interim Report of the Special Committee on Post-traumatic Stress

Disorder. Washington, D.C.: VA, Special Committee on Post-traumatic

Stress Disorder, July 1, 1993.

Page 41 GAO/HEHS-96-113 Vet Center Program
Bibliography

_____. The Long Journey Home III: The Third Progress Report on the

Specialized PTSD Programs. West Haven, Conn.: Northeast Program

Evaluation Center, May 1, 1993.

_____. A Program Evaluation of the Department of Veterans Affairs Post

Traumatic Stress Disorder (PTSD) Programs. Report No. 1990-04.

Washington, D.C.: VA, Deputy Assistant Secretary for Program

Coordination and Evaluation, May 1991.

Friedman, Matthew J., Lawrence C. Kolb, Arthur Arnold, and others. Third

Annual Report of the Chief Medical Director’s Special Committee on

Post-Traumatic Stress Disorder. Washington, D.C.: VA, Feb. 1, 1987.

Kulka, Richard A., William E. Schlenger, John A. Fairbank, and others.

National Vietnam Veterans Readjustment Study. Research Triangle Park,

N.C.: Research Triangle Institute, Nov. 7, 1988.

(101474) Page 42 GAO/HEHS-96-113 Vet Center Program
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