DOD and VA Health Care: Action Needed to Strengthen Integration across Care Coordination and Case Management Programs
Published: 2011-10-06T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: In a May 2011 testimony before this subcommittee (GAO-11-572T), based on a March 2011 report (GAO-11-250), GAO highlighted challenges for the Federal Recovery Coordination Program (FRCP), developed by the Departments of Defense (DOD) and Veterans Affairs (VA) to assist some of the most severely wounded, ill, and injured servicemembers, veterans, and their families. Specifically, GAO reported on challenges in FRCP enrollment, staffing needs, caseloads, and placement locations. GAO also cited challenges faced by the FRCP when coordinating with other VA and DOD programs, including DOD's Recovery Coordination Program (RCP), which can result in duplication of effort and enrollee confusion. In this statement, GAO examines the status of DOD and VA's efforts to (1) implement GAO's March 2011 recommendations and (2) identify and analyze potential options to functionally integrate the FRCP and RCP. This statement is based on GAO's March 2011 report and updated information obtained in September 2011.
section_title: What GAO Found
paragraphs: VA has made progress addressing each of the recommendations from GAO's March 2011 report on program management issues related to enrollment decisions, caseloads, and program staffing needs and placement decisions for the Federal Recovery Coordinators (FRC) the FRCP uses to coordinate care. These recommendations were directed to the Secretary of VA because VA maintains administrative control of the program, and DOD and VA were asked to provide a response to this subcommittee about how the departments could jointly implement these recommendations. DOD has provided limited assistance to VA with the implementation of GAO's recommendation about enrollment through an e-mail communication about referrals to the FRCP to the commanders of the military services' wounded warrior programs. Despite this effort, however, VA officials stated that they have not noticed any change in referral numbers or patterns from DOD since the e-mail was sent. DOD and VA have made little progress reaching agreement on options to better integrate the FRCP and RCP, although they have made a number of attempts to address this issue. Most recently, DOD and VA experienced difficulty jointly providing potential options for integrating these programs in response to this subcommittee's May 26, 2011, request to the deputy secretaries, who co-chair the DOD and VA Wounded, Ill, and Injured Senior Oversight Committee (Senior Oversight Committee). On September 12, 2011--almost 3 months after the subcommittee requested a response--the co-chairs of the Senior Oversight Committee issued a joint letter that stated that the departments are considering several options to maximize care coordination resources. However, these options have not been finalized and were not specifically identified or outlined in the letter. The two departments have made prior attempts to jointly develop options for improved collaboration and potential integration of the FRCP and RCP, but despite the identification of various options, no final decisions to revamp, merge, or eliminate programs have been agreed upon. This lack of progress illustrates DOD's and VA's continued difficulty in collaborating to resolve duplication and overlap between care coordination programs. Furthermore, as we have previously reported, there are numerous programs in addition to the FRCP and RCP that provide similar services to recovering servicemembers and veterans-- many of whom are enrolled in more than one program and therefore have multiple care coordinators and case managers. We found that inadequate information exchange and poor coordination between these programs has resulted in not only redundancy, but confusion and frustration for enrollees, particularly when care coordinators and case managers duplicate or contradict one another's efforts. Consequently, the intended purpose of these programs--to better manage and facilitate care and services--may actually have the opposite effect. We recommend that the Secretaries of DOD and VA direct the Senior Oversight Committee to expeditiously develop and implement a plan to strengthen functional integration across all DOD and VA care coordination and case management programs, including the FRCP and RCP, to reduce redundancy and overlap. We obtained oral comments on the content of this statement from both DOD and VA officials, and we incorporated their comments as appropriate.

section_title: Letter
paragraphs: I am pleased to be here today as you discuss the actions taken by the  Departments of Defense (DOD) and Veterans Affairs (VA) to address  issues of concern that were raised during your May 13, 2011, hearing on  the Federal Recovery Coordination Program (FRCP). Our statement for  that hearing, based on our March 2011 report, outlined several  implementation issues for the FRCP, which was jointly implemented by  DOD and VA to assist some of the most severely wounded, ill, and  injured servicemembers, veterans, and their families with access to care,  services, and benefits. Specifically, we reported on challenges faced by  FRCP leadership when identifying potentially eligible individuals for  program enrollment and determining staffing needs and placement  locations. We also cited challenges faced by the FRCP when coordinating  with other VA and DOD care coordination and case management  programs that support wounded servicemembers, veterans, and their  families, including DOD’s Recovery Coordination Program (RCP).  Specifically, we reported that poor coordination among these programs  can result in duplication of effort and enrollee confusion because these  programs often provide similar services and individuals may be enrolled  in more than one program.
Based on the concerns raised during the May 2011 hearing, your  subcommittee requested that DOD and VA provide a detailed response  on how they plan to jointly implement the recommendations to improve  FRCP management that were outlined in our report. You also requested  that the two departments analyze potential options for integrating the  FRCP and RCP under a single administrative umbrella to reduce  redundancy and to better fulfill the goal of establishing a seamless  transition for wounded servicemembers and their families. Although a  response was requested by June 20, 2011, the departments had not  responded by September 2, 2011, when this subcommittee announced  that it intended to hold an oversight hearing on continuing concerns about  the care coordination issues of the FRCP and RCP.
Our review of DOD’s and VA’s care coordination and case management  programs, including the FRCP and RCP, is part of a body of ongoing  work that is focused on the continuity of care for recovering  servicemembers and veterans. My testimony today addresses the status  of DOD and VA’s efforts to (1) implement the recommendations to  improve FRCP management from our March 2011 report and (2) identify  and analyze potential options to integrate the FRCP and the RCP as  requested by this subcommittee.
We conducted the original performance audit for our 2011 report from  September 2009 through March 2011 and obtained updated data and  additional information in September 2011 for this testimony. Specifically,  to obtain information on the status of the recommendations contained in  our March 2011 report, we reviewed documentation provided by VA and  interviewed the Acting Executive Director for the FRCP. Although our  recommendations were directed to VA, which administers the program,  we also obtained information from DOD officials that described to what  extent they have worked with VA to implement them based on your  request for the departments to work together. To obtain information  regarding the status of DOD and VA’s efforts aimed at identifying and  analyzing options for integrating or otherwise revamping the FRCP and  RCP, we conducted interviews with DOD and VA officials and reviewed  documents provided by both departments. We also obtained updated  information about DOD’s and VA’s care coordination and case  management programs by reviewing program documentation and by  interviewing DOD and VA program officials.
We conducted our work for this testimony in accordance with generally  accepted government auditing standards. Those standards require that  we plan and perform the audit to obtain sufficient, appropriate evidence to  provide a reasonable basis for our findings and conclusions based on our  audit objectives. We believe that the evidence obtained provides a  reasonable basis for our findings and conclusions based on our audit  objectives.
subsections: section_title: Background
paragraphs: The FRCP was jointly developed by DOD and VA following critical media  reports of deficiencies in the provision and coordination of outpatient  services at Walter Reed Army Medical Center. It was established to assist  severely wounded, ill, and injured Operation Enduring Freedom (OEF)  and Operation Iraqi Freedom (OIF) servicemembers, veterans, and their  families with access to care, services, and benefits provided through  DOD, VA, other federal agencies, states, and the private sector. The  FRCP is intended to serve individuals who are highly unlikely to return to  active duty and most likely will be separated from the military, including  those who have suffered traumatic brain injuries, amputations, burns,  spinal cord injuries, visual impairment, and post-traumatic stress disorder.  From January 2008—when FRCP enrollment began—to September 12,  2011, the FRCP has provided services to a total of 1,827  servicemembers and veterans; of these, 777 are currently active  enrollees.
As the first care coordination program developed collaboratively by DOD  and VA, the FRCP uses Federal Recovery Coordinators (FRC) to monitor  and coordinate both the clinical and nonclinical services needed by  program enrollees; FRCs are intended to accomplish this by serving as  the single point of contact among case managers of DOD, VA, and other  governmental and private care coordination and case management  programs. As of September 12, 2011, there were 21 FRCs located at  various military treatment facilities and VA medical centers. Although the  program was jointly created by DOD and VA, it is administered by VA,  and FRCs are VA employees.
Separately, the RCP was established in response to the National Defense  Authorization Act for Fiscal Year 2008 to improve the care, management,  and transition of recovering servicemembers. It is a DOD-specific  program that uses Recovery Care Coordinators (RCC) to provide  nonclinical care coordination to both seriously and severely wounded, ill,  and injured servicemembers. Servicemembers who are severely  wounded, ill, and injured and who will most likely be medically separated  from the military, also are to be assigned an FRC. While the program is  centrally coordinated by DOD’s Office of Wounded Warrior Care and  Transition Policy, it has been implemented separately by each of the  military services, which have integrated RCCs within their existing  wounded warrior programs. According to DOD’s Office of Wounded  Warrior Care and Transition Policy, in September 2011, there were 162  RCCs and over 170 Army Advocates who worked in more than 100  locations, including military treatment facilities and VA medical centers.  As of September 2011, these RCCs have assisted approximately 14,000  recovering servicemembers and their families and sometimes continue  this assistance for those servicemembers who separate from active  duty.
The FRCP and RCP are two of at least a dozen DOD and VA programs  that provide care coordination and case management services to  recovering servicemembers, veterans, and their families, as we have  previously reported. Although these programs may vary in terms of the  severity of injuries or illnesses among the population they serve, or in the  types of services they provide, many, including the FRCP and RCP,  provide similar services. (See table 1.)
section_title: VA Has Made Progress in Addressing Our Recommendations to Improve FRCP Management Processes, and DOD Has Provided Limited Assistance
paragraphs: VA has recently made progress addressing the recommendations from  our March 2011 report, and although our recommendations were directed  to VA, DOD has provided limited assistance for one of the  recommendations. We previously reported that the FRCP would benefit  from more definitive management processes to strengthen program  oversight and decision making, and that program leadership could no  longer rely on the informal management processes it had developed to  oversee and manage key aspects of the program. Because VA maintains  administrative control of the program, we recommended that the  Secretary of VA direct the FRCP to take actions to address management  issues related to FRC enrollment decisions, FRCs’ caseloads, and  program staffing needs and placement decisions. VA concurred with all of  our recommendations and its progress in addressing them is outlined  below:    FRC enrollment decisions. To ensure that referred servicemembers  and veterans who need FRC services are enrolled in the program, we  recommended that the FRCP establish adequate internal controls  regarding enrollment decisions by requiring FRCs to record the  factors they consider in making enrollment decisions, to develop and  implement a methodology and protocols for assessing the  appropriateness of enrollment decisions, and to refine the  methodology as needed.
In May 2011, VA reported that the FRCP had fully implemented an  interim solution, which requires that FRCs present each enrollment  decision to FRCP management for review and approval. The  discussion between the FRC and management and the final decisions  are documented in the program’s data management system. As of  September 2011, VA reported that the FRCP continues to review and  refine the enrollment process and establish document protocols.    FRC caseloads. In an effort to improve the management of FRCs’  caseloads, we recommended that the FRCP complete the  development of a workload assessment tool, which would enable the  program to assess the complexity of services needed by enrollees  and the amount of time required to provide services.
As of September 2011, the FRCP has implemented a workload  intensity tool within the program’s data management system, and  FRCs began using it for all new referrals in September 2011.  According to the Acting Executive Director for the FRCP, the FRCP  will be monitoring the effectiveness of the workload intensity tool and  will be making modifications to it as needed.    Staffing needs and placement decisions. We recommended that the  FRCP clearly define and document the decision-making process for  determining when VA should hire FRCs, how many it should hire, and  that the FRCP develop and document a clear rationale for FRC  placement.
In September 2011, VA reported that the FRCP has documented the  formula that the program currently uses to determine the number of  FRC positions required. In addition, the FRCP is developing a  systematic analysis to better inform decisions about the future  placement of FRCs. This analysis considers referrals received by the  program, client location upon reintegration into the community, and  requests from programs or facilities for placing FRCs at particular  locations. According to the Acting Executive Director for the FRCP,  the FRCP will report updated information about staffing and  placement processes annually in its business operation planning  document.
Although our recommendations to improve the management of the FRCP  were directed to the Secretary of VA, both DOD and VA were asked to  provide a response to this subcommittee about how the departments  could jointly implement the recommendations. DOD has provided limited  assistance to VA with the implementation of our recommendation  regarding enrollment. Specifically, according to DOD and VA officials, an  e-mail communication was sent on June 30, 2011, to the commanders of  the military services’ wounded warrior programs stating that they should  refer all severely wounded, ill, and injured servicemembers who could  benefit from the services of an FRC to the program for evaluation.  Despite this effort, VA officials stated that they have not noticed any  change in referral numbers or patterns from DOD since the e-mail was  sent.
section_title: DOD and VA Have Made Little Progress Reaching Agreement on Options to Better Integrate Care Coordination Programs
paragraphs: DOD and VA have made little progress reaching agreement on options to  better integrate the FRCP and RCP, although they have made a number  of attempts to address this issue. Most recently, DOD and VA  experienced difficulty jointly providing potential options for integrating  these programs in response to this subcommittee’s May 26, 2011,  request to the deputy secretaries, who co-chair the DOD and VA  Wounded, Ill, and Injured Senior Oversight Committee (Senior Oversight  Committee). The subcommittee requested that the co-chairs provide a  written response to the subcommittee by June 20, 2011. In the absence  of such a response, on August 19, 2011, the subcommittee contacted the  Secretaries of DOD and VA and requested that they facilitate moving this  matter forward.
On September 12, 2011, the co-chairs of the Senior Oversight Committee  issued a joint letter that stated that the departments are considering  several options to maximize care coordination resources. However, these  options have not been finalized and were not specifically identified or  outlined in the letter. According to DOD and VA officials, the development  of this response involved a back-and-forth between the departments  because of disagreement over its contents. Although officials of both  departments collaborated on the development of the letter, changes were  made during the review process that resulted in the delay of its release to  the subcommittee. According to DOD and VA officials, after VA had  signed the letter and sent it to DOD for review and signature, DOD  officials unilaterally modified the wording, to which VA officials objected.  Officials from both departments told us that the resulting impasse caused  considerable delay in finalizing the letter and was resolved only after DOD  agreed to withdraw its changes. Issuance of the letter followed notification  by the subcommittee that it would hold a hearing on the FRCP and RCP  care coordination issue in September 2011.
The two departments have made prior attempts to jointly develop options  for improved collaboration and potential integration of the FRCP and  RCP. Despite these efforts, no final decisions to revamp, merge, or  eliminate programs have been agreed upon. For example:    Beginning in December 2010, the Senior Oversight Committee  directed its care management work group to conduct an inventory of  DOD and VA case managers and perform a feasibility study of  recommendations on the governance, roles, and mission of DOD and  VA care coordination. According to DOD and VA officials, this  information was requested for the purpose of formulating options for  improving DOD and VA care coordination. DOD officials stated that  following compilation of this information, no action was taken by the  committee, and care coordination was subsequently removed from  the Senior Oversight Committee’s agenda as other issues, such as  budget reductions, were given higher priority. Recently, care  coordination has again been placed on the committee’s agenda for a  meeting scheduled in October 2011.
In March 2011, the DOD Office of Wounded Warrior Care and  Transition Policy sponsored a summit that included a review of DOD  and VA care coordination issues. This effort resulted in the  development of five recommendations to improve collaboration  between the FRCP and RCP, including a more standardized  methodology for making referrals to the FRCP, and two  recommendations to redefine the FRCP and the RCP. However, there  was no joint response to these recommendations and no agreement  appears to have been reached to jointly implement them. Although  DOD officials contend that they have taken action on many of these  recommendations within DOD’s care coordination program, VA  maintains that no substantive action has been taken to jointly  implement them. The degree of disagreement that exists between  DOD and VA on implementing these recommendations may be  illustrated by the continued disagreement between the departments  about when the FRC should engage with a seriously wounded, ill, and  injured servicemember. In discussing one of the outcomes of this  coordination summit, DOD officials asserted that the FRCP should  become engaged with the servicemember during rehabilitation after  medical treatment has been finished. In contrast, VA maintains that  the point of engagement should be in the early stage of medical  treatment to build rapport and trust with their clients and their clients’  families throughout their course of care.
In July 2011, a task force consisting of staff representing different VA  programs, including the FRCP, began meeting independently of DOD to  examine more broadly the range of services VA provides to the wounded,  ill, and injured veterans it serves. VA officials said that this task force was  formed to provide a critical examination of how VA’s care coordination  and case management programs are meeting the needs of this  population. However, a VA official stated that this is an ongoing effort,  and that the task force has not yet identified any options or  recommendations related to its review. While the task force has not yet  shared information about its efforts with DOD, a VA official told us that it  is planning to make a presentation of its efforts to the Senior Oversight  Committee at a meeting scheduled in October 2011.
The lack of progress to date in reaching agreement on options to better  integrate the FRCP and the RCP illustrates DOD’s and VA’s continued  difficulty in collaborating to resolve care coordination program duplication  and overlap. We currently have work underway to further study this issue  and identify the key impediments that continue to affect recovering  servicemembers and veterans during the course of their care.  Additionally, as we have previously reported, there are numerous  programs in addition to the FRCP and RCP that provide similar services  to recovering servicemembers and veterans—many of whom are enrolled  in more than one program and therefore have multiple care coordinators  and case managers. For example, as of September 12, 2011, 75 percent  of active FRCP enrollees also were enrolled in DOD’s wounded warrior  programs. According to one FRC, his enrollees have, on average, eight  case managers who are affiliated with different programs. We found that  inadequate information exchange and poor coordination between these  programs has resulted in not only redundancy, but confusion and  frustration for enrollees, particularly when care coordinators and case  managers duplicate or contradict one another’s efforts. For example, an  FRC told us that in one instance there were five case managers working  on the same life insurance issue for an individual. In another example, an  FRC and RCC were not aware the other was involved in coordinating  care for the same servicemember and had unknowingly established  conflicting recovery goals for this individual. In this case, a  servicemember with multiple amputations was advised by his FRC to  separate from the military in order to receive needed services from VA,  whereas his RCC set a goal of remaining on active duty. These conflicting  goals caused considerable confusion for this servicemember and his  family.
section_title: Conclusions
paragraphs: Numerous programs, including the FRCP and RCP, have been  established or modified to improve care coordination and case  management for recovering servicemembers, veterans, and their  families—individuals who because of the severity of their injuries and  illnesses could particularly benefit from these services. While well  intended, the proliferation of these programs, which often provide similar  services, has resulted not only in inefficiencies, but also confusion for  those being served. Consequently, the intended purpose of these  programs—to better manage and facilitate care and services—may  actually have the opposite effect. Particularly disconcerting is the  continued lack of progress by DOD and VA to more effectively align and  integrate their care coordination and case management programs across  the departments. This concern is heightened further as the number of  enrollees served by these programs continues to grow. Without  interdepartmental coordination and action to better coordinate these  programs, problems with duplication and overlap will persist, and perhaps  worsen. Moreover, the confusion this creates for recovering  servicemembers, veterans, and their families may hamper their recovery.
section_title: Recommendation for Executive Action
paragraphs: To improve the effectiveness, efficiency, and efficacy of services for  recovering servicemembers, veterans, and their families, we recommend  that the Secretaries of DOD and VA direct the Senior Oversight  Committee to expeditiously develop and implement a plan to strengthen  functional integration across all DOD and VA care coordination and case  management programs that serve this population, including the FRCP  and RCP, to reduce redundancy and overlap.
section_title: Agency Comments
paragraphs: We obtained oral comments on the content of this statement from both  DOD and VA officials. These officials provided additional information and  technical comments, which we incorporated as appropriate.
Chairwoman Buerkle, Ranking Member Michaud, and Members of the  Subcommittee, this completes my prepared statement. I would be  pleased to respond to any questions that you may have at this time.
section_title: GAO Contact and Staff Acknowledgments
paragraphs: If you or your staff have any questions about this testimony, please  contact me at (202) 512-7114 or draperd@gao.gov. Contact points for our  Offices of Congressional Relations and Public Affairs may be found on  the last page of this statement. Individuals who made key contributions to  this testimony include Bonnie Anderson, Assistant Director; Jennie Apter;  Frederick Caison; Deitra Lee; Mariel Lifshitz; and Elise Pressma.
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