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

Letter

Background

VA’s Role in Supporting Veterans during Their Readjustment to Civilian Life

VA administers a wide range of programs that provide benefits and services to eligible veterans who seek out the agency for assistance as they readjust to civilian life. For example, VA offers health care, disability compensation, educational benefits, life insurance, vocational rehabilitation services, and home loans. In 2014, VA requested $152 billion to support its programs that provided benefits and services to veterans. Of this amount, VA requested an estimated $58 billion for medical care for veterans, including almost $7 billion in mental health care. VA also requested an estimated $58.6 billion in disability compensation benefits to veterans with disabilities that resulted from their military service.

The Wounded Warrior Act was enacted as part of the National Defense Authorization Act for Fiscal Year 2008. For requirements in the Act related to the comprehensive policy to be jointly developed and implemented by DOD and VA, see Pub. L. No. 110-181, tit. XVI, § 1611, 122 Stat. 3, 430, 433. The Act defines a “recovering service member” as a member of the Armed Forces, including the National Guard or Reserve, who is undergoing medical treatment, recuperation, or therapy and is in an outpatient status while recovering from a serious injury or illness related to the member’s military service. See 122 Stat. 432. the services that are offered to them. In addition, the WWA required that the policy include provisions related to the tracking of recovering servicemembers to conduct oversight of their care, management, and transition. In 2009, DOD and VA began developing the Virtual Lifetime Electronic Record Initiative, to share health, benefit, and administrative data, such as personnel records and military history records securely. The VOW to Hire Heroes Act of 2011(VOW Act) made several changes to the Transition Assistance Program (TAP), a program that provides departing servicemembers counseling and offers employment assistance and information on federal veteran benefits, among other things. Concurrent with this Act, the administration initiated a redesign of TAP. The law also generally required servicemembers to attend TAP prior to separating from their service. The VOW Act required departing servicemembers to participate in a workshop on finding employment as part of TAP, among other changes. Other provisions of the VOW Act include allowing servicemembers to apply for civilian federal government positions as veterans prior to separating from the military, ensuring the program is tailored to individuals and the 21st century job market.

Furthermore, VA and DOD collaborated in the development of several programs for servicemembers to receive VA disability compensation. The Benefits Delivery at Discharge program provides separating and retiring servicemembers the ability to apply for VA disability compensation when they have between 60 and 180 days remaining on active duty. Similarly, through the Quick Start program, VA and DOD provide the same service for those servicemembers who have less than 60 days remaining on active duty. In addition, VA collaborates with DOD to operate the Integrated Disability Evaluation System (IDES). IDES consolidates VA’s and DOD’s separate disability rating decisions into a single VA rating- decision and requires staff to perform outreach and nonclinical case management and explain VA results and processes to servicemembers.

Characteristics of Veterans Readjusting to Civilian Life

Since September 11, 2001, the U.S. military has seen a shift in the demographics of those who have served in combat. Of the 2.1 million servicemembers who have deployed in support of Operation Enduring Freedom, Operation Iraqi Freedom, and Operation New Dawn (OEF/OIF/OND), about 12 percent were women, and 33 percent were members of the National Guard or Reserves. By comparison, during the Persian Gulf War in 1990, 6.8 percent of servicemembers were women, and 16 percent were members of the National Guard or Reserves. During the Vietnam War, about 0.2 percent of servicemembers were women and only 0.4 percent were members of the National Guard or Reserves.

Moreover, veterans who have left the military since September 11, 2001, like veterans from prior eras, have had varied years of service and military experiences. They may have served for 20 years or more in the military and never served in combat, or they may have only served for a year or two. As of fiscal year 2012, more than 1.4 million veterans who have been receiving military retiree payments were in the military for 20 or more years. Between October 2001 and December 2012, more than 1.6 million servicemembers who served during OEF/OIF/OND had become veterans.health care services and over 600,000 were receiving disability compensation benefits.

The Readjustment Process for Veterans

When serving in the military, many servicemembers become accustomed to its culture and structure of discipline and hierarchy and giving priority to the group over the individual. During their service, all members of the military are employed and receive regular paychecks; medical care; and other benefits, such as housing allowances. Once they leave the military and become veterans, they must learn to become a civilian again. They are responsible for finding a job, going back to school, obtaining health insurance, child care, and finding a place to live, among other life activities. If veterans are also recovering from their war experiences, it can compound the difficulty they experience in successfully completing their readjustment.

Veterans Experience Difficulty When Readjusting to Civilian Life but Extent Is Unknown

Readjusting Veterans May Experience a Range of Economic, Social, and Other Difficulties

Veterans we spoke to and VA officials confirmed that veterans face a variety of difficulties related to readjusting to civilian life, including financial and employment, relationships, legal difficulties, homelessness, and substance abuse. One of VA’s strategic objectives is to improve veteran wellness and economic security. VA’s strategic plan also states that the ultimate measure of its success is the veteran’s success after leaving military service. However, there is limited and incomplete data available to assess the extent to which these veterans are affected by these difficulties. Therefore, it is not known to what extent veterans are facing one or a combination of these problems when they readjust to civilian life.

Financial and employment. Some veterans in our discussion groups at three of the four sites we visited said that they and several of their peers struggled financially in the time period immediately following their discharge, particularly if they had a family to support. VA officials confirmed that some veterans have experienced a range of difficulties after separating from the military, especially if they had no source of income as they readjust to civilian life. One of the veterans we spoke to said that his income dropped by four-fifths when he lost his military pay and benefits and could not find anything but a minimum wage job. Other veterans at one of the sites we visited described the challenge of paying for their living expenses during long waits for civilian employment or VA benefits to be processed. According to a 2008 study that examined unemployment among OEF/OIF veterans who had separated from the military by the end of 2006, veterans had a higher unemployment rate (6.5 percent) than nonveterans (4.7 percent). Veterans at three of the four sites we visited reported experiencing financial difficulties as they started civilian employment or received benefits. Several veterans we interviewed said they had applied for VA benefits in order to support themselves and endured lengthy waits for a VA decision. VA officials at two of the sites we visited and veterans at three of the sites mentioned that many veterans faced difficulties with the costs of civilian life, particularly housing, food, transportation, and child care. In particular, VA officials at one site we visited told us that veterans found the Post-9/11 G.I. Bill’s benefits for attending college were not enough to cover living expenses, especially during months that veterans do not attend school, such as during a summer break.no comprehensive data that identified the extent to which readjusting veterans experienced financial difficulties.

However, during our review we found Relationships. As they work to readjust to civilian life, many veterans can experience relationship difficulties. Several veterans at three of the sites we visited said that they had difficulty adjusting to family life, and often felt that they could not inform their families of their struggles. Those who had talked to their families felt that their family members did not understand them very well. One veteran reported unintentionally assaulting his wife during nightmares while sleeping; another said he was reluctant to spend time individually with his children for fear of becoming angry and losing control. VA officials at two of the four sites we visited noted that they are seeing many veterans with marital issues and at one VA medical center, officials told us that some veterans seem to have no support system in place. However, during our review we found no studies or comprehensive data that identified the extent to which readjusting veterans experienced this issue.

Legal problems. Some veterans recently separated from the military also face legal difficulties, including being arrested, convicted of a crime, and sentenced to serve time in jail. Although we found some data related to this issue, these may not represent the extent that veterans experience legal difficulties. For example, according to a 2007 report from the Department of Justice, there were an estimated 5,280 OEF/OIF veterans who had separated from the military between 2002 and 2004 who were incarcerated in either state or federal correctional facilities in 2004. Those data might represent an undercount, as one VA official tasked with outreach to veterans in correctional settings told us that not all veterans disclose their veteran status when they go to jail. In some areas, there are veterans treatment courts designed to serve the unique needs of veterans in the criminal justice system. According to VA, there were 257 veterans courts in the United States in 2013.

S. Metraux, L. Clegg, J. Daigh, D. Culhane, and V. Kane, “Risk Factors for Becoming Homeless Among a Cohort of Veterans Who Served in the Era of the Iraq and Afghanistan Conflicts,” American Journal of Public Health, vol. 103, no. S2 (2013): S256, S258, S259.

2011.identified the extent to which readjusting veterans were experiencing homelessness.

D. Nazarian, R. Kimerling, and S. Frayne, “Posttraumatic Stress Disorder, Substance Use Disorders, and Medical Comorbidity Among Returning U.S. Veterans,” Journal of Traumatic Stress, vol. 25 (April 2012): 221, 224. Results from a sample of veterans who sought treatment cannot be generalized to a broader population of veterans (particularly those that had not sought VA treatment). mental health conditions. Some of the veterans and VA officials we spoke with at one site said that veterans were sometimes afraid to take their prescribed medications, or believed that the medications were not working (especially on pain symptoms). Some veterans turned to alcohol and illegal drugs to manage their physical or emotional pain. Other veterans said that the use of prescribed medication, particularly painkillers, causes addiction, sleepiness, or other side effects. VA officials at two of the sites we visited reported that some veterans appear at VA facilities seeking help for physical or mental conditions, including a substance abuse problem that must also be treated. A study with a small sample of veterans found that those who experienced any type of trauma were far more likely to screen positive for substance abuse than those who had not experienced any type of trauma.

A Sizable Minority of Post 9-11 Veterans Have Physical and Mental Health Conditions

A sizable minority of veterans who have served since September 11, 2001, had physical or mental health conditions in the first few years of their readjustment to civilian life. Although the literature we reviewed provided a limited perspective of veterans’ early readjustment experiences, a number of physical health conditions emerged, particularly musculoskeletal problems and pain, which can contribute to difficulties in integrating back into civilian life. Physical health conditions are the most common for recently-separated veterans. According to a 2010 study, 32 percent of veterans had been diagnosed by either DOD or VA with diseases of the musculoskeletal system and connective tissues after separating from the military, and about 27 percent had been diagnosed with diseases of the nervous system and sense organs. Other studies that focused on OEF/OIF veterans receiving health care through VA show that between 43 and 49 percent reported some level of pain, with the majority of this group reporting moderate to severe pain—a level of pain that was more likely to interfere with functional activities. VA officials at two of the four sites we visited told us that reports of pain were common, and it was a difficult problem for VA and veterans to manage. Studies also found that pain was frequently associated with other physical and mental health conditions.

Authors of these studies acknowledged the limitations of generalizing the results from a sample of veterans who sought treatment to a broader population of veterans (particularly those that had not sought VA treatment). Estimates could be influenced by methodologies that tended to include either veterans’ self-reported conditions or a review of clinical records. Although the veterans in the studies typically completed one or more questionnaires that had been previously validated, self-reported data do not reflect diagnoses by clinical professionals and a social desirability factor could lead to underreporting of certain sensitive problems or inflated symptom reporting in an effort to seek benefits, such as disability compensation. veterans were diagnosed by VA or DOD with a mental disorder or psychosocial problem after their separation from the military, including 10 percent who were diagnosed with PTSD and about 3 percent who had Traumatic Brain Injury (TBI). Other studies estimated that 10 to 12 percent of post-9/11 veterans were diagnosed with PTSD. These percentages do not include veterans who sought treatment for their mental health conditions from private providers or who have not sought treatment at all. For readjusting OEF/OIF veterans, estimates of PTSD for the studies in our review generally ranged from 13 to 18 percent. VA officials at two sites and veterans at one site said PTSD and other mental health conditions, in some instances, made it difficult for some veterans to keep a job or relate to family members. VA officials at all four sites, as well as veterans at one site, reported that some veterans believe that employers will turn them down for certain jobs or their security clearance will be in jeopardy due to past or current mental conditions, particularly PTSD. VA officials at two of the sites we visited said that many veterans feel stigmatized about seeking mental health treatment. Officials added that, in many cases, mental health problems are only identified—and the possibility of treatment discussed—after some veterans seek VA treatment for their physical health conditions.

Many veterans with mental health conditions have screened positive for other conditions or received more than one diagnosis. More specifically, a 2007 study of recently-separated veterans who were diagnosed with a mental health condition by VA shows that 56 percent of them had more than one mental health diagnosis. Another study noted that high percentages of veterans who sought treatment had both PTSD and depression. Veterans who had experienced trauma were far more likely to screen positive for depression than those who had not experienced trauma. VA officials at two sites we visited also mentioned the effects of Military Sexual Trauma (MST) on victims, including the sense of betrayal that results. Victims are often reluctant to divulge such incidents (whether in the military or after separation). If military commanders ignored victims’ allegations, VA officials said that it creates a second betrayal. Experiences with MST may lead to PTSD and depression. Finally, VA officials at one site we visited mentioned that experiencing both physical and mental health conditions at the same time were challenging during their readjustment. A 2008 study noted that the severity of PTSD was significantly associated with poorer physical health functioning, even after accounting for demographic factors, combat and chemical exposure, and health risk behaviors. Also, another study found that a significantly larger proportion of veterans suffering from headaches, in comparison to those without headaches, had experienced physical injury and screened positive for depression and PTSD.

Veterans with Certain Characteristics May Be More Likely to Experience Difficulties

Some groups of veterans may be more likely to experience readjustment difficulties or be diagnosed with a physical or mental condition than others. In a study we reviewed, veterans with combat exposure were almost four times more likely to be diagnosed with PTSD than those without combat exposure. This study found that veterans who had served in ground units of the Army or Marines had PTSD rates that were 3.7 times higher than those who had served in the Navy or Air Force. Another study that tracked OEF/OIF veterans seeking treatment with the VA shows that younger veterans of active duty service were at a higher risk for diagnoses of PTSD or mental health compared with active duty veterans at least 40 years old, which the authors attribute to younger veterans more likely being at lower rank and having had greater combat exposure.

Studies we reviewed showed that younger veterans experienced higher rates of mental health diagnoses and alcohol abuse than older veterans. One study reported that veterans of younger age groups were at a higher risk of receiving PTSD and other mental health diagnoses compared with those in the oldest age group (at least 40 years of age). Another study indicated that younger veterans were more likely to engage in binge drinking than older veterans. Age was also significantly associated with screening positive for possible alcohol abuse. Some VA officials we spoke to on our site visits stated that many young veterans have difficulties in finding a job and a place to live. They may also deny they have a problem, refuse to seek help, or only do so after their lives have turned for the worse. VA officials we spoke to said that some young people joined the military to escape economic or social difficulties at home may return to civilian life to find that some of their difficulties remained. Also, VA officials told us that if veterans had certain problems before they joined the military, such as mental health or substance abuse problems, they will probably have them after they leave the military.

Studies we reviewed provided varying results regarding any differences in the readjustment experience by other demographic characteristics such as gender, race, and ethnicity. One study found that PTSD was less frequently diagnosed in female veterans than in male veterans (9.9 percent versus 11.3 percent), but depression was more frequently diagnosed (12.2 percent vs. 7.5 percent). Another study found that PTSD was again diagnosed less frequently for female veterans than male veterans at 28.2 percent and 35.7 percent, respectively; the prevalence of substance abuse diagnosed was 6.2 percent for females and 12.5 percent for males. The prevalence of PTSD and substance abuse together was 3.8 percent and 8.1 percent, respectively, for females and males. Another study found that female veterans were less likely to screen positive for binge drinking. However, another study reported that the proportion of patients with possible PTSD symptoms did not vary substantially according to gender or race. One study found that differences across these demographic groups of OEF/OIF vets regarding risk for receiving mental health or PTSD diagnoses were minimal.

VA Offers an Array of Services to Readjusting Veterans, but Long-Standing Weaknesses Hinder Available Support

VA Offers a Range of Benefits and Services to Veterans Early in the Readjustment Process

VA offers assistance to servicemembers before they leave military service by informing them through outreach and education on the range of benefits and services available to them. The types of benefits and services VA offers range from education to health care and life insurance to burial and memorial benefits. VA officials told us they use VA liaisons and outreach efforts, including the Transition Assistance Program (TAP). According to VA officials, VA liaisons are located on many military bases and play a key role in educating servicemembers about VA benefits and services. More specifically, VA liaisons assist with transferring individuals to Veterans Health Administration (VHA) health care facilities and provide information to servicemembers, veterans, and their families about VHA health care services. TAP provides information on services that are available, including services and benefits offered through the VA, either while servicemembers are on active duty or after they have separated from the military. TAP also provides separating servicemembers with counseling and information on available employment assistance and other federal benefits, identifies servicemembers who did not meet the TAP career readiness standards, and provides referral to the appropriate federal partners for additional supports and services. In addition, VA officials told us National Guard and Reserve members can learn about VA services and benefits through the Yellow Ribbon Reintegration Program (YRRP). YRRP connects servicemembers, families, and communities with resources using the YRRP website, newsletter, and YYRP-sponsored events. According to officials, YRRP is designed to make individuals aware of the supports and services available to them.

VA reaches out to veterans through a variety of activities and tools. Veterans can learn about VA, for example, through mobile Vet Centers, Welcome Home events, as well as community events. Mobile Vet Centers, which are customized recreational vehicles, allow VA staff the ability to travel to communities to provide information and render counseling services to veterans, especially to veterans living in rural areas. Welcome Home events are held at VA medical centers and offer health screenings and disseminate VA benefits information.VA also educates veterans and family members through the VA website and uses various social media outlets including Facebook™ and Twitter™.

Although VA reaches out to veterans in a number of ways, servicemembers and veterans must take the initiative to register for VA benefits and services either online, by mail, over the phone using a toll- free number, or they can do so in person at a VA medical facility or regional office. Veterans can also work with veteran service organizations (VSO) to apply for VA benefits and services. VSOs act as advocates for veterans during their application for benefits and can assist them with obtaining medical records and explaining the benefits and services that VA offers. Senior VA officials told us that VA conducts outreach to veterans, but ultimately it is up to the veteran to sign up for the benefits and services. In recent years, VA has encouraged servicemembers and veterans to apply for VA benefits, such as medical care and disability compensation, using the agency’s eBenefits system. eBenefits is designed to enable veterans, servicemembers, and families to learn about and manage their military and veterans benefits and personal information online. Many VA officials told us they encourage servicemembers and veterans to apply for benefits through this system.Officials from one medical facility we visited told us that one of the advantages of using eBenefits is that it allows veterans to search for the benefits and services they could be entitled to from their residence, instead of having to come to a VA facility.

For veterans who were wounded, became ill, or injured as a result of their service, VA offers specific benefits and services. Disability compensation is a monetary benefit paid to veterans with disabilities that were the result of their military service. This benefit award is based on the severity of disability. The Vocational Rehabilitation and Employment (VR&E) program helps eligible veterans prepare for, obtain, and maintain suitable employment or achieve independence in daily living. VR&E offers job training, education, employment, job coaching, and independent living services. For veterans receiving health care services for their medical conditions, VA offers prosthetic equipment such as home respiratory therapy, artificial limbs, wheelchairs, and optical and electronic devices for visual impairments.conditions, such as PTSD or depression, may receive mental health treatment and counseling services at VA medical centers and Vet Centers.

Veterans who suffer with mental health For the most severely wounded, ill, and injured servicemembers and veterans, VA provides intensive case management services. Under the Federal Recovery Coordination Program (FRCP), VA serves servicemembers and veterans with complex medical or social problems which may include traumatic brain injury, amputation, burn, spinal cord injury, blindness, PTSD, as well as those considered at risk for psychosocial complications. Federal Recover Coordinators advocate in all clinical and non-clinical aspects of recovery, rehabilitation, and reintegration and participate in the development of a Federal Individual Recovery Plan to provide coordination of care and benefits through the continuum of care. VA also operates Polytrauma Rehabilitation Centers that provide integrated inpatient rehabilitation to address a variety of health issues including physical, cognitive, emotional adjustment, and health and wellness. The centers serve patients who are in prolonged states of reduced consciousness, including coma.

For veterans of the Iraq and Afghanistan conflicts, VA provides additional benefits and services. These individuals may be eligible to receive education benefits through the Post-9/11 GI Bill which provides participants up to 36 months of education benefits to defray the costs of post-secondary degrees, technical training, and other expenses, such as books and supplies, and housing, among other costs. Veterans who served in combat generally are eligible to receive 5 years of free health care through the VA. In addition, all post-9/11 veterans who enter the VA health care system are referred to the Operation Enduring Freedom(OEF)/Operation Iraqi Freedom (OIF)/Operation New Dawn (OND) Care Coordination Program, which screens these veterans to determine if and the extent to which care is needed and assists them with accessing VA and community resources.designed to identify combat veterans and the degree of care that is needed to treat their medical conditions. If the screenings indicate case management is needed, veterans are referred to the Post-Deployment Integrated Care Initiative (PDIC). The PDIC provides an integrated approach to health care by treating the veteran with physical and mental health care, and social work simultaneously, rather than identifying and treating one problem at a time. According to program managers, this approach provides patient-centered care and increased coordination between providers. It also includes a comprehensive psychosocial and medical intake process for combat veterans with full integration of all services as well as regular meetings by medical care providers to discuss patient care and system issues. VA officials told us that while only veterans who have experienced combat situations are eligible to receive care through PDIC, VHA is exploring the possibility of expanding this practice to all veterans.

Lengthy Wait Times for Benefits and Services, among Other Factors, Can Hinder Veterans’ Readjustment

VA’s Continuing Service Provision Challenges

Medical care. VA continues to face long-standing challenges in providing some benefits and services in a timely way, which can hinder veterans as they readjust to their civilian lives. Our past reports, as well as reports by VA, have highlighted the continuing challenges VA faces in ensuring veterans are able to access medical care. For over a decade we have reported on continuing issues with VA medical service delivery including, in 2004, we found that some veterans in Chattanooga, Tennessee, encountered difficulties with accessing VA’s inpatient and outpatient health care services. We recommended that VA explore alternatives to further improve access to health care for these veterans by expediting the opening of additional VA medical facilities.

Subsequently, VA reviewed Chattanooga veterans’ access to inpatient and outpatient health care and opened two clinics. However, in 2009, VA reported that its facilities were unable to keep up with a steady increase in the demand for outpatient care services, leading to veterans not being able to access medical care. The report noted that VA added new guidance and performance measures to help alleviate excessive wait times for medical appointments. In 2011, we found that veterans were hindered from accessing mental health care from VA in part because of difficulty in scheduling appointments. Although VA reported that they were making improvements toward achieving timely access to medical appointments, in 2012, we found that medical appointment wait times reported by VHA were unreliable. We recommended that VA improve the reliability of its medical appointment wait time measures, ensure medical centers consistently implement the scheduling policy, and require medical centers to allocate staffing resources based on scheduling needs. VA reported revising its scheduling policy and developing a training module that schedulers were required to complete, implementing revised wait time measures, and studying options to better understand staffing level gaps. That same year, VA’s Office of Inspector General found that VA had overstated its success in providing veterans with timely appointments for mental health treatment.

In 2014, VA completed an audit to determine if broader, more systemic problems existed and found multiple deficiencies with VA’s appointment scheduling practices for medical care. However, veteran complaints about long wait times persist. VA officials and veterans also told us during our site visits that veterans continued to wait a long time to see VA physicians. At two of the four medical facilities we visited, VA officials told us that veterans have expressed frustration with how long it was taking to see a physician. Officials from one of the medical centers told us that there are long wait times to get appointments and some veterans stop using VA services because of the lack of timely appointments. Veterans from three of the four sites we visited complained about the lengthy wait times to see their physicians. One veteran told us that VA does not give veterans a choice of appointment times, and added this can be problematic if one is employed or attending school. He also told us that veterans do not want to miss these appointments because it can take months to reschedule.

Disability compensation. We have reported for over 10 years, and we heard confirmations during interviews with VA officials and veterans, on the continuing challenge VA faces in processing disability compensation in a timely fashion. For example, in 2003, we found that while VA acted to improve the timeliness of its disability claims processing, the agency remained far from achieving its goals. At a 2008 congressional hearing, we testified that despite VA taking steps to improve its disability claims process, challenges remained in reducing the backlog and wait times for processing claims. In 2012, we reported that the number of days to process disability compensation benefits was increasing and recommended that VA partner with other federal agencies to reduce timeframes and ensure the development of a robust backlog plan. VA agreed with our recommendations and reported initiating a pilot program to centralize records requests and published a strategic plan to eliminate the disability compensation claims backlog. While VA addressed several of our recommendations, we concluded that additional follow up would be needed. In fiscal year 2014, VA reported that 58 percent of veterans experienced wait times that were longer than its goal of 125 days and the average time to complete a claim was 378 days. For veterans, especially those in the beginning phases of their readjustment, making timely decisions on disability compensation benefits can potentially lessen the accompanying financial transition difficulties. Veterans from three of the sites we visited pointed to claims processing timeliness as a factor in their difficulty with readjusting to civilian life. For example, one female veteran told us that VA took 15 months to process her claim, and during this time, she was unable to support herself and had to reside with her family. Another veteran told us he has been waiting 2 years for his disability compensation to be processed, has run out of unemployment benefits, and is now on the verge of becoming homeless.

Post-9/11 GI Bill. Since the Post-9/11 GI Bill was implemented in 2009, VA has had challenges informing veterans about the program and protecting them from questionable recruiting practices by some post- secondary schools. In 2011, we reported that veterans wanted more information about the program, including how to compare Post-9/11 GI Bill benefits with other VA education benefits, as well as the effect of dropping or adding classes. We recommended that VA develop performance measures for outreach to servicemembers and veterans and for the quality of information provided by its Right Now Web service. We also recommended VA consider developing and maintaining an online policy manual for the Post-9/11 GI Bill, and provide updates to school certifying officials nationwide. VA addressed some of our recommendations but we concluded that additional monitoring of its new outreach performance measures was needed, and we continued to urge VA to measure the quality of its Right Now Web service. In 2014, we reported that VA’s response to protecting veterans from schools that were using inappropriate or aggressive recruiting practices was not always sufficient. More specifically, we found that while VA offered education counseling services to students, applying for the services was difficult and not all veterans were aware of its availability. We concluded that if veterans are not better protected and informed, they may end up using their educational benefits on programs that do not meet their career goals and recommended that VA improve outreach and accessibility of its education counseling services.and noted that it was taking additional steps to enhance the outreach and delivery of its education counseling services.

VA’s Continuing Issues Collaborating with DOD

Integrated Disability Evaluation System. Similarly to VA’s Disability Compensation, VA and DOD’s Integrated Disability Evaluation System (IDES) has had difficulty with making timely decisions on servicemembers’ claims for VA disability compensation. In 2010, we testified that the time to make decisions on IDES claims was affected by insufficient staffing and VA and DOD medical staff disagreeing over servicemember diagnoses. In 2011, we found that as program participation increased, so did the processing times for benefits. We recommended that VA and DOD develop a system-wide IDES monitoring mechanism. VA reported upgrading the IDES tracking system to include data fields that can capture, monitor and report when diagnostic disagreements occur, but we are continuing to monitor the tracking system to determine whether the agency can effectively monitor cases with diagnostic disagreements. In 2012, we reported that the processing times for decisions made for IDES claims continued to increase. We recommended that VA ensure care coordination and disability evaluation issues are fully resolved by the agencies and that its partners have sustained leadership attention and collaboration to ensure continuity of care and seamless transition for servicemembers. VA agreed with our recommendation and reported that the agency had established a committee with DOD to address comprehensive overhaul of the care coordination process. In 2013, VA reported that 16 percent of servicemembers were awarded VA disability compensation benefits within 30 days of their discharge from the service. Being able to provide compensation benefits to veterans shortly after they were discharged from the service would bring greater financial security, thereby reducing the risk for negative outcomes such as bankruptcy and homelessness.

Electronic medical records. In addition, VA continues to face long- standing problems coordinating with DOD on sharing electronic medical records. Developing a method for sharing electronic health records that can be accessed throughout a patient’s military and veteran status is particularly important. This method can help ensure greater availability of health care information for servicemembers and veterans at the time and place of care. Since 1998, VA and DOD have tried different ways to enable the sharing of electronic servicemember medical records, but our past reports and VA reports have shown ongoing challenges. For example, in 2003, we found that VA faced problems in developing an information technology strategy for sharing information with DOD on patients and that VA and DOD continued to operate separate information technology systems. A 2008 VA report noted that service treatment records continued to be transferred from DOD to VA by paper copy because the infrastructure to transfer the records electronically had not yet been built and its current efforts to have a health information exchange had one or more serious flaws. In 2011, VA highlighted its efforts to address the incompatibility between VA and DOD electronic health records systems by attempting to create a virtual lifetime electronic record, but we found impediments persisted in the agencies’ efforts to electronically view or exchange health information. Our report cited insufficient real-time and electronic access to comprehensive health information possibly delaying the receipt of care and benefits. We recommended that VA ensure electronic sharing of health records issues are fully resolved by the agencies and its partners have sustained leadership attention and collaboration to ensure continuity of care and seamless transition for servicemembers. VA agreed with our recommendations, and reported establishing a committee to review the care coordination of servicemembers; however, VA did not identify actions it would take to address electronic sharing of health records. In 2013, VA and DOD testified that their long-term plans for sharing medical record data were too expensive to continue and that they were exploring a different strategy. Veterans from all of the sites we visited told us of the difficulties they had with obtaining copies of their medical records. For example, one veteran told us that his medical records were not centrally located, making it difficult for him to collect his full record. Without medical records describing the treatment veterans received while in the military, VA faces difficulties with ensuring continuity of care when veterans transition to VA’s health system.

Medication. VA has also had long-standing problems collaborating with DOD on managing medications during veterans’ readjustments. As early as, 2002, we found there was an increased risk for patient medication errors because VA and DOD had separate and uncoordinated information and formulary systems—lists of available medicines. We recommended that VA and its partner improve its capabilities for sharing electronic information. VA had agreed with our recommendations and in fiscal 2007 it had started to deploy a system to view patient medication and allergy information. However, in 2003, we reported that VA and DOD providers and pharmacists were still unable to electronically access health information to aid in making medication decisions for veterans, such as verifying drug allergies and interactions. A decade later, in 2013, we again found that VA’s and DOD’s efforts in managing servicemember medications during their transition of care were somewhat limited because not all DOD military treatment facilities offered such transition assistance. We recommended that VA and DOD identify and apply best practices for managing servicemembers’ medication needs during transitions of care. While both agencies agreed with our recommendations, VA and DOD did not identify any actions to address them. During our site visits, one veteran at a medical facility told us how medications that were prescribed by DOD medical staff were not forwarded to VA, resulting in him being prescribed different medications. As our previous work has found, medication management is critical to effective continuity of care for servicemembers transitioning out of the military because of the potential adverse health effects that could arise if not taken as intended.

Agency Officials and Veterans Report a Range of Challenges and Opportunities to Better Support Readjusting Veterans

During our interviews with agency officials and discussions with veterans and other stakeholder groups, we heard a number of challenges that VA faces in helping veterans during the readjustment experience. First, although VA has an agreement with DOD to let VA know when servicemembers are leaving the military, some VA officials told us it can be difficult to identify recently separated veterans, including those who may be experiencing readjustment difficulties, because they did not know who was leaving the military. Second, at two of the sites we visited, veterans we spoke with told us they separated too quickly from the military without the time they needed to prepare for certain aspects of civilian life, such as finding a job, making sure they were financially stable, or becoming better acquainted with what VA offered. Third, we repeatedly heard from VA official and veterans that some veterans may hesitate to use VA services. For example, officials at one site we visited told us that some younger veterans do not want to be diagnosed as having PTSD because it will keep them from entering certain civilian careers, such as homeland security. Officials at two of the sites we visited told us that some veterans try to manage their own issues or problems, instead of seeking assistance. At one of the sites we visited, veterans told us they hesitated to enroll in VA services because they did not want to ask for help. Lastly, VA officials told us that despite an increased effort to educate National Guard and Reserve members, before and after they demobilize, some are likely being missed. Should these veterans not receive VA’s assistance in a timely way, any difficulties they may be experiencing during their readjustment to civilian life may worsen.

In light of the difficulties we heard, several VA officials suggested ways that VA could improve its support to veterans with an elevated risk of experiencing a difficult readjustment. First, some called for additional VA research. At one site we visited, VA officials suggested there were opportunities to research ways to identify individuals who are predisposed to PTSD as well as conducting a study on reasons veterans are not using VA services. Second, in discussing the issue of the speed of transition out of the military, VA officials at one site we visited suggested establishing a “buffer zone” that would allow servicemembers time to readjust to being a civilian, before they are discharged from the military. Such a buffer zone has the potential to enhance VA’s ability to reach out to servicemembers before they become veterans, assess their needs, and prepare the appropriate services for when they leave. While this effort would need to be developed and coordinated with DOD, veterans at all of the sites we visited noted that having time to adjust to the idea of being a civilian and relearning what civilian life is like would be beneficial.

Consistent with the importance that VA’s strategic plan places on veterans’ success after leaving military service, the opportunity to possibly better serve veterans at risk for having readjustment difficulties could also be informed by the approach VA takes to support ill and injured veterans. For example, veterans who enter the OEF/OIF/OND Care Coordination Program receive a full mental health assessment. These assessments inform case managers about the difficulties veterans are facing and helps inform where they refer veterans for further assistance. Senior VA officials told us the assessments conducted by the OEF/OIF/OND Care Coordination Program can be used as gateways to provide veterans, who are experiencing difficulties such as, TBI, depression, and alcohol abuse, with an integrated treatment approach. These officials added that the goal is to treat veterans holistically, rather than offering mental, physical and social work care separately. Similarly, the FRCP was designed to coordinate clinical and nonclinical services for the most seriously wounded, ill, or injured. Servicemembers and veterans who are enrolled in the program are offered assistance with developing a plan that sets recovery goals and then guides them through the continuum of care of medical treatment and stabilization, rehabilitation, and community reintegration. FRCP employs dedicated care coordinators to guide servicemembers, veterans, and their families through the complex systems of health care, services, and benefits provided by DOD, VA, other federal agencies, and the private sector. To the extent that VA does not consider this approach for veterans likely to experience difficult transitions, especially those with known risk factors, some veterans may be left to themselves to deal with the after effects of combat. Importantly, some veterans we spoke with said that obtaining support early in the readjustment process is crucial because veterans who receive assistance immediately after separating from the military may have a better chance of achieving a successful readjustment. According to Standards for Internal Control in the Federal Government, agencies should identify risks, estimate the risk’s significance, assess the likelihood of its occurrence, and decide how to manage the risk and what actions should be taken.is not occurring as early as possible, VA could be missing an opportunity to use its resources most efficiently and effectively. That is, if veterans do not receive the fullness—or any—of the support they need, the difficulties that emerge early in the readjustment process may worsen, resulting in potentially greater harm to the veteran and putting the agency at risk for an increase in the amount of resources it must then provide in the veteran’s readjustment process.

Conclusions

As over 1 million servicemembers separate from the military over the next 6 years, many will rely upon the programs administered by VA for support during their transition. For some veterans, this transition will go smoothly and without major difficulty. For others, however, the first few years after they leave the military will be difficult. Even though hundreds of articles, studies, and reports have been written about the experiences of veterans, relatively few discuss how recently separated veterans are adjusting to civilian life, and the issue of how well veterans are faring is still not well understood. Meanwhile, despite VA’s network of outreach efforts and the range of benefits and services it administers, many veterans continue to struggle to access support, and the agency continues to face long- standing challenges in providing benefits in a timely manner. And, while the Transition Assistance Program may help identify some of those at risk for having a difficult readjustment, the program does not cover the breadth of issues many veterans face once they leave the military. As a result, some veterans who need support may be missed. However, until VA has a better understanding of the needs of recently-separated veterans, and which veterans may be more likely to face difficulties, it is difficult to know what steps VA should take. For instance, if many veterans face multiple problems that need to be addressed across its organizational boundaries, from health care, disability, and employment services, then more coordinated case management services may be needed. If veterans wait too long to seek out the help they need, then an effort to identify and target veterans for early intervention may be needed. If VA discovers severe struggles exist among a relatively narrow but identifiable small group of veterans during the initial years of civilian life, then VA is better positioned to take an early and cost-effective approach to helping rebuild lives. For veterans, having timely access to programs and services may improve their chances of having positive health, economic, and social outcomes. For VA, better-supported veterans may be less likely to end up in need of more intensive care and case management services over time, which would put less strain on VA’s limited resources.

Recommendation for Executive Action

We recommend that the Secretary of Veterans Affairs take steps to better understand both the difficulties faced by readjusting veterans and the characteristics of those who may be more likely to face such difficulties, and use the results to determine how best to enhance its benefits and services to these veterans.

Agency Comments and Our Evaluation

We provided a draft of this report to VA for review and comment. In its written comments, reproduced in appendix II, VA generally agreed with our conclusions and concurred with our recommendation. VA also described its recent efforts and plans for improvement. For example, VA described its implementation of recent changes to the Transition Assistance Program, now known as the Transition Goals, Plans, Success program, and its plans to use an upcoming longitudinal evaluation to inform policy changes and program improvements. VA also provided technical comments that were incorporated, as appropriate.

We are sending copies of this report to appropriate congressional committees, the Secretary of Veterans Affairs, and other interested parties. In addition, the report is available at no charge on the GAO website at http://www.gao.gov.

If you or your staff have questions about this report, please contact me at (202) 512-7215 or bertonid@gao.gov. Contact points for our Offices of Congressional Relations and Public Affairs may be found on the last page of this report. Key contributors to this report are listed in appendix III.

Appendix I: Objectives, Scope, and Methodology

The objectives of this review were to examine what is known about (1) the extent to which veterans experience difficulties during their readjustment to civilian life, and (2) how VA assists veterans in their readjustment, and what challenges and opportunities exist. To address these objectives, we conducted a literature search, interviewed relevant officials from VA and DOD, reviewed VA’s strategic plan, annual performance reports, and other documents, visited four locations with VA facilities, and held eight discussion groups with 45 veterans and family members. We also interviewed national representatives from the Wounded Warrior Project and Disabled American Veterans. We focused on the initial readjustment period, and for the purposes of this review defined it as the first 5 years after a veteran separates from the military. The scope of this review was active, reserve, and National Guard OEF/OIF/OND-era veterans who separated from military service after September 11, 2001. Active servicemembers and veterans of the Coast Guard were outside the scope of this study. While the readjustment period for each veteran may vary, and some may continue to experience difficulties beyond the first few years, we focused our review on the initial readjustment period.

Literature Search

We conducted an extensive search for studies on the difficulties faced by readjusting veterans, and then screened the studies in two phases. The purpose of the first phase was to identify the range and types of difficulties experienced by post-9/11 veterans in the first few years after they separated from the military. The purpose of the second phase was to identify the percentage of veterans who experienced each difficulty we identified, and the characteristics of the veterans who experienced them.

We conducted electronic searches of over 30 databases. Key databases searched include ArticleFirst, CINAHL, Electronic Collections Online, Education Resources Information Center, MEDLINE, National Technical Information Service, PolicyFile, ProQuest, PsycINFO, SciSearch, Social Sciences Abstracts, Sociological Abstracts, and WorldCat. We searched for English-language documents published between September 2001 and May 2013, using Boolean search phrases designed to capture difficulties experienced by veterans within our scope, including variations of the words “veteran”, “challenge”, “problem”, “civilian”, “transition”, “discharge”, “return”, “re-entry” or “re-integration”, “Iraq”, Afghanistan”, “Enduring Freedom”, and “war on terror”, From these sources, we identified 401 documents that were potentially relevant to our review.

For the first phase, we reviewed the titles and abstracts for each of the 401 documents and for additional documents we identified by searching GAO and the Congressional Research Service’s report databases and conducting general Internet searches. We looked for common themes and developed a list of issues or themes about veterans’ readjustment difficulties. One analyst performed these review tasks, and then another analyst verified the results. They discussed any disagreements on the reviews, screenings, and themes, and worked with a third analyst to resolve any remaining disagreements. We presented this list to VA officials and veterans during our interviews and site visits and asked whether we had identified the types of difficulties faced by recently transitioned veterans. In general, the officials and veterans agreed that our list captured the range and types of difficulties faced by recently transitioned veterans, and we made a few additions based on these interviews.

For the second phase, we screened out documents that were not published books, peer-reviewed journals, state or federal government reports, or reports from associations and research organizations (e.g., RAND). We started with the same 401 documents from our original literature search and screened out 114 documents that were from the following sources: unpublished papers, dissertations and theses, general news articles, conference papers, and hearings.

We reviewed the titles and abstracts of the remaining 287 documents and excluded 179 that focused exclusively on out-of-scope individuals or unambiguously used methods that would not provide relevant prevalence information. Our screening criteria also excluded articles that did not report data from the population relevant to this engagement (U.S. military veterans who had already transitioned from the military to civilian life after 2001); collected data from case studies, focus groups, or other qualitative methods or in a single U.S. county or city; or were non-empirical theory or opinion articles. Two analysts (one with content expertise and one with methodological expertise) independently reviewed each document’s title and abstract according to a detailed coding manual to indicate whether it should be included for further review or excluded based on one of the screening criteria. Initial disagreements between analysts were resolved through discussion. When in doubt, a document was included rather than excluded during this abstract review.

We then reviewed the remaining 108 documents in a more detailed screening step. Two analysts with the same mix of expertise as above reviewed the complete documents and excluded articles that did not meet any of the screening criteria above, did not report any quantitative data relevant to our review, or did not report data for recently-transitioned veterans (i.e., those who had transitioned from the military to civilian life within 5 years previous to the start of the study’s data collection). Additionally, documents that included reviews of the literature but did not collect new data (referred to as “review articles” hereafter) were cataloged but excluded at this stage. Initial coding disagreements between analysts were resolved through discussion. When in doubt, a document was included rather than excluded during this step. Only 13 documents met all our screening criteria for a full review.

We then examined the bibliographies of those 13 documents along with the bibliographies of 24 review articles and identified 136 additional potentially relevant documents. Then, using the same exclusion criteria noted above, one analyst coded each document and a second analyst reviewed each document and concurred or did not concur with the initial coding. Disagreements were resolved through discussion. When in doubt, a document was included rather than excluded at this step. We excluded 124 of these documents, which resulted in 12 additional documents to fully review.

Two analysts then conducted a full review of the 25 documents (13 from the original search and 12 from the second search) to extract relevant prevalence and characteristic information and identify important caveats for our uses of the results. We excluded an additional seven documents during our full review stage, thus leaving 18 of them that met our inclusion criteria. The studies that were included are shown in table 2. We have described the limitations of the results for our use of individual studies within the body of this report.

Visits to VA Facilities

We visited VA facilities in four locations across the United States. We selected the locations based on a number of factors including; geographic diversity, a mix of military services with bases in the area (i.e., Army, Navy, Air Force, or Marines), a high concentration of veterans among the local population, and close proximity to VA facilities. At each of the selected locations, we visited one VA Medical Center and one Vet Center. In three of the four locations, we visited VA regional offices that were closest to the VA Medical Center. At the VA Medical Centers, we spoke with officials from the OEF/OIF/OND Care Coordination Program and the Post Deployment Integrated Care Initiative as these programs specifically serve readjusting veterans. Similarly, Vet Centers serve readjusting veterans, and at each of those facilities we spoke with counselors and senior Vet Center staff. At the regional offices we spoke with officials from Disability Compensation, Vocational Rehabilitation and Employment (VR&E), homeless coordinator programs as well as senior regional office officials. We included Disability Compensation and VR&E because these programs serve large numbers of veterans, including readjusting veterans. We included homeless coordinators because VA offers specific programs for veterans at risk of becoming homeless, which is one of the difficulties we identified through our initial research.

At each VA Medical Center and Vet Center, we conducted nongeneralizable discussion groups with veterans to gain a better understanding of their experiences with readjusting to civilian life. VA officials from each center invited veterans who had separated from the military within the last few years and who served during the OEF/OIF era (since September 11, 2001). At each location we visited we conducted two group discussions with veterans with between two and eight veterans attending each discussion. At two of the discussion groups, family members were present and a total of 45 veterans and family members participated. At the start of each discussion group we asked the veterans to rate how well they felt prepared for their transition from military to civilian life. We also asked them to rate the level of difficulty they had with employment, getting the right health care, being healthy, going back to school, getting along with family and friends, managing finances, getting assistance from VA, avoiding legal trouble, and finding a place to live. We used their responses to guide the discussions to gain a qualitative understating for why veterans experienced difficulties with their readjustment and what VA could do to better assist them. We conducted interviews with representatives from veteran service organizations at three of the four locations we visited because of their experience in working with veterans including representatives from American Legion, AmVets, Disabled American Veterans, the Military Order of the Purple Heart and Veterans of Foreign Wars.

We conducted this performance audit from March 2013 to September 2014 in accordance with generally accepted government auditing standards. These standards require that we plan and perform the audit to obtain sufficient, appropriate evidence to provide a reasonable basis for our findings and conclusions based on our audit objectives. We believe that the evidence obtained provides a reasonable basis for our findings and conclusions based on our audit objectives.

Appendix II: Comments from the Department of Veterans Affairs

Appendix III: GAO Contact and Staff Acknowledgments

GAO Contact

Staff Acknowledgments

In addition to the contact named above, Brett Fallavollita (Assistant Director); Paul Schearf (Analyst-In-Charge), Janina Austin, David Chrisinger, Lorraine Ettaro, Jeffrey Fiore, David Forgosh, Ashley McCall, Sheila McCoy, Michael Silver, Almeta Spencer, Roger Thomas, Karin Wallestad, James Whitcomb, and Paul Wright made key contributions to this report.

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