Recovering Servicemembers: DOD and VA Have Made Progress to Jointly Develop Required Policies but Additional Challenges Remain
Published: 2009-04-29T00:00:00

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 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 developing and implementing the policies. This statement provides preliminary information on (1) the progress DOD and VA have made in jointly developing the comprehensive policies required in the NDAA 2008 and (2) the challenges DOD and VA are encountering in the joint development and initial implementation 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 March 2009, 60 of the 76 requirements GAO identified have been completed and the remaining 16 requirements are in progress. DOD and VA have completed all of the policy development requirements for medical and 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 Directive-Type Memorandum that was developed in consultation with VA. DOD officials reported that more information will be provided in a subsequent policy instruction, which will be issued in June 2009. VA also plans to issue related policy guidance in June 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 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 responsibilities. GAO shared the information contained in this statement with DOD and VA officials, and they agreed with the information GAO presented.

section_title: Letter
paragraphs: We are pleased to be here today as you examine issues related to meeting  the critical needs of recovering servicemembers by reviewing the progress  made by the Department of Defense (DOD) and the Department of  Veterans Affairs (VA) in jointly developing policies mandated by the  National Defense Authorization Act for Fiscal Year 2008 (NDAA 2008).
Over 1.6 million U.S. troops have deployed in Operation Enduring  Freedom (OEF) and Operation Iraqi Freedom (OIF) since October 2001.  In February 2009, DOD reported that over 33,000 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 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. Generally, senior officials from the SOC sign and  issue interim policy guidance, which is then vetted through DOD’s and  VA’s internal processes to be finalized as department policies.
The 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 GAO to report on the progress  DOD and VA make in developing and implementing the comprehensive  policy. Our work 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.
In my testimony today, I will discuss our preliminary findings on (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 and initial  implementation of these policies.
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 address  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. To identify the challenges DOD and VA  encountered in jointly developing and initially implementing 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 relevant DOD and VA officials. We shared the  information contained in this statement with DOD and VA officials, and  they agreed with the information we presented.
We conducted our work from May 2008 through April 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.
subsections: section_title: Background
paragraphs: Over the past 8 years, DOD has designated over 33,000 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 medical care from  VA.
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 transitioning 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. 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 would 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 resource for recovering servicemembers, veterans, and  their families. In addition, the SOC has undertaken initiatives specifically  related to the requirements contained in sections 1611 through 1614 of the  NDAA 2008. Specifically, the SOC supported the development of several  programs to improve the care and management of benefits to 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 by the  medical evaluation board that documents medical conditions that may  limit a servicemember’s ability to serve in the military, disability ratings  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, or those who are catastrophically injured. These  servicemembers are highly unlikely to be able to return to duty and will  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 developing 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 Regarding 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 still were unlikely to return to duty and continue their  careers in the military. 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 June 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 in June 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 an agency 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 due to 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—that 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 June 2009.
section_title: DOD and VA Officials Experienced Challenges during Joint Development and Initial Implementation 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, challenges have arisen during the initial  implementation of some of the NDAA 2008 policies. Finally, 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 and family caregiver legislation is being prepared, with  anticipated implementation of new benefits for caregivers in fiscal year  2010.
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 are not uniformly defined. Consequently, standardized  definitions are needed 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 March 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 relat 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 heal care providers who treat members of the National Guard and Reserve Section 1614 of the NDAA 2008 requires the departments to improve  medical and support services provided to members of the National G and Reserves. In pursuing these objectives, VA faced challenges relate the release of medical information to DOD on reservists and Nationa l  Guard servicemembers who have received treatment for PTSD or o 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 challe of sharing and protecting sensitive medical information on  s.  nge  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 develop policy to clarify the privacy rights of patients who  receive medical services from VA while serving in the military, and a protecting the confidential records of VA patients who may also be treat 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: Future Challenges Could Impede the Joint Implementation of Policy Initiatives
paragraphs: In addition to challenges encountered during the joint development of  policy for recovering servicemembers, additional challenges have arisen as  DOD and VA have begun implementing NDAA 2008 policy initiatives.
Medical examinations conducted as part of the DOD/VA disability  evaluation system pilot. In 2007, DOD and VA jointly began to develop  policy to improve the disability evaluation process for recovering  servicemembers and began pilot testing these new procedures in the  disability system. One significant innovation of the disability evaluation  system pilot is the use of a single physical examination for multiple  purposes, such as for both disability determinations and disability benefits  from both departments. In our review of the disability evaluation system  pilot, we reported that DOD and VA had tracked challenges that arose  during implementation of the pilot but had not yet resolved all of them.  For example, one unresolved issue was uncertainty about who will  conduct the single physical examination when a VA medical center is not  located nearby. Another challenge that could emerge in the future is linked  to VA’s announcement in November 2008 that it would cease providing  physical reexaminations for recovering servicemembers placed on the  Temporary Disability Retired List (TDRL). However, VA made an  exception to its decision and will continue to provide reexaminations for  TDRL servicemembers participating in the disability evaluation system  pilot. In March 2009, VA officials told us that they were developing a policy  to clarify this issue.
Electronic health information sharing between DOD and VA. The two  departments have been working for over a decade to share electronic  health information and have continued to make progress toward increased  information sharing through ongoing initiatives and activities. However,  the departments continue to face challenges in managing the activities  required to achieve this goal. As we previously reported, the  departments’ plans to further increase their electronic sharing capab do not consistently identify results-oriented performance measures, whic are essential for assessing progress toward the delivery of that capabilit Further challenging the departments is the need to complete all necessary  activities to fully set up their IPO, including hiring a permanent Director  and Deputy Director. Defining results-oriented performance goals in its  plans and ensuring that they are met is an important responsibility of this  office. Until these challenges are fully addressed, the departments and  their stakeholders may lack the comprehensive understanding that they  need to effectively manage their progress toward achieving increased  sharing of information between the departments. Moreover, not fully  addressing these challenges increases the risk that DOD and VA may not  develop and implement comprehensive policies to improve the care,  management, and transition of recovering servicemembers and veterans.  ilities  h  y.
section_title: Changes to the SOC’s Staff and Scope of Policy Development Responsibilities Could Pose Future Challenges
paragraphs: Recent changes to staff and working relationships within the SOC could  pose future challenges to DOD’s and VA’s efforts to develop joint policy.  Since December 2008, the SOC has experienced turnover in leadership and  changes in policy development responsibilities. The SOC is undergoing  leadership changes caused by the turnover in presidential administrations  as well as turnover in some of its key staff. For example, the DOD and VA  deputy secretaries who previously co-chaired the SOC departed in January  2009. As a short-term measure, the Secretaries of VA and DOD have co- chaired a SOC meeting.
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 memo, 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 roles and 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. LOA 4  continues to be responsible for developing a component for the disability  evaluation system pilot and the individual recovery plans for the Federal  Recovery Coordination Program. It is not clear how the IPO will ensure  effective coordination with the SOC’s LOAs for the development of IT  applications for these initiatives. Given that IT 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 impact negatively on the development of improved  policies for recovering servicemembers.
Mr. Chairman, this completes our prepared remarks. We would be happy  to respond to any questions you or other members of the Subcommittee  may have at this time.
section_title: Contacts and Acknowledgments
paragraphs: For further information about this testimony, please contact Randall B.  Williamson at (202) 512-7114 or williamsonr@gao.gov, Daniel Bertoni at  (202) 512-7215 or bertonid@gao.gov, or Valerie C. Melvin at (202) 512-6304  or melvinv@gao.gov. Contact points for our Offices of Congressional  Relations and Public Affairs may be found on the last page of this  testimony. GAO staff who made key contributions to this testimony 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 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 and VA’s efforts to develop policy related to each requirement, as of  April 2009.
section_title: Appendix II: GAO Contacts and Staff Acknowledgments
subsections: section_title: GAO Contacts
section_title: Acknowledgments
paragraphs: In addition to the contacts named above, Bonnie Anderson, Assistant  Director; Mark Bird, Assistant Director; Susannah Bloch; Catina Bradley;  April Brantley; Frederick Caison; Joel Green; Lisa Motley; Elise Pressma; J.  Michael Resser; Regina Santucci; Kelly Shaw; Eric Trout; and Gregory  Whitney made key contributions to this testimony.
This is a work of the U.S. government and is not subject to copyright protection in the  United States. The published product may be reproduced and distributed in its entirety  without further permission from GAO. However, because this work may contain  copyrighted images or other material, permission from the copyright holder may be  necessary if you wish to reproduce this material separately.