Army Health Care: Progress Made in Staffing and Monitoring Units that Provide Outpatient Case Management, but Additional Steps Needed
Published: 2009-04-20T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: In February 2007, a series of Washington Post articles disclosed problems at Walter Reed Army Medical Center, particularly with the management of servicemembers receiving outpatient care. In response, the Army established Warrior Transition Units (WTU) for servicemembers requiring complex case management. Each servicemember in a WTU is assigned to a Triad of Care--a primary care manager, a nurse case manager, and a squad leader--who provide case management services to ensure continuity of care. The Army established staff-to-servicemember ratios for each Triad of Care position. This report examines (1) the Army's ongoing efforts to staff WTU Triad of Care positions and (2) how the Army monitors the recovery process of WTU servicemembers. GAO reviewed WTU policies, analyzed Army staffing and monitoring data, interviewed Army officials, and visited five selected WTUs.
section_title: What GAO Found
paragraphs: The Army has taken several steps to help ensure that WTUs are staffed appropriately. First, the Army developed policies aimed at reducing WTU staffing shortfalls, including a policy requiring the reassignment of other personnel on an installation to fill open WTU positions. Second, in October 2008, the Army revised its WTU staffing model, including the staff-to-servicemember ratios for two of its Triad of Care positions, because an Army study determined that the existing ratios were not adequate to provide an appropriate level of care to servicemembers in WTUs. The Army has made considerable progress in meeting the new ratios, and as of January 2009, the Triad of Care positions at most WTUs were fully staffed. However, staffing ratios for the WTU at Walter Reed Army Medical Center were not revised, even though the Army recognizes that servicemembers treated at this facility have more complex health care needs than servicemembers at other WTUs. Walter Reed might require a different staffing model, for example, one that decreases the number of servicemembers assigned to staff members, but the Army does not plan to conduct an assessment of Walter Reed's staffing model. Third, the Army modified its WTU placement and exit criteria for full-time servicemembers, excluding Army Reserve and National Guard servicemembers who comprise about one-third of the WTU population. These changes are intended to help ensure that only those who need complex case management are in WTUs. Those with less serious health care needs can be reassigned to other units on the installation to continue their recovery. As the Army expected, the WTU population of full-time servicemembers declined by about 1,500 in the 4 months after implementation of the new criteria. To monitor the recovery process of WTU servicemembers, the Army has implemented transition plans for individual servicemembers as well as various upward feedback mechanisms to identify concerns and gauge satisfaction. In January 2008, the Army issued a policy establishing Comprehensive Transition Plans, which can be used to monitor and coordinate servicemembers' care. To help ensure consistent implementation of these plans among its WTUs, the Army is developing a new policy that includes the systematic collection of performance measures across WTUs. However, despite Army officials' repeated assurances to GAO that this policy was forthcoming, it had not been finalized as of February 27, 2009. The Army's feedback mechanisms include its Warrior Transition Unit Program Satisfaction Survey, which collects information from servicemembers in WTUs on a number of issues, including the primary care manager and nurse case manager. However, the survey's response rates for the WTUs have been low (13 to 35 percent) and the Army has not determined whether the results obtained from the respondents are representative of all WTU servicemembers. An Army official told GAO that the Army does not plan to conduct analyses to determine whether the survey results are representative, because it is satisfied with the response rates. In GAO's view, the response rates are too low for the Army to reliably report satisfaction of servicemembers in WTUs.

section_title: Letter
paragraphs: Approximately 24,000 Army servicemembers have been wounded in action  in Operations Enduring Freedom (OEF) and Iraqi Freedom (OIF), as of  December 2008. Due to improved battlefield medicine, those who might  have died in past conflicts are now surviving, many with multiple serious  injuries that require extensive outpatient rehabilitation, such as  amputations, burns, and traumatic brain injuries. Seriously injured  servicemembers are usually transported to military treatment facilities  (MTF) in the United States, with most treated at Walter Reed Army  Medical Center or the National Naval Medical Center. In February 2007, a  series of Washington Post articles disclosed serious deficiencies at Walter  Reed, particularly with the management of servicemembers who had been  released from the hospital and were receiving care and other services as  outpatients. Specifically, the articles reported that some servicemembers  remained in outpatient status for months and sometimes years without a  clear understanding about their plans of care or the future of their military  service. Furthermore, several review groups were tasked with  investigating the reported problems. The groups identified, among other  things, numerous problems with the Army’s management of  servicemembers in an outpatient status, including inadequate case  management, which helps ensure continuity of care by guiding a person’s  care from one service, provider, or agency to another. For example, one  review group found inadequate coordination of care for some patients  who visited numerous therapists, specialists, and other providers and  received differing treatment plans and multiple medications.
In response to the deficiencies reported by the media, the Army took  several actions, most notably initiating the development of the Army  Medical Action Plan in March 2007. (This plan is currently referred to as  the Warrior Care & Transition Program.) The Army used this plan to  implement changes in the management of outpatient care for  servicemembers returning from OEF and OIF as well as for other  servicemembers receiving outpatient care at Army facilities. One key  component of the plan was the establishment of a new type of Army unit  for servicemembers that provides complex outpatient case management  services—the Warrior Transition Unit (WTU). In June 2007, the Army  began implementing WTUs, and as of January 2009 the Army had  established WTUs at 33 MTFs located at military installations across the  United States and at 3 MTFs overseas. Each servicemember in a unit is  assigned to a team of three key staff referred to as the Triad of Care—a  primary care manager, a nurse case manager, and a squad leader. The  primary care manager is usually a physician who provides oversight of the  servicemember’s medical care; the nurse case manager is a registered  nurse who coordinates and monitors options and services to meet the  servicemember’s health care needs; and the squad leader is a  noncommissioned officer who provides direct oversight of the  servicemembers, ensuring they attend medical and administrative  appointments. The Triad of Care is collectively responsible for providing  case management services to ensure continuity of care. In order to  determine the staffing levels for the Triad of Care positions, the Army  established specific staff-to-servicemember ratios, basing staffing needs on  the number of WTU servicemembers, which almost tripled in the first year  at the 33 U.S.-based WTUs—from about 3,500 in June 2007 to about 10,300  in June 2008.
In September 2007, we reported preliminary observations on the Army’s  initial efforts to establish the WTUs and staff the Triad of Care positions.  Subsequently, in February 2008, we provided a status update on the  Army’s efforts to staff the Triad of Care positions in its WTUs. We found  that although the Army had made considerable progress implementing the  WTUs, about a third of the units had less than 90 percent of staff needed to  meet the staff-to-servicemember ratios that the Army had established for  the Triad of Care positions. We also noted that an emerging challenge for  the Army was gathering reliable and objective data to monitor the  performance of WTUs and to determine how well the units were meeting  servicemembers’ recovery needs. This report updates our previous work  and focuses on the progress that the Army has made in implementing the  WTUs. Specifically, for this report, we examined (1) the Army’s ongoing  efforts related to staffing WTU Triad of Care positions and (2) how the  Army is monitoring the recovery process of servicemembers in WTUs.
To conduct our work, we obtained documentation from and interviewed  officials with the Army’s Office of the Surgeon General, Medical  Command, Warrior Care and Transition Office, Manpower Analysis  Agency, and Office of the Inspector General. In addition, we visited five  selected WTU locations—Forts Benning and Gordon (Georgia), Fort Lewis  (Washington), Fort Sam Houston (Texas), and Walter Reed Army Medical  Center (Washington, D.C.)—to obtain information from Army officials  about their efforts to staff the WTUs and about their local mechanisms for  monitoring servicemembers’ recovery process. We selected these sites  because they represent different regional Medical Commands and they  vary in the number of servicemembers placed in the WTU.
To assess the Army’s ongoing efforts related to staffing the WTU Triad of  Care positions, we analyzed the Army’s Triad of Care staffing data and  WTU servicemember population data—on which staffing needs are  based—for the 33 WTUs that have been established within the United  States. Our analysis did not include the WTUs that have been established  overseas. We also reviewed Army policies, including staff-to- servicemember ratios and WTU entry and exit criteria. We did not verify  the accuracy of the Army’s staffing and population data; however, we  interviewed agency officials knowledgeable about the data, and we  determined that they were sufficiently reliable for the purposes of this  report. We also did not evaluate the appropriateness of the Triad of Care  ratios for meeting the staffing needs of the WTUs. To determine how the  Army is monitoring the recovery process of WTU servicemembers, we  reviewed Army policies, documents, and data on selected monitoring  efforts that the Army has underway, including efforts to develop transition  plans for individual servicemembers and to obtain feedback from  servicemembers and their families. We reviewed Army data on the number  of servicemembers who had been in a WTU for at least 30 days and who  had transition plans as of January 6, 2009. For the Warrior Transition Unit  Program Satisfaction Survey, we reviewed the Army’s survey  questionnaire, protocol, and results for the period July 2007 through  September 2008, which were the most recently available data at the time  of our review. We assessed the reliability of the transition plan and survey  data by reviewing related documentation or speaking with knowledgeable  agency officials and determined the data to be sufficiently reliable for our  purposes.
We conducted this performance audit from June 2007 through April 2009  in accordance with generally accepted government auditing standards.  Those standards require that we plan and perform the audit to obtain  sufficient, appropriate evidence to provide a reasonable basis for our  findings and conclusions based on our audit objectives. We believe that  the evidence obtained provides a reasonable basis for our findings and  conclusions based on our audit objectives. Additional information about  our scope and methodology is provided in appendix I.
subsections: section_title: Background
paragraphs: In June 2007, the Army began establishing WTUs at United States military  installations with MTFs that were providing medical care to 35 or more  eligible servicemembers. As of January 2009, the Army was operating 33 of  these WTUs. (See fig. 1.) The Army has also established WTUs at locations  in Germany—Bavaria, Heidelberg, and Landstuhl. For servicemembers  with less complex medical needs, the Army uses its existing network of  community-based health care organizations, which it now refers to as  community-based WTUs. The community-based WTUs allow  servicemembers to live at home and receive medical care while remaining  on active duty.
A servicemember was eligible for placement in a WTU if he or she required  more than 6 months of medical treatment and required complex case  management. Army guidance specifies that the mission of servicemembers  assigned to a WTU is to heal and transition—return to duty or to civilian  life—and while WTU servicemembers may have work assignments in the  unit, this work may not take precedent over the servicemembers’  treatment. WTUs have a defined staffing structure that includes leadership  positions of commanders and platoon sergeants, as well as administrative  staff, such as human resources and financial management specialists.  Within each unit, the servicemember is assigned to a team of three key  staff—the Triad of Care—who provide case management services to  ensure continuity of care. (See fig. 2.)
Servicemembers in the WTUs vary by the type of medical condition for  which they are receiving care and include Army active component,  Reserve, and National Guard servicemembers. Active component  servicemembers comprise about two-thirds of the WTU population, and  active duty Reserve and National Guard servicemembers collectively  comprise about one-third. As of December 1, 2008, about 60 percent of  servicemembers in WTUs had been wounded in combat or had incurred a  noncombat injury or illness during OEF or OIF, which may have resulted  in burns, amputations, or other types of conditions. The remaining  servicemembers in the units included those who may have been referred  to the WTU for completion of the disability evaluation process; those who  incurred a noncombat injury, such as during a training exercise; and those  who incurred a noncombat illness such as cancer that required complex  case management.
section_title: The Army Issued Additional WTU Policies to Reduce Staffing Shortfalls, Modify Its Staffing Model, and Revise Servicemember Entry and Exit Criteria
paragraphs: The Army has issued additional WTU policies aimed at reducing staffing  shortfalls, modifying the staffing model, and revising servicemember entry  and exit criteria. To reduce staffing shortfalls, the Army issued policies  designed to ensure that WTUs achieve and maintain staffing at required  staff-to-servicemember ratios. The Army also implemented a revised WTU  staffing model that includes new staff-to-servicemember ratios for two of  the three Triad of Care positions. In addition, the Army issued policies to  revise its criteria for servicemembers entering and leaving WTUs—a policy  that affects population size and staffing needs.
subsections: section_title: New WTU Staffing Policies Helped Reduce WTU Triad of Care Staffing Shortfalls
paragraphs: Although the Army had increased the number of staff being assigned to the  WTUs, staffing shortfalls continued through June 2008. When we last  reported on the Army’s progress in staffing the WTUs in February 2008,  the Army had established a goal of having at least 90 percent of Triad of  Care staff positions filled to meet the staff-to-servicemember ratios that it  had established for its WTUs. These ratios were 1:200 for primary care  managers; 1:18 for nurse case managers at Army medical centers that  normally see servicemembers with more acute conditions and 1:36 for  other types of Army medical treatment facilities; and 1:12 for squad  leaders. At that time, the Army had 1,141 Triad of Care staff for its WTUs,  and 11 WTUs had less than 90 percent of needed staff for one or more  Triad of Care positions—representing a total shortfall of 64 staff. As of  June 25, 2008, WTU Triad of Care staff had increased to 1,328, but because  the size of the WTU servicemember population continued to grow and  increase staffing needs, 21 WTUs were not meeting this goal and had  staffing shortfalls in 108 Triad of Care positions. However, it is important  to note that WTU staffing shortfalls represent a specific point in time.  WTU staffing needs may vary daily based on both the number of  servicemembers entering and exiting the WTUs and with fluctuations in  the number of Triad of Care staff, who may deploy or otherwise be  reassigned or leave.
To address challenges in fully staffing the WTUs, including Triad of Care  positions, the Army issued new policies in July 2008 for staffing the WTUs.  The Army’s new policies included a requirement that local leadership— WTU commanders, MTF commanders, and senior installation  commanders—fill 100 percent of WTU staff shortages, including those  related to the Triad of Care, by July 14, 2008. For example, commanders  were directed to fill the positions using personnel present on the  installation, such as physicians and nurses who work in the MTFs, and to  ensure continued 100 percent staffing from July 14, 2008, forward.
As of August 2008, after the implementation of these new staffing policies,  Army data indicated that Triad of Care staffing shortfalls had been  reduced considerably, and the Army had generally met its goal of 100  percent staffing of its WTUs, with only a few exceptions. As of August 25,  2008, four WTUs had staffing shortfalls in four Triad of Care positions  total—Balboa was missing one nurse case manager, Fort Belvoir was  missing one squad leader, and Fort Drum and Fort Irwin were each  missing one primary care manager.
section_title: The Army Implemented a New WTU Staffing Model in Response to Study Findings, but Walter Reed Was Excluded from This Study
paragraphs: On October 16, 2008, the Army implemented revisions to its WTU staffing  model, including changes to two of its Triad of Care staff-to- servicemember ratios. (See fig. 3.) These policy changes were based on a  study initiated by the Army in February 2008 that found that some of the  existing staff-to-servicemember ratios were not adequate for providing an  appropriate level of care to servicemembers in WTUs. The study team  recommended changes to the Triad of Care staffing ratios for nurse case  managers and squad leaders. The team also recommended realigning  existing medical and administrative support staff in the WTU to provide  direct assistance to the nurse case manager and hiring new staff to support  the primary care manager.
The Army applied the revised ratios to all the WTUs except Walter Reed  Army Medical Center. Army officials told us that the study team excluded  Walter Reed from its review because the population receiving care at  Walter Reed has more complex medical needs than the population at other  WTUs. As a result, Walter Reed is continuing to operate under its original  staff-to-servicemember ratios—1:200 for primary care managers, 1:18 for  nurse case managers, and 1:12 for squad leaders. Despite the  servicemember population at Walter Reed having more complex medical  needs, these ratios are not much different than the revised ratios  established for other WTUs. According to WTU officials from Walter Reed,  Triad of Care staff who work with servicemembers with more complex  medical needs generally require higher staff-to-servicemember ratios, but  an assessment of acuity—the complexity of servicemembers’ needs—is  necessary for determining the exact ratios that would be appropriate for  Triad of Care positions at this location. Army officials told us that the  Army currently does not have a plan for conducting a study of Walter  Reed’s staffing model because this facility is scheduled to close in 2011  under Base Realignment and Closure 2005. According to Army officials,  the WTU at Walter Reed will be moved to the newly established Walter  Reed National Military Medical Center in Bethesda, Maryland. The WTU  servicemember population from Walter Reed will be dispersed among the  WTU at the new medical center and the WTUs at Fort Belvoir and Fort  Meade.
Nonetheless, the Army had made considerable progress in meeting the  new WTU staff-to-servicemember ratios for the Triad of Care positions. On  January 12, 2009, 4 of the 32 WTUs in the United States (excluding Walter  Reed Army Medical Center) had a total shortfall of seven Triad of Care  positions—three primary care managers and four squad leaders. Walter  Reed, which continued to operate under its original Triad of Care staff-to- servicemember ratios, did not have any shortfalls.
section_title: Revised WTU Servicemember Entry and Exit Criteria Have Decreased WTU Population Growth, Which Determines Staffing Needs
paragraphs: In July 2008, the Army also implemented policies revising WTU  servicemember entry and exit criteria to increase emphasis on  servicemembers needing complex case management. The revised policies  stated that feedback from WTU officials, MTF commanders, and other  senior officials indicated that many servicemembers in WTUs did not need  the complex case management that the units provided. For example,  officials from one WTU we visited told us that the WTUs included  servicemembers who had conditions that were not complex, such as a  broken leg, or who were waiting to finish the Army’s disability evaluation  process and no longer had medical appointments. Army officials  indicated that the growth of the WTU population—partially due to the  inclusion of servicemembers who did not need complex case  management—had impeded its ability to achieve and maintain staff for its  Triad of Care positions in accordance with its staff-to-servicemember  ratios.
The Army’s July 2008 policies modified WTU entry and exit criteria  specifically for active component servicemembers. These revised criteria  do not apply to Reserve and National Guard servicemembers, who  comprise about one-third of the WTU population. Army policy indicates  that Reserve and National Guard servicemembers are generally eligible for  placement in a WTU if they need health care for conditions identified,  incurred, or aggravated while on active duty, and they will remain in the  WTU until their medical condition is resolved and they are eligible to be  released from active duty or they complete the Army’s disability evaluation  process. According to an Army official, the Army is also exploring ways to  apply the revised entry and exit criteria to Reserve and National Guard  servicemembers and is planning to issue a corresponding policy in March  2009.
The Army’s revised WTU entry criteria for active component  servicemembers are intended to help ensure that only those who need  complex case management are placed in the WTU. For example, according  to the original criteria, a servicemember was eligible for placement in a  WTU if he or she had complex medical needs requiring more than   6 months of treatment and did not include an assessment of the  servicemember’s ability to perform his or her duties. The revised criteria  state that an active component servicemember is eligible for placement in  a WTU if he or she has complex medical conditions that require case  management and will not be able to train for or contribute to the mission  of a unit for more than 6 months.
The WTU exit criteria, which had not been explicitly articulated in the  original WTU policy, now allow local leadership greater flexibility in  reassigning active component servicemembers to other units on the  installation. Previously, an active component servicemember would  remain in a WTU until he or she was able to return to duty and completed  his or her medical treatment or was discharged from the Army, even if the  servicemember’s medical care could be managed outside a WTU. The exit  criteria state that an active component servicemember who is expected to  return to duty may be reassigned to a unit on the installation before being  found medically fit to return to duty if certain conditions are met. In  particular, the servicemember may be reassigned if the servicemember’s  remaining medical needs can be managed outside a WTU and if the  servicemember’s reassignment has been approved by the Triad of Care  and by leadership of the WTU, MTF, and installation.
Along with its policies establishing the revised entry and exit criteria, the  Army required the Warrior Care and Transition Office to assess the  effectiveness of the revised entry and exit criteria in ensuring that only  those servicemembers needing complex case management are in the  WTUs and to monitor the effects of the revised criteria. Specifically, the  Warrior Care and Transition Office was tasked with developing measures  for assessing the criteria’s effectiveness. According to Army officials, the  Warrior Care and Transition Office has not developed any additional  measures to determine the effectiveness of the revised entry and exit  criteria, but instead is relying on existing measures. For example, the  number of servicemembers in WTUs decreased after implementation of  the criteria, as the Army anticipated. Specifically, Army data show that the  active component population of the WTUs has declined each month since  the new entry and exit criteria went into effect, from about 8,400 in July  2008 to about 6,900 in November 2008. Army officials also said that length  of stay can be used to assess the entry and exit criteria because  servicemembers requiring complex care would be expected to have longer  lengths of stay in the WTU.
The policy with the revised entry and exit criteria also includes a provision  for the Army Inspector General to assess the criteria as part of a broader  provision to conduct a follow-up inspection of the Army’s disability  evaluation process and WTUs. An official within the Army’s Office of the  Inspector General told us that this inspection is included in its proposed  long-range inspection plan for fiscal years 2009 and 2010, which is pending  approval by the Secretary of the Army.
section_title: The Army Uses Various Mechanisms to Monitor WTU Servicemembers’ Recovery, but Its Feedback Mechanisms May Not Provide Complete Information
paragraphs: To monitor the recovery process of WTU servicemembers, the Army uses  individual transition plans and various upward feedback mechanisms, but  its feedback mechanisms may not provide complete information on the  performance of WTUs. The Army’s feedback mechanisms, which include a  telephone hotline and a satisfaction survey, provide a way for  servicemembers and their families to raise concerns about WTU-related  issues. However, while this may provide helpful and important information  to Army leadership, the concerns raised through these mechanisms are not  necessarily representative of the concerns of all WTU servicemembers and  their families.
subsections: section_title: The Army Is Implementing Plans for Monitoring the Recovery of Individual Servicemembers
paragraphs: To facilitate servicemembers’ recovery, the Army has developed a process  for coordinating and monitoring the care that servicemembers receive  while in a WTU. In January 2008, the Army issued a policy establishing  Comprehensive Transition Plans for WTU servicemembers. A plan  includes a servicemember’s medical conditions and vocational training  needs, as well as his or her expectations and goals for the recovery  process. The Army requires that a servicemember’s transition plan be  developed within 30 days of his or her placement into the WTU by WTU  leadership and Triad of Care staff with input from the servicemember and  his or her family. The WTU and MTF commanders are responsible for  ensuring that the transition plan is developed.
Army policy requires that the Triad of Care monitor the servicemember’s  transition plan weekly. For example, officials told us that meetings, which  may include staff in addition to the Triad of Care, are held to determine  whether the goals documented in the servicemember’s transition plan are  being met and to modify the plan as necessary. Additionally, according to  an Army official, conducting periodic formal evaluations of the transition  plan is required to determine whether the servicemember should   (1) return to duty, (2) continue rehabilitation, or (3) be referred to the  Army disability evaluation process. An official said that these formal  evaluations occur at least every 3 months, but can occur more often based  on the servicemember’s transition plan.
In addition to actions already underway, the Army is developing additional  policy to assist WTUs in developing the Comprehensive Transition Plans,  which could help ensure that the plans are implemented consistently  across WTUs and that the transition needs of all servicemembers in the  WTUs are regularly assessed. According to the Army, this additional policy  will include guidance on setting goals with servicemembers and their  families. It will also include performance measures that will allow the  Army to more systematically monitor the extent to which WTUs have  developed transition plans for its servicemembers. For example, according  to the Army, the performance measures will include the number of  servicemembers in WTUs for more than 30 days who do not have a  transition plan. The policy will require that the performance measures be  reported at least monthly. During a 6-month period over the course of our  review, Army officials had provided us with various dates for which they  had expected that this policy would be finalized, but this had not yet  occurred as of February 27, 2009.
Related to one of these performance measures, the Army has begun  reporting data on the number of servicemembers in WTUs for more than  30 days who had a transition plan. Our analysis of these data shows that as  of January 6, 2009, 94 percent of all servicemembers in WTUs across the  United States had transition plans. Specifically, between 84 and   100 percent of servicemembers at 32 of 33 WTUs had transition plans. At  the remaining WTU, 73 percent of servicemembers had transition plans.  Officials from this WTU said that, because of the rapid growth in the WTU  servicemember population, there were insufficient staff in some positions  involved in developing the transition plan, such as social workers. As a  result, officials were first developing transition plans for servicemembers  who had the greatest need. Additionally, officials said that some  servicemembers did not need transition plans because they were in the  process of leaving the WTU.
section_title: The Army Obtains Information on Servicemembers’ Concerns through Various Upward Feedback Mechanisms, but This Information May Not Be Representative of All WTU Servicemembers
paragraphs: Using various upward feedback mechanisms, the Army has obtained  information about different aspects of its WTUs, including the Triad of  Care. (See table 1.) For example, the Army requires each of its WTUs to  hold monthly Town Hall meetings to serve as a forum for WTU  servicemembers and their family members to voice their concerns directly  to WTU and installation leadership. Additionally, after the media reported  deficiencies at Walter Reed Army Medical Center, the Army established  two other feedback mechanisms—the Wounded Soldier and Family  Hotline and the Ombudsman Program—which are also available to  servicemembers receiving care at the MTF who are not part of the WTU  and their families. Through both of these mechanisms, Army personnel are  available to address servicemembers’ concerns about medical and  nonmedical issues, including transportation, financial, legal, and housing  concerns. The Army collects and analyzes data from these feedback  mechanisms to identify trends and potential problem areas. While this may  provide helpful and important information to Army leadership about the  performance of the WTUs, the concerns raised through these mechanisms  are not necessarily representative of all concerns of WTU servicemembers  and their families because they are dependent upon the initiative taken by  individuals and because they may include concerns from servicemembers  not in WTUs.
In addition, the Army obtains feedback on WTUs through its Warrior  Transition Unit Program Satisfaction Survey, which solicits feedback on  the performance of WTUs, including the WTUs in Germany and the  community-based WTUs. This survey is designed to assess  servicemembers’ satisfaction with various aspects of WTUs, including the  primary care manager and nurse case manager. The Army began  administering this survey in June 2007 to servicemembers who had been  placed in WTUs. The Army mails the survey to WTU servicemembers on  the 30-, 120-, 280-, and 410-day anniversaries of their placement into the  WTU. In February 2008, the Army began following up by telephone with  servicemembers who did not respond 30 days after the surveys were  mailed.
Although the Army has used this survey to report relatively high  satisfaction rates among WTU servicemembers, including servicemembers  at WTUs in Germany and community-based WTUs, the survey results may  not be representative of all WTU servicemembers. During the period July  2007 through September 2008, the Army’s data showed that for WTUs at  military installations, the percentage of servicemembers satisfied ranged  between approximately 60 and 80 percent, and for the community-based  WTUs, between approximately 80 and 90 percent. However, the overall  monthly response rates for WTU respondents ranged between 13 and   35 percent for the period June 2007 through September 2008, which was  the most current data available at the time of our review. Such a low  response rate decreases the likelihood that the survey results accurately  reflect the views and characteristics of the target population.
Despite low response rates, the Army has not conducted additional  analyses to determine whether its survey results are representative of the  entire WTU servicemember population. According to Office of  Management and Budget guidelines, best practices to ensure that survey  results are representative of the target population include conducting a  nonresponse analysis for surveys with a response rate lower than   80 percent. Although the Army was not required to seek the Office of  Management and Budget’s approval for the Warrior Transition Unit  Program Satisfaction Survey, these are generally accepted best practices  and are relevant for the purposes of assessing whether the survey results  are representative of all WTU servicemembers. A nonresponse analysis  may be completed on more than one occasion, depending on how  frequently the survey is administered. A nonresponse analysis can be used  to determine if the responses from nonresponding servicemembers would  be the same as the responses from responding servicemembers. Therefore,  this analysis could help the Army determine whether its WTU satisfaction  survey results are representative of all WTU servicemembers. An Army  official told us that the Army does not plan to conduct nonresponse  analyses because it is satisfied with the response rates that it has been  receiving since it began following up with servicemembers by telephone in  February 2008. For the period February 2008 through September 2008,  WTU response rates for both mail and telephone respondents, including  WTUs in Germany and community-based WTUs, have ranged between 26  and 35 percent. In addition, this official told us that beginning in Spring  2009 the Army no longer plans to conduct this survey by mail, but will  conduct this survey solely by telephone, and expects response rates to  further increase once this occurs.
Nonetheless, the Army has used its survey results to monitor trends and  identify areas for improvement. For example, the Army conducted  additional analyses of nine WTUs, which are among the largest WTUs. For  one of these WTUs, the Army reported that additional analyses indicated  that factors contributing to low satisfaction included decreased  satisfaction about pain control and financial issues. The analyses also  showed that servicemembers in this WTU for more than 280 days were the  most dissatisfied.
While Army leadership may use the Warrior Transition Unit Program  Satisfaction Survey results to identify areas for improvement, Army  officials at some locations we visited said that low response rates and lack  of specific information limits the usefulness of the survey at the local level.  Consequently, some WTUs have undertaken local efforts to collect  information about servicemembers’ satisfaction. Army officials at three of  the WTUs we visited told us that they have independently conducted local  satisfaction surveys to obtain specific information from their  servicemembers. These local efforts have focused on gauging satisfaction  in several areas, including, for example, satisfaction with nurse case  managers, primary care managers, and squad leaders. The local surveys do  not replace the Army-wide satisfaction survey, and Army officials reported  that they have been able to use them to improve services at individual  WTUs. For example, at one location we visited, officials administered a  satisfaction survey in January 2008 and August 2008 that focused on the  nurse case managers. These results showed that, while servicemembers  were generally satisfied with their nurse case managers, a few  servicemembers commented that their nurse case manager’s caseload was  too large. In response to the survey results, the WTU has worked to  balance the caseload among the nurse case managers so that no case  manager has an excessive number of WTU servicemembers.
section_title: Conclusions
paragraphs: After problems at Walter Reed Army Medical Center were disclosed in  early 2007, the Army dedicated significant resources and attention to  improving outpatient care for servicemembers through the establishment  of the WTUs. Initially, the Army faced challenges fully staffing the units to  serve an increasing population, but revisions to WTU policies substantially  reduced staffing shortfalls and appeared to manage population growth for  active component servicemembers. As of January 2009, almost all of the  Triad of Care positions in the WTUs were fully staffed. In addition, the  number of active component servicemembers in WTUs decreased within  the first 4 months of implementing the revised entry and exit criteria.  Sustained attention to staffing levels and the implementation of the revised  WTU entry and exit criteria will be important for maintaining these gains  and helping to ensure that servicemembers are getting the care that they  need.
The Army demonstrated its dedication to caring for its WTU  servicemembers by studying and revising its staffing model, including  staff-to-servicemember ratios for selected positions, to help ensure the  WTUs were providing an appropriate level of care. However, a lingering  concern—in light of the study’s findings not applying to the WTU at Walter  Reed Army Medical Center—is that the Army does not have a plan to  conduct a similar study for this WTU. The population receiving care at  Walter Reed has more complex health care needs than the population at  other WTUs, and might also require, for example, higher staff-to- servicemember ratios. Without an assessment of the current staffing  model that considers this complexity, the Army cannot be assured that it is  providing an appropriate level of care to servicemembers at Walter Reed.  This evaluation could help the Army determine the appropriate staffing  model for the population at Walter Reed and ensure that previously  reported problems with coordination of care and treatment for this  population do not recur. Furthermore, an assessment of Walter Reed’s  staffing model could help the Army make staffing decisions in preparation  for the transfer of seriously injured servicemembers to other facilities  once Walter Reed closes in 2011.
Continued monitoring of the Army’s WTUs, including servicemembers’  recovery process, will be important for ensuring that these units are  meeting servicemembers’ needs. The Army’s Comprehensive Transition  Plans appear to be a significant step towards ensuring that  servicemembers are receiving the care they need by regularly assessing  their progress. However, the Army has not finalized policy that would  allow it to systematically determine whether WTUs are consistently  developing these plans. The Army has also established various upward  feedback mechanisms that help inform Army leadership about issues WTU  servicemembers are facing, but they do not provide information on the  overall effectiveness of the WTUs. The Army’s Warrior Transition Unit  Program Satisfaction Survey could potentially be used to collect  information representative of the WTU population. However, the survey  has had low response rates, and the Army has not performed additional  analysis to determine whether these results are representative of all WTU  servicemembers. Although the Army’s plan to conduct the satisfaction  survey solely by telephone may increase response rates, nonresponse  analyses may still be warranted because the response rates may remain  well below 80 percent—the level where generally accepted best practices  call for nonresponse analyses to ensure that survey results are  representative. Without representative information, the Army cannot  reliably report servicemembers’ satisfaction with the WTUs, and without  such data Army officials could potentially be unaware of serious  deficiencies like those that were identified at Walter Reed in 2007.
section_title: Recommendations for Executive Action
paragraphs: We recommend that the Secretary of Defense direct the Secretary of the  Army to take the following three actions:    To help ensure that the WTU at Walter Reed Army Medical Center is  providing an appropriate level of care to servicemembers and help the  Army make future staffing decisions for the WTUs that will be caring for  this population once Walter Reed closes, the Army should examine Walter  Reed’s WTU staffing model, including its Triad of Care staff-to- servicemember ratios, in light of the complexity of the health care needs  of servicemembers placed in this WTU.
To help ensure that the Comprehensive Transition Plans are implemented  consistently across WTUs and that the Army has performance data for  monitoring the implementation of the transition plans, the Army should  expedite efforts to finalize and implement its policy for guiding the  development of the Comprehensive Transition Plans.
To determine whether the results of the Warrior Transition Unit Program  Satisfaction Survey can be used to assess the effectiveness of the WTUs,  the Army should take steps to determine whether the results are  representative of all servicemembers in WTUs, such as by conducting  nonresponse analyses, and should take additional steps if necessary to  obtain results that are representative.
section_title: Agency Comments and Our Evaluation
paragraphs: In commenting on a draft of this report, DOD stated that it concurred with  our findings and recommendations. (DOD’s comments are reprinted in  appendix II.) However, DOD’s description of the actions that it has taken  and those that it plans to take to respond to the recommendations did not  fully address two of the recommendations.
In response to our recommendation to examine the WTU staffing model at  Walter Reed Army Medical Center, DOD indicated that the Army has  multiple planning efforts and studies underway to prepare for the closing  of Walter Reed. For example, it indicated that the Center for Army  Analysis is determining the capacity and capabilities of Fort Meade, Fort  Belvoir, and the new Walter Reed National Military Medical Center to  determine how best to provide the appropriate level of care and services  to these WTU servicemembers. DOD also indicated that Walter Reed has  sufficient resources to provide appropriate care until the new Walter Reed  is completed. Specifically, DOD commented that Walter Reed’s staffing  has met or in certain areas exceeded that of other WTUs—for example,  nurse case managers have dedicated supervisory assistance available to  them at all times and the Walter Reed nurse case manager staff-to- servicemember ratio is 1:18, compared to 1:20 at other WTUs. In  describing the Army’s efforts and studies, however, DOD did not indicate  how, if at all, they would be examining the WTU staffing model at Walter  Reed, including the Triad of Care staff-to-servicemember ratios.  Furthermore, although Walter Reed may have additional resources and its  nurse case managers may operate under a slightly higher ratio, the  population receiving care at Walter Reed has more complex health care  needs than the population at other WTUs. We continue to believe that  without an assessment of the current staffing model that considers this  complexity, the Army cannot be assured that it is providing an appropriate  level of care to servicemembers at Walter Reed. Furthermore, we continue  to believe that such an assessment can help the Army make future staffing  decisions for the WTUs that will be caring for this WTU population once  Walter Reed closes. As such, it is imperative that DOD take all actions  necessary to examine the WTU staffing model at Walter Reed.
With respect to our recommendation for the Army to take steps to  determine whether the results of the Warrior Transition Unit Program  Satisfaction Survey are representative of all servicemembers in WTUs,  DOD’s response does not indicate that the Army will be taking the actions  that we recommended. DOD indicated that the Army’s change to  telephone surveys has greatly increased response rates and a nonresponse  analysis is currently not required. However, DOD did not indicate its most  recent response rates. Although DOD indicated that the Army would  reevaluate the need for a nonresponse analysis by September 1, 2009,  unless the change to telephone surveys has resulted in a response rate that  is 80 percent or higher, we believe that taking steps to determine whether  the results are representative of all servicemembers in WTUs is warranted.  Without such data, we continue to believe that the Army cannot reliably  report servicemembers’ satisfaction with the WTUs and that Army  leadership could potentially be unaware of serious deficiencies in some of  its WTUs.
With regard to our recommendation for the Army to finalize and  implement its policy for guiding the development of Comprehensive  Transition Plans, DOD responded that the policy was signed on March 10,  2009. DOD also indicated that staff associated with the Army’s  Organizational Inspection Program are assisting with the implementation  of the plans and will validate compliance with the new policy.
We are sending copies of this report to the Secretary of Defense, relevant  congressional committees, and other interested parties. The report also is  available at no charge on GAO’s Web site at http://www.gao.gov.
If you or your staff members have any questions about this report, please  contact me at (202) 512-7114 or williamsonr@gao.gov. Contact points for  our Offices of Congressional Relations and Public Affairs may be found on  the last page of this report. Key contributors to this report are listed in  appendix III.
section_title: Appendix I: Scope and Methodology
paragraphs: Overall, to evaluate the Army’s efforts to staff and monitor its Warrior  Transition Units (WTU), we obtained documentation from and interviewed  officials with the Army’s Office of the Surgeon General, Medical  Command, Warrior Care and Transition Office, Manpower Analysis  Agency, and Office of the Inspector General. To gain an understanding of  staffing and monitoring activities at individual WTUs, we visited five WTU  locations—Forts Benning and Gordon (Georgia), Fort Lewis  (Washington), Fort Sam Houston (Texas), and Walter Reed Army Medical  Center (Washington, D.C.). We selected these locations because they  represent different Army regional Medical Commands and they vary in the  number of servicemembers placed in the WTU. Because we did not visit a  representative sample of WTUs, the results from these visits cannot be  generalized to other WTUs. At each location, we met with WTU command  staff, nurse case managers or primary care managers, and servicemembers  placed in the WTU to gain their perspectives on case management services  being provided through the WTU. We also met with officials representing  the Army’s regional Medical Command to discuss case management  services, including staffing and monitoring. Lastly, we met with officials  representing the Case Management Society of America to obtain their  perspectives on the Army’s WTUs and efforts to monitor healthcare  provided to servicemembers.
More specifically, to assess the Army’s ongoing efforts to staff its WTU  Triad of Care positions—primary care managers, nurse case managers,  and squad leaders—we obtained and reviewed the Army Warrior Care &  Transition Program, which established policies for implementing the  WTUs. We also reviewed additional staffing policies that the Army  established in July 2008. These policies included additional requirements  for staffing the WTUs and a new WTU staffing model that included revised  WTU staff-to-servicemember ratios. To determine the extent to which the  Army was meeting its staff-to-servicemember ratios for its Triad of Care  positions, we analyzed Army staffing and servicemember population data  for the 33 WTUs that were established at MTFs located at Army  installations within the United States. We did not verify the accuracy of  these data. We did, however, speak with Army officials regarding the  reliability of the data and determined them to be sufficiently reliable for  the purposes of our review. We also did not evaluate the appropriateness  of the Triad of Care ratios for meeting the staffing needs of the WTUs.
To determine how the Army is monitoring the recovery process of  servicemembers in WTUs, we reviewed the Army’s policy and guidance  regarding the implementation of its Comprehensive Transition Plans. We  also spoke with an Army official about a draft policy related to the  documentation of the transition plans that would include performance  measures to track compliance. To determine the extent to which the 33  WTUs within the United States had plans for individual servicemembers,  we analyzed the Army’s biweekly data on the number of servicemembers  who had been in the WTU for at least 30 days who had a transition plan.  We did not verify the accuracy of these data. We did, however, speak with  an Army official regarding the reliability of the data and determined them  to be sufficiently reliable for the purposes of our review. We also reviewed  protocols and procedures for selected upward feedback mechanisms. The  Army uses a number of mechanisms for obtaining feedback from  servicemembers and their families to address WTU-related issues, but we  did not review every mechanism. We focused on the Town Hall Meeting,  Wounded Soldier and Family Hotline, the Ombudsman Program, and the  Warrior Transition Unit Program Satisfaction Survey. We focused on these  mechanisms because they were implemented shortly after the media  reported deficiencies at Walter Reed Army Medical Center and because  they provide WTU servicemembers and their families with methods for  sharing their experiences and concerns about health care and case  management with Army leadership. For the Army’s Warrior Transition  Unit Program Satisfaction Survey, which is used to assess  servicemembers’ satisfaction across all WTUs, we reviewed the survey  questionnaire, protocol, and results for the period July 2007 through  September 2008, which were the most recent data available at the time of  our review. We reviewed and analyzed Army data on the number of  surveys mailed monthly and corresponding response rates for all of the  WTUs, including the overseas and community-based WTUs. We assessed  the reliability of these data by reviewing related documentation and  speaking with knowledgeable agency officials and determined the data to  be sufficiently reliable for our purposes. We also reviewed the Office of  Management and Budget Standards and Guidelines for Statistical  Surveys (September 2006) to identify standards for statistical surveys  conducted by federal agencies, including best practices for ensuring that  survey results are representative of the target population. Although the  Army is not required to seek Office of Management and Budget approval to  conduct its satisfaction survey, these guidelines are relevant for assessing  whether survey results are representative. Lastly, three WTUs we visited  administered local surveys and we obtained and reviewed their survey  questionnaires and corresponding results, when available. However, we  did not review the survey methodology for those WTUs that administered  a local survey. Further, because these local surveys collected data that  were specific to these WTUs, the survey results cannot be generalized to  all WTUs.
We conducted this performance audit from June 2007 to April 2009, in  accordance with generally accepted government auditing standards. Those  standards require that we plan and perform the audit to obtain sufficient,  appropriate evidence to provide a reasonable basis for our findings and  conclusions based on our audit objectives. We believe that the evidence  obtained provides a reasonable basis for our findings and conclusions  based on our audit objectives.
section_title: Appendix II: Comments from the Department of Defense
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, Bonnie Anderson, Assistant  Director; Janina Austin; Susannah Bloch; Christopher Langford; Lisa  Motley; Jessica C. Smith; C. Jenna Sondhelm; and Suzanne Worth made  major contributions to this report.