DOD and VA Health Care: Federal Recovery Coordination Program Continues to Expand but Faces Significant Challenges
Published: 2011-03-23T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: In 2007, following reports of poor case management for outpatients at Walter Reed Army Medical Center, the Departments of Defense (DOD) and Veterans Affairs (VA) jointly developed the Federal Recovery Coordination Program (FRCP) to coordinate the clinical and nonclinical services needed by severely wounded, ill, and injured servicemembers and veterans. The FRCP, which continues to expand, is administered by VA, and the care coordinators, called Federal Recovery Coordinators (FRC), are VA employees. This report examines (1) whether servicemembers and veterans who need FRCP services are being identified and enrolled in the program, (2) staffing challenges confronting the FRCP, and (3) challenges facing the FRCP in its efforts to coordinate care for enrollees. GAO reviewed FRCP policies and procedures and conducted over 170 interviews of FRCP officials, FRCs, headquarters officials and staff of DOD and VA case management programs, and staff at medical facilities where FRCs are located.
section_title: What GAO Found
paragraphs: It is unclear whether all individuals who could benefit from the FRCP's care coordination services are being identified and enrolled in the program. Because neither DOD nor VA medical and benefits information systems classify servicemembers and veterans as "severely wounded, ill, and injured," FRCs cannot readily identify potential enrollees using existing data sources. Instead, the program must rely on referrals to identify eligible individuals. Once these individuals are identified, FRCs must evaluate them and make their enrollment determinations--a process that involves considerable judgment by FRCs because of broad criteria. However, FRCP leadership does not systematically review FRCs' enrollment decisions, and as a result, program officials cannot ensure that referred individuals who could benefit from the program are enrolled and, conversely, that the individuals who are not enrolled are referred to other programs. The FRCP faces challenges in determining staffing needs, including managing FRCs' caseloads and deciding when VA should hire additional FRCs and where to place them. According to the FRCP Executive Director, appropriately balanced caseloads (size and mix) are difficult to determine because there are no comparable criteria against which to base caseloads for this program because of its unique care coordination activities. The program has taken other steps to manage FRCs' caseloads, including the use of an informal FRC-to-enrollee ratio. Because these methods have some limitations, the FRCP is developing a customized workload assessment tool to help balance the size and mix of FRCs' caseloads but has not determined when this tool will be completed. In addition, the FRCP has not clearly defined or documented the processes for making staffing decisions in FRCP policies or procedures. As a result, it is difficult to determine how staffing decisions are made, or how this process could be sustained during a change in leadership. Finally, the FRCP's basis for placing FRCs at DOD and VA facilities has changed over time, and the program lacks a clear and consistent rationale for making these decisions, which would help ensure that FRCs are located where they could provide maximum benefit to current and potential enrollees. A key challenge facing the FRCP concerns limitations on sharing information needed to coordinate services for enrollees, who may be enrolled in multiple DOD and VA case management programs. These limitations are often blamed for duplication of services and enrollee confusion, prompting two military wounded warrior programs to cease making referrals to the FRCP. One such limitation existed because VA had not completed public disclosure actions necessary to enable the sharing of information from the FRCP's information system. In January 2011, VA completed the process needed to resolve this issue. In addition, incompatibility among information systems used by different case management programs limits data sharing. Although the ultimate solution to information system incompatibility is beyond the capacity of the FRCP to resolve, the program has initiated an effort to improve information exchange.
section_title: What GAO Recommends
paragraphs: GAO recommends that VA direct the FRCP Executive Director to establish systematic oversight of enrollment decisions, complete development of a workload assessment tool, document staffing decisions, and develop and document a rationale for FRC placement. GAO received comments from DOD and VA; VA concurred with GAO's recommendations.

section_title: Letter
paragraphs: In 2007, in response to critical media reports of deficiencies in the  provision of outpatient services at Walter Reed Army Medical Center,  various review groups investigated the challenges that the Departments of  Defense (DOD) and Veterans Affairs (VA) faced in providing care to  recovering servicemembers. The review groups cited common areas of  concern, including case management, which helps ensure continuity of  care by coordinating services from multiple providers and guiding  transitions between providers or agencies or back to the civilian  community. One of these review groups, the President’s Commission on  Care for America’s Returning Wounded Warriors—commonly referred to  as the Dole-Shalala Commission—issued a report that noted that while  the military services did provide case management, some servicemembers  were being assigned multiple case managers, having no single person to  monitor and coordinate their activities, which often resulted in confusion,  redundancy, and delay. To address these shortcomings, the commission  recommended strengthening the continuity of care for recovering  servicemembers through the use of individualized recovery plans that  would be developed and monitored by skilled recovery coordinators who  would have the ability to operate across departments. In response, the  joint DOD and VA Wounded, Ill, and Injured Senior Oversight Committee  (Senior Oversight Committee) developed the Federal Recovery  Coordination Program (FRCP) to assist severely wounded Operation  Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF)  servicemembers, veterans, and their families with access to care, services,  and benefits. The FRCP was envisioned to serve severely wounded, ill, or  injured servicemembers and veterans, including those who had suffered  traumatic brain injuries, amputations, burns, spinal cord injuries, visual  impairment, and post-traumatic stress disorder. (In this report, we use  “severely wounded” to denote severely wounded, ill, and injured  servicemembers and veterans, as appropriate.) According to VA officials,  the number of severely wounded servicemembers in the OEF/OIF conflicts  is not known with certainty because “severely wounded” is not a  categorical designation used by DOD or VA medical or benefits programs.  Estimates of the size of the severely wounded population vary, depending  on definitions and methodology.
Although the FRCP is the first care coordination program jointly  developed by DOD and VA, it is but one of several recently introduced or  revised programs intended to improve the continuity of care for wounded  servicemembers and veterans. Other programs include the wounded  warrior programs operated by the military services; VA’s OEF/OIF Care  Management Program; and DOD’s Recovery Coordination Program, which  is separately implemented and managed by each military service.  However, the FRCP was intended to complement rather than duplicate the  efforts of clinical and nonclinical case management programs in both DOD  and VA through the use of senior-level coordinators called Federal  Recovery Coordinators (FRC). Unlike case managers, FRCs are intended  to be care coordinators whose planning, coordination, monitoring, and  problem-resolution activities encompass both health services and benefits  provided through DOD, VA, other federal agencies, states, and the private  sector. Care coordination programs are typically more comprehensive in  scope than clinical or nonclinical case management programs, and care  coordinators, such as FRCs, may serve as a link between multiple case  managers. The FRCs strive to work with each enrollee to create a  comprehensive Federal Individual Recovery Plan to identify his or her  goals and subsequently to coordinate and monitor the clinical and  nonclinical services needed to achieve the enrollee’s goals—interacting  with the enrollee for a lifetime if necessary. The FRCP is administered by  VA, and the FRCs are VA employees.
An evaluation of the FRCP during the program’s initial implementation  phase identified a number of challenges facing the program, including the  determination of appropriate staffing levels for FRCs. This evaluation  noted that staffing levels were difficult to determine, given the absence of  a widely accepted estimate of the size of the severely wounded population.  In addition, the FRCs’ unprecedented care coordination role and work  activities meant that it was not known how many FRCs would be required  to address the needs of enrollees. This evaluation also noted that the  program should consider future FRC placement in response to the  expected increase in the number of enrollees, who could be located in  different parts of the country.
Since beginning operation in January 2008, the FRCP has grown  considerably, but the program experienced turmoil in its early stages. At  the time of the program’s introduction, eight FRCs were placed at three  military treatment facilities—Walter Reed Army Medical Center, National  Naval Medical Center, and Brooke Army Medical Center. However, within  the first 7 months of its implementation, six of the original eight FRCs left  the program, VA moved oversight of the program directly under the VA  Secretary, and the FRCP Executive Director was replaced in July 2008.  Under the new Executive Director, the FRCP enlarged its staff, increased  the number of enrollees, and expanded the number of locations where  FRCs are assigned. As of September 2010, the program employed 20 FRCs,  who were serving about 600 servicemembers and veterans. These FRCs  were located at six military treatment facilities, three VA medical centers,  and the headquarters of one military service’s wounded warrior program.  While the FRCs are physically located at certain facilities, their enrollees  are scattered throughout the country and may not be receiving care at the  facility where their assigned FRC is located.
Our review of the FRCP is one in a series of engagements focused on the  continuity of care for recovering servicemembers and veterans, which  resulted from requests from multiple congressional requesters. In light of  continued concerns about DOD’s and VA’s efforts to support  servicemembers and veterans, this report examines (1) whether  servicemembers and veterans who need FRCP services are being  identified and enrolled in the program, (2) staffing challenges confronting  the FRCP, and (3) the challenges facing the FRCP in its efforts to  coordinate care for severely wounded servicemembers and veterans.
To address these objectives, we conducted more than 170 interviews of  the following groups: FRCs; FRCP leadership, which includes the  Executive Director, the Deputy Director for Health, and the Deputy  Director for Benefits; leadership officials with DOD and VA case  management programs (collectively referred to as program officials),  including leadership officials from each military service’s wounded  warrior program; and medical facility directors and staff at DOD and VA  medical facilities (referred to as medical facility staff). We interviewed the  FRCs individually to learn about challenges they have encountered, using  comprehensive interviews of the 15 FRCs who were working in the FRCP  in or before December 2009 and limited interviews of the 5 FRCs who  were hired in January 2010. To develop an understanding about how  clinical and nonclinical officials and staff interact with the FRCs, we  conducted site visits and telephone interviews with program officials at  DOD and VA headquarters and medical facility staff at the DOD and VA  medical facilities where FRCs are located. These facilities included Walter  Reed Army Medical Center; National Naval Medical Center; Brooke Army  Medical Center; Naval Medical Center-San Diego; Naval Hospital Camp  Pendleton; Eisenhower Army Medical Center; and the VA medical centers  in Houston, Texas; Providence, Rhode Island; and Tampa, Florida. In  addition, we visited three VA medical centers with which FRCs have  significant interaction—the facilities in Richmond, Virginia; Augusta,  Georgia; and San Diego, California. We performed content analysis of the  qualitative information obtained from the FRCs, DOD and VA program  officials, and medical facility staff by grouping their responses by topic  and then identifying response patterns. Content analysis of qualitative  information obtained from DOD and VA program officials and medical  facility staff was conducted using a software package, which enabled us  to analyze responses to specific interview topics for a large number of  interviews. (See app. I for a discussion of how we used the software  package.) However, the results from our site visits and interviews cannot  be generalized because while all DOD and VA facilities could potentially  interact with FRCs, our review focused on facilities where FRCs are  located as well as some facilities where FRCs have significant interaction.  In addition, we obtained and reviewed documentation related to the  FRCP, including VA’s October 2009 handbook on care management of  OEF and OIF Veterans; the FRCP Standard Operating Procedures; the  FRCP fiscal year 2010 operating plan; and draft FRCP procedures, such as  the VA handbook on the FRCP.
We conducted this performance audit from September 2009 through  March 2011 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: Servicemembers wounded in recent conflicts are surviving injuries that  would have been fatal in past conflicts, in part because of advanced  protective equipment and medical treatment. However, the severity of  their injuries can result in a lengthy transition from patient status back to  active duty or to veteran status. Most severely wounded servicemembers  from the conflicts in Iraq and Afghanistan initially are evacuated to  Landstuhl Regional Medical Center in Germany for treatment. From there,  they are usually transported to military treatment facilities in the United  States, with most of the severely wounded admitted to Walter Reed Army  Medical Center, the National Naval Medical Center, or Brooke Army  Medical Center.
Acute medical treatment and stabilization is the first of three phases in the  “continuum of care” experienced by severely wounded servicemembers.  The second phase of the continuum is rehabilitation at a DOD, VA, or  civilian facility. (The recovery needs of some servicemembers receiving  rehabilitation may require their return to a medical center for acute  medical care, such as surgical procedures.) The third phase of the  continuum is reintegration—either return to active duty or to the civilian  community as a veteran, where they may receive health care from DOD,  VA, or civilian providers.
subsections: section_title: FRCP Enrollees
paragraphs: From January 2008—when FRCP enrollment began—through September  2010, the FRCP provided services to a total of 1,268 servicemembers and  veterans. As of September 2010, the program had 607 active enrollees,  ranging in age from 19 to 61 years, with a median age of 27 years. About  half of the enrollees were or had been married. Fifty-eight percent had  designated another person as his or her primary caregiver, and 38 percent  had delegated legal authority to another person. (See table 1 for additional  demographic information about current FRCP enrollees.)
section_title: FRC Activities
paragraphs: FRCs are senior-level registered nurses and licensed social workers whose  principal role is to coordinate services with case managers rather than  provide services directly to enrollees. FRCs are expected to serve as the  single point of contact for the enrollees and their families and to assist the  enrollees in a number of ways. FRCP care coordination guidelines identify  FRC activities, which are outlined in table 2.
According to FRCP policy, the FRC’s primary responsibility is to develop  and monitor progress of each enrollee as detailed in that person’s Federal  Individual Recovery Plan, which is created and implemented by the FRC  with input from the enrollee and his or her family and clinical team. This  plan is to be a comprehensive, client-centered plan that sets individualized  goals for recovery and is intended to guide and support the enrollee  through the continuum of care. FRCs update Federal Individual Recovery  Plans to reflect changing conditions or enrollee goals.
Based on their diagnoses and other factors, enrollees are likely to require a  complex array of clinical and nonclinical services from multiple providers  and facilities. (See table 3.) In providing care coordination services, the  FRC may engage with an enrollee’s health care providers, other care  coordinators, and case managers, such as those with the military services’  wounded warrior programs. As care coordinators, FRCs are generally not  expected to directly provide the services needed by enrollees. However,  FRCs may provide services directly to enrollees in certain situations, such  as when they cannot determine whether a case manager has taken care of  an issue for an FRCP enrollee, when asked to resolve complex problems,  or when making complicated arrangements, for example, identifying and  arranging admission to a substance abuse treatment program for a veteran  who was beginning to develop violent behaviors and had refused to  complete a VA drug rehabilitation treatment program.
section_title: Problems Identifying Potential Enrollees and Reviewing Enrollment Decisions Make It Unclear Whether Those Needing FRCP Services Are Enrolled
paragraphs: It is unclear whether all of the eligible “severely wounded, ill, and injured”  servicemembers and veterans who could benefit from the FRCP are being  enrolled in the program. The FRCP cannot readily identify these  individuals because the “severely wounded, ill, and injured” classification  is not captured in existing data sources. Additionally, the program’s broad  eligibility criteria cannot be used systematically to identify potentially  eligible servicemembers and veterans. Instead, the FRCP must rely on  referrals from others to identify these individuals, although the program  has also taken steps to identify potential enrollees through the FRCs’  efforts at medical facilities and through a “look back” initiative to identify  eligible veterans who were wounded prior to program implementation. In  addition, the FRCs must exercise judgment in applying the program’s  criteria for enrollment determinations, and FRCP leadership does not  systematically review these decisions to ensure that these criteria are  applied appropriately so that referred individuals who could benefit from  the program are enrolled, and that individuals who could be served by less  intensive services are referred to other programs.
subsections: section_title: The FRCP’s Potential Enrollee Population Cannot Be Readily Identified from Existing Data Sources, but the FRCP Has Taken a Number of Steps to Identify Potentially Eligible Individuals
paragraphs: FRCP officials have experienced difficulties in identifying the potentially  eligible population of “severely wounded, ill, or injured” servicemembers  and veterans, and as a result, it is unclear whether all of these individuals  who could benefit from care coordination services are enrolled in the  program. The Senior Oversight Committee, which created the FRCP,  developed a three-level care categorization system to differentiate the  population of wounded servicemembers and veterans for different  programs based on the severity of their conditions. In this system,    Category 1 servicemembers are those with mild wounds, illnesses, or  injuries who are expected to return to duty in less than 180 days;    Category 2 servicemembers are those with serious wounds, illnesses, or  injuries who are unlikely to return to duty in less than 180 days and  possibly may be medically separated from the military; and    Category 3 servicemembers are severely wounded, ill, or injured  individuals whose medical conditions are highly likely to prevent their  return to duty and also likely to result in medical separation from the  military.
Individuals who fall under category 3 may be considered for enrollment  into the FRCP, while individuals falling under categories 1 or 2 may qualify  for other types of programs. However, according to the FRCP Executive  Director, these are administrative categories that are not captured in  existing VA or DOD medical or benefits data systems or included in  medical or benefits records. As a result, the FRCP cannot use this  classification to systematically identify the population of potentially  eligible severely wounded servicemembers and veterans using available  data sources. In addition, the FRCP Executive Director and FRCs told us  that the broad eligibility criteria developed for the FRCP must be used on  a case-by-case basis to identify potentially eligible individuals for the  program because these criteria require some judgment. Therefore, the  criteria cannot be used systematically to identify the program’s potentially  eligible population. These criteria include both specific medical diagnoses  and requirements that are somewhat subjective, such as whether an  individual may benefit from a recovery plan. To decide whether potential  enrollees may benefit from a recovery plan, FRCs reported that they  evaluate the complexity of a situation by examining issues such as future  medical needs, family dynamics, and any financial or legal problems— information that is not readily available in any one data source.
As a result, to identify potentially eligible individuals, the FRCP relies on  referrals from others, including program officials and medical facility staff.  Sources of referrals include, for example, wounded warrior program staff,  Recovery Care Coordinators, and clinical treatment teams. Of the program  officials and medical facility staff we spoke with who discussed referrals,  more than half (25 of 47) had made a referral to the program. However,  more than half (15 of 27) of the program officials and medical facility staff  we interviewed who responded to questions on eligibility also felt that the  FRCP eligibility criteria were unclear. In addition to relying on referrals,  the FRCs also take steps to identify potential enrollees. Some FRCs stated  that they review their facility’s list of incoming severely wounded  servicemembers and attend weekly multidisciplinary team meetings where  hospital officials and medical staff discuss severely wounded patients’  cases.
In an attempt to ensure that eligible veterans who were wounded prior to  the program’s inception are enrolled in the program, the FRCP conducted  a “look back” initiative in May 2010. Because no single data source  contains sufficient information, the FRCP Executive Director told us that  she combined five DOD and VA data sets and used multiple “proxy”  factors to narrow the data from 40,000 veterans’ records to the final list of  potentially eligible veterans. For example, the Veterans Benefits  Administration’s 100 percent disability compensation list and medical  diagnostic codes were used to help identify this population. Based on this  analysis, the FRCP Executive Director reported that the program  contacted approximately 300 potential enrollees to determine whether  they could benefit from an FRC’s assistance. As a result, 35 of those  severely wounded veterans will be further evaluated for potential  enrollment.
According to the FRCP Executive Director, this analysis was prioritized to  focus on severely wounded veterans who were most likely to need FRC  assistance. The Executive Director told us that, as a result, the list was not  comprehensive—for example, the program did not contact veterans who  were already enrolled in VA’s OEF/OIF Care Management Program under  the assumption that they were already receiving adequate case  management. Additionally, the FRCP Executive Director told us that  identifying 35 veterans indicated that the FRCP is not reaching all  potentially eligible veterans through its normal referral process or that  information about the program is not reaching severely wounded veterans.  The FRCP Executive Director added that once it is complete, this effort  will be assessed to determine whether another “look back” is needed, but  as of February 2011, leadership officials had not yet determined whether  they would conduct a subsequent “look back.”
section_title: Enrollment Decisions Require FRC Judgment, and FRCP Leadership Does Not Systematically Review These Decisions to Ensure That Referred Individuals Who Could Benefit Are Enrolled
paragraphs: Following the identification of potentially eligible servicemembers and  veterans, FRCs use a more thorough application of the program’s  eligibility criteria to evaluate these individuals for enrollment. The  eligibility criteria are broad and require FRCs to exercise judgment with  their enrollment decisions. However, FRCP leadership does not  systematically review these decisions to ensure that referred individuals  who could benefit from the program are enrolled while those requiring  less intensive services are referred to other programs.
Eligibility criteria for the program—developed by the Senior Oversight  Committee—specify that enrollees    be receiving acute care in a military treatment facility;    be diagnosed or referred for one or more of the following: spinal cord  injury, burns, amputation, visual impairment, traumatic brain injury, or  post-traumatic stress disorder;    be considered at risk for psychosocial complication; or    may benefit from a recovery plan.
Because some of these criteria are subjective, particularly whether an  individual is at risk for psychosocial complications or would benefit from  a recovery plan, the FRCs must use their judgment when deciding whether  an individual should be enrolled in the program. According to the FRCP  Executive Director, the program’s criteria are intended to provide  guidance for the FRCs, giving them the flexibility to enroll severely  wounded servicemembers and veterans, rather than being restrictive. The  Executive Director added that FRCs strive to enroll severely wounded  servicemembers and veterans in cases where having an FRC can add value  to existing case management efforts.
To evaluate servicemembers and veterans for program eligibility, FRCs  must make subjective assessments of the impact their care coordination  efforts could have on potential enrollees. This involves FRCs making  assessments of the severity of potential enrollees’ medical conditions to  determine future medical needs—such as rehabilitation—and nonmedical  issues—such as caregiver status. FRCs obtain information from a number  of sources, including DOD and VA medical records, as well as records  from private sector providers. They may also discuss potential enrollees’  situations with members of multidisciplinary teams providing medical  treatment, family members, and the potential enrollees. At the end of the  evaluation period, the FRC will consider a potential enrollee’s need for  care coordination based on the collected information and determine  whether the individual should be enrolled in the program, provided  temporary assistance, or referred to another program.
While it is necessary for FRCs to use their judgment in making enrollment  decisions, the FRCP does not systematically review the factors and  reasons for enrolling, providing temporary assistance, or referring  potentially eligible servicemembers and veterans to other programs.  Systematic review could involve the use of a defined protocol for the  review of eligibility decisions made by FRCs. According to federal internal  control standards, agencies should establish ongoing internal control  activities to provide reasonable assurance that decisions are consistent  with applicable criteria—in this case, criteria designed to ensure that  those in need of care coordination services are enrolled in the program.  While the FRCs indicate in their data management system—the Veterans  Tracking Application—whether they decided to enroll an individual, FRCP  leadership told us they do not require that the FRCs record the factors  they considered to support this decision. Additionally, FRCP leadership  told us that while they closely review all enrollment decisions made by  new FRCs, they do not perform similar reviews of decisions made by more  experienced FRCs. Instead, FRCP leadership and experienced FRCs  discuss the FRCs’ recommended actions on newly referred individuals as  part of weekly telephone conversations. However, FRCP officials  acknowledged that these discussions with the FRCs may not be  comprehensive and that there is no section in the Veterans Tracking  Application dedicated to recording these discussions. Without specific  documentation of the factors the FRCs considered when making their  enrollment decisions and absent internal controls and systematic oversight  of much of the enrollment process, it is difficult to determine whether  severely wounded servicemembers and veterans who are referred and  could benefit from the program are actually enrolled and severely  wounded servicemembers and veterans who could be served by less  intensive services are referred to other programs. Additionally, this issue  could become even more problematic as the program’s enrollment  continues to increase and FRCP leadership has to review more enrollment  decisions.
section_title: The FRCP Faces Challenges in Determining Staffing Needs and Has Not Clearly Defined or Documented Its Processes for Managing FRCs’ Caseloads, Making Staffing Decisions, and Placing FRCs
paragraphs: Several challenges confront the FRCP in determining staffing needs for the  program, including how to manage FRCs’ caseloads, deciding when VA  should hire FRCs, and determining where to place them in the field to best  serve current and potential enrollees. The FRCP has not established a  formal caseload size for FRCs because there are no comparable criteria  upon which to determine caseload size because of the program’s unique  care coordination activities. Also, while establishing an appropriate  caseload size for FRCs may help FRCP leadership determine how many  FRCs VA should hire, it remains difficult for FRCP leadership to determine  when VA should hire FRCs. Finally, the FRCP lacks a clear and consistent  rationale for making decisions about where to place FRCs in the field.
subsections: section_title: FRCs Have Expressed Concerns about Heavy Caseloads, and the FRCP Is Developing a Workload Assessment Tool That Should Help Address This Concern
paragraphs: The FRCs we spoke with expressed concerns about the high number of  enrollees assigned to them and cited the need for improved caseload  management. Specifically, 11 of the 15 FRCs we interviewed identified  inadequate caseload management as a concern. Eight of these FRCs  expressed concerns about the large number of cases assigned to them. As  of September 30, 2010, FRCs’ caseloads ranged from 25 to 48, with two- thirds of the FRCs (10 of 15) having caseloads that exceeded the informal  target ratio of 1 FRC for every 30 enrollees established by the FRCP  Executive Director to manage FRC caseloads. Some FRCs told us that the  large number of cases required them to work long hours and sometimes  forced them to limit the amount of time that they could devote to an  enrollee. In addition, more than half of the FRCs (8 of 15) expressed  concerns that FRCP leadership does not adequately account for the  services required by existing enrollees in their caseloads when assigning  new cases. For example, one FRC told us that the types of cases assigned  to her were stressful. She indicated that she had been assigned two  enrollees with terminal conditions because she was skilled at managing  the issues related to these types of cases, but she is now reluctant to take  another terminally ill enrollee because it is emotionally draining to deal  with end-of-life issues. However, an FRCP leadership official told us that  FRCs have the flexibility to forward a referral to the FRCP central office  for assignment to another FRC as a means of managing their existing  caseloads.
According to the FRCP Executive Director, an appropriate caseload is  difficult to determine because care coordination is a new type of function,  and there are no comparable criteria against which to measure and base  caseload size for this program because of its unique activities.  Additionally, the FRCs’ caseloads are dynamic in that the needs of each  enrollee differ and may change over time. For example, out of a caseload  of 30 clients, 5 may need intensive crisis management, while the remaining  25 enrollees may only need periodic contact or limited services. However,  as noted by FRCP leadership and some FRCs, the needs of these enrollees,  and consequently, the time required of an FRC, may change as enrollees  move through different stages of the continuum of care.
As a means of managing FRCs’ caseloads, the FRCP Executive Director  cited two actions in particular that FRCP leadership uses to assess and  manage FRC caseloads.
FRCP leadership uses an informal FRC-to-enrollee target ratio of 1 to 30  (with a targeted range of 25 to 35 enrollees per FRC), which is based on  the FRCP Executive Director’s experience in managing the program over  time.
Weekly telephone calls with each FRC are used by FRCP leadership to  discuss issues related to their assigned cases and to gauge workload  burden.
The FRCP Executive Director told us that the program is developing a  customized workload assessment tool to help balance FRCs’ caseloads— in other words, to ensure that an FRC’s caseload mix is manageable. The  objective of the workload assessment tool is to identify specific enrollee  characteristics, such as medical diagnosis, and to correlate each  characteristic with the amount of time an FRC would be required to spend  on addressing issues related to it. One method being considered is the  assignment of a point value to each identified enrollee characteristic.  Adding up the number of points for the characteristics of all enrollees in  an FRC’s caseload would provide an estimate of that FRC’s workload  burden. However, according to the FRCP Executive Director, the  development of such a tool has been difficult, primarily because the  enrollee characteristics that existing workload assessment tools use to  determine how much time it takes to address an issue are not relevant to  the care coordination activities that FRCs perform. As a result, program  leadership continues to consider different methods of assessing FRCs’  workloads, including measurement tools that have already been validated  for other purposes, to identify a method that could potentially be relevant  for the program. The FRCP Executive Director is uncertain how long it  will take to develop a workload assessment tool and has not established  timelines to complete this effort. Without a workload assessment tool, the  program does not have the data it needs to develop a more comprehensive  caseload management strategy and to better determine appropriate  caseload size for FRCs.
section_title: FRCP Staffing Decisions Are Based on Ongoing Program Monitoring Efforts, but This Process Has Not Been Clearly Defined or Documented
paragraphs: While establishing appropriate FRC caseloads should help FRCP  leadership better determine how many FRCs VA should hire, determining  when VA should hire FRCs has been another staffing challenge. Currently,  the FRCP Executive Director’s decisions about when VA should hire FRCs  are based on various ongoing monitoring efforts. The FRCP Executive  Director told us that staffing decisions regarding FRCs are difficult to  make because the FRCP cannot predict the number of potentially eligible  servicemembers and veterans, which is affected by the OEF/OIF conflicts.  In the absence of being able to project the number of potentially eligible  servicemembers and veterans, the FRCP Executive Director said she uses  other methods to predict future trends and guide the staffing process. One  method involves monitoring FRCs’ workloads as an indicator that  workload levels are increasing and new FRCs are needed. In this regard,  the FRCP Executive Director told us that FRCP leadership conducts  weekly telephone calls with each FRC to discuss issues related to their  caseloads. The FRCP Executive Director told us that another method she  uses to predict staffing needs is through the analysis of the number of new  referrals and enrollment rates in the program, which she uses to create a  quarterly report that highlights the projected number of FRCs that the  program may need. For example, the average number of new referrals  grew from 25 a month in 2008 to 35 a month in 2009. VA hired five FRCs in  January 2010 in part because of this increase in the number of referrals  and the expected resulting increase in the number of enrolled  servicemembers and veterans. The FRCP Executive Director told us that  the referral data collected in 2010 show that the number of new referrals  continued to increase and averaged 50 a month, which indicates a  continuing need for more FRCs. According to the FRCP Executive  Director, she routinely shares this information with the Secretary of  Veterans Affairs as advance notice that a request for additional FRCs may  be forthcoming because it takes about   6 months for VA to hire a new FRC. The FRCP Executive Director told us  that the program’s ongoing monitoring efforts are the most logical  approach for determining when and how many FRCs VA should hire in the  absence of knowing the number of potentially eligible servicemembers  and veterans.
While these methods appear to be reasonable given the lack of overall data  on the numbers of severely wounded servicemembers and veterans, the  staffing process is not well documented. Internal control standards  applicable to all federal agencies state that an agency should effectively  communicate its policies and procedures by providing clear  documentation that is readily available for examination. Consistent with  this internal control standard, we would expect the FRCP to have  documented procedures outlining its process for making staffing  decisions. FRCP leadership documented staffing projections for fiscal year  2010 in the program’s annual operating plan, citing that ongoing analysis of  referrals and enrollment rates was important in making those projections.  However, the process used by program leadership—specifically how the  referral and enrollment data are used in making staffing decisions—has  not been clearly defined or documented in the operating plan or any of the  other program policies or procedures. By documenting this information,  the FRCP would have greater assurance that the process developed by the  current leadership will be maintained during management changes.
section_title: The FRCP Lacks a Clear and Consistent Rationale for Making FRC Placement Decisions
paragraphs: Deciding where to place FRCs to best serve current and potential  enrollees’ needs is another key staffing issue, despite the fact that FRCs  often coordinate services for enrollees who are located throughout the  country and may not be receiving care at the facility where their assigned  FRC is located. The FRCP’s basis for making decisions about where to  place FRCs has varied over time, and the program currently lacks a clear  and consistent rationale for making FRC placement decisions. As of  September 2010, 20 FRCs were located at 10 facilities. (See fig. 1.)
When the FRCP began operating in 2008, eight FRCs were placed at the  three military treatment facilities where the majority of severely wounded  servicemembers were receiving treatment. According to the FRCP  Executive Director, the placement of FRCs at military treatment facilities  helped with the identification of servicemembers who could benefit from  FRCP services. In addition, some FRCs told us that being located at the  military treatment facilities allowed them to develop relationships with the  enrollees, their families, and the case managers who would be providing  direct services to the enrollees. However, as the program expanded,  placement of some FRCs was not based on a rationale or an analysis of  where FRCs could provide the maximum benefit to severely wounded  servicemembers and veterans. For example, some DOD and VA officials  we spoke with expressed concerns about the FRCP’s placement decisions,  particularly the placement of FRCs at facilities that do not treat a large  population of severely wounded servicemembers or veterans. DOD  officials told us that it was not clear why there were FRCs assigned to a  military treatment facility that typically does not treat severely wounded  servicemembers. Similarly, a VA medical center official stated that it was  unclear why FRCs were initially placed at two VA medical centers that had  few FRCP enrollees being treated there, rather than at VA medical centers  where a significant number of severely wounded veterans may be  receiving treatment. There was no official FRCP documentation that  explained the basis for these decisions, which were made by FRCP  officials who are no longer with the program.
After the FRCP leadership changed in July 2008, decisions to place FRCs  have been based on several factors. According to the FRCP Executive  Director, some placement decisions focused on ensuring that enough  FRCs were in place to meet the demands of the FRCP workload by  replacing FRCs who had left the program and by adding FRCs at facilities  where only one FRC was located. She explained that where possible, it is  helpful to have at least two FRCs at each facility so that there can be  backup support, particularly for administrative purposes such as coverage,  when an FRC is on leave. However, the FRCP Executive Director told us  that more recently—from March 2010 through September 2010—FRC  placement decisions have primarily been based on requests or  recommendations from DOD and VA officials. For example, in June 2010,  the FRCP relocated an FRC to a military wounded warrior program  headquarters facility in response to a request from the program’s director.  FRCP officials have also decided to place some new FRCs at two VA  medical centers where servicemembers and veterans with polytrauma  injuries receive care, based on recommendations from DOD and VA  officials.
The FRCP Executive Director explained that the FRCP had not  established a systematic rationale for FRC placement because the program  initially lacked the data upon which to base these determinations.  Additionally, she told us that every placement of an FRC at a VA or DOD  facility is a negotiation and depends on the facility’s ability to  accommodate an FRC, including the provision of work space and  equipment. However, she told us that she and other FRCP leadership  officials have begun to think about how to improve the FRCP’s process for  deciding where to place FRCs. In August 2010, the FRCP Executive  Director explained that a planned update of the Veterans Tracking  Application would collect additional information that would allow FRCP  officials to identify the location of individuals who refer potential  enrollees. She anticipates being able to use these data to identify the  locations and facilities where the most referrals are being made.  According to the FRCP Executive Director, this information along with  other factors, such as placement recommendations from DOD and VA  officials, could be used in making future placement decisions. However, as  of December 2010, she had not established a specific time frame for this  effort. Developing a clear and consistent rationale for placing FRCs, which  includes a systematic analysis of program data, should help ensure that  FRCs are located where they could provide the maximum benefit to  current and potential enrollees.
section_title: The FRCP Faces Challenges That Limit Its Ability to Coordinate Care but Is Taking Steps to Address Them
paragraphs: FRCs and others identified challenges that can limit the FRCP’s efforts to  coordinate the services needed by severely wounded servicemembers and  veterans. One challenge involves limitations on the FRCP’s ability to share  information with the large number of programs that provide care  coordination and case management services to wounded servicemembers  and veterans. These limitations—which are the result of restrictions on the  disclosure of enrollee information and data systems’ incompatibility— have sometimes resulted in confusion and the duplication of services for  enrollees. Efforts by the FRCP to improve information sharing are  ongoing. Another challenge is that FRCs often have difficulty obtaining  resources from the facilities at which they are located—such as  telephones, computers, and private office space—that they need to  perform their care coordination activities, including communicating with  enrollees across the country. This can affect the quality of services to  enrollees, and the FRCP is working to resolve these logistical issues.
subsections: section_title: Coordination among the FRCP and DOD and VA Case Management Programs Is Impeded by Limitations on Their Ability to Share Information, and Efforts to Address These Limitations Are Ongoing
paragraphs: Coordination among DOD and VA programs that provide care  coordination and case management is difficult because of the large  number of such programs that exist to address the needs of wounded  servicemembers and veterans and the limitations in the ability of these  programs to share information. Although these programs vary in terms of  the severity of the injuries among the servicemembers or veterans they  serve and the specific types of services they coordinate, many programs  have similar functions. (See table 4.)
For the purposes of this table, we have categorized the severity of enrollees’ injuries according to the  injury categories established by the DOD and VA Wounded, Ill, and Injured Senior Oversight  Committee. Servicemembers with mild wounds, illness, or injury are expected to return to duty in less  than 180 days; those with serious wounds, illness, or injury are unlikely to return to duty in less than   180 days and possibly may be medically separated from the military; and those who are severely  wounded, ill, or injured are highly unlikely to return to duty and also likely to medically separate from  the military. These categories are not necessarily used by the programs themselves.
The military wounded warrior programs are the Army Wounded Warrior Program, Marine Wounded  Warrior Regiment, Navy Safe Harbor, Air Force Warrior and Survivor Care Program, and Special  Operations Command’s Care Coalition.
An FRC placed at Special Operations Command’s Care Coalition headquarters coordinates clinical  and nonclinical care for Care Coalition and other FRCP enrollees.
OEF/OIF refers to Operation Enduring Freedom and Operation Iraqi Freedom.
An OEF/OIF care manager supervises the case managers and transition patient advocates and may  also maintain a caseload of wounded veterans.
According to VA, in some instances, patients are transferred to VA medical facilities while still in the  acute phase of the care continuum and may receive services from VA care management or  polytrauma program staff.
Many recovering servicemembers and veterans are enrolled in more than  one program. For example, in September 2010, approximately 84 percent  of FRCP enrollees were also enrolled in a military service wounded  warrior program. According to one FRC, his enrollees have, on average,  eight case managers who are affiliated with different programs. Individuals  enrolled in multiple programs may have recovery plans or goals that have  been developed by different programs. Moreover, some case managers of  other programs consider themselves to be the single point of contact for  their enrollees, even those enrolled in the FRCP. Because the majority of  FRCP enrollees are enrolled in more than one program, there is a high  likelihood that without adequate information exchange and coordination,  FRCs and case managers could duplicate one another’s efforts, confuse  enrollees and families, waste resources, or mistakenly believe that  someone else has taken care of a task for an enrollee. The extent of  overlap and the lack of information sharing by the FRCP have prompted  some programs to limit FRCs’ involvement with servicemembers when  they are receiving initial medical treatment at a military treatment facility.  At two of the military treatment facilities we visited, for example, a  military program serving wounded servicemembers delays referrals to the  FRCP until a servicemember approaches the point when he or she is  preparing to transition to another facility or VA.
subsections: section_title: Information Disclosure Requirements Limited the FRCP’s Information Sharing with DOD’s Wounded Warrior Programs
paragraphs: Prior to January 2011, VA had not completed public disclosure actions  necessary to enable the sharing of information from the Veterans Tracking  Application, the information system used by the FRCP that contains each  enrollee’s personal information and Federal Individual Recovery Plan. As a  result, VA management had advised the FRCP that the program could not  provide staff of non-VA programs (such as those affiliated with DOD) with  its enrollees’ personally identifiable information, such as names,  addresses, Social Security numbers, and details of Federal Individual  Recovery Plans. Specifically, VA had not completed the System of  Records Notification process for the Veterans Tracking Application, a  process required by the Privacy Act of 1974 that requires federal agencies  to publish in the Federal Register a notice of the existence, purpose, and  routine uses of every “system of records” that contains information that  may be linked to individuals.
Although this limitation did not prevent FRCs from performing their care  coordination responsibilities, it has been a source of frustration for others.  Specifically, officials of several of DOD’s wounded warrior programs  contend that the inability to receive enrollment information from the  FRCP has caused difficulties. The director of one program, for example,  told us that not having the names of servicemembers enrolled in the FRCP  resulted in a situation in which an FRC and a wounded warrior program  Recovery Care Coordinator were not aware that 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 Recovery Care Coordinator set a goal of remaining on active  duty. These conflicting goals caused considerable confusion for this  servicemember and his family. Furthermore, leadership officials of two of  the military services’ wounded warrior programs told us that they have  instructed their staff not to make referrals to the FRCP to avoid confusion  and potential duplication of activities, citing issues associated with  information sharing.
In August 2010, prompted by the FRCP, VA initiated the public-disclosure  process to facilitate information sharing. In December 2010, VA published  a notice in the Federal Register that describes the compilation of  information in the Veterans Tracking Application and routine uses of that  information. VA received no comments on the notice during the public  comment period, which ended on January 10, 2011. The new system of  records became effective on that date and the FRCP was able to share  certain enrollee information, such as the names of enrollees, with DOD  programs.
section_title: DOD and VA Data System Incompatibility Impedes Information Sharing among the FRCP and DOD’s Wounded Warrior Programs
paragraphs: Another factor that limits information sharing is the inability of the  information systems used by the FRCP, the DOD Recovery Coordination  Program, and the five military services’ wounded warrior programs to  exchange information directly with one another. As a result, FRCs cannot  readily access information from data systems used by case management  programs about their enrollees and information about an individual cannot  be easily transferred among systems. To help address this issue, the FRCP  has spearheaded an effort, known as the Information Sharing Initiative, to  identify an approach for the direct exchange of information between DOD  and VA care coordination and case management information systems in  the future. The FRCP Executive Director explained that this initiative  primarily includes identifying the data that need to be exchanged as well  as identifying the data systems where these data originate and  subsequently developing a technical solution to electronically exchange  this information. Further, she noted that the Information Sharing Initiative  is a grassroots effort and that work on the initiative has been performed by  DOD and VA employees in addition to their normal duties, making a  completion date difficult to estimate. An official from the Interagency  Program Office, which oversees major information technology initiatives  jointly undertaken by DOD and VA, said that the Information Sharing  Initiative was a well-considered initial step but notes that the ultimate goal  of direct information exchange among programs’ information systems  faces daunting challenges, such as resolving conflicting DOD and VA  policies pertaining to information exchange. We have previously reported  on DOD’s and VA’s efforts to electronically exchange health care  information, including the departments’ progress toward increasing their  capabilities to share medical and nonmedical history and physical exam  data. We have found that despite the departments’ progress, their efforts  to meet clinicians’ evolving needs to exchange health information and to  create a single lifetime electronic record for each servicemember, which is  intended to streamline the transition of electronic records between the  two departments, are ongoing.
Recognizing that these limitations on information sharing exist, the FRCP  is also taking steps to emphasize FRCs’ principal role of coordinating with  case managers rather than providing services to enrollees themselves,  which should help prevent unintentional duplication of effort. Because  FRCs may provide a direct service in some instances, proper information  sharing is necessary so that staff from multiple programs may not  unknowingly perform the same task for an enrollee. 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. According to the FRCP  Executive Director, the Federal Individual Recovery Plan process has  been improved to encourage coordination by FRCs and also to reinforce  their primary role as care coordinators. To accomplish these objectives, in  January 2011 the FRCP upgraded the Veterans Tracking Application, in  which Federal Individual Recovery Plans are maintained, by adding a  record of the names of the case managers who are responsible for  completing activities linked to enrollees’ planning goals. In addition, the  Veterans Tracking Application began displaying indicators to inform each  FRC about the completion status of every goal-related activity planned for  each enrollee, based on the completion dates that the FRCs put into the  system. The FRCP Executive Director believes that such an indicator  system, when linked to the names of the case managers who are  responsible for completing the activities, will reinforce the FRCs’ care  coordination role by encouraging them to actively follow up with others  on the status of individual tasks rather than taking on these tasks  themselves.
section_title: FRCs Face Difficulties in Obtaining Access to Equipment, Technology Support, and Work Space at Their Medical Facilities, but FRCP Leadership Is Taking Steps to Remedy These Issues
paragraphs: FRCs and others identified several types of logistical problems that have  affected the FRCs’ ability to carry out their responsibilities in dealing with  FRCP enrollees and coordinating with wounded warrior programs. These  issues center around three specific areas: provision of equipment (such as  computers, printers, landline telephones, and BlackBerrys), technology  support (such as equipment maintenance, software upgrades, and systems  security), and private work space at the medical facilities.
Provision of equipment. Most of the FRCs’ work is done using  computers, accessing data management systems, and communicating with  enrollees and DOD and VA facility staff by e-mail and phone. However,  about half of the FRCs told us that they have been hindered in their ability  to perform their care coordination responsibilities by the lack of  appropriate technology resources at the facilities at which they work.  Some FRCs expressed frustration with delays in obtaining appropriate  computer or communications equipment when they first reported to their  facilities, and this experience was echoed by nearly all of the FRCs hired  in January 2010. For example, one FRC said she waited more than 6 weeks  at the facility to receive a DOD computer and landline telephone. Another  FRC reported that he has found that e-mail is an effective mode of  communication with enrollees with traumatic brain injuries because he  can provide detailed instructions to them, but when he was hired he did  not receive a DOD computer and a landline telephone with long-distance  calling capability for 8 months. Consequently, he had to resort to mailing  letters and brochures to current and potential enrollees.
Technology support. In addition to the lack of equipment, some FRCs  cited the lack of technology support as a factor that hindered their care  coordination activities. Technological support includes functions such as  connectivity to information systems, installing security systems, and  equipment upgrading and repair. An FRCP deputy director told us that the  lack of such support is often experienced by new FRCs, but it is also an  ongoing issue for many, especially after a facility computer system is  upgraded and the FRCs’ equipment becomes incompatible. Additionally,  several FRCs have had difficulty with their BlackBerrys, either because  the facility was unable to install a security patch needed to access e-mails  or because poor reception made the device unusable. Some FRCs also  reported their inability to access DOD medical records (although this issue  is beyond the scope of a single program to address)—for example, FRCs  located at VA medical centers must ask FRCs at military treatment  facilities to access enrollees’ DOD records and then fax them to the FRCs  at the VA medical centers. Finally, FRCP officials noted that equipment  repair has been a problem for some FRCs—one FRC told us that she had  to use a malfunctioning laptop computer issued to her by the local VA  medical center for 8 months.
Work space. Some FRCs noted that they had been assigned work space at  the facility that was unsuitable for conducting sensitive conversations with  enrollees, family members, and coworkers. At a major medical center, we  observed that FRCs were located in tightly spaced cubicles that allowed  nearby staff to easily overhear their conversations. A recently transferred  FRC told us that when she arrived at her new medical center, she found  that she had no office and had been located in an open room that serves as  the call center for triage nurses. Lacking the privacy needed to make  confidential calls to her enrollees, this FRC resorted to making sensitive  phone calls from her car in the parking lot. At another treatment facility,  an FRC who shared an office with staff from another program had to take  phone calls with enrollees in the stairwell in order to have privacy. Finally,  two recently hired FRCs were not only placed in the same office but also  had to share the same desk.
The provision of equipment, technology support, and work space is  covered by memoranda of agreement between the FRCP and the DOD and  VA facilities where FRCs are located. However, an FRCP deputy director  told us that obtaining compliance with the memoranda of agreement at  some facilities is an ongoing challenge and that equipment maintenance  and systems upgrades are persistent issues for all FRCs. In some  instances, after FRCs had made repeated requests for needed resources  without result, the FRCP Executive Director intervened with medical  center officials or through the Senior Oversight Committee to obtain a  resolution. A leadership official for a wounded warrior program told us  that some military medical centers have difficulty satisfying requests for  equipment and space from programs such as the FRCP because these  facilities house and support various DOD and VA support programs and all  make requests for resources. This official pointed out that at one military  treatment facility, a military case manager was relocated in order to make  an office available to an FRC. An FRCP deputy director added that given  the frequent turnover of military staff, medical center officials are  sometimes unaware that their facility is responsible for providing  resources and services to FRCs.
FRCP officials reviewed existing memoranda of agreement between the  FRCP and DOD and VA medical facilities to determine where  improvements could be made to ensure that the FRCs have the tools and  privacy required to do their work. The program has developed three new  templates for memoranda of agreement that will be used when FRCs are  located in new settings: one each for military treatment facilities, VA  medical centers where servicemembers and veterans with polytrauma  injuries receive care, and military wounded warrior programs. These new  memoranda are more detailed than the previous versions, and they  identify who is responsible for providing specific resources and services.  The FRCP is using the revised agreements in its negotiations for logistical  support for newly placed FRCs at two VA medical centers and with the  Special Operations Command wounded warrior program. Following  implementation of the new memoranda of agreement, the FRCP plans to  revise existing agreements to make them consistent with the newer  versions, but no specific timetable has been established to complete these  revisions.
section_title: Conclusions
paragraphs: Since its inception, the FRCP has increased the number of enrollees,  enlarged its staff considerably, and expanded the number of locations  where FRCs are assigned. However, the program faces significant  challenges as it matures. As the first joint care coordination program for  DOD and VA, the FRCP represents a new paradigm in patient support for  the departments. Because of its unprecedented nature, the program  cannot refer to preexisting data or policies and procedures to manage the  program, and as a result, FRCP leadership had to develop management  processes as the program was being implemented and has largely relied on  informal processes to oversee and manage key aspects of the program.  However, now that the program has been operating for several years and  continues to grow, it has become apparent that the program would benefit  from more definitive management processes to strengthen program  oversight and decision making.
While the program has overcome some early setbacks and has established  processes related to enrollment and staffing, these processes are not  clearly documented or systematic. Because enrollment decisions are not  well documented or systematically reviewed by FRCP leadership, it is  unclear whether referred servicemembers and veterans who need FRC  services are being enrolled in the program. Additionally, as the number of  individuals enrolled in the program steadily increases, it will be important  for the FRCP to appropriately balance FRCs’ workload to ensure that  enrollees receive the services they need and to prevent FRC burnout.  While program leadership recognizes this issue and is developing a  customized workload tool, there is no firm timeline for the completion of  this effort. The FRCP also needs clearly documented processes and  criteria for guiding staffing and placement decisions. Without this, it will  be difficult to provide continuity to subsequent program leadership and to  place FRCs where they would best serve the needs of current and future  enrollees.
Some of the daunting challenges facing FRCs and the program are beyond  the capability of the program’s leadership to resolve. The exchange of  information among DOD and VA data systems, in particular, has been a  long-standing issue and will require interdepartmental action. Similarly,  the duplication of effort resulting from the proliferation and overlap of  DOD and VA programs that support recovering servicemembers and  veterans can best be resolved through interdepartmental coordination and  action.
section_title: Recommendations for Executive Action
paragraphs: We recommend that the Secretary of Veterans Affairs direct the Executive  Director of the FRCP to take four actions:  1.  Ensure that referred servicemembers and veterans who need FRC  services are enrolled in the program by establishing adequate internal  controls regarding the FRCs’ enrollment decisions. To accomplish this,  the FRCP leadership should require FRCs to record in the Veterans Tracking Application the  factors they consider in making an enrollment decision,    develop and implement a methodology and protocol for assessing the  appropriateness of enrollment decisions, and refine the methodology as needed. 2.  Complete development of the FRCP’s workload assessment tool that  will enable the program to assess the complexity of services needed by  enrollees and the amount of time required to provide services to  improve the management of FRCs’ caseloads. 3.  Clearly define and document the FRCP’s decision-making process for  determining when and how many FRCs VA should hire to ensure that  subsequent FRCP leadership can understand the methods currently  used to make staffing decisions. 4.  Develop and document a clear rationale for the placement of FRCs,  which should include a systematic analysis of data, such as referral  locations, to ensure that future FRC placement decisions are strategic  in providing maximum benefit for the program’s population.
section_title: Agency Comments and Our Evaluation
paragraphs: DOD and VA each provided comments on a draft of this report. In its  comments, DOD stated that it continues to work with VA to fully integrate  their efforts and to increase collaboration between the two departments.  (DOD’s comments are reprinted in app. II.) In its comments, VA stated that  it generally agrees with GAO’s conclusions and concurs with our  recommendations to the Secretary. (VA’s comments are reprinted in app.  III.) VA’s responses to each of our recommendations are as follows:    To ensure that referred servicemembers and veterans who need FRC  services are enrolled in the program, VA indicated that the FRCP will  document decisions and factors used to assess a potential enrollee’s  eligibility for the program. In addition, the program will establish clear  documentation requirements according to a defined protocol within the  program’s data management system.
To complete the development of the FRCP’s workload assessment tool, VA  indicated that the FRCP will continue field-testing a new assessment tool,  which will require at least a year to complete.
To document the decision-making process for determining when and how  many FRCs VA should hire, VA stated that the FRCP will clearly document  the current process used for making staffing decisions. In addition, the  staffing processes and plans will be updated annually in the FRCP  business operation planning document.
To develop and document a clear rationale for the placement of FRCs, VA  indicated that the FRCP will develop an FRC placement strategy based  upon a systematic analysis of data over the next 6 months. This process  will be documented and updated annually in the FRCP business operation  planning document.
VA provided an additional comment regarding the progress made toward  the exchange of data between VA and DOD’s wounded warrior  information systems. VA stated that it anticipates that an initial set of data  will be available for exchange between VA and DOD by the end of fiscal  year 2011. The departments plan to expand the exchange of data to  support improved collaboration on care plans in fiscal year 2012.
We are sending copies of this report to the Secretary of Defense and the  Secretary of Veterans Affairs and other interested parties. The report also  is available at no charge on the GAO Web site at http://www.gao.gov.
If you or your staff members have any questions about this report, please  contact me at (202) 512-7114 or williamsonr@gao.gov. Contact points for  our Offices of Congressional Relations and Public Affairs may be found on  the last page of this report. Key contributors to this report are listed in  appendix IV.
section_title: Appendix I: The Use of Software to Analyze Testimonial Evidence
paragraphs: To conduct a content analysis of our interviews with program officials and  medical facility staff, we used a qualitative data analysis software package.  The software facilitated our analysis of over 150 of the 170 interviews we  conducted and helped us to identify and quantify interviewees’ responses  on various topics. The program’s coding capabilities allowed us to group  our interviewees’ responses into categories. It also provided a centralized  location where all of our documents could be reviewed and analyzed.
We took a number of steps to ensure that our analysis was  methodologically sound. First, we defined categories to organize the views  of the Department of Defense and the Department of Veterans Affairs  program officials and medical facility staff by specific topics, including the  Federal Recovery Coordination Program’s (FRCP) eligibility criteria, the  interviewees’ interactions with the Federal Recovery Coordinators (FRC),  overlap and duplication of activities among the FRCP and the case  management programs with which the FRCs interacted, knowledge of the  FRC role, and challenges faced by the FRCs. These categories were  chosen based on themes we heard during our interviews with the program  officials and medical facility staff. We conducted an intercoder reliability  check to ensure the accuracy of the category definitions. To do this, two  analysts coded a sample of 15 interviews into the categories. A  methodologist compared the analyses to determine where inconsistencies  occurred and, as a result, what categories needed more specific  definitions.
Once the category definitions were finalized, the same two analysts  divided the categories among them and coded their categories for all of  the interview documents. When the coding was completed, both analysts  reviewed every code made by the other analyst and indicated whether they  agreed or disagreed with the code. Changes were then made accordingly.  We subsequently analyzed the interviewees’ responses based on the  defined categories. This analysis allowed us to quantify interviewees’  responses within each category.
section_title: Appendix II: Comments from the Department of Defense
section_title: Appendix III: Comments from the Department of Veterans Affairs
section_title: Appendix IV: GAO Contact and Staff Acknowledgments
subsections: section_title: Staff Acknowledgments
paragraphs: In addition to the contact named above, Bonnie Anderson, Assistant  Director; Susannah Bloch; Frederick Caison; Elizabeth Conklin; Cynthia  Gilbert; Deitra Lee; Lisa Motley; Kristina Martin; Steven Putansu; and  Suzanne Worth made key contributions to this report.