VA Health Care: Mild Traumatic Brain Injury Screening and Evaluation Implemented for OEF/OIF Veterans, but Challenges Remain
Published: 2008-02-08T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: Traumatic brain injury (TBI) has emerged as a leading injury among servicemembers serving in the Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) combat theaters. The widespread use of improvised explosive devices, such as roadside bombs, in these combat theaters increases the likelihood that servicemembers will be exposed to incidents that can cause a TBI. TBIs can vary from mild to severe, and in general, mild TBI can be difficult to identify. Because mild TBI can have lasting effects if not identified and treated, concerns have been raised about how the Department of Veterans Affairs (VA) identifies and treats OEF/OIF veterans with a mild TBI. In this report GAO describes VA's (1) efforts to screen OEF/OIF veterans for mild TBI, (2) steps taken so that those OEF/OIF veterans at risk for mild TBI are evaluated and treated, and (3) challenges in screening and evaluating OEF/OIF veterans for mild TBI. GAO reviewed VA's policies, interviewed VA officials and TBI experts, and reviewed nine VA medical facilities' efforts to implement TBI screening and evaluation processes.
section_title: What GAO Found
paragraphs: To screen OEF/OIF veterans for mild TBI, VA implemented in its medical facilities in April 2007 a computer-based screening tool to identify OEF/OIF veterans who may have a mild TBI. VA's tool consists of questions that VA must ask all OEF/OIF veterans when they come to a VA medical facility for care. VA issued a policy requiring its medical facilities to use the tool to screen all OEF/OIF veterans who present for care in any clinic in the facility, including primary care and specialty care clinics. The policy has guidance on what types of providers may administer the tool and directs providers that a positive screening result requires a further evaluation by a specialist to determine if the veteran has mild TBI. VA's screening efforts depend on its TBI screening tool and VA recognizes the importance of determining the tool's clinical validity and reliability--that is, how effectively the tool identifies those who are and are not at risk for mild TBI and if the tool would yield consistent results if administered to the same veteran more than once. However, VA is planning to but has not yet begun to determine the tool's validity and reliability. VA's screening tool was based largely on a tool developed and validated by the Defense and Veterans Brain Injury Center (DVBIC)--a medical and educational collaboration among DOD, VA, and two civilian partners--used at selected military bases to screen returning OEF/OIF servicemembers for TBI. However, because VA's tool is a modified version of DVBIC's tool and is used to screen a slightly different population, the results of the validity study of DVBIC's tool are not directly applicable to VA's tool. To help ensure that OEF/OIF veterans identified as at risk for a mild TBI by VA's screening tool are evaluated and treated, VA developed a national protocol for their evaluation and treatment. According to VA's protocol, veterans with a positive screening result should be offered a follow-up evaluation by a specialist to determine if they have a mild TBI. The follow-up evaluation should include a history of the veteran's injury, a physical examination targeted to the veteran's symptoms, and the use of a checklist to assess the presence and severity of symptoms associated with mild TBI. VA has established training for its providers to enhance use of the protocol and help ensure veterans are evaluated and treated for mild TBI. Providers at some VA medical facilities we visited had difficulties fully following the protocol. However, the facilities had taken steps to resolve the difficulties, and VA has put in place measures to help providers follow the protocol. VA faces clinical and cultural challenges in its efforts to screen and evaluate mild TBI in OEF/OIF veterans. Clinical challenges include the lack of existing objective diagnostic tests that can definitively identify mild TBI. Also, many symptoms of mild TBI are similar to those associated with other conditions, such as post-traumatic stress disorder, making a diagnosis of mild TBI harder to reach. Some characteristics of the OEF/OIF veteran population present cultural challenges in that they may affect veterans' willingness to seek care for TBI symptoms. For example, some may believe that being labeled with a TBI could affect their ability to stay in the National Guard or Reserves.

section_title: Letter
paragraphs: Traumatic brain injury (TBI) has emerged as a leading injury among U.S.  forces serving in military operations in Afghanistan and Iraq—known as  Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF),  respectively. The nature of the current conflicts—in particular the  widespread use of improvised explosive devices (IED)—increases the  likelihood that active duty servicemembers will be exposed to incidents  such as blasts that can cause a TBI, which is defined as an injury caused  by a blow or jolt to the head or a penetrating head injury that disrupts the  normal function of the brain. According to the Defense and Veterans  Brain Injury Center (DVBIC), of the servicemembers who required  medical evacuation for battle-related injuries from the OEF/OIF combat  theaters to Walter Reed Army Medical Center from January 2003 through  June 2007, 30 percent had sustained some form of TBI.
TBIs can vary greatly in terms of severity—from mild cases that might  involve a brief change in mental status, such as being dazed or confused,  to severe cases that may involve an extended period of unconsciousness  or amnesia after the injury. Servicemembers who sustain even a mild TBI  may experience short-term physical symptoms such as headaches or  dizziness, emotional symptoms such as anxiety or irritability, cognitive  deficits such as difficulty concentrating, or sleep disturbances. Some  servicemembers may experience symptoms related to mild TBI months or  even years after the injury. In general, a mild TBI—which is commonly  referred to as a concussion—can be more difficult to identify than a severe  TBI. With mild TBI, there may be no observable head injury. In addition, in  the combat theater, a mild TBI may not be identified when it occurs at the  same time as other combat injuries that are more visible or life- threatening, such as orthopedic injuries or open wounds. Furthermore,  some of the symptoms of mild TBI—such as irritability and insomnia—are  similar to those associated with other conditions, such as post-traumatic  stress disorder (PTSD). Identifying mild TBI is important, as treatment can  mitigate the physical, emotional, and cognitive effects of the injury.
As the OEF and OIF military operations have continued, increasing  numbers of servicemembers from these conflicts have transitioned to  veteran status and have become eligible to receive health care from the  Department of Veterans Affairs (VA). As of October 2007, roughly 750,000  OEF/OIF servicemembers had left active duty and become eligible for VA  health care, and over one-third of these veterans—about 260,000—had  accessed some type of VA health care services, which are provided at VA  medical facilities nationwide. Some of these OEF/OIF veterans seeking  care at VA medical facilities have been exposed to events during their  military service that could cause a mild TBI.
An OEF/OIF veteran’s first interaction with a VA provider may occur  months or even years after exposure to an event that could have caused a  mild TBI. Some of these veterans might not seek care from VA until  several months or even years after their return from the combat theater  and their transition to veteran status. Moreover, OEF/OIF veterans who do  seek VA care soon after their return from the combat theater could have  sustained a mild TBI many months prior to their return. While veterans  who sustained a mild TBI during their military service may have  successfully been treated by Department of Defense (DOD) providers for  the condition or may have had their symptoms resolve on their own, other  OEF/OIF veterans could still be experiencing mild TBI-related symptoms  when they seek care from VA. According to VA officials, it is important  that OEF/OIF veterans who seek care from VA are screened to determine  whether they might have a mild TBI, evaluated to confirm a diagnosis of  mild TBI and have their symptoms assessed, and treated as needed.
Because mild TBI can have lasting effects if not identified and treated,  concerns have been raised about the extent to which VA identifies and  treats OEF/OIF veterans who have sustained a mild TBI. You asked us to  identify how VA ensures that OEF/OIF veterans who have experienced a  mild TBI are identified and treated when they seek care at VA medical  facilities, as well as the obstacles to identifying veterans with mild TBI.  Specifically, in this report, we describe (1) VA’s efforts to screen OEF/OIF  veterans for mild TBI, (2) the steps that VA has taken to help ensure that  OEF/OIF veterans identified as being at risk for a mild TBI are evaluated  and treated, and (3) the challenges that VA faces in screening and  evaluating OEF/OIF veterans for mild TBI.
To describe VA’s efforts to screen OEF/OIF veterans for mild TBI; the  steps VA has taken to help ensure that OEF/OIF veterans identified as  being at risk for a mild TBI are evaluated and treated; and the challenges  that VA faces in screening and evaluating OEF/OIF veterans for mild TBI,  we reviewed VA policies and procedures for the screening, evaluation, and  treatment of mild TBI in OEF/OIF veterans. The policies and procedures  we reviewed included the guidance VA developed for its medical facilities  to use to screen and evaluate OEF/OIF veterans who may have a TBI.  Some of the VA policies and procedures we reviewed pertain to TBI  generally, including mild TBI. We also interviewed VA headquarters  officials responsible for VA’s efforts to screen, evaluate, and treat OEF/OIF  veterans with mild TBI. We also conducted site visits to a total of six VA  medical facilities located in Decatur, Georgia; Augusta, Georgia;  Baltimore, Maryland; Dublin, Georgia; Richmond, Virginia; and the District  of Columbia. In addition to these site visits, we conducted phone  interviews with staff from three other VA medical facilities located in  Hines, Illinois; Iron Mountain, Michigan; and Tomah, Wisconsin. The nine  facilities we reviewed represent a judgmental sample that was selected in  order to include (1) varying geographic areas, including rural areas;   (2) facilities that had been utilized by relatively high numbers of OEF/OIF  veterans as compared to other VA medical facilities as of the end of  calendar year 2006; and (3) facilities from each of the four tiers of facilities  that comprise VA’s polytrauma system of care. The findings from our site  visits and phone interviews with VA medical facility staff cannot be  generalized to other VA medical facilities.
At the six VA medical facilities we visited and for our phone interviews  with the three additional VA medical facilities, we interviewed clinical and  administrative staff to learn about their implementation of VA’s policies  and procedures for mild TBI screening, evaluation, and treatment as well  as their experiences in screening, evaluating, and treating mild TBI in  OEF/OIF veterans. For each of these facilities we reviewed documents  related to mild TBI screening, evaluation, and treatment efforts. We  conducted the facility interviews between April and July 2007. In addition,  we conducted follow-up with the nine VA medical facilities in September  and October 2007. Because VA implemented new mild TBI screening,  evaluation, and treatment processes in April 2007, our review focused on  the early implementation phase of these new processes.
In addition to reviewing VA’s efforts related to screening, evaluation, and  treatment of mild TBI in OEF/OIF veterans, we also interviewed TBI  experts from DOD—including staff from the DVBIC—the Centers for  Disease Control and Prevention (CDC), and the National Institutes of  Health (NIH) about TBI screening, evaluation, and treatment issues and  reviewed relevant documents from those organizations. We also  interviewed TBI researchers and other TBI experts from academic  institutions, advocacy organizations, and private sector rehabilitation  facilities and asked them about various TBI issues. Finally, we conducted  a literature review on research related to TBI—including mild TBI—within  civilian and military populations.
We focused our work on VA policies and procedures regarding mild TBI  screening, evaluation, and treatment and did not assess the clinical  appropriateness or effectiveness of VA’s mild TBI screening and  evaluation efforts or the treatment provided to OEF/OIF veterans with  mild TBI. We performed our work from December 2006 through February  2008 in accordance with generally accepted government auditing  standards.
subsections: section_title: Background
paragraphs: In the military setting, mild TBI has become an increasing concern in  recent years with respect to OEF/OIF servicemembers and veterans.  Blasts due to IEDs and other explosive devices have been one of the  leading causes of injury for those serving in OEF and OIF—and in  particular have been a leading cause of TBI. TBI has been a frequent  diagnosis among OEF/OIF servicemembers medically evacuated to Walter  Reed Army Medical Center or the National Naval Medical Center. Mild  TBI can also be present in servicemembers whose injuries do not result in  medical evacuation out of the combat theater. According to DOD, TBI  screening and assessments conducted from 2004 to 2006 for several  groups of Army and Marine Corps servicemembers returning from  OEF/OIF to selected military bases found that about 10 to 20 percent of  those servicemembers had sustained a mild TBI, although those groups  are not necessarily representative of the overall Army and Marine Corps  populations returning from OEF/OIF or of the Air Force and Navy  populations returning from OEF/OIF, who in general have much less  combat exposure than other servicemembers.
subsections: section_title: Mild TBI
paragraphs: In the absence of a consensus definition of mild TBI among clinicians and  medical associations, VA has adopted a definition for mild TBI that is  consistent with the one developed by the American Congress of  Rehabilitation Medicine (ACRM). The ACRM—and thus, VA—defines a  person as having a mild TBI if the person had a traumatically-induced  physiological disruption of brain function as demonstrated after an event  by at least one of the following: (1) any period of loss of consciousness;  (2) any loss of memory for events immediately before or after the event;  (3) any alteration in mental state at the time of the event, for example  feeling dazed, disoriented, or confused; and (4) a focal neurological deficit  or deficits that may or may not have been transient, for example loss of  coordination, speech difficulties, or double vision. ACRM’s definition  further specifies that a person may be designated as having a mild TBI  only if the severity of the injury does not include a loss of consciousness  that lasted longer than approximately 30 minutes, post-traumatic amnesia  lasting longer than 24 hours, and, after 30 minutes from the event, an initial  Glasgow Coma Score of less than 13. Such symptoms may indicate a TBI  more severe than mild TBI.
Mild TBI can result in symptoms that can be categorized as physical,  cognitive, emotional, or sleep-related, and can cause short- or long-term  difficulties that affect an individual’s ability to function, according to CDC  guidance. (See table 1 for examples of symptoms associated with mild TBI  as categorized by CDC.) The symptoms of mild TBI can be subtle and may  not appear for days or weeks after the injury. According to literature on  mild TBI in the civilian population, the duration of mild TBI symptoms can  vary. Most with mild TBI have symptoms that resolve within hours, days,  or weeks. Others, however, experience persistent symptoms that last for  several months or longer.
Although symptoms of mild TBI may appear to be mild in nature, they can  lead to significant long-term impairments that affect an individual’s ability  to function. For example, individuals may have difficulty returning to  routine daily activities and may be unable to return to work for weeks or  months. Individuals with mild TBI may also have multiple co-occurring  physical injuries, such as orthopedic injuries, depending on the event that  caused the mild TBI.
According to CDC, treatment for individuals who have sustained a mild  TBI may include increased rest, refraining from participation in activities  that are likely to result in additional head injury, management of existing  symptoms, and education about mild TBI symptoms and what to expect  during recovery. For some cases, rehabilitative or cognitive therapies,  counseling, or medications might be used. Currently, there are no  evidence-based clinical practice guidelines that address treatment of mild  TBI.
section_title: VA Health Care Services for OEF/OIF Veterans and DOD Servicemembers
paragraphs: Veterans who have served in combat in certain conflicts, including  OEF/OIF veterans, are presumed to be eligible for VA health care services  for any condition for a period of up to 5 years, even if there is insufficient  medical evidence to conclude that the condition is attributable to military  service. This presumptive eligibility includes those National Guard and  Reserve members who have left active duty and returned to their units. If  veterans do not enroll until after the presumptive period, they will be  subject to the same eligibility and enrollment rules as other veterans, who  generally have to prove that a medical problem is connected to their  military service or that they have incomes below certain thresholds. As of  October 2007, according to VA, about 260,000 or over one-third of veterans  who had returned from service in OEF or OIF, including National Guard  and Reserve members, had accessed VA for various health care needs.
In some circumstances, VA also provides health care to active duty  OEF/OIF servicemembers. Under existing DOD-VA agreements, OEF/OIF  servicemembers may obtain health care services, such as rehabilitative  care, from VA facilities while the servicemembers are still on active duty.  DOD determines whether servicemembers receive care from VA, at one of  DOD’s own military treatment facilities (MTF), or from a TRICARE civilian  provider. OEF/OIF servicemembers may be referred by MTFs to VA for  care on an inpatient or outpatient basis.
OEF/OIF veterans and in some cases OEF/OIF servicemembers may  obtain VA health care through VA’s national health care system, which  provided health care services to nearly 5.5 million patients in 2006. VA’s  health care system is organized into 21 regional health care networks that  comprise VA medical facilities, community-based outpatient clinics  (CBOC), and Vet Centers. VA medical facilities offer services that range  from primary care to complex specialty care, such as cardiac or spinal  cord injury care. VA’s CBOCs, which are associated with VA medical  facilities, mainly provide primary care services. Vet Centers offer  readjustment and family counseling, employment services, bereavement  counseling, and a range of social services to assist veterans in readjusting  from wartime military service to civilian life.
VA has classified its medical facilities into a four-tiered polytrauma system  of care to help address the medical needs of returning OEF/OIF veterans,  in particular those who have suffered polytraumatic injuries—that is,  injuries to more than one part of the body or organ system, one of which  may be life threatening, resulting in physical, cognitive, psychological, or  psychosocial impairments and functional disability. Veterans with  polytraumatic injuries may have injuries or conditions such as TBI,  amputations, multiple fractures, and burns to the body. Each of the four  tiers in VA’s polytrauma system of care, referred to by VA as components,  represents medical facilities that offer different levels of specialty services.  Medical facilities in the first three tiers have designated polytrauma teams  to care for polytrauma patients.
Component I sites, Polytrauma Rehabilitation Centers, are four regional  medical facilities that provide acute comprehensive medical and  rehabilitative care for the severely injured. These facilities have a team of  rehabilitation professionals and consultants from other specialties related  to polytrauma and serve as resources for other VA medical facilities and  DOD MTFs.
Component II sites, Polytrauma Network Sites, are 21 medical facilities  that provide specialized, post-acute rehabilitation services. There is one  Polytrauma Network Site in each of VA’s 21 regional health care networks,  including one at each of the four Component I sites.
Component III sites, Polytrauma Support Clinic Teams, are medical  facilities that have facility-based teams of providers with rehabilitation  expertise who deliver follow-up services to veterans and assist in the  management of stable polytrauma conditions that are a consequence of  the injuries sustained by veterans.
Component IV sites, Polytrauma Points of Contact, are present at medical  facilities that do not have Component I, II, or III services. Each of these  medical facilities has a point of contact whose role is to ensure that  veterans are referred to a facility capable of providing the services they  require.
section_title: VA Has Implemented a TBI Screening Tool at Its Medical Facilities but Has Not Determined the Clinical Validity and Reliability of the Tool
paragraphs: In April 2007, VA implemented in its medical facilities a computer-based  screening tool to identify OEF/OIF veterans who may have a mild TBI.  VA’s screening tool consists of a series of questions that VA providers  must ask OEF/OIF veterans when the veterans come to a VA medical  facility for care. Although VA’s TBI policy does not require VA medical  facilities to conduct outreach to veterans who have not been seen at the  medical facility since the TBI screening tool was implemented, we found  that a majority of the nine medical facilities we reviewed were conducting  various forms of outreach to encourage OEF/OIF veterans to come to the  medical facility for TBI screening. While VA’s screening efforts depend on  its TBI screening tool, VA has not determined the clinical validity and  reliability of the screening tool—that is, respectively, how effective the  tool is in identifying those who are and are not at risk for mild TBI and  whether the screening tool would yield consistent results if administered  to the same veteran more than once.
subsections: section_title: VA Has Implemented a TBI Screening Tool to Be Used in VA Medical Facilities
paragraphs: To screen OEF/OIF veterans for mild TBI, VA has implemented a TBI  screening tool to be used when OEF/OIF veterans seek care at VA medical  facilities. The screening tool, which VA implemented across its medical  facilities in April 2007, can be used to screen for TBIs of varying severities,  but is primarily intended to identify those OEF/OIF veterans at risk for  mild TBI given that more severe forms of TBI are more easily identified.  VA’s screening tool consists of a series of questions asked of OEF/OIF  veterans who come to a VA medical facility for care. VA requires its  medical facilities to use the TBI screening tool to screen every OEF/OIF  veteran who presents for care at any clinic in the medical facility,  including primary care, dental, and urgent care clinics, CBOCs, or  specialty clinics, such as cardiology or orthopedic clinics. When a VA  provider accesses a veteran’s electronic VA medical record during a clinic  appointment, the provider is prompted by a computer-based clinical  reminder to complete the TBI screening tool.
In order to complete the TBI screening, VA providers are required to ask  OEF/OIF veterans a series of questions to identify those who are  experiencing symptoms that may indicate a mild TBI. After prompting the  provider to ask initial screening questions designed to confirm that the  veteran is an OEF or OIF veteran, the screening tool then prompts the VA  provider to ask whether the veteran has been previously diagnosed with a  TBI. If the veteran has been previously diagnosed with a TBI, the  screening is considered to be completed and the provider should ask  whether the OEF/OIF veteran would like to obtain care from a VA  specialty provider. The provider is to document any refusal of specialty  care in the veteran’s electronic VA medical record. A depiction of VA’s TBI  screening process is provided in figure 1.
For OEF/OIF veterans who have not been previously diagnosed with a  TBI, VA’s TBI screening tool prompts the provider to continue the  screening process by asking four sequential sets of questions that are used  to identify OEF/OIF veterans who are at risk for a mild TBI. The first set of  questions asks whether the veteran has experienced an event that could  increase the risk of a possible mild TBI—specifically blasts or explosions,  a vehicle accident or crash, a fragment wound or bullet wound above the  shoulders, or a fall. If the veteran reports experiencing any of these events,  a second set of questions asks about the immediate effects after the event,  including a loss of consciousness, being dazed or confused, not  remembering the event, a concussion, or a head injury. If the veteran  reports experiencing any of these effects, then a third set of questions asks  the veteran about symptoms that may have begun or gotten worse after  the event, specifically memory problems or lapses, balance problems or  dizziness, sensitivity to bright light, irritability, headaches, or sleep  problems. Finally, if the veteran reports experiencing any of these  symptoms, a fourth set of questions asks whether the veteran has  experienced, within the week prior to the TBI screening, any of the  symptoms listed in the third set of questions.
Under VA’s policy for its TBI screening tool, if the OEF/OIF veteran  answers “no” to all of the questions in any of the four sections of the TBI  screening tool, VA considers the veteran to have screened negative for a  possible mild TBI. However, if the veteran answers “yes” to one or more  questions in each of the four sections, then VA considers the veteran to  have screened positive for a possible mild TBI. In guidance issued on the  use of the TBI screening tool, VA directs providers to not diagnose a  patient with a mild TBI based solely on the results of the TBI screening  tool because it is possible to respond positively to all four sections and not  have a mild TBI, due to the presence of conditions such as PTSD that  present similar symptoms. Instead, VA policy requires that veterans who  screen positive on VA’s TBI screening tool be offered a follow-up  evaluation with a specialty provider who can determine whether the  veteran has a mild TBI. VA officials reported that as of August 2007 about  61,000 OEF/OIF veterans had been screened for TBI and of those, nearly  20 percent had screened positive for possible TBI.
Although VA has a requirement that its facilities screen OEF/OIF veterans  for mild TBI, veterans can refuse to participate in the screening. While  VA’s policy does not specify what steps facility providers should take if a  veteran refuses to be screened for TBI, according to a VA headquarters  official, the provider must document the refusal in the veteran’s electronic  VA medical record. This official also stated that the clinical reminder for  TBI screening should continue to appear at subsequent clinic visits. Seven  of the nine facilities we reviewed estimated that 2 percent or less of the  OEF/OIF veterans offered TBI screening refused. The remaining two  facilities did not provide estimates of the number of OEF/OIF veterans  that had refused the TBI screening tool.
According to VA’s policy for its TBI screening tool, the TBI screening tool  may be administered by physicians or other clinical providers, such as  nurse practitioners, physician’s assistants, and nurses, who have the  clinical background to review results with the veteran. Across the nine VA  facilities we reviewed, we found variation in the types of VA providers  who were responsible for administering the TBI screening tool to OEF/OIF  veterans. At three facilities, we found that physicians or nurse  practitioners were administering the TBI screening tool, and at the  remaining six facilities, providers such as registered nurses or social  workers in addition to physicians and nurse practitioners were  administering the TBI screening tool. Further, in two of those six facilities,  medical facility officials told us that dental technicians and licensed  practical nurses were able to administer the TBI screening tool.
VA’s policy on TBI screening includes a requirement that all VA clinical  staff who administer the TBI screening tool complete VA’s TBI training  module. This training module—an online course produced by VA in  January 2004—is designed to provide an overview of TBI, in order to help  providers identify veterans at risk for a TBI. At seven of the nine VA  facilities we reviewed, VA facility officials reported that VA providers  administering the TBI screening tool had completed VA’s required training.  At one of the two remaining facilities, officials reported that many  providers had completed VA’s required training and that officials at the  facility were reviewing providers’ completion of VA’s TBI training module  to ensure that all providers administering the TBI screening tool had  completed VA’s required training. At the remaining facility, officials  reported that nurses at the facility had just recently begun administering  the TBI screening tool and had not yet completed VA’s TBI training  module at the time of our visit.
In addition to the required TBI training module, VA has also developed  other training related to TBI screening for providers who administer the  screen to OEF/OIF veterans. VA has provided training on TBI and the TBI  screening tool to its medical facilities through satellite broadcasts and  educational materials about TBI, including pamphlets and brochures, and  held national conferences in April and August 2007 that focused in part on  how to administer the TBI screening tool and who should be screened  using it. In addition, VA has also conducted national conference calls  between VA headquarters and VA medical facilities to address concerns  facilities had in implementing and using the TBI screening tool.
In an effort to ensure that all VA medical facilities are utilizing the tool to  screen OEF/OIF veterans for mild TBI, VA has implemented a TBI  screening performance measure for fiscal year 2008. The performance  measure is designed to assess the extent to which OEF/OIF veterans who  seek care at VA medical facilities are being screened for TBI. Performance  measures are routinely used by VA to hold managers accountable for the  quality of health care provided to veterans at their medical facilities and to  track facilities’ progress in meeting performance goals established by VA.
section_title: VA Medical Facilities We Reviewed Conducted Various Forms of Outreach to OEF/OIF Veterans to Increase Participation in TBI Screening
paragraphs: To increase awareness of and participation in TBI screening of OEF/OIF  veterans, the nine VA medical facilities we reviewed were conducting  various outreach efforts to OEF/OIF veterans, even though VA’s TBI policy  does not require VA medical facilities to conduct outreach. Specifically we  found that five of the nine facilities we reviewed were in the process of  contacting veterans who had received care at the facility before the  medical facility had implemented VA’s TBI screening tool in order to  encourage the veterans to be screened for mild TBI. Medical facility  officials reported that they were contacting these veterans by telephone or  mail. Officials from two of the five facilities reported administering the  screening tool to OEF/OIF veterans over the phone, while medical officials  at three of the five facilities reported encouraging OEF/OIF veterans to  return to the medical facility to be screened for TBI.
Some VA medical facilities were providing outreach to OEF/OIF veterans  through TBI-related education efforts. For example, VA medical facility  officials told us they attend DOD post-deployment events to provide  OEF/OIF veterans—and OEF/OIF servicemembers who in the future will  become OEF/OIF veterans—information about VA’s health care system,  including information about VA’s TBI screening efforts. VA officials told us  that they hope the information provided at the post-deployment events  encourages those eligible for VA health care benefits to be screened for  mild TBI at a VA medical facility. Moreover, two medical facilities we  reviewed had administered the TBI screening tool during these post- deployment events.
Facility officials also told us they reach out to veterans through Vet  Centers by providing information on TBI rather than waiting for veterans  to come into a VA medical facility for care. In addition, two facilities  reported that they made TBI-related information available through  community resources in order to reach out to OEF/OIF veterans. For  example, one facility asked businesses and organizations such as doctors’  offices, stores, churches, and schools to share information about TBI and  VA health care services with community members. The other facility  shared TBI-related information using media outlets such as television  broadcasts, radio broadcasts, and newspapers to increase awareness of  TBI in the community.
section_title: Although VA’s TBI Screening Efforts Depend on the Screening Tool, VA Has Not Determined the Tool’s Clinical Validity and Reliability
paragraphs: The key component of VA’s efforts to screen OEF/OIF veterans for mild  TBI is VA’s requirement that VA medical facilities administer the TBI  screening tool to these veterans when they seek care at VA facilities.  However, VA has not assessed the clinical validity and reliability of the  screening tool—that is, respectively, how effective the tool is in identifying  those who are and are not at risk for mild TBI, and whether the screening  tool would yield consistent results if the tool was administered to the same  veteran more than once.
VA based its screening tool largely on a TBI screening tool developed and  used by the DVBIC—the Brief Traumatic Brain Injury Screen (BTBIS).  The BTBIS has been used at select military bases to screen returning  OEF/OIF servicemembers for TBI and has been shown to be clinically  valid, according to the DVBIC. When developing its screening tool, VA  made some changes to the questions contained in the BTBIS. These  changes were based on a review of other TBI screening instruments,  published reports of the symptoms that follow a mild TBI, and the  experience of MTFs with using modified versions of the BTBIS. The goal  of VA’s changes was to develop a highly sensitive screening tool that  would err on the side of being overly-inclusive in identifying veterans who  may be at risk for having a TBI. VA recognized that using a highly sensitive  TBI screening tool would result in some veterans who screen positive for  possible TBI later being found after follow-up evaluation to not have a TBI.  According to VA officials, VA specifically chose to develop a highly  sensitive TBI screening tool to reduce the risk of not identifying those  veterans who have a TBI.
A study of the validity and reliability of VA’s TBI screening tool is  important for several reasons. First, because VA’s TBI screening tool is a  modified version of the BTBIS and is being used to screen a slightly  different population, the results from DVBIC’s validity study of the BTBIS  would not be directly applicable to VA’s screening tool. In addition, a  study of the validity of VA’s screening tool would provide information on  how well the TBI screening tool distinguishes between OEF/OIF veterans  who are at risk for a mild TBI and those who are not, according to VA  officials. Like other screening tools, VA’s TBI screening tool may result in  some false positives—OEF/OIF veterans who screen positive for possible  mild TBI but do not have the condition—and some false negatives— OEF/OIF veterans who screen negative on VA’s TBI screening tool but  actually have a mild TBI. One consequence of false positives is that  OEF/OIF veterans who screen positive for possible mild TBI on VA’s TBI  screening tool but do not have a mild TBI may worry that they have the  condition when they do not. Also, because veterans who screen positive  are to receive a follow-up evaluation by a specialty provider to determine  whether they actually have a mild TBI, false positives affect specialty  providers’ workload and may affect their capacity to see other veterans. In  contrast, OEF/OIF veterans who screen negative for possible mild TBI but  actually have the condition are at risk for not being evaluated and treated  for their symptoms. Knowing both the validity and reliability of the TBI  screening tool would help VA providers and OEF/OIF veterans understand  the significance of the TBI screening results, including the likelihood of  veterans having the same screening results if they were screened again by  the same provider or a different provider.
VA officials recognize the need to conduct a study to assess the clinical  validity and reliability of the TBI screening tool. VA officials decided to  begin implementing TBI screening for OEF/OIF veterans before  conducting such a study in order to avoid delaying the start of VA’s TBI  screening efforts. According to VA officials, VA planned to study the TBI  screening tool after its medical facilities had begun using the tool to screen  OEF/OIF veterans. Officials informed us in September 2007 that a validity  and reliability study was in the development phase and would assess  issues such as the likelihood that an OEF/OIF veteran who screens  positive for possible mild TBI actually has a mild TBI and the likelihood  that an OEF/OIF veteran who screens negative for possible mild TBI does  not have a mild TBI. At that time, VA had not yet determined when the  study would take place, which researchers would conduct it, how it would  be performed, or what funding mechanism would be used. As of  December 2007, VA had not begun the study.
section_title: VA Has Implemented a Protocol to Help Ensure Evaluation and Treatment of OEF/OIF Veterans Who Screen Positive for Possible TBI; However, Some Medical Facilities Had Difficulties Fully Following the Protocol
paragraphs: VA has implemented a national protocol to help ensure that OEF/OIF  veterans who screen positive on its TBI screening tool are evaluated by a  specialty provider and receive treatment, if necessary, for mild TBI. VA  requires providers at its facilities to follow the evaluation and treatment  protocol, which reminds providers to offer follow-up evaluations,  establishes requirements for setting evaluation appointments, and  provides guidance for evaluating and treating veterans’ symptoms. VA has  established training for its providers to enhance providers’ use of the  protocol and thereby help ensure veterans are evaluated and treated for  mild TBI. However, providers at some VA facilities have had difficulties  fully following the protocol. Specifically, some providers reported  difficulties implementing electronic requests for follow-up evaluations and  did not always use a symptom checklist—used to assess the presence and  severity of symptoms associated with mild TBI—during follow-up  evaluations. VA medical facilities have taken steps to resolve these  difficulties, and VA has put in place measures to help ensure that all VA  providers follow the protocol. At the VA medical facilities we reviewed,  providers stated that conducting VA’s TBI follow-up evaluations was not  currently causing significant capacity problems for their specialty  departments responsible for conducting the follow-up evaluations.  However, specialty providers at some facilities we reviewed reported that  an increased need for follow-up evaluations could cause increases in  specialty providers’ workloads and that additional specialty providers  could be needed in order to expand the specialty departments’ capacity to  evaluate OEF/OIF veterans for mild TBI.
subsections: section_title: VA Has Implemented a Protocol to Help Ensure Evaluation and Treatment of OEF/OIF Veterans Who Screen Positive on VA’s TBI Screening Tool
paragraphs: To help ensure that OEF/OIF veterans who screen positive on VA’s TBI  screening tool are evaluated for a possible mild TBI and treated if  necessary, VA has implemented a national evaluation and treatment  protocol for its medical facility providers to follow. One way the protocol  helps ensure that OEF/OIF veterans are evaluated for mild TBI is by  requiring the provider administering the TBI screening tool to discuss  positive results with veterans and offer them the opportunity for a follow- up evaluation with a specialty provider. The purpose of the follow-up  evaluation is to further evaluate the veteran’s symptoms and to determine  whether the veteran has a mild TBI. If the veteran refuses to participate in  the follow-up evaluation, the protocol requires the provider to document  the refusal in the veteran’s electronic VA medical record. Providers are  encouraged to provide education on TBI and to maintain an open door for  veterans refusing to participate in the follow-up evaluation by advising  them to return if they want care at a later date.
Another way VA’s evaluation and treatment protocol helps to ensure that  OEF/OIF veterans receive follow-up evaluations for mild TBI is by  establishing requirements for scheduling appointments for these  evaluations with specialty providers. For veterans who have agreed to  participate in the follow-up evaluation, providers are to send an electronic  request for consultation to a specialty department designated by the VA  medical facility as responsible for the evaluations. According to the  protocol, the specialty department receiving the consultation request must  contact the veteran within 1 week to set up an appointment for the follow- up evaluation. If the contact effort is unsuccessful, the protocol states that  subsequent efforts are to include two telephone calls 1 week apart and, if  still unsuccessful, a certified letter sent to the veteran. According to the  protocol, efforts to contact the veteran to schedule a follow-up evaluation  are to be documented in the veteran’s electronic VA medical record.
Under VA’s evaluation and treatment protocol, VA medical facilities can  designate, within VA headquarters guidelines, which specialty  department—and thus which type of provider—should conduct the follow- up evaluations. VA medical facilities we reviewed varied as to which  types of specialty providers were designated to conduct the follow-up  evaluation following a positive TBI screen. Five VA medical facilities we  reviewed referred OEF/OIF veterans to an interdisciplinary team of  specialists affiliated with the facility’s polytrauma team, while the four  other facilities referred veterans to a neurologist, physical medical and  rehabilitation physician, or psychiatrist for the follow-up evaluation. One  of the medical facilities we reviewed made these referrals for a follow-up  evaluation to a local specialty provider practicing in the community, while  the remaining eight medical facilities utilized specialty providers within  their facility. Furthermore, as part of the follow-up evaluation at one  facility, all OEF/OIF veterans who screened positive on the TBI screening  tool were being seen by a vision specialist and some vision problems had  been identified through that process.
In addition to helping ensure that appointments for follow-up evaluations  are made, VA’s evaluation and treatment protocol also provides guidance  for VA specialty providers on evaluating and treating veterans for mild  TBI. VA requires that the VA specialty providers who conduct the follow- up evaluations and the providers who provide treatment for mild TBI use  VA’s protocol to help determine if a diagnosis of mild TBI should be made  and, if so, what course of treatment should be followed. According to the  protocol, providers conducting the follow-up evaluations should obtain a  complete history of the veteran’s injury and current symptoms, conduct a  physical examination targeted to the veteran’s symptoms, and use a  symptom checklist to assess the presence and severity of various  symptoms associated with mild TBI. (VA’s TBI follow-up evaluation  process is depicted in fig. 2.) The symptom checklist lists 22  neurobehavioral symptoms associated with mild TBI, such as headaches,  dizziness, memory problems, irritability problems, and poor concentration.  (See app. II for VA’s symptom checklist.) For each symptom on the  checklist the OEF/OIF veteran reports experiencing, VA’s protocol  provides recommendations on additional physical examinations and tests  that should be conducted and guidance on creating an individualized  treatment plan for the veteran. If the veteran’s symptoms persist, the  protocol includes guidance on when the veteran should be referred to  other VA medical facilities for more intensive evaluation or treatment.
As allowed by VA’s evaluation and treatment protocol, medical facilities  we reviewed varied in how they used the symptom checklist, including  which type of provider administered the symptom checklist, when the  symptom checklist was administered, and how the symptom checklist  results were utilized. Some facilities reported that specialty providers  administered the symptom checklist during the course of their evaluation.  Another facility reported that a nonspecialist provider, such as a nurse or  social worker, administered the symptom checklist prior to the specialty  provider meeting with the veteran. Afterwards, the specialty provider used  the responses to guide the follow-up evaluation or treatment plan. Still  other facilities reported that a multidisciplinary team used the symptom  checklist as a tool to help determine which specialty provider in the  facility would be best to conduct the follow-up evaluation of the veteran.
To help VA monitor the extent to which its medical facilities are following  the evaluation and treatment protocol, VA has implemented for fiscal year  2008 two TBI performance measures related to the follow-up evaluation.  One of the two VA performance measures is designed to track whether  facility staff contacted veterans who screened positive on the TBI  screening tool within 1 week of screening to schedule the follow-up  evaluation and, if unsuccessful, made subsequent attempts to contact the  veteran. The other TBI performance measure is designed to track whether  specialty providers completed the follow-up evaluation for veterans who  screened positive on VA’s TBI screening tool within 30 days of VA’s initial  contact with the veterans. In addition, VA implemented in November 2007  a computer-based template intended to help ensure providers follow the  protocol when conducting a follow-up evaluation. The template will also  provide a standardized method to document the results of this evaluation.
section_title: VA Has Established Training for Its Providers to Help Enhance Their Use of the Protocol
paragraphs: VA has established nationwide training to help enhance its providers’ use  of the evaluation and treatment protocol and thereby help ensure veterans  are evaluated and treated for mild TBI. Under VA policy, VA providers  conducting the follow-up evaluations are required to complete training VA  developed on its protocol for evaluating and treating veterans with mild  TBI. The training consists of VA’s online TBI training module, which is  also required of providers conducting VA’s TBI screening, and three  satellite broadcasts providing information on the TBI screening tool and  on the evaluation and treatment protocol. While the TBI training module  provides an overview of TBI, the satellite broadcasts—produced in 2007  and aired to VA medical facilities periodically—are designed to provide  information and guidance on using the protocol for evaluation and  treatment efforts related to mild TBI. In particular, the satellite broadcasts  provide information on how to perform the follow-up evaluation, how to  confirm a mild TBI diagnosis, how to establish a treatment plan, and when  to make referrals to a higher level of VA care. According to VA officials,  the non-VA specialty providers that medical facilities may use to conduct  the follow-up evaluations are not required to complete VA’s online TBI  training module and the training VA developed on the evaluation and  treatment protocol. A VA official told us this was the case because VA  expects that referrals for follow-up evaluations will be made to specialty  providers with TBI expertise. A VA official also noted that VA is willing to  provide training on VA’s evaluation and treatment protocol to non-VA  providers.
In addition to the training VA requires, VA has provided other training to  help its providers use the evaluation and treatment protocol. At two  national training conferences held in April and August of 2007, VA  provided training on evaluating and treating veterans with mild TBI,  including training on using the protocol. In addition, through conference  calls between staff at VA headquarters and VA medical facilities and  through educational materials contained on VA’s internal Web site, VA has  also provided training on using the protocol. According to a VA official, VA  decided to provide some of its training, such as the second satellite  broadcast, after learning during conference calls between VA headquarters  and VA medical facilities that some providers conducting follow-up  evaluations focused on using the symptom checklist and did not always  obtain a detailed medical history and conduct a targeted physical  examination.
section_title: Two VA Medical Facilities We Reviewed Had Difficulty Fully Following VA’s Protocol
paragraphs: Although VA has implemented its evaluation and treatment protocol  across its facilities, we found one of the VA medical facilities we reviewed  had difficulty following the part of the protocol that specifies how  facilities should contact OEF/OIF veterans who screened positive to  schedule the follow-up evaluation. According to the protocol, if a veteran  screens positive, the TBI screening tool should automatically prompt the  VA provider administering the screen to electronically send a request for  consultation to the specialty department that will conduct the follow-up  evaluation. However, providers at this facility identified cases where  OEF/OIF veterans had screened positive on VA’s TBI screening tool, but  the specialty department responsible for completing the follow-up  evaluation did not receive the electronic consultation request, as specified  by VA’s protocol. As a result, 27 veterans that screened positive on the TBI  screening tool at this medical facility had not been contacted by the  specialty department responsible for conducting the follow-up evaluation  to schedule an appointment.
During the period of our review, officials at the facility recognized the  problem with the electronic notification and took corrective action.  Because of the potential for this problem at other VA medical facilities, we  notified a VA headquarters official about this problem. When asked if this  problem had been discussed with VA medical facilities systemwide, VA  officials told us that the problem had not been specifically addressed or  investigated at other VA medical facilities, but that facilities generally had  not reported this type of problem during conference calls between VA  headquarters and VA medical facilities held to discuss potential problems.  In the future, similar problems scheduling follow-up evaluations may be  identified through one of VA’s new performance measures related to the  TBI follow-up evaluation process. The performance measure, which was  implemented in the first quarter of fiscal year 2008, is designed to  retrospectively track whether veterans who screened positive on the TBI  screening tool—including those who screened positive on the TBI  screening tool in fiscal year 2007—were contacted by the specialty  department in a timely manner to schedule the follow-up evaluation as  required by VA’s evaluation and treatment protocol. However, because this  performance measure was not implemented until the first quarter of fiscal  year 2008, veterans who screened positive in fiscal year 2007 who were not  contacted by the specialty department may not be identified until the  performance measure results are made available to the medical facilities in  fiscal year 2008, unless the medical facilities identify these veterans  through their own tracking mechanisms.
At two of the VA medical facilities we reviewed, including the facility that  reported problems with the electronic notification, we also found that  providers were not fully following VA’s evaluation and treatment protocol  at the time of our site visit, though they were doing so several months  later. For example, at one facility we reviewed in July 2007, three months  after national implementation of the protocol, one of two specialty  providers designated to conduct the follow-up evaluation at the medical  facility had not learned about the protocol or the symptom checklist until  the day before our site visit. At another VA medical facility we reviewed in  July 2007, the designated specialty providers were familiar with the  protocol, including the symptom checklist, but facility staff told us that  they were not yet using the symptom checklist as part of the follow-up  evaluations due to staff workload and clinic capacity issues. Facility staff  told us that they planned to fully implement the protocol, by using the  symptom checklist once an additional provider had been hired and  trained. When we followed up with the facilities in September and October  2007, the facilities told us that the specialty providers are now using the  symptom checklist. Both facilities told us that they had created a template  in the computerized medical record system that helps specialty providers  ensure they are following the protocol and completing the symptom  checklist in the course of their follow-up evaluation.
section_title: Some VA Specialty Providers Reported That an Increased Need for Follow-up Evaluations Could Create a Need to Expand Specialty Departments’ Capacity
paragraphs: At the VA medical facilities we reviewed, providers stated that conducting  VA’s TBI follow-up evaluations was not currently causing significant  capacity problems for their specialty departments. However, according to  providers at some facilities, an increased need for such evaluations could  result in increases in specialty providers’ workloads. At the time of our  review, VA medical facilities were just beginning to screen and evaluate  OEF/OIF veterans for mild TBI using VA’s new screening and evaluation  processes, and providers reported no significant capacity problems in  their specialty departments caused by the TBI follow-up evaluations.  However, VA providers and officials at several facilities told us that as VA  screens more OEF/OIF veterans over time, the resulting demand for  follow-up evaluations is likely to increase. In addition, DOD is planning to  but has not yet begun to routinely screen OEF/OIF servicemembers for  possible TBI after their return from combat theaters as part of DOD’s post- deployment health assessment process. Once DOD begins its screening  efforts, VA facilities could see an increase in demand for TBI-related  evaluations for OEF/OIF veterans, including those veterans who are  deactivated members of the National Guard and Reserves and—like other  OEF/OIF veterans—are presumptively eligible for VA care at no cost for  up to 5 years. According to VA specialty providers at some facilities, an  increase in demand for follow-up evaluations could result in VA’s specialty  departments needing to add more providers in order to expand specialty  departments’ capacity to provide follow-up TBI evaluations for OEF/OIF  veterans.
section_title: VA Faces Clinical and Cultural Challenges in Screening and Evaluating OEF/OIF Veterans for Mild TBI
paragraphs: VA faces a number of clinical and cultural challenges in its efforts to  screen and evaluate OEF/OIF veterans for mild TBI. The lack of objective  diagnostic tests that can identify mild TBI, and the fact that many  symptoms of mild TBI are similar to those of other conditions, such as  PTSD, represent clinical challenges to VA’s screening and evaluation  efforts. In addition, several characteristics of the OEF/OIF veteran  population create cultural challenges to VA’s efforts to the extent that the  characteristics make OEF/OIF veterans unwilling to report experiencing  TBI-related symptoms or unwilling to seek care for such symptoms.
subsections: section_title: Lack of Objective Diagnostic Tests and Overlap of Mild TBI Symptoms with Those of Other Conditions Present Clinical Challenges
paragraphs: VA faces a number of clinical challenges in its efforts to screen OEF/OIF  veterans for mild TBI and evaluate those who screen positive on the TBI  screening tool. One challenge is that there are currently no objective  diagnostic tests—such as laboratory tests or neuroimaging tests like MRI  and computed tomography (CT) scans—that can definitively and reliably  identify mild TBI. While neuroimaging tests yield information about  injury to the brain for some patients with mild TBI, most patients with  mild TBI have normal neuroimaging test results. Similarly, there are no  laboratory tests such as blood tests that can detect whether an OEF/OIF  veteran has a mild TBI.
In the absence of objective diagnostic tests that definitively determine if  an OEF/OIF veteran has a mild TBI, VA providers must screen and  evaluate veterans using the veterans’ own descriptions of their exposures  to incidents that might have caused a mild TBI as well as their descriptions  of past and current symptoms that could indicate a mild TBI. However,  using self-reported information to screen and evaluate in order to make a  clinical diagnosis can be challenging. Self-reported information can reflect  the veteran’s own recollections of the incident and symptoms but can also  reflect what the veteran was told by others who observed the incident if  the veteran had lost consciousness or had memory loss. According to  officials we interviewed at several VA medical facilities, it can be difficult  to obtain from veterans a clear history of the veteran’s exposure to  incidents as well as symptoms. One reason officials cited was the lapse of  time between the incident that could have caused a mild TBI and the  screening for TBI. Officials explained that in many instances, months or  even years have passed between an incident and the time a veteran  undergoes TBI screening and subsequent evaluation, and that amount of  time can complicate the veteran’s ability to accurately and completely  recall the incident and the symptoms experienced afterwards. At one VA  medical facility, for example, officials reported that it could be 2 to 3 years  after the initial injury before VA providers see veterans for their initial TBI  screening. Finally, medical facility officials also noted that memory  problems due to the mild TBI itself can adversely affect the accuracy of  the information that an OEF/OIF veteran provides.
Another clinical challenge VA faces in its TBI screening and evaluation  effort is the fact that many symptoms of mild TBI are similar to the  symptoms associated with other conditions, which makes a definitive  diagnosis of mild TBI more difficult to reach. Many symptoms of mild  TBI—such as insomnia and irritability—are similar to those of PTSD.  Officials at all nine medical facilities we reviewed reported that this  overlap in symptoms posed a challenge for them. They noted that OEF/OIF  veterans may have symptoms that could indicate either PTSD or mild TBI,  or both, and that it can be difficult to determine which condition or  conditions the OEF/OIF veteran has. Deployment to a combat theater can  put OEF/OIF veterans at risk for other mental health conditions as well— such as anxiety or depression. These mental health conditions may be  symptoms of mild TBI themselves and may also lead to additional  symptoms—such as difficulty sleeping or memory problems—that overlap  with those of mild TBI. Complicating this challenge is the fact that certain  combat experiences, such as exposure to an explosive blast, can put  OEF/OIF veterans at risk for mental health conditions as well as for mild  TBI. In addition, some symptoms of mild TBI—such as headaches and  anxiety—are commonly found in the general population or may predate  the injury, which can make it difficult to determine whether these  symptoms can be attributed specifically to a mild TBI.
An additional clinical challenge reported by VA medical facility officials is  that OEF/OIF veterans with mild TBI might not realize that they have an  injury and should seek health care. VA officials and TBI experts stated that  for some OEF/OIF veterans, their mild TBI symptoms may be subtle and  easy to overlook, while other OEF/OIF veterans may not realize they have  an injury because they do not have an obvious physical injury, such as a  head wound. In addition, OEF/OIF veterans with mild TBI might be aware  that they are experiencing symptoms such as headaches or difficulties  completing tasks, but they might not connect those problems to a specific  deployment-related incident or realize that the problems indicate a  physical injury that needs to be evaluated and treated. For example,  officials at several VA medical facilities reported that many OEF/OIF  veterans notice problems after they attempt to resume their regular  activities after deployment. Officials also noted that difficulties such as  memory or concentration problems may arise once veterans return to  work or school. These veterans may not, however, connect these  difficulties to a possible injury and realize that they need to seek care.
Facility officials have found that OEF/OIF veterans’ family members are  often recognizing the veterans’ behavioral or emotional changes or  symptoms and encouraging them to seek VA care. This has led several  facilities to take steps to educate their local communities about TBI  symptoms and VA services, to help OEF/OIF veterans, their families, and  community members learn more about the condition and to facilitate  veterans being screened and evaluated for TBI.
Memory problems that can occur in OEF/OIF veterans with mild TBI can  create a challenge when OEF/OIF veterans forget that they are due to  come to a VA medical facility for screening and evaluation appointments.  Officials at several facilities we reviewed have observed that many  OEF/OIF veterans with mild TBI need help remembering when they have  appointments. Officials have found that hand-held computers and  reminder phone calls can be effective in helping to ensure that OEF/OIF  veterans keep their appointments and receive needed care.
section_title: Characteristics of Military Culture and of OEF/OIF Veterans Create Cultural Challenges to VA’s Mild TBI Screening and Evaluation Efforts
paragraphs: Several characteristics of the OEF/OIF veteran population create cultural  challenges to VA’s effort to screen OEF/OIF veterans for mild TBI and  evaluate those who screen positive. For example, several aspects of  military culture may discourage OEF/OIF veterans from seeking care for  TBI-related symptoms, even though the veterans have returned to civilian  life. According to VA officials, some OEF/OIF veterans may have concerns  about being perceived as physically weak, and these concerns may stem in  part from the military culture that emphasizes being strong and self- sufficient. In addition, VA officials stated that OEF/OIF veterans may not  want to risk being labeled with a condition that could be perceived as a  mental illness, due to the stigma associated with mental illness. Finally,  according to staff at several of the VA facilities we reviewed, some  OEF/OIF veterans have expressed concerns that reporting symptoms  associated with a TBI could compromise their ability to remain in the  National Guard or Reserves or to obtain law enforcement or security jobs  after their military obligation is completed. Such veterans are concerned  that documentation in their medical record regarding TBI-related  symptoms could adversely affect their future employment plans.
Another cultural challenge to screening and evaluating OEF/OIF veterans  for TBI is that these veterans may not schedule appointments or keep  existing appointments for VA care in a timely manner due to work and  family priorities or constraints. OEF/OIF veterans tend to be younger than  other VA patients and often work or are in school full-time or have young  children to care for, according to VA medical facility officials. OEF/OIF  veterans may be returning to the jobs they held prior to deployment or  starting new jobs. Facility officials have found that some employed  OEF/OIF veterans are concerned with the possible consequences of taking  too much time off from work to seek care and have difficulty coming to VA  facilities to be screened and evaluated for mild TBI due to their work  schedules. Other OEF/OIF veterans are enrolled in school and have  difficulties making it to appointments because of their class schedules.  Facility officials also noted that some veterans do not have available  childcare and must miss appointments to stay home with their children.  Facility staff also reported that OEF/OIF veterans often want to return to  their lives in the community after their deployment and, as a result, may  not make their own health care needs a priority when they first return  home. Lastly, according to officials at several VA facilities, OEF/OIF  veterans who screen positive for a possible TBI may have to travel a  substantial distance to reach VA facilities for their follow-up evaluations.  At one facility we reviewed, officials reported that the area it serves is  characterized by small towns and farms and that some OEF/OIF veterans  may have to drive 100 miles to reach the VA facility. These factors have  contributed to VA facilities having high rates of no-shows for  appointments for OEF/OIF veterans. For example, two facilities we  reviewed reported a 50 percent or greater clinic no-show rate for OEF/OIF  veterans.
In order to address these cultural challenges related to screening and  evaluating OEF/OIF veterans for TBI, officials at the medical facilities we  reviewed reported using various strategies. For example, in order to  facilitate veterans coming to the appointments or rescheduling  appointments they were unable to keep, some facilities sent reminder  letters to or called OEF/OIF veterans to inform them about the day and  time of their upcoming follow-up evaluation. At some facilities we  reviewed, social workers, case managers, or nurses used phone calls and  letters to contact OEF/OIF veterans who did not show up for follow-up  evaluations or other appointments, to encourage them to come in for care.  Several facilities we reviewed arranged for the follow-up evaluation to  take place on the same day that the OEF/OIF veteran was screened for  TBI, or have scheduled multiple appointments on one day so the OEF/OIF  veteran does not have to miss multiple days of work or school for  appointments.
Another characteristic of OEF/OIF veterans that creates a cultural  challenge for VA is that OEF/OIF veterans may not want to seek care, such  as TBI screening and evaluation services, at VA medical facilities due to  their perceptions about VA health care or the population served by VA  facilities. Officials at some VA medical facilities told us that some OEF/OIF  veterans saw VA facilities as serving an elderly veteran population and not  the younger OEF/OIF population—or thought that VA providers did not  want to treat younger veterans. These impressions made some OEF/OIF  veterans hesitant to seek VA care. Facility officials reported that they  sought to counter these impressions by educating OEF/OIF veterans about  VA’s health care system and emphasizing that VA is providing care for the  OEF/OIF population.
section_title: Conclusions
paragraphs: With TBI a leading injury among U.S. forces serving in military operations  in Afghanistan and Iraq, VA has taken positive steps in its efforts to ensure  that veterans from these conflicts who are still experiencing the effects of  mild TBI are identified, evaluated, and treated when they seek care at VA  medical facilities. Our work during the start-up phase of VA’s efforts  shows that VA facilities have made progress implementing VA’s TBI  screening tool and VA’s national TBI evaluation and treatment protocol.  Although we found that there were difficulties following some of the  protocol’s requirements at two VA medical facilities, those facilities had  taken steps to address those issues. VA has implemented new TBI-related  performance measures for fiscal year 2008 as well as a computer-based  template to be used with the follow-up evaluation, which are both  designed to help ensure that VA providers are following the TBI protocol.
As VA moves beyond the start-up phase of its TBI efforts, one of VA’s  remaining challenges is ensuring that the basis of its efforts—its TBI  screening tool—is valid and reliable. VA recognizes the importance of  evaluating the screening tool’s validity and reliability—and is planning to  do so. However, VA has not yet begun its evaluation. Until VA evaluates  the TBI screening tool’s validity and reliability, VA providers will continue  to use the screening tool without knowing how effective the tool is in  identifying which veterans are and are not at risk for having mild TBI.
section_title: Recommendation for Executive Action
paragraphs: To establish whether the use of VA’s TBI screening tool is effective in  identifying OEF/OIF veterans at risk for mild TBI, we recommend that the  Secretary of Veterans Affairs direct the Under Secretary for Health to  expeditiously evaluate the clinical validity and reliability of VA’s TBI  screening tool.
section_title: Agency Comments
paragraphs: In commenting on a draft of this report, VA concurred with our findings,  conclusions, and recommendation to expedite the evaluation of the  validity and reliability of the TBI screening tool. In its comments, VA  updated its plans to finalize a validation study of the TBI screening tool  and agreed to fast-track the validation study, with preliminary results  expected by the end of 2008. VA noted that it also plans to study the health  needs and outcomes of veterans with TBI and to look for more accurate  methods of diagnosing TBI, with a particular focus on veterans who may  have coexisting conditions such as PTSD, substance abuse, and physical  trauma. VA also noted that more time and research may be needed to  ensure consensus in the medical community about the diagnosis of TBI  and the implications for recovery. VA further commented that the lack of  any objective diagnostic test to definitively and reliably identify mild TBI is  not unique to VA. We agree and have included clarifying language in the  report to indicate that this is not a limitation unique to VA. VA’s written  comments are reprinted in appendix III. VA also provided technical  comments, which we have incorporated as appropriate.
We provided a draft of this report to DOD for comment. DOD declined to  provide comments on the draft report.
We are sending copies of this report to the Secretary of Veterans Affairs  and the Secretary of Defense. We will also provide copies to others upon  request. In addition, the report is available at no charge on the GAO Web  site at http://www.gao.gov. If you or your staff have any questions about  this report, please contact me at (202) 512-7114 or kanofm@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 that made  major contributions to this report are listed in appendix IV.
section_title: Appendix I: List of VA Medical Facilities, by Type of Polytrauma Component Site
paragraphs: Component I sites, Polytrauma Rehabilitation Centers, are four regional  medical facilities that provide acute comprehensive medical and  rehabilitative care for the severely injured. These centers have a team of  rehabilitation professionals and consultants from other specialties related  to polytrauma and serve as resources for other Department of Veterans  Affairs (VA) medical facilities.
Component II sites, Polytrauma Network Sites, are 21 medical facilities  that provide specialized, post-acute rehabilitation services. There is one  Polytrauma Network Site in each of VA’s 21 regional health care networks,  including one at each of the four Component I sites.
Component III sites, Polytrauma Support Clinic Teams, are medical  facilities that have facility-based teams of providers with rehabilitation  expertise who deliver follow-up services to veterans and assist in the  management of stable polytrauma conditions that are a consequence of  the injuries sustained by veterans.
Component IV sites, Polytrauma Points of Contact, are present at medical  facilities that do not have Component I, II, or III services. Each of these  medical facilities has a point of contact whose role is to ensure that  veterans are referred to a facility capable of providing the services they  require.
section_title: Appendix II: Symptom Checklist Included in VA’s National Traumatic Brain Injury Evaluation and Treatment Protocol
paragraphs: Appendix II: Symptom Checklist Included in  VA’s National Traumatic Brain Injury  Evaluation and Treatment Protocol Please rate the following symptoms with regard to how much they have disturbed you  SINCE YOUR INJURY.
section_title: Appendix III: Comments from the Department of Veterans Affairs
section_title: Appendix IV: GAO Contact and Staff Acknowledgments
subsections: section_title: Acknowledgments
paragraphs: In addition to the contact named above, Marcia Mann, Assistant Director;  Robin Burke; Sarah Burton; Krister Friday; Adrienne Griffin; Kelli Jones;  Giao N. Nguyen; and Jessica Cobert Smith made key contributions to this  report.
section_title: Related GAO Products
paragraphs: VA and DOD Health Care: Administration of DOD’s Post-Deployment  Health Reassessment to National Guard and Reserve Servicemembers  and VA’s Interaction with DOD. GAO-08-181R. Washington, D.C.:   January 25, 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.
VA and DOD Health Care: Efforts to Provide Seamless Transition of  Care for OEF and OIF Servicemembers and Veterans. GAO-06-794R.  Washington, D.C.: June 30, 2006.