Recovering Servicemembers and Veterans: Sustained Leadership Attention and Systematic Oversight Needed to Resolve Persistent Problems Affecting Care and Benefits
Published: 2012-11-16T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: The National Defense Authorization Act for Fiscal Year 2008 required DOD and VA to jointly develop and implement policy on the care, management, and transition of recovering servicemembers. It also required GAO to report on DOD's and VA's progress in addressing these requirements. This report specifically examines (1) the extent to which DOD and VA have resolved persistent problems facing recovering servicemembers and veterans as they navigate the recovery care continuum, and (2) the reasons DOD and VA leadership have not been able to fully resolve any remaining problems. To address these objectives, GAO visited 11 DOD and VA medical facilities selected for population size and range of available resources and met with servicemembers and veterans to identify problems they continue to face. GAO also reviewed documents related to specific DOD and VA programs that assist recovering servicemembers and veterans and interviewed the leadership and staff of these programs to determine why problems have not been fully resolved.
section_title: What GAO Found
paragraphs: Deficiencies exposed at Walter Reed Army Medical Center in 2007 served as a catalyst compelling the Departments of Defense (DOD) and Veterans Affairs (VA) to address a host of problems for wounded, ill, and injured servicemembers and veterans as they navigate through the recovery care continuum. This continuum extends from acute medical treatment and stabilization, through rehabilitation to reintegration, either back to active duty or to the civilian community as a veteran. In spite of 5 years of departmental efforts, recovering servicemembers and veterans are still facing problems with this process and may not be getting the services they need. Key departmental efforts included the creation or modification of various care coordination and case management programs, including the military services' wounded warrior programs. However, these programs are not always accessible to those who need them due to the inconsistent methods, such as referrals, used to identify potentially eligible servicemembers, as well as inconsistent eligibility criteria across the military services' wounded warrior programs. The departments also jointly established an integrated disability evaluation system to expedite the delivery of benefits to servicemembers. However, processing times for disability determinations under the new system have increased since 2007, resulting in lengthy wait times that limit servicemembers' ability to plan for their future. Finally, despite years of incremental efforts, DOD and VA have yet to develop sufficient capabilities for electronically sharing complete health records, which potentially delays servicemembers' receipt of coordinated care and benefits as they transition from DOD's to VA's health care system.
Collectively, a lack of leadership, oversight, resources, and collaboration has contributed to the departments' inability to fully resolve problems facing recovering servicemembers and veterans. Initially, departmental leadership exhibited focus and commitment--through the Senior Oversight Committee--to addressing problems related to case management and care coordination, disability evaluation systems, and data sharing between DOD and VA. However, the committee's oversight waned over time, and in January 2012, it was merged with the VA/DOD Joint Executive Council. Whether this council--which has primarily focused on long-term strategic planning--can effectively address the shorter-term policy focused issues once managed by the Senior Oversight Committee remains to be seen. Furthermore, DOD does not provide central oversight of the military services' wounded warrior programs, preventing it from determining how well these programs are working across the department. However, despite these shortcomings, the departments continue to take steps to resolve identified problems, such as increasing the number of staff involved with the electronic sharing of health records and the integrated disability evaluation process. Additionally, while the departments' previous attempts to collaborate on how to resolve case management and care coordination problems have largely been unsuccessful, a joint task force established in May 2012 is focused on resolving long-standing areas of disagreement between VA, DOD, and the military services. However, without more robust oversight and military service compliance, consistent implementation of policies that result in more effective case management and care coordination programs may be unattainable. GAO recommends that DOD provide central oversight of the military services' wounded warrior programs and that DOD and VA sustain high-level leadership attention and collaboration to fully resolve identified problems. DOD partially concurred with the recommendation for central oversight of the wounded warrior programs, citing issues with common eligibility criteria and systematic monitoring. DOD and VA both concurred with the recommendation for sustained leadership attention.
section_title: What GAO Recommends
paragraphs: GAO recommends that DOD provide central oversight of the military services wounded warrior programs and that DOD and VA sustain high-level leadership attention and collaboration to fully resolve identified problems. DOD partially concurred with the recommendation for central oversight of the wounded warrior programs, citing issues with common eligibility criteria and systematic monitoring. DOD and VA both concurred with the recommendation for sustained leadership attention.

section_title: Letter
paragraphs: A series of media reports in early 2007 disclosed troublesome  deficiencies in the provision of outpatient services at Walter Reed Army  Medical Center in Washington, D.C. These reports prompted broader  questions about whether the Departments of Defense (DOD) and  Veterans Affairs (VA) were fully prepared to meet the needs of the  growing number of servicemembers and veterans returning from recent  conflicts. Several review groups were subsequently tasked with  investigating the reported problems and identifying recommendations.  These groups identified common areas of concern including: inadequate  case management to ensure continuity of care, confusing disability  evaluation systems, and insufficient sharing of servicemembers’ health  records and other data between DOD and VA—all long-standing  problems that we have reported on extensively.
To elevate the response to concerns raised by these review groups, DOD  and VA established the Wounded, Ill, and Injured Senior Oversight  Committee (Senior Oversight Committee) in May 2007. The committee  was intended to operate on a short-term basis to review and implement  the recommendations made by the various review groups and improve  seamlessness in the provision of care for recovering servicemembers and  veterans. It was cochaired by the Deputy Secretaries of Defense and  Veterans Affairs and included the military service Secretaries and other  high-ranking officials within the departments. Congress subsequently  passed the National Defense Authorization Act for Fiscal Year 2008  (NDAA 2008) requiring the Secretary of Defense and the Secretary of  Veterans Affairs to jointly develop and implement policy, to the extent  feasible, to improve the care, management, and transition of recovering  servicemembers. Because of its related ongoing work, the Senior  Oversight Committee also assumed responsibility for addressing these  requirements.
Despite actions taken by DOD and VA to address the problems identified  at Walter Reed in 2007, concerns remain that recovering servicemembers  and veterans continue to face many of the same problems as they did in  2007 navigating the recovery care continuum, from acute medical  treatment and stabilization, through rehabilitation, to reintegration—either  back to active duty or to the civilian community as a veteran. In 2009,  Congress required DOD to establish a task force to assess the  effectiveness of DOD programs and policies developed to assist  recovering servicemembers and to make recommendations for   The DOD Task  continuous improvements of such policies and programs. Force on the Care, Management, and Transition of Recovering Wounded,  Ill, and Injured Members of the Armed Forces—referred to as the  Recovering Warrior Task Force—issued its first report in September  2011; it contained 21 recommendations on a variety of issues affecting  recovering servicemembers. Additionally, congressional committees held  multiple hearings in 2010 and 2011 that highlighted ongoing difficulties  facing these servicemembers and veterans, including issues with  duplication and poor coordination among case management and care  coordination programs, delays in completing the disability evaluation  process, and the lack of full interoperability between DOD’s and VA’s  computer systems.
The NDAA 2008 required that we report on DOD’s and VA’s progress in  developing and implementing joint policy on issues related to the care,  management, and transition of recovering servicemembers. As  discussed with the committees of jurisdiction, we have reviewed and  reported on the departments’ progress with respect to various topic areas.  This review, which is focused on the continuity of care for recovering  servicemembers and veterans, is the latest in our body of work. In this  review, we are reporting on  1.  the extent to which DOD and VA have resolved persistent problems  facing recovering servicemembers and veterans as they navigate the  recovery care continuum and  2.  the reasons DOD and VA leadership have not been able to fully  resolve any remaining problems.
To respond to these objectives, we interviewed the directors of the  following case management and care coordination programs,the Army Warrior Care and Transition Command’s Warrior Transition  Units and the Army Wounded Warrior Program,  the Navy Safe Harbor Program,  the Air Force Recovery Care Program and the Air Force Wounded  Warrior Program, the Marine Corps Wounded Warrior Regiment, the United States Special Operations Command’s Care Coalition, the Federal Recovery Coordination Program, and
VA’s Operation Enduring Freedom/Operation Iraqi Freedom/  Operation New Dawn (OEF/OIF/OND) Care Management Program.
We collected data for each of these programs, such as the number of  enrollees over time. (See app. I for data on enrollment and population  characteristics for these programs.) We also reviewed documents  describing the scope, mission, and leadership of these selected  programs.
In addition, we took the following steps to determine the extent to which  DOD and VA have resolved persistent problems affecting recovering  servicemembers and veterans along the recovery care continuum:
We visited a judgmental sample of 11 DOD military treatment facilities  (MTF) and VA Medical Centers (VAMC) to identify variations in how  care coordination and case management programs are being  operated at the local level. We focused on Army and Marine Corps  MTFs because, collectively, the wounded warrior programs for these  military services serve more than 70 percent of the wounded, ill, and  injured servicemember and veteran population. We selected facilities  that provide or have access to significant medical and rehabilitation  resources as well as facilities that have fewer medical or rehabilitation  resources. The sites we visited included MTFs at Fort Bragg (N.C.),  Fort Knox (Ky.), Fort Carson (Colo.), Fort Belvoir (Va.), Fort Meade  (Md.), Walter Reed National Military Medical Center (Md.), Camp  Lejeune (N.C.), and Quantico (Va.), and VAMCs in Richmond,  Virginia; Denver, Colorado; and the District of Columbia. At these  facilities, we met with local leadership officials and the officials  responsible for managing the facilities’ case management and care  coordination programs, and we obtained information on how these  programs were working as well as the types of problems that  recovering servicemembers and veterans continue to face. While at  these facilities, we met with recovering servicemembers and veterans  to obtain information about their experiences.
We interviewed officials from military and veteran advocacy groups to  obtain their members’ perspective on any problems that persist in  navigating the recovery care continuum.
We interviewed the director of the VA Liaison for Healthcare Program  to understand VA’s role in assisting recovering servicemembers’  transition from DOD’s to VA’s health care system.
We met with members of the Recovering Warrior Task Force,  reviewed relevant task force documentation, and attended its public  meetings to obtain information about problems they identified that  affect recovering servicemembers and veterans.
We reviewed published and ongoing studies and GAO reportsdescribing problems that recovering servicemembers and veterans  face, including issues related to the disability evaluation system and  the electronic sharing of health records between DOD and VA.
To identify the reasons why DOD and VA leadership have not fully  resolved any remaining problems facing recovering servicemembers and  veterans, we reviewed relevant documentation to identify the roles of  DOD and VA offices that coordinate or oversee case management or  care coordination programs, their placement within their respective  departments, and whether and how these offices monitor the  performance of the programs we reviewed. We also obtained information  about organizational and program changes, including officials’ views  about the potential impact of these changes. We also interviewed key  DOD and VA leadership officials, such as the Deputy Assistant Secretary  of Defense for Wounded Warrior Care and Transition Policy, VA’s Chief  of Staff, and former and current officials from the departments’  coordinating and oversight offices, including the Senior Oversight  Committee, DOD’s Office of Wounded Warrior Care and Transition  Policy, the Interagency Program Office, and the VA/DOD Collaboration  Service, which is an office within VA. To obtain information about recent  efforts DOD and VA have initiated to address problems facing  servicemembers and veterans, we interviewed DOD and VA officials  participating in these activities, including officials involved in the DOD and  VA Warrior Care and Coordination Taskforce. We also reviewed the  documentation available regarding the departments’ recent efforts;  however, we predominately relied on testimonial evidence provided by  these officials.
The NDAA 2008 also requires us to certify whether we had timely access  to sufficient information to make informed judgments on the matters  covered by our report. We were provided sufficient information in a timely  manner to assess the extent to which DOD and VA have resolved  persistent problems facing recovering servicemembers and veterans as  they navigate the recovery care continuum and the reasons DOD and VA  leadership have not been able to fully resolve any remaining problems.
We conducted this performance audit from July 2011 through September  2012 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: Review groups identified significant problems after the media reports  concerning Walter Reed. Initial efforts to respond to these problems were  primarily coordinated through the Senior Oversight Committee, and DOD  and VA undertook additional efforts to respond to these problems.
subsections: section_title: Review Groups Identified Problems across the Recovery Care Continuum
paragraphs: Following the revelations at Walter Reed, several review groups noted  significant problems that may arise during servicemembers’ recovery from  wounds, illnesses, and injuries. Some of these problems involve the  provision of appropriate medical care, while others involve the acquisition  of needed DOD and VA benefits. In 2007, one of the review groups, the  President’s Commission on Care for America’s Returning Wounded  Warriors—commonly referred to as the Dole-Shalala Commission—noted  that recovering servicemembers depend on the effective and efficient  provision of medical services and benefits across the recovery care  continuum, which is separated into three phases:  recovery, when wounded, ill, and injured servicemembers are  stabilized and receive acute inpatient medical treatment at an MTF,  VAMC, or private medical facility;  rehabilitation, when recovering servicemembers with complex trauma,  such as missing limbs, receive medical and rehabilitative care; and  reintegration, when servicemembers either return to active duty or to  the civilian community as veterans.
A recovering servicemember or veteran may not experience the recovery  care continuum as a linear process, and may move back and forth across  the continuum over time, depending on his or her medical needs. For  example, a servicemember who has transitioned to the rehabilitation  phase may go back to the recovery phase if there is a need to return to  an MTF to obtain acute medical care, such as a surgical procedure.
section_title: Initial Efforts to Address Problems Were Coordinated by the Senior Oversight Committee
paragraphs: DOD and VA took a number of steps to address the problems identified  by the review groups that investigated the issues raised by the Walter  Reed media reports. As an initial step, the departments established the  Senior Oversight Committee to coordinate and oversee DOD’s and VA’s  efforts to jointly resolve these problems. Through this committee, DOD  and VA created programs and initiatives to assist recovering  servicemembers and veterans as they navigate the recovery care  continuum. Key efforts included the establishment of the integrated  disability evaluation system (IDES), the Federal Recovery Coordination  Program (FRCP), the Recovery Coordination Program (RCP), and the  Interagency Program Office. (See fig. 1.)
Senior Oversight Committee. The Senior Oversight Committee was  responsible for ensuring that the recommendations—which totaled more  than 600 from the various review groups—were properly reviewed,  coordinated, implemented, and resourced. Supporting the Senior  Oversight Committee was an Overarching Integrated Product Team, the  membership of which included the Assistant Secretaries of Defense, the  military departments’ Assistant Secretaries for Manpower and Reserve  Affairs, and various senior officials from DOD and VA. This team  coordinated, integrated, and synchronized the work of the eight “Lines of  Action” (LOA) that focused on specific issues, including case  management, disability evaluation systems, and data sharing between  DOD and VA. (See fig. 2.)
Each LOA included representation from DOD, including each military  service, and VA. They performed the bulk of the work to address the  issues and recommendations of the various review groups, including  establishing plans, setting and tracking milestones, and identifying and  enacting early and short-term solutions. More specifically, the LOAs were  as follows:
LOA 1—Disability Evaluation: Responsible for addressing efforts to  reform the DOD and VA disability evaluation systems.
LOA 2—Traumatic Brain Injury (TBI)/Post Traumatic Stress Disorder  (PTSD): Responsible for addressing issues related to TBI/PTSD.
LOA 3—Case Management: Responsible for addressing issues  related to the care, management, and transition of recovering  servicemembers from recovery to rehabilitation and reintegration.
LOA 4—DOD/VA Data Sharing: Responsible for addressing issues  regarding the electronic exchange of DOD and VA health records.
LOA 5—Facilities: Responsible for addressing issues relating to  military and VA medical facilities.
LOA 6—”Clean Sheet” Review: Developed recommendations to  improve care and benefits without the constraints of existing laws,  regulations, organizational roles, personnel constraints, or budgets.
LOA 7—Legislation and Public Affairs: Responsible for addressing  legal and other issues for policy development.
LOA 8—Personnel, Pay, and Financial Support: Responsible for  addressing compensation and benefit issues.
Some of the key efforts initiated out of the LOAs included the  establishment of an integrated disability evaluation system, care  coordination programs, and steps towards the electronic exchange of  DOD and VA health records—a responsibility that was later assumed by  the Interagency Program Office.
DOD/VA Integrated Disability Evaluation System. Through LOA 1, DOD  and VA jointly began to develop and pilot IDES to improve the disability  evaluation process by eliminating duplication in DOD’s and VA’s separate  evaluation systems and expediting the receipt of VA benefits. Specifically,  IDES merges DOD’s and VA’s separate medical exams for  servicemembers into a single exam process; consolidates DOD’s and  VA’s separate disability rating decisions into a single VA rating decision;  and provides staff to perform outreach and nonclinical case management  and explain VA results and processes to servicemembers. By October  2011, DOD and VA had fully deployed IDES at 139 MTFs in the United  States and several other countries.
Care Coordination Programs. LOA 3 took the lead role in addressing  problems with uncoordinated case management for recovering  servicemembers and veterans through the establishment of two care  coordination programs—the FRCP and the RCP. The FRCP was based  on a recommendation from the Dole-Shalala Commission that a single  individual—a recovery coordinator—would work with existing DOD and  VA case managers to ensure that servicemembers had the resources  needed for their care. LOA 3 designed the FRCP to assist “severely”  wounded, ill, and injured OEF and OIF servicemembers, veterans, and  their families with access to care, services, and benefits. This population  includes servicemembers and veterans who suffer from traumatic brain  injuries, amputations, burns, spinal cord injuries, visual impairment, and  PTSD. The program uses federal recovery coordinators to monitor and  coordinate clinical services, including facilitating and coordinating medical  appointments, and nonclinical services, such as providing assistance with  obtaining financial benefits or special accommodations, needed by  program enrollees and their families. Federal recovery coordinators, who  are senior-level registered nurses and licensed clinical social workers,  were intended to serve as the single point of contact among all of the  case managers of DOD, VA, and other governmental and  nongovernmental programs that provide services directly to  servicemembers and veterans. Although the FRCP was designed as a  joint program, it is administered by VA, and the federal recovery  coordinators are VA employees.
LOA 3 subsequently developed the RCP in response to a requirement in  the NDAA 2008. The RCP is a DOD-specific program that uses recovery  care coordinators to coordinate nonclinical services and resources for  “seriously” wounded, ill, and injured servicemembers who may return to  active duty, unlike those categorized as “severely” wounded, ill, and  injured, who are not likely to return to duty and would be served by the  FRCP. The military services were responsible for separately  implementing the RCP through each of their existing wounded warrior  programs as a means of providing care coordination services to program  enrollees.
Electronic Sharing of Health Records. LOA 4 was focused on addressing  issues related to the electronic exchange of DOD and VA health records.  However, this effort was superseded by the NDAA 2008, which required  the establishment of the Interagency Program Office to serve as a single  point of accountability for both departments in the development and  implementation of interoperable electronic health records.DOD and VA retained the responsibility for the development and   Although  management of the information technology systems, the Interagency  Program Office was responsible for ensuring the implementation of an  electronic health records system or capabilities that allowed for the  complete sharing of health care information for the provision of clinical  care. In October 2011, the Interagency Program Office also became  accountable for DOD’s and VA’s work on developing an integrated  electronic health records system that both departments would use for  their beneficiaries.
section_title: Additional Efforts by DOD and VA to Address Problems Facing Recovering Servicemembers and Veterans
paragraphs: In addition to the Senior Oversight Committee’s efforts, DOD, its military  services, and VA developed or modified a number of programs and  initiatives to assist recovering servicemembers and veterans in navigating  the recovery care continuum.
Military Services’ Wounded Warrior Programs. The military services’  wounded warrior programs were established to assist recovering  servicemembers during their recovery, rehabilitation, and initial  reintegration back to active duty or to civilian life. Most of these programs  provide nonclinical case management services to the recovering  servicemembers; that is, they help to resolve issues related to finances,  benefits and compensation, administrative and personnel paperwork,  housing, and transportation. In addition, the wounded warrior programs  serve as the central point of access to other types of services or  resources that support recovering servicemembers, such as clinical case  management, care coordination, and career, education, and readiness  services. (See table 1.) If a wounded warrior program does not directly  provide a service or resource, it can facilitate servicemembers’ access to  that service or resource. Although the wounded warrior programs were  intended mainly to provide services to recovering servicemembers, all but  one of the programs continue to assist individuals after they have  transitioned to veteran status.
VA Transition Programs. VA’s Liaison for Healthcare Program and its  OEF/OIF/OND Care Management Program assist recovering  servicemembers with transitioning from DOD’s to VA’s health care  system. As of August 2012, the Liaison for Healthcare Program employed  33 liaisons at 18 MTFs nationwide. After a DOD or VA treatment team  determines that a recovering servicemember is medically ready to  transition to a VAMC, a VA liaison facilitates the transfer from an MTF to  a VAMC closest to their homes or to the most appropriate locations for  the specialized services their medical condition requires. VA liaisons  follow recovering servicemembers as they enter the VA health care  system, ensuring that their first VA appointments are scheduled.  Thereafter, the VA OEF/OIF/OND Care Management Program team  assigned to each recovering individual coordinates the individual’s care at  the VAMC and provides ongoing follow-up.OEF/OIF/OND Care Management Program team in place to coordinate  patient care activities.
section_title: DOD and VA Have Not Fully Resolved Persistent Problems with Case Management and Care Coordination, Disability Evaluation Systems, and Electronic Sharing of Health Records
subsections: section_title: Recovering Servicemembers and Veterans Do Not Always Have Access to the Case Management and Care Coordination Programs Designed to Assist Them
paragraphs: Recovering servicemembers’ access to case management and care  coordination programs has been impeded by two main factors—(1) the  limited ability to identify and refer those servicemembers who could  benefit from enrollment in the programs along with officials’ reluctance to  refer them, and (2) variations in eligibility criteria among the military  services’ wounded warrior programs, resulting in access disparities for  similarly situated recovering servicemembers.
We found that referrals may be lacking or delayed (1) from military  service unit commanders to wounded warrior programs; (2) from  wounded warrior programs to the FRCP; and (3) for certain groups of  servicemembers, such as those with “invisible injuries” as well as  members of the National Guard and Reserve.
Referral to the military services’ wounded warrior programs. The military  services’ wounded warrior programs primarily use referrals to identify  recovering servicemembers that might be eligible for enrollment.  However, we found that the methods for referral, which include casualty  reports and direct referrals, are imprecise, such that all servicemembers  who could benefit from being enrolled in these programs are not  necessarily identified and referred.
Officials from three wounded warrior programs told us that casualty  reports are the primary method for receiving referrals. Casualty reports  are initial alerts to military personnel, including wounded warrior program  officials, that a servicemember has been injured. These reports can be  initiated by unit commands or other military personnel as a method of  referral to the wounded warrior programs. However, wounded warrior  program officials from four wounded warrior programs told us that  casualty reports are not created after every injury or may be created late  in a servicemember’s recovery. In particular, some of these officials said  that military service unit command staff may delay or not create casualty  reports for servicemembers not injured in combat, such as for injuries that  occur stateside or while on leave, because servicemembers’ units may  not find out about such incidents immediately.
We found that referrals by unit command staff are most likely, because they have the  most knowledge about servicemembers’ conditions, injuries, and treatment locations. their recovery as a result of staying in their units and not being referred to  a wounded warrior program earlier. For example, a recovering  servicemember told us that despite having been recently discharged from  a hospital for arm injuries, he was required to operate a floor buffing  machine in his unit, which was difficult for him as a result of his injuries.  He did not receive rehabilitative treatment for his injuries until he was  assigned to a wounded warrior program. Furthermore, we found that most  of the military services’ wounded warrior programs do not always track  the number of referrals to their programs, including data on whether or  not servicemembers referred to the programs were actually enrolled. (See  table 14 in app. I for additional information about referral data.) Without  this information, it is not clear whether all those who could benefit from a  wounded warrior program are being enrolled.
Referral to the FRCP. In addition to problems with referrals to wounded  warrior programs, wounded warrior program officials sometimes delay or  fail to make referrals of potentially eligible servicemembers to the FRCP,  which coordinates care across the departments and throughout the  recovery care continuum. As we have previously reported, the FRCP  relies predominantly on referrals from other sources, including wounded  warrior program officials and clinical treatment teams, because it does not  have a systematic way to identify potential enrollees. Referrals to the  FRCP are important because federal recovery coordinators are intended  to provide continuity of care throughout servicemembers’ recovery,  starting with their initial treatment at an MTF and throughout the recovery  care continuum. They can also assist in facilitating recovering  servicemembers’ access to VA services and benefits while  servicemembers are still on active duty, according to VA officials.  However, we found that officials from wounded warrior programs view the  jointly created and established FRCP as a VA program and, therefore,  delay their referrals until it is certain that the servicemember will become  a veteran.
Referrals for certain servicemember populations. We found that certain  servicemember populations may be at greater risk for not being identified  for DOD and VA case management and care coordination programs.
Specifically, according to wounded warrior program officials,  servicemembers who have undiagnosed, “invisible” wounds, such as  PTSD and TBI, may be at greater risk of not being referred to a wounded  warrior program or the FRCP until it becomes apparent that the  servicemember cannot be deployed. For example, a servicemember told  us that although he was experiencing anxiety every time he put on his  uniform, it was not until he had a severe anxiety attack, as a result of his  PTSD, that he was hospitalized and then referred to a wounded warrior  program. According to officials representing military advocacy  organizations, National Guard and Reserve servicemembers may be  particularly reluctant to identify injuries and illnesses because they are  eager to return home and do not want to be delayed at the installation for  an evaluation of any conditions they may have. However, these officials  said that when these servicemembers have been deactivated and  problems manifest themselves later on, they may experience difficulties  establishing that their injuries or illnesses are a result of their service in  the military, which could make it difficult for them to access services and  programs provided by DOD and VA.
Because of variations in eligibility criteria among the military services’  wounded warrior programs, DOD cannot assure that similarly situated  servicemembers have equitable access to these programs, leading to  disparities in the level of assistance provided across the military services.  (See table 2.) For example, servicemembers can only be eligible for the  Air Force Wounded Warrior Program if they have a combat-related injury  or illness, whereas servicemembers with combat or non-combat-related  injuries or illnesses can be eligible for the Army’s Warrior Transition Units.
As a result of these differences in eligibility criteria, recovering  servicemembers in one military service may qualify for entry in their  wounded warrior program while similarly situated servicemembers in  another military service do not have access to their program.  Consequently, according to wounded warrior program officials, some  recovering servicemembers do not have access to services that would  otherwise be available to them, including the RCP and Operation  Warfighter. Additionally, because wounded warrior programs facilitate  access to other programs and services, including the VA Liaison for  Healthcare Program and the Warrior Athlete Reconditioning Program,  not being eligible for a particular wounded warrior program could preclude  a servicemember from receiving the services of these other programs.  Military coalition officials who advocate for recovering servicemembers  and their families told us the lack of standardization across similar  programs, such as the military services’ wounded warrior programs, is  one of the main reasons recovering servicemembers “fall through the  cracks” or do not get the services that they need when they are  navigating the recovery care continuum.
DOD is aware of inconsistencies in eligibility criteria among the military  services’ wounded warrior programs and the potential for disparities in the  provision of services and assistance that may result. DOD has not taken  action to correct this, however, despite the identification of this issue as a  potential problem for recovering servicemembers by a congressionally  mandated DOD task force. Specifically, in its 2011 annual report to  congressional committees, the Recovering Warrior Task Force noted that  as a result of differences in eligibility criteria among the military services,  certain subpopulations of recovering servicemembers may be at a  disadvantage. In response to this report, DOD stated that although there  are no DOD-wide criteria for entry into wounded warrior programs, the  individual military services already have policies in place as a result of the  flexibility given to them by DOD.
section_title: Delays in DOD’s and VA’s Integrated Disability Evaluation System Persist, Limiting Recovering Servicemembers’ Ability to Plan for Their Future
paragraphs: Although IDES provides improved timeliness over the separate DOD and  VA disability evaluation systems, processing times have continued to  increase since its implementation in November 2007, resulting in  frustration and uncertainty for servicemembers going through the  process. In a May 2012 hearing, we testified that the average number of  days for servicemembers to complete the IDES process and receive VA  benefits increased from 283 in fiscal year 2008 to 394 in fiscal year 2011  for active duty cases (compared to the goal of 295 days) and from 297 to 420 for reserve cases, respectively (compared to the goal of 305 days).
As we have previously testified, other reasons that could impact the increase in IDES  processing times include large case loads and insufficient staff to complete a stage of  IDES in a timely manner. the status of their case. For example, a servicemember told us that after  going through the IDES process, receiving a rating, and filing an appeal  over a year ago, he still did not know the status of his case, negatively  affecting his ability to plan for his future. Similarly, a wounded warrior  program official also told us that her program has had several  servicemembers lose job opportunities because they applied for positions  thinking that they would be through the IDES process by a certain date,  but when that date was pushed back, the employers rescinded their  offers.
Wounded warrior program officials from some of the sites we visited told  us that extended waiting periods resulting from the disability process also  may lead to some recovering servicemembers engaging in negative  behavior, including drug use. Wounded warrior program officials told us  that after waiting for so long in the wounded warrior barracks due to the  lengthy disability process, servicemembers can get depressed, resist or  just stop going to medical appointments, and stop working on their  recovery. Similarly, the DOD Inspector General has reported that lengthy  IDES processing times has contributed to a negative and even  counterproductive environment, which was not conducive to  servicemembers’ recovery and transition. To prevent these problems,  we found that two wounded warrior programs require recovering  servicemembers to participate in programs such as the Warrior Athlete  Reconditioning Program and Operation Warfighter. A recovering  servicemember told us that soon after being assigned to the wounded  warrior program, he was referred to the Warrior Athlete Reconditioning  Program, which gave him something to do other than “sitting around.”  Another recovering servicemember told us that the Warrior Athlete  Reconditioning Program is an effective motivator for recovery.
Conversely, the servicemembers could take actions that may impact their  own processing times in IDES and, therefore, their length of stay in a  wounded warrior program. We found that some servicemembers may  appeal their disability decisions to prolong their own recovery and  transition out of the military. According to wounded warrior program  officials from some of the sites we visited, some servicemembers resist  their transfer out of the wounded warrior program and the military  because they want to continue to take advantage of the opportunities and  services available to them, including the financial security of a regular  paycheck. For example, a wounded warrior program official and a VA  official told us that some servicemembers will purposefully miss  appointments to delay the IDES process because they feel that they are  not ready to leave the program.
section_title: DOD and VA Have Yet to Develop Sufficient Capability to Electronically Share Health Records, Potentially Delaying Servicemembers’ Receipt of Coordinated Care and Benefits
paragraphs: The departments have not yet developed sufficient capability to  electronically share servicemembers’ and veterans’ complete health  records, which can delay the receipt of care and benefits for recovering  servicemembers and veterans. As we have previously reported, for over a  decade DOD and VA have undertaken several efforts to improve the  ability of their information technology systems to electronically share  health records. For example, the Federal Health Information Exchange,  which was started in 2001 and completed in 2004, allows DOD to  electronically transfer servicemembers’ health information to VA when  they leave active duty. In addition, the departments’ Bidirectional Health  Information Exchange was established in 2004 to allow clinicians in both  departments to view limited health information on patients who receive  care from both departments. More recently, the departments have  undertaken two new joint initiatives, the Virtual Lifetime Electronic Record  and an integrated electronic health records system, in an effort to  increase electronic health record interoperability and modernize their  systems.
We found that although DOD and VA care providers were expected to  have access to some electronic health record information across the  departments, the DOD and VA care providers that we spoke to still did  not have the ability to electronically share complete health records for  recovering servicemembers who were transferring between DOD’s and  VA’s health care systems, and therefore they had to use other methods.
For example, wounded warrior program and VA officials told us that they  had to resort to copying and faxing recovering servicemembers’ health  records to VAMC staff in preparation for a servicemember’s transition  from DOD’s to VA’s health care system because there was not an  automatic, electronic way to transfer them. In addition to copying and  faxing health records, according to VA officials we spoke with, DOD and  VA staff may hold a video-teleconference between the transferring MTF  and receiving VA health care facilities to exchange information.
In addition, wounded warrior program and VA officials who help  servicemembers transition from DOD to VA told us that they only share  with VA facilities the health records necessary for the treatment of a  recovering servicemember’s current condition. As a result,  servicemembers’ and veterans’ complete health records are not always  shared between departments when transferring facilities, and ultimately,  the responsibility to collect and provide a complete health record to the  VA facility can fall on the recovering servicemember and veteran. A VA  official told us that this process can be complicated because DOD  separately maintains servicemembers’ inpatient, outpatient, and  behavioral health records and does not have a single database that can  identify all of the medical facilities where a servicemember received  treatment. Further, according to VA and DOD officials, delaying the  collection and assembly of a servicemember’s complete medical history  until the start of the disability process could result in servicemembers  having to be reexamined when they are demobilized, needing to establish  that their injuries were connected to their time in the military, thus possibly  delaying a servicemember’s or veteran’s receipt of VA benefits.
Both departments have needed to create programs and provide staff to  assist recovering servicemembers during their transition from a DOD MTF  to a VAMC. For example, VA Liaisons and DOD nurse case managers  help recovering servicemembers transition from DOD to VA by  assembling their health records and sharing them with the VAMC where  the servicemember will be receiving treatment. According to DOD and VA  staff that assist servicemembers in their transition from one system to  another, DOD nurse case managers at installations that do not have VA  Liaisons do not always have the same knowledge of VA services and  benefits, and may not be informed of the appropriate referral methods or  contacts used by VA Liaisons to provide a servicemember with a  seamless transition to a VAMC. A DOD official told us that at locations  where the VA Liaison program is not available, the transition process for  recovering servicemembers from DOD to VA is more difficult. This official  understood how to properly transfer servicemembers’ records from the  DOD facility to the receiving VA facility only because of past VA  experience.
section_title: DOD and VA Have Not Fully Resolved Long-standing Problems Due to Deficiencies in Leadership and Oversight, Resources, and Collaboration
subsections: section_title: Lack of Leadership and Oversight Has Limited DOD’s and VA’s Ability to Effectively Manage Programs for Recovering Servicemembers and Veterans
paragraphs: The lack of leadership and program oversight has limited DOD’s and VA’s  ability to effectively manage programs created to serve recovering  servicemembers and veterans. Two bodies established to oversee these  programs, the Senior Oversight Committee and the Office of Wounded  Warrior Care and Transition Policy (WWCTP), lacked consistent  leadership attention and oversight capabilities. In addition, DOD does not  have a central office that oversees or collects common data on the  military services’ wounded warrior programs.
The Joint Executive Council was established by law in November 2003 to provide senior  leadership for collaboration and resource sharing between DOD and VA. Through a joint  strategic planning process, the Joint Executive Council recommends to the Secretaries  the strategic direction for the joint coordination and sharing efforts between the two  departments and oversees the implementation of those efforts. high-level leadership participation without substitution of lower-ranking  rapid policy development and quick decision making, and  rigorous monitoring to hold the military services and the two  departments accountable for needed actions.
Sustaining the Senior Oversight Committee’s original momentum over  time became difficult, and its waning influence and effectiveness became  evident in a number of ways:
Starting in December 2008, the Senior Oversight Committee  experienced leadership changes, including the departure of its  cochairs, the Deputy Secretaries, as well as turnover in some of its  key staff. According to a former Senior Oversight Committee  executive, the personal commitment and strong relationship between  the Deputy Secretaries who initially cochaired the Senior Oversight  Committee served as a unifying and confidence building force that  was not replicated by subsequent leadership, while leadership  turnover in the DOD offices supporting the Senior Oversight  Committee negatively impacted its ability to function effectively.
As we have previously reported, the Senior Oversight Committee also  began to encounter challenges when DOD “disrupted the unity of  command” by changing the organizational structure of the committee  and realigning and incorporating the committee’s staff and  responsibilities into existing or newly created DOD and VA offices,  such as WWCTP.us that the new staffing arrangement did not adequately support the  committee’s efforts, and VA did not provide full-time staff members to  support the committee, as it had in the past. Later in October 2008,  VA established the Office of VA/DOD Collaboration Services, and VA  supported Senior Oversight Committee efforts, along with broader  collaboration efforts, through this separate office.
Officials formerly involved with the committee told
The committee began meeting less frequently. For example, in  contrast to weekly meetings held during its initial year of operation, in  fiscal year 2011, the committee met less than 11 hours in total.
Top DOD leadership no longer consistently attended Senior Oversight  Committee meetings. According to a former Senior Oversight  Committee official, the second Deputy Secretary of Defense to  cochair the committee sent the Deputy Undersecretary of Defense for  Personnel and Readiness to represent DOD in his place.
The Senior Oversight Committee no longer made relatively quick  decisions. According to former Senior Oversight Committee executive  and support staff, frequent substitutions by lower-ranking officials at  Senior Oversight Committee meetings no longer allowed for quick  decision making and transformed Senior Oversight Committee  meetings into informational briefings.
The Senior Oversight Committee no longer tracked or monitored  progress of its policy initiatives or assigned tasks. According to a  former LOA cochair and a cognizant support staff member, by 2011  the Senior Oversight Committee was no longer routinely using a  tracking mechanism to hold the departments accountable for  completing appointed tasks. Later that year, the Recovering Warrior  Task Force reported that the Senior Oversight Committee no longer  had a formal mechanism for assessing the status of the committee’s  initiatives and goals, leaving no way to determine whether initiatives  or goals had been partially or fully implemented or met.
In its September 2011 report, the Recovering Warrior Task Force  recommended combining the Senior Oversight Committee and Joint  Executive Council to improve effectiveness and reduce redundancies as  both entities had similar membership and operating structures. In January  2012, the Joint Executive Council cochairs agreed to consolidate the two  groups. The Senior Oversight Committee’s working groups for care  coordination and the integrated disability evaluation system were  realigned within the Joint Executive Council, and a Wounded, Ill, and  Injured Council was established under the Joint Executive Council to  oversee emerging issues for recovering servicemembers and veterans.
Whether the Joint Executive Council can effectively address the issues  once managed by the Senior Oversight Committee has yet to be seen.  Several DOD and VA officials expressed concern to us about the ability of  the Joint Executive Council to focus on rapid, short-term policy decision  making rather than the longer-term strategic planning role that it has  traditionally played. For example, according to a DOD official, historically,  the Joint Executive Council has not been able to drive policy decision  making, and therefore, issues that should have been decided by the Joint  Executive Council were taken directly to the Secretaries for resolution,  raising doubts about the ability of the Joint Executive Council to function  effectively. A former Senior Oversight Committee executive noted that the  Joint Executive Council cochairs are not of equivalent rank, another  challenge that may serve as a barrier to the council’s ability to make  decisions and drive policy changes. Specifically, the VA cochair is the  Deputy Secretary, who has control over all relevant offices within VA,  while the DOD cochair is the Deputy Undersecretary of Defense for  Personnel and Readiness, whose responsibilities include establishing  health and benefit policies affecting recovering servicemembers and  directing the military services to comply with such policies but lacks  authority in enforcing the military services’ implementation of these  policies. The Recovering Warrior Task Force also cited concerns about  the rank of the DOD cochair of the Joint Executive Council, stating that a  higher level of leadership is needed to sustain departmental attention on  key initiatives such as IDES and electronic health records. Furthermore,  as of August 2012, DOD officials told us that the Joint Executive Council  is operating under the original procedures that were in place prior to the  entities merging. As a result, it is unclear at this time how the Joint  Executive Council will provide oversight and accountability for issues  once addressed by the Senior Oversight Committee.
In 2008, WWCTP became responsible for overseeing the RCP among  other programs that provide assistance to recovering servicemembers.  However, WWCTP’s ability to oversee the RCP, including its ability to  monitor program performance and ensure compliance with DOD policy, is  limited by its lack of operational authority, such as budget and tasking  authority, over the military services that implement the program.  According to WWCTP officials, this lack of operational authority  challenges WWCTP’s ability to direct the military services on their  implementation of the program. For example, although WWCTP has been  responsible for RCP oversight since 2008, the office was not able to  collect basic program data, such as monthly enrollment numbers, on a  consistent basis until October 2011. According to a WWCTP official,  although WWCTP requested monthly data submissions from the military  services, the information was provided on an ad hoc basis; sometimes  the services would submit it, and other times they would not. Data- collection efforts still remain a challenge for WWCTP. For example, the  Army’s Wounded Warrior Program, which serves as the Army’s care  coordination program, only agrees to share partial data with WWCTP,  arguing that the Army is only obligated to share data on servicemembers  served by WWCTP-contracted personnel.
Getting the military services to implement consistent care coordination  policies also poses a challenge for WWCTP. WWCTP officials said that  while WWCTP can develop policy to guide the military services, the  military services may interpret that policy and implement their programs  differently. Consequently, some DOD officials assert that the military  services have not consistently implemented the RCP in accordance with  DOD policy—an observation that is shared by the Recovering Warrior  Task Force. DOD policy requires that care coordination should be  provided to those who are “seriously” and “severely” wounded, ill, and  injured, but the Army only provides care coordination to recovering  servicemembers who are “severely” wounded, ill, and injured. As a  result, some servicemembers who could benefit from having someone  coordinate their care and benefits as they navigate the recovery care  continuum do not have access to those services.
Some WWCTP officials with whom we spoke expressed the view that the  military services have been inconsistent in their cooperation with  WWCTP, with cooperation being better on issues that represent priorities  of top leadership. Specifically, WWCTP officials told us that top DOD  leadership has not been pressured to resolve lingering care coordination  issues as much as other more visible issues, such as IDES and electronic  medical record interoperability problems confronting the departments.  Consequently, WWCTP officials said that the military services cooperate  with WWCTP’s efforts to oversee IDES and to monitor whether the  military services achieve their goals for timely completion of the IDES  process. Although these goals have not consistently been achieved,officials told us that military service cooperation has not been an  impediment to overseeing IDES as it has been for overseeing care  coordination. Conversely, the military services have not been as inclined  to cooperate with WWCTP on its oversight of the RCP relative to these  other issues.
In addition to limited operational authority over the military services,  turnover in leadership and other staffing changes have also limited  WWCTP’s ability to provide consistent direction and oversight for the  RCP, according to WWCTP officials. Specifically:
Three different DOD officials have led WWCTP since its inception in  2008. According to WWCTP staff, each of these officials had different  visions and priorities for the office, which led to disruptions in RCP  oversight. For example, a major oversight initiative—to collect  satisfaction survey data across the RCP—was abandoned when a  new official was appointed. In addition, the RCP has been led by three  different directors, with the most recent director leaving in June 2012.
In September through December 2011, WWCTP’s contracted staffing  was temporarily reduced by 70 percent when a contract expired and  was not immediately renewed, according to DOD. Staff reductions  primarily impacted WWCTP’s ability to oversee the RCP, since many  RCP support staff members were lost. For example, according to a  WWCTP official, the office was no longer able to make monitoring  visits to the RCP program sites. However, in July 2012 a contract was  awarded that allowed WWCTP to engage additional staff to support  the RCP, according to a WWCTP official.
In June 2012, DOD changed the name of the WWCTP office to the  Office of Warrior Care Policy and moved it under the Assistant  Secretary of Defense for Health Affairs. According to a DOD official,  the change was made as part of a realignment of DOD’s  organizational structure in response to statutory requirements. An  official in Health Affairs said that the move will be beneficial because it  will provide greater access to resources, including human resources  and information technology, among others. However, it is too early to  determine the full effect of this change.
There is currently no central office or authority that oversees or collects  common data on the military services’ wounded warrior programs,  preventing DOD from both assessing how well the programs are working  across the department and leveraging the strengths of each program by  sharing proven best practices across the military services.
Each of the military service Secretaries created their own wounded  warrior programs to meet their military service’s unique needs. Because  each service developed its own policy to govern its wounded warrior  programs and no central, unified DOD policy exists to govern these  programs, no central DOD office—such as WWCTP—may direct how  these programs operate. This lack of central oversight over the wounded  warrior programs has been one of the main reasons for the large  discrepancies between these programs. The 2011 Recovering Warrior  Task Force report recommended that the Secretary of Defense enforce  the existing policy guidance regarding the Army’s and Marines’ wounded  warrior transition units’ entrance criteria. However, in its response to this  recommendation, DOD supported the military service Secretaries’  discretion in establishing their own policies in this regard, saying that  there is no central DOD policy on the establishment of transition units and  entrance criteria, and that the policies were established by the  Secretaries for their specific populations.
While no common data are collected on the performance of wounded  warrior programs across the military services, each individual program  has initiated internal efforts to collect and analyze performance data. The  type and quality of data vary by program, however. For example, the  largest of the wounded warrior programs, the Army Warrior Care and  Transition Program, has collected wounded warrior program performance  survey data on a continuous basis since March 2007 and has developed  outcome measures to determine the impact of its services. However,  smaller programs, such as the Air Force Wounded Warrior Program and  the United States Special Operations Command’s Care Coalition have  measured baseline program satisfaction levels, but they do not have  additional years of survey data to monitor any changes over time. (See  table 3 for information about the types of performance data collected by  each of the wounded warrior programs.)
Some DOD officials with whom we spoke questioned why common  measures have not been developed. For example, a DOD official in  charge of wounded warrior care at an MTF suggested developing a  measurement tool to determine what aspects of the programs help  recovering servicemembers. Another DOD official involved with wounded  warrior program performance measurement commented that it is common  practice for DOD to share performance measurement practices and  standard metrics across the military services.
In September 2011, citing wide disparity across the military services in  their implementation of wounded warrior programs and policies, the  Recovering Warrior Task Force made four recommendations for creating  common standards to ensure parity in the programs and services  provided to recovering servicemembers across DOD. For example, the  first recommendation called for a common nomenclature, or consistent  definitions to be used in DOD policy to identify recovering  servicemembers who may require and be eligible for assistance. The task  force concluded that common definitions are needed to promote  consistent levels of care among the military services and would better  enable DOD to compare across programs and identify best practices. In  its response to the task force, DOD acknowledged that some of these  recommendations were valid and that DOD should take actions to  address them. However, at the time of the Recovering Warrior Task  Force’s 2012 report, these recommendations had not been implemented,  and the task force is continuing to follow DOD’s efforts to implement   Moreover, even if DOD decided to take some actions in this  them.regard, it is unclear who would have responsibility for addressing them,  since there is no central oversight office or authority for these programs.
section_title: Insufficient Staffing and Budget Control Have Contributed to DOD’s and VA’s Inability to Resolve Delays with Disability Determinations and Electronically Share Health Records
paragraphs: In addition to problems with leadership and oversight of care coordination  and case management programs, DOD and VA have a longstanding track  record of insufficient staffing to address delays in disability determinations  and insufficient staffing and control over the budget to oversee the  development of systems with improved capabilities for electronically  sharing health records.
Insufficient staffing across both departments has affected DOD’s and  VA’s ability to reduce disability determination delays and meet their IDES  timeliness goals. We raised concerns about staffing in 2010, when we  reported that DOD and VA did not sufficiently staff many key positions in  the IDES process, including DOD board liaisons, who counsel  servicemembers and ensure that documentation submitted for  consideration is complete and accurate, and medical evaluation board  physicians, who review medical and service records to identify conditions  that limit a servicemember’s ability to serve in the military. In 2012, we  continued to report evidence of staffing shortages, including high  caseloads for DOD board liaisons and VA case managers as well as  insufficient numbers of physicians to write narrative summaries needed to  complete the medical evaluation board stage of the IDES process in a   Some recovering servicemembers told us they do not  timely manner.receive sufficient support from their DOD board liaisons, and that there  are not enough liaisons to efficiently meet the needs of all the recovering  servicemembers going through the IDES process.
Delays in the disability determination process are expected to continue.  VA anticipates a much larger caseload of all disability and other benefit  claims in the near future, not just those claims associated with IDES  cases. Specifically, a high-level VA official told us that new laws, such as  the Veterans Opportunity to Work Act, will encourage all transitioning servicemembers—not just those going through the IDES process—to  claim VA benefits. This official also told us that DOD and VA have a much  larger problem to address as a surge of 300,000 servicemembers begin  to transition into the VA system as troops return home from Iraq and  Afghanistan. Without adequate planning and adequate resources, these  servicemembers may experience much longer processing times in the  disability benefits systems.
DOD and VA are working to address staffing challenges in some of the  IDES processes that are most delayed. We have previously reported that  the Army, for example, is in the midst of a major hiring initiative to  increase staffing dedicated to its medical evaluation boards, which will  include additional DOD board liaisons and medical evaluation board  physician positions. Additionally, VA officials said that the agency has  added staffing to its IDES rating sites to handle the demand for  preliminary disability ratings, rating reconsiderations, and final benefit  decisions, which has increased the number of preliminary VA ratings  completed and slightly improved processing times. But it is too early to tell  the extent to which VA’s efforts will continue to improve processing times.
The Interagency Program Office was established by law single point of accountability for joint DOD and VA efforts to implement  fully interoperable electronic health record systems or capabilities, but this  office was not given sufficient staffing or budget control by DOD and VA  to effectively facilitate the departments’ efforts. According to an  Interagency Program Office official, the office was never fully staffed and  was challenged by a high degree of turnover in staffing and leadership  that served in a temporary or acting capacity.
The Interagency Program Office’s initial charter limited its ability to  exercise authority over DOD and VA. Specifically, the charter stated that  control of the budget, contracts, and technical development remained  wholly within the two departments’ program offices. The charter conveyed  no authority in these areas to the Interagency Program Office. As a  former Interagency Program Office official testified in July 2011, the office  lacked control of budgeting and contracting necessary to achieve its  intended purpose, and without this, it could not sufficiently oversee the  departments’ efforts and compliance with the requirements in NDAA  2008. As a result, each department continued to pursue separate strategies, rather than a unified interoperable approach, according to this  former official.
See Pub. L. No. 110-181, § 1635, 122 Stat. 3, 460-63 (2008).
The Interagency Program Office was rechartered in October 2011 and  provided an expanded staff and new authorities under the charter,  including control over the budget. According to Interagency Program  Office officials, when hiring under the new charter is completed, the office  will have a staff of 236 personnel, more than seven times the number of   In addition, the  staff originally allotted to the office by DOD and VA.charter provides the Interagency Program Office with the authority to  lead, oversee, and manage budget and contracting for electronic health  record sharing efforts. According to Interagency Program Office officials,  budget control is the essential component for overseeing progress and  ensuring accountability for the departments’ efforts.
With the enhanced charter, as well as plans for an expanded staff to  oversee the implementation of a single joint electronic health record  system, the Interagency Program Office will have more resources to draw  upon and support department interoperability initiatives. However, it is still  too early to determine whether this investment of resources will be  sufficient to meet the office’s goals for 2017. provision of additional resources, Interagency Program Office officials told  us that as of July 2012, the office is staffed at approximately 48 percent  and that hiring additional staff in time to meet appointed implementation  deadlines remains one of its biggest challenges.
section_title: Despite Repeated Attempts, DOD and VA Have Failed to Effectively Collaborate to Align Their Care Coordination Programs; New Efforts Are Under Way
paragraphs: According to DOD and VA officials, the departments have identified 54 joint capabilities  that will be implemented by the end of fiscal year 2017. will depend upon achieving cooperation between the departments—which  has been elusive for many years—as well as with the military services.
With the creation of the RCP, the FRCP was no longer the single point of  contact with respect to servicemembers’ care coordination, and early on,  there were concerns and some confusion about how the FRCP and the  RCP would align without creating overlapping and duplicative services.  Shortly after the RCP was established, DOD sent a report to  congressional committees outlining a medical category assignment  process that was based on the severity of each servicemember’s medical  condition, along with input from the servicemember and his or her unit  commander, to determine whether servicemembers would be directed to  either the FRCP or to the RCP for care coordination services. In concept,  the medical category assignment process would have resulted in  wounded, ill, and injured servicemembers being assigned to one of three  categories: “mild,” “serious,” or “severe.” Under this approach, the FRCP  would provide care coordination services for “severely” wounded, ill, and  injured servicemembers and the RCP would serve those who were  “seriously” wounded, ill, and injured. (See app. II for additional information  on the intended medical category assignment process for DOD and VA  care coordination programs.)
Despite DOD’s attempt to define the populations served by the FRCP and  the RCP, neither the military services’ wounded warrior programs, which  implement the RCP, nor VA, which administers the FRCP, implemented  DOD’s assignment process. Instead, these programs expanded their  enrollment to include both “seriously” and “severely” recovering  servicemembers and veterans, which resulted in both programs serving  the same populations, thereby setting up the likelihood of overlap and  duplication of services. As we have previously reported, this duplication  issue is compounded by the numerous other programs that also provide  services to recovering servicemembers and veterans and have  overlapping roles as well. It is not uncommon for recovering  servicemembers to be enrolled in more than one case management or  care coordination program and end up with multiple care coordinators and  case managers—each of whom develop different care plans for the same  servicemember. The care plans may even conflict with one another,  which could conceivably adversely affect the servicemember’s recovery  process. In fact, in the course of previous work, we found instances  where inadequate information exchange and poor coordination between  these programs resulted not only in duplication of effort and overlap of  services, but also confusion and frustration for servicemembers and their  families. In addition, DOD and VA officials acknowledge that the  multiplicity of care coordination and case management programs causes  confusion even among members of care coordination teams. In October  2011, we recommended that the Secretaries of Defense and Veterans  Affairs 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 to reduce  redundancy and overlap.
Although DOD and VA have not yet aligned care coordination policy for  the FRCP and RCP, we have found indications that care coordinators and  case managers at some locations have been cooperating to some degree  and trying to work more closely with one another. In the course of our  visits to 11 DOD and VA facilities during this review, we found that care  coordinators and case managers in many locations had attempted—with  some success—to clarify their roles and to limit the degree of overlap and  duplication in the services they provide to recovering servicemembers  and veterans. However, such local attempts to improve the degree of  cooperation and coordination among the programs are not systemic and  depend on individual personalities and circumstances. They may not be  sustainable without agreement by DOD and VA and the alignment of  policy governing case management and care coordination programs.
Another critical issue on which DOD and VA have disagreed pertains to  the stage in a servicemember’s recovery when the FRCP should get  involved in the coordination of services. Because the FRCP depends on  referrals from other programs as a basis for becoming involved with  recovering servicemembers, this can be a significant issue. Currently,  neither DOD nor VA policy clearly defines when referrals are to be made;  consequently, most wounded warrior programs delay referrals to the  FRCP until it becomes clear that the servicemember will be separated  from the military. Senior DOD officials stated that wounded warrior  program officials justify this practice on the basis that referring a recently  wounded servicemember to the FRCP—a VA-operated program—sends  a negative message to a recovering servicemember that his or her  military career has ended, even though the FRCP was designed as a joint  program. Additionally, the belief among the military that they should “take  care of their own,” contributes to the reluctance to involve the FRCP. On  their part, VA maintains that its point of engagement should be in the  early stage of medical treatment to build rapport and trust and to begin  coordinating the services needed by severely wounded servicemembers.
Despite multiple efforts over the last several years to align their care  coordination and case management programs, DOD and VA have failed  to implement lasting measures to resolve underlying problems concerning  the aligning of roles and responsibilities of the FRCP, RCP, and case  management programs. Previous attempts include the following:
December 2010. The Senior Oversight Committee directed its case  management work group to perform a feasibility study of  recommendations on the governance, roles, and mission of DOD and  VA care coordination. However, no action was taken by the committee  and care coordination was subsequently removed from the Senior  Oversight Committee’s agenda as other issues were given higher  priority.
March 2011. WWCTP sponsored a joint summit that included officials  from VA and the military services to review DOD and VA care  coordination issues. Although this collaboration resulted in the  development of five recommendations related to care coordination, no  agreement was reached by the departments to jointly implement  them. A DOD participant told us that VA did not agree with the  recommendations, and a VA official involved in the summit concurred,  alleging that the recommendations appeared to suggest eliminating  overlap and duplication between the FRCP and RCP by ending the  FRCP.
May 2011. Concerned with overlap and duplication between the DOD  and VA care coordination programs, the House Committee on  Veterans Affairs, Subcommittee on Health directed the Deputy  Secretaries of DOD and VA to provide an analysis of how the FRCP  and RCP could be integrated under a “single umbrella” by June 20,  2011. In the absence of such a response, the subcommittee  scheduled a congressional hearing and requested that options for  addressing this issue be presented. Following the notification of the  hearing, the departments developed a joint letter and submitted it to  the subcommittee in September 2011. This letter, however, did not  identify or outline options for aligning the FRCP and the RCP. In a  hearing held by the subcommittee in early October 2011, neither VA  nor DOD outlined definitive plans to address this issue.
September 2011. The Recovering Warrior Task Force issued the first  of four annual reports that included 21 recommendations, including a  recommendation that the roles of care coordinators be clarified. In  DOD’s official response to congressional committees, the Under  Secretary of Defense stated that the department would implement the  Recovering Warrior Task Force’s recommendations. However, a  Recovering Warrior Task Force member stated that the Recovering  Warrior Task Force concluded that in most cases DOD has not made  significant changes to its programs to achieve the outcomes intended  by the recommendations. In August 2012, the Recovering Warrior  Task Force reported that DOD has fully implemented only 2 of the 21  recommendations. However, a DOD official whose office is  responsible for coordinating DOD’s responses to the Recovering  Warrior Task Force’s recommendations stated that DOD is in the  process of addressing several more of the 2011 Recovering Warrior  Task Force recommendations.
October 2011–April 2012. VA declined DOD’s requests to discuss  care coordination and case management policy issues during this  period, according to DOD and VA senior officials, because VA had  established its own task force to conduct an internal review of its care  coordination and case management activities, including the FRCP.  After completing its initial assessment, VA briefed WWCTP officials on  the process it was using to review its care coordination and case  management activities, but chose not to discuss realignment of the  FRCP and RCP at that time, according to DOD officials who attended  this briefing. Instead, the VA Chief of Staff said that he approached  the Army’s Warrior Transition Command—which has the largest  number of recovering servicemembers—to propose developing  guidelines for better integrating Army’s wounded warrior program with  the FRCP, including identifying when the Army’s wounded warrior  programs should refer a recovering servicemember to the FRCP, and  replacing multiple care coordination plans with a single,  comprehensive planning document. However, a high-level DOD  official criticized this initiative as a tactic to minimize central input from  the Office of the Secretary of Defense and pointed out that this effort  would result in an agreement with only a single military branch. In  contrast, VA’s Chief of Staff told us that VA took this approach in the  hope that if an agreement could be reached with Army, the other  military branches would follow suit.
More recently, in May 2012, VA and DOD developed a new task force,  the VA/DOD Warrior Care and Coordination Task Force, which  represents an effort to comprehensively address problems caused by the  lack of integration between DOD’s and VA’s care coordination and case  management programs. The task force has developed recommendations  that are intended to achieve a coordinated, interdepartmental approach to  care coordination and case management programs, according to a task  force official. On August 10, 2012, the task force presented the following  recommendations to the Joint Executive Council for its consideration: establish and charter an interagency governance structure  responsible for coordinating VA and DOD policy, establish and charter an interagency care coordination community of align the FRCP to function in a consultant and resource-facilitator role, clarify the lead coordinator role and responsibilities for executing a  recovering servicemember’s comprehensive plan,  identify the business requirements for technical tools to support the  interagency comprehensive plan, and accelerate existing information-sharing efforts for care coordination.
The Joint Executive Council provisionally approved the six  recommendations, but withheld final approval pending receipt of  additional information from the task force, such as an estimate of  resources required to implement the recommendations, as well as   details of the proposed interagency governance structure. The Joint  Executive Council instructed the task force to present the additional  information to them in another decision briefing, which was scheduled for   September 20, 2012. Absent final approval from the Joint Executive  Council, the task force’s next step was to hold a status briefing for the  DOD and VA Secretaries on September 10, 2012, to discuss the task  force’s recommended course of action for care coordination.
Given the inability of past task forces to effect changes that better align  DOD and VA care coordination and case management policies, it is too  soon to determine the full effect of the departments’ efforts to manage  care coordination services regarding outcomes for recovering  servicemembers and veterans. Although VA and DOD appear to be  moving in a positive direction on care coordination, notable barriers  remain:
There is concern as to whether the Joint Executive Council can  effectively lead the effort to realign VA’s and DOD’s care coordination  policy. Some high-ranking and cognizant DOD officials we talked with  expressed concerns that the recently merged Joint Executive Council  may not have the capability to effectively monitor the actions taken by  DOD and VA to implement the task force’s recommendations. Some  officials we talked with viewed the council as taking too long to resolve  issues due to both the infrequency of its meetings and the difficulties  DOD and VA members have in agreeing with one another.
Following approval of its recommended course of action, task force  documents indicate that a detailed plan will be completed by July  2013. VA’s task force cochair stated that some aspects of the planned  changes could take years to implement, particularly as they transition  existing enrollees of programs affected by significant revisions. For  example, VA intends to conduct a case-by-case review of every  FRCP enrollee before modifying the FRCP to function in a consultant  and resource-facilitator role, according to VA’s Task Force cochair.
One of the most fundamental challenges to resolving care  coordination problems is the issue of obtaining the cooperation of the  military services to implement a new approach to care coordination  and case management, especially in light of past difficulties of working  in concert with DOD and VA programs and policies. DOD and VA  leadership officials stated that even if new solutions and policies were  to be approved by the departments, changes would be made only if  the individual military services implement the new policies as directed  by the Secretary of Defense. Several DOD and VA officials identified  concurrence and support of the military services as the most difficult  element to achieve. Ultimately, the military services’ compliance with  the departments’ agreed-upon strategy for care coordination and case  management programs will determine how seamlessly recovering  servicemembers and veterans will be able to navigate the recovery  care continuum.
section_title: Conclusions
paragraphs: The deficiencies exposed at Walter Reed in 2007 served as a catalyst  compelling DOD and VA to address a host of problems that complicate  the course of a wounded, ill, and injured servicemember’s recovery,  rehabilitation, and return to active duty or civilian life. We believe strongly  and have reported already that fixing the long-standing and complex  problems highlighted in the wake of the Walter Reed media accounts as  expeditiously as possible is critical to ensuring high-quality care for  returning servicemembers and veterans. We continue to believe that the  departments’ success ultimately depends on sustained attention,  systematic oversight, and sufficient resources from both DOD and VA.  However, this has not yet occurred, and as a result, after 5 years,  recovering servicemembers and veterans are still facing problems as they  navigate the recovery care continuum, including access to some of the  programs designed to assist them. The transition period from DOD’s to  VA’s health care system is particularly critical, as servicemembers  continue to experience delays in the disability evaluation system and the  departments continue to use methods other than a common information  technology system to share servicemembers’ health information. Until  these problems are resolved, recovering servicemembers and veterans  may still face difficulties getting the services they need to maximize their  potential when they return to active duty or transition to civilian life.
Initially, departmental leadership exhibited focus and commitment— through the Senior Oversight Committee—to addressing problems related  to case management and care coordination, disability evaluation systems,  and data sharing between DOD and VA. However, over time, waning  leadership attention, a failure to oversee critical wounded warrior  functions and programs, limited resources, and the inability to achieve a  collaborative environment— particularly with care coordination—have  impeded the departments’ ability to fully resolve these problems. A key  element in resolving current care coordination issues in particular is  eliciting the cooperation of the military services, which are responsible for  implementing various wounded warrior programs and ensuring that these  programs operate as intended—which has sometimes not been the case,  as with the RCP. Also, absent clear direction and central oversight and  accountability among the military services’ wounded warrior programs,  true cooperation and program effectiveness may be in jeopardy.
We believe that at the heart of the problem is the need for strong and  unwavering leadership to bring about changes that best serve our  nation’s recovering servicemembers and veterans. This leadership should  be united across both DOD and VA and centered on the individual  servicemember’s or veteran’s recovery. Many task forces—including the  VA/DOD Warrior Care and Coordination Task Force and the Recovering  Warrior Task Force—have already attempted to bring a spirit of  cooperativeness and clear direction and purpose among the different  programs providing services to this population. However, to date, these  efforts have not fully resolved key issues, and our nation’s recovering  servicemembers and veterans continue to face obstacles and challenges,  especially as they transition from DOD’s to VA’s health care system.  Certainly, the fluidity and focus of the departments’ leadership over the  last several years, especially related to care coordination, have added to  the challenges of developing consistent policy, effective oversight, and  mechanisms to monitor progress and hold programs accountable. The  departments have recently taken steps to improve problems related to  care coordination, disability evaluations, and the electronic sharing of  health records, through concerted efforts to coordinate on policy, increase  staffing resources, and provide control over the budget, respectively.  However, it is too early to determine the effectiveness of these efforts,  and sustained leadership attention will be critical to their success. The  need to fully resolve remaining problems is urgent as there will be an  increasing demand for services from both DOD and VA as the current  conflicts come to an end. If not resolved now, these same problems will  persist into the future for recovering servicemembers and veterans.
section_title: Recommendations for Executive Action
paragraphs: To ensure that servicemembers have equitable access to the military  services’ wounded warrior programs, including the RCP, and to establish  central accountability for these programs, we recommend that the  Secretary of Defense establish or designate an office to centrally oversee  and monitor the activities of the military services’ wounded warrior  programs to include the following:
Develop consistent eligibility criteria to ensure that similarly situated  recovering servicemembers from different military services have  uniform access to these programs.
Direct the military services’ wounded warrior programs to fully comply  with the policies governing care coordination and case management  programs and any future changes to these policies.
Develop a common mechanism to systematically monitor the  performance of the wounded warrior programs—to include the  establishment of common terms and definitions—and report this  information on a biannual basis to the Armed Services Committees of  the House of Representatives and the Senate.
To ensure that persistent challenges with care coordination, disability  evaluation, and the electronic sharing of health records are fully resolved,  we recommend that the Secretaries of Defense and Veterans Affairs  ensure that these issues receive sustained leadership attention and  collaboration at the highest levels with a singular focus on what is best for  the individual servicemember or veteran to ensure continuity of care and  a seamless transition from DOD to VA. This should include holding the  Joint Executive Council accountable for ensuring that key issues affecting recovering servicemembers and  veterans get sufficient consideration, including recommendations  made by the Warrior Care and Coordination Task Force and the  Recovering Warrior Task Force; developing mechanisms for making joint policy decisions;  involving the appropriate decision-makers for timely implementation of  policy; and establishing mechanisms to systematically oversee joint initiatives and  ensure that outcomes and goals are identified and achieved.
section_title: Agency Comments and Our Evaluation
paragraphs: DOD and VA reviewed a draft of this report and provided comments,  which are reprinted in appendixes III and IV. DOD and VA also provided  technical comments, which we incorporated as appropriate.
DOD concurred with specific components of our first recommendation  regarding the establishment of central accountability for the military  services’ wounded warrior programs. In particular, DOD agreed that a  single office should have oversight responsibility for the military services’  wounded warrior programs and that these programs should fully comply  with the policies governing care coordination and case management  programs and any future changes to these policies.
However, DOD only partially concurred with other components of our first  recommendation—that DOD develop consistent eligibility criteria for  enrollment in wounded warrior programs and that DOD establish a  common mechanism to systematically monitor the performance of these  programs. In its comments, DOD explained that the three military service  Secretaries should have the ability to control entrance criteria into their  wounded warrior programs and added that it does not believe that  differences in eligibility criteria for these programs results in noticeable  differences in access to these programs by recovering servicemembers  or their families. DOD did not offer a rationale, however, as to why the  military service Secretaries should unilaterally determine eligibility criteria  for their wounded warrior programs, other than to suggest that flexibility is  important and necessary. Moreover, as we have reported, DOD does not  systematically assess or monitor these programs across the department,  and as a result, we believe that DOD has no basis to assert that there are  no noticeable differences in access to these programs. Overall, we  believe that similarly situated wounded, ill, and injured servicemembers  should be given the same access to wounded warrior programs and the  assistance these programs provide, regardless of their branch of military  service.
With respect to developing a common mechanism to systematically  monitor the performance of the wounded warrior programs, DOD  responded that the Interagency Care and Coordination Committee will  conduct an inventory of all wounded warrior programs to identify  duplication and areas for gaining efficiencies. In commenting on our  recommendation to also report its performance information on the  wounded warrior programs to the Armed Services Committees on a  biannual basis, DOD stated that the department reports progress through  the Joint Executive Council’s annual strategic planning report and any  additional reporting would be redundant and of limited value. We  disagree. The Joint Executive Council’s strategic planning and annual  reports focus on joint efforts between the departments and do not report  on the performance of the military services’ wounded warrior programs.  Therefore, we do not believe that the performance information on the  wounded warrior programs would be redundant or of limited value given  that the department itself is currently unable to systematically determine  how well these programs are functioning. As we reported, one of the key  problems hindering a department-wide assessment of these programs is  the lack of common terms and definitions used by the military services.  Although DOD acknowledges that this is an issue, it asserts that it has  instituted some common definitions through the Senior Oversight  Committee and through its instruction for the RCP and that it will work  towards a common understanding and use of these approved definitions.  Although we are aware of efforts to define some terms, on the basis of  our work, it does not appear that the military services are using them  consistently. Therefore, substantial progress towards a common  understanding and use will be critical to the department’s ability to  oversee these programs.
DOD did not respond directly to our recommendation for developing a  common mechanism for performance measurement, which we found is  not systematically conducted across the wounded warrior programs.  During our collection of performance data from the wounded warrior  programs, we found that the programs vary in their ability to report  performance outcome measures on the basis of what each program  chooses to track. In addition, we found that some of the programs had  difficulty reporting basic data, such as enrollment numbers, and only  compiled these data following our request—sometimes taking about   5 months to do so. Lastly, our recommendation is consistent with the call  of the Interagency Care and Coordination Committee that the military  programs develop more useful quantitative and qualitative metrics that  would effectively demonstrate their performance. Until DOD takes the  necessary steps to assess these programs department-wide, it will never  know with certitude whether these programs are meeting the needs of its  recovering servicemember population.
DOD and VA both concurred with our second recommendation that the  departments ensure that care coordination, disability evaluation, and  electronic health record sharing receive sustained leadership attention  and collaboration at the highest levels, with a singular focus on what is  best for the individual servicemember or veteran to ensure continuity of  care and a seamless transition from DOD to VA.
In addition to its comments on our recommendation, VA asserted that the  care coordination challenges facing both departments are broader and  more complex than issues concerning just the FRCP and RCP and that  our overall analysis and conclusions are over simplified. VA stated that  through its recently formed task force, both departments identified over   40 programs that provide some level of coordination or management of  care and services across the continuum of care and acknowledged that  there is no common operational picture that facilitates collaborative  planning or situational awareness. We agree that the care coordination  challenges are broader and more complex than the FRCP and RCP.  Specifically, in October 2011, we recommended that the departments  strengthen functional integration across all care coordination and case   Similarly,  management programs to reduce redundancy and overlap.our current recommendation is broad and does not focus exclusively on  these two programs as our review also included other programs, such as  the military services’ wounded warrior programs, VA’s Liaison for  Healthcare Program, and VA’s OEF/OIF/OND Care Management  Program. The scope of our review was directed by Congress, who  required us to report on the progress DOD and VA in implementing the  programs involved with the care, management, and transition of  wounded, ill, and injured servicemembers that they established. Our  specific discussion of the FRCP and RCP served to illustrate, until  recently, a continued lack of collaboration between the departments to  better align these programs and better serve recovering servicemembers  and veterans. Furthermore, during detailed discussions with top-level VA  and DOD officials, they focused on the FRCP and RCP issue as the main  sticking point in achieving coordination and cooperation among the two  departments with respect to care coordination and case management.  We are encouraged that the departments are now taking steps to identify  all programs that need better alignment and integration. However, as we  have stated, the key to resolving this and other problems is the need for  strong and unwavering leadership that is united across both departments  and focused on the individual servicemember’s or veteran’s recovery.
VA also suggested further clarifications to our report.
VA suggested that we clarify that while the VA Liaison for Healthcare  Program facilitates the transfer of recovering servicemembers from  DOD’s to VA’s health care system, it is a DOD or VA treatment team  that determines if the servicemember is medically ready to begin the  transition process. VA also suggested that we add that that the  OEF/OIF/OND Care Management Program screens all returning  combat veterans for case management services. We incorporated  VA’s suggested changes.
VA disagrees with a DOD-attributed statement that the Joint  Executive Council historically has not driven policy decision making  and that, at times, decisions were taken directly to the DOD and VA  Secretaries for resolution. The statement that we attribute to the DOD  official relates to the period prior to the integration of the Senior  Oversight Committee with the Joint Executive Council. As mentioned  in the report, it is too early to ascertain whether the newly merged  Joint Executive Council will be able to make decisions and drive policy  changes in DOD and VA.
VA provided clarification about how the Joint Executive Council is  currently providing oversight and accountability for wounded warrior  issues that were once addressed by the Senior Oversight Committee.  We recognize the effort that the Joint Executive Council is now  making to track wounded warrior issues, including the integrated  disability evaluation system and care coordination. However, we have  not had the opportunity to review this tracking mechanism now in  place to comment on its effectiveness.
VA asserts that the size of the overlap between the FRCP and RCP  population is fairly small. Although the number of seriously injured  servicemembers may be comparatively small, this situation has been  and continues to be a major concern in that these individuals and their  families represent a highly vulnerable population. Further, during our  review, one high-level DOD official we spoke with characterized the  FRCP/RCP overlap as the most difficult policy issue to resolve. While  we understand that DOD and VA now intend to harmonize care  coordination policies within a broader context of interdepartmental  care coordination and case management practice, many of the  proposed revisions—including the role to be played by the FRCP— are neither fully developed nor implemented by the separate DOD and  VA programs at this time.
In our report, we explain that VA declined DOD’s requests to discuss  care coordination and case management policy issues—for the better  part of 1 year—on the basis that VA was conducting an internal  review of its care coordination and case management activities. In its  comments, VA stated that the use of the word “decline” is misleading,  and suggested that we change our text to state that VA asked DOD to  defer collaboration until the internal review was conducted. Despite  VA’s characterization that our statement is misleading, we maintain  that this finding was based on remarks made by high-level DOD  officials that were subsequently corroborated by senior VA officials.
We are sending copies of this report to appropriate congressional  committees, the Secretary of Defense, the Secretary of Veterans Affairs,  and other interested parties. The report also is available at no charge on  GAO’s website 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 V.
section_title: Appendix I: Enrollment and Populations for Select Department of Defense and Department of Veterans Affairs Programs
paragraphs: Both the Department of Defense (DOD) and the Department of Veterans  Affairs (VA) operate care coordination and case management programs  designed to assist servicemembers and veterans as they navigate the  recovery care continuum, from acute medical treatment and stabilization,  through rehabilitation, to reintegration—either back to active duty or to the  civilian community as a veteran. This appendix describes selected DOD  and VA programs and includes data on enrollment and population  characteristics as well as the type of information each program tracks on  referrals.
subsections: section_title: DOD Wounded Warrior Programs
paragraphs: Within DOD, each military service has established its own wounded  warrior program or a complement of programs to assist wounded, ill, and  injured servicemembers during their recovery and rehabilitation, and to  help with the transition back to active duty or to civilian life. Wounded  warrior programs range in size from the largest, the Army’s Warrior  Transition Units and Community-Based Warrior Transition Units, with  18,762 enrollees served in fiscal year 2011, to the smallest, the Navy  Safe Harbor Program, with 784 enrollees served in fiscal year 2011. (See  table 4 for a list of the DOD wounded warrior programs and enrollment for  fiscal year 2011.)
Programs differ in their organization and function. For example, two of the  wounded warrior programs—the Army’s Warrior Transition Units and the  Marine Corps Wounded Warrior Regiment—are organized under  separate military commands, which means that wounded, ill, and injured  servicemembers enrolled in these programs may be removed from their  parent units or commands and assigned or attached to a separate unit or  regiment that provides command and controlservicemember as well as administrative support. These servicemembers  may be housed in separate barracks while receiving medical care and  waiting to transition back to active duty or civilian life. The other wounded  warrior programs do not assign or attach servicemembers to a separate  command structure, but provide services while recovering  servicemembers remain with their parent units. The services provided by  the wounded warrior programs also vary. A servicemember may receive  either case management or care coordination services or both, depending  on how the military service’s wounded warrior program is structured. For  example, the Navy Safe Harbor Program only provides care coordination  services and does not have a case management component, whereas  the Marine Corps Wounded Warrior Regiment provides all  servicemembers with both case management and care coordination  services. A further distinction is whether or not a program serves veterans  as well as servicemembers. For example, the Army Warrior Transition  Units do not serve veterans, but eligible veterans are served through the  Army Wounded Warrior Program. The remainder of the wounded warrior  programs continue to provide support to any enrollee who needs services  even after the enrollee has transitioned to veteran status.
subsections: section_title: Army Warrior Care and Transition Program
paragraphs: The Army’s Warrior Care and Transition Program, which was established  in May 2007, consists of two components that support the recovery  process for wounded, ill, and injured servicemembers—the Warrior  Transition Unitsoperates a number of warrior transition units located at Army installations  across the country. Recovering servicemembers who are attached or  assigned to a warrior transition unit generally are housed in barracks and  receive medical care, rehabilitative services, professional development  and clinical and nonclinical case management services in order to help   and the Army Wounded Warrior Program. The Army  them in their transition back to active duty or to the civilian community.  Army Warrior Transition Units vary in size and functionality, including  community-based warrior transition units, which primarily serve Reserve  Component servicemembers. In fiscal year 2011, there were a total of  14,906 recovering servicemembers assigned or attached to 29 warrior  transition units and 3,856 recovering servicemembers assigned or  attached to 10 community-based warrior transition units. (See table 5.)  According to Army policy, recovering servicemembers assigned or  attached to the units are expected to require 6 months or more of  rehabilitative care or require complex medical management.   was established in April 2004 to  The Army Wounded Warrior Program assist severely wounded, ill, and injured servicemembers, their families,  and caregivers. Army Wounded Warrior Program enrollees are assigned  an Advocate who provides nonclinical care coordination services, which  include assisting enrollees with benefit information, career guidance,  finances, and the integrated disability evaluation system (IDES) process.  Recovering servicemembers are eligible for Army Wounded Warrior  Program services if they have, or are expected to receive, an Army  disability rating of 30 percent or greater in one or more specific categories  or a combined rating of 50 percent or greater for conditions that are the  result of combat or are combat-related. The most severely wounded, ill, or  injured servicemembers who are assigned to warrior transition units are  also enrolled in the Army Wounded Warrior Program. The Army Wounded  Warrior Program also provides services to veterans. In fiscal year 2011,  nearly three-fourths of the population (6,953) were veterans. (See   table 6.)
The Army Wounded Warrior Program was originally named the Disabled Soldier  Support System.
Army Wounded Warrior Program officials said that the program does not specifically track whether or  when an enrollee transitions to veteran status because it has no impact on enrollees’ eligibility for the  program and whether they leave the program. Rather, these data have been derived by the program  by counting the number of enrolled servicemembers who received a certificate of release or  discharge from active duty within each fiscal year.  Enrollees considered to have “left for other reasons” include those who died while enrolled in the  Army Wounded Warrior Program.
section_title: Navy Safe Harbor Program
paragraphs: The Navy Safe Harbor Program office was established in 2005. Over  time, this office expanded its reach and mission, and in 2008 the program  became responsible for nonclinical care coordination and oversight of all  severely (and high-risk nonseverely) wounded, ill, and injured Sailors and   Recovering servicemembers enrolled in the program  Coast Guardsmen.are assigned to nonmedical care managers who are geographically  dispersed at major military treatment facilities and Veterans Affairs  polytrauma medical centers. The program’s nonmedical care managers  assist enrollees with services such as pay and personnel, legal, housing,  as well as education and training benefits. In addition, enrollees obtain  support from centrally located experts in transition and benefits  assistance, such as a liaison to the Department of Labor and a Navy Staff  Judge Advocate. Recovering servicemembers enrolled in the program are  enrolled for life and, if desired, receive support from Navy Safe Harbor  personnel after they transition to veteran status. (See table 7.)
The Air Force Warrior and Survivor Care Program supports wounded, ill,  and injured servicemembers through its Air Force Wounded Warrior  Program and the Air Force Recovery Care Program. The Air Force  Wounded Warrior Program was established in June 2005 to provide  nonclinical case management to Airmen, Air National Guard, and  Reserve Component servicemembers who have combat-related illnesses  or injuries. Each enrolled servicemember is assigned a nonmedical care  manager, who serves as an advocate for enrollees to obtain services  from agencies and organizations that support the needs of enrolled  servicemembers, their families and caregivers. The Air Force Wounded  Warrior Program continues to provide services to enrollees once they  transition to veteran status. (See table 8.)
The Air Force Recovery Care Program was established in November  2008 to provide nonclinical care coordination services for seriously ill and  injured Airmen, Air National Guard, and Reserve Component  servicemembers. Each enrolled servicemember is assigned a care  coordinator who oversees the coordination of services and assists  enrollees’ with nonclinical needs, such as employment and benefits.  These care coordinators also work with enrolled servicemembers to  develop their recovery plans and career goals. Enrollees who have  combat-related illness or injuries are concurrently enrolled in the Air Force  Wounded Warrior Program. For example, in fiscal year 2011, almost 300  Air Force Recovery Care Program enrollees were also either tracked or  actively assisted by the Air Force Wounded Warrior Program. (See   table 9.)
The Marine Corps established the Wounded Warrior Regiment in May  2007 to provide and facilitate assistance to wounded, ill, and injured  Marines and their family members throughout the recovery process. The  Wounded Warrior Regiment is a single command that oversees  nonmedical care for the total Marine force, including Active Duty,  Reserve, retired, and veteran Marines. The regiment enrolls Marines  regardless of whether they have combat- or non-combat-related  conditions. The regiment commands the operation of two wounded  warrior battalions and 14 detachments located at 12 principal military  treatment facilities and four Veterans Affairs polytrauma medical centers  across the United States and overseas. A Marine enrolled in the regiment  can either stay with his or her parent unit and be supported by the  regiment, or be assigned or attached to one of the regiment’s battalions  and detachments, depending on their specific needs. Generally, Marines  who require more than 90 days of medical treatment or rehabilitation are  assigned or attached to a battalion or detachment. The District Injured  Support Cells Program is the component of the Wounded Warrior  Regiment that provides services to veterans. District Injured Support  Coordinators are located at 30 sites across the United States to provide  support, including nonmedical care management to its enrollees. In fiscal  year 2011, the District Injured Support Coordinators provided support to  1,488 veterans. (See table 10.)
The United States Special Operations Command established the Care  Coalition in August 2005 to track, support, and advocate for Special  Operations Force’s wounded, ill, and injured servicemembers regardless  of their duty status or whether their conditions are combat-related. (See  table 11.) All enrollees are assigned an Advocate and are entitled to  advocate services for life. Advocates assist enrollees with health care and  financial benefits, transition processes, and link enrollees with needed  government and nongovernment resources. Because the United States  Special Operations Command’s Care Coalition serves servicemembers  from across the military services, it serves as a liaison with, and  complements, the military services’ wounded warrior programs. United  States Special Operations Command’s Care Coalition enrollees are often  concurrently enrolled in their own military service’s wounded warrior  program. However, according to a Care Coalition official, the Care  Coalition serves as the lead program for case management and care  coordination for dually enrolled servicemembers.
section_title: VA Case Management and Care Coordination Programs
paragraphs: VA operates a number of case management and care coordination  programs that provide assistance to recovering servicemembers and  veterans, including the Operation Enduring Freedom/Operation Iraqi  Freedom/Operation New Dawn (OEF/OIF/OND) Care Management  Program and the Federal Recovery Coordination Program (FRCP).  These two programs assist wounded servicemembers and veterans to  navigate the recovery care continuum.
subsections: section_title: OEF/OIF/OND Care Management Program
paragraphs: The OEF/OIF/OND Care Management Program was established in March  2007 to provide case management to wounded, ill, and injured  servicemembers and veterans who screen positive for the need for case  management or request case management services. (See table 12).  Each of VA’s 152 Medical Centers (VAMC) has an OEF/OIF/OND Care  Management team in place to manage patient care activities and ensure  that servicemembers and veterans are receiving patient-centered,  integrated care and benefits. Members of the OEF/OIF/OND Care  Management team include: a Program Manager, Clinical Case Managers,  and a Transition Patient Advocate.
The FRCP was established in January 2008. Developed as a joint  program by DOD and VA, but administered by VA, the program was  designed to provide care coordination services to servicemembers and  veterans who were “severely” wounded, ill, and injured after September  11, 2001. (See table 13.) The program uses federal recovery coordinators  to monitor and coordinate clinical services, including facilitating and  coordinating medical appointments, and nonclinical services, such as  providing assistance with obtaining financial benefits or special  accommodations, needed by program enrollees and their families.  Federal recovery coordinators serve as the single point of contact among  all of the case managers of DOD, VA, and other governmental and  private case management programs that provide services directly to  servicemembers and veterans.
section_title: Referral Information Tracked by DOD and VA Case Management and Care Coordination Programs
paragraphs: DOD and VA case management and care coordination programs  primarily identify servicemembers and veterans who may be eligible for  enrollment through referrals. Tracking referral information, including the  number of those who were referred and enrolled or not enrolled in the  program, may indicate whether the programs are identifying those who  could benefit from their services. However, fewer than half of the DOD  and VA case management and care coordination programs that we  reviewed track this type of referral information. (See table 14.)
section_title: Appendix II: Medical Category Assignment Process for Care Coordination Programs
paragraphs: The Senior Oversight Committee intended for the Federal Recovery  Coordination Program (FRCP) and the Recovery Coordination Program  (RCP) to be complementary programs, specifically identifying which  population of wounded, ill, and injured servicemembers would be  assigned to the two programs. On the basis of work done for the  committee, the Department of Defense (DOD) sent a report to  congressional committees in 2008 outlining a medical category  assignment process based on the severity of each servicemember’s  medical condition, along with input from the servicemember and his or her  unit commander, to determine whether servicemembers would be  directed either to the FRCP or to the RCP programs for care coordination  services.
In concept, the medical category assignment process would have  resulted in wounded, injured, or ill servicemembers being assigned to one  of three categories. Servicemembers designated as Category 1 were  those who were found to have mild injury or illness, who were expected to  return to duty in less than 180 days of medical treatment, and primarily  received local outpatient and short-term inpatient treatment and  rehabilitation. Servicemembers designated as Category 2 were those with  serious injury or illness, who were unlikely to return to duty in less than  180 days, and may be medically separated from the military.  Servicemembers designated as Category 3 were those with severe injury  or illness, who were highly unlikely to return to duty, and were most likely  to be medically separated from the military. The category designation was  intended to be used to determine whether the recovering servicemember  was subsequently referred to a care coordination program, in that  Category 1 servicemembers would not be referred to a care coordination  program, unless their medical or psychological conditions worsen;  Category 2 servicemembers would be referred to the RCP; and   Category 3 servicemembers would be referred to the FRCP. (See fig. 3.)
section_title: Appendix III: Comments from the Department of Defense
section_title: Appendix IV: Comments from the Department of Veterans Affairs
section_title: Appendix V: GAO Contact and Staff Acknowledgments
subsections: section_title: GAO Contact
section_title: Staff Acknowledgments
paragraphs: In addition to the contact name above, Bonnie Anderson, Assistant  Director; Mark Bird, Assistant Director; Michele Grgich, Assistant Director;  Jennie Apter; Frederick Caison; Heather Collins; Dan Concepcion;  Melissa Jaynes; Deitra Lee; Mariel Lifshitz; Lisa Motley; Elise Pressma;  and Greg Whitney made key contributions to this report.
section_title: Related GAO Products
paragraphs: Military Disability System: Improved Monitoring Needed to Better Track  and Manage Performance. GAO-12-676. Washington, D.C.: August 28,  2012.
Military Disability System: Preliminary Observations on Efforts to Improve  Performance. GAO-12-718T. Washington, D.C.: May 23, 2012.
More Efficient and Effective Government: Opportunities to Reduce  Duplication, Overlap and Fragmentation, Achieve Savings, and Enhance  Revenue. GAO-12-449T. Washington, D.C.: February 28, 2012.  2012 Annual Report: Opportunities to Reduce Duplication, Overlap and  Fragmentation, Achieve Savings, and Enhance Revenue.  GAO-12-342SP. Washington, D.C.: February 28, 2012.
DOD and VA Health Care: Action Needed to Strengthen Integration  across Care Coordination and Case Management Programs.  GAO-12-129T. Washington, D.C.: October 6, 2011.
VA and DOD Health Care: First Federal Health Care Center Established,  but Implementation Concerns Need to Be Addressed. GAO-11-570.  Washington, D.C.: July 19, 2011.
Federal Recovery Coordination Program: Enrollment, Staffing, and Care  Coordination Pose Significant Challenges. GAO-11-572T. Washington,  D.C.: May 13, 2011.
Information Technology: Department of Veterans Affairs Faces Ongoing  Management Challenges. GAO-11-663T. Washington, D.C.: May 11,  2011.
Military and Veterans Disability System: Worldwide Deployment of  Integrated System Warrants Careful Monitoring. GAO-11-633T.  Washington, D.C.: May 4, 2011.
DOD and VA Health Care: Federal Recovery Coordination Program  Continues to Expand but Faces Significant Challenges. GAO-11-250.  Washington, D.C.: March 23, 2011.
Electronic Health Records: DOD and VA Should Remove Barriers and  Improve Efforts to Meet Their Common System Needs. GAO-11-265.  Washington, D.C.: February 2, 2011.
Military and Veterans Disability System: Pilot Has Achieved Some Goals,  but Further Planning and Monitoring Needed. GAO-11-69. Washington,  D.C.: December 6, 2010.
Military and Veterans Disability System: Preliminary Observations on  Evaluation and Planned Expansion of DOD/VA Pilot. GAO-11-191T.  Washington, D.C.: November 18, 2010.
Electronic Health Records: DOD and VA Interoperability Efforts Are  Ongoing; Program Office Needs to Implement Recommended  Improvements. GAO-10-332. Washington, D.C.: January 28, 2010.
Electronic Health Records: DOD and VA Efforts to Achieve Full  Interoperability Are Ongoing; Program Office Management Needs  Improvement. GAO-09-775. Washington, D.C.: July 28, 2009.
Recovering Servicemembers: DOD and VA Have Jointly Developed the  Majority of Required Policies but Challenges Remain. GAO-09-728.  Washington, D.C.: July 8, 2009.
Recovering Servicemembers: DOD and VA Have Made Progress to  Jointly Develop Required Policies but Additional Challenges Remain.  GAO-09-540T. Washington, D.C.: April 29, 2009.
Army Health Care: Progress Made in Staffing and Monitoring Units that  Provide Outpatient Case Management, but Additional Steps Needed.  GAO-09-357. Washington, D.C.: April 20, 2009.
Electronic Health Records: DOD’s and VA’s Sharing of Information Could  Benefit from Improved Management. GAO-09-268. Washington, D.C.:  January 28, 2009.
Electronic Health Records: DOD and VA Have Increased Their Sharing of  Health Information, but More Work Remains. GAO-08-954. Washington,  D.C.: July 28, 2008.
DOD and VA: Preliminary Observations on Efforts to Improve Care  Management and Disability Evaluations for Servicemembers.  GAO-08-514T. Washington, D.C.: February 27, 2008.
DOD and VA: Preliminary Observations on Efforts to Improve Health Care  and Disability Evaluations for Returning Servicemembers.  GAO-07-1256T. Washington, D.C.: September 26, 2007.
DOD and VA Health Care: Challenges Encountered by Injured  Servicemembers during Their Recovery Process. GAO-07-589T.  Washington, D.C.: March 5, 2007.