jurisdiction: US

text: b"Report No. SPO-2011-010 September 30, 2011\n\n\n\n\n Special Plans and Operations\n\n\n\n Assessment of DOD Wounded Warrior Matters -\n Fort Drum\n\x0c Inspector General Special Plans & Operations\n United States Department of Defense Our mission is to to provide assessment oversight that facilitates\n informed, timely decision-making by senior leaders of the DoD and\n the U.S. Congress, addressing priority national security objectives.\n Vision\n One professional team strengthening the integrity, efficiency, \n\n and effectiveness of the Department of Defense \n General Information\n programs and operations. \n\n Forward questions or comments concerning this assessment and report and other\n Mission activities conducted by the Office of Special Plans & Operations to spo@dodig.mil\n\n\n Promote integrity, accountability, and improvement of Department \n Deputy Inspector General for Special Plans & Operations\n Department of Defense Inspector General\n of Defense personnel, programs and operations to support the \n\n 400 Army Navy Drive\n Department's mission and serve the public interest.\n\n Arlington, VA 22202-4704\n\n\n\n\n Visit us at www.dodig.mil\n\n\n DEPARTMENT OF DEFENSE\nThe Department of Defense Inspector General is an independent, objective agency within the U.S. Department\nof Defense that was created by the Inspector General Act of 1978, as amended. DoD IG is dedicated to serving\nthe warfighter and the taxpayer by conducting audits, investigations, inspections, and assessments that result in\nimprovements to the Department. DoD IG provides guidance and recommendations to the Department of\nDefense and the Congress.\n hot line make a difference\n 800.424.9098\n Report www.dodig.mil/hotline\n Fraud, Waste, Mismanagement, Abuse of Authority\n Suspected Threats to Homeland Security\n Defense Hotline,The Pentagon, Washington, DC 20301-1900 Unauthorized Disclosures of Classified Information\n\x0c\x0cDISTRIBUTION:\n\nUNDER SECRETARY OF DEFENSE FOR PERSONNEL AND READINESS\n DEPUTY UNDER SECRETARY OF DEFENSE FOR WOUNDED WARRIOR CARE\n AND TRANSITION POLICY\n ASSISTANT SECRETARY OF DEFENSE FOR HEALTH AFFAIRS\n ASSISTANT SECRETARY OF DEFENSE FOR RESERVE AFFAIRS\nDIRECTOR, JOINT STAFF\nCOMMANDANT OF THE MARINE CORPS\n MEDICAL OFFICER OF THE MARINE CORPS\nCHIEF, NATIONAL GUARD BUREAU\nASSISTANT SECRETARY OF THE ARMY FOR MANPOWER AND RESERVE AFFAIRS\nDEPUTY CHIEF OF STAFF, G\xe2\x80\x931, U.S. ARMY\nTHE SURGEON GENERAL/COMMANDER, U.S. ARMY MEDICAL COMMAND\nCOMMANDING GENERAL, NORTHERN REGIONAL MEDICAL COMMAND\nCOMMANDER, WARRIOR TRANSITION COMMAND\n COMMANDER, FORT DRUM MEDICAL DEPARTMENT ACTIVITY\nSURGEON GENERAL OF THE NAVY AND CHIEF, BUREAU OF MEDICINE AND\n SURGERY\nSURGEON GENERAL OF THE AIR FORCE\nASSISTANT SECRETARY OF THE AIR FORCE (FINANCIAL MANAGEMENT AND\n COMPTROLLER)\nAUDITOR GENERAL, DEPARTMENT OF THE ARMY\nINSPECTOR GENERAL, DEPARTMENT OF THE ARMY\nNAVAL INSPECTOR GENERAL\nINSPECTOR GENERAL, OFFICE OF THE SECRETARY OF VETERANS AFFAIRS\nGOVERNMENT ACCOUNTABILITY OFFICE\n\nSENATE COMMITTEE ON APPROPRIATIONS, SUBCOMMITTEE ON DEFENSE\nSENATE COMMITTEE ON ARMED SERVICES\nSENATE COMMITTEE ON HOMELAND SECURITY AND GOVERNMENTAL AFFAIRS\nHOUSE COMMITTEE ON APPROPRIATIONS, SUBCOMMITTEE ON DEFENSE\nHOUSE COMMITTEE ON ARMED SERVICES\nHOUSE COMMITTEE ON OVERSIGHT AND GOVERNMENT REFORM\n\x0cReport No. SPO-2011-010 (Project No. D2010-D00SPO-0209.001) September 30, 2011\n\n\n\n Results in Brief: Assessment of DoD\n Wounded Warrior Matters \xe2\x80\x93 Fort Drum\n\nWhat We Did \xe2\x80\xa2 Ensure that Fort Drum Warriors meet the\n eligibility criteria for entry or attachment\nWe assessed whether the programs for the care, to the WTB\nmanagement, and transition of Warriors in \xe2\x80\xa2 Ensure that Fort Drum provides a\nTransition at the 3rd Battalion, 85th Mountain positive recovery and transition\nInfantry Regiment at Fort Drum, New York, environment for its Warriors\n(hereafter the Fort Drum Warrior Transition\n \xe2\x80\xa2 Ensure that timely access to specialty\nBattalion [WTB]) were managed effectively and\n medical care is available for Fort Drum\nefficiently. Specifically, we evaluated the\n Warriors\nmissions, policies, and processes in place to\n \xe2\x80\xa2 Develop a program for high-risk\nassist Warriors in Transition with their return to\n medication management, education,\nduty status or transition to civilian life, and the\nDoD programs for Warriors affected with training, and safety\nTraumatic Brain Injury and Post Traumatic \xe2\x80\xa2 Provide Fort Drum Warriors with a\nStress Disorder. program of productive activities that\n positively impact their transition\n \xe2\x80\xa2 Develop procedures to ensure that\nWhat We Found Warrior Comprehensive Transition Plans\nWe identified two initiatives implemented at the and Triad of Care processes are\nFort Drum WTB that we believed to be beneficial and accessible to Warriors\nnoteworthy practices for supporting the \xe2\x80\xa2 Develop comprehensive training\ncomprehensive care, healing, and transition of programs for WTB staff, civilian medical\nWarriors. personnel, and other civilians supporting\nWe also identified a number of significant Warriors\nchallenges that we recommend the Commanding\nGeneral, 10th Mountain Division; Warrior Management Comments\nTransition Command (WTC), MEDDAC, and and Our Response\nWTB leadership address, which if resolved,\nshould increase program effectiveness. The Acting Commander, 10th Mountain\n Division, Commander, Fort Drum Medical\nFinally, we recognized that it was important to Department Activity; and the Commander,\ngive a voice to the Warriors themselves. We Warrior Transition Battalion concurred with a\nsuggest that the WTC, MEDDAC, and WTB number of our recommendations. However,\nleadership and staff consider Warrior comments, there are several recommendations that were not\nas discussed in this report, so they are cognizant addressed and several that require additional\nof the Warriors\xe2\x80\x99 views and concerns and can comments. Therefore, we request that the\ntake appropriate action. Commanding General, Northern Regional\n Medical Command, and Commander, Warrior\nWhat We Recommend Transition Command provide additional\nWe recommend that the Commanding General, comments to the final report by November 7,\n10th Mountain Division, WTC, MEDDAC and 2011. Please see the recommendations table on\nWTB leadership: the back of this page.\n \xe2\x80\xa2 Develop an operational definition of a\n successful transition end state for Fort\n Drum Warriors\n\n\n\n i\n\x0cReport No. SPO-2011-010 (Project No. D2010-D00SPO-0209.001) September 30, 2011\n\n\n\n\nRecommendations Table\n Management Recommendations No Additional Comments\n Requiring Comment Required\nCommanding General, B.1.1., B.1.2., B.1.3.\nNorthern Regional Medical B.2.1., B.2.2., B.2.3.\nCommand B.3.1., B.3.2.\n B.4.1., B.4.2.\n C.3.1., C.3.2., C.3.3., C.3.4., C.3.5.\n C.7.1., C.7.2., C.7.3., C.7.4.\n C.11.2.a., C.11.2.b.\n C.12.1., C.12.2.\nCommander, Warrior C.4.1., C.4.2.\nTransition Command\nCommander, 3rd Battalion, C.1.1., C.1.2.\n85th Mountain Infantry C.2.1.\nRegiment C.5.\n C.6.\n C.8.\n C.9.\n C.10.2.a., C.10.2.b.\n C.11.1.\n\n\n\n\nPlease provide comments by November 7, 2011.\n\n\n\n\n ii\n\x0cTable of Contents\n\nRESULTS IN BRIEF I\nINTRODUCTION 1\n Objectives 1\n Background 2\nPART I - NOTEWORTHY PRACTICES 9\n Observation A. Noteworthy Practices - 3rd Battalion, 85th Mountain Infantry\n Regiment (Warrior Transition Battalion) 11\nPART II - CHALLENGES 15\n Observation B. Challenges - Fort Drum Medical Department Activity 17\n Observation C. Challenges - Fort Drum Warrior Transition Battalion 30\nPART III - WARRIORS SPEAK 65\nAPPENDIX A. SCOPE, METHODOLOGY, AND ACRONYMS 85\nAPPENDIX B. SUMMARY OF PRIOR COVERAGE 89\nAPPENDIX C. REPORTING OTHER ISSUES 91\nAPPENDIX D. ARMY GUIDANCE FOR WARRIOR TRANSITION\nUNITS 93\nAPPENDIX E. MANAGEMENT COMMENTS 95\n\x0cThis Page Intentionally Left Blank\n\x0cIntroduction\nObjectives\nThe broad objective of this ongoing assessment is to determine whether the DoD programs for\nthe care, management, and transition of recovering Service members wounded during\ndeployment in Operation Iraqi Freedom or Operation Enduring Freedom were managed\neffectively and efficiently. 1\nSpecific Objectives\nOur specific objectives were to evaluate the missions, the policies, and processes of:\n \xe2\x80\xa2 Military units, beginning with the Army and Marine Corps, established to support the\n recovery of Service members and their transition to duty status (Active or Reserve\n Components) 2 or to civilian life; and\n \xe2\x80\xa2 DoD programs for Service members affected with Traumatic Brain Injury (TBI) and Post\n Traumatic Stress Disorder (PTSD).\nAssessment Approach\nThis is the second of multiple assessments that will be conducted at Army and Marine Corps\nWarrior transition units. To obtain unbiased data, not unduly reflecting the views of either the\nsupporters or detractors of the program, we used a two-pronged approach to select our\nrespondents. First, we determined how many Service members were required to be interviewed,\nthen we applied a simple random sample approach to determine the Service members we should\ninterview, as described in Appendix A. We subsequently performed interviews with Army\nwounded, ill, and injured personnel, to include 96 individual interviews with Soldiers and\n26 additional Soldiers in 5 group interviews.\n\nSecond, we interviewed all available members of the key groups at each site responsible for the\nWarriors\xe2\x80\x99 care. Specifically, we conducted meetings and interviews during our 2-week visit at\nFort Drum that included unit commanders, staff officers, and Warrior Transition Battalion\n(WTB) military staff, as well as civilian staff and contractors. A list of the meetings conducted\nat the Fort Drum Medical Department Activity (MEDDAC) 3and the 3rd Battalion, 85th Mountain\nInfantry Regiment, which is the Fort Drum WTB, 4 is shown in Appendix A, along\n\n\n1\n Subsequent to our project announcement and at the initiation of our fieldwork, the Army\xe2\x80\x99s Warrior Transition\nCommand (WTC) informed us that approximately 10 percent of the Soldiers assigned or attached to Warrior\nTransition Units (WTUs) were combat wounded.\n2\n The Army is comprised of two distinct and equally important components, the Regular Army (the Active\nComponent) and the Army National Guard and the Army Reserve (the Reserve Components).\n3\n MEDDAC refers to all U.S. Army Medical and Dental Activity including ancillary, administrative and logistics\nsupport.\n4\n During our site visit, the WTU at Fort Drum had the provisional title of 3rd Battalion, 85th Mountain Infantry\nRegiment in lieu of calling themselves a WTU. Leaders believed that if titled like a traditional infantry unit,\nWarriors would feel a sense of belonging with the 10th Mountain Division, which is the division to which most of\nthe Fort Drum Warriors were assigned before becoming wounded, ill, or injured. To maintain continuity of\nreporting across all WTUs, we will refer to this unit as the \xe2\x80\x9cFort Drum WTB\xe2\x80\x9d or \xe2\x80\x9cWTB\xe2\x80\x9d in this report.\n\n\n\n\n 1\n\x0cwith the scope, methodology, and acronyms of this assessment. The prior coverage of this\nsubject area is discussed in Appendix B.\n\nThe observations and corresponding recommendations in this report focus on what we learned at\nFort Drum. In addition, noteworthy practices that may have application at other Warrior\nTransition Units (WTUs) are also described.\n\nAdditional reports and/or assessments may be subsequently performed by the DoD Office of the\nInspector General on DoD Wounded Warrior matters or other related issues as they are\nidentified. Any specific issues, concerns, and challenges that we identified at Fort Drum that\nmay have to be addressed in future assessments and/or reports are discussed in Appendix C.\n\nBackground\nAccording to the Army\xe2\x80\x99s Warrior Transition Command (WTC), there are approximately 10,000\nWarriors in Transition in the Army WTUs. Close to 1,000 were wounded in combat,\napproximately 2,100 were injured or became sick and were treated while deployed in Southwest\nAsia, approximately 2,000 recently returned from a deployment prior to entry into a WTU but\nwere not treated during the deployment, and approximately 4,900 had never been deployed. 5\n\nArmy Guidance\nArmy guidance for the care and management of Warriors in Transition (hereafter, \xe2\x80\x9cWarriors\xe2\x80\x9d) is\ncontained in the \xe2\x80\x9cWarrior Transition Unit Consolidated Guidance (Administrative),\xe2\x80\x9d March 20,\n2009 (hereafter, \xe2\x80\x9cConsolidated Guidance\xe2\x80\x9d). The purpose of the Consolidated Guidance is to\nprescribe the policies and procedures for the administration of Soldiers assigned or attached to\nWTUs. The Consolidated Guidance addresses items such as eligibility criteria for a Soldier\xe2\x80\x99s\nassignment or attachment to a WTU; staffing ratios of Army care team members; and other\nadministrative procedures for Soldiers being considered for assignment or attachment to a WTU.\nFor additional information on the Consolidated Guidance, see Appendix D for summary\ndescription.\n\nWarriors in Transition\nThe Army\xe2\x80\x99s wounded, ill, and injured Service members are referred to as Warriors in Transition.\nAccording to the Consolidated Guidance, the Warrior in Transition mission is:\n I am a Warrior in Transition. My job is to heal as I transition back to duty or\n become a productive, responsible citizen in society. This is not a status but a\n mission. I will succeed in this mission because I am a Warrior.\n\nWarrior Transition Units\nIn 2007, the Army created 35 WTUs at major Army installations primarily in the continental\nUnited States (CONUS) but also at other sites outside CONUS to better support the recovery\nprocess of the Army\xe2\x80\x99s wounded, ill, and injured Service members. Army WTUs vary in size and\n\n\n5\n Figures provided by the Army WTC, Program Performance and Effectiveness Branch.\n\n\n\n\n 2\n\x0cfunctionality and were established either as brigades, battalions, companies, or community-based\nunits. 6 As of May 2010, there were 26 WTUs located in CONUS, 1 in Hawaii, 2 in Alaska, and\n3 in Germany, as well as, 8 community-based WTUs located in CONUS and 1 in Puerto Rico.\n\nThe commander of each WTU reports to the commander of the Military Treatment Facility\n(MTF) that is co-located with the WTU. Army WTU care teams consist of, but are not limited\nto, military staff, physicians, nurses, behavioral health specialists such as psychologists and\nsocial workers, occupational therapists, and numerous outside organizations offering resources to\nthe Warriors in support of mission accomplishment.\n\nWTUs provide this critical support to Soldiers who meet the eligibility criteria, which generally\nrequire that: (1) a Soldier has a temporary profile, 7 or is anticipated to receive a profile, for more\nthan 6 months with duty limitations that preclude the Soldier from training for or contributing to\nunit mission accomplishment, and (2) the acuity of the wound, illness, or injury requires clinical\ncase management to ensure appropriate, timely, and effective utilization and access to medical\ncare services to support healing and rehabilitation. 8\n\nTriad of Care\nAt the nucleus of the WTU is the \xe2\x80\x9cTriad of Care,\xe2\x80\x9d which is comprised of a squad leader, a nurse\ncase manager, and a primary care manager (a physician). The Triad of Care staff was established\nto envelop the Warriors and their families in comprehensive care and support, which is focused\non each Warrior\xe2\x80\x99s primary mission \xe2\x80\x93 to heal. Specifically, the Triad of Care works together as a\nteam to collect Soldier data and information and develop a plan of care specific to each Soldier.\nThe plan of care addresses medical treatment, administrative requirements, support needs, and\ndisposition. The intention is for all of these elements to work together to ensure advocacy for the\nWarriors, continuity of care, and a seamless transition back into the force or to a productive\ncivilian life.\n\nIn accordance with Fragmentary Order (FRAGO) 3 to Execution Order (EXORD) 188-07,\nMarch 20, 2009, established the WTU Triad of Care staff to Warriors ratios at: squad leader\n(1:10), nurse case manager (1:20), and primary care manager (1:200).\nThe Triad of Care structure is shown in Figure 1.\n\n\n\n6\n Community-Based WTUs are primarily for Reserve Component Soldiers. According to the Consolidated\nGuidance, the Community-Based WTU is a program that allows Warriors to live at home and perform duty at a\nlocation near home while receiving medical care from the Tri-Service Medical Care network, the Department of\nVeterans Affairs, or Military Treatment Facility (MTF) providers in or near the Soldier\xe2\x80\x99s community.\n7\n According to Army Regulation 40-501, \xe2\x80\x9cStandards of Medical Fitness,\xe2\x80\x9d December 14, 2007, the basic purpose of\nthe physical profile serial is to provide an index to overall functional capacity. The physical profile serial system is\nbased primarily upon the function of body systems and their relation to military duties. The six factors that are\nevaluated are: physical capacity or stamina, upper extremities, lower extremities, hearing and ears, eyes, and\npsychiatric. Profiles can be either permanent or temporary.\n8\n Army National Guard and Army Reserve Soldiers may be eligible for assignment or attachment to a WTU but fall\nunder a different and more complex process than Active Component Soldiers. The processes are shown in the\nConsolidated Guidance.\n\n\n\n\n 3\n\x0c Figure 1. Triad of Care\n\n\n\n\nThe following is a brief description of each Triad of Care member\xe2\x80\x99s roles and responsibilities.\n \xe2\x80\xa2 Squad Leader \xe2\x80\x93 traditionally a Non-Commissioned Officer (NCO) in the rank of\n Sergeant (E-5) or Staff Sergeant (E-6) and the front line leadership for all Warriors.\n Their duty description includes, but is not limited to: accounting for Warriors daily,\n counseling them and guiding them in their Comprehensive Transition Plan (CTP), 9\n ensuring that they attend all appointments, tracking all of their administrative\n requirements, and building trust and bonding with Warriors and their families.\n \xe2\x80\xa2 Nurse Case Manager \xe2\x80\x93 a civilian or Army military nurse that provides the\n individualized attention needed to support the medical treatment, recovery, and\n rehabilitation phases of care of the Warriors. The goal of case management is to\n orchestrate the best care for the Warriors by monitoring progression of care, Transition\n Review Board 10 recommendations, and Warriors\xe2\x80\x99 respective goals to actively and\n proactively facilitate transition of the Warrior from one level of care to the next.\n \xe2\x80\xa2 Primary Care Manager \xe2\x80\x93 usually a physician, who is the medical point of contact and\n healthcare advocate for the Warrior. They provide primary oversight and continuity of\n healthcare and are to ensure the level of care provided is of the highest quality. They are\n the gateway to all specialty care (such as behavioral health specialists or orthopedic\n surgeons) and they coordinate with other physicians to ensure that the Warriors are\n getting the treatment that they need.\n\nFort Drum\nFort Drum is the home of the 10th Mountain Division (Light Infantry), its supporting elements,\nand several tenant units, to include the MEDDAC and the WTB. The MEDDAC Commander\n\n\n\n\n9\n The CTP is a plan that takes a broad look at the current status of a Warrior and formulates a program of action\naimed to help the Warrior move from one stage of his/her transition to the next. For additional information on the\nCTP, see Observation C and Part III, Warriors Speak.\n10\n Transition Review Boards are intended to facilitate dialogue between the Warrior and the Triad of Care, chain of\ncommand, and other members of the Warrior\xe2\x80\x99s care team, as appropriate, regarding both the Comprehensive\nTransition Plan progress and future strategy for the Warrior\xe2\x80\x99s transition.\n\n\n\n\n 4\n\x0cexercises command and control over the WTB at Fort Drum, which is a battalion-sized unit. 11\nThe Fort Drum organizational structure that supported the Warriors in the WTB during our\nassessment in August 2010 is shown in Figure 2.\n\n Figure 2. Fort Drum Organizational Structure for Warriors\n\n MEDDAC\n Commander\n\n\n Command WTB WTB\n Sgt Major Commander Chaplain\n\n\n\n Executive Headquarters\n WTB Surgeon Alpha Company Bravo Company\n Officer Company\n\n\n Battalion Primary Care\n Staff Manager\n NCM*\n Supervisor\n Primary Care\n Manager\n 18 Nurse Case\n Managers\n Primary Care\n Manager (v)**\n *NCM Nurse Case Manager\n **(V) Vacant\n\n\nFort Drum Medical Department Activity\nThe MEDDAC treatment facilities at Fort Drum are mainly primary and ambulatory care 12 and\ninclude the Guthrie Ambulatory Health Care Clinic, the Connor Troop Medical Clinic, and the\nWilcox Clinic. Because Fort Drum did not have an in-patient 13 hospital, the MEDDAC relied on\ncommunity support from the two local affiliated hospitals, the Carthage Area Hospital and\nSamaritan Medical Center. The services provided on Fort Drum and in nearby Watertown, NY,\nincluded, but were not limited to:\n \xe2\x80\xa2 Primary Care \xe2\x80\x93 family practice, pediatrics, and acute care 14\n \xe2\x80\xa2 Specialty Care \xe2\x80\x93 optometry, obstetrics/gynecology, dermatology, and musculoskeletal\n care\n \xe2\x80\xa2 Ancillary Services \xe2\x80\x93 radiology, laboratory, and pharmacy\n\n\n11\n A battalion is a military unit of around 300\xe2\x80\x931,300 soldiers usually consisting of between two and seven companies\nand typically commanded by either a Lieutenant Colonel or a Colonel.\n12\n Primary Care refers to health care professionals who act as a first point of consultation for patients regarding basic\nor general health care, before being referred elsewhere. Primary care is comprehensive when the primary provider\nenters into a sustained partnership with you, the patient, to take responsibility for the overall coordination for the\ncare of your health problems, whether biological, behavioral or social. Ambulatory Care includes diagnosis,\nobservation, treatment, and rehabilitation that are provided on an outpatient basis.\n13\n Inpatient Care refers to medical treatment that is provided in a hospital or other facility, and requires at least one\novernight stay.\n14\n According to Taber\xe2\x80\x99s Cyclopedic Medical Dictionary, 11th Edition, 1970, an acute care issue is defined as an issue\nthat has rapid onset, severe symptoms, a short course, and is not chronic in nature.\n\n\n\n\n 5\n\x0c \xe2\x80\xa2 Behavioral Health Care \xe2\x80\x93 alcohol and substance abuse, social work services, psychiatry\n and psychology, and community mental health services\n \xe2\x80\xa2 Preventive Medicine \xe2\x80\x93 occupational health, environmental health, audiology, and\n nutrition\n\nWarrior Transition Battalion\nAs of July 22, 2010, the WTB staff population had grown to approximately 100 military\nmembers and 50 civilians to oversee the health, welfare, and morale of approximately 300\nWarriors. The WTB consisted of a headquarters company and two additional companies (Alpha\nand Bravo companies) that collectively provided unit leadership and focused on meeting the\ncommand and control functions.\n\nThe mission of the Fort Drum WTB was to provide command and control, administrative\nsupport and services, quality prime care, and case management services for Soldiers qualifying\nfor Warriors in Transition (in accordance with Army Regulation 40-400); synchronize clinical\ncare, disposition and transition; and promote readiness to return to the Army or transition to\ncivilian life.\n\nThe WTB included a nurse case management staff (a supervisor and 18 nurse case managers), a\nbattalion surgeon, and three primary care managers (one position which was vacant as of\nAugust 2, 2010).\n\nBetween June 1, 2007, 15 and the completion of our site visit on August 13, 2010, the Fort Drum\nWTB transitioned a total of 1,155 Warriors. Table 1 shows the status of those Warriors.\n\n Table 1. Status of Warriors Who Transitioned Through the Fort Drum WTB\n Between June 1, 2007, and August 13, 2010\n Returned to Duty 346\n Transitioned from the U.S. Army to Civilian Life 801\n Deceased 2\n Administrative or Adverse Actions 6\n Total Warriors in Transition 1,155\n\nAs of August 13, 2010, there were 310 Warriors assigned to the Fort Drum WTB. Of the 310\nWarriors, 43 were combat wounded; 29 were treated in a contingency theatre area of operations;\nand 238 were ill or injured. 16 Of the 238 ill or injured Warriors, 130 had previously deployed to\n\n\n15\n June 1, 2007, is the date that the U.S. Army WTC was officially activated.\n16\n According to an official from the U.S. Army WTC, the following definitions apply to Warriors in Transition:\n\xe2\x80\x9cCombat Wounded\xe2\x80\x9d - Soldiers who have been wounded by enemy actions while serving in a contingency theatre\narea of operations. \xe2\x80\x9cTreated in a Contingency Theatre Area of Operations\xe2\x80\x9d - Soldiers who became ill or injured and\nwere treated by medical personnel while serving within a contingency theatre area of operations. \xe2\x80\x9cIll or Injured\xe2\x80\x9d -\nSoldiers who became ill or injured and were treated by medical personnel outside of a contingency theatre area of\noperations.\n\n\n\n\n 6\n\x0ca contingency theatre area of operations. The return to duty rate for Warriors in the Fort Drum\nWTB is 30 percent compared to the overall rate of 47 percent for all Warriors tracked by the\nWTC.\n\nTraumatic Brain Injury and Post Traumatic Stress Disorder\nTwo increasingly common diagnoses for recovering Service members are TBI 17 and PTSD. 18\nTBI is also referred to by its common term, \xe2\x80\x9cconcussion,\xe2\x80\x9d which is when someone receives a\ndirect blow or a jolt to their head that disrupts the function of the brain. Service members may\nsustain concussions or TBIs when exposed to a blast or explosion (sometimes on multiple\noccasions), which may lead to serious symptoms. There are three different levels of TBI (mild,\nmoderate, and severe) based on the severity of damage to the brain.\n\nPTSD is an anxiety disorder or condition that develops after someone has experienced or\nwitnessed a life-threatening or traumatic event, which may include a combat event. PTSD\nusually begins immediately after the traumatic event but it could start later, even years later. A\nPTSD event likely involved actual or perceived death or serious injury and caused an intense\nemotional reaction of fear, hopelessness, or horror.\n\nThe TBI Clinic and Behavioral Health Department (which includes the Army Substance Abuse\nProgram, Fort Drum/Samaritan Behavioral Health Clinic [satellite clinic], and Social Work\nServices) provided services at the Fort Drum WTB to Warriors and their families who were\naffected by TBI and/or PTSD, as well as those needing care for other behavioral health issues.\n\n\n\n\n17\n The definition of TBI is from multiple sources, including \xe2\x80\x9cTypes of Brain Injury,\xe2\x80\x9d Brain Injury Association of\nAmerica, October 15, 2008; and \xe2\x80\x9cForce Health Protection and Readiness Quick TBI and PTSD Facts,\xe2\x80\x9d Force Health\nProtection and Readiness, October 15, 2008.\n18\n The definition of PTSD is from multiple sources, including \xe2\x80\x9cForce Health Protection and Readiness Quick TBI\nand PTSD Facts,\xe2\x80\x9d October 15, 2008; and Jessica Hamblen, PhD, \xe2\x80\x9cWhat is PTSD?\xe2\x80\x9d National Center for PTSD,\nU.S. Department of Veterans Affairs, October 15, 2008.\n\n\n\n\n 7\n\x0cThis Page Intentionally Left Blank\n\n\n\n\n 8\n\x0c Part I -\nNoteworthy Practices\n\n\n\n\n 9\n\x0cThis Page Intentionally Left Blank\n\n\n\n\n 10\n\x0cObservation A. Noteworthy Practices for the\n3rd Battalion, 85th Mountain Infantry Regiment\n(Warrior Transition Battalion)\nWe observed two noteworthy practices that the Fort Drum WTB leadership instituted with\nrespect to providing quality services for Warriors in Transition.\n\n A.1. As needed, Warriors were provided a Personal Digital Assistant (PDA)\n\n A.2. All Warriors were required to obtain a comprehensive orientation on Soldier and\n Family Assistance Center (SFAC) services\n\nThese noteworthy practices may be applicable for utilization at other WTUs and should be\nconsidered for implementation now, if appropriate. We plan to identify other noteworthy\npractices in a summary report after all field assessments are completed and reemphasize that the\nWarrior Transition Command consider them for implementation throughout all of the Army\nWTUs, as appropriate.\n\n\n\n\n 11\n\x0cA.1. Warriors were Provided Personal Digital Assistants\n Warriors with memory or other cognitive medical issues were provided PDAs.\n This helped Warriors make and keep appointments and also enabled WTB\n staff to contact Warriors more easily.\n\nA.1. Background\nA PDA is a small, mobile, handheld device that provides information storage and retrieval\ncapabilities for personal or business use, often used for keeping schedules and calendars handy.\nPDAs were provided to Warriors to assist them in daily tracking of appointments and as a\nreminder of when to take medications.\nA.1. Discussion\nDuring multiple interviews, it was reported that support for Warriors, diagnosed with TBI and/or\nPTSD, was adequate on the installation and more importantly within the WTB. During a group\ninterview with WTB leadership, they stated their belief that if you \xe2\x80\x9ctreat Warriors in Transition\nas human beings, you will be more effective in dealing with PTSD and TBI cases.\xe2\x80\x9d They further\nexplained that compassion for the individual Warrior was critical to being an effective leader in\nthe WTB. This included understanding the special considerations for Warriors diagnosed with\nTBI and/or PTSD, such as memory issues.\n\nTo assist those Warriors with memory or other cognitive issues, they were issued PDAs. The\nWarriors utilized these devices to assist them with remembering appointments, briefings,\ntraining, or other required events, as well as to provide reminders about when to take\nmedications or perform other required tasks that were essential for their healing and transition.\nThe PDA also made it easier for WTB staff to contact the Warrior by phone.\n\nA.1. Conclusion\nThe PDAs, provided to Warriors, were very helpful in assisting Warriors tracking and making\ntheir scheduled appointments. This may ultimately assist with a more timely recovery and\ntransition. Additionally, we conclude this assistance to Warriors will likely result in a more\nefficient use of DoD, Department of Veterans Affairs (DVA), and civilian resources because of\nthe reduction of missed appointments.\n\nA.1. Recommendation\nWe recommend that the Warrior Transition Command provide Personal Digital Assistants to\nWarriors with memory or other cognitive medical issues at other United States Army Warrior\nTransition Units, where applicable.\n\n\n\n\n 12\n\x0cA.2. Orientation to the Soldier and Family Assistance Center\n Warriors assigned or attached to the Fort Drum WTB were required to in-\n process through the SFAC to ensure that they received a comprehensive\n orientation on the services available to them and their families. This\n comprehensive knowledge of available resources may greatly assist with\n easing the stress and smoothing the transition for Warriors and their families.\n\nA.2. Background\nThe SFAC was a component of the total continuum of Warrior care that provided integrated\nsupport services for Warriors and their families at a \xe2\x80\x9cone-stop\xe2\x80\x9d location near the WTU. The Fort\nDrum SFAC specifically provided crucial, non-medical services necessary to smooth the\ntransition for Warriors and their families, for families residing in the Fort Drum area whose\nSoldier was healing elsewhere, and for the spouses and families of fallen Warriors.\n\nFort Drum SFAC services were provided in three ways: by the resident staff members at the\nSFAC; by experts brought to the SFAC location; and through off-site appointments when\nnecessary, practical, and prudent. The SFAC services included:\n \xe2\x80\xa2 Army Career and Alumni Program \xe2\x80\x93 career counseling, job search support, resume and\n employment workshops, and job fairs\n \xe2\x80\xa2 Army Wounded Warrior Program \xe2\x80\x93 wounded Soldier advocates, benefits advisors,\n military transition, and career and education guides\n \xe2\x80\xa2 Child and Youth Services \xe2\x80\x93 childcare, child youth and school services liaisons, and other\n resource assistance\n \xe2\x80\xa2 Education Specialist \xe2\x80\x93 GoArmyEd\xc2\xae 19 enrollment assistance, Montgomery GI Bill\n assistance, Army and civilian testing, and educational and guidance counseling\n \xe2\x80\xa2 Human Resources Specialist \xe2\x80\x93 assistance with updating records (Service members\xe2\x80\x99\n Group Life Insurance, Defense Eligibility Enrollment Reporting System), forwarding\n documents to the official military personnel file, and processing separation and retirement\n orders\n \xe2\x80\xa2 Social Services Coordinator \xe2\x80\x93 information and assistance in finding solutions to life\n problems (stress management, substance abuse, and re-adjustment counseling)\n \xe2\x80\xa2 Traumatic Servicemembers\xe2\x80\x99 Group Life Insurance 20 \xe2\x80\x93 information and assistance with\n obtaining a traumatic injury protection rider under the Servicemembers\xe2\x80\x99 Group Life\n Insurance\n \xe2\x80\xa2 Financial Counselor \xe2\x80\x93 assistance with budget development, financial crisis counseling,\n and financial planning for the future\n\n\n\n19\n GoArmyEd\xc2\xae is an online portal that automates paper-based processes for requesting tuition assistance online for\nclassroom, distance learning, and eArmyU online college courses.\n20\n Traumatic Servicemembers\xe2\x80\x99 Group Life Insurance provides for payment to any member of the uniformed services\ncovered by Servicemembers\xe2\x80\x99 Group Life Insurance who sustains specific catastrophic injuries.\n\n\n\n\n 13\n\x0cThe Fort Drum SFAC also offered legal services, chaplain assistance, federal and state Veterans\nservices, and access to a Department of Labor representative.\n\nA.2. Discussion\nAll Warriors assigned or attached to the Fort Drum WTB were required to in-process through the\naforementioned SFAC groups to ensure that they received a comprehensive orientation on the\nservices available to them and their families. Warriors were required to obtain a signature on\ntheir in-processing checklist from a representative within each group, which signified that they\nwere briefed on the available services. The SFAC Director validated that the Warriors\ncompleted the full in-processing with his signature on their in-processing checklists. The SFAC\nstaff scheduled Wednesdays and Friday mornings for in-processing new Warriors.\n\nA.2. Conclusion\nRequiring Warriors to obtain a comprehensive orientation on SFAC services may ensure that\nWarriors are aware of the available services to them and their families. This comprehensive\nknowledge of available resources can greatly assist to ease the stress and smooth the transition\nfor Warriors and their families.\n\nA.2. Recommendation\nWe recommend that the Warrior Transition Command establish policy requiring Warriors\nassigned to Warrior Transition Units to in-process through the Soldier and Family Assistance\nCenter to ensure that they receive a comprehensive orientation on the services available to them\nand their families.\n\n\n\n\n 14\n\x0cPart II - Challenges\n\n\n\n\n 15\n\x0cThis Page Intentionally Left Blank\n\n\n\n\n 16\n\x0cObservation B. Challenges for the Fort Drum\nMedical Department Activity\nThe Fort Drum MEDDAC should address four challenges related to Warriors\xe2\x80\x99 medical care in\norder to ensure the safe and effective care, healing, and transition of Warriors. The four\nchallenges included:\n\n B.1. Warriors\xe2\x80\x99 Timely Access to Specialty Medical Care: Specialty medical care\n appointments for Warriors assigned to the WTB were not within established\n standards. As a result, Warriors at Fort Drum WTB were at risk of being delayed\n in returning to duty or transitioning to civilian life.\n\n B.2. Medication Management for Warriors: Medical and WTB staff expressed\n concern that Warriors appeared to be inappropriately medicated for their medical\n conditions. Consequently, Fort Drum\xe2\x80\x99s medical community prescription practices\n could lead to potentially harmful medication-related incidents or enduring health\n problems.\n\n B.3. Complete and Accurate Medication Profiles for Warriors: Medical care personnel\n may not have had a complete and accurate picture of each Warrior\xe2\x80\x99s medication\n profile. Consequently, without complete Warrior prescription information,\n inaccurate clinical, behavioral health, and/or disability management decisions\n could potentially be made.\n\n B.4. Obtaining Warriors\xe2\x80\x99 Medical Results from Off-Post 21 Providers: The MEDDAC\n Referral Management Office and the Health Net Federal Services contractor 22\n were not obtaining medical results from off-post medical care providers within\n established standards. 23 Consequently, the lack of timeliness in providing the\n results of medical referral updates to Warriors\xe2\x80\x99 medical records could have an\n adverse impact on clinical (including behavioral and mental health, and/or\n disability management) decisions made on behalf of Warriors.\n\n\n\n\n21\n Off-Post refers to medical facilities outside Fort Drum proper; outside the gates of a military installation.\n22\n Health Net Federal Services is the Tri-Service Medical Care (TRICARE) North Region managed care support\ncontractor.\n23\n Standards for MEDDAC Referral Management: 95% within 10 days; Health Net Federal Services: 98% within\n10 days; 100% within 30 days.\n\n\n\n\n 17\n\x0cB.1. Warriors\xe2\x80\x99 Timely Access to Specialty Medical Care\n Specialty medical care appointments for Warriors assigned to the WTB were\n not within established standards. As a result, Warriors at Fort Drum WTB\n were at risk of being delayed in returning to duty or transitioning to civilian\n life.\n\nB.1. Background\nBarriers to health care in rural areas typically include long travel distances for specialty care,\nlack of confidentiality in small towns, and lack of psychosocial support and case management.\nAdditionally, winter travel in the rural Fort Drum/Watertown area can be difficult with\ntemperatures often near zero degrees and a mean average snow fall of 84 inches.\n\nFort Drum is located in rural upstate New York, just outside of Watertown, NY and\napproximately 30 miles from the Canadian border. The population of Fort Drum is\napproximately 36,000 active duty Soldiers and family members while the population of\nWatertown is approximately 28,000. The nearest large city (Syracuse, New York) is\napproximately 70 miles away and has a population of approximately 750,000.\n\nThe MEDDAC at Fort Drum provided primary care and limited specialty care services at the\nGuthrie Ambulatory Health Care Clinic, Conner Troop Medical Clinic, and Wilcox Clinic.\nBecause Fort Drum did not have an in-patient military hospital, the MEDDAC relied on local\ncommunity hospitals for many services.\n\nThe availability of medical care in the immediate vicinity of Fort Drum/Watertown is limited to:\n \xe2\x80\xa2 Optometry, obstetrics/gynecology, dermatology, and musculoskeletal specialty care\n \xe2\x80\xa2 Radiology, laboratory, and pharmacy ancillary services\n \xe2\x80\xa2 Alcohol and substance abuse, social work services, psychiatry and psychology, and\n community mental health and behavioral health care\n \xe2\x80\xa2 Occupational health, environmental health, audiology, nutrition, and preventive medicine\nTo meet the behavioral health demands of active-duty soldiers, and other DoD eligible\nbeneficiaries, the Coleman Clinic community partnership was established between Samaritan\nMedical Center in Watertown, NY and Health Net Federal Services. Behavioral Health services\ninclude, assessment, diagnosis and treatment of behavioral health conditions, including but not\nlimited to counseling, group and individual therapy, education and medication management.\n\nAlso in the immediate vicinity of Fort Drum/Watertown is the Watertown Veterans\nAdministration (VA) Outpatient Clinic which provides primary care services and behavioral\nhealth services. However, for specialty medical care services, the Watertown VA relied on the\nVA Healthcare, Upstate New York facility located in Syracuse, NY.\n\n\n\n\n 18\n\x0cB.1. Discussion\nWarriors indicated that for the most part, they were satisfied with their primary care managers.\nHowever, Warriors reported in multiple interviews that they had challenges receiving specialty\ncare. They felt that they did not receive timely access to certain types of specialty medical care,\nsuch as behavioral health services, neurology, and sleep clinic appointments.\n\nWarriors indicated that access to behavioral health services was one problematic issue. For\nexample, a Warrior stated that he asked for a psychologist to see him at a behavioral health clinic\nin July 2010, but was told that it would take two-to-three months for one to be assigned to him.\nAnother Warrior stated that although he liked working with his current behavioral health\nspecialist, he was switching to another because his current specialist is overbooked.\n\nA Fort Drum behavioral health specialist acknowledged that they had insufficient numbers of\nproviders and had a difficult time meeting their access to care standards. As a result, for\nbehavioral health services, they had to rely heavily on providers located at the Coleman Clinic.\n\nDuring an individual interview, a Warrior reported problems with his neurologist. He showed up\nfor a scheduled appointment in February, but was not seen and was rescheduled for a new\nappointment in August, 6 months later. Another Warrior stated that during his neurology\nappointment for epilepsy, the specialist was hasty during the appointment, which ended up being\ntoo short and unsatisfactory. Finally, another Warrior mentioned that his access to specialty\nmedical care was \xe2\x80\x9cgood, when you finally get an appointment.\xe2\x80\x9d He mentioned that the long\nwaits were for neurology and sleep studies, and that his wait for his sleep study was\napproximately three months.\n\nFort Drum MEDDAC provided the list of the top five specialty medical services with the longest\nappointment wait times at Fort Drum. See Table 2.\n\n\n Table 2. Fort Drum MEDDAC: Top Five Longest Average Wait Times for Active Duty\n Specialty Services\n (as of September 1, 2010)\n Specialty Service Average Wait (in Days)\n Gastroenterology 45+\n Ear, Nose, and Throat (ENT) 45+\n Rheumatology 45+\n Endocrinology 45+\n Pulmonary (Sleep Studies) 40+\n\nAs evidenced, all five specialty appointment wait times exceeded the TRICARE access to care\nstandards. The TRICARE 24 access to care standard for specialty medical care services specifies\n\n\n24\n TRICARE is the healthcare program serving Uniformed Service members, retirees, and their families worldwide.\n\n\n\n\n 19\n\x0cthat beneficiaries must be offered an appointment, with an appropriately trained provider within\nan established timeframe. The established TRICARE access to care standards 25 for appointment\ntimes is that wellness and specialty care appointments shall not exceed 28 days. 26 Warriors were\nroutinely sent out of the area (75 miles or more) to receive care after established TRICARE\nstandards could not be met.\n\nB.1. Conclusion\nAccess to certain specialty medical care is a challenge due to the location of Fort Drum.\nHowever, the ramification of not receiving timely care is that Warriors at Fort Drum may not be\nable to achieve timely transitions.\n\nWarriors assigned to the Fort Drum WTB risk having their timely healing and transition hindered\nbecause of the lack of readily accessible specialty medical care. For amplifying remarks by\nWarriors concerning this section, refer to Part III, Warriors Speak.\n\nB.1. Recommendations, Management Comments, and Our Response\n\nRevised and Redirected Recommendations\nBased on the non responsive comments to the recommendations received from the Fort Drum\nMedical Department Activity, we have revised and redirected the draft report recommendations\nB.1.1, B.1.2, B.1.3 to the Commanding General, Northern Regional Medical Command.\n\nB.1. We recommend that the Commanding General, Northern Regional Medical Command:\n\n B.1.1. Obtain three months worth of data from Fort Drum Medical Department Activity\n showing numbers of appointments not scheduled and appointments scheduled that did not\n meet standards and analyze the data to quantify the extent of the service failures, and use\n the results as a basis to respond to B.1.2., and B.1.3.\n\n B.1.2. Direct a manpower study to assess the need and feasibility to add specialty medical\n providers to the Fort Drum medical facilities; and\n\n B.1.3. Assess the need and feasibility of Fort Drum entering into a joint venture with the\n Watertown Department of Veterans Affairs to add needed medical providers to the\n Watertown Veterans Administration Outpatient Clinic.\n\n\n\n\n25\n Access to care standards were promulgated in the Office of the Surgeon General/Medical Command.\n(OTSG/MEDCOM) Policy Memorandum 08-028, \xe2\x80\x9cMedical Treatment Facility (MTF) Access Standards for Active\nDuty Service Members,\xe2\x80\x9d July 3, 2008.\n26\n A wellness care appointment is designated for patients who require a visit for a wellness/preventive health\nconcern or with their Primary Care Manager (PCM) for an initial visit; a specialty care appointment is designated for\npatients who require an initial consult, referral, or initial self-referral, specialty care appointments to include medical\nprocedures.\n\n\n\n\n 20\n\x0cU.S. Army Medical Department Activity Comments\nThe Commander, Fort Drum Medical Department Activity concurred with the finding that\nspecialty medical care appointments are outside of enhanced access to care standards, but did not\nagree these delays are delaying return to duty or transition to civilian life. The Commander\nexplained that Fort Drum is a medically underserved area with limited access to specialty care.\nMeeting the 7 day WTB Enhanced Access to Care Standard was extremely difficult, if not\nimpossible, for many specialties that the WTB Soldiers routinely require. Frequently, Soldiers\nare referred out of the local area, within a 1-3 hour drive time, to obtain specialty care. Many of\nthe soldiers are unable to drive and therefore require a non-medical attendant to transport them to\nspecialty care appointments, which requires coordination and time. The Commander explained\nthat the TRICARE network providers were not contractually required to meet the WTB\nEnhanced Access to Care standard of 7 days. They are held to the 28-day standard.\n\nFurthermore, the Commander identified efforts currently in place to ensure WTB referrals were\nprocessed and booked as quickly as possible, these include:\n\n a. Dedicated Referrals Manager. Each referral is tracked from the time it is entered into\n CHCS/AHLTA until an authorization is received (if an authorization is required). The\n Nurse Case Manager (NCM) is notified and given the authorization, then is responsible to\n book the appointment.\n b. The WTB developed a database which tracked all WTB referrals generated and\n scheduled appointments. NCMs receive the updated spreadsheet which indicates what\n appointments have not been scheduled and what appointments were scheduled that did\n not meet the standard.\n c. NCMs having difficulty obtaining access to care within the 7-day standard contact the\n Referrals Management Office (RMO) for assistance. At that time, the referral\n authorization can be modified to another provider who can meet the access standard (if\n available).\n\nOur Response\nThe Commander\xe2\x80\x99s comments are non responsive. We acknowledge that access to certain\nspecialty medical care is a challenge due to the location of Fort Drum. We also acknowledge\nthat the Fort Drum Medical Department Activity has put in place processes for tracking referrals\nand appointments to determine if access to specialty care is within established standards.\n\nHowever, it is unclear as to whether these current practices ensure that access to care and\nreferrals are meeting the established access to care standards. Therefore, we ask that in response\nto the final report, the Commanding General, Northern Regional Medical Command obtain and\nanalyze three months worth of data from Fort Drum Medical Department Activity showing the\nnumbers of appointments not scheduled, and appointments scheduled that did not meet standard\nand to quantify the extent of the service failures, and use the results as a basis to respond to\nB.1.2., and B.1.3. If challenges still remain, we ask that a response be provided on a way ahead\nto ensure Warriors timely access to specialty care.\n\n\n\n\n 21\n\x0cB.2. Medication Management for Warriors\n Medical and WTB staff expressed concern that Warriors appeared to be\n inappropriately medicated for their medical conditions. Consequently, Fort\n Drum\xe2\x80\x99s medical community prescription practices could lead to potentially\n harmful medication-related incidents or enduring health problems.\n\nB.2. Background\nWarrior Transition Command Policy Memorandum 10-033, \xe2\x80\x9cWarrior Transition\nUnit/Community Based Warrior Transition Unit Risk Assessment and Mitigation Policy,\xe2\x80\x9d\nJune 16, 2010, requires programs for high-risk medication management, education, and training.\nThis policy also states that training should specifically address the dangers associated with\npolypharmacy, which is the use of a number of different drugs, possibly prescribed by different\ndoctors and filled in different pharmacies, by a patient who may have one or several health\nproblems.\n\nB.2. Discussion\nClinical and WTB staff expressed concern that Warriors were being overmedicated. Warriors\ninterviewed, on the other hand, reported having trouble obtaining necessary medications for their\nconditions without being labeled as a drug addict or \xe2\x80\x9cjunkie\xe2\x80\x9d (see Part III, Warriors Speak).\n\nA group of primary care managers interviewed stated that they believed that Warriors were\nreceiving more medications than was appropriate for their medical conditions. One primary care\nmanager commented that the numbers and types of medications that some of the Warriors were\ntaking was a \xe2\x80\x9cscary situation.\xe2\x80\x9d This primary care manager further stated that some Warriors\ncome to the Fort Drum WTB already taking prescribed opioid medications, 27 and there did not\nseem to be an effort over time to reduce those types of medications.\n\nDuring two different group interviews with nurse case managers, they explained that Warriors\nwere demanding medications from primary care managers and specialists, especially those who\nwere more liberal in their treatment plans, and it appeared that the Warriors would too often get\nwhat they wanted. One nurse case manager added that Warriors would threaten to go to their\ncongressman and complain if they did not get the pain medications that they wanted, causing\nphysicians to often give in to their demands. The nurse case managers agreed that insomnia and\nnightmares were common medical issues for Warriors but contended, nonetheless, that sleep\nmedications appeared to be overly prescribed.\n\n\n\n\n27\n According to the Merriam-Webster, Inc., Medical Dictionary, copyright 2010, an opioid possesses some\nproperties characteristic of opiate narcotics but are not derived from opium.\n\n\n\n\n 22\n\x0cNurse case managers indicated that many of their Warriors were taking prescription medications\nsuch as Vicodin and Percocet. 28 They had concluded that providers were prescribing narcotics\nbefore trying other non-narcotic medications to support Warriors\xe2\x80\x99 pain needs. Finally, a group of\nsquad leaders agreed that addiction issues were a problem and that Warriors\xe2\x80\x99 medications\nseemed to be overprescribed. A WTB command team member agreed, and stated that \xe2\x80\x9chalf of\nthe Warriors are \xe2\x80\x98stoned\xe2\x80\x99 on psychotropic drugs.\xe2\x80\x9d\n\nB.2. Conclusion\nAdherence to Warrior Transition Command Policy Memorandum 10-033 could significantly\nreduce the risk of Warriors being inappropriately medicated for their medical conditions. We\nbelieve that developing standard operating procedures for overall medication management, to\ninclude polypharmacy management and medication reconciliations, 29 and pain management\npractices including use of alternative therapies, and using these procedures to help provide\nappropriate staff with necessary education and training, could significantly assist in the\nidentification and reduction of potentially harmful Warrior medication-related incidents. For\namplifying remarks by Warriors concerning this section, refer to Part III, Warriors Speak.\n\nB.2. Recommendations, Management Comments, and Our Response\n\nRedirected Recommendations\nFort Drum Medical Department Activity has yet to provide a response to the recommendations.\nTherefore, we have redirected the draft report recommendations B.2.1, B.2.2, B.2.3 to the\nCommanding General, Northern Regional Medical Command.\n\nB.2. We recommend that the Commanding General, Northern Regional Medical Command:\n\n B.2.1. Enforce Warrior Transition Command Policy Memorandum 10-033, titled\n \xe2\x80\x9cWarrior Transition Unit/Community Based Warrior Transition Unit Risk Assessment\n and Mitigation Policy,\xe2\x80\x9d dated June 16, 2010;\n\n B.2.2. Develop standard operating procedures for overall medication management, to\n include polypharmacy management and medication reconciliations, and pain\n management practices including use of alternative therapies; and\n\n B.2.3. Develop a comprehensive training program for all Warrior Transition Battalion\n medical providers, pharmacy staff, and other staff that provides the necessary education\n and training for the identification of risk of potentially dangerous medication-related\n incidents for Warriors.\n\n\n28\n Vicodin is a tablet containing a combination of acetaminophen and hydrocodone, and is used to relieve moderate\nto severe pain. Percocet, the combination of oxycodone and acetaminophen, is a narcotic pain reliever used to treat\nmoderate to severe acute (short-term) pain.\n29\n Medication reconciliation is a formal process of identifying the most complete and accurate list of medications a\npatient is taking and using that list to provide correct medications for the patient anywhere within the healthcare\nsystem.\n\n\n\n\n 23\n\x0cB.3. Complete and Accurate Medication Profiles for Warriors\n Medical care personnel may not have had a complete and accurate picture of\n each Warrior\xe2\x80\x99s medication profile. Consequently, without complete Warrior\n prescription information, inaccurate clinical, behavioral health, and/or\n disability management decisions could potentially be made.\n\nB.3. Background\nAt Fort Drum, Warriors also obtained medical care from non-DoD providers, off-post. This\noften resulted in Warriors receiving medications prescribed by these medical care providers. The\ndispensing of these medications was documented by the pharmacy from which they were\npurchased in the Pharmacy Data Transaction Service (PDTS). PDTS is a centralized drug data\nrepository that stores patient prescription data, including drugs ordered outside of a MTF, such as\norders from TRICARE pharmacies, mail order pharmacies, or other DoD facilities.\n\nHowever, to be able to monitor Warriors\xe2\x80\x99 medication consumption the PDTS record of\nmedications prescribed had to be electronically transferred into the Armed Forces Health\nLongitudinal Technology Application (AHLTA) database, 30 which documented personnel\nmedical records. In 2007, an interface was developed so that AHLTA users would see the PDTS\nmedications in the AHLTA medication module to have complete awareness of all medications\nprescribed to patients and to any potential adverse medication reactions.\n\nB.3. Discussion\nFort Drum\xe2\x80\x99s WTB pharmacist determined that not all medications documented in PDTS were\nbeing transferred to the AHLTA database. This was causing medical care personnel to\npotentially not have a complete and accurate picture of each Warrior\xe2\x80\x99s medication profile. The\nproblem was reported to the Fort Drum MEDDAC Management Information Department, which\nthen raised this deficiency to the Defense Health Information Management System 31 program\noffice. In September 2010, a Defense Health Information Management System representative\ndistributed an e-mail to affected users notifying them of their awareness of the issue and\ndescribing potential mitigating actions that could be taken while their analysis of the issue\ncontinued. The Fort Drum pharmacist re-identified the PDTS/AHLTA interface problems in\nboth February and March of 2011.\n\nSubsequent to our site visit, we were informed that the Fort Drum MEDDAC developed policies\nto mitigate the effects of the PDTS/AHLTA interface problem. First, the Fort Drum MEDDAC\nblocked all TRICARE benefits for controlled substances except behavioral health-related\nmedications, resulting in all Warriors having to procure controlled substances from an on-post\n\n\n30\n Armed Forces Health Longitudinal Technology Application (AHLTA) is the medical and dental clinical\ninformation system that generates and maintains a comprehensive, lifelong, computer-based patient record for every\nSoldier, Sailor, Airman, and Marine; their family members; and others entitled to DoD military health care.\n31\n The Defense Health Information Management System provides information management and information\ntechnology solutions that capture, manage, and share healthcare data for the military\xe2\x80\x99s electronic health record.\n\n\n\n\n 24\n\x0cpharmacy, eliminating the need for entries into PDTS. Second, the WTB pharmacist conducted\nmedication reconciliations on all high-risk Warriors at Fort Drum (approximately 85 Warriors)\nweekly by comparing information from multiple databases and medication reports. This was a\nlengthy and cumbersome process which precluded it from being adopted by the medical\nproviders who wrote prescriptions. Because of this process the Fort Drum WTB pharmacist\ncould only conduct medication reconciliation on all non-high risk Warriors at Fort Drum\n(approximately 320 Warriors) once every three months.\n\nIn response to our question, the Fort Drum WTB pharmacist did not know if the PDTS/AHLTA\ninterface issue had ever caused a specific Warrior medication problem because of an adverse\nmedication reaction caused by incorrect medication reconciliation.\n\nB.3. Conclusion\nFort Drum MEDDAC acted correctly when it recognized the PDTS/AHLTA interface problems\nand took appropriate steps to mitigate the risk. However, the Defense Health Information\nManagement system program office has not yet been able to address the PDTS/AHLTA interface\nproblems. Therefore, medical care personnel did not have a complete and accurate picture of\neach Warrior\xe2\x80\x99s medication profile. We believe it is essential that Fort Drum MEDDAC\nleadership develop and widely distribute procedures to ensure that those responsible for\nreviewing and/or managing Warriors\xe2\x80\x99 medications are aware of these additional procedures to\nuse so they have a complete and accurate picture of each Warrior\xe2\x80\x99s medication profile. By\nincorporating these procedures this may assist medical care providers by helping them to avoid\ninaccurate clinical, behavioral health, and/or disability management decisions.\n\nB.3. Recommendation, Management Comments, and Our Response\n\nRevised and Redirected Recommendation\nFort Drum Medical Department Activity has yet to provide a response to recommendation B.3.1.\nTherefore we have revised and redirected the draft report recommendation to the Commanding\nGeneral, Northern Regional Medical Command.\n\nB.3. We recommend that the Commanding General, Northern Regional Medical Command:\n\n B.3.1. Engage with the Defense Health Information Management System program office\n about the Pharmacy Data Transaction Service/Armed Forces Health Longitudinal\n Technology Application interface issue to determine when reported system deficiency\n issues will be resolved\n\nRedirected Recommendation\nBased on the partial comments received from the Fort Drum Medical Department Activity we\nhave redirected the draft report recommendation B.3.2., to the Commanding General, Northern\nRegional Medical Command.\n\n\n\n\n 25\n\x0cB.3. We recommend that the Commanding General, Northern Regional Medical Command:\n\n B.3.2. Develop and widely distribute procedures to all Fort Drum Medical Department\n Activity and Warrior Transition Battalion personnel responsible for managing and/or\n reviewing medication profiles for Warriors in Transition that explain the necessary steps\n and precautions to be taken to ensure a complete and accurate record of the medication\n profile for each Warrior in Transition.\n\nU.S. Army Medical Department Activity Comments\nThe Commander, Fort Drum Medical Department Activity concurred with our recommendation.\nThe Commander explained that incomplete medication profiles for Warriors and others were due\nto incomplete crossover of information occurring between CHCS/AHLTA. Additionally, this\nissue was brought forth by the WTB pharmacist and examples were provided during the IG visit.\n\nThe Commander stated that while awaiting an automation solution from MEDCOM, the\nfollowing actions were taking place, the pharmacy was (1) encouraging providers and NCMs to\nuse CHCS to get a more complete picture and (2) having Fort Drum pharmacists and technicians,\nespecially the WTB and CTMC pharmacists and technicians, review patient profiles closely to\nidentify potential issues.\n\nOur Response\nThe Commander\xe2\x80\x99s comments are partially responsive. Based on the Commander\xe2\x80\x99s response, it is\nnot clear that outside of having the pharmacy encourage providers and others to review patient\nprofiles closely, what concrete actions were put in place to ensure procedures were being\nfollowed to prevent the possibility of adverse medication interactions. In response to the final\nreport, we request that the Commander, Northern Regional Medical Command provide\nadditional comments on this recommendation, specifically, to what formal written policies have\nbeen implemented to mitigate any adverse medication interactions.\n\n\n\n\n 26\n\x0cB.4. Obtaining Warriors\xe2\x80\x99 Medical Results from Off-Post\nProviders\n The MEDDAC Referral Management Office and the Health Net Federal\n Services contractor were not obtaining medical results from off-post medical\n care providers to update Warrior medical records consistent with established\n timeline standards. Consequently, the lack of timeliness in providing the\n results of medical referral updates to Warriors\xe2\x80\x99 medical records could have an\n adverse impact on clinical (including behavioral and mental health, and/or\n disability management) decisions made on behalf of Warriors.\n\nB.4. Background\nWarriors assigned to the Fort Drum WTB often obtained medical care at medical facilities not\nlocated on Fort Drum (off-post). When off-post medical care was required, the Warrior\xe2\x80\x99s\nprimary care manager would write a referral, 32 which was then processed through the Fort Drum\nMEDDAC Referral Management Office. It was explained that the Fort Drum MEDDAC\nReferral Management Office considered all Warriors\xe2\x80\x99 referrals as \xe2\x80\x9chigh priority\xe2\x80\x9d and that there\nwas one clerk dedicated to track Warriors\xe2\x80\x99 referrals to ensure that appointments were authorized\nin a timely manner.\n\nOnce a Warrior\xe2\x80\x99s medical care was performed off-post, the Fort Drum MEDDAC Referral\nManagement Office and the Health Net Federal Services contractor shared the responsibility for\nobtaining the results from the off-post medical care provider.\n\nThe MEDDAC Referral Management Office was responsible for obtaining referral results except\nfor those referrals made by the Health Net Federal Services contractor. The Fort Drum\nMEDDAC Referral Management Office created a \xe2\x80\x9cReports Cell\xe2\x80\x9d which was responsible for\nobtaining referral results for the diagnostic testing; coordinating with Health Net Federal\nServices on the receipt of all other referral result reports; and ensuring that all reports were\nscanned into the patient\xe2\x80\x99s electronic medical record in AHLTA.\n\nB.4. Discussion\nHowever, during multiple group meetings with nurse case managers, they indicated that the\nreferral standards were not always met at Fort Drum. Nurse case managers stated that they\n\xe2\x80\x9cdon\xe2\x80\x99t get the best support from the MEDDAC Referral Management Office.\xe2\x80\x9d This resulted in\nnurse case managers having to directly contact off-post providers to obtain Warriors\xe2\x80\x99 referral\nresults. One nurse case manager stated that the Referral Management Office did not obtain\nreferral results in a timely fashion. Another nurse case manager stated that they had to obtain\n\n\n\n32\n A referral is the recommendation of a medical or paramedical professional to see any practitioner or specialist\nother than the person\xe2\x80\x99s primary care physician. The term \xe2\x80\x9creferral\xe2\x80\x9d can refer both to the act of sending a person to\nanother doctor or therapist, and to the actual paper authorizing the visit.\n\n\n\n\n 27\n\x0cmedical referral results directly themselves so the results could be provided to the primary care\nmanagers for timely considerations in Warriors\xe2\x80\x99 treatment plans.\n\nB.4. Conclusion\nReferral results must be obtained in a timely manner so that primary care managers can properly\nmanage Warriors\xe2\x80\x99 treatment plans. Delays in referral feedback reflected a systemic dysfunction;\nrisked unnecessary extensions to Warrior transition time; and could impact important clinical,\nbehavioral health, and/or disability management decisions. Policy and standards were already in\nplace which, if followed, would facilitate the Fort Drum MEDDAC Referral Management Office\nand Health Net Federal Services contractor in obtaining referred medical care results in a timely\nmanner.\n\nB.4. Recommendations, Management Comments, and Our Response\n\nRevised and Redirected Recommendation\nFort Drum Medical Department Activity has yet to provide a response to recommendation B.4.1.\nTherefore we have revised and redirected the draft report recommendation to the Commanding\nGeneral, Northern Regional Medical Command.\n\nB.4. We recommend that the Commanding General, Northern Regional Medical Command:\n\n B.4.1. Provide an update regarding DoD and contractor referral standards for the Referral\n Management Office and Health Net Federal Services as to whether they are meeting their\n respective obligations for Fort Drum.\n\nRedirected Recommendation\nBased on the partial comments received from the Fort Drum Medical Department Activity we\nhave redirected the draft report recommendations B.4.2., to the Commanding General, Northern\nRegional Medical Command.\n\nB.4. We recommend that the Commanding General, Northern Regional Medical Command:\n\n B.4.2. Define and promulgate referral management standards to all Warrior in Transition\n support personnel.\n\nU.S. Army Medical Department Activity Comments\nThe Commander, Fort Drum Medical Department Activity concurred with the recommendation.\nThe Commander explained that even though WTB Soldiers fall under the Enhanced Access to\nCare standards, requiring them to be seen for specialty care within 7 days of their referral there is\nnothing that distinguishes the return of CLR/off-post medical reports for WTB/Warriors. The\nCommander noted that there is no contractual \xe2\x80\x9cestablished standard\xe2\x80\x9d for the return of reports for\nWTB Warriors, indicating that they fall under the same process and timeliness, which requires\nthe network provider to return the CLR to the medical treatment facility within 30 days from the\ndate of appointment for a routine referral.\n\n\n\n\n 28\n\x0cAdditionally, the Commander stated that in order to expedite CLR returns, the Managed Care\nDivision had created a CLR/Reports Cell group that focused specifically on obtaining CLRs,\ninputting them into patients\xe2\x80\x99 AHLTA records and notifying the requesting provider. Results are\nusually returned within hours and approximately 95 percent of requests are completed within one\nbusiness day.\n\nOur Response\nThe Commander\xe2\x80\x99s comments are partially responsive. We acknowledge that a \xe2\x80\x9cReport Cell\xe2\x80\x9d had\nbeen created within the MEDDAC Referral Management Office which was responsible for\nobtaining referral results, coordinating on the receipt of all other referral result reports and\nensuring that reports were scanned into the patient\xe2\x80\x99s electronic medical record in AHLTA.\nHowever, it is unclear as to whether these current processes had an impact in meeting specialty\ncare access to care standards with the contractor. Therefore, we ask that in the final report, the\nCommander, Northern Regional Medical Command obtain three months of data and provide an\nanalysis telling us whether or not current practices shows mitigation.\n\n\n\n\n 29\n\x0cObservation C. Challenges for the 3rd Battalion,\n85th Mountain Infantry Regiment (Warrior\nTransition Battalion)\nThe Fort Drum WTB should address twelve challenges related to Warriors\xe2\x80\x99 transition in order to\nensure the safe and effective care, healing, and transition of Warriors. We identified the\nfollowing challenges:\n\n C.1. Definition of a Successful Transition: The WTB did not have an operational\n definition of a \xe2\x80\x9csuccessful\xe2\x80\x9d transition to civilian status. Consequently, it was not\n evident that the WTB knew specifically how to accomplish their mission\n objective.\n\n C.2. Creating a Positive Environment for Warriors\xe2\x80\x99 Transitions: Fort Drum\xe2\x80\x99s WTB\n leadership did not foster a positive environment to facilitate Warriors\xe2\x80\x99 transitions.\n Consequently, Warriors were recovering and transitioning in an environment that\n did not provide positive physical, mental, or spiritual healing processes or\n effectively promote unit \xe2\x80\x9cEspirit de Corps.\xe2\x80\x9d\n\n C.3. Adequate Staff Orientation and Training in Support of Warriors\xe2\x80\x99 Transitions:\n WTB staff orientation and training did not adequately prepare them to lead\n Warriors through the transition process. Consequently, the WTB staff was at risk\n of not having the skills and information necessary to assist with Warriors\xe2\x80\x99 mission\n to heal and transition.\n\n C.4. Eligibility Criteria for Soldiers Assigned or Attached to the Warrior Transition\n Battalion: Some Soldiers assigned to the WTB were perceived not to meet\n eligibility criteria. Consequently, Soldiers who might not have been eligible to be\n in the WTB potentially reduced available resources for the eligible Warriors\xe2\x80\x99\n transitions, and possibly contributed to the negative command climate supported\n by the perception that the WTB was a \xe2\x80\x9cdumping ground.\xe2\x80\x9d\n\n C.5. Activities to Positively Impact Warriors\xe2\x80\x99 Transition: Warriors lacked meaningful\n programs of constructive activities to assist with transition. Consequently,\n Warriors were limited in how they could positively impact their own transitions to\n civilian life.\n\n C.6. Complying with Warriors\xe2\x80\x99 Medical Profiles: WTB staff did not always adhere to\n Warriors\xe2\x80\x99 medical profiles and recommendations. Consequently, Warriors were\n subjected to performing physical activities that risked further injuring existing\n wounds or acquiring new injuries that could prolong transitions, require additional\n medical needs, or restart fit for duty evaluations.\n\n C.7. Understanding Military Processes to Effectively and Efficiently Support Warriors\n in Transition: The Fort Drum medical system relied on civilian medical personnel\n\n\n 30\n\x0c who may not have fully understood military processes. Consequently, Warriors\n were at risk of not being efficiently and effectively supported during their\n transitions.\n\nC.8. Representation at Weekly Triad of Care Meetings: The weekly Triad of Care\n meetings were not being attended by all of the Triad of Care members who were\n intimately involved in aspects of the Warriors\xe2\x80\x99 care and transition. Consequently,\n the Triad meetings were not fulfilling their intent of having key elements work\n together to ensure advocacy for the Warriors, continuity of care, and a seamless\n transition.\n\nC.9. Execution of Warriors\xe2\x80\x99 Comprehensive Transition Plans: Warriors\xe2\x80\x99\n Comprehensive Transition Plans (CTPs) were not always executed effectively.\n Consequently, Warriors may have been at risk of not accessing the full benefits of\n tools and resources available to help fulfill their transition goals.\n\nC.10. Utilizing the Army Knowledge Online (AKO) to Administer the CTP: The Army\n Knowledge Online (AKO) platform for administering the CTP hindered staff and\n Warrior implementation of the CTP. Consequently, WTB staff and Warriors\n were not always utilizing the CTP to obtain its full benefits.\n\nC.11. Proximity of Warriors\xe2\x80\x99 Medical Care and Support: The physical locations of the\n nurse case managers, WTB clinic, and WTB pharmacy unduly hampered\n Warriors\xe2\x80\x99 access to medical care. Consequently, Warriors were physically\n located away from their medical support staff which may have lead to limited,\n direct interaction with them, and potentially caused Warriors to drive while\n medicated.\n\nC.12. Administrative Support for Nurse Case Managers: Medical support assistants\n were not being fully utilized to provide administrative support to nurse case\n managers. Consequently, nurse case managers were not always able to\n effectively and timely engage with Warriors, putting them at risk of unnecessarily\n prolonged transitions.\n\n\n\n\n 31\n\x0cC.1. Definition of a Successful Transition\n The WTB did not have an operational definition of a \xe2\x80\x9csuccessful\xe2\x80\x9d transition to\n civilian status. Consequently, it was not evident that the WTB knew\n specifically how to accomplish their mission objective.\n\nC.1. Background\nThe Army\xe2\x80\x99s Consolidated Guidance places emphasis on expeditious administrative processing\nfor Warriors, 33 to include the Army\xe2\x80\x99s goal and intent regarding processing Warriors through the\nWTU program. However, the Army guidance does not clearly define mission success with\nregard to preparing Warriors to make a successful transition to civilian life.\n\nC.1. Discussion\nIt was not evident from available data that the WTB had an operational definition as to what\nconstituted a successful transition end-state, specifically with regard to transitioning to \xe2\x80\x9ca\nproductive, responsible citizen in society.\xe2\x80\x9d 34 Therefore, there was no measure of mission\naccomplishment with respect to the mission objective. Further, the WTB did not have clear\ncriteria for measuring the transition process (success or failure) so as to determine what progress\na Warrior was making towards being prepared to transition to civilian life or whether it was\nnecessary to continue to remain assigned or attached to the WTB.\n\nDuring a meeting with the WTB command team, one official stated that a successful transition\nwas defined as, \xe2\x80\x9cto rehab the Soldier and return them to the fight;\xe2\x80\x9d in other words, the focus\nappeared to be only on returning Warriors to duty. However, the command team could not\nexplain what a successful transition to \xe2\x80\x9ca productive, responsible citizen in society\xe2\x80\x9d meant nor\ncould they provide a unit definition.\n\nC.1. Conclusion\nFor mission success to be fully achieved by the Fort Drum WTB, it is imperative that the\nmanagement, staff, and the Warriors themselves have a clear operational definition of a\n\xe2\x80\x9csuccessful transition\xe2\x80\x9d end-state. Related metrics should also be developed to measure progress\ntowards the end state transition goal, and so that the timeliness of the process can be tracked to\nidentify choke points and necessary adjustments can be made to improve the transition process.\nWithout these metrics the Warriors are at risk of being at the WTU for a longer time than\nnecessary.\n\nMoreover, a clear operational definition of a \xe2\x80\x9csuccessful transition\xe2\x80\x9d end-state, with associated\nmetrics, will help to ensure that the WTB and Warriors can successfully accomplish their\n\n\n33\n The emphasis on the expeditious administrative processing for Warriors found in the Consolidated Guidance is\ndiscussed in Appendix D of this report.\n34\n This cite, \xe2\x80\x9ca productive, responsible citizen in society,\xe2\x80\x9d was taken from the Warrior mission statement, which can\nbe reviewed in its entirety in the Background section of this report.\n\n\n\n\n 32\n\x0cmission of achieving recovery and transition towards professional and personal goals whether\nreturning to the military force or transitioning to a productive civilian life. For amplifying\nremarks by Warriors concerning this section, refer to Part III, Warriors Speak.\n\nC.1. Recommendations, Management Comments, and Our Response\nC.1. We recommend that the Commander, 3rd Battalion, 85th Mountain Infantry\nRegiment:\n C.1.1. Develop an operational definition of a successful transition end-state that\n specifically defines mission accomplishment for Warriors\xe2\x80\x99 transition to civilian life;\n and\n\n C.1.2. Develop metrics for Warriors\xe2\x80\x99 transitions that define (1) measures of success\n or failure; (2) timelines of transition to include identifying choke points; (3)\n transition processes that need improvement.\n\n3rd Battalion, 85th Mountain Infantry Regiment Comments\nThe Commander, 3rd Battalion, 85th Mountain Infantry Regiment did not concur with our\nrecommendations. The Commander explained that the definition of a successful transition is\ndifferent for each Soldier who enters the WTB. Soldiers either Return to Duty (RTD) or\ntransition out of the service. Because of the wide spectrum of Soldiers, the battalion\xe2\x80\x99s mission\nstatement is broad. Additionally, the commander noted that each Soldier assigned to the WTB\nmeets with the senior occupational therapist who develops a Comprehensive Transition Plan\n(CTP) that lays out what track the Soldier would like to execute. Thus, each Soldier has their\nmission statement and definition of success at that point.\n\nThe Commander further commented that since February 2011, implementation of the transition\nprogram has been ongoing and the mission statement of the warrior has been posted in numerous\nbattalion areas.\n\nOur Response\nThe Commander\xe2\x80\x99s comments are responsive and the actions meet the intent of the\nrecommendation. No further action is required.\n\n\n\n\n 33\n\x0cC.2. Creating a Positive Environment for Warriors\xe2\x80\x99\nTransitions\n Fort Drum\xe2\x80\x99s WTB leadership did not foster a positive environment to facilitate\n Warriors\xe2\x80\x99 transitions. Consequently, Warriors were recovering and\n transitioning in an environment that did not provide positive physical, mental,\n or spiritual healing processes or effectively promote unit \xe2\x80\x9cEspirit de Corps.\xe2\x80\x9d\n\nC.2. Background\nThe Consolidated Guidance states that the WTU concept of operation includes establishing\nconditions that facilitate a Soldier\xe2\x80\x99s physical, mental and spiritual healing process. Warrior\nTransition Command Policy Memorandum 09-001, \xe2\x80\x9cWarrior in Transition (WT) Medical and\nMilitary Responsibilities,\xe2\x80\x9d March 8, 2010, states that the WTU chain of command must provide\naccessible, responsive, and compassionate leadership, and serve as the avenue of choice for\nSoldiers seeking assistance. It further states that through sustained interaction, commanders at\nall levels should build confidence among Warriors in Transition that the chain of command is\ncommitted to each Soldier\xe2\x80\x99s success.\n\nC.2. Discussion\nThere were multiple factors that contributed to the overall negative command climate within the\nFort Drum WTB. Those factors included inadequate communication within the unit; poor\ntreatment of Warriors by WTB staff; the stigma of the WTB being a \xe2\x80\x9cdumping ground\xe2\x80\x9d; and\nWarrior attitudes towards the WTB; all of which are discussed below.\n\nUnit Communication\nWe observed and were told about instances of poor or inadequate communication between the\ncommand teams, WTB staff and Warriors. Programs and resources seemed to not be fully\nutilized (such as government vehicles, available training and education programs, and other\nuseful resources) in support of Warriors\xe2\x80\x99 recovery and transition.\n\nFor example, WTB staff and Warriors seemed to be unaware of the transportation assets\navailable to them. We were told by squad leaders that they were forced to use their privately\nowned vehicles to support the needs of the Warriors and that there were very few dedicated\ngovernment vehicles. However, during an interview with members of the WTB leadership, they\nstated they had adequate transportation assets, to include five civilian contracted drivers that\nwere largely underutilized. The transportation assets included 25 vehicles, two of which were\nhandicap-accessible buses.\n\nIn addition, a large contingent of Warriors said they were not permitted to take resident\neducational courses in preparation for their transition to civilian life. However, a member of the\nWTB leadership said that Warriors could go to school during a portion of the duty day provided\nthat they submit a plan showing that their classroom attendance would not impact their medical\nappointments. This official stated that this issue had been addressed at WTB Town Hall\nmeetings for Warriors in the past. He supported his claim with the example of one Warrior who\n\n\n\n 34\n\x0cwas featured on the cover of a local community college magazine he attended. When asked how\nmany other Warriors were attending resident college courses, the official stated that there were\nno other Warriors that he was aware of, indicating that the education opportunity was not being\neffectively promoted and supported.\n\nFinally, during assessment team meetings with other command team members, they also\nmaintained that morale-inducing communication within the WTB was severely lacking. They\ncommented that the unit leaders understood accountability, but that was all that they were\nfocused on. In addition, they reported that there was no deliberate attempt to provide Warriors\nwith constructive training to facilitate their transition.\n\nWe believe leadership needs to ensure that communication among the command team, WTB\nstaff, and Warriors is appropriate to the Warriors\xe2\x80\x99 medical conditions and difficulties they face.\nNotwithstanding that this is a military unit there must be sufficient positive and understanding\ndialogue with Warriors to effectively influence achieving the Fort Drum WTB mission to\npromote Warrior healing, recovery, and transition.\n\nWTB Staff Treatment of Warriors\nWTB leadership stated that they had implemented a deliberate and thorough process at the\ninstallation and unit level to select NCOs to become WTB squad leaders. It was explained that\nthe majority of the squad leaders were active component Soldiers selected from the\n10th Mountain Division, but candidates were also received from the Army National Guard and\nReserve components.\n\nThe process for active component staff began with 10th Mountain Division Brigade Command\nSergeants Majors 35 identifying potential staff members and interviewing those candidates. Once\nthey approved their candidate, the candidates\xe2\x80\x99 names and contact information were forwarded to\nthe Fort Drum WTB Command Sergeant Major, 36 who then conducted a second interview. The\nscreening and selection criteria for active component WTB staff NCOs included:\n \xe2\x80\xa2 A review of the Soldier\xe2\x80\x99s medical profile to ensure that he or she could physically serve\n as a squad leader\n \xe2\x80\xa2 Demonstrated proven ability to serve as an effective leader\n \xe2\x80\xa2 A determination of whether any family issues or considerations could potentially impact\n the Soldier\xe2\x80\x99s service as a squad leader\n \xe2\x80\xa2 The number of previous deployments for each Soldier and consideration for those who\n may need additional time at home after multiple deployments\n \xe2\x80\xa2 A demonstrated desire to help Soldiers\nWhen the WTB Command Sergeant Major approved a candidate for a staff position, the\n10th Mountain Division personnel office issued orders for that person\xe2\x80\x99s assignment to the WTB.\n\n\n\n35\n This is a position and not a rank. He or she is the senior enlisted advisor to the Brigade Commander.\n36\n This is a position and not a rank. He or she is the senior enlisted advisor to the Battalion Commander.\n\n\n\n\n 35\n\x0cThe selection process for staff members from the Army National Guard and Reserve differed\ncompared to that of the active component. WTB leadership relied on right-of-refusal for Guard\nand Reserve nominees rather than a direct role in the selection process. The Guard and Reserve\nnomination process included:\n \xe2\x80\xa2 An administrative nomination process by the Army National Guard or Reserve to select\n Guard or Reserve candidates for assignment to the WTB\n \xe2\x80\xa2 A review by the WTB Command Sergeant Major of the Guard or Reserves candidate\xe2\x80\x99s\n Enlisted Record Brief 37\n \xe2\x80\xa2 The right-of-refusal by the WTB leadership if the Guard or Reserve candidate did not\n meet the criteria of the position; which was determined using the same selection and\n screening criteria for active duty personnel\nDuring our interviews, the WTB leadership reported that they believed the processes for squad\nleader selection worked well and ultimately provided the WTB with a qualified selection of staff\nto fill squad leader positions. While the Fort Drum WTB leadership implemented a deliberate\nand thorough selection process at the installation and unit level for NCOs to become WTB squad\nleaders, many who came from 10th Mountain Division brigades were residing on Fort Drum.\nWhile a deliberate screening and selection process existed, we observed and were told that many\nof the selected leaders exhibited leadership qualities suited for an infantry unit, and that type of\nleadership focus did not work effectively with the unique population of Warriors.\n\nWTB staff provided information about the command climate and poor treatment of Warriors\nwithin the Fort Drum WTB. One staff member stated that morale in the unit was low, and that\nthe Soldiers often felt humiliated by WTB staff. For example, those Warriors who were of a\nhigher rank than the WTB staff were often humiliated or degraded by lower ranking staff\nmembers. The staff member added that some Warriors complained about emotional pain; some\ndue to combat stress and others due to how they were being treated in the WTB. Additionally,\nthe staff member provided information about a squad leader who said that he was pressured by\nother WTB staff to force injured Soldiers, who relied on canes for support, to participate in\nphysical training beyond their capability. This squad leader refused to do so, but other staff gave\ninto the pressure.\n\nThe social worker stated that WTB leaders with infantry experience could be very tough on the\nWarriors and this might not be helpful to their recovery. However, the social worker felt that the\nstaff tried to be compassionate, but that did not always occur in reality. A third staff member\nconcluded that the WTB staff needed to lower the overall field of emotional intensity they\ngenerated to have a more positive effect on Warriors\xe2\x80\x99 healing and transition. The above noted\ncomments are characteristic of the attitude purveyed during the team\xe2\x80\x99s interviews with most\nWTB staff.\n\n\n\n\n37\n The Enlisted Record Brief (ERB) contains personal information, qualification skills, training, and assignment\nhistory for enlisted Soldiers and is used in making decisions regarding future assignments of Soldiers.\n\n\n\n\n 36\n\x0cWarriors and their families rely on WTB staff to support their needs with understanding of their\nunique situations and challenges. We believe that staff selected for WTB assignment need to\nbetter understand Warriors\xe2\x80\x99 problems and how to effectively engage them, exhibit compassion,\nbe respectful at all times, and make a constructive commitment to best assist their Warriors as\nthey transition back to duty or to a productive civilian life. The leadership chain of command\nneeds to consistently emphasize these objectives.\n\nStigma Attached to the WTB\nFort Drum WTB suffered a stigma of being a \xe2\x80\x9cdumping ground.\xe2\x80\x9d This perception was\nsubscribed to by Fort Drum units, the WTB staff, and many of the Warriors assigned to the\nWTB. We were told by some of the staff that they spent a considerable amount of time\nattempting to overcome this stigma. During a group interview, staff explained that less than\n20 percent of the units on Fort Drum ever contacted Warriors from their units. When they did\ncontact a previously assigned Soldier who was now a Warrior, it was usually to gain control or\naccountability of equipment previously issued to that Soldier. This behavior reinforced a \xe2\x80\x9cfire\nand forget\xe2\x80\x9d attitude by these previous units that was not conducive to high morale or a desire to\nreturn to active military service, if that was an option.\n\nThis \xe2\x80\x9cdumping ground\xe2\x80\x9d environment was reinforced by the general contention that \xe2\x80\x9cgood\nSoldiers\xe2\x80\x9d were kept in their regular units while \xe2\x80\x9cproblem Soldiers\xe2\x80\x9d were passed on to the WTB.\nThis was illustrated by the WTB staff with a story of a Soldier who was a below-the-knee\namputee that remained with his 10th Mountain unit rather than receiving a transfer to the WTB.\nThis Soldier did not become known to the WTB until he was out-processing from Fort Drum.\n\nThe \xe2\x80\x9cdumping ground\xe2\x80\x9d stigma also existed amongst the Warriors. During a group interview, one\nWarrior commented, \xe2\x80\x9cThere are some Soldiers who should not be in the WTB. For example, a\nSoldier is here who is on an extended profile for not shaving.\xe2\x80\x9d Another Warrior said that he felt\nthat his old unit dumped him there because they didn\xe2\x80\x99t want to deal with him in his present\nmedical condition. A third Warrior suggested that the combat wounded be separated from other\nWarriors because of the perception that the WTB is a \xe2\x80\x9cdumping ground.\xe2\x80\x9d He said that having\nthe combat wounded assigned together would be a source of pride for them. Finally, a Warrior\nstated that he believes the rest of Fort Drum generally perceives them as rejects.\n\nWe believe that deliberate steps need to be taken to ensure that Warriors accepted into the WTB\nmeet the Army\xe2\x80\x99s eligibility criteria to avoid the \xe2\x80\x9cdumping ground\xe2\x80\x9d stigma. It would also ensure\nthat the limited resources at the Fort Drum WTB are fully utilized in support of truly eligible\nWarriors and focused on their care, recovery, and transition.\n\nPerception of Warrior Attitudes\nThere was a perception that incentives and personal benefits existed to motivate Warriors to\nremain in the WTB rather than transitioning out. While the team did not validate these\nperceptions, we noted during group interviews, command staff described some Warriors as\n\xe2\x80\x9cgaming the system.\xe2\x80\x9d For example, with regards to PTSD, the command staff said that some\nWarriors would play \xe2\x80\x9cbarracks lawyers\xe2\x80\x9d and tell other Warriors that if you claimed PTSD you\nwould get an automatic 50 percent disability rating. Additionally, the command staff felt that\n\xe2\x80\x9csleep apnea is contagious\xe2\x80\x9d and many Warriors seemed to be diagnosed with this condition.\n\n\n 37\n\x0cWTB staff also explained that the DVA had a calculation tool on their website that was intended\nfor people who received a diagnosis and wanted to estimate their individual disability claim.\nWhat in practice was happening was that Warriors were using the calculator to determine the\nbest \xe2\x80\x9cconditions\xe2\x80\x9d to report to boost individual ratings and disability claims. They described it as\na \xe2\x80\x9cmortgage-like calculator\xe2\x80\x9d that Warriors used to get the most they could from the system.\n\nWe observed many instances in which lengthy processes, vague timelines, and the command\nenvironment may have contributed to Warrior frustration and desire to leave the WTB as quickly\nas possible. A WTB staff member stated, \xe2\x80\x9cOnly an estimated one in 75 say that they like the\nWTB and feel helped and supported by this process. The rest of the majority just complain that\nthey can\xe2\x80\x99t wait to get out.\xe2\x80\x9d\n\nThis staff member further explained that one Soldier said that he would rather be in Iraq being\nshot at than be in this WTB. Other Warrior comments mirrored this sentiment, to include one\nWarrior who stated that it is so bad in the WTB, \xe2\x80\x9cI\xe2\x80\x99d rather be in jail.\xe2\x80\x9d\n\nC.2. Conclusion\nThe WTB leadership needs to ensure proper communication with and treatment of the Warriors,\nas well as work to change the negative stigma associated with being assigned or attached to the\nWTB as a Warrior. Leadership focus on developing unit \xe2\x80\x9cEsprit de Corps\xe2\x80\x9d and promoting a\npositive command climate could provide a healthy environment for Warriors which promotes\nhealing, recovery, and preparation for Warrior transition. For amplifying remarks by Warriors\nconcerning this section, refer to Part III, Warriors Speak.\n\nC.2. Recommendations, Management Comments, and Our Response\nC.2. We recommend that the Commander, 3rd Battalion, 85th Mountain Infantry Regiment\nestablish a positive command environment that effectively supports Warrior transitions by:\n\n C.2.1. Conducting a confidential climate survey with all Warriors in Transition and\n Warrior Transition Battalion Staff to determine opinions about the current\n environment with regard to, at a minimum: command climate and leadership, unit\n communication, treatment of Warriors in Transition, Warrior Transition Battalion\n stigma, and Warrior in Transition attitudes.\n\n C.2.2. Utilizing the results of the climate survey recommended in C.2.1. to make the\n necessary adjustments within the Warrior Transition Battalion to ensure the\n appropriate working and healing environment is provided for all Staff and\n Warriors in Transition.\n\n3rd Battalion, 85th Mountain Infantry Regiment Comments\nThe Commander, 3rd Battalion, 85th Mountain Infantry Regiment partially concurred with our\nrecommendation. The Commander stated that developing an \xe2\x80\x9cEspirit de Corps\xe2\x80\x9d for Warriors in\na transitional state is a challenge, noting that the mission of the battalion is to transition Soldiers\neither back to the fight or into society. The Commander further commented that battalion\n\n\n\n 38\n\x0cleadership has made it priority to develop a positive environment for each Warrior by providing\nas many positive events and experiences as possible for each individual.\n\nFurthermore, the battalion has hired a transition coordinator who integrates Employment,\nEducation and Internship (EEI) support to each Warrior to assist with their individual healing\nprocess. He further explained that the unit has a Family Readiness Support Assistant (FRSA)\nwho has the mission of promoting unit \xe2\x80\x9cEspirit de Corps\xe2\x80\x9d and wellness and does this by\ncoordinating with many agencies (i.e., ACS, chaplain, MWR, the Red Cross and others) to\norganize and execute activities for the Warrior.\n\nAccording to the Commander, the Battalion Command commenced a command climate survey\non July 28, 2011 with completion by August 1, 2011. The Commander further explained that the\nentire chain of command was committed to providing a positive, physical, mental, or spiritual\nhealing processes that effectively promotes unit \xe2\x80\x9cEspirit de Corps.\xe2\x80\x9d\n\nOur Response\nThe Commander, 3rd Battalion, 85th Mountain Infantry Regiment\xe2\x80\x99s comments are responsive and\nthe actions meet the intent of the recommendation.\n\n\n\n\n 39\n\x0cC.3. Adequate Staff Orientation and Training in Support of\nWarriors\xe2\x80\x99 Transitions\n WTB staff orientation and training did not adequately prepare them to lead\n Warriors through the transition process. Consequently, the WTB staff was at\n risk of not having the skills and information necessary to assist with Warriors\xe2\x80\x99\n mission to heal and transition.\n\nC.3. Discussion\nThe WTB staff plays pivotal roles in assisting Warriors with their healing and transition. As\nsuch, it is imperative that the training and support provided to the staff is thoroughly informative\nand all-inclusive. However, with regard to current training, the Fort Drum WTB staff:\n \xe2\x80\xa2 Viewed the squad leader orientation course as inadequate\n \xe2\x80\xa2 Recommended initial and continuous TBI and PTSD awareness training, as well as\n training in pain management, substance abuse, and other behavioral health issues\nSeveral squad leaders explained that they received a two-week training course when first arriving\nat the WTB while others stated that they took just an online course before beginning their duties\nas a squad leader. While these orientation courses were perceived as somewhat beneficial, many\nbelieved that shadowing another squad leader and receiving on-the-job training before taking on\ntheir squad leader responsibilities would be more useful training tools. Squad leaders also\nagreed that more training on TBI and PTSD would help them execute their Warrior support\nresponsibilities because of the high number of Warriors in the WTB with one or both of these\nconditions.\n\nIn addition, most staff that we interviewed expressed the need for additional, specialized training\nin areas such as behavioral health, substance abuse, pain management, medication issues,\nArmy/military policies and procedures and how they affect Warriors. The WTB Surgeon felt\nthat it would have been beneficial for him and all primary care managers to attend the two-week\nresident training course at Fort Sam Houston before taking on their WTB responsibilities. He\nalso recommended that medical personnel obtain additional training on PTSD, TBI, chronic pain,\nand substance abuse. The WTU Pharmacist also agreed that additional training on pain\nmanagement, drug addictions, TBI, PTSD and other behavioral health conditions would be\nbeneficial.\n\nIn addition, a group of company commanders and first sergeants also believed they needed more\ninformation and training regarding Warriors\xe2\x80\x99 medical needs, such as impacts of certain\nmedications, symptoms of certain conditions, profiles, the Disability Evaluation System, 38 and\n\n\n\n38\n The Disability Evaluation System should include a medical evaluation board (an informal process initiated by at\nleast two active duty physicians who compile, assess, and evaluate the medical history of a Service member and\ndecide if the individual should return to duty or be referred to a physical evaluation board); a physical evaluation\nboard (a formal fitness-for-duty and disability determination); an appellate review process; and a final disposition.\n\n\n\n\n 40\n\x0cthe support services available to Warriors, such as the qualifications and authorizations for non-\nmedical attendants. 39\n\nDuring multiple group interviews, nurse case managers overwhelmingly agreed that they needed\ninitial and ongoing training on behavioral health issues such as PTSD, substance abuse, and\ndepression. They also recommended additional training on TBI, psychiatric medications, and\nFort Drum-specific policies and procedures.\n\nOther civilian specialists agreed that training outside of their specialty was needed because of the\nunique issues among the Warrior population. Before being hired at the WTB, the occupational\ntherapist had no prior experience with the military and received no training to acclimate him to\nthe Army. He claimed that dealing with WTB Warriors was distinctly different from individuals\nhe dealt with through his civilian practice, which made it a difficult challenge to work at Fort\nDrum. He recommended that occupational therapists receive training on military culture, as well\nas behavioral health issues because of the prevalence of TBI and PTSD in the population that\nthey assist.\n\nThe social workers agreed that specialized training was necessary. One social worker suggested\ntraining on military-specific processes, such as the Medical Evaluation Board (MEB), Military\nOccupational Specialty (MOS) 40/Medical Retention Board, 41 and DVA entitlements. 42 Another\nsocial worker wanted additional training on TBI and PTSD, how military members and their\nfamilies are affected by these issues, and to learn how they could be of greater assistance.\n\nC.3. Conclusion\nAppropriate training for WTB staff is required to ensure the most effective and efficient\nmanagement and support of the Warrior\xe2\x80\x99s mission to heal and transition. For amplifying\nremarks by Warriors concerning this section, refer to Part III, Warriors Speak.\n\n\n\n\n39\n When the need arises for non-medical care and assistance during a Warrior\xe2\x80\x99s treatment at a MTF, medical\nauthorities will authorize a non-medical attendant to assist the Soldier. For additional information on non-medical\nattendants, see Part III, Warriors Speak: Comments from Warriors in Transition.\n40\n A Military Occupational Specialty (MOS) code is a job designation assigned to a particular Soldier or Marine in\nthe U.S. Army and U.S. Marine Corps, respectively.\n41\n A MOS/Medical Retention Board is an administrative board, formally conducted, to evaluate a Soldier\xe2\x80\x99s ability to\nperform their military specialty to standard.\n42\n The Department of Veterans Affairs (VA) operates programs to benefit veterans and members of their families.\nBenefits include compensation payments for disabilities or death related to military service, pensions, education, and\nrehabilitation. The VA also guarantees home loans, provides burial services for veterans, and operates a medical\ncare program that includes nursing homes, clinics, and medical centers.\n\n\n\n\n 41\n\x0cC.3. Recommendations, Management Comments, and Our Response\n\nRedirected Recommendations\nBased on the non responsive comments received from the 3rd Battalion, 85th Mountain Infantry\nRegiment we have redirected the draft report recommendations C.3.1. \xe2\x80\x93 C.3.5., to the\nCommanding General, Northern Regional Medical Command.\n\nC.3. We recommend that the Commanding General, Northern Regional Medical Command:\n\nDevelop a comprehensive training program for all Warrior Transition Battalion non-\ncommissioned officers, nurse case managers, and other staff as applicable. The program should\noffer training opportunities tailored to meeting individual needs and should include at a\nminimum:\n\n C.3.1. The skills and knowledge required for dealing with Warrior in Transition\n population, which include but are not limited to: military culture, Army processes and\n procedures, Medical Evaluation Board requirements and procedures, the Disability\n Evaluation System, and the Armed Forces Health Longitudinal Technology Application\n electronic medical record;\n\n C.3.2. The medical education required to understand Traumatic Brain Injury, behavioral\n health issues, and Post Traumatic Stress Disorder and their signs and symptoms;\n\n C.3.3. The medical education required to understand and recognize common medications\n used, potential interactions, and side effects;\n\n C.3.4. The knowledge about entitlements and services provided for and available to\n Warriors in Transition, which include but are not limited to: entitlements from the\n Department of Veterans Affairs, as well as a comprehensive overview of the services\n provided at the Traumatic Brain Injury Clinic, Behavioral Health Department, and\n Soldier and Family Assistance Center so that staff can provide knowledgeable assistance\n and referrals to Warriors in Transition; and\n\n C.3.5. The opportunity to shadow a fellow staff member who executes the same or\n similar responsibilities that will be required of new personnel, or to conduct a\n \xe2\x80\x9creplacement in place/transfer of authority\xe2\x80\x9d with outgoing and incoming personnel as\n executed in traditional military units.\n\n3rd Battalion, 85th Mountain Infantry Regiment Comments\nThe Commander, 3rd Battalion, 85th Mountain Infantry Regiment did not concur with our\nrecommendations. The Commander explained that the WTB staff is hand-selected by the Senior\nNon-Commissioned Officer (NCO) in the battalion from Active Duty, National Guard and\nReserve Soldiers. The Commander stated that the majority of these Soldiers are combat veterans\nwho have the skills and leadership ability required to be Squad Leaders, Platoon Sergeants and\nFirst Sergeants. Additionally, the Commander commented that each NCO is required to attend\nthe two-week cadre-training course prior to working with Warriors. These NCOs are required to\n\n\n 42\n\x0cattend monthly NCOPD\xe2\x80\x99s and complete ongoing training. All Nurse Case Managers must also\nattend the required training.\n\nFurthermore, the Commander stated that cadre members attended a two-week cadre-training\ncourse tailored to Warrior Transition Battalions in addition to the Cadre Training Course in San\nAntonio, Texas. As of May 2011, the 3/85th started an internship program where cadre members\nconduct \xe2\x80\x9cleft seat \xe2\x80\x93 right seat\xe2\x80\x9d rides with veteran cadre members which also includes nurse case\nmanagers.\n\nOur Response\nThe Commander, 3rd Battalion, 85th Mountain Infantry Regiment comments are non responsive.\nThe Commander\xe2\x80\x99s response addresses required training, specifically, the two-week cadre\ntraining for Squad Leaders, Platoon Sergeant\xe2\x80\x99s, First Sergeant\xe2\x80\x99s, and Nurse Case Managers.\nHowever, it does not address the areas of additional recommended training for staff to assist with\nproficiency, understanding of Warrior medical needs, knowledge about medical evaluation board\nprocesses and entitlements, and on-going training needs as identified in C.3.1. \xe2\x80\x93 C.3.5. We ask\nthat the Commanding General, Northern Regional Medical Command provide a response to the\nfinal report recommendations with regards to the development of additional training for WTB\ncadre and staff that is specific to meeting on-going training needs after orientation.\n\n\n\n\n 43\n\x0cC.4. Eligibility Criteria for Soldiers Assigned or Attached to\nthe Warrior Transition Battalion\n Some Soldiers assigned to the WTB were perceived not to meet eligibility\n criteria. Consequently, Soldiers who might not have been eligible to be in the\n WTB potentially reduced available resources for the eligible Warriors\xe2\x80\x99\n transitions, and possibly contributed to the negative command climate\n supported by the perception that the WTB was a \xe2\x80\x9cdumping ground.\xe2\x80\x9d\n\nC.4. Background\nThe eligibility criteria for a Soldier\xe2\x80\x99s assignment or attachment to a WTU generally requires that\n(1) a Soldier has a profile for more than 6 months with duty limitations, and (2) the acuity of the\nwound, illness, or injury requires clinical case management. For the complete definition of the\neligibility criteria, see the Background section of this report.\n\nC.4. Discussion\nThe issue of accepting Warriors into the program who did not meet the eligibility criteria for\nassignment to the WTB was raised by WTB staff. For example, during a group interview with\nWTB company-level staff, they stated that the guidance governing assignment to the WTB had\nnot been consistently followed, resulting in the WTB being perceived to have become a\n\xe2\x80\x9cdumping ground.\xe2\x80\x9d\n\nMultiple squad leaders agreed with this perception. During a group interview, squad leaders\nasserted that Soldiers who did not meet the eligibility criteria were in the WTB because units on\nFort Drum knew how to \xe2\x80\x9cwork the system.\xe2\x80\x9d During an individual interview, one squad leader\nspecifically stated, \xe2\x80\x9cSoldiers with behavioral health issues have an automatic pass to the WTB.\nWe accept those who we know do not meet the entry criteria mainly when they assert a\nbehavioral health issue. It seems that if the Division wants a Soldier in the WTB, they will get\nhim/her into the WTB.\xe2\x80\x9d Finally, another squad leader estimated that 20 percent of Warriors are\nin the WTB so that Fort Drum units can obtain replacements.\n\nAdditionally, a 10th Mountain Division Brigade was deactivated and the Soldiers who were\ndeployable were subsequently re-assigned throughout Fort Drum. However, the Soldiers who\nwere not medically ready to deploy or were awaiting discharge from the Army were assigned to\nthe WTB. This decision was made by the 10th Mountain Division Commander, who as the\nSenior Mission Commander responsible for the WTB has the authority to assign Soldiers to the\nWTB as he deems appropriate. Therefore, there were a legacy number of assigned Warriors in\nthe WTB who did not meet the intended WTC assignment criteria.\n\nFurthermore, Warriors also expressed the perception that Soldiers who did not meet the\neligibility criteria were in the WTB. Specifically, during a group interview, one Warrior\ncommented, \xe2\x80\x9cThere are some Soldiers who should not be in the WTB. For example, a Soldier is\nhere who is on an extended profile for not shaving.\xe2\x80\x9d\n\n\n\n\n 44\n\x0cC.4. Conclusion\nWe did not review in detail the decision-making process for admitting Soldiers into the WTB.\nOur conclusions were based on results of interviews with the members of the chain of command,\nbattalion staff, cadre, medical staff and Warriors. However, if the reported assignment practices\nare true, it may have resulted in diminishing the resources applied to Warriors that meet the\neligibility criteria. Not adhering to the assignment eligibility criteria could also have contributed\nto the negative command climate.\n\nIf appropriate assignment criteria are not being consistently applied; deliberate steps need to be\ntaken to rectify the situation. Adhering to eligibility criteria for Warrior assignment would likely\nassist in removing the \xe2\x80\x9cdumping ground\xe2\x80\x9d stigma held by many within the WTB and by Fort\nDrum personnel and units. It would also ensure that the limited resources at the Fort Drum WTB\nare fully utilized in support of truly eligible Warriors and their care, recovery, and transition. For\namplifying remarks by Warriors concerning this section, refer to Part III, Warriors Speak.\n\nC.4. Recommendations, Management Comments, and Our Response\nRevised and Redirected Recommendations\nWe have revised and redirected the draft report recommendations to the Commander, Warrior\nTransition Command to provide a response to recommendations C.4.1. and C.4.2.\n\nC.4. We recommend that the Commander, Warrior Transition Command:\n\n C.4.1. Review and respond about the Fort Drum Warrior Transition Battalion\n implementation of the Army eligibility criteria to determine if practices are appropriate,\n transparent, and clearly defined for determining Soldier eligibility.\n\nC.4. We recommend that the Commander, Warrior Transition Command:\n\n C.4.2. Review and respond about the Fort Drum Warrior Transition Battalion assignment\n waiver process to determine if an appropriate, transparent, and clearly defined waiver\n system for determining Soldier eligibility is being adhered to.\n\n10th Mountain Division Comments\nThe Acting Commander, 10th Mountain Division concurred with recommendation C.4.1.,\nexplaining that Fort Drum has an established process, transparent, and clearly defined system for\nevaluation of Soldiers for the WTU.\n\nThe Acting Commander, 10th Mountain Division did not concur with recommendation C.4.2.\nThe Commander non concurred that Soldiers are admitted to WTU by an assignment waiver\nprocess that does not meet the standards established by the Warrior Transition Command. The\nCommander explained that a Triad of Leadership Board with representation by WTU Command,\nDivision Command, and MEDDAC Command reviews cases where a Soldier does not clearly\nmeet eligibility for entrance into the WTU or the Soldier\xe2\x80\x99s chain of command disagrees with a\nSoldier not being granted entrance into the WTU.\n\n\n\n 45\n\x0cOur Response\nThe Acting Commander\xe2\x80\x99s comments are non responsive. The Acting Commander restated the\nestablished Army policy for eligibility criteria of Warriors to the WTB. However, he did not\nstate what steps Fort Drum has taken to ensure that the implementation of the Army eligibility\ncriteria was being carried out in a clearly defined and transparent manner.\n\nWe did not review in detail the decision-making process for admitting soldiers into the WTB.\nOur conclusions were based on results of interviews with the members of the chain of command,\nbattalion staff, cadre, medical staff and Warriors. However, if the reported assignment practices\nare true, it may have resulted in diminishing the resources applied to Warriors that met the\neligibility criteria. Not adhering to the assignment eligibility criteria could also have contributed\nto the negative command climate.\n\nDuring our interviews with Warriors, cadre and staff, we were repeatedly told that the Army\neligibility criteria process was not being followed, and that there was a perception of \xe2\x80\x9cdumping.\xe2\x80\x9d\nOur interviews clearly show there was a widely held perception that Soldiers assigned to the\nWTB did not meet the eligibility criteria. For example, there were some Soldiers assigned to de-\nactivated or demobilized units 43 who were awaiting discharge from the Army and/or not\nmedically ready to deploy being assigned to the WTB. Soldiers may be deemed medically\nunready for deployment due to factors not relevant to admission into the WTB. We were also\nmade aware that the Senior NCO chain at Fort Drum played a major, albeit informal role, in\ndetermining who gets assigned to the WTU, which further contributed to the perception of\n\xe2\x80\x9cdumping.\xe2\x80\x9d\n\nTherefore, we are referring these recommendations to the Commander, Warrior Transition\nCommand to review the implementation of the Army eligibility criteria and assignment waiver\nprocess utilized by the Fort Drum WTB, and to provide a response to these recommendations.\n\n\n\n\n43\n The units were the 174th Infantry Brigade, a U.S. Army Reserve Unit stationed at Fort Drum with the mission of\nproviding operational training in the First Army, when the unit found out they were to be deactivated from Fort\nDrum to Joint Base McGuire-Dix-Lakehurst, they started sending patients to the WTU since around 2007. The 86th\nInfantry Brigade Combat Team is a National Guard Light Infantry Brigade that mobilized in December 2009 at\nCamp Atterbury, Indiana and deployed to Afghanistan in support of OEF. The 86th IBCT returned in December\n2010, and was demobilized.\n\n\n\n\n 46\n\x0cC.5. Activities to Positively Impact Warriors\xe2\x80\x99 Transition\n Warriors lacked meaningful programs of constructive activities to assist with\n their transition. Consequently, Warriors were limited in how they could\n positively impact their own transitions to civilian life.\n\nC.5. Background\nThe mission of the Fort Drum WTB was to provide command and control, administrative\nsupport and services, quality prime care, and case management services for Soldiers qualifying\nfor Warriors in Transition (in accordance with Army Regulation 40-400); synchronize clinical\ncare, disposition and transition; and promote readiness to return to the Army or transition to\ncivilian life.\n\nC.5. Discussion\nWTB did not have a definitive mission end state and associated metrics to measure success. As a\nresult identifying and implementing beneficial Warrior activities that promote transition to\ncivilian life was challenging. There did not appear to be any comprehensive program to provide\nWarriors with constructive educational and training activities to effectively use their time and\nassist in their preparation to make a successful transition to a productive, responsible citizen in\nsociety once they departed the WTB.\n\nWe were told by multiple WTB staff and Warriors that the WTB unwritten \xe2\x80\x9ccommand policy\xe2\x80\x9d in\nforce, prohibited Warriors from attending resident educational courses or vocational training\nduring the duty day. During a meeting with WTB leadership, our question regarding educational\nopportunities for Warriors during the duty day was answered with, \xe2\x80\x9cgoing to school is a privilege\nnot a policy.\xe2\x80\x9d\n\nA squad leader explained that in the past, Warriors used tuition assistance and applied for\nresident education courses. However, some did not go to class, failed their courses, and had to\nrepay their tuition. As a result, the command decided to make resident schooling off-limits\nduring the duty day. This same squad leader felt that the current command policy unfairly\npunished the entire unit. He believed that Warriors should have the ability to use the education\ncenter during the day and the chance to prove that they could responsibly balance their healing\n(medical appointments) with their transition (classes and schoolwork).\n\nThe majority of Warriors also expressed frustration over lack of constructive daily activities.\nThe preponderance of Warriors interviewed stated that their day consisted of attendance at\nmilitary formations, medical appointments (if any), and physical training. Warriors stated that\nthe WTB staff tried to find them \xe2\x80\x9cjobs\xe2\x80\x9d around Fort Drum, but some of those who had jobs\nconsidered them menial tasks, and others did not have jobs because they were unable to find one\nthat positively impacted their transition. Several Warriors stated that if they were permitted to\ntake resident college courses, they would take advantage of that opportunity.\n\nA number of Warriors found activities on their own to fill their days, to include volunteer\nopportunities (United Service Organizations, Education Center, the Guthrie Clinic, the Museum,\n\n\n\n 47\n\x0cSalvation Army, and SFAC), on-line college courses, or duties at their previous Fort Drum unit.\nHowever, although those Warriors\xe2\x80\x99 days were occupied with such activities, the assessment\nteam\xe2\x80\x99s view was that those activities did not necessarily prepare those Warriors for a successful\ntransition to civilian life.\n\nC.5. Conclusion\nWarrior accountability and medical processes are and should be an Army and WTB priority, but\nadequate and appropriate occupational preparation is just as important and is indeed fundamental\nto the Warrior\xe2\x80\x99s transition to civilian life. Warriors should be provided with meaningful\nactivities, and educational opportunities suited to the needs of each Warrior, that will\nproductively impact their transition and best prepare them for becoming productive, responsible\ncitizens in society. For amplifying remarks by Warriors concerning this section, refer to Part III,\nWarriors Speak.\n\nC.5. Recommendation, Management Comments, and Our Response\nC.5. We recommend that the Commander, 3rd Battalion, 85th Mountain Infantry Regiment\nprovide a comprehensive program of constructive education and training, tailored to\nindividual Warrior in Transition needs and plans, in order to facilitate Warrior recovery\nand transition.\n\n3rd Battalion, 85th Mountain Infantry Regiment Comments\nThe Commander, 3rd Battalion, 85th Mountain Infantry Regiment concurred with the\nrecommendation. The Commander explained that this is an issue at Fort Drum given the\nlocation of the post. Fort Drum is unable to use the programs, facilities and the resources offered\nat posts closer to urban areas.\n\nFurthermore, the Commander stated that on July 25, 2011 the Education, Employment, and\nInternship (EEI) Policy was implemented and signed into effect by the 3-85 BN Commander.\nThe Transition Coordinator as well as the Occupational Therapists each work with every soldier\nto develop a program to impact their own personal transition to civilian life maximizing\nutilization of available resources. Additionally, the Transition Coordinator works with on-post\nagencies to allow Warriors the opportunity to work and pursue educational opportunities to help\nwith transitioning to civilian life.\n\nOur Response\nThe Commander, 3rd Battalion, 85th Mountain Infantry Regiment\xe2\x80\x99s comments are responsive and\nthe actions meet the intent of the recommendation. No further action is required.\n\n\n\n\n 48\n\x0cC.6. Complying With Warriors\xe2\x80\x99 Medical Profiles\n WTB staff did not always adhere to Warriors\xe2\x80\x99 medical profiles and\n recommendations. Consequently, Warriors were subjected to performing\n physical activities that risked further injuring existing wounds or acquiring\n new injuries that could prolong transitions, require additional medical needs,\n or restart fit for duty evaluations.\nC.6. Background\nWarrior Transition Command Policy Memorandum 09-001, \xe2\x80\x9cWarrior in Transition (WT)\nMedical and Military Responsibilities,\xe2\x80\x9d March 8, 2010, states the following about profiles:\nWTs [Warriors] will adhere to and the chain of command will enforce all medical profiles, to\ninclude no alcohol profiles. Profiles are designed to ensure a positive rehabilitative process and\nhealing. If unsure, Soldiers should seek guidance on what actions are permissible and non-\npermissible within the parameters of the profile. The chain of command, as well as the WT\nshould emphasize capabilities vice disabilities. Adaptive physical activity is critical to overall\nsuccessful healing and transition.\n\nC.6. Discussion\nAlthough it is WTC policy to include \xe2\x80\x9cadaptive physical activity\xe2\x80\x9d in the Warrior recovery\nprogram, it was evident that physical training was not always conducive to ensuring a \xe2\x80\x9cpositive\nrehabilitative process and healing.\xe2\x80\x9d Rather, the execution of this Command Policy\nMemorandum seemed to manifest another aspect of the negative command climate and lack of\nunit cohesion, which led to improper treatment of Warriors.\n\nThis was apparent in some of the staff\xe2\x80\x99s attitudes toward and treatment of Warriors\xe2\x80\x99 medical\nprofiles. WTB staff reportedly overrode Warrior medical profiles, in some instances,\ndemonstrating a lack of understanding of or disregard for the stated policy. This disregard for\nWarrior physical limitations was observed by our team, and noted during interviews with\nmedical professionals.\n\nOne example included a Warrior who was diagnosed with cancer. This Warrior\xe2\x80\x99s doctor told\nhim to stay away from crowds (i.e. no formations at the WTB) because of his weakened immune\nsystem. However, the staff required him to be at formation and to stand in ranks. He was also\nunder medical orders to rest and do no physical training, yet the staff required him to take part in\nphysical training. Another staff member told us of a Warrior with a profile that allowed him to\nwalk with the use of a cane. The staff made this Warrior participate in physical training by\nwalking, but we were told that this Warrior was constantly harassed by staff to \xe2\x80\x9cwalk faster.\xe2\x80\x9d A\nthird example included a Warrior diagnosed with Attention Deficit Hyperactivity Disorder who\nwas directed to sit at the guard desk without being allowed to read. A mental health professional\nexplained that this would be difficult for anyone, but even more difficult for someone with\nAttention Deficit Hyperactivity Disorder who needs something to occupy his or her mind.\n\nWe also observed Warriors, requiring canes, being forced to stand for the entire event while\nattending morning formation. When we asked the WTB staff about the practice of overriding\n\n\n\n 49\n\x0cWarrior medical profiles, we were told that the profile was a recommendation from the medical\nstaff and that the Commander was not required to accept or adhere to the recommendation.\nHowever, Warriors and other staff were concerned that WTB staff overriding these medical\nprofile recommendations could hinder the Warriors\xe2\x80\x99 recovery and prolong their healing.\n\nC.6. Conclusion\nRecommendations made by medical professionals should be adhered to by staff to ensure that\neach Warrior is focused on proper healing and is not placed in a situation that could hinder their\nrecovery. There is an apparent lack of clarity and understanding by the WTB command and staff\nregarding the significance of adherence to these profiles and the circumstances, if any, under\nwhich the Command may be authorized to disregard medical profiles and also specific guidance\nfrom a medical care provider regarding a Warrior\xe2\x80\x99s medical recovery. For amplifying remarks\nby Warriors concerning this section, refer to Part III, Warriors Speak.\n\nC.6. Recommendation, Management Comments, and Our Response\nC.6. We recommend that the Commander, 3rd Battalion, 85th Mountain Infantry Regiment,\nensure that all profiles and medical recommendations are consistently applied and are not\noverridden by Warrior Transition Battalion Staff.\n\n3rd Battalion, 85th Mountain Infantry Regiment Comments\nThe Commander, 3rd Battalion, 85th Mountain Infantry Regiment did not concur with our\nrecommendation. The Commander explained that all profiles are reviewed by the BN Surgeon\nand at no time are Warriors subjected to performing physical activities that would risk further\ninjury. Additionally, the WTB is developing an adaptive sports program that is formulating a\npositive profile telling him/her what adaptive sports events that he/she can participate in to assist\nwith recovery.\n\nSince January 2011 a modified Physical Readiness Training (PRT) program has been offered.\nEach profile is reviewed and updated by the nurse case managers and the WTB staff has direct\ncommunication with Primary Care manager (PCM) to ensure that profile recommendations are\nfollowed.\n\nOur Response\nThe Commander, 3rd Battalion, 85th Mountain Infantry Regiment\xe2\x80\x99s comments are responsive and\nthe actions meet the intent of the recommendation. No further action is required.\n\n\n\n\n 50\n\x0cC.7. Understanding Military Processes to Efficiently and\nEffectively Support Warriors in Transition\n The Fort Drum medical system relied on civilian medical personnel who may\n not have fully understood military processes. Consequently, Warriors were at\n risk of not being efficiently and effectively supported during their transitions.\n\nC.7. Discussion\nSeveral individuals \xe2\x80\x93 to include clinical staff, nurse case managers, and Warriors \xe2\x80\x93 commented\nthat medical personnel treating the Warrior population should understand the military culture,\nArmy processes, and specific related Warrior care issues to be effective in supporting Warriors\xe2\x80\x99\nneeds. Reportedly, however, some civilian health care providers and clinical support staff did\nnot fully understand military processes for Warriors.\n\nThe WTB Surgeon believed that primary care managers should be experienced military service\nproviders. If medical care from contractors from outside of the military were necessary, he also\nmaintained that they needed to understand the basics of the Army culture, treatment of Soldiers,\nthe profiling and MEB processes, and using AHLTA for medical documentation. The Fort Drum\nWTB Pharmacist agreed that the learning curve was \xe2\x80\x9chuge\xe2\x80\x9d for civilian primary care managers\nin the WTB clinic, specifically in the areas of using the AHLTA system and being familiar with\nArmy policies and procedures.\n\nA group of nurse case managers echoed these sentiments almost verbatim. They felt that in their\nexperience, contracted primary care managers are limited in their effectiveness when they have\nno prior experience in dealing with the military. They stated that civilian providers don\xe2\x80\x99t\nunderstand the profiling system, MEB paperwork, and use of the computer to document medical\ninformation in AHLTA.\n\nFinally, Warriors agreed that civilian providers employed by the DoD and assigned to the WTB\nneed to understand the military system, especially in the case of war-related injuries. One\nWarrior stated that he had to explain his conditions to his civilian primary care manager at least\ntwice because his doctor was new to Fort Drum and did not know how the system worked.\nAnother Warrior stated that the civilian primary care managers are great people and treat them\nwell, but have no idea about the military or the Army. Because of this, the Warrior stated that\nhe would rather have a military doctor. Finally, another Warrior simply stated that the civilian\nprimary care managers \xe2\x80\x9cneed to learn more about the Army.\xe2\x80\x9d\n\nC.7. Conclusion\nThe individuals we interviewed understood that uniformed military providers and clinical\nsupport staff were often not available because they were assigned to deployed or deploying units;\nand therefore, civilian support was needed to supplement WTB medical needs. However, they\nall strongly suggested, and we agree, that civilian providers and support staff need to obtain the\nnecessary training on military culture, DoD and Army policies and processes, and specific\nWarrior care issues to be efficient and effective in their care and treatment of Warriors.\nFor amplifying remarks by Warriors concerning this section, refer to Part III, Warriors Speak.\n\n\n 51\n\x0cC.7. Recommendation, Management Comments, and Our Response\n\nRedirected Recommendations\nBased on the non responsive comments received from the 3rd Battalion, 85th Mountain Infantry\nRegiment we have redirected the draft report recommendations C.7.1. \xe2\x80\x93 C.7.4., to the\nCommanding General, Northern Regional Medical Command.\n\nC.7. We recommend that the Commanding General, Northern Regional Medical Command:\n\nDevelop a comprehensive training program for all primary care managers and other civilian\nproviders or medical support staff working on Fort Drum with Warriors in Transition be\nprovided with training opportunities tailored to meeting their individual needs. The training\nshould include at a minimum:\n\n C.7.1. Familiarization of military culture, Army processes and procedures, Medical\n Evaluation Board requirements and procedures, the Disability Evaluation System, and the\n Armed Forces Health Longitudinal Technology Application electronic medical record;\n\n C.7.2. The medical education required to understand Traumatic Brain Injury, behavioral\n health issues and Post Traumatic Stress Disorder and their signs and symptoms;\n\n C.7.3. The medical education required to understand and recognize common medications\n used, potential interactions, and side effects; and\n\n C.7.4. The knowledge about entitlements and services provided for and available to\n Warriors in Transition, which include but are not limited to: entitlements from the\n Department of Veterans Affairs, as well as a comprehensive overview of the services\n provided at the Traumatic Brain Injury Clinic, Behavioral Health Department, and\n Soldier and Family Assistance Center so that staff can provide knowledgeable assistance\n and referrals to Warriors in Transition.\n\n3rd Battalion, 85th Mountain Infantry Regiment Comments\nThe Commander, 3rd Battalion, 85th Mountain Infantry Regiment concurred with our\nrecommendations. The Commander explained that medical care for Fort Drum, NY relies upon\ncivilian medical specialists, often with no military experience. Additional Army Nurse Case\nManagers were hired; and to balance the limited military knowledge of the supporting civilian\nproviders, WTU PCMs review all referral documentation to ensure the provider\xe2\x80\x99s intentions are\nmet.\n\nOur Response\nThe Commander, 3rd Battalion, 85th Mountain Infantry Regiment\xe2\x80\x99s comments are non\nresponsive. While the Commander concurred with our recommendations, there was no reference\nmade to the development of a comprehensive training program for all primary care managers and\nother civilian providers or medical support staff that was tailored to meeting their individual\nneeds as was recommended in C.7. The Commander included comments that additional Nurse\n\n\n\n 52\n\x0cCase Managers were hired, however no specifics were provided regarding the numbers of new\nhires, nor a date. In response to the final report, we request that the Commanding General,\nNorthern Regional Medical Command provide information on Army Nurse Case Managers\nhiring practices, to include numbers and dates. Additionally, we recommend that an action plan\nfor formalization of a comprehensive training program that addresses recommendations C.7.1. -\nC.7.4. be developed and request that it be provided.\n\n\n\n\n 53\n\x0cC.8. Representation at Weekly Triad of Care Meetings\n The weekly Triad of Care meetings were not being attended by all of the Triad\n of Care members who were intimately involved in aspects of the Warriors\xe2\x80\x99\n care and transition. Consequently, the Triad meetings were not fulfilling their\n intent of having key elements work together to ensure advocacy for the\n Warriors, continuity of care, and a seamless transition.\n\nC.8. Background\nAt the heart of the WTU system\xe2\x80\x99s success is the \xe2\x80\x9cTriad of Care.\xe2\x80\x9d The Triad is comprised of a\nsquad leader, nurse case manager, and primary care manager. Optimally, the Triad of Care\nworks together to ensure advocacy for Warriors, continuity of care, and a seamless transition\nback into the force or to a productive civilian life. The squad leader leads the Soldiers, and the\nnurse case manager coordinates their care. The primary health care manager oversees medical\ncare, which can be complex, given the multiple physical and mental health issues experienced by\nsome Soldiers. These professionals are responsible for putting the Soldier first, cutting through\nred tape, and minding all relevant recovery and transition details.\n\nC.8. Discussion\nWe were informed during multiple interviews with nurse case managers and squad leaders that\nattendees of the Triad of Care meetings had recently changed. One group of nurse case\nmanagers stated that Triad meetings used to include nurse case managers, primary care\nmanagers, squad leaders, social workers, pharmacists, and company staff. But, social workers,\npharmacists, and primary care managers were recently excluded by the WTB Command, and\nplatoon sergeants began representing squad leaders at these meetings. The nurse case managers\nbelieved that previous meetings were more effective at fully sharing information with all\nconcerned parties, and that in addition the format had since become more of a \xe2\x80\x9cstatus report\nbriefing\xe2\x80\x9d instead of an open discussion of pertinent information on each Soldier\xe2\x80\x99s status.\n\nSquad leaders agreed that the changes to attendees at Triad meetings had negatively impacted the\ncommunication process between medical and non-medical unit leadership. One squad leader\nspecifically stated that he was concerned that squad leaders were now excluded from Triad of\nCare meetings. He contended that \xe2\x80\x9csquad leaders are a key part of the Triad of Care\xe2\x80\x9d and need\nto be there to understand how best to perform their duties, not to learn about what took place\nsecond hand. Another squad leader added that squad leader to primary care manager\ncommunications are truly necessary and therefore, primary care managers needed to attend the\nTriad meetings as well.\n\nC.8. Conclusion\nThe three members of the Triad of Care \xe2\x80\x93 the squad leader, nurse case manager, and primary\ncare manager \xe2\x80\x93 envelope the Warrior in comprehensive care and support as each Warrior heals\nand transitions from the WTB. Therefore, it is imperative that these members, as well as other\nstaff who are intimately involved in aspects of the Warriors care and transition, should attend the\nTriad of Care meetings so that comprehensive care and tailored support can be provided for each\n\n\n\n 54\n\x0cindividual Warrior. For amplifying remarks by Warriors concerning this section, refer to Part\nIII, Warriors Speak.\n\nC.8. Recommendation, Management Comments, and Our Response\nC.8. We recommend that the Commander, 3rd Battalion, 85th Mountain Infantry Regiment\nensure the Triad of Care meetings include at a minimum the squad leaders, nurse case\nmanagers, and primary care managers, as well as other appropriate staff members.\n\n3rd Battalion, 85th Mountain Infantry Regiment Comments\nThe Commander, 3rd Battalion, 85th Mountain Infantry Regiment did concur with our\nrecommendation. The Commander explained that the Triad of Care meeting has been changed\nto include Squad leaders, Platoon Sergeants, NCMs and Social Workers who discuss each\nSoldiers issues and medical plan. As of January 2010, the Triad of Care meetings are held every\nTuesday and are the number one priority of work. Attendance is monitored and all key members\nare required to attend every meeting.\n\nOur Response\nThe Commander, 3rd Battalion, 85th Mountain Infantry Regiment\xe2\x80\x99s comments are responsive and\nthe actions meet the intent of the recommendation. No further action is required.\n\n\n\n\n 55\n\x0cC.9. Execution of Warriors\xe2\x80\x99 Comprehensive Transition Plans\n Warriors\xe2\x80\x99 Comprehensive Transition Plans (CTPs) were not always executed\n effectively. Consequently, Warriors may have been at risk of not accessing\n the full benefits of tools and resources available to help fulfill their transition\n goals.\n\nC.9. Background\nWhen appropriately used, the CTP provides a broad perspective of the current status of a Warrior\nand the formulation of a program of actions aimed to help the Warrior move from one stage of\nhis/her transition to the next. The Warrior provides initial input on his or her goals in five\nclinical self-assessment categories, 44 and twelve non-clinical self-assessment categories, 45 and\nthe Warrior\xe2\x80\x99s desired transition status. A plan is then formulated to help guide the Warrior on a\npath to receive medical care and achieve transition with the help of the squad leader, nurse case\nmanager, primary care manager, social worker, occupational therapist, and other medical care\nproviders.\n\nC.9. Discussion\nWTB staff generally agreed that the CTP was a \xe2\x80\x9ccheck the block\xe2\x80\x9d requirement and had not been\nmade operational in support of Warriors, as intended. This perception was shared by battalion\nstaff, company commanders, first sergeants, squad leaders, and nurse case managers.\n\nMembers of the WTB leadership stated that the CTP concept was valid, but the operational\nimplementation was severely lacking. One WTB staff member stated that while he understood\nthe need for squad leaders to provide input, he believed that the CTP would be more beneficial if\napplied on an individual basis by someone who understood transition counseling \xe2\x80\x93 such as a\nvocational rehabilitative counselor \xe2\x80\x93 to assist Warriors with developing meaningful lifetime\ngoals.\n\nA group of company commanders and first sergeants also understood the concept of the CTP and\nbelieved that there was some benefit to be gained. But, the group also felt that there were too\nmany modules with repetitive information that did not require weekly updates for each Warrior,\nsuch as information concerning Warriors\xe2\x80\x99 long term goals. They all maintained that the CTP had\nbecome a task to maintain, rather than a true value to the Warriors.\n\nDuring a group interview, nurse case managers agreed that all Warriors do not need the detailed\nand regimented activity of completing the CTP to effectively plan their transition. In a separate\ngroup interview, nurse case managers stated that in theory, the CTP was a valuable tool, but in\n\n\n\n44\n These 5 categories are activities of daily living, health care, medication, pain, and behavioral health.\n45\n These 12 categories are work plan, education, employment, weight control, physical fitness, well being, social,\nfamily, financial, housing, administrative support, and transportation.\n\n\n\n\n 56\n\x0creality, it was not assisting Warriors in their recovery and transition. One nurse case manager\nstated, \xe2\x80\x9cIf the Warrior believed in it, maybe it would be more helpful.\xe2\x80\x9d\n\nSquad leaders provided mixed reviews when asked whether they felt the CTP had a positive\neffect on the Warriors\xe2\x80\x99 recovery and transition. Some thought that it could be useful, but \xe2\x80\x9cits\nusefulness is up to the Warrior.\xe2\x80\x9d Most others believed that the CTP was a waste of everyone\xe2\x80\x99s\ntime, stating that Warriors complained because their status did not change from week to week\nand that, moreover, they did not know what was realistic for goal setting until they knew how\nlong their medical care or medical boards would take. One squad leader believed that discussing\nWarriors\xe2\x80\x99 goals with them, making recommendations, and guiding them through the process\nwould be more helpful versus it being a \xe2\x80\x9ccheck the block\xe2\x80\x9d exercise. Another squad leader\nsuggested that the CTP be applied to all Warriors as individuals and updated on a case-by-case\nbasis.\n\nC.9. Conclusion\nA situational or individual approach to Warriors\xe2\x80\x99 utilization of the CTP would be more beneficial\nto the transition process than as a mandatory requirement for all. A tailored situational approach\nto CTP implementation would enable staff to gain additional time with their Warriors and\nprovide them with more personalized guidance during the transition process. For amplifying\nremarks by Warriors concerning this section, refer to Part III, Warriors Speak.\n\nC.9. Recommendation, Management Comments, and Our Response\nC.9. We recommend that the Commander, 3rd Battalion, 85th Mountain Infantry Regiment\ndevelop procedures and training to ensure that the Comprehensive Transition Plan process\nis individually tailored and effective for Warriors in Transition.\n\n3rd Battalion, 85th Mountain Infantry Regiment Comments\nThe Commander, 3rd Battalion, 85th Mountain Infantry Regiment partially concurred with\ncomments to our recommendation. The Commander stated that in the last 12 months the CTP\nhas been completely revised and all individuals required to complete the CTP have been hired to\ninclude a CTP Management Analyst for each company who ensures proper utilization of CTPs.\nAll Commanders and the OT supervisor attended additional training on the CTP as of August 8,\n2011. Based on guidance received through Northern Regional Command, the scrimmage\nprocess of the CTP is being held every Monday.\n\nOur Response\nThe Commander, 3rd Battalion, 85th Mountain Infantry Regiment\xe2\x80\x99s comments are responsive and\nthe actions meet the intent of the recommendation. No further action is required.\n\n\n\n\n 57\n\x0cC.10. Utilizing the Army Knowledge Online to Administer the\nComprehensive Transition Plan\n The Army Knowledge Online (AKO) platform for administering the CTP\n hindered staff and Warrior implementation of the CTP. Consequently, WTB\n staff and Warriors were not always utilizing the CTP to obtain its full benefits.\n\nC.10. Background\nAKO is the United States Army\xe2\x80\x99s main intranet. It is said to be the world\xe2\x80\x99s largest corporate\nintranet. AKO provides the Army with a single entry point for access to the Internet and the\nsharing of knowledge and information, making AKO the Army\xe2\x80\x99s only enterprise collaboration\ntool operating throughout the Department of the Army worldwide. The main AKO intranet\nserves over 2 million registered users, including active duty and retired service personnel and\ntheir family members, and provides access to over 300 applications and services, including the\nCTP.\n\nC.10. Discussion\nWTB staff stated that the AKO platform hindered their assistance in helping Warriors transition.\nThey experienced the AKO platform as cumbersome to use, and were forced to duplicate efforts\nby either completing hard copy documentation manually or maintaining an electronic version of\ntheir Warriors\xe2\x80\x99 CTPs off-line.\n\nDuring a group interview, the WTB company staff stated that the AKO platform did not work\ndue to extraordinarily slow download times and system \xe2\x80\x9ctime outs\xe2\x80\x9d during inputs, making the\nAKO platform too cumbersome to use. The WTB company staff stated that they were forced to\nmaintain their own legacy system to document day-to-day inputs into Warriors\xe2\x80\x99 CTPs. They\nwere then required to input this information into the Warriors\xe2\x80\x99 official CTPs on AKO, essentially\na duplication of efforts, which they felt wasted too much of leadership\xe2\x80\x99s time. They concluded\nthat Warriors rarely provided positive remarks about the CTP and its support of their transition\nfrom the military to life as a civilian.\n\nThe WTB leadership suggested that the Army consider placing the CTP on the Medical\nOccupational Data System, which is a web-based application that received high praise from the\nArmy Medical Department at Fort Drum.\n\nSquad leaders echoed these sentiments, and their comments included the following:\n \xe2\x80\xa2 \xe2\x80\x9cThe CTP causes the AKO system to overload.\xe2\x80\x9d\n \xe2\x80\xa2 \xe2\x80\x9cThe new AKO system does not work. I cannot access it 50 percent of the time. They\n need to take the CTP off of AKO and put it on its own server.\xe2\x80\x9d\n \xe2\x80\xa2 \xe2\x80\x9cThe program is ridiculously long and AKO makes it even more time consuming. It\n needs to be web-based and have its own maintenance.\xe2\x80\x9d\n \xe2\x80\xa2 \xe2\x80\x9cAKO on-line is a mess. The negative effect that the CTP has is because of the\n frustration with AKO and the lack of on-line accessibility.\xe2\x80\x9d\n\n\n\n\n 58\n\x0cFinally, during multiple group interviews with nurse case managers, they agreed that the AKO\nplatform was too slow and often \xe2\x80\x9ckicked them out of the system.\xe2\x80\x9d They were also documenting\nhard copy risk assessments for Warriors (double work) due to unreliability of AKO and the CTP\nmodule.\n\nC.10. Conclusion\nThe CTP application needs modification to make it a meaningful management tool that is more\nefficient for Warriors and WTB Staff to use. In its present configuration, it is ineffective for use\nas a tool that facilitates Warrior recovery and transition. For amplifying remarks by Warriors\nconcerning this section, refer to Part III, Warriors Speak.\n\nC.10. Recommendations, Management Comments, and Our Response\nC.10. We recommend that the Commander, Warrior Transition Command:\n\n C.10.1. Engage with the appropriate Department of the Army Headquarters\n personnel to determine ways to improve the use of the Army Knowledge Online\n platform in support of implementation of the Comprehensive Transition Plan.\n\nC.10.2. We recommend that the Commander, 3rd Battalion, 85th Mountain Infantry\n Regiment develop alternative procedures to ensure the Comprehensive Transition Plan\n administration via the Army Knowledge Online platform does not:\n\n C.10.2.a. Require duplicative efforts on the part of the Warrior Transition\n Battalion staff and Warriors in Transition;\n\n C.10.2.b. Hinder Warriors in Transition from participating in the\n Comprehensive Transition Plan process due to cumbersome and timely\n requirements.\n\n3rd Battalion, 85th Mountain Infantry Regiment Comments\nThe Commander, 3rd Battalion, 85th Mountain Infantry Regiment concurred with comments to\nour recommendations. The Commander explained that problems still exist with the AKO\nplatform; however, the hiring of the CTP Management Analyst is making an impact. Having one\nindividual who can focus on the CTP platform has improved communication among the CTP\nusers. Furthermore, effective March 28, 2011, an analyst has been assigned to each company\nwhich has greatly improved the efficiency and accuracy of the CTP input process.\n\nOur Response\nThe Commander, 3rd Battalion, 85th Mountain Infantry Regiment\xe2\x80\x99s comments are responsive and\nthe actions meet the intent of the recommendations. No further action is required.\n\n\n\n\n 59\n\x0cC.11. Proximity of Warriors\xe2\x80\x99 Medical Care and Support\n The physical locations of the nurse case managers, WTB clinic, and WTB\n pharmacy unduly hampered Warriors\xe2\x80\x99 access to medical care. Consequently,\n Warriors were physically located away from their medical support staff which\n may have lead to limited, direct interaction with them, and potentially caused\n Warriors to drive while medicated.\n\nC.11. Background\nIn support of comprehensive Warrior care, a new WTB Campus is being built near the Guthrie\nClinic on Fort Drum. The planned facilities were scheduled in the following phases:\n \xe2\x80\xa2 Phase 1 \xe2\x80\x93 approximately 200 barracks spaces and a two-company headquarters building\n (completed)\n \xe2\x80\xa2 Phase 2 \xe2\x80\x93 additional 100 barracks spaces, a battalion headquarters building, and an SFAC\n building (the Army Corps of Engineers was preparing to advertise this project during our\n site visit)\n \xe2\x80\xa2 Phase 3 \xe2\x80\x93 additional barracks spaces, a third company headquarters, and an\n administration facility (contingent on supplemental funding)\n \xe2\x80\xa2 Phase 4 \xe2\x80\x93 a dining facility and a physical therapy facility (contingent on supplemental\n funding)\nUntil this campus is completed, the nurse case managers, who are an integral part of the\nWarrior\xe2\x80\x99s Triad of Care, had to be physically located in a modular building near the WTB\nheadquarters. The distance from location to the nurse case managers to the Warrior barracks and\ncompany headquarters building \xe2\x80\x93 which houses the company staff, squad leaders, and other\ncivilian staff (such as social workers) \xe2\x80\x93 was approximately three miles. Further, the WTB\nprimary care clinic and the WTB pharmacy that Warriors used were physically located near or in\nthe Conner Troop Medical Clinic, which was also approximately three miles from the WTB\ncompany headquarters building and Warrior barracks.\n\nC.11. Discussion\nThe current Warrior campus facilities generated concerns among the staff about the decentralized\nphysical location of:\n \xe2\x80\xa2 Nurse case managers, which limited their ability to support an effective Triad of Care\n relationship\n \xe2\x80\xa2 The Warrior clinic and pharmacy which were far (3 miles) from the Warrior barracks\nDuring a group meeting, nurse case managers explained that they were located near the WTB\nheadquarters because of space limitations in the company headquarters building. The original\nWarrior campus plan was for the nurse case mangers to be located in the company headquarters\nbuilding near the Warrior barracks. However, as their numbers increased, they outgrew the\navailable space and were moved to their current location.\n\nNurse case managers believed that, because they were not co-located, they could not readily\nwork side-by-side with Warriors, to effectively address their care issues, which limited their\n\n\n 60\n\x0ceffectiveness. Additionally, there was concern that Warriors had to drive or find other\ntransportation to get a face-to-face meeting with their nurse case manager, which was, again,\ninefficient and potentially dangerous (if Warriors were driving while medicated). Warriors also\nrecognized that not having the nurse case managers centrally located impacted their recovery and\ntransition. One Warrior stated, \xe2\x80\x9cBring the nurse case managers in the building so that they can\nbest assist the Soldiers assigned to this unit.\xe2\x80\x9d\n\nLocation of the Clinic and Pharmacy\nWarriors saw their primary care managers for routine appointments at the WTB primary care\nclinic. This clinic also supported a \xe2\x80\x9csick call\xe2\x80\x9d beginning at 7 a.m. during the week for Warriors\nwith acute care issues on a first-come, first-served basis. There was some concern expressed by\nWarriors that the physical location of the WTB primary care clinic a few miles from the Warrior\nbarracks unnecessarily hampered Warriors\xe2\x80\x99 access to their primary care managers.\n\nWarriors were also scheduled for appointments at the Guthrie Ambulatory Health Care Clinic,\nwhich was located within walking distance of the Warrior barracks. The WTB campus facilities\nwere built next to the Guthrie Clinic to provide Warriors the efficiency and ease of access to\nmedical care services. There was a pharmacy in the Guthrie Clinic, but Warriors could not\nobtain medications or refills at that pharmacy. Instead, Warriors were required to use the\npharmacy in the Connor Troop Medical Clinic. A WTB staff member stated, \xe2\x80\x9cThey moved the\nSoldiers here to be close to the Guthrie clinic, then moved the place where they can get their\nmedications to another location. So, Soldiers have to travel to get their medications when there\nis a pharmacy across the street.\xe2\x80\x9d\n\nWarriors were also confused as to why the WTB pharmacy was relocated. One Warrior\nspecifically explained, \xe2\x80\x9cThey moved the WTB barracks so we are across from Guthrie [clinic]\nwhen we used to be across from the Connor Troop Medical Clinic. Then, they moved the\nmedication pick-up point from Guthrie to near Connor [Troop Medical Clinic]. The distance is a\nfew miles so WTB members have to walk, drive, or take a shuttle. They need to make it faster\nand easier to get medication refills.\xe2\x80\x9d\n\nC.11. Conclusion\nThe facilities that are planned to be built at the WTB campus should alleviate the decentralized\nphysical locations of nurse case managers, the primary care clinic, and the designated WTB\npharmacy. However, phases three and four are contingent on supplemental funding. If these\nphases are not executed because they are not funded, the physical separation of nurse case\nmanagers, the WTC primary care clinic, and the WTB pharmacy from the WTB barracks and\ncompany headquarters will continue indefinitely.\n\nWe believe that Warriors should have easy access to the nurse case manger, primary care, and\ntheir pharmacy. Until (if) the final two phases of construction are complete, the Fort Drum WTB\nshould consider feasibility of having the nurse case managers work closer to Warriors, squad\nleaders, and other staff. Physically locating nurse case managers near the Warriors and staff\nwould likely support improved communications with Warriors, and better support Triad of Care\nmember relationships. For amplifying remarks by Warriors concerning this section, refer to Part\nIII, Warriors Speak.\n\n\n 61\n\x0cC.11. Recommendations, Management Comments, and Our Response\n\nC.11.1. We recommend that the Commander, 3rd Battalion, 85th Mountain Infantry\nRegiment conduct an assessment to determine whether it is financially and logistically\nfeasible to have the nurse case managers, Warriors in Transition Battalion primary care\nclinic, and/or Warrior pharmacy located near the Warrior in Transition campus.\n\n3rd Battalion, 85th Mountain Infantry Regiment Comments\nThe Commander, 3rd Battalion, 85th Mountain Infantry Regiment concurred with comments to\nour recommendation. The Commander explained that the WTB is working to have all NCMs\nlocated next to Guthrie Ambulatory Clinic, the barracks and company headquarters as part of the\nnext phase of construction. As of May 25, 2011, WTs have been housed next to the Guthrie\nAmbulatory Clinic.\n\nOur Response\nThe Commander, 3rd Battalion, 85th Mountain Infantry Regiment\xe2\x80\x99s comments are responsive and\nthe actions meet the intent of the recommendations. No further action is required.\n\nRevised and Redirected Recommendation\nThe 3rd Battalion, 85th Mountain Infantry Regiment provided no comments to recommendations\nC.11.2.a, and C.11.2.b. We have redirected the draft report recommendations C.11.2.a, and\nC.11.2.b. to the Commanding General, Northern Regional Medical Command.\n\nC.11.2. We recommend the Commanding General, Northern Regional Medical Command:\n\nDevelop and widely distribute policy and procedures for Warrior Transition Unit personnel\nresponsible for managing transportation of Warriors. Specifically, address those practices that:\n\n C.11.2.a. Prevent Warriors in Transition from driving while medicated; and\n\n C.11.2.b. Ensure Warriors in Transition are provided consistent access to nurse case\n managers, primary care, and pharmacy services.\n\n\n\n\n 62\n\x0cC.12. Administrative Support for Nurse Case Managers\n Medical support assistants were not being fully utilized to provide\n administrative support to nurse case managers. Consequently, nurse case\n managers were not always able to effectively and timely engage with\n Warriors, putting them at risk of unnecessarily prolonged transitions.\n\nC.12. Background\nThe Bravo company supervisory nurse case manager stated that they were authorized one\nmedical support assistant for each company (headquarters, Alpha, and Bravo), and one office\nautomation assistant to support all three companies. Only two of these positions were filled\nduring our site visit; a hiring action was initiated for the vacant third position. Also, the medical\nsupport assistant for the headquarters company was vacant.\n\nC.12. Discussion\nThe nurse case managers stated that they required additional, consistent administrative support to\nbe able to effectively engage with their Warriors. During a group interview with nurse case\nmanagers, they acknowledged that there were administrative assistants providing support to the\ncompanies, but for unknown reasons these individuals were not always available. They stated\nthat they needed more reliable administrative support to help make appointments and follow-up\non other Warrior concerns and needs. During a separate group interview with nurse case\nmanagers, they echoed that to make medical appointments for Warriors, consistent company\nadministrative support was required. Currently that support is unavailable. They stated that they\nneeded more administrative support and felt that they should have nurse case manager assistants\nto provide this support.\n\nA third group of nurse case managers stated that administrative requirements had doubled, if not\ntripled, over the last several years and these additional administrative requirements were taxing.\nFor example, there was a requirement for them to update the Medical Occupational Data System\nweekly, provide their weekly CTP input on their Warriors, and conduct and document peer\nreviews. They concluded that additional administrative support was needed because the two\n\xe2\x80\x9cfull-time\xe2\x80\x9d individuals providing clerical support were not always available on a consistent basis.\n\nC.12. Conclusion\nThe supervisory nurse case manager is responsible to ensure that the medical support assistants\nfor each company are fully utilized in providing administrative support to nurse case managers.\nAlso, the supervisory nurse case manager should conduct a needs assessment to determine\nwhether additional administrative support positions are required. If additional personnel support\nrequirements are identified, the supervisory nurse case manager should present the requirement\nto MEDDAC and WTB management for resourcing.\n\n\n\n\n 63\n\x0cC.12. Recommendations, Management Comments, and Our Response\nThe 3rd Battalion, 85th Mountain Infantry Regiment comments are non responsive. We have\nredirected the draft report recommendations C.12.1, and C.12.2. to the Commanding General,\nNorthern Regional Medical Command.\n\nRedirected Recommendations\nC.12. We recommend that the Commanding General, Northern Regional Medical Command:\n\n C.12.1. Ensure that the medical support assistants are fully utilized in providing\n administrative support to nurse case managers; and\n\n C.12.2. Conduct a needs assessment to determine and resource additional administrative\n support requirements.\n\n3rd Battalion, 85th Mountain Infantry Regiment Comments\nThe Commander, 3rd Battalion, 85th Mountain Infantry Regiment concurred with comments to\nour recommendations. The Commander explained that there is a process in place for hiring\nadditional Medical Support Assistants to support NCMs.\n\nOur Response\nThe Commander, 3rd Battalion, 85th Mountain Infantry Regiment\xe2\x80\x99s comments are non\nresponsive. The Commander\xe2\x80\x99s response does identify the need for additional Medical Support\nAssistants. However, it does not address if a needs assessment was conducted, nor specify the\nnumbers of Medical Support Assistants being hired and what roles they will fill. We ask that the\nCommanding General, Northern Regional Medical Command provide a response to the\nrecommendations.\n\n\n\n\n 64\n\x0cPart III - Warriors Speak\n\n\n\n\n 65\n\x0cThis Page Intentionally Left Blank\n\n\n\n\n 66\n\x0cPart III. Warriors Speak\nWe believe that it is important to give a voice to Warriors assigned to the WTB. We felt that\nincluding comments made by Warriors themselves could best illustrate their various experiences\nin the unique development of the WTU mission and environment.\nWe interviewed 122 Active Component, Army National Guard, and Army Reserve Warriors,\nboth individually and in group settings, at the Fort Drum WTB. Those Warriors provided both\npositive feedback and concerns about their access to medical care and certain aspects of\ninstallation support. Interviewed Warriors stated that:\n \xe2\x80\xa2 Equitable access to medical care was provided to Active Component, Army National\n Guard, and Army Reserve Warriors for the condition(s) that required their assignment or\n attachment to the Fort Drum WTB\n \xe2\x80\xa2 Installation support services and activities were available to assist Warriors in their\n recovery and transition\n\nWe also noted twenty-one common themes from Warrior interviews that we believe require the\nattention of all Fort Drum WTB management and staff. These twenty-one common themes were\ncategorized under one of the following six groups:\n\n \xe2\x80\xa2 Command Climate and Leadership\n \xe2\x80\xa2 Preparation for Transition\n \xe2\x80\xa2 Health Care Services\n \xe2\x80\xa2 Comprehensive Transition Plans\n \xe2\x80\xa2 Warrior Safety\n \xe2\x80\xa2 Family Concerns\nWarrior Good News\nWarriors that were interviewed during our visit provided positive feedback in two specific areas:\nequitable access to medical care and availability of installation support services and activities,\nboth of which are discussed below.\n\nEquitable Access to Medical Care\nAn overwhelming majority of the Active Component, Army National Guard, and Army Reserve\nWarriors that we interviewed stated that they received equitable access to medical care for the\ncondition(s) that required their assignment or attachment to the Fort Drum WTB.\n\nOne Warrior who had been at the WTB for approximately four months stated that he had not\nheard of or seen any discrepancies in treatment for rank, component (Active Duty, Army\nNational Guard, and U.S. Army Reserve), or combat versus non-combat wounded Warriors. He\nalso stated that he believed that everyone in the unit received equal treatment. Another Warrior,\na U.S. Army Reservist, commented that the staff was sensitive to the thought that a Reservist\nmight not understand the WTB process and might need more guidance than an active duty\nSoldier, but for care issues, \xe2\x80\x9cwe are all treated the same.\xe2\x80\x9d\n\n\n\n\n 67\n\x0cDuring a group interview with junior enlisted Warriors, they believed that all Warriors received\nequal access to medical care because no one knew who was combat-wounded versus non-combat\nwounded.\n\nInstallation Support Services and Activities\nSeveral Warriors that we interviewed felt that quality support services were available through the\nFort Drum installation. These installation support services were lauded because of their overall\nassistance to Warrior healing and transition. A few of the comments provided by Warriors\nfollow.\n\nOne Warrior commented that he only needed a few more credits to complete his Associate\xe2\x80\x99s\ndegree. He stated that with the help of the Education Center on post, he was \xe2\x80\x9con the right track\xe2\x80\x9d\nto completing his degree. Another Warrior commented that he utilized the scuba program that\nwas offered on the installation; specifically stating, \xe2\x80\x9cThe scuba program is awesome and very\ntherapeutic.\xe2\x80\x9d Another Warrior mentioned that the finance office on post was very helpful with\npay issues that he encountered. Finally, many Warriors stated that the services offered at the\nSFAC were very helpful in providing transition assistance.\nWarriors\xe2\x80\x99 Concerns\nThere were several common themes we noted from our Warrior interviews. We believe that\nthese concerns warrant the attention of MEDDAC and WTB management and staff. Warriors\xe2\x80\x99\ncomments about those concerns are expressed in the following paragraphs.\nCommand Climate and Leadership\nWarriors largely agreed that the command climate and leadership were hindering their recovery\nand transition. Specifically, Warriors:\n \xe2\x80\xa2 Felt that the negative command climate was detrimental to their healing and transition\n \xe2\x80\xa2 Expressed a fear of retribution if they utilized the Commander\xe2\x80\x99s open door policy\n \xe2\x80\xa2 Reported inconsistent and ineffective communication throughout the unit\n \xe2\x80\xa2 Felt that squad leaders were only focused on their accountability rather than individual\n Warrior needs\n \xe2\x80\xa2 Reported that individual infractions often resulted in mass punishment and loss of\n privileges for all\n \xe2\x80\xa2 Conveyed that military customs and courtesies were not always observed and enforced by\n staff\n \xe2\x80\xa2 Stated that losing units generally do not contact them once they were assigned to the\n WTB (\xe2\x80\x9cfire and forget\xe2\x80\x9d attitude)\nWTB Environment\nThe themes of a negative command climate and poor treatment were pervasive throughout our\nWarrior interviews. Warriors cited numerous and assorted examples of detrimental command\nclimate and callous treatment that led to their anger, depression, frustration, and lack of\nmotivation. Examples of the negative climate and treatment included:\n\n \xe2\x80\xa2 A Warrior commented that the unit segregated along racial lines and by MOS, saying that\n it was like high school with cliques.\n\n\n\n 68\n\x0c \xe2\x80\xa2 Another Warrior commented about racial issues; specifically that there was racism in the\n unit and a definite issue with favoritism.\n \xe2\x80\xa2 During an individual interview, a Warrior explained that the staff made some Warriors\n call them after appointments, but didn\xe2\x80\x99t make their \xe2\x80\x9cbuddies\xe2\x80\x9d call. This Warrior\n concluded that favoritism was definitely apparent in the WTB.\n \xe2\x80\xa2 One Warrior talked about a staff member who treated him like a three year old, with an\n \xe2\x80\x9calways in your face\xe2\x80\x9d attitude, bullying him and constantly using derogatory remarks.\n \xe2\x80\xa2 A Warrior explained that discrimination against Guard and Reserve Soldiers was very\n subtle. Staff made snide comments or called specific Warriors \xe2\x80\x9cnames\xe2\x80\x9d that reflected\n their medical conditions. Guard and Reserve Warriors were then called those names in\n front of the rest of the Soldiers at formations.\nOpen Door Policy\nDuring an interview with WTB leadership, it was explained that the WTB Commander, like all\ncommanders at Fort Drum, had an open door policy for Soldiers who sought direct interface with\nthe Commander to resolve any issue. When asked \xe2\x80\x9chow many Warriors use this open door\npolicy,\xe2\x80\x9d a WTB leader stated that they did not experience a high volume of Warriors and as such,\nthis leader concluded that Warriors had no problems that required the Commander\xe2\x80\x99s direct\nintervention.\nWarriors provided different insights into the lack of utilization of the WTB Commander\xe2\x80\x99s open\ndoor policy. Those comments included:\n \xe2\x80\xa2 One Warrior stated, \xe2\x80\x9cWe won\xe2\x80\x99t use the open door policy to see the Commander, as this\n will do no good.\xe2\x80\x9d\n \xe2\x80\xa2 Another Warrior didn\xe2\x80\x99t believe that they could see the WTB Commander without\n repercussions.\n \xe2\x80\xa2 A third Warrior stated, \xe2\x80\x9cThe open door policy to the Battalion Commander is not used\n because everyone here is afraid that they will be punished or otherwise retaliated against\n for bringing problems up to the Commander.\xe2\x80\x9d\n \xe2\x80\xa2 Another Warrior explained that although he was a senior enlisted Soldier with over\n 18 years of active duty, he needed an escort to go visit individuals within the Battalion.\n\nWTB Communication\nWe were told about and observed several instances of inconsistent and ineffective\ncommunication within the WTB. Examples of poor communication included \xe2\x80\x9cinformation\noverload\xe2\x80\x9d as well as failures to obtain information in a timely manner.\n\nOne Warrior stated, \xe2\x80\x9cThis organization needs to communicate better with the Soldiers. I feel like\nI am \xe2\x80\x98drinking water from a fire hose\xe2\x80\x99 and things that come easy to active duty Soldiers are\ndefinitely not coming easy to Reservists. I am not even sure if I will be paid next month!\xe2\x80\x9d\nAnother Warrior commented that in his experience, it appeared that the squad leaders had\ncommunication issues, seemed unorganized, and were unable to provide timely information. He\nfurther stated that the squad leaders appeared that they were not informed about services\navailable to the Warriors.\n\n\n\n\n 69\n\x0cWarriors also commented on the lack of transportation assets that were available to support their\nneeds. Many of the Warriors\xe2\x80\x99 comments contradicted those made by WTB leadership about this\ntopic which served as verification that communication gaps existed. For example, one Warrior\nclaimed that the vans were often broken, specifically stating, \xe2\x80\x9cEveryone has appointments and\nthe WTB is under-sourced in transportation.\xe2\x80\x9d Another Warrior commented that a need existed\nfor a duty driver to transport them across Fort Drum to allow them to make appointments and use\nbase services. A third Warrior mentioned that he did not see the need for large passenger vans\nwhen the majority of the trips were for one Soldier only.\n\nFurther, Warriors provided examples of communication deficiencies with spouses living in the\nFort Drum area, and for family members and support groups outside of the geographic area.\n \xe2\x80\xa2 During multiple group interviews, there was a consensus among Warriors that\n information was generally not provided to spouses and that family members were not\n contacted.\n \xe2\x80\xa2 During an individual interview, one Warrior commented that his wife was at Fort Drum\n with him, but the WTB did not reach out to her or call her.\n \xe2\x80\xa2 Another Warrior relayed that her spouse was never called by the WTB and family\n outreach was nonexistent. When the spouse tried to engage with WTB staff to obtain\n information, the individuals who were approached would reply that they were unaware of\n the specific details of his spouse\xe2\x80\x99s case.\n \xe2\x80\xa2 A Warrior whose family lived in Syracuse stated that the WTB did not consider families\n who were not from the local area.\n\nSquad Leader Focus\nWarriors felt that squad leaders were more focused on maintaining accountability of their\nwhereabouts and other administrative requirements than focusing on individual Warrior needs.\nWarriors also felt that WTB staff was too focused on operating the WTB as a traditional unit and\nreturning Warriors to duty, which was not conducive to mission accomplishment; specifically in\nthe area of helping Warriors become \xe2\x80\x9cproductive, responsible citizens in society.\xe2\x80\x9d\n\nThe following comments were provided by Warriors about how staff focused on accountability\nover the Warrior population and other administrative responsibilities instead of the Warriors\nthemselves:\n \xe2\x80\xa2 One Warrior\xe2\x80\x99s opinion was, \xe2\x80\x9cThere is way too much accountability. We have two hours\n of physical training each day and very few people are able to even do PT [physical\n training]. So we end up sitting in the gym in pain.\xe2\x80\x9d\n \xe2\x80\xa2 Another Warrior recommended that physical training should be \xe2\x80\x9con your own\xe2\x80\x9d and not\n used as an \xe2\x80\x9caccountability formation.\xe2\x80\x9d\n \xe2\x80\xa2 A third Warrior stated that he understood that accountability in a WTB is important, but\n asked, \xe2\x80\x9cDo you have to do PT [physical training] every day for accountability?\xe2\x80\x9d\n \xe2\x80\xa2 A Warrior stated that his squad leader was busy all the time and seemed to be too busy\n doing paperwork to take care of Warrior issues.\n \xe2\x80\xa2 During a group interview, several Warriors commented that the squad leaders were\n grossly overworked and were required to pull staff duty.\n\n\n\n 70\n\x0c \xe2\x80\xa2 A Warrior who had previously been a staff member said, \xe2\x80\x9cIn the Fort Drum WTB, they\n try to control everything; the more they try and control, the more things slip through their\n fingers.\xe2\x80\x9d\n \xe2\x80\xa2 Another Warrior stated simply, \xe2\x80\x9cThe squad leader needs to take more time with the\n individual.\xe2\x80\x9d\nWarriors also provided the following comments about how squad leaders were focused on\nreturning Soldiers to duty and were not versed on helping Warriors transition out of the Army:\n \xe2\x80\xa2 One Warrior believed that squad leaders treated WTB members like regular Soldiers,\n which did not help their transition. The Warrior expressed that there were WTB\n members who really needed help, but weren\xe2\x80\x99t receiving the proper assistance because\n they were being treated like they were in a regular unit.\n \xe2\x80\xa2 Another Warrior commented, \xe2\x80\x9cThis place is more like a boot camp than a place to heal.\xe2\x80\x9d\n \xe2\x80\xa2 A Warrior who was previously assigned to the Walter Reed WTB stated that Walter Reed\n was better suited to assist the Warriors who were getting out, while Fort Drum was great\n at helping the Soldiers transition back in [to the Army].\n \xe2\x80\xa2 A Warrior mentioned that squad leaders needed to be proactive with helping WTB\n members obtain employment, preferably in a job where they could gain skills that would\n help with their transition.\n \xe2\x80\xa2 A Warrior adamantly suggested, \xe2\x80\x9cLet me go to school to maximize my academic\n potential! All we do is wait for paperwork to sign and having to pass the time ultimately\n gets guys into trouble.\xe2\x80\x9d\n\n\xe2\x80\x9cOne Bad Apple Spoils the Whole Bunch\xe2\x80\x9d\nThe Warriors expressed concern with how Warrior infractions were handled by the WTB staff\nand leadership. Specifically, infractions of WTB policies were dealt with by punishing the group\nen mass instead of dealing with the individual violator(s).\nSpecific comments from Warriors concerning mass punishment included, but were not limited\nto:\n \xe2\x80\xa2 \xe2\x80\x9cThe battalion [WTB] has a mass punishment mentality.\xe2\x80\x9d\n \xe2\x80\xa2 \xe2\x80\x9c[The WTB should] punish the violators not the masses.\xe2\x80\x9d\n \xe2\x80\xa2 \xe2\x80\x9cTreat each Soldier as an individual and stop the mass punishment.\xe2\x80\x9d\n \xe2\x80\xa2 \xe2\x80\x9cUniform Code of Military Justice 46 actions seem to be adjudicated in an appropriate\n manner; however, once they are given, mass policies are created to prevent others from\n committing offenses and that is ridiculous. Certain privileges like going to school during\n the duty day are forbidden after some people did not conduct themselves appropriately.\n This mass application of discipline is a result of a poor command climate in the unit.\xe2\x80\x9d\n \xe2\x80\xa2 \xe2\x80\x9cSenior enlisted Soldiers are treated the same as the junior most troops with regard to\n mass punishment for infractions. For example, just because there was one instance of a\n\n\n\n\n46\n The Uniform Code of Military Justice is the congressional code of military criminal law applicable to all\nU.S. military members worldwide.\n\n\n\n\n 71\n\x0c Warrior being out of the area when she checked out on leave, now everyone (including\n senior enlisted) has to check in and out on leave in person.\xe2\x80\x9d\n\nMilitary Customs and Courtesies\nMilitary customs and courtesies ensure proper respect for the chain of command and build a\nfoundation for self-discipline. They include acts of respect and courtesy when dealing with other\npeople and have evolved as a result of the need for order, mutual respect, and the sense of\nfraternity that exists among military personnel. Military customs and courtesies go beyond basic\npoliteness; they play an extremely important role in building morale, esprit de corps, discipline,\nand mission effectiveness.\nWarriors indicated that military customs and courtesies between staff and Warriors, as well as\namong Warriors themselves, are not consistently adhered to, enforced, and are often outright\ndisregarded. The following were comments provided by Warriors during both group and\nindividual interviews:\n \xe2\x80\xa2 A Warrior commented that some of the staff were not respectful of the senior NCOs that\n were Warriors; and although they were not \xe2\x80\x9cin charge,\xe2\x80\x9d they were still NCOs and should\n be treated as such. He further stated that this behavior made the younger enlisted think\n that acting disrespectful was acceptable.\n \xe2\x80\xa2 A Warrior stated that customs and courtesies of the Army do not exist in this WTB. He\n explained that there is an \xe2\x80\x9cus against them\xe2\x80\x9d mentality in the unit, and the staff does not\n enforce customs and courtesies between the Warriors.\n \xe2\x80\xa2 Another Warrior said that some Warriors do not show due respect to the squad leaders in\n dress, posture, and attitude.\n \xe2\x80\xa2 A Warrior explained that the senior enlisted Warriors are treated the same as the junior\n enlisted Warriors. For example, to visit Educational Services on post, this senior enlisted\n Warrior was required to have a senior NCO staff escort him.\n \xe2\x80\xa2 Another Warrior stated that Warriors are considered to be \xe2\x80\x9cjust patients,\xe2\x80\x9d and regardless\n of their rank, they get no respect. He provided an example of one Warrior who abused\n the privilege of calling to report departure on leave, resulting in all Warriors having to\n report in person.\n \xe2\x80\xa2 About customs and courtesies, a Warrior stated, \xe2\x80\x9cOne day you are a senior NCO and the\n next day you are just a Soldier in formation.\xe2\x80\x9d\n\n\xe2\x80\x9cFire and Forget\xe2\x80\x9d\nThe majority of the Warriors assigned to the WTB were previously assigned to the 10th Mountain\nDivision or other Fort Drum units. Many of those Warriors had been medically evacuated from\ntheater or assigned to the WTB upon their unit\xe2\x80\x99s return. Once in the WTB, the majority of the\nWarriors said that their unit or rear detachment leadership had not made contact with them.\n\nOne Warrior commented, \xe2\x80\x9cI have had no contact with my former unit. They failed to process my\nPurple Heart and that really bothers me.\xe2\x80\x9d Another Warrior gave the opinion that \xe2\x80\x9cthey\xe2\x80\x9d make\ncontact only because they still have the Warrior\xe2\x80\x99s gear and the Warrior will eventually have to\nreturn that gear to that unit. When asked if his previous unit contacted him, another Warrior\nanswered, \xe2\x80\x9cNot at all, but they should! I have an award in my personnel file that is not mine and\nI need to get that fixed.\xe2\x80\x9d\n\n\n 72\n\x0cDuring a group interview with officers and senior NCOs, when asked whether their previous unit\nmaintained contact with them, three out of four Warriors responded with negative comments,\nwhich included:\n \xe2\x80\xa2 \xe2\x80\x9cI feel like I have fallen off the face of the earth.\xe2\x80\x9d\n \xe2\x80\xa2 \xe2\x80\x9cMy unit is down range but they are still keeping contact with me.\xe2\x80\x9d\n \xe2\x80\xa2 \xe2\x80\x9cMy unit treats me like dirt.\xe2\x80\x9d\n \xe2\x80\xa2 \xe2\x80\x9cNo. I am having problems getting my Officer\xe2\x80\x99s Evaluation Report and my medal.\xe2\x80\x9d\n\nPreparation for Transition\nIt is important that each Warrior assigned or attached to the WTB receive adequate and\nappropriate preparation to transition to productive, responsible citizens in society. However, at\nthe Fort Drum WTB, Warriors largely:\n \xe2\x80\xa2 Had no clear understanding of what a \xe2\x80\x9csuccessful transition\xe2\x80\x9d end-state from the WTB\n meant\n \xe2\x80\xa2 Described a lack of structured days with meaningful activities to prepare for transition to\n civilian life, to include not being able to attend resident educational courses or vocational\n training during the duty day\n \xe2\x80\xa2 Explained that unclear transition timelines resulted in lack of planning and preparation\n for transition to civilian life\n\nSuccessful Transition\nPreparation for a successful transition \xe2\x80\x93 whether returning to duty in the same MOS, in a new\nMOS, or returning to civilian life as a productive member of society \xe2\x80\x93 was on the minds of the\nmajority of Warriors we interviewed. For many of these Warriors, the military and their MOS\nwere all they had known. For those who could no longer carry out their duties in their MOS due\nto their condition or injuries, their concern about acquiring new skills and training to prepare for\nthe future either in the military or in the civilian world dominated their thoughts.\n\nWhen Warriors were asked to describe their definition of a successful transition from the WTB, a\nmultitude of answers were provided. When it specifically came to successfully transitioning to a\ncivilian life, many were focused on either being enrolled in college courses or having jobs\nsolidified before they medically retired from the Army. However, many were concerned that\nbecause of unknowns with their transition, this would not be the case. Their comments included:\n \xe2\x80\xa2 One Warrior commented that no one had thought about what skill sets an infantryman\n needed for a successful transition to the civilian world.\n \xe2\x80\xa2 Other Warriors whose MOSs were also in the infantry career field were concerned that\n the types of civilian jobs they were prepared for (policeman, fireman, prison guard)\n would not be available to them when they got out of the Army.\n \xe2\x80\xa2 Another Warrior was not ready to transition to civilian life because he was afraid of the\n \xe2\x80\x9cunknown unknowns\xe2\x80\x9d with getting out of the military. Having joined the military at age\n 18, the military was all he had known.\n \xe2\x80\xa2 A Warrior said that he had no \xe2\x80\x9cplan B\xe2\x80\x9d and was unsure of what to do after the Army. He\n suggested that the WTB give Soldiers more guidance.\n\n\n\n\n 73\n\x0c \xe2\x80\xa2 Another Warrior stated that he could not define a successful transition because in his\n case, he could not make plans because of a lack of information. He was worried about\n what the future held and had no idea which direction his life would go. He had no home\n to move to and no future employment.\n \xe2\x80\xa2 Finally, a Warrior keenly observed and commented, \xe2\x80\x9cA transition unit is a transition unit.\n There should be different processes for different paths, but those processes are not in\n place yet [at the WTB].\xe2\x80\x9d\n\nActivities to Prepare for Transition\nThe Warriors stressed the criticality of constructive transition activities as the foundation of a\nsuccessful transition whether returning to the same MOS, transitioning to a different MOS, or\nleaving the military and returning to civilian life. The Warriors we interviewed expressed\nconcern that the WTB was not consistently affording them adequate, thoughtful, and reasonable\nactivities in support of their transitions.\n\nWarriors who wanted to remain on active duty and either return to the same MOS or receive\ntraining in another MOS expressed concern with their transition preparation:\n \xe2\x80\xa2 A Warrior returning to duty in the same MOS wanted refresher training in that MOS to\n ensure that his training and experience were still current.\n \xe2\x80\xa2 Another Warrior wanted to return to duty, but needed to cross-train in a new MOS, which\n required a security clearance. However, the Warrior was restricted from completing the\n paperwork until his MEB was complete. The Warrior said, \xe2\x80\x9cBeing in limbo kind of\n sucks.\xe2\x80\x9d\n \xe2\x80\xa2 A third Warrior who could no longer perform in his current MOS said that no one had\n discussed with him the opportunity to reclassify to another MOS; instead, he was\n encouraged to medically retire.\n \xe2\x80\xa2 A Warrior wanted to transition to another MOS and stay in the Army, but had met\n challenges. He either did not qualify for certain positions or was too high of a rank to be\n moved into other positions. So, the Warrior felt forced to medically retire.\n \xe2\x80\xa2 Due to one Warrior\xe2\x80\x99s condition, he could not remain in a combat MOS. Class sizes at\n Advanced Individual Training 47 kept him from getting the training for another MOS, so\n he would be medically retiring.\n\nWarriors\xe2\x80\x99 comments regarding the lack of constructive transition activities in preparation for\ncivilian life included but were not limited to:\n \xe2\x80\xa2 One Warrior commented that if he were to have a smooth transition, he would already be\n enrolled in college course so that school and work experiences would provide\n opportunities for future tangible employment. \xe2\x80\x9cWithout the ability to go to school [while\n in the WTB], I am \xe2\x80\x98stuck\xe2\x80\x99 until I get out of here.\xe2\x80\x9d\n\n\n47\n After Soldiers complete Basic Combat Training, they move to Advanced Individual Training (AIT), where they\nlearn the skills to perform their Army jobs. At AIT school, Soldiers receive hands-on training and field instruction\nto make them experts in that specific career field.\n\n\n\n\n 74\n\x0c \xe2\x80\xa2 As previously mentioned in Observation C.5., WTB leadership expressed that Warriors\n could go to school during the duty day provided that they submit a plan showing that\n their classroom attendance would not impact their medical appointments. However,\n during a group interview, one Warrior stated that he knew of others who submitted plans\n to take courses during the duty day, but they were all rejected.\n \xe2\x80\xa2 A third Warrior commented that his work assignment at the Fort Drum museum did not\n match his transition plan to be a physical therapist. He also stated that he received no\n counseling to help toward his transition goal.\n \xe2\x80\xa2 Another Warrior \xe2\x80\x9cwished there were a landscaping job on post.\xe2\x80\x9d The Warrior was a\n \xe2\x80\x9clevel-one certified\xe2\x80\x9d landscaper and wanted to pursue landscaping upon leaving the\n Army. He did not think that the WTB would allow him to have a landscaping job on post\n even though it would help his transition to civilian life.\n \xe2\x80\xa2 A Warrior commented that schooling would enable him to get a head start on completing\n his education once in the civilian world. The Warrior planned to be a foreign language\n teacher and possibly move into literature and language.\n\nTransition Timelines\nIn addition to concerns over a lack of constructive activities for a successful transition, Warriors\nwere concerned with the lengthy process and the lack of clarity on steps and expected timelines\nduring their assignment or attachment to the WTB. The Warriors who expressed the biggest\nconcerns had been at the WTB for a period of time spanning six months to two-and-a-half years.\n\nWarriors were experiencing and expressing added frustration because they were unaware of how\nlong they would be in the WTB, and therefore, could not always plan their transitions\naccordingly. Comments from Warriors about unknown timelines included:\n \xe2\x80\xa2 \xe2\x80\x9cI have been here so long that I have missed four job opportunities. They need to move\n on people as quickly as possible in order to avoid this hover status that I have been in. I\n want to depart in a timely manner and recommend holding the unit leadership\n accountable for delays in Warriors\xe2\x80\x99 departures.\xe2\x80\x9d\n \xe2\x80\xa2 \xe2\x80\x9cA year in the WTB is way too long! No one should have to wait more than 6 months,\n even guys with PTSD/TBI issues. Give me a timeline that I can work with and plan my\n life.\xe2\x80\x9d\n \xe2\x80\xa2 \xe2\x80\x9cBeing in the WTB is like being in a holding company; I feel like I am in limbo because I\n do not know if I will be retained.\xe2\x80\x9d\n \xe2\x80\xa2 \xe2\x80\x9cNothing happens here quickly.\xe2\x80\x9d\n \xe2\x80\xa2 \xe2\x80\x9cThe biggest problem is the waiting and the not knowing.\xe2\x80\x9d\nWarriors in a group interview also expressed concern about having no idea of their transition\ndates. They added that without a firm, or even approximate date, they could not apply for\ncollege or jobs. Another Warrior commented that her nurse case manager told her she might be\nat the WTB for another 6 months, while a representative at the DVA said she might be there for\nanother year. The Warrior said that she was confused and frustrated and wished someone would\nhelp her.\n\n\n\n\n 75\n\x0cHealth Care Services\nThere were multiple health care-related issues discussed in previous Observations that were also\naddressed by Warriors. Warriors reported concerns about access to specialty medical care and\nmedication management, among other issues. Specifically, Warriors:\n \xe2\x80\xa2 Reported that access to specialty care (such as behavioral health and orthopedics) was not\n always timely\n \xe2\x80\xa2 Perceived that a use of multiple primary care managers hindered their continuity of care\n \xe2\x80\xa2 Provided instances of incomplete medical records possibly causing delays in evaluation\n board processing and transition to DVA care\n \xe2\x80\xa2 Feared that their needs for medication to manage pain resulted in being labeled a \xe2\x80\x9cjunkie\xe2\x80\x9d\n\nAccess to Specialty Medical Care\nWarriors reported that they were not receiving timely access to certain types of specialty medical\ncare. Access to behavioral health appeared to be the most challenging. Additional comments\nfrom Warriors about access to specialty medical care included:\n \xe2\x80\xa2 A Warrior reported that her behavioral health specialist was not helping, stopped her\n medications, and was a terrible specialist. She requested another specialist, but was\n required to continue seeing the same one, which landed her in the hospital as an in-patient\n earlier this year.\n \xe2\x80\xa2 A different Warrior who had been at the WTB for about five months stated that it took\n him three to four weeks to get a neurology appointment and it took up to three months to\n get a pain management appointment.\n \xe2\x80\xa2 Another Warrior stated that the few times that he was able to access his orthopedic\n surgeon, the appointment went well. Although it was a long process, he was scheduled to\n see his orthopedic surgeon later in the month and was hopeful for assistance in healing\n his back.\n \xe2\x80\xa2 During an individual interview, a Warrior explained that there was a long wait for\n neurology appointments off-base, and there was too long of a wait for orthopedic\n appointments on-base; both of which led to frustration.\n \xe2\x80\xa2 A Warrior expressed concerns that he drove about 45 miles for a physical therapy\n appointment and had to wait an average of one month to get the appointments. He also\n stated he had been waiting over three weeks for a specialty follow-up appointment that\n was to be scheduled after his last surgery and his nurse case manager had not yet made\n the appointment.\n\nContinuity of Care\nWarriors expressed concerns about how changes to their primary care managers or other\nproviders impeded their continuity of care and their transition back to duty or to civilian life.\nWarriors\xe2\x80\x99 comments about continuity of care included:\n \xe2\x80\xa2 \xe2\x80\x9cI feel like I am starting over each time I see a new doctor. Seeing too many docs\n impedes my transition process.\xe2\x80\x9d\n \xe2\x80\xa2 \xe2\x80\x9cI believe that changing primary care managers too many times is the reason medical\n evaluation boards and medical retention boards are delayed.\xe2\x80\x9d\n\n\n\n\n 76\n\x0c \xe2\x80\xa2 \xe2\x80\x9cI keep getting bounced around, and constantly changing primary care managers makes\n the transition process choppy. It breaks the continuity of care, especially with pain\n management, because of the doctor\xe2\x80\x99s reluctance to dispense medications until he has seen\n you a few times.\xe2\x80\x9d\n \xe2\x80\xa2 \xe2\x80\x9cIf you have to go to sick call, you see another doctor, not your primary care manager.\n So, you have to explain everything all over again to another doctor.\xe2\x80\x9d\n \xe2\x80\xa2 \xe2\x80\x9cI\xe2\x80\x99ve experienced a communication problem because my prior primary care manager did\n not record notes, so repetition of my case particulars to a new primary care manager was\n required.\xe2\x80\x9d\n \xe2\x80\xa2 \xe2\x80\x9cI\xe2\x80\x99ve had 6 primary care managers over the last two and a half years, to include\n 2 civilians and 4 military docs. It is difficult to recruit good civilian practitioners to come\n to Fort Drum because of the location and the fact that case loads are excessive.\xe2\x80\x9d\n\nMedical Record Management\nDuring individual and group interviews, Warriors acknowledged that obtaining complete\nmedical records to meet requirements for evaluation board processing and to avoid delays in\ntransitioning to DVA had been a continuing challenge. Warriors\xe2\x80\x99 comments about challenges\nwith medical record management included:\n \xe2\x80\xa2 One Warrior explained that there was a problem with his medical records getting lost. He\n stated that he tracked them through Baghdad and into Kuwait, but after that, no one had\n any idea where his medical records were.\n \xe2\x80\xa2 Another Warrior stated that she had to track down her own medical records and packages\n because her nurse case manager was not doing her job.\n \xe2\x80\xa2 During an individual interview, a Warrior explained that after the DVA had already had\n his medical records for 5 months, they recently called and told him that they were\n missing a document from his medical records.\n \xe2\x80\xa2 A Warrior explained that he received a memorandum from the physical evaluation board\n stated that there were 8 items showing discrepancies within his medical records and\n narrative summaries.\n \xe2\x80\xa2 During a group interview, it was the group consensus that medical record management\n was a big problem, and it could take the patient administration division up to 4 weeks to\n pull one\xe2\x80\x99s records. There was a big fear among the group that not everything that related\n to their combat injury or transition process was making it into their records. When\n specifically discussing off-base records, many group members explained that they paid\n up to 75 dollars (non-reimbursable) to obtain copies of their records to have confidence\n that all medical information was entered into their consolidated medical records.\n\nMedication Management\nSome of the WTB staff were concerned that Warriors were overmedicated. However, Warriors\ncontradicted this perception with anxiety that their needs for medication to manage pain resulted\nin being labeled a \xe2\x80\x9cjunkie.\xe2\x80\x9d Specifically, Warriors stated:\n \xe2\x80\xa2 \xe2\x80\x9cI have a fear of talking about a possible increase in my pain medications. When that\n happens, I feel like I am treated like a drug addict. Patients seeking an adjustment in\n their medications should not be treated like \xe2\x80\x9cjunkies.\xe2\x80\x9d Plus, if I ask about adjusting my\n medications, I run the risk of being punished by being taken off of my meds altogether.\xe2\x80\x9d\n\n\n 77\n\x0c \xe2\x80\xa2 \xe2\x80\x9cI could not get pain medication for my back so I took drugs and drank a lot of alcohol to\n reduce the pain. A lot of guys here do drugs and drink in order to deal with the pain they\n are experiencing. If you ask for an increase in medications you are looked at as being a\n \xe2\x80\x98junkie.\xe2\x80\x99 So a lot of guys either suck it up or turn to drugs and alcohol to lessen the\n pain.\xe2\x80\x9d\n \xe2\x80\xa2 \xe2\x80\x9cI had difficulty getting my primary care manager to understand that I had some pain\n issues with my shoulders and bulging discs in my back and couldn\xe2\x80\x99t get meds to help me\n with my pain.\xe2\x80\x9d\n \xe2\x80\xa2 \xe2\x80\x9cI am sick of the attitude that all of the Soldiers are drug addicts. I have a \xe2\x80\x98bone-on-bone\n grinding action\xe2\x80\x99 in my back, but the doctors won\xe2\x80\x99t listen or increase my pain medications\n because it appears that I am drug-seeking.\xe2\x80\x9d\n \xe2\x80\xa2 \xe2\x80\x9cMy former primary care manager was horrible. He had a bad attitude, rushed my\n appointments, and was quick to label me as a drug seeker.\xe2\x80\x9d\n\nComprehensive Transition Plans\nWarriors largely agreed with WTB staff comments about the CTP; specifically that it was:\n \xe2\x80\xa2 A \xe2\x80\x9ccheck the block\xe2\x80\x9d requirement that replaced leadership interaction; and\n \xe2\x80\xa2 Too slow and cumbersome on the AKO platform.\n\n\xe2\x80\x9cOne Size Fits All\xe2\x80\x9d\nWarriors agreed that the CTP was a \xe2\x80\x9ccheck the block\xe2\x80\x9d requirement that was not beneficial for all.\nWarriors also stated that the CTP replaced leadership interaction and inputs were not always\nnecessary on a weekly basis. The following are additional comments provided by Warriors\nabout the CTP:\n \xe2\x80\xa2 \xe2\x80\x9cI believe that it is useless because unless you get a red marker, no one pays attention. I\n wrote down stupid stuff to see if anyone would catch it, and no one did. It is a check the\n block requirement and a waste of time, and if someone really wants to make it beneficial,\n the squad leaders should be having meaningful sit-down sessions with the Soldiers.\xe2\x80\x9d\n \xe2\x80\xa2 \xe2\x80\x9cI think it\xe2\x80\x99s [the CTP\xe2\x80\x99s] stupid. I fill it out weekly on my own on the computer, but no\n one talks to me about my weekly input.\xe2\x80\x9d\n \xe2\x80\xa2 \xe2\x80\x9cI see the CTP as a replacement for face-to-face counseling.\xe2\x80\x9d\n \xe2\x80\xa2 \xe2\x80\x9cNo one reads them anyway and I\xe2\x80\x99ve received no feedback.\xe2\x80\x9d\n \xe2\x80\xa2 \xe2\x80\x9cThe goals and other things on your plan aren\xe2\x80\x99t addressed. My question is, \xe2\x80\x98who is really\n reading it anyhow?\xe2\x80\x99\xe2\x80\x9d\n \xe2\x80\xa2 \xe2\x80\x9cI recommend that the on-line CTP be scrapped and replaced with a process that requires\n the squad leader, nurse case manager, and platoon sergeant to talk face-to-face with each\n other and us.\xe2\x80\x9d\n \xe2\x80\xa2 \xe2\x80\x9cThere are a large number of ridiculously vague questions and there is never a product\n that results from filling out the questions contained in the CTP. I would change the\n process by leading Soldiers. As an NCO, I would use the elements of the CTP to assist\n me as a guide, but I would lead them [the Warriors]\xe2\x80\xa6not expect them to fill out a\n questionnaire.\xe2\x80\x9d\n \xe2\x80\xa2 \xe2\x80\x9cI would scratch the CTP system. It is a babysitting paper drill that does nothing for the\n Warriors. If they want to help, they should let us go to school or vocational training,\n which will result in our success after the Army.\xe2\x80\x9d\n\n\n 78\n\x0cArmy Knowledge Online Platform\nWarriors commented that having to complete the CTP online via the AKO platform was too slow\nand cumbersome. Some Warriors shared that as a result of the problems they encountered with\nAKO, they were discouraged from maintaining their CTPs altogether. Warriors\xe2\x80\x99 comments\nmirrored those made by staff.\n\nSpecifically, Warriors comments included that the AKO version of the CTP had problems and\ncould not be accessed from computers at home. As a result, Warriors had to access their CTPs\nthrough squad leader laptops or at the SFAC or the United Service Organization. Other Warriors\ncommented that AKO had access problems, and didn\xe2\x80\x99t always work. When asked whether he\nhad a CTP, one Warrior responded, \xe2\x80\x9cIf it is the thing that we do on the internet, I have heard that\nit is shoddy and that AKO is not helpful at all. So I choose not to participate in this [CTP]\nprocess.\xe2\x80\x9d\n\nWarrior Safety\nWarriors provided multiple comments on various safety issues. Specifically, Warriors were\nconcerned that:\n \xe2\x80\xa2 They regularly drove while medicated\n \xe2\x80\xa2 They were unable to perform assigned duties because of medical conditions and\n prescribed medications\n \xe2\x80\xa2 Physical training events were outside of their medical profiles\n\nDriving While Medicated\nSafety was an important concern for Warriors, both for themselves and for fellow Warriors. Due\nto their varying, complex, and distinct medical conditions, many of the Warriors were prescribed\nnumerous pain, sleep, and other medications that caused them to experience drowsiness and/or to\nnot be fully alert. To illustrate their concerns, Warriors provided numerous examples of how the\nWTB imposed certain military duties, formations, or other activities requiring some Warriors to\ndrive motor vehicles while heavily medicated.\n\nA Warrior provided the example of when the WTB scheduled a urinalysis for 100 percent of the\nWarriors in the middle of the night. He lived off post and had to drive to the WTB while on\nsleep and pain medications. He stated that he managed his night time medications based on a set\nschedule, and when they gave an \xe2\x80\x9corder to show\xe2\x80\x9d for the urinalysis, he followed those orders,\ncausing him to violate the precautions listed on the warning label (do not operate a vehicle while\ntaking this medication) and drive while heavily medicated.\n\nAnother Warrior also observed that many of the Warriors were heavily medicated. He remarked,\n\xe2\x80\x9cThey drive to formations while heavily medicated. How safe is that? There are formations at\nthe end of the day and that places people on the roads again while medicated. With two\n\n\n\n\n 79\n\x0cformations as well as [Charge of Quarters] CQ 48 duties, I believe that Warriors\xe2\x80\x99 medical profiles\nare being violated.\xe2\x80\x9d\n\nOther Warriors explained that they felt that staff needed to be more sensitive and understanding\nwith regard to Warrior profiles, specifically driving while medicated. One Warrior stated that\nher profile only discussed opiate-based medications, but she took other medications that affected\nher driving ability. But, the staff said that she could still drive, so she was unable to obtain post\ntransportation. When asked how the WTB could help his transition, another Warrior replied,\n\xe2\x80\x9cDon\xe2\x80\x99t hold grudges against Soldiers. I live 45 minutes away and must drive and it can be\ndifficult to make it to the base in the morning.\xe2\x80\x9d\n\nPerforming Assigned Duties\nWarriors at the Fort Drum WTB were assigned military duties that they performed in addition to\ntheir formations, medical processing, appointments, and other requirements. They expressed\nconcern that consideration of their individual medical conditions was not given when developing\nand assigning those military duties.\n\nOne Warrior explained that in his experience, staff would not consider exempting a Warrior from\nnight duty even if they were taking certain medications. The Warrior stated that certain staff\neven encouraged Warriors to not take sleep medications if they were required to stand night duty.\nAnother Warrior who had difficulty sleeping remarked that if Warriors failed to be on time for\nformations, they would be punished with a night duty assignment at the barracks. He stated that\nthis seemed contrary to what was required for their healing and recovery. A third Warrior\nexplained that although he felt that CQ duty was \xe2\x80\x9cridiculous,\xe2\x80\x9d they were required to \xe2\x80\x9cpull duty\xe2\x80\x9d\nthree times per week and sometimes over the weekends. He added that there were guys pulling\nduty who were medicated and sometimes \xe2\x80\x9ccould not remember where they were.\xe2\x80\x9d\n\nAnother Warrior stated that she personally experienced a situation where squad leaders did not\nconsider physical limitations of the wounded when assigning military duties. Specifically, the\nWTB recently executed a barracks move and she was not offered any assistance, even though her\nprofile stated that she should not lift more than 20 pounds. She stated that the WTB should do a\nbetter job screening personnel for WTB positions to make sure they are the right people for this\njob.\n\nFinally, during a group interview, Warriors shared that CQ duty was required for all Warriors;\neven those who experienced problems with medications, physical stress, and exposure to\nsituations that may affect those with PTSD (e.g. a Soldier badly cutting himself in his barracks\nroom).\n\n\n\n\n48\n Charge of Quarters (CQ) describes tasked duty in which a Service member guards the front entrance to the\nbarracks, and handles his unit\xe2\x80\x99s administrative matters after hours.\n\n\n\n\n 80\n\x0cPhysical Training Events\nWarriors\xe2\x80\x99 eligibility for assignment or attachment to a WTU requires a temporary profile, or an\nanticipated profile, for more than 6 months with duty limitations that preclude the Soldier from\ntraining for or contributing to unit mission accomplishment. As such, the Warriors we\ninterviewed were given profiles by a medical professional that were consistent with the wounds,\nillnesses, or injuries that brought them to the WTB.\n\nSeveral Warriors mentioned their concerns about how staff violated, or at least failed to consider,\nWarriors\xe2\x80\x99 medical profiles. They also voiced their concerns about how violations of their\nmedical profiles opened them up to re-injury and/or further injury, creating the possibility of\nprolonging their transition processes and adding to their time at the WTB. The following\ncomments were provided by Warriors about medical profile management:\n \xe2\x80\xa2 A senior Warrior explained that in his opinion, profile restrictions during physical\n training were \xe2\x80\x9cpushed to the limits.\xe2\x80\x9d For example, if the profile was \xe2\x80\x9cwalk only,\xe2\x80\x9d staff\n required Warriors to walk on uneven ground around the soccer field. The Warrior\n commented that the leadership made their own interpretation of what a Warrior\xe2\x80\x99s profile\n and corresponding restrictions meant.\n \xe2\x80\xa2 Another Warrior said that the staff asked him to do things that violated his profile. When\n a profile said that one cannot sit for more than 15 minutes, staff would say, \xe2\x80\x9cThen get up\n after 14 minutes.\xe2\x80\x9d The Warrior also stated that he understood that accountability in a\n WTB was important, but asked, \xe2\x80\x9cDo you have to do PT [physical training] every day for\n accountability? You are told that you need to take it easy, but then they treat us like we\n are all return to duty [Soldiers]. They are trying to run this unit to meet Army standards\n like a real unit.\xe2\x80\x9d\n \xe2\x80\xa2 A third Warrior questioned why Soldiers transitioning to civilian life had to go to\n physical training daily, especially those with neck braces, canes, or other profiles.\n \xe2\x80\xa2 A different Warrior commented that some Soldiers were on profiles restricting them to\n only walk about one-tenth of a mile before they were required to sit and rest. But, when\n this happened, the staff yelled at them for sitting.\n\nA few Warriors had considered the issue so thoroughly they provided recommendations on how\nto meet the intent of physical training while considering the physical limitations of the Warriors.\nThese recommendations included having Warriors complete physical training on their own\nwithin their own limitations; and during a group interview, Warriors recommended assigning\ntrainers to adapt physical training for Warriors so they could meet physical fitness standards.\n\nFamily Concerns\nWarriors stated that their families were a significant part of their healing and recovery and family\nmembers were often not fully integrated into their transition. Specifically, Warriors expressed\nthat:\n \xe2\x80\xa2 A dedicated family member orientation was absent in the unit\n\n\n\n\n 81\n\x0c \xe2\x80\xa2 Non-medical attendants 49 were generally discouraged, eligibility criteria were unclear,\n and reimbursements for those with non-medical attendants were delayed\n\nFamily Member Orientation\nWarriors explained that personal support from their family members, significant others, and\nfriends was important to their overall healing and transition. Although many of the Fort Drum\nWTB Warriors were from Fort Drum units and had personal support in the immediate area, other\nWarriors were from different parts of the state and country and had no local support system.\nRegardless of their personal situations, Warriors stressed the importance of having some sort of\npersonal support structure involved in their transition.\n\nGeneral comments about family support included ones made during a group interview, where the\nconsensus was that information was generally not provided to spouses and support for families\nwas lacking. During an individual interview, a Warrior said that the unit did not consider those\nWarriors who did not have a support group in the immediate vicinity, and that there was no\nthought given to communicating with and helping their families. It was the opinion of another\nWarrior that the WTB was not meeting the families\xe2\x80\x99 needs and specifically didn\xe2\x80\x99t consider the\nfamilies who weren\xe2\x80\x99t local.\n\nWarrior stories included one who shared that her family had been not integrated into her\nrecovery and transition, and therefore, the family was sent home. Her spouse was never called\nand there was no outreach from the WTB. The spouse had attempted to talk to people at the\nWTB to obtain information about his wife, but the individuals spoken to would just say, \xe2\x80\x9cI don\xe2\x80\x99t\nknow\xe2\x80\x9d when asked any questions. The Warrior stated that the entire process had put a terrible\nstrain on their marriage.\n\nAnother Warrior believed that his family would be more involved with his care if they were\nclose to Fort Drum, but they were in another state. He still thought it would be helpful if they\nreached out to his family to at least offer support or suggestions for dealing with his conditions.\n\nSeveral Warriors had suggestions for how to better involve families, significant others, and\nfriends into their recovery process. One Warrior recommended that the WTB involve the total\nfamily (not just spouses) and be more supportive of the Soldiers who were single. Another\nWarrior believed that spouses should be integrated into the process and more outreach should be\nconducted so the spouses knew what the Soldiers were going through. Finally, a Warrior\nsuggested that there be more classes/groups for spouses and children of Warriors.\n\nNon-Medical Attendants\nIt was apparent during multiple interviews that criteria for obtaining a non-medical attendant\nwere unclear, obtaining them was generally discouraged, and reimbursements for those with\nnon-medical attendants were delayed.\n\n\n49\n When the need arises for non-medical care and assistance during a Warrior\xe2\x80\x99s treatment at a medical treatment\nfacility, medical authorities will authorize a non-medical attendant to assist the Soldier.\n\n\n\n\n 82\n\x0cFor example, there appeared to be some misunderstanding of the program and what qualified a\nWarrior to have a non-medical attendant. When asked about how his personal support structure\nwas involved in his activities at the WTB, a Warrior replied, \xe2\x80\x9cI am single and when my family\nvisited me I paid for them to come. I have no idea about the non-medical attendant program and\ndid not have one.\xe2\x80\x9d\n\nAnother Warrior reported that the WTB did not seem supportive of the non-medical attendant\nprogram. This Warrior was also single and her family lived in New York City and was unable to\nparticipate. The Warrior tried to get permission to have a family member become her non-\nmedical attendant, but the request was denied by the WTB. The Warrior added that she was not\nprovided an explanation as to why her request was denied.\n\nFinally, during a group interview, several Warriors explained the frustrations they encountered\nwhen trying to obtain reimbursements for their non-medical attendants. First, they were not\naware as to how non-medical attendants should be paid (through TRICARE or the Defense\nTravel System); and second, they explained that reimbursements for non-medical attendants\ncould take up to three months.\n\nConclusion\nWarriors provided positive comments about their access to medical care and certain aspects of\ninstallation support. However, they also expressed many concerns about other aspects of their\nrecovery and transition that we believe warranted specific mention. Because several of these\nthemes were addressed in previous Observations, we are not making formal recommendations\nabout the Warriors\xe2\x80\x99 concerns expressed in this section. However, we do recommend that the\nCommanding General, 10th Mountain Division, Warrior Transition Command, Fort Drum\nleadership, Fort Drum MEDDAC leadership and staff, and WTB management and staff review\nthe concerns voiced by Warriors to more effectively support their healing and transition.\n\n\n\n\n 83\n\x0cThis Page Intentionally Left Blank\n\n\n\n\n 84\n\x0cAppendix A. Scope, Methodology, and\nAcronyms\nWe announced and began this assessment on April 16, 2010. Based on our objectives, the\nassessment was planned and performed to obtain sufficient evidence to provide a reasonable\nbasis for our observations, conclusions, and recommendations. The team used professional\njudgment to develop reportable themes drawn from multiple sources, to include interviews with\nindividuals and groups of individuals, observations at visited sites, and reviews of documents.\n\nWe visited the Medical Department Activity (MEDDAC) and the 3rd Battalion, 85th Mountain\nInfantry Regiment [hereafter, the Fort Drum Warrior Transition Battalion (WTB)] located at Fort\nDrum, New York, from August 2-12, 2010. During our 2-week site visit to that location, we\nobserved battalion operations and formations; viewed living quarters, campus facilities, and\nselected operations at the medical facility; and examined pertinent documentation. We also\nperformed meetings and interviews \xe2\x80\x93 ranging from unit commanders, staff officers, and WTB\nstaff, to civilian staff and contractors \xe2\x80\x93 as shown below:\n \xe2\x80\xa2 MEDDAC Commander and Sergeant Major \xe2\x80\xa2 Primary care managers\n \xe2\x80\xa2 Deputy Commander for Clinical Services \xe2\x80\xa2 Nurse case managers\n \xe2\x80\xa2 Deputy Commander for Administration \xe2\x80\xa2 Behavioral Health Clinical\n \xe2\x80\xa2 Deputy Commander for Nursing Services Psychologists\n \xe2\x80\xa2 WTB Commander, Sergeant Major, and \xe2\x80\xa2 Behavioral Health Licensed Clinical\n Executive Officer Social Workers\n \xe2\x80\xa2 WTB Operations and Personnel Officers \xe2\x80\xa2 Occupational Therapists\n \xe2\x80\xa2 WTB Surgeon \xe2\x80\xa2 Soldier and Family Assistance\n \xe2\x80\xa2 WTB Pharmacist Center Director\n \xe2\x80\xa2 WTB Chaplain \xe2\x80\xa2 Physical Evaluation Board Liaison\n \xe2\x80\xa2 WTB Company Commanders Officer\n \xe2\x80\xa2 WTB First Sergeants \xe2\x80\xa2 Ombudsman\n \xe2\x80\xa2 WTB Platoon Sergeants \xe2\x80\xa2 Family Readiness Support Assistant\n \xe2\x80\xa2 WTB Squad Leaders \xe2\x80\xa2 Families of Recovering Service\n Members\nFurther, we performed interviews with WTB recovering Service members, to include\n96 individual interviews with Soldiers, and 5 group interviews with additional Soldiers grouped\nby rank. The 5 group interviews were comprised of the following participants:\n \xe2\x80\xa2 4 Army Officer/Senior Enlisted = 4 Active Component\n \xe2\x80\xa2 6 Senior Enlisted = 2 Active Component, 2 National Guardsmen, 2 Reservists\n \xe2\x80\xa2 8 Army E5 \xe2\x80\x93 E7 = 7 Active Component, 1 Reservist\n \xe2\x80\xa2 6 Army E1 \xe2\x80\x93 E4 = 6 Active Component\n \xe2\x80\xa2 2 Army E1 \xe2\x80\x93 E4 = 2 National Guardsmen\n\nWe prepared standardized sets of questions that were used during individual and group sessions,\nwhich were tailored to the type or group of personnel being interviewed. Those interviews\nprimarily included but were not limited to recovering Soldiers and members of the Triad of Care\n\n\n\n 85\n\x0c\xe2\x80\x93 primary care managers, nurse case managers, and WTB squad leaders. The standardized\ninterview questions for these groups included among others, topics such as access to care, use of\nComprehensive Transition Plans, responsibilities for Triad of Care members, working\nrelationships amongst the Triad of Care members, and discipline issues within the WTB.\n\nUse of Technical Assistance and Computer-Processed Data\nWe did not use computer-processed data to perform this assessment. However, analysts from the\nDoD Office of the Inspector General, Deputy Inspector General for Audit, Quantitative Methods\nand Analysis Division, used a simple random sample approach to determine the number of Army\nWarriors in Transition (Warriors) we should interview at the Fort Drum WTB to obtain a\nrepresentative sample. The random sample was used to avoid any biases that might have been\nintroduced by selecting interviewees non-statistically.\n\nThe analysts used a list of Warriors identified by name, rank, and WTB company assignment\n(Alpha Company, Bravo Company, and Headquarters Company), which we obtained from the\nFort Drum WTB. As of June 28, 2010, there were 300 Soldiers at the Fort Drum WTB,\ncomprising the total population from which we drew our random sample.\n\nThe analysts used a program called the Statistical Analysis System and its internal random\nnumber generator to assign random values to each individual, then sorted all 300 Soldiers into\nrandom number sequence. Using this method, the analysts calculated a sample size of\n56 Warriors for individual interviews. The sample size is based on a 90 percent confidence\nlevel, a planned margin of error of 10 percent, and the statistically conservative assumption of a\n50 percent error rate.\n\nThe team used this approach to first determine whether any reportable themes (noteworthy\npractices, good news, issues, concerns, and challenges) were identified by those most impacted\nby their assignment to the WTB: the Warriors. We met and interviewed others \xe2\x80\x93 ranging from\nunit commanders, staff officers, and WTB staff, to civilian staff and contractors \xe2\x80\x93 to corroborate\nthe identified themes or to identify other reportable themes not readily known to the Warriors.\n\nOn July 7, 2010, we provided the list of Warriors to be interviewed from our randomly generated\nsample to the Fort Drum WTB. With a requirement of 56 interviews, we advised the Fort Drum\nWTB that those 56 interview slots should be filled with Warriors from the primary list, assigned\nvalues 1 through 65 in random order sequence until all interview slots were full. If the WTB was\nunable to fill all 56 slots with the primary sample provided, we provided a list of 34 alternates\nthat could be used (for a total of 99 randomly selected Warriors). We further advised the Fort\nDrum WTB that a justification must be provided for any individuals in that sequence that were\nunable to attend an interview for mitigating reasons such as convalescent leave, annual leave,\nmedical appointments, physical impairments, logistical constraints, etc. Below are the results\nfrom our interviews with individual Warrior\xe2\x80\x99s at the Fort Drum WTB.\n\n\n\n\n 86\n\x0cOf the 99 Warriors statistically selected with random order numbers 1 through 99:\n \xe2\x80\xa2 46 Warriors from the primary list of 65 were interviewed;\n \xe2\x80\xa2 21 Warriors from the alternate list of 34 were interviewed; and\n \xe2\x80\xa2 32 Warriors were excused.\nThe Fort Drum WTB provided an acceptable excuse for all the Warriors who were unavailable\nfor the interviews. However, due to some confusion and miscommunication the WTB squad\nleaders brought in 29 additional Warriors for interviews. As a result, we ended up interviewing a\ntotal of 96 individual Army Warriors at the Fort Drum WTB. We believe that the information\nobtained from the 67 individuals selected as part of our original random sample provided a\nreasonable indication of the views of the total population, and we found that the views provided\nby the additional 29 Warriors interviewed mirrored those of the statistically selected Warriors.\n\nAcronym List\nThe following acronyms were used in this report.\n\nAHLTA Armed Forces Health Longitudinal Technology Application\nAKO Army Knowledge Online\nCONUS Continental United States\nCQ Charge of Quarters\nCTP Comprehensive Transition Plan\nDVA Department of Veterans Affairs\nMEB Medical Evaluation Board\nMEDDAC Medical Department Activity\nMOS Military Occupational Specialty\nMTF Military Treatment Facility\nNCO Non-Commissioned Officer\nPDA Personal Digital Assistant\nPDTS Pharmacy Data Transaction Service\nPT Physical Training\nPTSD Post Traumatic Stress Disorder\nSFAC Soldier and Family Assistance Center\nTBI Traumatic Brain Injury\nTRICARE Tri-Service Medical Care\nWT Warrior in Transition\nWTB Warrior Transition Battalion\nWTC Warrior Transition Command\nWTU Warrior Transition Unit\n\n\n\n\n 87\n\x0cThis Page Intentionally Left Blank\n\n\n\n\n 88\n\x0cAppendix B. Summary of Prior Coverage\nDuring the last 6 years, there has been a host of prior coverage of DoD and Department of\nVeterans Affairs (DVA) health care services and management, disability programs, and benefits.\nThe Government Accountability Office (GAO), the Department of Defense Inspector General\n(DOD IG), and the Naval Audit Service have issued 17 reports specific to DoD Warrior Care and\nTransition Programs. Unrestricted GAO reports can be accessed over the Internet at\nhttp://www.gao.gov. Unrestricted DOD IG reports can be accessed at\nhttp://www.dodig.mil/PUBS/index.html. Naval Audit Service reports are not available over the\nInternet.\n\nGAO\nGAO Report No. GAO-11-551, \xe2\x80\x9cDefense Health Care: DOD Lacks Assurance that Selected\nReserve Members Are Informed about TRICARE Reserve Select,\xe2\x80\x9d June 3, 2011\n\nGAO Report No. GAO-11-572T, \xe2\x80\x9cFederal Recovery Coordination Program Enrollment,\nStaffing, and Care Coordination Pose Significant Challenges,\xe2\x80\x9d May 13, 2011\n\nGAO Report No. GAO-11-633T, \xe2\x80\x9cMilitary and Veterans Disability System: Worldwide\nDeployment of Integrated System Warrants Careful Monitoring,\xe2\x80\x9d May 4, 2011\n\nGAO Report No. GAO-11-32, \xe2\x80\x9cVA Health Care: VA Spends Millions on Post-Traumatic Stress\nDisorder Research and Incorporates Research Outcomes into Guidelines and Policy for Post-\nTraumatic Stress Disorder Services,\xe2\x80\x9d January 24, 2011\n\nGAO Report No. GAO-11-69, \xe2\x80\x9cMilitary and Veterans Disability System: Pilot Has Achieved\nSome Goals, but Further Planning and Monitoring Needed,\xe2\x80\x9d December 6, 2010\n\nGAO Report No. GAO-09-357, \xe2\x80\x9cArmy Health Care: Progress Made in Staffing and Monitoring\nUnits that Provide Outpatient Case Management, but Additional Steps Needed,\xe2\x80\x9d April 20, 2009\n\nGAO Report No. GAO-09-31, \xe2\x80\x9cDefense Health Care: Additional Efforts Needed to Ensure\nCompliance with Personality Disorder Separation Requirements,\xe2\x80\x9d October 31, 2008\n\nGAO Report No. GAO-08-635, \xe2\x80\x9cFederal Disability Programs: More Strategic Coordination\nCould Help Overcome Challenges to Needed Transformation,\xe2\x80\x9d May 20, 2008\n\nGAO Report No. GAO-08-615, \xe2\x80\x9cDOD Health Care: Mental Health and Traumatic Brain Injury\nScreening Efforts Implemented, but Consistent Pre-Deployment Medical Record Review\nPolicies Needed,\xe2\x80\x9d May 30, 2008\n\nGAO Report No. GAO-08-514T, \xe2\x80\x9cDOD and VA: Preliminary Observations on Efforts to\nImprove Care Management and Disability Evaluations for Servicemembers,\xe2\x80\x9d February 27, 2008\n\n\n\n\n 89\n\x0cGAO Report No. GAO-07-1256T, \xe2\x80\x9cDOD and VA: Preliminary Observations on Efforts to\nImprove Health Care and Disability Evaluations for Returning Servicemembers,\xe2\x80\x9d September 26,\n2007\n\nGAO Report No. GAO-06-397, \xe2\x80\x9cPost-Traumatic Stress Disorder: DOD Needs to Identify the\nFactors Its Providers Use to Make Mental Health Evaluation Referrals for Servicemembers,\xe2\x80\x9d\nMay 11, 2006\n\nDOD IG\nDOD IG Report No. SPO-2011-004, \xe2\x80\x9cAssessment of DOD Wounded Warrior Matters \xe2\x80\x93 Fort\nSam Houston,\xe2\x80\x9d March 17, 2011\n\nDOD IG Report No. IE-2008-005, \xe2\x80\x9cDoD/VA Care Transition Process for Service Members\nInjured in Operation Iraqi Freedom/Operation Enduring Freedom,\xe2\x80\x9d June 12, 2008\n\nDOD IG Report No. IE-2008-003, \xe2\x80\x9cObservations and Critique of the DoD Task Force on\nMental Health,\xe2\x80\x9d April 15, 2008\n\nArmy\nArmy Audit Report No. A-2011-0008-IEM, \xe2\x80\x9cArmy Warrior Care and Transition Program,\xe2\x80\x9d\nOctober 21, 2010\n\nNavy\nNaval Audit Service Report No. N2009-0046, \xe2\x80\x9cMarine Corps Transition Assistance Management\nProgram - Preseparation Counseling Requirement,\xe2\x80\x9d September 15, 2009\n\nNaval Audit Service Report No. N2009-0009, \xe2\x80\x9cDepartment of the Navy Fisher Houses,\xe2\x80\x9d\nNovember 4, 2008\n\n\n\n\n 90\n\x0cAppendix C. Reporting Other Issues\nWe are performing the Assessment of DoD Wounded Warrior Matters at multiple Army\nlocations and plan to report on each location separately. This report focused on whether the\nprograms for the care, management, and transition of Warriors in Transition at the Fort Drum\nWarrior Transition Battalion (WTB), Watertown, New York, were managed effectively and\nefficiently.\n\nWe also plan to report on issues, concerns, and challenges that were common amongst most, if\nnot all, Army Warrior Transition Units at the conclusion of our Army site visits. That report or\nmultiple reports will be provided to appropriate organizations to provide information on or\nidentify corrective actions addressing those issues, concerns, and challenges. Those\norganizations may include but are not limited to the Office of the Deputy Under Secretary of\nDefense for Wounded Warrior Care and Transition Policy; the Assistant Secretary of the Army\nfor Manpower and Reserve Affairs; the U.S. Army Medical Department, Office of the Surgeon\nGeneral; and the U.S. Army Medical Command, Warrior Transition Command.\n\nThis appendix captures issues, concerns, and challenges we identified at the Fort Drum WTB\n(with corresponding page references noted) that may likely be included in an additional report(s).\nWe may issue an additional report(s) before the conclusion of our Army site visits if we consider\nthese other matters of interest urgent.\n\n Table 1. Potential Items for Future Reports\n\n Report\n Issue, Concerns, and Challenges\n Reference(s)\n Warrior Access to Specialty Medical Care Page 19, 72\n Medication Management for Warriors Page 22, 73,\n 74\n Armed Forces Health Longitudinal Technology Medication Module Interface Page 24\n Definition of a Successful Transition End-State for Warriors Page 31, 69-\n 71\n Comprehensive Transition Plans (Requirements and Administration) Page 51-54,\n 74-75\n Non-Medical Attendant Criteria Page 78\n Eligibility of Warriors for Warrior Transition Units Page 41\n Experience, Selection, and Training of Some Staff Page 38\n Warriors Safety, Profiles and Medical Recommendations Page 45, 75\n Medical Records Management for Warriors Page 73\n Additional Post-Traumatic Stress Disorder and Traumatic Brain Injury Training Page 38\n\n\n\n 91\n\x0cThis Page Intentionally Left Blank\n\n\n\n\n 92\n\x0cAppendix D. Army Guidance for Warrior\nTransition Units\nArmy guidance for the care and management of Warriors is contained in the \xe2\x80\x9cWarrior Transition\nUnit Consolidated Guidance (Administrative),\xe2\x80\x9d March 20, 2009 (hereafter, \xe2\x80\x9cConsolidated\nGuidance\xe2\x80\x9d). It was revised in March 20, 2009 to update policies and guidance for the care and\nmanagement of Warriors. According to the Consolidated Guidance, a Warrior is a Soldier who\nis assigned or attached to a Warrior Transition Unit (WTU) whose primary mission is to heal.\n\nThe Consolidated Guidance addresses specific policy guidance regarding assignment or\nattachment to a WTU, the process for the issuance of orders to Soldiers, and other administrative\nprocedures for Soldiers being considered for assignment or attachment to a WTU. The\npublication also summarizes existing personnel policies for family escort, non-medical attendant,\nhousing prioritization, leave, and other administrative procedures for Soldiers assigned or\nattached to a WTU. Further, it provides information on the Physical Disability Evaluation\nSystem for Soldiers processing through this system.\n\nPertinent Federal statutes, regulations, and other standards governing these programs and\nservices are cited throughout the Consolidated Guidance and are collated in a reference section.\nThe document also states that, previously, there was no overarching Army collective or\nregulatory administrative guidance for WTUs.\n\nThe authority for WTUs is provided by:\n \xe2\x80\xa2 Department of the Army EXORD [Execute Order] 118-07 Healing Warriors,\n June 21, 2007\n \xe2\x80\xa2 Department of the Army FRAGO [Fragmentary Order] 1 to EXORD 118-07 Healing\n Warriors, August 16, 2007.\n \xe2\x80\xa2 Department of the Army FRAGO 2 to EXORD 118-07 Healing Warriors,\n December 14, 2007.\n \xe2\x80\xa2 Department of the Army FRAGO 3 to EXORD 118-07 Healing Warriors, July 1, 2008.\nThe overview of the WTU program is stated as:\n \xe2\x80\xa2 Vision \xe2\x80\x93 to create an institutionalized, Soldier-centered WTU program that ensures\n standardization, quality outcomes, and consistency with seamless transitions of the\n Soldier\xe2\x80\x99s medical and duty status from points of entry to disposition.\n \xe2\x80\xa2 Goal \xe2\x80\x93 to expeditiously and effectively evaluate, treat, return to duty, and/or\n administratively process out of the Army, and refer to the appropriate follow-on\n healthcare system, Soldiers with medical conditions.\n \xe2\x80\xa2 Intent \xe2\x80\x93 to provide Soldiers with optimal medical benefit, expeditious and comprehensive\n personnel and administrative processing, while receiving medical care. The Army will\n take care of its Soldiers through high quality, expert medical care. For those who will\n leave the Army, the Army will administratively process them with speed and compassion.\n The Army will assist with transitioning Soldiers\xe2\x80\x99 medical needs to the Department of\n Veterans Affairs for follow-on care.\n\n\n\n 93\n\x0cThe objectives of the WTU program are stated as:\n \xe2\x80\xa2 \xe2\x80\x9cAddress and ensure resolution on all aspects of personnel administration and processing\n for the WT [a Warrior] from points of entry through disposition, to include processing\n through the Physical Disability Evaluation System (PDES). Final disposition occurs\n when the WT is determined/found medically cleared for duty or the PDES process is\n complete, including appeals.\xe2\x80\x9d\n \xe2\x80\xa2 \xe2\x80\x9cAddress and ensure resolution on the administrative aspect of medical management for\n the WT, including Tri-Service Medical Care (TRICARE) and/or Veterans Health\n Administration follow on medical care.\xe2\x80\x9d\n \xe2\x80\xa2 \xe2\x80\x9cAddress and ensure resolution on command and control (C2), including logistical\n support, for the WT assigned or attached to garrison units, Medical Treatment Facilities\n (MTF), Warrior Transition Units (WTU), and Community-Based Warrior Transition Unit\n (CBWTU).\xe2\x80\x9d 50\n \xe2\x80\xa2 \xe2\x80\x9cAddress and ensure resolution on the accountability and tracking of the WT in real time\n as he/she progresses through the WT process and if necessary, the PDES process.\xe2\x80\x9d\nThe Mission Essential Task List of the WTU program states that the Army will\xe2\x80\x93\n \xe2\x80\xa2 \xe2\x80\x9cProvide Command/Control and Administrative Support (including pay) trained to focus\n on special needs of WT Soldiers.\xe2\x80\x9d\n \xe2\x80\xa2 \xe2\x80\x9cProvide high quality, expert medical care, and case management support - Primary Care\n Provider, Case Manager, Behavioral Health, Specialty Providers.\xe2\x80\x9d\n \xe2\x80\xa2 \xe2\x80\x9cAdministratively process with speed and compassion those who will leave the Army.\xe2\x80\x9d\n \xe2\x80\xa2 \xe2\x80\x9cFacilitate transition of separating and REFRAD\xe2\x80\x99ing [Release From Active Duty]\n Soldiers to the VHA [Veterans Health Administration] or TRICARE for follow-on care.\xe2\x80\x9d\nThe WTU concept of operations is stated as:\n \xe2\x80\xa2 \xe2\x80\x9cProvide Soldiers high-quality living conditions.\xe2\x80\x9d\n \xe2\x80\xa2 \xe2\x80\x9cPrevent unnecessary procedural delays.\xe2\x80\x9d\n \xe2\x80\xa2 \xe2\x80\x9cEstablish conditions that facilitate Soldier\xe2\x80\x99s healing process physically, mentally, and\n spiritually.\xe2\x80\x9d\n \xe2\x80\xa2 \xe2\x80\x9cProvide a Triad of Warrior Support that consist of Platoon Sergeant/Squad Leader, Case\n Manager (CM), and Primary Care Manager (PCM), working together to ensure advocacy\n for WT Soldiers, continuity of care and a seamless transition in the force or return to a\n productive civilian life.\xe2\x80\x9d\n\n\n\n\n50\n Community-Based WTUs are primarily for Reserve Component Soldiers. Community-Based WTU is a program\nthat allows Warriors to live at home and perform duty at a location near home while receiving medical care from the\nTri-Service Medical Care network, the Department of Veterans Affairs, or Military Treatment Facility providers in\nor near the Soldier\xe2\x80\x99s community.\n\n\n\n\n 94\n\x0cAppendix E. 10th Mountain Division Comments\n\n\n\n\n 95\n\x0c96\n\x0cFort Drum Medical Department Activity and\nWarrior Transition Battalion Comments\n\n\n\n\n 97\n\x0c98\n\x0c99\n\x0c100\n\x0c101\n\x0c102\n\x0c103\n\x0c104\n\x0c Inspector General Special Plans & Operations\n United States Department of Defense Provide assessment oversight that addresses priority national security\n objectives to facilitate informed, timely decision-making by senior\n leaders of the DOD and the U.S. Congress.\n Vision\n One professional team strengthening the integrity, efficiency,\n and effectiveness of the Department of Defense General Information\n programs and operations.\n Forward questions or comments concerning this assessment and report and other\n Mission activities conducted by the Office of Special Plans & Operations to spo@dodig.mil\n\n\n Promote integrity, accountability, and improvement of Department Deputy Inspector General for Special Plans & Operations\n\n Department of Defense Inspector General\n\n of Defense personnel, programs and operations to support the\n 400 Army Navy Drive\n\n Department's mission and serve the public interest.\n Arlington, VA 22202-4704\n\n\n\n\n\n Visit us at www.dodig.mil\n\n\n DEPARTMENT OF DEFENSE\n\n\n\n hot line\nThe Department of Defense Inspector General is an independent, objective agency within the U.S. Department\nof Defense that was created by the Inspector General Act of 1978, as amended. DoD IG is dedicated to serving make a difference Report www.dodig.mil/hotline\nthe warfighter and the taxpayer by conducting audits, investigations, inspections, and assessments that result in 800.424.9098\nimprovements to the Department. DoD IG provides guidance and recommendations to the Department of Fraud, Waste, Mismanagement, Abuse of Authority\n Suspected Threats to Homeland Security\nDefense and the Congress. Defense Hotline,The Pentagon, Washington, DC 20301-1900 Unauthorized Disclosures of Classified Information\n\x0c\x0c"