Veterans Affairs: Better Understanding Needed to Enhance Services to Veterans Readjusting to Civilian Life
Published: 2014-09-10T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: Over the next 6 years, over 1 million servicemembers are expected to leave the military. As was the case with past generations of veterans, the transition from military to civilian life can be challenging for post-9/11 veterans as well. Over the last several years, veterans' struggles to successfully readjust to civilian life have been the subject of numerous Congressional hearings.
Providing support and services for transitioning veterans is a key issue facing the nation. This report examines what is known about (1) the extent to which veterans experience difficulties during their readjustment to civilian life; and (2) how VA assists veterans in their readjustment, as well as what challenges and opportunities exist. GAO conducted a literature search, interviewed VA and DOD officials, and held eight nongeneralizable discussion groups with a total of 45 veterans and family members. GAO also conducted interviews with relevant officials at VA facilities in four states. GAO selected these sites based on diversity of military service branches in a local area, geography, a high concentration of veterans, and proximity to VA resources.
section_title: What GAO Found
paragraphs: While many veterans who served in the military after September 11, 2001, have successfully readjusted to civilian life with minimal difficulties in the first few years after they were discharged, others have experienced difficulties, according to veterans GAO heard from in discussion groups and studies GAO reviewed. These readjustment difficulties include financial and employment, relationships, legal, homelessness, and substance abuse. According to VA's strategic plan, one of its strategic objectives is to improve veteran wellness and economic security, and it states that the ultimate measure of VA's success is the veteran's success after leaving military service. However, there is limited and incomplete data to assess the extent to which veterans experience readjustment difficulties. Therefore, it is not known to what extent veterans are facing one or a combination of problems when they readjust to civilian life. There is relatively more information available on the number of veterans who had a physical or mental condition within a few years of leaving the military. For example, one 2010 study shows that 32 percent of recently-separated veterans were diagnosed by either the Department of Defense (DOD) or the Department of Veterans Affairs (VA) with a disease or injury of the musculoskeletal system. In this and other studies reviewed by GAO, estimates for Post-Traumatic Stress Disorder (PTSD) varied from 10 to 12 percent. According to these studies, some groups of veterans--those who had served in combat and younger veterans--were more likely than others to experience readjustment difficulties or be diagnosed with a mental health condition.
While an array of VA benefits and services are available during a veteran's first few years out of the military, GAO has identified long-standing challenges with VA's delivery and management of this support. Specifically, VA provides a wide range of services and benefits through several programs, such as education, health care, counseling, employment, home loans, and insurance. VA informs veterans of these benefits and services before they leave military service through outreach and education. However, GAO's prior work over the last decade has shown that VA has struggled for years to, among other issues, (1) provide timely access to medical appointments, (2) make timely disability compensation decisions, and (3) coordinate the transfer of medical records from DOD. GAO has made numerous prior recommendations to address these issues, and VA has taken some actions to implement them; however, some recommendations remain unaddressed, and GAO continues to monitor VA's progress. Agency officials and veterans GAO spoke with during this review suggested additional actions that VA can implement to improve its assistance for transitioning veterans. For example, a few VA staff suggested that VA conduct additional research to identify veterans who are predisposed to PTSD and better understand why some veterans do not use VA services. Veterans at all of the sites GAO visited suggested that it would be beneficial for separating servicemembers to have additional time to adjust to the idea of being a civilian and relearning what civilian life is like. Without comprehensive information on the difficulties experienced by recently-separated veterans, VA cannot assess risks to achieving its objectives and may be missing opportunities to enhance assistance to veterans by not providing needed services early in the veteran's readjustment process. GAO recommends that VA take steps to better understand the difficulties faced by readjusting veterans and use this information to determine how best to enhance its benefits and services for these veterans. VA concurred with GAO's recommendation and described its recent efforts and plans for improvement.
section_title: What GAO Recommends
paragraphs: GAO recommends that VA take steps to better understand the difficulties faced by readjusting veterans and use this information to determine how best to enhance its benefits and services for these veterans. VA concurred with GAO’s recommendation and described its recent efforts and plans for improvement.

section_title: Letter
paragraphs: From 2014 to 2020, the U.S. Department of Veterans Affairs (VA)  anticipates that over 1 million servicemembers will join the 2.3 million  veterans who have already left the military since the terrorist attacks of  September 11, 2001. As has been the case with past generations of  veterans, making the transition from military to civilian life can be  challenging for post-9/11 veterans as well. While the U.S. Department of  Defense (DOD) has a role in assisting servicemembers with preparing for  their transition, it is primarily VA’s role to assist veterans after they  separate from the military and begin readjusting to civilian life. To that  end, VA administers a wide variety of benefits and services for veterans  including health care, education benefits, and disability compensation  benefits. While many veterans have made the readjustment without major  difficulty, others may struggle with physical and mental health problems,  financial difficulties, and unemployment. In the past few years, veterans  experiencing these struggles have been the subject of numerous  Congressional hearings and have received prominent media attention. In  addition, GAO has issued multiple reports on this subject, and has  designated supporting transitioning veterans as a key issue facing the  nation.
We have prepared this report under the Comptroller General’s authority  as part of a continued effort to help policymakers better understand how  veterans readjust into civilian life and the challenges VA faces in serving  them. We defined the readjustment period as the first 5 years after a  veteran separates from the military. For this review we examined what is  known about: (1) the extent to which veterans experience difficulties  during their readjustment to civilian life, and (2) how VA assists veterans  in their readjustment, as well as what challenges and opportunities exist.
To examine the extent to which veterans experience difficulties during  their readjustment to civilian life, we conducted a literature search and  interviewed relevant officials. More specifically, we searched for studies  published in books, reports, and peer-reviewed journals published from  September 2001 to May 2013 that described difficulties experienced by  veterans; categorized and screened the sources; and then identified  reliable quantitative information on the difficulties presented. We  screened over 500 articles and identified 18 that had reliable quantitative  information that was relevant for our review. We also interviewed officials  from VA and DOD, as well as representatives from veteran service  organizations. In examining how VA assists veterans in their  readjustment, and what challenges and opportunities exist, we reviewed  VA’s strategic plan, annual performance reports, and other documents,  and visited four sites: San Diego, California; Baltimore, Maryland;  Fayetteville, North Carolina; and San Antonio, Texas. We selected these  sites based on geographic diversity, diversity of military services (i.e.,  Army, Navy, Air Force, and Marines) in a local area, a high concentration  of veterans among the local population, and proximity to VA resources. At  each location, we visited a VA Medical Center and Readjustment  Counseling Service (Vet Center) and interviewed relevant program  officials, representatives, and veterans. At three locations, we visited the  closest VA regional office. We also held eight nongeneralizable  discussion groups with 45 veterans and family members.
We conducted this performance audit from March 2013 to September  2014 in accordance with generally accepted government auditing  standards. These 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. For more information on  our scope and methodology, see appendix I.
subsections: section_title: Background
subsections: section_title: VA’s Role in Supporting Veterans during Their Readjustment to Civilian Life
paragraphs: VA administers a wide range of programs that provide benefits and  services to eligible veterans who seek out the agency for assistance as  they readjust to civilian life. For example, VA offers health care, disability  compensation, educational benefits, life insurance, vocational  rehabilitation services, and home loans.  In 2014, VA requested $152  billion to support its programs that provided benefits and services to  veterans. Of this amount, VA requested an estimated $58 billion for  medical care for veterans, including almost $7 billion in mental health  care. VA also requested an estimated $58.6 billion in disability  compensation benefits to veterans with disabilities that resulted from their  military service.
The Wounded Warrior Act was enacted as part of the National Defense Authorization Act  for Fiscal Year 2008. For requirements in the Act related to the comprehensive policy to  be jointly developed and implemented by DOD and VA, see Pub. L. No. 110-181, tit. XVI,  § 1611, 122 Stat. 3, 430, 433. The Act defines a “recovering service member” as a  member of the Armed Forces, including the National Guard or Reserve, who is  undergoing medical treatment, recuperation, or therapy and is in an outpatient status while  recovering from a serious injury or illness related to the member’s military service. See  122 Stat. 432. the services that are offered to them. In addition, the WWA required that  the policy include provisions related to the tracking of recovering  servicemembers to conduct oversight of their care, management, and  transition. In 2009, DOD and VA began developing the Virtual Lifetime  Electronic Record Initiative, to share health, benefit, and administrative  data, such as personnel records and military history records securely.  The VOW to Hire Heroes Act of 2011(VOW Act) made several changes to  the Transition Assistance Program (TAP), a program that provides  departing servicemembers counseling and offers employment assistance  and information on federal veteran benefits, among other things.  Concurrent with this Act, the administration initiated a redesign of TAP.  The law also generally required servicemembers to attend TAP prior to  separating from their service. The VOW Act required departing  servicemembers to participate in a workshop on finding employment as  part of TAP, among other changes. Other provisions of the VOW Act  include allowing servicemembers to apply for civilian federal government  positions as veterans prior to separating from the military, ensuring the  program is tailored to individuals and the 21st century job market.
Furthermore, VA and DOD collaborated in the development of several  programs for servicemembers to receive VA disability compensation. The  Benefits Delivery at Discharge program provides separating and retiring  servicemembers the ability to apply for VA disability compensation when  they have between 60 and 180 days remaining on active duty. Similarly,  through the Quick Start program, VA and DOD provide the same service  for those servicemembers who have less than 60 days remaining on  active duty. In addition, VA collaborates with DOD to operate the  Integrated Disability Evaluation System (IDES). IDES consolidates VA’s  and DOD’s separate disability rating decisions into a single VA rating- decision and requires staff to perform outreach and nonclinical case  management and explain VA results and processes to servicemembers.
section_title: Characteristics of Veterans Readjusting to Civilian Life
paragraphs: Since September 11, 2001, the U.S. military has seen a shift in the  demographics of those who have served in combat. Of the 2.1 million  servicemembers who have deployed in support of Operation Enduring  Freedom, Operation Iraqi Freedom, and Operation New Dawn  (OEF/OIF/OND), about 12 percent were women, and 33 percent were  members of the National Guard or Reserves. By comparison, during the  Persian Gulf War in 1990, 6.8 percent of servicemembers were women,  and 16 percent were members of the National Guard or Reserves. During  the Vietnam War, about 0.2 percent of servicemembers were women and  only 0.4 percent were members of the National Guard or Reserves.
Moreover, veterans who have left the military since September 11, 2001,  like veterans from prior eras, have had varied years of service and  military experiences. They may have served for 20 years or more in the  military and never served in combat, or they may have only served for a  year or two. As of fiscal year 2012, more than 1.4 million veterans who  have been receiving military retiree payments were in the military for 20  or more years. Between October 2001 and December 2012, more than  1.6 million servicemembers who served during OEF/OIF/OND had  become veterans.health care services and over 600,000 were receiving disability  compensation benefits.
section_title: The Readjustment Process for Veterans
paragraphs: When serving in the military, many servicemembers become accustomed  to its culture and structure of discipline and hierarchy and giving priority to  the group over the individual. During their service, all members of the  military are employed and receive regular paychecks; medical care; and  other benefits, such as housing allowances. Once they leave the military  and become veterans, they must learn to become a civilian again. They  are responsible for finding a job, going back to school, obtaining health  insurance, child care, and finding a place to live, among other life  activities. If veterans are also recovering from their war experiences, it  can compound the difficulty they experience in successfully completing  their readjustment.
section_title: Veterans Experience Difficulty When Readjusting to Civilian Life but Extent Is Unknown
subsections: section_title: Readjusting Veterans May Experience a Range of Economic, Social, and Other Difficulties
paragraphs: Veterans we spoke to and VA officials confirmed that veterans face a  variety of difficulties related to readjusting to civilian life, including  financial and employment, relationships, legal difficulties, homelessness,  and substance abuse. One of VA’s strategic objectives is to improve  veteran wellness and economic security. VA’s strategic plan also states  that the ultimate measure of its success is the veteran’s success after  leaving military service. However, there is limited and incomplete data  available to assess the extent to which these veterans are affected by  these difficulties. Therefore, it is not known to what extent veterans are  facing one or a combination of these problems when they readjust to  civilian life.
Financial and employment. Some veterans in our discussion groups at  three of the four sites we visited said that they and several of their peers  struggled financially in the time period immediately following their  discharge, particularly if they had a family to support. VA officials  confirmed that some veterans have experienced a range of difficulties  after separating from the military, especially if they had no source of  income as they readjust to civilian life. One of the veterans we spoke to  said that his income dropped by four-fifths when he lost his military pay  and benefits and could not find anything but a minimum wage job. Other  veterans at one of the sites we visited described the challenge of paying  for their living expenses during long waits for civilian employment or VA  benefits to be processed. According to a 2008 study that examined  unemployment among OEF/OIF veterans who had separated from the  military by the end of 2006, veterans had a higher unemployment rate  (6.5 percent) than nonveterans (4.7 percent). Veterans at three of the  four sites we visited reported experiencing financial difficulties as they  started civilian employment or received benefits. Several veterans we  interviewed said they had applied for VA benefits in order to support  themselves and endured lengthy waits for a VA decision. VA officials at  two of the sites we visited and veterans at three of the sites mentioned  that many veterans faced difficulties with the costs of civilian life,  particularly housing, food, transportation, and child care. In particular, VA  officials at one site we visited told us that veterans found the Post-9/11  G.I. Bill’s benefits for attending college were not enough to cover living  expenses, especially during months that veterans do not attend school,  such as during a summer break.no comprehensive data that identified the extent to which readjusting  veterans experienced financial difficulties.
However, during our review we found  Relationships. As they work to readjust to civilian life, many veterans  can experience relationship difficulties. Several veterans at three of the  sites we visited said that they had difficulty adjusting to family life, and  often felt that they could not inform their families of their struggles. Those  who had talked to their families felt that their family members did not  understand them very well. One veteran reported unintentionally  assaulting his wife during nightmares while sleeping; another said he was  reluctant to spend time individually with his children for fear of becoming  angry and losing control. VA officials at two of the four sites we visited  noted that they are seeing many veterans with marital issues and at one  VA medical center, officials told us that some veterans seem to have no  support system in place. However, during our review we found no studies  or comprehensive data that identified the extent to which readjusting  veterans experienced this issue.
Legal problems. Some veterans recently separated from the military also  face legal difficulties, including being arrested, convicted of a crime, and  sentenced to serve time in jail. Although we found some data related to  this issue, these may not represent the extent that veterans experience  legal difficulties. For example, according to a 2007 report from the  Department of Justice, there were an estimated 5,280 OEF/OIF veterans  who had separated from the military between 2002 and 2004 who were  incarcerated in either state or federal correctional facilities in 2004.  Those data might represent an undercount, as one VA official tasked with  outreach to veterans in correctional settings told us that not all veterans  disclose their veteran status when they go to jail. In some areas, there are  veterans treatment courts designed to serve the unique needs of veterans  in the criminal justice system. According to VA, there were 257 veterans  courts in the United States in 2013.
S. Metraux, L. Clegg, J. Daigh, D. Culhane, and V. Kane, “Risk Factors for Becoming  Homeless Among a Cohort of Veterans Who Served in the Era of the Iraq and  Afghanistan Conflicts,” American Journal of Public Health, vol. 103, no. S2 (2013): S256,  S258, S259.
2011.identified the extent to which readjusting veterans were experiencing  homelessness.
D. Nazarian, R. Kimerling, and S. Frayne, “Posttraumatic Stress Disorder, Substance  Use Disorders, and Medical Comorbidity Among Returning U.S. Veterans,” Journal of  Traumatic Stress, vol. 25 (April 2012): 221, 224. Results from a sample of veterans who  sought treatment cannot be generalized to a broader population of veterans (particularly  those that had not sought VA treatment). mental health conditions. Some of the veterans and VA officials we  spoke with at one site said that veterans were sometimes afraid to take  their prescribed medications, or believed that the medications were not  working (especially on pain symptoms). Some veterans turned to alcohol  and illegal drugs to manage their physical or emotional pain. Other  veterans said that the use of prescribed medication, particularly  painkillers, causes addiction, sleepiness, or other side effects. VA officials  at two of the sites we visited reported that some veterans appear at VA  facilities seeking help for physical or mental conditions, including a  substance abuse problem that must also be treated. A study with a small  sample of veterans found that those who experienced any type of trauma  were far more likely to screen positive for substance abuse than those  who had not experienced any type of trauma.
section_title: A Sizable Minority of Post 9-11 Veterans Have Physical and Mental Health Conditions
paragraphs: A sizable minority of veterans who have served since September 11,  2001, had physical or mental health conditions in the first few years of  their readjustment to civilian life. Although the literature we reviewed  provided a limited perspective of veterans’ early readjustment  experiences, a number of physical health conditions emerged, particularly  musculoskeletal problems and pain, which can contribute to difficulties in  integrating back into civilian life. Physical health conditions are the most  common for recently-separated veterans. According to a 2010 study, 32  percent of veterans had been diagnosed by either DOD or VA with  diseases of the musculoskeletal system and connective tissues after  separating from the military, and about 27 percent had been diagnosed  with diseases of the nervous system and sense organs. Other studies  that focused on OEF/OIF veterans receiving health care through VA show  that between 43 and 49 percent reported some level of pain, with the  majority of this group reporting moderate to severe pain—a level of pain  that was more likely to interfere with functional activities. VA officials at  two of the four sites we visited told us that reports of pain were common,  and it was a difficult problem for VA and veterans to manage. Studies  also found that pain was frequently associated with other physical and  mental health conditions.
Authors of these studies acknowledged the limitations of generalizing the results from a  sample of veterans who sought treatment to a broader population of veterans (particularly  those that had not sought VA treatment). Estimates could be influenced by methodologies  that tended to include either veterans’ self-reported conditions or a review of clinical  records. Although the veterans in the studies typically completed one or more  questionnaires that had been previously validated, self-reported data do not reflect  diagnoses by clinical professionals and a social desirability factor could lead to  underreporting of certain sensitive problems or inflated symptom reporting in an effort to  seek benefits, such as disability compensation. veterans were diagnosed by VA or DOD with a mental disorder or  psychosocial problem after their separation from the military, including  10 percent who were diagnosed with PTSD and about 3 percent who had  Traumatic Brain Injury (TBI). Other studies estimated that 10 to 12  percent of post-9/11 veterans were diagnosed with PTSD. These  percentages do not include veterans who sought treatment for their  mental health conditions from private providers or who have not sought  treatment at all. For readjusting OEF/OIF veterans, estimates of PTSD for  the studies in our review generally ranged from 13 to 18 percent. VA  officials at two sites and veterans at one site said PTSD and other mental  health conditions, in some instances, made it difficult for some veterans to  keep a job or relate to family members. VA officials at all four sites, as  well as veterans at one site, reported that some veterans believe that  employers will turn them down for certain jobs or their security clearance  will be in jeopardy due to past or current mental conditions, particularly  PTSD. VA officials at two of the sites we visited said that many veterans  feel stigmatized about seeking mental health treatment. Officials added  that, in many cases, mental health problems are only identified—and the  possibility of treatment discussed—after some veterans seek VA  treatment for their physical health conditions.
Many veterans with mental health conditions have screened positive for  other conditions or received more than one diagnosis. More specifically, a  2007 study of recently-separated veterans who were diagnosed with a  mental health condition by VA shows that 56 percent of them had more  than one mental health diagnosis. Another study noted that high  percentages of veterans who sought treatment had both PTSD and  depression. Veterans who had experienced trauma were far more likely  to screen positive for depression than those who had not experienced  trauma. VA officials at two sites we visited also mentioned the effects of  Military Sexual Trauma (MST) on victims, including the sense of betrayal  that results. Victims are often reluctant to divulge such incidents (whether  in the military or after separation). If military commanders ignored victims’  allegations, VA officials said that it creates a second betrayal.  Experiences with MST may lead to PTSD and depression. Finally, VA  officials at one site we visited mentioned that experiencing both physical  and mental health conditions at the same time were challenging during  their readjustment. A 2008 study noted that the severity of PTSD was  significantly associated with poorer physical health functioning, even after  accounting for demographic factors, combat and chemical exposure, and  health risk behaviors. Also, another study found that a significantly  larger proportion of veterans suffering from headaches, in comparison to  those without headaches, had experienced physical injury and screened  positive for depression and PTSD.
section_title: Veterans with Certain Characteristics May Be More Likely to Experience Difficulties
paragraphs: Some groups of veterans may be more likely to experience readjustment  difficulties or be diagnosed with a physical or mental condition than  others. In a study we reviewed, veterans with combat exposure were  almost four times more likely to be diagnosed with PTSD than those  without combat exposure. This study found that veterans who had served  in ground units of the Army or Marines had PTSD rates that were 3.7  times higher than those who had served in the Navy or Air Force.  Another study that tracked OEF/OIF veterans seeking treatment with the  VA shows that younger veterans of active duty service were at a higher  risk for diagnoses of PTSD or mental health compared with active duty  veterans at least 40 years old, which the authors attribute to younger  veterans more likely being at lower rank and having had greater combat  exposure.
Studies we reviewed showed that younger veterans experienced higher  rates of mental health diagnoses and alcohol abuse than older veterans.  One study reported that veterans of younger age groups were at a higher  risk of receiving PTSD and other mental health diagnoses compared with  those in the oldest age group (at least 40 years of age). Another study  indicated that younger veterans were more likely to engage in binge  drinking than older veterans. Age was also significantly associated with  screening positive for possible alcohol abuse. Some VA officials we  spoke to on our site visits stated that many young veterans have  difficulties in finding a job and a place to live. They may also deny they  have a problem, refuse to seek help, or only do so after their lives have  turned for the worse. VA officials we spoke to said that some young  people joined the military to escape economic or social difficulties at  home may return to civilian life to find that some of their difficulties  remained. Also, VA officials told us that if veterans had certain problems  before they joined the military, such as mental health or substance abuse  problems, they will probably have them after they leave the military.
Studies we reviewed provided varying results regarding any differences in  the readjustment experience by other demographic characteristics such  as gender, race, and ethnicity. One study found that PTSD was less  frequently diagnosed in female veterans than in male veterans (9.9  percent versus 11.3 percent), but depression was more frequently  diagnosed (12.2 percent vs. 7.5 percent). Another study found that  PTSD was again diagnosed less frequently for female veterans than male  veterans at 28.2 percent and 35.7 percent, respectively; the prevalence of  substance abuse diagnosed was 6.2 percent for females and 12.5  percent for males. The prevalence of PTSD and substance abuse  together was 3.8 percent and 8.1 percent, respectively, for females and  males. Another study found that female veterans were less likely to  screen positive for binge drinking. However, another study reported that  the proportion of patients with possible PTSD symptoms did not vary  substantially according to gender or race. One study found that  differences across these demographic groups of OEF/OIF vets regarding  risk for receiving mental health or PTSD diagnoses were minimal.
section_title: VA Offers an Array of Services to Readjusting Veterans, but Long-Standing Weaknesses Hinder Available Support
subsections: section_title: VA Offers a Range of Benefits and Services to Veterans Early in the Readjustment Process
paragraphs: VA offers assistance to servicemembers before they leave military service  by informing them through outreach and education on the range of  benefits and services available to them. The types of benefits and  services VA offers range from education to health care and life insurance  to burial and memorial benefits. VA officials told us they use VA liaisons  and outreach efforts, including the Transition Assistance Program (TAP).  According to VA officials, VA liaisons are located on many military bases  and play a key role in educating servicemembers about VA benefits and  services. More specifically, VA liaisons assist with transferring individuals  to Veterans Health Administration (VHA) health care facilities and provide  information to servicemembers, veterans, and their families about VHA  health care services. TAP provides information on services that are  available, including services and benefits offered through the VA, either  while servicemembers are on active duty or after they have separated  from the military. TAP also provides separating servicemembers with  counseling and information on available employment assistance and  other federal benefits, identifies servicemembers who did not meet the  TAP career readiness standards, and provides referral to the appropriate  federal partners for additional supports and services. In addition, VA  officials told us National Guard and Reserve members can learn about  VA services and benefits through the Yellow Ribbon Reintegration  Program (YRRP). YRRP connects servicemembers, families, and  communities with resources using the YRRP website, newsletter, and  YYRP-sponsored events. According to officials, YRRP is designed to  make individuals aware of the supports and services available to them.
VA reaches out to veterans through a variety of activities and tools.  Veterans can learn about VA, for example, through mobile Vet Centers,  Welcome Home events, as well as community events. Mobile Vet  Centers, which are customized recreational vehicles, allow VA staff the  ability to travel to communities to provide information and render  counseling services to veterans, especially to veterans living in rural  areas. Welcome Home events are held at VA medical centers and offer  health screenings and disseminate VA benefits information.VA also  educates veterans and family members through the VA website and uses  various social media outlets including Facebook™ and Twitter™.
Although VA reaches out to veterans in a number of ways,  servicemembers and veterans must take the initiative to register for VA  benefits and services either online, by mail, over the phone using a toll- free number, or they can do so in person at a VA medical facility or  regional office. Veterans can also work with veteran service organizations  (VSO) to apply for VA benefits and services. VSOs act as advocates for  veterans during their application for benefits and can assist them with  obtaining medical records and explaining the benefits and services that  VA offers. Senior VA officials told us that VA conducts outreach to  veterans, but ultimately it is up to the veteran to sign up for the benefits  and services. In recent years, VA has encouraged servicemembers and  veterans to apply for VA benefits, such as medical care and disability  compensation, using the agency’s eBenefits system. eBenefits is  designed to enable veterans, servicemembers, and families to learn  about and manage their military and veterans benefits and personal  information online. Many VA officials told us they encourage  servicemembers and veterans to apply for benefits through this system.Officials from one medical facility we visited told us that one of the  advantages of using eBenefits is that it allows veterans to search for the  benefits and services they could be entitled to from their residence,  instead of having to come to a VA facility.
For veterans who were wounded, became ill, or injured as a result of their  service, VA offers specific benefits and services. Disability compensation  is a monetary benefit paid to veterans with disabilities that were the result  of their military service. This benefit award is based on the severity of  disability. The Vocational Rehabilitation and Employment (VR&E)  program helps eligible veterans prepare for, obtain, and maintain suitable  employment or achieve independence in daily living. VR&E offers job  training, education, employment, job coaching, and independent living  services. For veterans receiving health care services for their medical  conditions, VA offers prosthetic equipment such as home respiratory  therapy, artificial limbs, wheelchairs, and optical and electronic devices  for visual impairments.conditions, such as PTSD or depression, may receive mental health  treatment and counseling services at VA medical centers and Vet  Centers.
Veterans who suffer with mental health  For the most severely wounded, ill, and injured servicemembers and  veterans, VA provides intensive case management services. Under the  Federal Recovery Coordination Program (FRCP), VA serves  servicemembers and veterans with complex medical or social problems  which may include traumatic brain injury, amputation, burn, spinal cord  injury, blindness, PTSD, as well as those considered at risk for  psychosocial complications. Federal Recover Coordinators advocate in all  clinical and non-clinical aspects of recovery, rehabilitation, and  reintegration and participate in the development of a Federal Individual  Recovery Plan to provide coordination of care and benefits through the  continuum of care. VA also operates Polytrauma Rehabilitation Centers  that provide integrated inpatient rehabilitation to address a variety of  health issues including physical, cognitive, emotional adjustment, and  health and wellness. The centers serve patients who are in prolonged  states of reduced consciousness, including coma.
For veterans of the Iraq and Afghanistan conflicts, VA provides additional  benefits and services. These individuals may be eligible to receive  education benefits through the Post-9/11 GI Bill which provides  participants up to 36 months of education benefits to defray the costs of  post-secondary degrees, technical training, and other expenses, such as  books and supplies, and housing, among other costs. Veterans who  served in combat generally are eligible to receive 5 years of free health  care through the VA. In addition, all post-9/11 veterans who enter the  VA health care system are referred to the Operation Enduring  Freedom(OEF)/Operation Iraqi Freedom (OIF)/Operation New Dawn  (OND) Care Coordination Program, which screens these veterans to  determine if and the extent to which care is needed and assists them with  accessing VA and community resources.designed to identify combat veterans and the degree of care that is  needed to treat their medical conditions. If the screenings indicate case  management is needed, veterans are referred to the Post-Deployment  Integrated Care Initiative (PDIC). The PDIC provides an integrated  approach to health care by treating the veteran with physical and mental  health care, and social work simultaneously, rather than identifying and  treating one problem at a time. According to program managers, this  approach provides patient-centered care and increased coordination  between providers. It also includes a comprehensive psychosocial and  medical intake process for combat veterans with full integration of all  services as well as regular meetings by medical care providers to discuss  patient care and system issues. VA officials told us that while only  veterans who have experienced combat situations are eligible to receive  care through PDIC, VHA is exploring the possibility of expanding this  practice to all veterans.
section_title: Lengthy Wait Times for Benefits and Services, among Other Factors, Can Hinder Veterans’ Readjustment
subsections: section_title: VA’s Continuing Service Provision Challenges
paragraphs: Medical care. VA continues to face long-standing challenges in providing  some benefits and services in a timely way, which can hinder veterans as  they readjust to their civilian lives. Our past reports, as well as reports by  VA, have highlighted the continuing challenges VA faces in ensuring  veterans are able to access medical care. For over a decade we have  reported on continuing issues with VA medical service delivery including,  in 2004, we found that some veterans in Chattanooga, Tennessee,  encountered difficulties with accessing VA’s inpatient and outpatient  health care services. We recommended that VA explore alternatives to  further improve access to health care for these veterans by expediting the  opening of additional VA medical facilities.
Subsequently, VA reviewed  Chattanooga veterans’ access to inpatient and outpatient health care and  opened two clinics. However, in 2009, VA reported that its facilities were  unable to keep up with a steady increase in the demand for outpatient  care services, leading to veterans not being able to access medical care.  The report noted that VA added new guidance and performance  measures to help alleviate excessive wait times for medical  appointments. In 2011, we found that veterans were hindered from  accessing mental health care from VA in part because of difficulty in  scheduling appointments. Although VA reported that they were making  improvements toward achieving timely access to medical appointments,  in 2012, we found that medical appointment wait times reported by VHA  were unreliable. We recommended that VA improve the reliability of its  medical appointment wait time measures, ensure medical centers  consistently implement the scheduling policy, and require medical centers  to allocate staffing resources based on scheduling needs. VA reported  revising its scheduling policy and developing a training module that  schedulers were required to complete, implementing revised wait time  measures, and studying options to better understand staffing level gaps.  That same year, VA’s Office of Inspector General found that VA had  overstated its success in providing veterans with timely appointments for  mental health treatment.
In 2014, VA completed an audit to determine if broader, more systemic  problems existed and found multiple deficiencies with VA’s appointment  scheduling practices for medical care. However, veteran complaints about long wait times persist. VA officials and veterans also told us during  our site visits that veterans continued to wait a long time to see VA  physicians. At two of the four medical facilities we visited, VA officials told  us that veterans have expressed frustration with how long it was taking to  see a physician. Officials from one of the medical centers told us that  there are long wait times to get appointments and some veterans stop  using VA services because of the lack of timely appointments. Veterans  from three of the four sites we visited complained about the lengthy wait  times to see their physicians. One veteran told us that VA does not give  veterans a choice of appointment times, and added this can be  problematic if one is employed or attending school. He also told us that  veterans do not want to miss these appointments because it can take  months to reschedule.
Disability compensation. We have reported for over 10 years, and we  heard confirmations during interviews with VA officials and veterans, on  the continuing challenge VA faces in processing disability compensation  in a timely fashion. For example, in 2003, we found that while VA acted to  improve the timeliness of its disability claims processing, the agency  remained far from achieving its goals. At a 2008 congressional hearing,  we testified that despite VA taking steps to improve its disability claims  process, challenges remained in reducing the backlog and wait times for  processing claims. In 2012, we reported that the number of days to  process disability compensation benefits was increasing and  recommended that VA partner with other federal agencies to reduce  timeframes and ensure the development of a robust backlog plan. VA  agreed with our recommendations and reported initiating a pilot program  to centralize records requests and published a strategic plan to eliminate  the disability compensation claims backlog. While VA addressed several  of our recommendations, we concluded that additional follow up would be  needed. In fiscal year 2014, VA reported that 58 percent of veterans  experienced wait times that were longer than its goal of 125 days and the  average time to complete a claim was 378 days. For veterans,  especially those in the beginning phases of their readjustment, making  timely decisions on disability compensation benefits can potentially lessen  the accompanying financial transition difficulties. Veterans from three of  the sites we visited pointed to claims processing timeliness as a factor in  their difficulty with readjusting to civilian life. For example, one female  veteran told us that VA took 15 months to process her claim, and during  this time, she was unable to support herself and had to reside with her  family. Another veteran told us he has been waiting 2 years for his  disability compensation to be processed, has run out of unemployment  benefits, and is now on the verge of becoming homeless.
Post-9/11 GI Bill. Since the Post-9/11 GI Bill was implemented in 2009,  VA has had challenges informing veterans about the program and  protecting them from questionable recruiting practices by some post- secondary schools. In 2011, we reported that veterans wanted more  information about the program, including how to compare Post-9/11 GI  Bill benefits with other VA education benefits, as well as the effect of  dropping or adding classes. We recommended that VA develop  performance measures for outreach to servicemembers and veterans and  for the quality of information provided by its Right Now Web service. We  also recommended VA consider developing and maintaining an online  policy manual for the Post-9/11 GI Bill, and provide updates to school  certifying officials nationwide. VA addressed some of our  recommendations but we concluded that additional monitoring of its new  outreach performance measures was needed, and we continued to urge  VA to measure the quality of its Right Now Web service. In 2014, we  reported that VA’s response to protecting veterans from schools that were  using inappropriate or aggressive recruiting practices was not always  sufficient. More specifically, we found that while VA offered education  counseling services to students, applying for the services was difficult and  not all veterans were aware of its availability. We concluded that if  veterans are not better protected and informed, they may end up using  their educational benefits on programs that do not meet their career goals  and recommended that VA improve outreach and accessibility of its  education counseling services.and noted that it was taking additional steps to enhance the outreach and  delivery of its education counseling services.
section_title: VA’s Continuing Issues Collaborating with DOD
paragraphs: Integrated Disability Evaluation System. Similarly to VA’s Disability  Compensation, VA and DOD’s Integrated Disability Evaluation System  (IDES) has had difficulty with making timely decisions on  servicemembers’ claims for VA disability compensation. In 2010, we  testified that the time to make decisions on IDES claims was affected by  insufficient staffing and VA and DOD medical staff disagreeing over  servicemember diagnoses. In 2011, we found that as program  participation increased, so did the processing times for benefits. We  recommended that VA and DOD develop a system-wide IDES monitoring  mechanism. VA reported upgrading the IDES tracking system to include  data fields that can capture, monitor and report when diagnostic  disagreements occur, but we are continuing to monitor the tracking  system to determine whether the agency can effectively monitor cases  with diagnostic disagreements. In 2012, we reported that the processing  times for decisions made for IDES claims continued to increase. We  recommended that VA ensure care coordination and disability evaluation  issues are fully resolved by the agencies and that its partners have  sustained leadership attention and collaboration to ensure continuity of  care and seamless transition for servicemembers. VA agreed with our  recommendation and reported that the agency had established a  committee with DOD to address comprehensive overhaul of the care  coordination process. In 2013, VA reported that 16 percent of  servicemembers were awarded VA disability compensation benefits  within 30 days of their discharge from the service. Being able to provide  compensation benefits to veterans shortly after they were discharged  from the service would bring greater financial security, thereby reducing  the risk for negative outcomes such as bankruptcy and homelessness.
Electronic medical records. In addition, VA continues to face long- standing problems coordinating with DOD on sharing electronic medical  records. Developing a method for sharing electronic health records that  can be accessed throughout a patient’s military and veteran status is  particularly important. This method can help ensure greater availability of  health care information for servicemembers and veterans at the time and  place of care. Since 1998, VA and DOD have tried different ways to  enable the sharing of electronic servicemember medical records, but our  past reports and VA reports have shown ongoing challenges. For  example, in 2003, we found that VA faced problems in developing an  information technology strategy for sharing information with DOD on  patients and that VA and DOD continued to operate separate information  technology systems. A 2008 VA report noted that service treatment  records continued to be transferred from DOD to VA by paper copy  because the infrastructure to transfer the records electronically had not  yet been built and its current efforts to have a health information  exchange had one or more serious flaws. In 2011, VA highlighted its  efforts to address the incompatibility between VA and DOD electronic  health records systems by attempting to create a virtual lifetime electronic  record, but we found impediments persisted in the agencies’ efforts to  electronically view or exchange health information. Our report cited  insufficient real-time and electronic access to comprehensive health  information possibly delaying the receipt of care and benefits. We  recommended that VA ensure electronic sharing of health records issues  are fully resolved by the agencies and its partners have sustained  leadership attention and collaboration to ensure continuity of care and  seamless transition for servicemembers. VA agreed with our  recommendations, and reported establishing a committee to review the  care coordination of servicemembers; however, VA did not identify  actions it would take to address electronic sharing of health records. In  2013, VA and DOD testified that their long-term plans for sharing medical  record data were too expensive to continue and that they were exploring  a different strategy. Veterans from all of the sites we visited told us of  the difficulties they had with obtaining copies of their medical records. For  example, one veteran told us that his medical records were not centrally  located, making it difficult for him to collect his full record. Without medical  records describing the treatment veterans received while in the military,  VA faces difficulties with ensuring continuity of care when veterans  transition to VA’s health system.
Medication. VA has also had long-standing problems collaborating with  DOD on managing medications during veterans’ readjustments. As early  as, 2002, we found there was an increased risk for patient medication  errors because VA and DOD had separate and uncoordinated information  and formulary systems—lists of available medicines. We recommended  that VA and its partner improve its capabilities for sharing electronic  information. VA had agreed with our recommendations and in fiscal  2007 it had started to deploy a system to view patient medication and  allergy information. However, in 2003, we reported that VA and DOD  providers and pharmacists were still unable to electronically access  health information to aid in making medication decisions for veterans,  such as verifying drug allergies and interactions. A decade later, in  2013, we again found that VA’s and DOD’s efforts in managing  servicemember medications during their transition of care were somewhat  limited because not all DOD military treatment facilities offered such  transition assistance. We recommended that VA and DOD identify and  apply best practices for managing servicemembers’ medication needs  during transitions of care. While both agencies agreed with our  recommendations, VA and DOD did not identify any actions to address  them. During our site visits, one veteran at a medical facility told us how  medications that were prescribed by DOD medical staff were not  forwarded to VA, resulting in him being prescribed different medications.  As our previous work has found, medication management is critical to  effective continuity of care for servicemembers transitioning out of the  military because of the potential adverse health effects that could arise if  not taken as intended.
section_title: Agency Officials and Veterans Report a Range of Challenges and Opportunities to Better Support Readjusting Veterans
paragraphs: During our interviews with agency officials and discussions with veterans  and other stakeholder groups, we heard a number of challenges that VA  faces in helping veterans during the readjustment experience. First,  although VA has an agreement with DOD to let VA know when  servicemembers are leaving the military, some VA officials told us it can  be difficult to identify recently separated veterans, including those who  may be experiencing readjustment difficulties, because they did not know  who was leaving the military. Second, at two of the sites we visited,  veterans we spoke with told us they separated too quickly from the  military without the time they needed to prepare for certain aspects of  civilian life, such as finding a job, making sure they were financially  stable, or becoming better acquainted with what VA offered. Third, we  repeatedly heard from VA official and veterans that some veterans may  hesitate to use VA services. For example, officials at one site we visited  told us that some younger veterans do not want to be diagnosed as  having PTSD because it will keep them from entering certain civilian  careers, such as homeland security. Officials at two of the sites we visited  told us that some veterans try to manage their own issues or problems,  instead of seeking assistance. At one of the sites we visited, veterans told  us they hesitated to enroll in VA services because they did not want to  ask for help. Lastly, VA officials told us that despite an increased effort to  educate National Guard and Reserve members, before and after they  demobilize, some are likely being missed. Should these veterans not  receive VA’s assistance in a timely way, any difficulties they may be  experiencing during their readjustment to civilian life may worsen.
In light of the difficulties we heard, several VA officials suggested ways  that VA could improve its support to veterans with an elevated risk of  experiencing a difficult readjustment. First, some called for additional VA  research. At one site we visited, VA officials suggested there were  opportunities to research ways to identify individuals who are predisposed  to PTSD as well as conducting a study on reasons veterans are not using  VA services. Second, in discussing the issue of the speed of transition out  of the military, VA officials at one site we visited suggested establishing a  “buffer zone” that would allow servicemembers time to readjust to being a  civilian, before they are discharged from the military. Such a buffer zone  has the potential to enhance VA’s ability to reach out to servicemembers  before they become veterans, assess their needs, and prepare the  appropriate services for when they leave. While this effort would need to  be developed and coordinated with DOD, veterans at all of the sites we  visited noted that having time to adjust to the idea of being a civilian and  relearning what civilian life is like would be beneficial.
Consistent with the importance that VA’s strategic plan places on  veterans’ success after leaving military service, the opportunity to  possibly better serve veterans at risk for having readjustment difficulties  could also be informed by the approach VA takes to support ill and injured  veterans. For example, veterans who enter the OEF/OIF/OND Care  Coordination Program receive a full mental health assessment. These  assessments inform case managers about the difficulties veterans are  facing and helps inform where they refer veterans for further assistance.  Senior VA officials told us the assessments conducted by the  OEF/OIF/OND Care Coordination Program can be used as gateways to  provide veterans, who are experiencing difficulties such as, TBI,  depression, and alcohol abuse, with an integrated treatment approach.  These officials added that the goal is to treat veterans holistically, rather  than offering mental, physical and social work care separately. Similarly,  the FRCP was designed to coordinate clinical and nonclinical services for  the most seriously wounded, ill, or injured. Servicemembers and veterans  who are enrolled in the program are offered assistance with developing a  plan that sets recovery goals and then guides them through the  continuum of care of medical treatment and stabilization, rehabilitation,  and community reintegration. FRCP employs dedicated care coordinators  to guide servicemembers, veterans, and their families through the  complex systems of health care, services, and benefits provided by DOD,  VA, other federal agencies, and the private sector. To the extent that VA  does not consider this approach for veterans likely to experience difficult  transitions, especially those with known risk factors, some veterans may  be left to themselves to deal with the after effects of combat. Importantly,  some veterans we spoke with said that obtaining support early in the  readjustment process is crucial because veterans who receive assistance  immediately after separating from the military may have a better chance  of achieving a successful readjustment. According to Standards for  Internal Control in the Federal Government, agencies should identify  risks, estimate the risk’s significance, assess the likelihood of its  occurrence, and decide how to manage the risk and what actions should  be taken.is not occurring as early as possible, VA could be missing an opportunity  to use its resources most efficiently and effectively. That is, if veterans do  not receive the fullness—or any—of the support they need, the difficulties  that emerge early in the readjustment process may worsen, resulting in  potentially greater harm to the veteran and putting the agency at risk for  an increase in the amount of resources it must then provide in the  veteran’s readjustment process.
section_title: Conclusions
paragraphs: As over 1 million servicemembers separate from the military over the next  6 years, many will rely upon the programs administered by VA for support  during their transition. For some veterans, this transition will go smoothly  and without major difficulty. For others, however, the first few years after  they leave the military will be difficult. Even though hundreds of articles,  studies, and reports have been written about the experiences of veterans,  relatively few discuss how recently separated veterans are adjusting to  civilian life, and the issue of how well veterans are faring is still not well  understood. Meanwhile, despite VA’s network of outreach efforts and the  range of benefits and services it administers, many veterans continue to  struggle to access support, and the agency continues to face long- standing challenges in providing benefits in a timely manner. And, while  the Transition Assistance Program may help identify some of those at risk  for having a difficult readjustment, the program does not cover the  breadth of issues many veterans face once they leave the military. As a  result, some veterans who need support may be missed. However, until  VA has a better understanding of the needs of recently-separated  veterans, and which veterans may be more likely to face difficulties, it is  difficult to know what steps VA should take. For instance, if many  veterans face multiple problems that need to be addressed across its  organizational boundaries, from health care, disability, and employment  services, then more coordinated case management services may be  needed. If veterans wait too long to seek out the help they need, then an  effort to identify and target veterans for early intervention may be needed.  If VA discovers severe struggles exist among a relatively narrow but  identifiable small group of veterans during the initial years of civilian life,  then VA is better positioned to take an early and cost-effective approach  to helping rebuild lives. For veterans, having timely access to programs  and services may improve their chances of having positive health,  economic, and social outcomes. For VA, better-supported veterans may  be less likely to end up in need of more intensive care and case  management services over time, which would put less strain on VA’s  limited resources.
section_title: Recommendation for Executive Action
paragraphs: We recommend that the Secretary of Veterans Affairs take steps to better  understand both the difficulties faced by readjusting veterans and the  characteristics of those who may be more likely to face such difficulties,  and use the results to determine how best to enhance its benefits and  services to these veterans.
section_title: Agency Comments and Our Evaluation
paragraphs: We provided a draft of this report to VA for review and comment. In its  written comments, reproduced in appendix II, VA generally agreed with  our conclusions and concurred with our recommendation. VA also  described its recent efforts and plans for improvement. For example, VA  described its implementation of recent changes to the Transition  Assistance Program, now known as the Transition Goals, Plans, Success  program, and its plans to use an upcoming longitudinal evaluation to  inform policy changes and program improvements. VA also provided  technical comments that were incorporated, as appropriate.
We are sending copies of this report to appropriate congressional  committees, the Secretary of Veterans Affairs, and other interested  parties. In addition, the report is available at no charge on the GAO  website at http://www.gao.gov.
If you or your staff have questions about this report, please contact me at  (202) 512-7215 or bertonid@gao.gov. Contact points for our Offices of   Congressional Relations and Public Affairs may be found on the last page  of this report. Key contributors to this report are listed in appendix III.
section_title: Appendix I: Objectives, Scope, and Methodology
paragraphs: The objectives of this review were to examine what is known about (1) the  extent to which veterans experience difficulties during their readjustment  to civilian life, and (2) how VA assists veterans in their readjustment, and  what challenges and opportunities exist. To address these objectives, we  conducted a literature search, interviewed relevant officials from VA and  DOD, reviewed VA’s strategic plan, annual performance reports, and  other documents, visited four locations with VA facilities, and held eight  discussion groups with 45 veterans and family members. We also  interviewed national representatives from the Wounded Warrior Project  and Disabled American Veterans. We focused on the initial readjustment  period, and for the purposes of this review defined it as the first 5 years  after a veteran separates from the military. The scope of this review was  active, reserve, and National Guard OEF/OIF/OND-era veterans who  separated from military service after September 11, 2001. Active  servicemembers and veterans of the Coast Guard were outside the scope  of this study. While the readjustment period for each veteran may vary,  and some may continue to experience difficulties beyond the first few  years, we focused our review on the initial readjustment period.
subsections: section_title: Literature Search
paragraphs: We conducted an extensive search for studies on the difficulties faced by  readjusting veterans, and then screened the studies in two phases. The  purpose of the first phase was to identify the range and types of  difficulties experienced by post-9/11 veterans in the first few years after  they separated from the military. The purpose of the second phase was to  identify the percentage of veterans who experienced each difficulty we  identified, and the characteristics of the veterans who experienced them.
We conducted electronic searches of over 30 databases. Key databases  searched include ArticleFirst, CINAHL, Electronic Collections Online,  Education Resources Information Center, MEDLINE, National Technical  Information Service, PolicyFile, ProQuest, PsycINFO, SciSearch, Social  Sciences Abstracts, Sociological Abstracts, and WorldCat. We searched  for English-language documents published between September 2001 and  May 2013, using Boolean search phrases designed to capture difficulties  experienced by veterans within our scope, including variations of the  words “veteran”, “challenge”, “problem”, “civilian”, “transition”, “discharge”,  “return”, “re-entry” or “re-integration”, “Iraq”, Afghanistan”, “Enduring  Freedom”, and “war on terror”, From these sources, we identified 401  documents that were potentially relevant to our review.
For the first phase, we reviewed the titles and abstracts for each of the  401 documents and for additional documents we identified by searching  GAO and the Congressional Research Service’s report databases and  conducting general Internet searches. We looked for common themes  and developed a list of issues or themes about veterans’ readjustment  difficulties. One analyst performed these review tasks, and then another  analyst verified the results. They discussed any disagreements on the  reviews, screenings, and themes, and worked with a third analyst to  resolve any remaining disagreements. We presented this list to VA  officials and veterans during our interviews and site visits and asked  whether we had identified the types of difficulties faced by recently  transitioned veterans. In general, the officials and veterans agreed that  our list captured the range and types of difficulties faced by recently  transitioned veterans, and we made a few additions based on these  interviews.
For the second phase, we screened out documents that were not  published books, peer-reviewed journals, state or federal government  reports, or reports from associations and research organizations (e.g.,  RAND). We started with the same 401 documents from our original  literature search and screened out 114 documents that were from the  following sources: unpublished papers, dissertations and theses, general  news articles, conference papers, and hearings.
We reviewed the titles and abstracts of the remaining 287 documents and  excluded 179 that focused exclusively on out-of-scope individuals or  unambiguously used methods that would not provide relevant prevalence  information. Our screening criteria also excluded articles that did not  report data from the population relevant to this engagement (U.S. military  veterans who had already transitioned from the military to civilian life after  2001); collected data from case studies, focus groups, or other qualitative  methods or in a single U.S. county or city; or were non-empirical theory or  opinion articles. Two analysts (one with content expertise and one with  methodological expertise) independently reviewed each document’s title  and abstract according to a detailed coding manual to indicate whether it  should be included for further review or excluded based on one of the  screening criteria. Initial disagreements between analysts were resolved  through discussion. When in doubt, a document was included rather than  excluded during this abstract review.
We then reviewed the remaining 108 documents in a more detailed  screening step. Two analysts with the same mix of expertise as above  reviewed the complete documents and excluded articles that did not meet  any of the screening criteria above, did not report any quantitative data  relevant to our review, or did not report data for recently-transitioned  veterans (i.e., those who had transitioned from the military to civilian life  within 5 years previous to the start of the study’s data collection).  Additionally, documents that included reviews of the literature but did not  collect new data (referred to as “review articles” hereafter) were cataloged  but excluded at this stage. Initial coding disagreements between analysts  were resolved through discussion. When in doubt, a document was  included rather than excluded during this step. Only 13 documents met all  our screening criteria for a full review.
We then examined the bibliographies of those 13 documents along with  the bibliographies of 24 review articles and identified 136 additional  potentially relevant documents. Then, using the same exclusion criteria  noted above, one analyst coded each document and a second analyst  reviewed each document and concurred or did not concur with the initial  coding. Disagreements were resolved through discussion. When in doubt,  a document was included rather than excluded at this step. We excluded  124 of these documents, which resulted in 12 additional documents to  fully review.
Two analysts then conducted a full review of the 25 documents (13 from  the original search and 12 from the second search) to extract relevant  prevalence and characteristic information and identify important caveats  for our uses of the results. We excluded an additional seven documents  during our full review stage, thus leaving 18 of them that met our inclusion  criteria. The studies that were included are shown in table 2. We have  described the limitations of the results for our use of individual studies  within the body of this report.
section_title: Visits to VA Facilities
paragraphs: We visited VA facilities in four locations across the United States. We  selected the locations based on a number of factors including; geographic  diversity, a mix of military services with bases in the area (i.e., Army,  Navy, Air Force, or Marines), a high concentration of veterans among the  local population, and close proximity to VA facilities. At each of the  selected locations, we visited one VA Medical Center and one Vet Center.  In three of the four locations, we visited VA regional offices that were  closest to the VA Medical Center. At the VA Medical Centers, we spoke  with officials from the OEF/OIF/OND Care Coordination Program and the  Post Deployment Integrated Care Initiative as these programs specifically  serve readjusting veterans. Similarly, Vet Centers serve readjusting  veterans, and at each of those facilities we spoke with counselors and  senior Vet Center staff. At the regional offices we spoke with officials from  Disability Compensation, Vocational Rehabilitation and Employment  (VR&E), homeless coordinator programs as well as senior regional office  officials. We included Disability Compensation and VR&E because these  programs serve large numbers of veterans, including readjusting  veterans. We included homeless coordinators because VA offers specific  programs for veterans at risk of becoming homeless, which is one of the  difficulties we identified through our initial research.
At each VA Medical Center and Vet Center, we conducted  nongeneralizable discussion groups with veterans to gain a better  understanding of their experiences with readjusting to civilian life. VA  officials from each center invited veterans who had separated from the  military within the last few years and who served during the OEF/OIF era  (since September 11, 2001). At each location we visited we conducted  two group discussions with veterans with between two and eight veterans  attending each discussion. At two of the discussion groups, family  members were present and a total of 45 veterans and family members  participated. At the start of each discussion group we asked the veterans  to rate how well they felt prepared for their transition from military to  civilian life. We also asked them to rate the level of difficulty they had with  employment, getting the right health care, being healthy, going back to  school, getting along with family and friends, managing finances, getting  assistance from VA, avoiding legal trouble, and finding a place to live. We  used their responses to guide the discussions to gain a qualitative  understating for why veterans experienced difficulties with their  readjustment and what VA could do to better assist them. We conducted  interviews with representatives from veteran service organizations at  three of the four locations we visited because of their experience in  working with veterans including representatives from American Legion,  AmVets, Disabled American Veterans, the Military Order of the Purple  Heart and Veterans of Foreign Wars.
We conducted this performance audit from March 2013 to September  2014 in accordance with generally accepted government auditing  standards. These 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: Comments from the Department of Veterans Affairs
section_title: Appendix III: GAO Contact and Staff Acknowledgments
subsections: section_title: GAO Contact
section_title: Staff Acknowledgments
paragraphs: In addition to the contact named above, Brett Fallavollita (Assistant  Director); Paul Schearf (Analyst-In-Charge), Janina Austin, David  Chrisinger, Lorraine Ettaro, Jeffrey Fiore, David Forgosh, Ashley McCall,  Sheila McCoy, Michael Silver, Almeta Spencer, Roger Thomas, Karin  Wallestad, James Whitcomb, and Paul Wright made key contributions to  this report.
section_title: Related GAO Products
paragraphs: Military Sexual Trauma: Improvements Made, but VA Can Do More to  Track and Improve the Consistency of Disability Claim Decisions.   GAO-14-477. Washington, D.C.: June 9, 2014.
VA Education Benefits: VA Should Strengthen Its Efforts to Help Veterans  Make Informed Education Choices. GAO-14-324. Washington, D.C.:   May 13, 2014.
Transitioning Veterans: Improved Oversight Needed to Enhance  Implementation of Transition Assistance Program. GAO-14-144.  Washington, D.C.: March 5, 2014.
VA Education Benefits: Student Characteristics and Outcomes Vary  across Schools. GAO-13-567. Washington, D.C.: July 25, 2013.
VA Health Care: Additional Steps Needed to Strengthen Beneficiary  Travel Program Management and Oversight. GAO-13-632. Washington,  D.C.: July 15, 2013.
VA Education Benefits: VA Needs to Improve Program Management and  Provide More Timely Information to Students. GAO-13-338. Washington,  D.C.: May 22, 2013.
Electronic Health Records: Long History of Management Challenges  Raises Concerns about VA’s and DOD’s New Approach to Sharing  Health Information. GAO-13-413T. Washington, D.C.: February 27, 2013.
VA Health Care: Reliability of Reported Outpatient Medical Appointment  Wait Times and Scheduling Oversight Need Improvement. GAO-13-130.  Washington, D.C.: December 21, 2012 (and related testimonies,   GAO-13-363T, February 13, 2013; and GAO-14-679T, June 9, 2014).
Veteran Homelessness: VA and HUD Are Working to Improve Data on  Supportive Housing Program. GAO-12-726. Washington, D.C.: June 26,  2012.
Veterans’ Disability Benefits: Timely Processing Remains a Daunting  Challenge. GAO-13-89. Washington, D.C.: December 21, 2012 (and  related testimony, GAO-13-453T, May 13, 2013).
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.
DOD and VA Health Care: Medication Needs during Transitions May Not  Be Managed for All Servicemembers. GAO-13-26. Washington, D.C.:  November 2, 2012.
VA and DOD Health Care: Department-Level Actions Needed to Assess  Collaboration Performance, Address Barriers, and Identify Opportunities.  GAO-12-992. Washington, D.C.: September 28, 2012.
Defense Health: Coordinating Authority Needed for Psychological Health  and Traumatic Brain Injury Activities. GAO-12-154. Washington, D.C.:  January 25, 2012.
Homeless Women Veterans: Actions Needed to Ensure Safe and  Appropriate Housing. GAO-12-182. Washington, D.C.: December 23,  2011.
VA Mental Health: Number of Veterans Receiving Care, Barriers Faced,  and Efforts to Increase Access. GAO-12-12. Washington, D.C.: October  14, 2011.
Veterans’ Education Benefits: Enhanced Guidance and Collaboration  Could Improve Administration of the Post-9/11 GI Bill Program.   GAO-11-356R. Washington, D.C.: May 5, 2011.
DOD and VA Health Care: Federal Recovery Coordination Program  Continues to Expand but Faces Significant Challenges. GAO-11-250.  Washington, D.C.: March 23, 2011.
VA Education Benefits: Actions Taken, but Outreach and Oversight Could  Be Improved. GAO-11-256. Washington, D.C.: February 28, 2011.
VA Health Care: VA Spends Millions on Post-Traumatic Stress Disorder  Research and Incorporates Research Outcomes into Guidelines and  Policy for Post-Traumatic Stress Disorder Services. GAO-11-32.  Washington, D.C.: January 24, 2011.
VA Health Care: Reporting of Spending and Workload for Mental Health  Services Could Be Improved. GAO-10-570. Washington, D.C.: May 28,  2010.
VA Health Care: VA Has Taken Steps to Make Services Available to  Women Veterans, but Needs to Revise Key Policies and Improve  Oversight Processes. GAO-10-287. Washington, D.C.: March 31, 2010.
Veterans’ Disability Benefits: VA Has Improved Its Programs for  Measuring Accuracy and Consistency, but Challenges Remain.   GAO-10-530T. Washington, D.C.: March 24, 2010.
Recovering Servicemembers: DOD and VA Have Made Progress to  Jointly Develop Required Policies but Additional Challenges Remain.  GAO-09-540T. Washington, D.C.: April 29, 2009.
VA National Initiatives and Local Programs that Address Education and  Support for Families of Returning Veterans. GAO-09-22R. Washington,  D.C.: October 22, 2008.
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.
Military and Veterans’ Benefits: Enhanced Services Could Improve  Transition Assistance for Reserves and National Guard. GAO-05-544.  Washington, D.C.: May 20, 2005.
DOD and VA: Systematic Data Sharing Would Help Expedite  Servicemembers’ Transition to VA Services. GAO-05-722T. Washington,  D.C.: May 19, 2005.