Recovering Servicemembers: DOD and VA Have Jointly Developed the Majority of Required Policies but Challenges Remain
Published: 2009-07-08T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: The National Defense Authorization Act for Fiscal Year 2008 (NDAA 2008) requires the Departments of Defense (DOD) and Veterans Affairs (VA) to jointly develop and implement comprehensive policies on the care, management, and transition of recovering servicemembers. The Wounded, Ill, and Injured Senior Oversight Committee (SOC)--jointly chaired by DOD and VA leadership--has assumed responsibility for these policies. The NDAA 2008 also requires GAO to report on the progress DOD and VA make in jointly developing and implementing the policies. This report focuses on the joint development of the policies. Implementation of the policies will be addressed in future reports. Specifically, this report provides information on (1) the progress DOD and VA have made in jointly developing the comprehensive policies required by the NDAA 2008 and (2) the challenges DOD and VA are encountering in the joint development of these policies. GAO determined the current status of policy development by assessing the status reported by SOC officials and analyzing supporting documentation. To identify challenges, GAO interviewed the Acting Under Secretary of Defense for Personnel and Readiness, the Executive Director and Chief of Staff of the SOC, the departmental co-leads for most of the SOC work groups, the Acting Director of DOD's Office of Transition Policy and Care Coordination, and other knowledgeable officials.
section_title: What GAO Found
paragraphs: DOD and VA have made substantial progress in jointly developing policies required by sections 1611 through 1614 of the NDAA 2008 in the areas of (1) care and management, (2) medical and disability evaluation, (3) return to active duty, and (4) transition of care and services received from DOD to VA. Overall, GAO's analysis showed that as of April 2009, 60 of the 76 policy requirements GAO identified have been completed and the remaining 16 policy requirements are in progress. DOD and VA have completed all of the policy development requirements for medical and physical disability evaluations, including issuing a report on the feasibility and advisability of consolidating the DOD and VA disability evaluation systems, although the pilot for this approach is still ongoing. DOD has also completed establishing standards for returning recovering servicemembers to active duty. More than two-thirds of the policy development requirements have been completed for the remaining two policy areas--care and management and the transition of recovering servicemembers from DOD to VA. Most of these requirements were addressed in a January 2009 DOD memorandum that was developed in consultation with VA. DOD officials reported that more information will be provided in a subsequent policy instruction, which is to be issued in August 2009. VA also plans to issue related policy guidance in the fourth quarter of 2009. DOD and VA officials told GAO that they have experienced numerous challenges as they worked to jointly develop policies to improve the care, management, and transition of recovering servicemembers. According to officials, these challenges contributed to the length of time required to issue policy guidance, and in some cases the challenges have not yet been completely resolved. For example, the SOC must still standardize key terminology relevant to policy issues affecting recovering servicemembers. DOD and VA agreement on key definitions for what constitutes "mental health," for instance, is important for developing policies that define the scope, eligibility, and service levels for recovering servicemembers. Recent changes affecting the SOC may also pose future challenges to policy development. Some officials have expressed concern that DOD's recent changes to staff supporting the SOC have disrupted the unity of command because SOC staff now report to three different officials within DOD and VA. However, it is too soon to determine how well DOD's staffing changes will work. Additionally, according to DOD and VA officials, the SOC's scope of responsibilities appears to be in flux. While the SOC will remain responsible for policy matters for recovering servicemembers, a number of policy issues may now be directed to the DOD and VA Joint Executive Council. Despite this uncertainty, DOD and VA officials told GAO that the SOC's work groups continue to carry out their roles and responsibilities. GAO provided a draft of this report to DOD and VA for comment. VA provided technical comments, which GAO incorporated as appropriate. DOD and VA did not provide other comments.

section_title: Letter
paragraphs: Over 1.6 million U.S. troops have deployed in Operation Enduring  Freedom (OEF) and Operation Iraqi Freedom (OIF) since October 2001.  In May 2009, the Department of Defense (DOD) reported that over 34,000  servicemembers have been wounded in action since the onset of these  conflicts. Because of improved battlefield medicine, those who might  have died in past conflicts are now surviving, many with multiple serious  injuries such as amputations, traumatic brain injury (TBI), and post- traumatic stress disorder (PTSD). Beyond adjusting to their injuries,  recovering servicemembers may face additional challenges, including  difficulties managing their outpatient recovery process, difficulties  navigating the military’s disability evaluation system, and problems  transitioning between care provided by DOD and care provided by the  Department of Veterans Affairs (VA).
Questions were raised in the media and by Congress about whether DOD  and VA are prepared to meet the needs of the increasing number of  recovering servicemembers and veterans. In February 2007, a series of  Washington Post articles disclosed deficiencies in the provision of  outpatient services at Walter Reed Army Medical Center, including poor  living conditions at Walter Reed, a confusing disability evaluation system,  and servicemembers remaining in outpatient status for months and  sometimes years without a clear understanding about their plan of care or  the future of their military service. Various review groups investigated the  challenges that DOD and VA faced in providing care to recovering  servicemembers and made a number of recommendations to address the  problems they identified. Shortly after the media disclosures, we testified  about the challenges facing recovering servicemembers during their  recovery process.
In May 2007, DOD and VA established the Wounded, Ill, and Injured Senior  Oversight Committee (SOC) to address the problems that had been  identified with the care of recovering servicemembers. The committee is  co-chaired by the Deputy Secretaries of DOD and VA and includes military  service Secretaries and other high-ranking officials within both  departments. One of the SOC’s primary responsibilities is to oversee the  development of policies in response to the recommendations of the review  groups that studied the issues associated with recovering servicemembers’  health care and benefits. SOC officials sign and issue interim policy  guidance, which is then developed by DOD and VA into finalized policies.  Although DOD and VA consider the SOC’s policies to be official, in this  report we refer to them as interim because they must still be finalized and  implemented by DOD and VA.
The National Defense Authorization Act for Fiscal Year 2008 (NDAA 2008),  which was enacted in January 2008, requires DOD and VA, to the extent  feasible, to jointly develop and implement a comprehensive policy on  improvements to the care, management, and transition of recovering  servicemembers. Specifically, section 1611(a) of the NDAA 2008 directs  DOD and VA to cover four key areas—(1) care and management,   (2) medical evaluation and disability evaluation, (3) the return of  servicemembers to active duty, and (4) the transition of recovering  servicemembers from DOD to VA. Because of the related ongoing work of  the SOC, it assumed responsibility for addressing these requirements. The  NDAA 2008 also requires that we report on the progress DOD and VA  make in developing and implementing the comprehensive policy. This  report is focused on the status of the development of the comprehensive  policy, which includes the development of multiple policies that are  further enumerated in sections 1611 through 1614 of the law.
Implementation of the policies will be addressed in a series of future  reports.
Specifically, we assessed (1) the progress DOD and VA have made in  jointly developing comprehensive policies for recovering servicemembers  in the areas of care and management, medical and disability evaluation,  return to active duty, and transition from care and services received from  DOD to VA as required by sections 1611 through 1614 of the NDAA 2008  and (2) the challenges DOD and VA are encountering in the joint  development of these policies. We testified on these issues on April 29,  2009, before the Personnel Subcommittee of the Senate Armed Services  Committee.
To assess the extent to which DOD and VA have made progress in  developing the required policies, we asked SOC representatives to report  on the status of policy development for the 76 individual requirements that  we identified in sections 1611 through 1614 of the NDAA 2008, which we  grouped into 14 categories. (See app. I for a summary of these  requirements and categories.) We also asked the SOC representatives to  provide documentation to substantiate the status of each requirement, and  we verified the reported status of each requirement by reviewing this  documentation. We determined whether each of the requirements (1) had  been completed, (2) was in progress, or (3) had not been acted upon. We  considered a requirement to have been “completed” if a document had  been signed and approved by DOD, VA, or both, at the SOC level, that  contained standards, guidelines, or procedures that addressed the  requirement, even if DOD, VA, or both plan to issue additional policies on  the subject. We considered a requirement to be “in progress” if  documentation demonstrated that work had been initiated to develop  standards, guidelines, or procedures that addressed the requirement. We  considered a requirement not to have been acted upon if no action had  been taken to develop standards, guidelines, or procedures that addressed  the requirement. We based our review in part on the interim policy  documents signed by DOD and VA officials working through the SOC. In  some cases, interim policy documents were signed by officials of both  departments, and in other cases, the documents were signed by officials of  one department, depending upon the requirement. Interim policy  documents could be in the form of memoranda of agreement, memoranda  of understanding, directives, decision- or directive-type memoranda,  instructions or policy memoranda, or other guidelines or forms of  guidance. In addition, we conducted follow-up interviews with DOD and  VA officials when we needed clarification on the reported progress or  additional documentation. We did not, however, evaluate the quality of the  policy documents we reviewed or the extent to which these policies have  been implemented. To identify the challenges DOD and VA encountered in  jointly developing the required policies, we interviewed officials from both  departments to obtain an account of their experiences in the policy  development process. In conducting our work, we interviewed the Acting  Under Secretary of Defense for Personnel and Readiness, the Executive  Director and Chief of Staff of the SOC, the departmental co-leads for most  of the SOC work groups, the Acting Director of DOD’s Office of Transition  Policy and Care Coordination, and other knowledgeable DOD and VA  officials.
The NDAA 2008 also requires us to certify whether we had timely access  to sufficient information to make informed judgments on the matters  covered by our report. We were provided sufficient information in a timely  manner to assess DOD and VA’s progress in jointly developing policies as  well as the challenges DOD and VA are encountering in developing  policies.
We conducted our work from May 2008 through July 2009 in accordance  with all sections of GAO’s Quality Assurance Framework that are relevant  to our objectives. The framework requires that we plan and perform the  engagement to obtain sufficient and appropriate evidence to meet our  stated objectives and to discuss any limitations in our work. We believe  that the information and data obtained, and the analysis conducted,  provide a reasonable basis for any findings and conclusions in this  product.
subsections: section_title: Background
paragraphs: Over the past 8 years, DOD has designated over 34,000 servicemembers  involved in OEF and OIF as wounded in action. The severity of injuries  can result in a lengthy process for a patient to either return to duty or to  transition to veteran status. The most seriously injured servicemembers  from these conflicts usually receive care at Walter Reed Army Medical  Center or the National Naval Medical Center. According to DOD officials,  once they are stabilized and discharged from the hospital, servicemembers  may relocate closer to their homes or military bases and be treated as  outpatients by the closest military or VA facility.
Recovering servicemembers potentially navigate two different disability  evaluation systems that serve different purposes. DOD’s system serves a  personnel management purpose by identifying servicemembers who are  no longer medically fit for duty. If a servicemember is found unfit because  of medical conditions incurred in the line of duty, the servicemember is  assigned a disability rating and can be discharged from duty. This  disability rating, along with years of service and other factors, determines  subsequent disability and health care benefits from DOD. Under VA’s  system, disability ratings help determine the level of disability  compensation a veteran receives and priority status for enrollment for  health care benefits. To determine eligibility for disability compensation,  VA evaluates all claimed medical conditions, whether they were evaluated  previously by the military service’s evaluation process or not. If VA finds  that a veteran has one or more service-connected disabilities that together  result in a final rating of at least 10 percent, VA will pay monthly  compensation and the veteran will be eligible to receive a higher priority  status for health care benefits enrollment.
subsections: section_title: Efforts to Address the Care and Benefits for Recovering Servicemembers
paragraphs: Efforts have been taken to address the deficiencies reported at Walter  Reed related to the care provided and the transition of recovering  servicemembers. After the press reports about Walter Reed, several high- level review groups were established to study the care and benefits  provided to recovering servicemembers by DOD and VA. In addition, two  previously-established review groups were already examining related  issues. The studies produced from all of these groups, released from   April 2007 through June 2008, contained over 400 recommendations  covering a broad range of topics, including case management, disability  evaluation systems, data sharing between the departments, and the need  to better understand and diagnose TBI and PTSD.
In May 2007, DOD and VA established the SOC as a temporary, 1-year  committee with the responsibility for addressing recommendations from  these reports. To conduct its work, the SOC established eight work groups  called lines of action (LOA). Each LOA is co-chaired by representatives  from DOD and VA and has representation from each military service. LOAs  are responsible for specific issues, such as disability evaluation systems  and case management. (See table 1 for an overview of the LOAs.) The  committee was originally intended to expire May 2008 but it was extended  to January 2009. Then, the NDAA 2009 extended the SOC through  December 2009.
In addition to addressing the published recommendations, the SOC  assumed responsibility for addressing the policy development and  reporting requirements contained in the NDAA 2008. Section 1611(a) of  the NDAA 2008 directs DOD and VA, to the extent feasible, to develop and  implement a comprehensive policy covering four areas—(1) care and  management, (2) medical evaluation and disability evaluation, (3) the  return of servicemembers to active duty, and (4) the transition of  recovering servicemembers from DOD to VA. The specific requirements  for each of these four areas are further enumerated in sections 1611  through 1614 of the law and include the development of multiple policies.  Table 2 summarizes the requirements for the jointly developed policies.
section_title: Selected Initiatives of the SOC
paragraphs: Since its inception, the SOC has completed many initiatives, such as  establishing the Defense Centers of Excellence for Psychological Health  and Traumatic Brain Injury and creating a National Resource Directory,  which is an online public resource for recovering servicemembers,  veterans, and their families. In addition, the SOC supported the  development of several programs to improve the care, management, and  transition of recovering servicemembers, including the disability  evaluation system pilot and the Federal Recovery Coordination Program.  These programs are currently in pilot or beginning phases.
Disability evaluation system pilot: DOD and VA are piloting a joint  disability evaluation system to improve the timeliness and resource use of  their separate disability evaluation systems. Key features of the pilot  include a single physical examination conducted to VA standards to be  used by a medical evaluation board to document medical conditions that  may limit a servicemember’s ability to serve in the military, a single source  disability rating prepared by VA for use by both DOD and VA in  determining disability benefits, and additional outreach and nonclinical  case management provided by VA staff at the DOD pilot locations to  explain VA results and processes to servicemembers. DOD and VA  anticipate a final report on the pilot in August 2009.
Federal Recovery Coordination Program: In 2007, DOD and VA  established the Federal Recovery Coordination Program in response to the  report by the President’s Commission on Care for America’s Returning  Wounded Warriors, commonly referred to as the Dole-Shalala  Commission. The commission’s report highlighted the need for better  coordination of care and additional support for families. The Federal  Recovery Coordination Program serves the most severely injured or ill  servicemembers. These servicemembers are highly unlikely to be able to  return to duty and may have to adjust to permanent disabling conditions.  The program was created to provide uniform and seamless care,  management, and transition of recovering servicemembers and their  families by assigning recovering servicemembers to coordinators who  manage the development and implementation of a recovery plan. Each  servicemember enrolled in the Federal Recovery Coordination Program  has a Federal Individual Recovery Plan, which tracks care, management,  and transition through recovery, rehabilitation, and reintegration.  Although the Federal Recovery Coordination Program is operated as a  joint DOD and VA program, VA is responsible for the administrative duties  and program personnel are employees of the agency.
Beyond these specific initiatives, the SOC took responsibility for issues  related to electronic health records through the work of LOA 4, the SOC’s  work group focused on DOD and VA data sharing. This LOA also  addressed issues more generally focused on joint DOD and VA data needs,  including overseeing the development of components for the disability  evaluation system pilot and the individual recovery plans for the Federal  Recovery Coordination Program. LOA 4’s progress on these issues was  monitored and overseen by the SOC. The NDAA 2008 established an  interagency program office (IPO) to serve as a single point of  accountability for both departments in the development and  implementation of interoperable electronic health records.  Subsequently, management oversight of many of LOA 4’s responsibilities  were transferred to the IPO. Also, the IPO’s scope of responsibility was  broadened to include personnel and benefits data sharing between DOD  and VA.
section_title: DOD and VA Have Completed the Majority of the Requirements to Jointly Develop Policies on Care and Management, Medical and Disability Evaluation, Return to Active Duty, and the Transition from DOD to VA
paragraphs: As of April 2009, DOD and VA have completed 60 of the 76 requirements  we identified for jointly developing policies for recovering  servicemembers on (1) care and management, (2) medical and disability  evaluation, (3) return to active duty, and (4) servicemember transition  from DOD to VA. The two departments have completed all requirements  for developing policy for two of the policy areas—medical and disability  evaluation and return to active duty. Of the 16 requirements that are in  progress, 10 are related to care and management and 6 are related to  servicemembers transitioning from DOD to VA. (See table 3.)
subsections: section_title: DOD and VA Have Completed More Than Two-Thirds of the Requirements for the Care and Management of Recovering Servicemembers
paragraphs: We found that more than two-thirds of the requirements for DOD’s and  VA’s joint policy development to improve the care and management of  recovering servicemembers have been completed, while the remaining  requirements are in progress. (See table 4.) We identified 38 requirements  for this policy area and grouped them into five categories. Although 28 of  the 38 requirements had been completed, one category—improving access  to medical and other health care services—had most of its requirements in  progress.
Most of the completed requirements were addressed in DOD’s January  2009 Directive-Type Memorandum (DTM), which was developed in  consultation with VA. This DTM, entitled Recovery Coordination  Program: Improvements to the Care, Management, and Transition of  Recovering Service Members, establishes interim policy for the  improvements to the care, management, and transition of recovering  servicemembers in response to sections 1611 and 1614 of the NDAA 2008.  In consultation with VA, DOD created the Recovery Coordination Program  in response to the NDAA 2008 requirements. This program, which was  launched in November 2008, extended the same comprehensive  coordination and transition support provided under the Federal Recovery  Coordination Program to servicemembers who were less severely injured  or ill, yet who are unlikely to return to active duty in less than 180 days.  This program follows the same structured process as the Federal Recovery  Coordination Program. However, DOD oversees this program and the  coordinators are DOD employees.
DOD’s January 2009 DTM includes information on the scope and program  elements of the Recovery Coordination Program as well as on the roles  and responsibilities of the recovery care coordinators, federal recovery  coordinators, and medical care case managers and non-medical care  managers. According to DOD officials, DOD took the lead in developing  policy to address the requirements for care and management because it  interpreted most of the requirements to refer to active duty  servicemembers.
According to DOD and VA officials, the January 2009 DTM serves as the  interim policy for care, management, and transition until the completion of  DOD’s comprehensive policy instruction, which is estimated to be  completed by August 2009. This policy instruction will contain more  detailed information on the policies outlined in the DTM. A VA official told  us that VA also plans to issue related policy guidance as part of a VA  handbook during the fourth quarter of 2009. The VA official noted that the  final form of the policy document would correspond with DOD’s  instruction.
section_title: DOD and VA Have Completed All of the Requirements for Developing Policy on the Medical Evaluation and Disability Evaluation of Recovering Servicemembers
paragraphs: DOD and VA have completed all of the requirements for developing policy  to improve the medical and physical disability evaluation of recovering  servicemembers. (See table 5.) We identified 18 requirements for this  policy area and grouped them into three categories: (1) policy for  improved medical evaluations, (2) policy for improved physical disability  evaluations, and (3) reporting on the feasibility and advisability of  consolidating DOD and VA disability evaluation systems.
DOD issued a series of memoranda that addressed the first two categories  starting in May 2007. These memoranda, some of which were developed in  collaboration with VA, contained policies and implementing guidance to  improve DOD’s existing disability evaluation system. To address the third  category in this policy area, DOD and VA have issued a report to Congress  that describes the organizing framework for consolidating the two  departments’ disability evaluation systems and states that the departments  are hopeful that consolidation would be feasible and advisable even  though the evaluation of this approach through the disability evaluation  system pilot is still ongoing. According to a DOD official, further  assessment of the feasibility and advisability of consolidation will be  conducted. DOD and VA anticipate issuing a final report on the pilot in  August 2009. However, as we reported in September 2008, it was unclear  what specific criteria DOD and VA will use to evaluate the success of the  pilot, and when sufficient data will be available to complete such an  evaluation.
section_title: DOD Has Completed Establishing Standards for Determining the Return of Recovering Servicemembers to Active Duty
paragraphs: DOD has completed the requirement for establishing standards for  determining the return of recovering servicemembers to active duty. (See  table 6.)
On March 13, 2008, DOD issued a DTM amending its existing policy on  retirement or separation due to a physical disability. The revised policy  states that the disability evaluation system will be the mechanism for  determining both retirement or separation and return to active duty  because of a physical disability. An additional revision to the existing DOD  policy allows DOD to consider requests for permanent limited active duty  or reserve status for servicemembers who have been determined to be  unfit because of a physical disability. Previously, DOD could consider such  cases only as exceptions to the general policy.
According to a DOD official, it is too early to tell whether the revisions will  have an effect on retirement rates or return-to-duty rates. DOD annually  assesses the disability evaluation system and tracks retirement and return  to duty rates. However, because of the length of time a servicemember  takes to move through the disability evaluation system—sometimes over a  year—it will take a while before changes resulting from the policy  revisions register in the annual assessment of the disability evaluation  system.
section_title: Over Two-Thirds of the Requirements for Improving the Transition of Recovering Servicemembers from DOD to VA Have Been Completed
paragraphs: DOD and VA have completed more than two-thirds of the requirements for  developing procedures, processes, or standards for improving the  transition of recovering servicemembers. (See table 7.) We identified 19  requirements for this policy area, and we grouped them into five  categories. We found that 13 of the 19 policy requirements have been  completed, including all of the requirements for two of the categories—the  development of a process for a joint separation and evaluation physical  examination and development of procedures for surveys and other  mechanisms to measure patient and family satisfaction with services for  recovering servicemembers. The remaining three categories contain  requirements that are still in progress.
Most of the requirements for improving the transition from DOD to VA  were addressed in DOD’s January 2009 DTM—Recovery Coordination  Program: Improvements to the Care, Management, and Transition of  Recovering Service Members—which establishes interim policy for the  care, management, and transition of recovering servicemembers through  the Recovery Coordination Program. However, we found that DOD’s DTM  includes limited detail related to the procedures, processes, and standards  for transition of recovering servicemembers. As a result, we could not  always directly link the interim policy in the DTM to the specific  requirements contained in section 1614 of the NDAA 2008. DOD and VA  officials noted that they will be further developing the procedures,  processes, and standards for the transition of recovering servicemembers  in a subsequent comprehensive policy instruction, which is estimated to  be completed by June 2009. A VA official reported that VA plans to  separately issue policy guidance addressing the requirements for  transitioning servicemembers from DOD to VA in the fourth quarter of  2009.
section_title: DOD and VA Officials Experienced Challenges during Joint Development of Required Policies
paragraphs: DOD and VA officials told us that they experienced numerous challenges  as they worked to jointly develop policies to improve the care,  management, and transition of recovering servicemembers. According to  officials, these challenges contributed to the length of time required to  issue policy guidance, and in some cases the challenges have not yet been  completely resolved. In addition, recent changes to the SOC staff,  including DOD’s organizational changes for staff supporting the SOC,  could pose challenges to the development of policy affecting recovering  servicemembers.
subsections: section_title: Various Challenges Arose during Policy Development
paragraphs: DOD and VA officials encountered numerous challenges during the course  of jointly developing policies to improve the care, management, and  transition of recovering servicemembers, as required by sections 1611  through 1614 of the NDAA 2008, in addition to responding to other  requirements of the law. Many of these challenges have been addressed,  but some have yet to be completely resolved. DOD and VA officials cited  the following examples of issues for which policy development was  particularly challenging.
Increased support for family caregivers. The NDAA 2008 includes a  number of provisions to strengthen support for families of recovering  servicemembers, including those who become caregivers. However, DOD  and VA officials on a SOC work group stated that before they could  develop policy to increase support for such families, they had to obtain  concrete evidence of their needs. Officials explained that while they did  have anecdotal information about the impact on families who provide care  to recovering servicemembers, they lacked the systematic data needed for  sound policy decisions—such as frequency of job loss and the economic  value of family-provided medical services. A work group official told us  that their proposals for increasing support to family caregivers were  rejected twice by the SOC, due in part to the lack of systematic data on  what would be needed. The work group then contracted with researchers  to obtain substantiating evidence, a study that required 18 months to  complete. In January 2009, the SOC approved the work group’s third  proposal. A provision for caregiver benefits based on the SOC’s proposal  was included in the NDAA 2010 bill that was introduced in May 2009.
Establishing standard definitions for operational terms. One of the  important tasks facing the SOC was the need to standardize key  terminology relevant to policy issues affecting recovering servicemembers.  DOD took the lead in working with its military services and VA officials to  identify and define key terms. DOD and VA officials told us that many of  the key terms found in existing DOD and VA policy, the reports from the  review groups, and the NDAA 2008, as well as those used by the different  military services were not uniformly defined. Consequently, standardized  definitions were important to promote agreement on issues such as  identifying the recovering servicemembers who are subject to NDAA  2008 requirements,  identifying categories of servicemembers who would receive services  from the different classes of case managers or be eligible for certain  benefits,    managing aspects of the disability evaluation process, and establishing criteria to guide research.
In some cases, standardized definitions were critical to policy  development. The importance of agreement on key terms is illustrated by  an issue encountered by the SOC’s work group responsible for family  support policy. In this case, before policy could be developed for  furnishing additional support to family members that provide medical care  to recovering servicemembers, the definition of “family” had to be agreed  upon. DOD and VA officials said that they considered two options: to  define the term narrowly to include a servicemember’s spouse, parents,  and children, or to use broader definitions that included distant relatives  and unrelated individuals with a connection to the servicemember. These  two definitions would result in significantly different numbers of family  members eligible to receive additional support services. DOD and VA  officials decided to use a broader definition to determine who would be  eligible for support.
Of the 41 key definitions identified for reconciliation, DOD and VA had  concurred on 33 as of April 2009 and these 33 standardized definitions are  now being used. Disagreement remains over the remaining definitions,  including the definition of “mental health.” A DOD official stated that given  the uncertainty associated with the organizational and procedural changes  recently introduced to the SOC (which are discussed below), obtaining  concurrence on the remaining definitions has been given lower priority.
Improving TBI and PTSD screening and treatment. Requirements related  to screening and treatment for TBI and PTSD were embedded in several  sections of the NDAA 2008, including section 1611, and were also  discussed extensively in a task force report on mental health. DOD and  VA officials told us that policy development for these issues was difficult.  For example, during development of improved TBI and PTSD treatment  policy, policymakers often lacked sufficient scientific information needed  to help achieve consensus on policy decisions. Also, members of the SOC  work group told us that they disagreed on appropriate models for  screening and treatment and struggled to reorient the military services to  patient-focused treatment. A senior DOD official stated that the adoption  of patient-focused models is particularly difficult for the military services  because, historically, the needs of the military have been given precedence  over the needs of individual servicemembers. To address these challenges,  the SOC oversaw the creation of the Defense Centers of Excellence for  Psychological Health and Traumatic Brain Injury—a partnership between  DOD and VA. While policies continue to be developed on these issues, TBI  and PTSD policy remains a challenge for DOD and VA. However, DOD  officials told us that the centers of excellence have made progress with  reducing knowledge gaps in psychological health and TBI treatment,  identifying best practices, and establishing clinical standards of care.
Release of psychological health treatment records to DOD by VA health  care providers who treat members of the National Guard and Reserves.  Section 1614 of the NDAA 2008 requires the departments to improve  medical and support services provided to members of the National Guard  and Reserves. In pursuing these objectives, VA faced challenges related to  the release of medical information to DOD on reservists and National  Guard servicemembers who have received treatment for PTSD or other  mental health conditions from VA. DOD requests medical information  from VA to help make command decisions about the reactivation of  servicemembers, but VA practitioners face an ethical dilemma if the  disclosure of medical treatment could compromise servicemembers’  medical conditions, particularly for those at risk of suicide. The challenge  of sharing and protecting sensitive medical information on  servicemembers who obtain treatment at VA was reviewed by the Blue  Ribbon Work Group on Suicide Prevention convened in 2008 at the behest  of the Secretary of Veterans Affairs. DOD and VA are continuing their  efforts to address the privacy rights of patients who receive medical  services from VA while serving in the military, and to protect the  confidential records of VA patients who may also be treated by the  military’s health care system. The need to resolve this challenge assumes  even greater importance in light of DOD’s and VA’s increasing capability to  exchange medical records electronically, which will expand DOD’s ability  to access records of servicemembers who have received medical  treatment from VA.
section_title: Changes to the SOC’s Staff and Scope of Responsibilities Could Pose Future Challenges to Joint Policy Development
paragraphs: The SOC has experienced turnover in leadership, reconfiguration in its  organizational structure at DOD, and changes affecting policy  development responsibilities. These changes could pose future challenges  to DOD’s and VA’s efforts to develop joint policy.
The SOC has experienced leadership changes caused by the turnover in  presidential administrations as well as turnover in some of its key staff.  For example, the outgoing deputy secretaries of DOD and VA, who  previously chaired the SOC, left their positions in January 2009 with the  change in administration, and new deputy secretaries were not confirmed  until February and April 2009. In their absence, the Secretaries of VA and  DOD co-chaired a SOC meeting as a short-term measure. DOD also  introduced other staffing changes to replace personnel who had been  temporarily detailed to the SOC and needed to return to their primary  duties. DOD had relied on temporarily-assigned staff to meet SOC staffing  needs because the SOC was originally envisioned as a short-term effort. In  a December 2008 memorandum, DOD outlined the realignment of its SOC  staff. This included the transition of responsibilities from detailed,  temporary SOC staff and executives to permanent staff in existing DOD  offices that managed similar issues. For example, the functions of LOA 7  (Legislation and Public Affairs) will now be overseen by the Assistant  Secretary of Defense for Legislative Affairs, the Assistant Secretary of  Defense for Public Affairs, and the DOD General Counsel. DOD also  established two new organizational structures—the Office of Transition  Policy and Care Coordination and an Executive Secretariat office. The  Office of Transition Policy and Care Coordination oversees transition  support for all servicemembers and serves as the permanent entity for  issues being addressed by LOA 1 (Disability Evaluation System), LOA 3  (Case Management), and LOA 8 (Personnel, Pay, and Financial Support).  The Executive Secretariat office is responsible for performance planning,  performance management, and SOC support functions. According to DOD  officials, the new offices were created to establish permanent  organizations that address a specific set of issues and to enhance  accountability for policy development and implementation as these offices  report directly to the Office of the Under Secretary of Defense for  Personnel and Readiness. Currently, many of the positions in these new  offices, including the director positions, are staffed by officials in an acting  capacity or are unfilled.
DOD’s changes to the SOC are important because of the potential effects  these changes could have on the development of policy for recovering  servicemembers. However, officials in both DOD and VA have mixed  reactions about the consequences of these changes. Some DOD officials  consider the organizational changes to the SOC to be positive  developments that will enhance the SOC’s effectiveness. They point out  that the SOC’s temporary staffing situation needed to be addressed, and  also that the two new offices were created to support the SOC and provide  focus on the implementation of key policy initiatives developed by the  SOC—primarily the disability evaluation system pilot and the new case  management programs. In contrast, others are concerned by DOD’s  changes, stating that the new organizations disrupt the unity of command  that once characterized the SOC’s management because personnel within  the SOC organization now report to three different officials within DOD  and VA. However, it is too soon to determine how well DOD’s new  structure will work in conjunction with the SOC. DOD and VA officials we  spoke with told us that the SOC’s work groups continue to carry out their  roles and responsibilities.
Finally, according to DOD and VA officials, the scope of responsibilities of  both the SOC and the DOD and VA Joint Executive Council appear to be in  flux and may evolve further still. According to DOD and VA officials,  changes to the oversight responsibilities of the SOC and the Joint  Executive Council are causing confusion. While the SOC will remain  responsible for policy matters directly related to recovering  servicemembers, a number of policy issues may now be directed to the  Joint Executive Council, including issues that the SOC had previously  addressed. For example, management oversight of many of LOA 4’s  responsibilities (DOD and VA Data Sharing) has transitioned from the SOC  to the IPO, which reports primarily to the Joint Executive Council. It is not  clear how the IPO will ensure effective coordination with the SOC’s LOAs  for overseeing the development of information technology applications for  the disability evaluation system pilot and the individual recovery plans for  the Federal Recovery Coordination Program. Given that information  technology support for two key SOC initiatives is identified in the joint  DOD/VA Information Interoperability Plan, if the IPO and the SOC do not  effectively coordinate with one another, the result may negatively affect  the development of improved policies for recovering servicemembers.
section_title: Agency Comments and Our Evaluation
paragraphs: We provided a draft of this report to DOD and VA for comment. VA  provided technical comments, which we incorporated as appropriate.  DOD and VA did not provide other comments.
We are sending copies of this report to the Secretaries of the Departments  of Defense and Veterans Affairs, congressional committees, and other  interested parties. The report is also available at no charge on GAO’s Web  site at http://www.gao.gov.
If you or your staff have questions about this report, please contact me at  (202) 512-7114 or at williamsonr@gao.gov. Contact points for our Offices  of Congressional Relations and Public Affairs may be found on the last  page of this report. GAO staff who made major contributions to this report  are listed in appendix II.
section_title: Appendix I: Summary of Selected Requirements from the National Defense Authorization Act for Fiscal Year 2008
paragraphs: To summarize the status of the Departments’ of Defense (DOD) and  Veterans Affairs (VA) efforts to jointly develop policies for each of the four  policy areas outlined in sections 1611 through 1614 of the National  Defense Authorization Act for Fiscal Year 2008 (NDAA 2008), we identified  76 requirements in these sections and grouped related requirements into  14 logical categories. Tables 8 through 11 enumerate the requirements in  each of GAO’s categories and provide the status of DOD’s and VA’s efforts  to develop policy related to each requirement, as of April 2009.
section_title: Appendix II: GAO Contact and Staff Acknowledgments
subsections: section_title: Acknowledgments
paragraphs: In addition to the contact named above, Bonnie Anderson, Assistant  Director; Susannah Bloch; Catina Bradley; April Brantley; Frederick  Caison; Lisa Motley; and Elise Pressma made major contributions to this  report.