Military Health Care: Army Needs to Improve Oversight of Warrior Transition Units
Published: 2016-07-12T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: The Army established its WTU program in 2007 after congressional interest and media coverage about substandard care for soldiers at the former Walter Reed Army Medical Center. The program is to coordinate care for soldiers recovering from serious physical and behavioral health conditions. As the WTU soldier population has declined, the Army has reduced its WTUs--from 45 in 2008 to a planned total of 14 by August 2016.
The House Report accompanying a bill for the National Defense Authorization Act for Fiscal Year 2016 included a provision for GAO to review the WTU program. GAO evaluated, among other things, the extent to which the Army has (1) assessed the effectiveness of the Triad of Care model; (2) established processes to oversee the selection of WTU personnel, assess their training, and adjust staff levels; and (3) assessed adherence to WTU admittance criteria and the impact of any changes to them. GAO conducted site visits to 5 WTUs, based on a mix of active and reserve component soldiers and other variables.
section_title: What GAO Found
paragraphs: The Army has not assessed the effectiveness of the Triad of Care model, the core structure of the Warrior Transition Unit (WTU) program, consisting of a team of three key staff that provide medical case management. The Army established the Triad of Care model at a time when WTU soldiers' diagnoses were primarily for physical conditions. Since then, the composition of diagnoses has changed significantly. Specifically, in 2008, about 36 percent of the 12,228 soldiers who entered the WTUs had a behavioral health diagnosis. In 2015, however, over half of the 2,628 soldiers who entered the WTUs, about 52 percent, had such a diagnosis. Despite the change in the composition of diagnoses, the Army has not assessed its approach for managing soldiers' care. Officials from the five WTUs that GAO visited stated that they have added social workers to the Triad as an ad-hoc measure to provide better case management and certain types of behavioral health services. These local adaptations represent efforts to meet an immediate medical need and support the need for analysis of whether the Triad model should change. Assessing the Triad in light of the changes in WTU soldiers' diagnoses would position the Army to better determine how to meet WTU soldiers' medical needs.
The Army faces challenges in its oversight of the selection of squad leaders and platoon sergeants to staff WTUs, in the evaluation of staff training, and in the ability to adjust future staff levels if needed. Specifically, the Army has established selection processes and updated its selection criteria for these WTU personnel, but it is not exercising oversight responsibility to track full adherence to these policies, specifically the Army's requirement to interview candidates for these positions. Candidates for these positions are drawn from a mix of Army occupations, and the selection process, including interviews, is intended to ensure the suitability of the staff selected for these sensitive positions. While the Army has taken steps to improve its training program for squad leaders and platoon sergeants, the program does not incorporate a post-training assessment of the application of training to the work environment. Without information that could be obtained from such assessments, the Army may miss an opportunity to incorporate information concerning the practical application of training. In addition, the Army has not developed plans for how it would increase WTU staff levels, if needed, to support any potential future increase in demand. The ability to reverse the decision to inactivate 11 WTUs by August 2016 was a key planning consideration for the Army. However, without a plan to address staff level changes, the Army lacks assurance that it can select, train, and assign staff to its WTUs in a timely manner.
While the Army has implemented a process for reviewing the eligibility of soldiers to be admitted to WTUs, it does not track instances in which Commanders have made exceptions to these criteria. By not tracking this information, the Army does not know how frequently such exceptions are made and cannot ensure the best use of resources. In addition, the Army is planning to expand a WTU-alternative program to the Army Reserve, but has not examined the costs and benefits of such an expansion. Without comparing the costs and benefits of program expansion with the current system, the Army could incur significant costs without clearly articulated benefits.
section_title: What GAO Recommends
paragraphs: GAO's recommendations include that the Army assess the Triad of Care model's effectiveness; track adherence to selection processes for WTU staff; assess the application of their training; develop plans to ensure the ability to adjust staff levels, if needed; track exceptions to WTU admittance criteria; and compare the costs and benefits of expanding a WTU-alternative program for Army Reserve soldiers. DOD concurred with each of GAO's recommendations.

section_title: Letter
paragraphs: After congressional interest and media coverage regarding deficiencies  related to medical care for Army soldiers recovering from serious medical  conditions at the former Walter Reed Army Medical Center, the Army in  2007 established its Warrior Transition Unit (WTU) program for active- duty, Army Reserve, and Army National Guard soldiers. The Army  created this program to manage recovering soldiers’ complex medical  needs using a uniform, Army-wide structure and approach to facilitate the  soldiers’ transition either back to the force or to separation from the Army.  The central structure of the WTU program is the Triad of Care staffing  model for managing soldiers’ care, which comprises a primary care  manager, a nurse case manager, and a squad leader or platoon sergeant  who work together to develop a plan of care for supporting each soldier’s  transition. According to Army data, the number of soldiers entering the  WTU program has declined from a peak of 12,228 in 2008 to 2,628 in  2015, and consequently the Army has reduced the number of WTUs,  from a high of 45 units in 2008 to the planned 14 units by August 2016.
WTUs are an asset of the local military treatment facility and, by  extension, under the command and control of the senior mission  Commander on the relevant installation. The Army’s Warrior Transition  Command is charged with providing policy and oversight of the WTU  program. The Warrior Transition Command is a subcommand of the Army  Medical Command, and reports to the Army Surgeon General. Starting  June 2016, the Warrior Transition Command will be reorganized as a  directorate within the Army Medical Command. The Army Surgeon  General, as Commanding General of the Army Medical Command, is  ultimately responsible for oversight of the Warrior Transition Command  and the WTU program.
Given the changes that are occurring in the Army’s WTU program, the  House Report accompanying a bill for the National Defense  Authorization Act for Fiscal Year 2016 included a provision for us to  review various aspects of the program. We examined the extent to which  the Army has (1) assessed the effectiveness of the Triad of Care staffing  model for managing WTU soldiers’ care; (2) established processes to  oversee its WTU personnel selection, assess the training of these  personnel, and adjust staff levels; (3) assessed adherence to WTU  admittance criteria and the impact of any changes to these criteria for the  active-duty and reserve components; and (4) instituted methods to  address WTU soldiers’ complaints.
To address the objectives, we reviewed policies governing the WTU  program, obtained and analyzed program documents and data, and  interviewed officials from the Warrior Transition Command, the Office of  the Army Surgeon General, and other Army offices with responsibilities  for medical and personnel management. We conducted site visits to five  WTUs. We selected these sites based on their mix of active-duty and  reserve components, data on soldier’s complaints, and geographic  dispersion. While the results from these visits are not generalizable, they  provide useful information on WTU operations and relevant issues.
For our first objective, we compared policy and other documents  concerning the use of the Triad of Care model with federal internal control  standards for risk assessment, which emphasize the need for  management to identify, analyze, and respond to any significant changes  that could affect its ability to achieve defined objectives. To identify  changes in the WTU population over time, we analyzed data from the  Warrior Transition Command on WTU soldiers’ medical diagnoses. We  found these data to be sufficiently reliable for our use based on interviews  with Warrior Transition Command officials about how the data were  captured, stored, and checked for accuracy. We spoke with Warrior  Transition Command officials about the Triad of Care model, changes  with the WTU soldier population, and their WTU inspections. We also  interviewed officials at each of the five WTUs we visited about the Triad of  Care model and the management of their soldiers’ care.
For our second objective, we compared current Army policies with  previous Army policies regarding selecting and training WTU staff. We  reviewed federal internal control standards, which state that  management should demonstrate a commitment to recruit, develop, and  retain competent individuals, and we reviewed our work identifying the  attributes of effective training. We obtained information on current  practices for selecting and training WTU staff and obtained the  perspectives of Army and WTU officials to provide context and clarity. We  focused on the selection and training of squad leaders and platoon  sergeants based on these discussions. We also reviewed policies  concerning the Army’s ability to adjust staff levels and federal internal  control standards, which emphasize the need to demonstrate a  commitment to competence through succession and contingency  planning, and the need for control activities such as the management of  human capital to maintain a continuity of needed skills and abilities. We  also interviewed Warrior Transition Command and WTU officials to  provide context and clarity.
For our third objective, we examined the Army’s policies and process for  admitting soldiers into the WTUs, including any proposed changes to  admittance criteria. We compared the Army’s application of these policies  with federal internal control standards which require that management  design control activities, such as establishment and review of  performance measures and indicators, to achieve objectives and respond  to risks. In addition, we compared plans for the introduction of a WTU- alternative program for the Army Reserve with our prior work, which  calls for a performance-based analysis of benefits and costs for each  alternative when considering program changes.
For our fourth objective, we obtained and analyzed information on the  Army’s approach for handling complaints by WTU soldiers. We  compared the Army’s approach for handling complaints with federal  internal control standards, which state that information should be  communicated to management and others who need it in such a way that  they can carry out their responsibilities. A more detailed discussion of  our scope and methodology is provided in appendix I.
We conducted this performance audit from August 2015 to July 2016 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
subsections: section_title: Evolution of the Army’s Approach for Caring for Wounded Soldiers
paragraphs: Due to improved battlefield medicine, soldiers who might have died in  past conflicts are now surviving, many with multiple serious injuries that  require extensive outpatient rehabilitation, such as amputations, burns,  and traumatic brain injuries. Prior to the establishment of WTUs, the Army  provided care for soldiers recovering from serious medical conditions  through Medical Hold and Holdover Units. According to Army  documents, the previous system did not have a uniform structure and  exhibited varying levels of resources. For example, some units fell under  the command of the local military treatment facility, while others fell under  the command of the local installation. In addition, the Army did not have a  uniform system of staffing, as the relevant command had to resource the  units by reassigning personnel from other missions and functions.  Further, the increased workload associated with care for these soldiers at  the local military treatment facility was not reflected in increased staffing  levels or resources.
In response to congressional interest and media coverage regarding  inadequate and substandard care for Army soldiers recovering from  serious medical conditions at the former Walter Reed Army Medical  Center, the Army in 2007 developed its Army Medical Action Plan. This  plan laid out a series of steps to address the problems highlighted at  Walter Reed and other facilities, including the establishment of the WTU  program. According to Army documents, the primary differences between  the previous system of Medical Hold and Holdover Units and the WTU  program was the establishment of (1) a uniform structure and ratios of  staff to WTU soldiers by specialty and (2) a program (the Comprehensive  Transition Plan) to facilitate the soldiers’ transition to either a return to the  force or separation from the Army.
The central structure of the WTU program is the Triad of Care model,  which includes a primary care manager, a nurse case manager, and a  squad leader or platoon sergeant, who direct and supervise the WTU  soldiers’ healing process. Along with these Triad of Care key staff, there  are other medical and nonmedical providers—such as social workers and  occupational therapists—who work together to develop a plan of care  specific to each soldier. The plan of care is intended to address the  soldiers’ medical needs and support their transition either back to duty or  to separation from the Army. This staffing model formalized the  relationship between some of the same positions that had existed in the  prior Medical Hold and Holdover Units’ and established ratios for the  number of WTU soldiers that were to be under the care of each of the  Triad of Care’s key staff. Figure 1 provides position descriptions and  staffing ratios for the Triad of Care model.
section_title: Trends in the Population of Soldiers in the WTU Program
paragraphs: In 2007, the Army began establishing individual WTUs at geographically  dispersed locations to serve active-duty, Army Reserve, and Army  National Guard soldiers needing this type of assistance. Figure 2 shows  trends in the WTU soldier population over time. In line with this reduction  in population, the Army reduced the number of WTUs from a high of 45 in  2008 to 25 in 2014, with plans to inactivate another 11 by August 2016. At  that point, the Army will have 14 WTUs remaining.
The Army uses an annual process known as a Strategic Posture Review  to determine the required capability and capacity for each WTU location  and for WTUs across the Army enterprise, such as determinations for the  number of WTUs. This process includes estimating the future population  of WTU soldiers using a model validated by the Army and then applying  the estimated population to the current capacity of WTUs based on  established ratios of the numbers of WTU soldiers to the numbers of  primary care managers, nurse case managers, and squad leaders. If  excess capacity is identified, the Warrior Transition Command reviews a  series of criteria to determine which WTUs should remain open. For  example, as part of the most recent review that recommended the  inactivation of 11 sites, Army officials stated that they had selected sites  to remain open that were co-located with force projection platforms and  the best Army medical facilities. These recommendations are ultimately  approved by senior Army officials.
The ability to reverse these inactivations if demand for WTUs were to rise  in the future was a key planning consideration in the decision to inactivate  11 WTUs by August 2016. As a result, the Army has issued policy to  maintain control and oversight of former WTU facilities at inactivating  locations. For example, the policy requires that the Installation  Management Command conduct annual inspections of inactivated WTU  facilities to ensure that compliance with Army standards for WTU  facilities. The same policy calls for the Army’s Installation Management  Command to be prepared to return deactivated facilities to WTU program  use within 180 days of notification of the unit’s reactivation.
section_title: Transition Process
paragraphs: While assigned to the WTU program, soldiers are to work toward meeting  the goals identified in their individualized Comprehensive Transition  Plan. This standardized framework has six main phases: (1) in- processing, (2) goal setting, (3) transition review, (4) rehabilitation, (5)  reintegration, and (6) post-transition. As part of the Comprehensive  Transition Plan and in addition to attending medical appointments,  soldiers might, depending on their needs, undergo physical rehabilitation,  meet with behavioral health therapists, participate in adaptive sports and  reconditioning programs, participate in internships and training, and  prepare to transition out of the WTU program. The last phase, post- transition, occurs after a soldier has left the WTU program.
The point in the WTU soldiers’ rehabilitation process when it can be  determined whether or not further medical care will cause a soldier to be  found fit for duty is called the medical retention determination point.  During their stay, WTU soldiers take part in activities to help them  transition either back to the Army or to separate from the Army. For WTU  soldiers who are returning to the Army, these activities could include  taking Army career-related education or training, including college  courses and other soldier development classes. For WTU soldiers who  are transitioning out of the Army, these activities could include going  through the disability evaluation systems, as well as participating in  education and readiness opportunities that fit with the soldiers’ career  goals. See appendix II for additional information concerning trends in  WTU soldiers’ separation from the Army and in WTU soldiers’ lengths of  stay in the WTU program.
section_title: The Army Has Not Assessed the Effectiveness of the Triad of Care Model despite the Change in the Composition of Diagnoses among WTU Soldiers
paragraphs: The Army has not assessed the effectiveness of the Triad of Care model,  the core structure of the WTU program and consisting of a team of three  key staff that provide medical case management. The Army designed the  Triad of Care model at a time when WTU soldiers’ diagnoses were  primarily for physical conditions. However, since then, the composition of  diagnoses has changed significantly. Despite this change, the Army has  not assessed its approach for managing soldiers’ medical care. The five  WTUs we visited reported having taken ad-hoc measures to help meet  the increase in behavioral health needs in the absence of such an  assessment. For example, medical officials at each of the five WTUs that  we visited told us that they include social workers as a fourth member of  the Triad of Care staff.
subsections: section_title: Composition of Diagnoses among WTU Soldiers Has Changed Significantly
paragraphs: The Army established the Triad of Care model at a time when WTU  soldiers’ diagnoses were primarily for physical conditions. Since then,  the composition of diagnoses has changed significantly. Specifically, in  2008, the first full year of the WTU program, about 36 percent of the  12,228 WTU soldiers had a behavioral health diagnosis, while in 2015,  over half of the 2,628 soldiers, about 52 percent, had such a diagnosis.  According to Warrior Transition Command officials, these diagnoses  include post-traumatic stress disorder diagnoses and all behavioral health  or psychiatric diagnoses that are not categorized as post-traumatic stress  disorder, such as major depression, anxiety disorder, panic disorder, and  schizophrenia.
Our analysis of these data showed that in 2008, 2,553 of 12,228 WTU  soldiers (about 21 percent) entered the WTU program with a behavioral  health issue as their primary diagnosis, compared with 830 of the 2,628  WTU soldiers in 2015 (about 32 percent). Moreover, over that same time  frame, 4,424 of 12,228 WTU soldiers (about 36 percent) entered the WTU  program with a behavioral health issue as their primary, secondary, or  tertiary diagnosis, compared with 1,355 of 2,628 WTU soldiers in 2015  (about 52 percent). Warrior Transition Command officials stated that the  greater prevalence of behavioral health issues is likely related to the  Army’s efforts to de-stigmatize behavioral health issues. They told us  that, as a result, it has now become acceptable for soldiers to notify  medical personnel when these issues arise, impacting the number of  soldiers being recognized and coming forward for assistance with  behavioral health diagnoses.
section_title: The Warrior Transition Command Has Not Assessed Whether Army- wide Changes to the Triad of Care Model Are Needed to Respond to the Change in the Composition of Diagnoses
paragraphs: While the Army conducts reviews and inspections of the WTU program  and WTUs, it has not assessed the effectiveness of the Triad of Care  model, in light of the change in the composition of diagnoses. Warrior  Transition Command senior officials told us that validation reviews of the  population and staffing models have been conducted on an approximately  3-year basis and that periodic unit inspections have also been conducted.
Validation reviews. The U.S. Army Manpower Analysis Agency  conducts validation reviews of the Warrior Transition Command’s  population and staffing models within the WTUs. These reviews  examine, among other things, the staffing ratios for different types of  personnel (including for members of the Triad of Care).
Unit inspections. The Warrior Transition Command conducts  inspections of each WTU under the Organizational Inspection  Program, inspections that are to assess numerous aspects of each  WTU’s operations and provide an avenue for other concerns to be  raised. These inspections generally include a pre-questionnaire to  WTU soldiers, their family members, and staff; a process evaluation to  determine a WTU’s adherence to policies and procedures; and an  after-action review with a WTU’s leadership and staff to rate the  inspection process.
According to Warrior Transition Command officials, these reviews and  inspections should indicate whether changes are needed to the Triad of  Care model. However, we found that while both validation reviews and  unit inspections assess important aspects of the Army’s approach to care,  neither has specifically assessed whether changes are needed to the  Triad of Care model to address, for example, the greater prevalence of  WTU soldiers’ behavioral health needs. The Army designed the Triad of  Care model at a time when the preponderance of injuries among WTU  soldiers were physical. Since that time, the Army has not assessed  whether these significant changes to the WTU soldier population’s  diagnoses have impacted its approach for managing soldiers’ medical  care. Federal standards for internal control state that management should  analyze relevant risks associated with achieving a program’s objectives.  The increasing prevalence of behavioral health diagnoses in WTU  soldiers and the resulting increase in soldiers’ need for behavioral health  services needs is one such relevant risk.
In the absence of an assessment by the Warrior Transition Command,  officials from each of the five WTUs we visited told us that they have  taken various ad-hoc steps to meet the challenges posed by the  increasing prevalence of behavioral health diagnoses. For example,  medical officials at each of the WTUs we visited told us that they include  social workers as an additional member of the Triad of Care model in  response to the need for specialized medical case management. While  social workers have always played a role in the WTUs’ interdisciplinary  team, officials at these WTUs told us that the greater prevalence of  behavioral health diagnoses among soldiers warranted a greater role for  social workers, who serve as the WTUs’ behavioral health experts.  Further, senior officials at several of these WTUs told us that they now  refer to their model as the “Quad of Care” or “Square of Care” in response  to the social workers’ inclusion. In addition, at four of the five WTUs,  social workers told us that they have been directly providing certain types  of behavioral health care to soldiers, such as therapy sessions, in part  because obtaining behavioral health appointments at the local military  treatment facility can be difficult. Medical officials from one of these four  WTUs also told us that, in addition to providing the social workers’  therapy sessions, the unit borrows a psychiatrist from the local military  treatment facility 2 days each week to provide behavioral health care. At  the remaining WTU, the local military treatment facility contracted for a  full-time psychiatrist in order to meet soldiers’ need for behavioral health  services.
While these local adaptations represent efforts to meet an immediate  need, they are not supported by analysis of whether the Triad of Care  model must change to meet the increasing behavioral health needs of the  WTU soldier population. For example, the differing approaches of various  WTUs, with some making greater use of social workers and others  turning to psychiatrists, merits review and assessment by the Army to  determine which approach best benefits WTU soldiers. Assessing the  Triad of Care model in light of changes in, for example, the prevalence of  behavioral health conditions would position the Army to better determine  how to meet WTU soldiers’ medical needs.
section_title: The Army Faces Challenges in Overseeing the Selection of Certain WTU Staff, in Evaluating Their Training, and in Adjusting Staff Levels if Needed
paragraphs: The Army has established selection processes and updated its selection  criteria to require additional information about potential squad leaders and  platoon sergeants for its WTUs, but the Army is not monitoring full  adherence to policy, specifically the requirement to interview candidates  for these positions. Further, while the Army had made improvements to its  training program, the program does not incorporate a post-training  assessment on the application of training to the work environment. In  addition, the Army has not developed a plan that explains how to meet  any potential increases in demand for staff, if needed, at the WTUs.
subsections: section_title: The Army Has Established Selection Processes and Updated Its Selection Criteria
paragraphs: The Army has established processes to select WTU squad leaders and  platoon sergeants, and has updated its selection criteria to require greater  experience and additional screening. WTU squad leaders and platoon  sergeants are selected by various methods based on whether they are  active duty or members of the reserve components, and the senior  Commander at the installation is the final approval authority for all  assignments. WTU positions are designed to be representative of the  entire Army, with a mix of military occupational specialties and all three  active and reserve components. Prior to selection, squad leaders and  platoon sergeants must meet minimum grade, experience, and training  qualifications.
Squad leader and platoon sergeant positions can be filled by personnel  sourced through one of the following: from the installation where the WTU  is located; the Human Resources Command; and, for reserve component  soldiers, the Tour of Duty system. Senior Commanders can identify  personnel from the installation where the WTU is located to interview for  squad leader and platoon sergeant positions. If senior Commanders are  unable to identify staff at the installation, a request is sent to the Human  Resources Command to identify personnel to be screened and sent to the  WTU program. Using the Tour of Duty system, reserve component  personnel can apply for open squad leader and platoon sergeant  positions, and local Commanders and their selection panels interview and  select the best-qualified candidates. Figure 3 shows the three sources  and the processes for filling the squad leader and platoon sergeant  positions.
In November 2015, the Army updated its selection policy for WTU squad  leaders and platoon sergeants. The November 2015 policy increases the  minimum grade and experience requirements and identifies minimum  training requirements. According to WTC officials, the updated  requirements give WTU squad leaders and platoon sergeants more  experience to draw from when working with WTU soldiers. In addition, the  policy identifies squad leaders and platoon sergeants as positions of  significant trust and authority. Through this designation, the Army  requires more screening, including through the use of records concerning  police encounters, substance abuse, sex offender status, and behavioral  health and records held by Army personnel offices.
The updated policy also requires WTU squad leaders and platoon  sergeants to have previously served successfully in a grade-equivalent  leadership position and to meet minimum grade and training  requirements. For example, potential squad leaders are required to hold  the minimum grade of E-6 and to have completed the Advanced Leader  Course, and potential platoon sergeants are required to hold the minimum  grade of E-7 and have completed the Senior Leader Course. Table 1 lists  the WTU program selection criteria for squad leaders and platoon  sergeants before and after November 2015.
section_title: The Army Is Not Monitoring Full Adherence to Selection Policy Requirement
paragraphs: Although the Army has updated its policy for selecting squad leaders and  platoon sergeants, the Warrior Transition Command is not monitoring full  adherence to this policy, specifically the requirement to interview  candidates for these positions. According to the policy effective before  November 2015, Commanders or their staff selection panels are required  to review the records of candidates and interview them to validate  whether a candidate possesses the required skills and attributes to work  as WTU staff. This provision did not change with the new regulation  effective November 2015. However, the Army does not have a  mechanism in place to monitor whether the interviews are conducted.
According to Warrior Transition Command guidance, the WTU selection  process for squad leaders and platoon sergeants is important to ensure  the selection of individuals who are best suited for the position. Warrior  Transition Command officials stated that squad leader and platoon  sergeant positions within the WTU are categorized as “broadening  positions” because they reflect responsibilities and duties outside of their  Army military occupational specialty. Candidates for these positions are  drawn from a mix of Army occupations, such as infantry or transportation  corps, and the selection process, including interviews, is intended to  ensure the suitability of the staff selected for the position. Warrior  Transition Command guidance recommends using the structured  interview process when evaluating candidates to significantly improve the  likelihood of selecting good candidates. A structured interviewed process  involves the WTU Commander or a staff selection board asking the same  questions of each candidate and scoring the answers using a pre- developed rating scale. The guidance explains that interviewing provides  Commanders and their selection panels the ability to learn more about  the candidate and gives candidates the opportunity to demonstrate their  responses to situational job scenarios such as supervising WTU soldiers  with behavioral health issues.
The Warrior Transition Command, which is responsible for oversight of  the WTU program and operations, has not monitored whether units  adhere to the requirement to interview squad leaders and platoon  sergeants for WTU positions. The Warrior Transition Command directs  the Army Human Resource Action Branch to conduct a quarterly analysis  of a random sample of squad leader and platoon sergeants’ records to  validate that candidates meet, for example, minimum grade and  experience requirements. However, this quarterly analysis does not  include validation of whether the selection process was followed as  required, including whether the candidate was interviewed. At four of the  five WTUs we visited, squad leaders and platoon sergeants told us that  they were not interviewed prior to assuming their positions. In contrast,  senior officials at three of the five WTUs we visited stated that they  believed that interviews for squad leaders and platoon sergeants are  conducted. However, in the absence of a mechanism to monitor this, the  Army does not have assurance that the interviews are being conducted.  When questioned why some interviews may not be conducted, Warrior  Transition Command officials stated that the interviews were encouraged,  which stands in contrast to the stated policy.
Federal internal control standards state that management should design  control activities to achieve objectives and respond to risks. Although  both the regulations effective as of November 2015 and before  November 2015 state that Commanders or their staff selection panels  will interview and review the records of candidates to validate whether a  candidate possesses the required skills and attributes to work as WTU  squad leaders and platoon sergeants, there is no internal control  procedure to monitor full adherence to this requirement. By not monitoring  full adherence to this requirement, the Army does not have assurance  that squad leaders and platoon sergeants being selected are well suited  to carry out the sensitive mission of the WTUs.
section_title: The Army Has Made Efforts to Improve Training, but Does Not Incorporate a Key Post- Training Assessment
paragraphs: The Army Medical Department Center and School has made efforts to  make improve WTU training for squad leaders and platoon sergeants, but  the program does not incorporate a post-training assessment of the  application of training to the work environment. At three of the five sites  we visited, WTU squad leaders and platoon sergeants, along with other  WTU staff, expressed concerns regarding squad leader and platoon  sergeants’ training. While the Army has implemented several practices to  incorporate feedback from participants and other WTU professionals into  its training program for squad leaders and platoon sergeants, these  efforts may not fully address the concerns.
Currently, according to school officials, the Army Medical Department  Center and School offers a 3-week residential training course that squad  leaders and platoons sergeants must take within 90 days of assuming  their duties. Prior to attending the residence course, staff must complete a  staff orientation distance learning course. In the first week of residence  training, squad leaders and platoon sergeants are required to take the  Cadre Resilience Course, designed to assist those caring for wounded, ill,  and injured soldiers and their families. According to Army Medical  Department Center and School officials, the second and third weeks of  training are designed specifically for the WTU and include information  related to, for example, communication skills, behavioral health issues,  the Comprehensive Transition Program, the case management system,  and role-playing activities. Army Medical Department Center and School  officials stated that the vast majority of squad leaders and platoon  sergeants come to the course with little to no knowledge of the WTU  concept. Army Medical Department Center and School officials also  stated that the training is designed to provide a foundation for squad  leaders and platoon sergeants to be able to perform their duties, and is  not intended to provide them with expert-level proficiency.
While the WTU training program is extensive, WTU squad leaders and  platoon sergeants at three of the five sites we visited stated that they  were not sufficiently prepared for their positions after taking the required  training. Specifically, squad leaders and platoon sergeants stated that  their training did not address the actual requirements of their positions,  such as the use of data systems and other day-to-day responsibilities.  Squad leaders and platoon sergeants expressed frustration with their  training, noting that there is no military occupational specialty similar to  their positions, and that their roles and responsibilities were unfamiliar  and dissimilar to anything in their prior Army experience. Candidates for  these positions are drawn from a mix of Army occupations, such as  infantry or transportation corps, and new squad leaders and platoon  sergeants may have no background working with soldiers with issues  typical of the WTU population, such as behavioral health issues. Other  WTU staff at these sites, such as nurse case managers, social workers,  and a WTU Commander stated that they also believe that current training  does not sufficiently prepare squad leaders and platoon sergeants for  their duties. For example, they noted that in some instances squad  leaders and platoon sergeants did not have a sufficient understanding of  behavioral health issues to be charged with responsibility for individuals  having these issues.
Our prior work on assessing strategic training efforts summarizes  attributes of effective training and development programs, including those  related to the evaluation of agency training and development efforts.  Such attributes include how the agency incorporates evaluation feedback  into the planning, design, and implementation of its training and  development efforts. According to school officials, the Army Medical  Department Center and School currently uses end-of-course surveys and  feedback from focus groups, WTU leadership, and staff to collect  information on the effectiveness of the courses offered and make  changes to course curricula. In addition, Army Medical Department  Center and Schools officials stated that the Warrior Transition Command  provides feedback from its Organizational Inspection Program regarding  training. Warrior Transition Command officials stated that they send  questionnaires prior to their Organizational Inspection Program and ask  questions during informal feedback sessions regarding the effectiveness  of squad leader and platoon sergeant training. These officials stated that  they believe their current approach provides sufficient feedback to  improve the training program.
While these efforts represent attempts to improve training through  feedback, they do not assess the application of training to the work  environment. Our prior work emphasizes that agencies should use  analytical approaches appropriate for assessing training and development  programs, such as assessing the application of training to the work  environment. Application of training to the work environment assesses  expected changes in behavior that trainees should exhibit on the job  because of the training. Army Medical Department Center and School  officials stated that the WTUs do not evaluate training of squad leaders  and platoon sergeant through assessments of how well they are able to  apply their training to the work environment. These officials noted that  they have previously proposed such an assessment to the Warrior  Transition Command as the Warrior Transition Command is responsible  for post-training assessments of staff. Army Medical Department Center  and School officials noted that 90 days post-training would be an  opportune time to collect information on the application of squad leaders  and platoon sergeants’ training to the work environment. However, no  action has been taken to date.
Without information that could be obtained from conducting post-training  assessments, the Army Medical Department Center and School may miss  a valuable opportunity to improve its programs by incorporating useful  information concerning the practical application of training. Similarly, the  Warrior Transition Command and WTUs may miss a valuable opportunity  to further assess the performance of the squad leaders and platoon  sergeants for the benefit of WTU soldiers.
section_title: The Army Has Not Developed Plans for Adjusting Staff Levels to Meet Any Potential Increases in Demand for WTUs
paragraphs: The Army has not developed plans for increasing its WTU staff levels in  the event of increased demand for WTUs. A key planning consideration in  the decision to inactivate 11 WTUs by August 2016 was the Army’s ability  to reverse these changes in the event that the demand for the Army’s  WTU program was to increase. The Army’s guidance highlights the  importance of reversibility, and establishes a number of relevant policies,  for example, to maintain control of inactive WTU facilities. According to  the Warrior Transition Command, the enduring 14 WTUs, if staffed by a  full complement of 1,475 staff, could manage up to 4,400 WTU soldiers.  With additional staff, the facilities at the enduring WTUs could support up  to 8,100 WTU soldiers. In line with this projection, the Army has outlined  plans for “expansion companies” at its enduring locations, with the  exception of Walter Reed National Military Medical Center and Brooke  Army Medical Center, that could operate on a temporary basis for a  period of 2 years, with an assessment after the first 9 months to  determine whether the company should be added to the unit’s permanent  staffing document. Each expansion company would require 55 WTU  personnel and could manage the care of up to 200 WTU soldiers.
While these plans represent positive steps toward planning for a potential  increase in WTU numbers, the Army has not addressed how it would staff  the expansion companies at these enduring WTUs, or at any of the 11  inactivating WTUs, if the need arises. Warrior Transition Command  officials stated that any change in the need for staff would be gradual. In  addition, the Warrior Transition Command’s population projection model  takes account of deployment cycles and could possibly anticipate a spike  in WTU admissions due to an increased operational tempo. However,  upswings in deployments and operational tempo could create spikes in  WTU soldier admissions, possibly resulting in the need to expand WTU  staff at a pace that is greater than the Army’s current expectations.
Regardless of the pace of any increase, the Army could face challenges  in its efforts to staff these units with appropriately selected and screened  personnel in a timely manner. As previously noted, the Warrior Transition  Command recently updated its selection requirements for squad leaders  and platoon sergeants. As the Warrior Transition Command implements  requirements for squad leaders and platoon sergeants to undergo  background checks and behavioral health records checks, effects from  these changes could result in an increase in the time required to select  WTU staff. The Warrior Transition Command has emphasized the  importance of the screening and selection process, noting that it is central  to the integrity of the WTU program and the duty to care for WTU  soldiers. In addition, WTUs are staffed by a number of other  professionals, including primary care managers, nurse case managers,  social workers, and transition coordination specialists, and hiring well- qualified candidates for these positions will also take time. For example,  after WTU nurse case managers attend a 3-week training course, they  must then complete a 4-week preceptorship at their assigned WTU  before they can manage a normal caseload of 20 WTU soldiers. Army  guidance notes the possibility of hiring term or temporary employees to  address any gaps. However, such an approach could negatively impact  the continuity of care, a central principle of the Army’s approach to WTU  care, because of turnover in key WTU staff.
To handle any sudden increase in demand, WTUs also could potentially  increase their ratios of squad leaders, nurse case managers, or primary  care managers to WTU soldiers to accommodate the additional demand,  but this too could have negative effects due to the heavier case  workloads that would result for these individuals. Warrior Transition  Command officials stated that they regularly monitor the ratios of these  team members to WTU soldiers, and the regulation underscores the  relationship between adhering to these ratios and the quality of care  provided. Further, officials such as squad leaders, platoon sergeants,  social workers, and nurse case managers at the five WTUs we visited  stated that the current ratios may be too high. At one site we visited,  officials have changed local policy to lower the ratio of squad leaders to  WTU soldiers.
Federal internal control standards emphasize the need for control  activities, such as the management of human capital, to maintain a  continuity of needed skills and abilities. While the Army’s recently issued  policy does not require the Warrior Transition Command to develop a  plan for increasing its staff levels in response to future demand, the policy  states that the Warrior Transition Command should “be prepared to  reactivate previously inactivated WTUs.” Senior Warrior Transition  Command officials told us that this is an implied requirement for a plan  related to staffing. However, they stated that they have not yet taken  steps to address this issue. Absent such a plan, the Army does not have  assurance that it can, with limited notice, expand its staffing to effectively  carry out the WTU mission.
section_title: The Army Does Not Track Instances in Which Commanders Have Made Exceptions to WTU Admittance Criteria and Has Not Analyzed Proposed Changes to Criteria for the Reserve Component
paragraphs: The Army has implemented a structured process for reviewing the  eligibility of soldiers to be admitted to WTUs, but it does not track  instances in which Commanders have made exceptions to these criteria  for active-duty soldiers. In addition, Warrior Transition Command and  Army Reserve officials stated that they came to an agreement that  admittance criteria for members of the reserve component will not change  until a WTU-alternative program is expanded to the Army Reserve.  However, the Army has not yet examined the costs and benefits of  expanding this alternative program relative to the current system.
subsections: section_title: The Army Does Not Track Instances in Which Commanders Have Made Exceptions to WTU Admittance Criteria for the Active-Duty Component
paragraphs: According to Warrior Transition Command officials, the Army does not  track instances in which individual WTUs have made exceptions to the  Army’s WTU admittance criteria for active-duty soldiers. While the Army  has established a structured process for reviewing the eligibility of  soldiers to enter WTUs, Warrior Transition Command officials stated that  the senior mission Commander at the relevant installation can choose to  admit soldiers to WTUs outside of this process by approving an exception  to the eligibility criteria.
Army regulations state that for admittance into the WTU program, active- duty component soldiers must either (1) need care requiring 6 months or  more of treatment or (2) have a significant behavioral health issue that  presents a danger to themselves or others. The Army’s structured  process for reviewing the eligibility of soldiers to enter WTUs comprises  the requirement that the WTU Commander, local hospital Commander,  and senior mission Commander compare potential WTU soldiers’ medical  case history with the WTU admittance criteria and decide whether  soldiers are eligible. Warrior Transition Command officials stated that  senior mission Commanders are able to approve exceptions to the criteria  under a variety of circumstances, such as the need for soldiers stationed  overseas to process disability status through DOD’s Integrated Disability  Evaluation System.
Officials at the Warrior Transition Command could not provide data of  how often exceptions to WTU admittance criteria were approved. Officials  noted that admitting soldiers who do not meet admittance criteria can be  appropriate in some situations. For example, the Department of Defense  and the Veterans Affairs system for assessing individuals’ medical fitness  for service and level of service-related disability, known as the Integrated  Disability Evaluation System, is available only to soldiers in the  continental United States, and soldiers stationed overseas can be  transferred to a military treatment facility in the continental United States  with an associated WTU to complete this process. WTU soldiers who will  not be returning to duty normally go through this process while in the  WTU.
Officials at our site visits expressed concern related to instances in which  soldiers were far into the Integrated Disability Evaluation System process,  near to the point of separation from the Army, and were assigned to a  WTU to stay for fewer than 6 months, sometimes for fewer than 30 days.  By virtue of the fact that a soldier is in the late stages of the Integrated  Disability Evaluation System process, the soldier is unlikely to be in the  Army for the standard admittance criteria period of 6 months or more of  care. At three of the five sites we visited, a variety of WTU officials, such  as nurse case managers, squad leaders, and social workers, among  others, expressed concern about this issue. Officials at these locations  noted that this was not the best use of WTU resources, and that such  soldiers did not have the necessary time to benefit from the medical and  career opportunities that the WTU program provides.
According to Warrior Transition Command officials, they do not track  instances in which individual WTUs make exceptions to the Army’s  admittance criteria because application of the eligibility criteria is the  responsibility of the senior mission Commander on the relevant  installation. Standards for Internal Control in the Federal Government  state that management should design control activities to achieve  objectives. These control activities might include performing top-level  reviews, for example, to ensure that performance is consistent with the  WTU program’s goals. However, by not tracking this information, the  Army does not know how frequently such exceptions are made and  cannot ensure the best use of resources.
section_title: The Army Has Not Yet Examined the Costs and Benefits of Expanding a WTU-Alternative Program for Army Reserve Soldiers
paragraphs: The Army is planning to expand an alternative WTU program to the Army  Reserve, but it has not yet examined the costs and benefits of this  expansion. Specifically, the Army has not yet estimated the costs and  benefits of expanding the Reserve Component Managed Care program,  which currently treats only National Guard soldiers with low-acuity, low- risk, non-complex medical needs. In addition, the Army has not compared  the cost of expanding this program with maintaining the status quo for  soldiers with similar low-acuity, low-risk, non-complex medical needs.  Army Reserve officials have confirmed their intention to participate in the  program, but have not yet established a timeline for its introduction.
Currently, active-duty soldiers must need care lasting 6 months or longer  to be admitted to a WTU. In contrast, reserve component soldiers must  need care lasting 30 days or longer. If reserve component soldiers meet  this threshold, they can be considered for admittance to a WTU  Community Care Unit if their medical needs are low-acuity, low-risk, and  non-complex. Warrior Transition Command and Army Reserve officials  stated that expansion of the Reserve Component Managed Care program  to the Army Reserve would be necessary if the Warrior Transition  Command were to change current WTU admittance policy, specifically by  applying the more stringent criteria for active-duty soldiers to members of  the reserve components. However, during the course of our review,  Warrior Transition Command officials stated that they came to an  agreement with the Army Reserve that admittance criteria will not change  until the Reserve Component Managed Care program is expanded to the  Army Reserve.
A senior Army Reserve official stated that the lower threshold for  members of the reserve components stems from requirements under  law and DOD instructions for such soldiers to remain in active federal  service for the purposes of disability evaluation or medical treatment.  Senior officials at the Warrior Transition Command noted that active-duty  soldiers needing fewer than 6 months of care can, instead of being  assigned to a WTU, remain with their line unit and receive medical care in  that setting. Meanwhile, reserve component soldiers must demobilize as  their active-duty orders end and, while they can receive DOD-funded  medical care for a period of time, cannot continue to receive their active- duty pay and other benefits. The 30-day treatment threshold therefore  allows those soldiers to enter the WTU, whereas active-duty soldiers with  similar short-term care needs can remain with their unit. Table 2  summarizes the admittance criteria for the WTU program and for the  WTU-alternative program.
Warrior Transition Command and Army Reserve officials told us that were  the more stringent active-duty criteria to be applied to members of the  reserve components, those Army Reserve soldiers needing fewer than 6  months of care would not be eligible for the WTU program, and would not  be able to receive their active duty pay while receiving short-term medical  treatment. According to Warrior Transition Command and Army Reserve  officials, access to active-duty pay is important because these soldiers  may not be medically able to return to civilian employment while receiving  medical care. Warrior Transition Command officials acknowledged that  this would put Army Reserve soldiers at a disadvantage compared with  active component soldiers. National Guard soldiers, meanwhile, could  potentially access the Reserve Component Managed Care Program,  which provides an alternative to WTUs for soldiers needing 179 days or  fewer of low-acuity, low-risk medical care while on active-duty orders,  entitling soldiers to active duty pay and benefits. Army Reserve or  National Guard soldiers with low-acuity, low-risk, non-complex conditions  can also be assigned to a WTU Community Care Unit, in which soldiers  are not physically located at a WTU, but receive remote medical case  management from their assigned WTU and receive medical care in their  local area, either in a military treatment facility or from a provider in the  TRICARE network. To be eligible, soldiers must not be in need of  complex medical case management, and must meet behavioral health- risk standards. According to Army data, as of February 2016, there were  155 Army Reserve soldiers in 11 Community Care Units across the  United States.
Army Reserve officials told us that they are in the early planning stages of  considering Reserve Component Managed Care expansion, and that no  cost estimates of such an expansion have yet been developed. As in the  National Guard, the active duty Army would pay for active duty pay and  medical care costs for the reservists in this program. However, officials  told us that the Army Reserve would incur costs because of the need to  tender a contract for nurse case managers for the program. Unlike the  National Guard, the Army Reserve does not currently have a large  network of contracted nurse case managers charged with improving  medical readiness. While the National Guard is able to utilize its existing  nurse case manager contract to service the program, officials stated that  the Army Reserve would incur new costs in procuring these services.  Further, Army officials have not yet articulated why expansion of the  Reserve Component Managed Care is preferable to any alternatives,  such as the continued use of WTU Community Care Units, especially in  light of the alternative program’s increased costs. One official told us that  this may stem from a desire to limit the time that reserve component  personnel spend in the WTU program.
Our Business Process Reengineering Assessment Guide states that  when considering program changes, officials should develop a  performance-based analysis of the benefits and costs for each  alternative, followed by a formal business case analysis making the case  for a change. In this case, such an analysis could assess the costs and  benefits of expanding the Reserve Component Managed Care program to  the Army Reserve with alternatives, such as the option of continuing the  current system of Community Care Units. As noted above, the Army  Reserve is in the early stages of considering Reserve Component  Managed Care expansion and no cost estimate has yet been conducted.  Senior officials from Warrior Transition Command and the Army Reserve  stated that expansion of the Reserve Component Managed Care program  requires fewer resources than WTUs and soldiers in this program, on  average, demonstrate shorter lengths of stay than soldiers in WTUs or  Community Care Units. However, without conducting a cost-benefit  analysis to analyze such factors, the Army Reserve may continue with  plans to expand the Reserve Component Managed Care program and  incur significant costs without clearly articulated benefits.
section_title: The Army Cannot Ensure Full Oversight of Soldiers’ Complaints
paragraphs: The Army has several methods that WTU soldiers can use to register a  complaint or express a concern about the WTU program, medical care, or  other issues. Although Army Medical Command oversees five complaint  methods available to WTU soldiers, it does not have an approach to  ensure that the Warrior Transition Command, which is charged with  oversight of the WTU program, has access to all of this information.  Standards for Internal Control in the Federal Government state that  information should be communicated to management and others who  need it in such a way that they can carry out their responsibilities.  However, absent information on potential challenges with the WTU  program, the Warrior Transition Command cannot fully carry out its  oversight and policy development responsibilities.
The Army has the following methods, among others, by which WTU  soldiers can register a complaint:  the WTU chain of command;
WTU town hall meetings, to be held at least quarterly at the  Commander’s discretion in order for the Commander to address the  WTU soldiers and listen to their concerns;  the local Army ombudsman, who is independent from WTU command  and located at most WTU sites; a toll-free hotline, including the Wounded Soldier and Family Hotline  managed by the Army Medical Command’s Medical Assistance  Group, which oversees both the hotline and the Ombudsman  program; and,  the WTU chaplain, a confidential source within the command.
The Army Medical Command, with direct purview over Warrior Transition  Command and the WTUs, oversees these five complaint methods. Local  WTU Commanders, who coordinate with military treatment facility  Commanders, manage their respective town hall meetings, and are part  of the WTU chain of command. The Army Medical Command’s Medical  Assistance Group oversees both the hotline and the Ombudsman  program. The Regional Medical Commands, which report to Army  Medical Command, provide chaplain support to the WTUs. The chaplain  corps adheres to standards of privileged and confidential communications  but, according to chaplains contacted throughout our review, they can  provide general and trend information to Commanders.
According to the Army’s Warrior Transition Regulation, the Warrior  Transition Command provides centralized oversight, guidance, and  advocacy in support of WTU soldiers and their families, including policy  development and oversight of the WTUs’ daily operations. In addition, the  regulation states that WTU soldiers and their families are to be assisted  through effective collaboration efforts, proactive communication,  responsive policy, and program oversight. However, information from  the three of the five complaint methods—chain of command, town hall  meetings, and chaplains—that Army Medical Command has purview over  may not be shared with the Warrior Transition Command, which therefore  may not be able to sufficiently identify and address systemic issues.  Warrior Transition Command officials stated that they do not generally  receive information about complaints from these complaint methods and  that complaints are mostly handled by the local chain of command, which  has the responsibility to investigate and resolve these complaints.
WTU staff at four sites we visited said they handle complaints locally as  much as possible, and infrequently contact senior leadership or the  Warrior Transition Command with complaints information. In interviews  with WTU staff at three of the sites we visited, officials stated that town  halls may provide useful information to local leadership and referrals to  other methods, but information from them typically is not forwarded to  senior leadership. If complaints are expressed and resolved locally and  information about them is not communicated further, senior leaders would  remain unaware, and, if present at multiple WTUs, their possible systemic  nature might go unidentified. In addition, at least one local senior official  at a site we visited expressed a lack of confidence in the town hall  system, stating that it yielded no useful information. Further, while Army  chaplains are bound by confidentiality rules concerning communication  between them and any soldier or family member, chaplains can share  general information with local Commanders and regional medical  commands, such as data on trends in the types of issues discussed, and  such information can provide valuable insight into the issues concerning  WTU soldiers.
The Warrior Transition Command does receive consistent information  from some complaint methods, specifically from the two managed by the  Ombudsman program. According to its operating procedures, the  Ombudsman program provides information on issues reported by soldiers  to local ombudsmen and the toll-free hotline through weekly reports to the  Army’s Office of the Surgeon General and the Warrior Transition  Command, as well as daily reports on WTU-related issues to the Warrior  Transition Command’s Commander and staff. However, the Ombudsman  program’s complaints information represents only two complaint methods  identified by the Warrior Transition Command and does not present  complete information about possible concerns raised by WTU soldiers.  For example, ombudsman data would not include complaints from town  hall meetings or the WTU chain of command unless WTU soldiers had  repeated their complaints to the local ombudsman or toll-free hotline.
While the Warrior Transition Command receives information from the two  programs run by the Ombudsman program, it does not consistently  receive information from the other three methods of expressing  complaints. Standards for Internal Control in the Federal Government  state that information should be communicated to management and  others who need it in such a way that they can carry out their  responsibilities. The Warrior Transition Command, as the entity which  provides strategic oversight and policy development support for the WTU  program, provides a focal point for coordination and support for the  program, and requires relevant information from the complaint methods to  inform its oversight responsibilities. Quality information and effective  communication about relevant complaints from all WTUs would enable  the Warrior Transition Command and the Army to identify and implement  necessary policy or program changes. However, the Army does not have  an approach to ensure relevant complaints information from the various  methods it presents to WTU soldiers is communicated to appropriate  senior leadership, such as the Warrior Transition Command. In addition,  the Army has not clarified which complaints information is important for  WTU program management and oversight. Warrior Transition Command  officials stated that they engage on a policy level when there is a trend or  ongoing problem, but did not explain how it would identify such systemic  issues absent relevant information from available complaint methods.  Given this, the Army cannot ensure that the Warrior Transition Command  has relevant, reliable, and timely information necessary to achieve its  objectives for oversight of and policy development for the WTU program  and may not be able to identify and address potential systemic issues  concerning the WTUs.
section_title: Conclusions
paragraphs: The Army has taken the following steps that signify its commitment to  strengthening its WTU program and not repeating some of the mistakes  made which led to the crisis of care at the former Walter Reed Army  Medical Center: WTUs are staffed with standard ratios of WTU soldiers to  providers; soldiers’ transition through the WTUs follows a structured  process; minimum standards for squad leaders and platoon sergeants are  being strengthened; and WTU soldiers have a range of methods for  expressing complaints. These changes represent efforts to develop policy  for the WTU program to help ensure quality of care and soldiers’ trust in  the program. However, the Army has not assessed how fundamental  aspects of the WTUs, such as the Triad of Care model, are impacted by  the changing composition of diagnoses for WTU soldiers, particularly the  increasing prevalence of behavioral health diagnoses. Additionally, in  areas ranging from screening requirements for WTU staff, WTU soldiers’  admittance criteria, and the complaints process, the Army has yet to  implement management controls to ensure that its policies are maintained  and implemented in practice. As the Warrior Transition Command moves  toward its transition to becoming a directorate within the Army Medical  Command, it will be important that its successor organization increase  oversight of the program to maintain the commitment to high-quality care  for WTU soldiers.
section_title: Recommendations for Executive Action
paragraphs: To increase oversight of the Army’s Warrior Transition Unit program, we  recommend that the Secretary of the Army direct the Army Surgeon  General to take the following six actions:
Assess the Triad of Care model’s effectiveness in light of the changes  in WTU diagnoses and take the appropriate action.
Exercise oversight responsibility to track full adherence to selection  processes for squad leaders and platoon sergeants, including the  requirement to conduct interviews for these positions.
Develop a mechanism to conduct post-training assessments on squad  leaders and platoon sergeants’ application of training to the work  environment and incorporate the results into the training program.
Develop plans to adjust staff levels, if needed, to accommodate a  potential future surge in demand.
Establish a process that assigns oversight responsibility for tracking  instances in which Commanders make exceptions to WTU entrance  criteria so that the Army Surgeon General is aware of the extent  Commanders’ decisions are consistent with program goals.
Develop and implement an approach and associated procedures for  providing senior leadership, such as the Warrior Transition Command,  with complaints information concerning the WTU program and WTU  soldiers.
To help ensure the best use of resources for managing the medical care  of soldiers recovering from serious medical conditions, we recommend  that the Secretary of the Army direct the Chief of the Army Reserve, in  conjunction with the Army Surgeon General, to take the following action:
Develop an analysis that compares the costs and benefits of  maintaining the current system of Community Care Units with the  costs and benefits of expanding the Reserve Component Managed  Care program.
section_title: Agency Comments
paragraphs: In written comments on a draft of this report, DOD concurred with our  seven recommendations to increase oversight of the Army’s Warrior  Transition Unit program and to help ensure the best use of resources for  managing the medical care of Army Reserve soldiers recovering from  serious medical conditions. DOD’s comments are reprinted in appendix  III.
We are sending copies of this report to the appropriate congressional  committees, the Secretary of Defense, the Deputy Secretary of Defense,  the Secretary of the Army, the Army Surgeon General, and the Chief of  the Army Reserve. In addition, the report is available at no charge on the  GAO website at http://www.gao.gov.
If you or your staff have any questions regarding this report, please  contact me at (202) 512-3604 or farrellb@gao.gov. Contact points for our  Offices of Congressional Relations and Public Affairs may be found on  the last page of this report. GAO staff who made key contributions to this  report are listed in appendix IV.
section_title: Appendix I: Scope and Methodology
paragraphs: To address the objectives for this review, we reviewed policies governing  the Army’s Warrior Transition Unit (WTU) program, including the Army  Medical Action Plan; analyzed program documents and data; and  interviewed officials from the Warrior Transition Command, the Office of  the Army Surgeon General, and other Army offices with responsibilities  for medical and personnel management. We conducted site visits to 5 of  the WTUs existing during the course of our review, which we selected  based on the mix of active-duty and reserve components, the number of  complaints reported to the ombudsman, and geographic dispersion. The  sites we visited were Walter Reed National Military Medical Center in  Bethesda, MD; Joint Base San Antonio in San Antonio, TX; Fort Hood in  Killeen, TX; Fort Carson in Colorado Springs, CO; and Fort Eustis in  Newport News, VA. At each site, we conducted interviews with squad  leaders, command staff, nurse case managers, social workers, and other  professionals. The results of these site visits are non-generalizable but  provide useful information on WTU program operations and relevant  issues.
To determine the extent to which the Army has assessed the  effectiveness of the Triad of Care staffing model for managing WTU  soldiers’ care, we compared policy and other documents concerning the  use of the Triad of Care model with federal internal control standards,  which emphasize the need for management to identify and analyze  relevant risks associated with achieving defined objectives. To identify  changes in the WTU population over time, we analyzed aggregate data  from the Warrior Transition Command on WTU soldiers’ medical  diagnoses upon entry into the WTU program from June 1, 2007 through  December 2015. We did not request or have access to any individual  WTU soldier’s information, including an individual soldier’s medical  records or diagnoses. We decided not to present data for soldiers who  entered a WTU in 2007 because it did not represent a full year of the  program. We found these data to be sufficiently reliable to show the  prevalence of behavioral health diagnoses at the time of the soldier’s  entry into the WTU program. We made this determination based on a  data reliability questionnaire filled out by Army officials, logic tests of the  data, and our conversations with Warrior Transition Command officials  about how the data were captured, stored, and checked for accuracy. We  also reviewed relevant documentation related to the Warrior Transition  Command’s most recent unit inspections conducted at each of the five  individual WTUs we visited (one WTU inspected in 2011, one WTU  inspected in 2014, and the remaining three inspected in 2015), and  observed one of these inspections in process to determine what types of  information were analyzed by the Warrior Transition Command. We  spoke with Warrior Transition Command officials about the Triad of Care  model, changes in the WTU soldier population, and their WTU  inspections. We also interviewed officials at each of the five WTUs we  visited about the Triad of Care model and the management of their  soldiers’ care.
To determine the extent to which the Army’s has established processes to  oversee its WTU personnel selection, assess the training of these  personnel, and adjust staff levels, we interviewed officials from the  Warrior Transition Command, the Human Resources Command, and  officials at various levels at each of the sites we visited concerning their  views of the selection of squad leaders and platoon sergeants. We also  interviewed officials at the Army Medical Department Center and School  regarding the WTU training program. We compared current and past  Army policies regarding the selection and training of squad leaders and  platoon sergeants and reviewed the content of our discussions with  squad leaders and platoon sergeants at various sites we visited. We  reviewed federal internal control standards which state that management  should demonstrate a commitment to recruit, develop, and retain  competent individuals and our prior work which summarizes the  attributes of effective training, including the need to ensure that training  goals and strategies are aligned with organizational goals and attributes  of effective training and development programs. Though WTU policies  address issues related to staff in various roles, collectively referred to as  “cadre,” we decided to focus on the selection and training of squad  leaders and platoon sergeants based on the content of our discussions  with officials at each of our site visits. We also discussed the Army’s  ability to adjust WTU staff levels with officials from the Warrior Transition  Command. We reviewed the Army’s policy in this area and the principle in  federal internal control standards that states that agencies need to  demonstrate a commitment to competence through succession and  contingency plans and to establish control activities, such as for the  management of human capital, to maintain a continuity of needed skills  and abilities.
To determine the extent to which the Army has assessed adherence to  WTU program admittance criteria and the impact of any changes to these  criteria for the active-duty and reserve components, we reviewed policies  and procedures for admitting soldiers into the WTU program, including  any proposed changes to the admittance criteria and discussed the  application of these policies and procedures with officials at each of the  sites we visited and with officials from the Warrior Transition Command.  We compared these policies and procedures with federal internal control  standards which require that management design control activities, such  as establishing and reviewing performance measures and indicators, to  achieve objectives and respond to risks, and noted any differences. In  addition, we reviewed documentation concerning the Army’s Reserve  Component Managed Care program, a WTU-alternative program, and its  proposed introduction to the Army Reserve, and discussed this  information, including estimated costs, with officials from the Army  Reserve and the Warrior Transition Command. We compared plans for  the introduction of the program to the Army Reserve with the requirement  in our Business Process Reengineering Assessment Guide for a  performance-based analysis of benefits and costs for each alternative  when considering program changes, and noted any differences.
To determine whether the Army had instituted methods to address the  complaints of WTU soldiers, we analyzed information on the Army’s  approach to handling complaints by WTU soldiers. We interviewed  program staff and officials regarding the Army’s approach and reviewed  related Army documentation, such as Army policies on its WTU and  chaplain corps programs. We compared the Army’s approach for handling  complaints with federal internal control standards which state that  information should be communicated to management and others who  need it in such a way that they can carry out their responsibilities.
We analyzed data regarding the number of soldiers in a WTU over time,  the date when they entered a WTU, and their average length of stay from  2007 to 2015. We found the data on the number of soldiers in a WTU  over time to be sufficiently reliable to present monthly changes in the  WTU soldiers’ census. For the data on when a soldier entered a WTU  and their lengths of stay, we determined that the 2007 and 2008 data  were unreliable because of missing data. We also chose not to report  data on when a soldier entered a WTU and their lengths of stay for 2015  because of the large number of soldiers that were still in the WTU  program when the data were reported by Warrior Transition Command  officials. Other than these exceptions, we found the data to be  sufficiently reliable for showing WTU soldiers’ lengths of stay from the  time of entry in the WTU program to the time of (1) exiting the WTU and  (2) until they had reached their medical retention decision point. For each  type of data, we made these determinations based on a data reliability  questionnaire filled out by Army officials, logic tests of the data, and our  conversations with Warrior Transition Command officials about how the  data were captured, stored, and checked for accuracy.
We conducted this performance audit from August 2015 to July 2016 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.
section_title: Appendix II: Trends in Warrior Transition Unit Soldiers’ Separation from the Army and Lengths of Stay in the Warrior Transition Unit Program
paragraphs: Of the Army soldiers who entered a Warrior Transition Unit (WTU)  between 2008 and the end of 2015, generally a higher percentage  separated from the Army than returned to the Army (see fig. 4).
WTU soldiers’ length of stay—from entry in the WTU until separation— peaked for soldiers who entered in 2009 and has generally decreased  since then. For example, the average length of stay was 407 days for  those soldiers who entered a WTU in 2009, and that number decreased  to 308 for those who entered a WTU in 2014. In addition, WTU soldiers  in the active component generally had shorter lengths of stay than those  in the Army National Guard or Army Reserve (see fig. 5).
Similarly, the average length of time between a WTU soldier’s entrance  into the WTU program and the medical retention determination point has  significantly decreased. For example, the average length of time to reach  the medical retention determination point has decreased by about 45  percent for those soldiers who had entered a WTU in 2009 as compared  with those who entered a WTU in 2014 (see fig.6).
section_title: Appendix III: Comments from the Department of Defense
section_title: Appendix IV: GAO Contact and Staff Acknowledgments
subsections: section_title: GAO Contact
section_title: Staff Acknowledgments
paragraphs: In addition to the contact named above, Lori Atkinson, Assistant Director;  Rebekah Boone; Nicole Collier; Mae Jones; Amie Lesser; Jeffrey  Mayhew; Michael Silver; Adam Smith; and Sabrina Streagle made key  contributions to this report.
section_title: Related GAO Products
paragraphs: Military and Veteran Support: DOD and VA Programs That Address the  Effects of Combat and Transition to Civilian Life. GAO-15-24.  Washington, D.C.: November 7, 2014.
Recovering Servicemembers and Veterans: Sustained Leadership  Attention and Systematic Oversight Needed to Resolve Persistent  Problems Affecting Care and Benefits. GAO-13-5. Washington, D.C.:  November 16, 2012.
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.
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.