Recovering Servicemembers and Veterans: Sustained Leadership Attention and Systematic Oversight Needed to Resolve Persistent Problems Affecting Care and Benefits
Released: 2012-11-16T00:00:00

Letter

Background

Review groups identified significant problems after the media reports concerning Walter Reed. Initial efforts to respond to these problems were primarily coordinated through the Senior Oversight Committee, and DOD and VA undertook additional efforts to respond to these problems.

Review Groups Identified Problems across the Recovery Care Continuum

Following the revelations at Walter Reed, several review groups noted significant problems that may arise during servicemembers’ recovery from wounds, illnesses, and injuries. Some of these problems involve the provision of appropriate medical care, while others involve the acquisition of needed DOD and VA benefits. In 2007, one of the review groups, the President’s Commission on Care for America’s Returning Wounded Warriors—commonly referred to as the Dole-Shalala Commission—noted that recovering servicemembers depend on the effective and efficient provision of medical services and benefits across the recovery care continuum, which is separated into three phases: recovery, when wounded, ill, and injured servicemembers are stabilized and receive acute inpatient medical treatment at an MTF, VAMC, or private medical facility; rehabilitation, when recovering servicemembers with complex trauma, such as missing limbs, receive medical and rehabilitative care; and reintegration, when servicemembers either return to active duty or to the civilian community as veterans.

A recovering servicemember or veteran may not experience the recovery care continuum as a linear process, and may move back and forth across the continuum over time, depending on his or her medical needs. For example, a servicemember who has transitioned to the rehabilitation phase may go back to the recovery phase if there is a need to return to an MTF to obtain acute medical care, such as a surgical procedure.

Initial Efforts to Address Problems Were Coordinated by the Senior Oversight Committee

DOD and VA took a number of steps to address the problems identified by the review groups that investigated the issues raised by the Walter Reed media reports. As an initial step, the departments established the Senior Oversight Committee to coordinate and oversee DOD’s and VA’s efforts to jointly resolve these problems. Through this committee, DOD and VA created programs and initiatives to assist recovering servicemembers and veterans as they navigate the recovery care continuum. Key efforts included the establishment of the integrated disability evaluation system (IDES), the Federal Recovery Coordination Program (FRCP), the Recovery Coordination Program (RCP), and the Interagency Program Office. (See fig. 1.)

Senior Oversight Committee. The Senior Oversight Committee was responsible for ensuring that the recommendations—which totaled more than 600 from the various review groups—were properly reviewed, coordinated, implemented, and resourced. Supporting the Senior Oversight Committee was an Overarching Integrated Product Team, the membership of which included the Assistant Secretaries of Defense, the military departments’ Assistant Secretaries for Manpower and Reserve Affairs, and various senior officials from DOD and VA. This team coordinated, integrated, and synchronized the work of the eight “Lines of Action” (LOA) that focused on specific issues, including case management, disability evaluation systems, and data sharing between DOD and VA. (See fig. 2.)

Each LOA included representation from DOD, including each military service, and VA. They performed the bulk of the work to address the issues and recommendations of the various review groups, including establishing plans, setting and tracking milestones, and identifying and enacting early and short-term solutions. More specifically, the LOAs were as follows:

LOA 1—Disability Evaluation: Responsible for addressing efforts to reform the DOD and VA disability evaluation systems.

LOA 2—Traumatic Brain Injury (TBI)/Post Traumatic Stress Disorder (PTSD): Responsible for addressing issues related to TBI/PTSD.

LOA 3—Case Management: Responsible for addressing issues related to the care, management, and transition of recovering servicemembers from recovery to rehabilitation and reintegration.

LOA 4—DOD/VA Data Sharing: Responsible for addressing issues regarding the electronic exchange of DOD and VA health records.

LOA 5—Facilities: Responsible for addressing issues relating to military and VA medical facilities.

LOA 6—”Clean Sheet” Review: Developed recommendations to improve care and benefits without the constraints of existing laws, regulations, organizational roles, personnel constraints, or budgets.

LOA 7—Legislation and Public Affairs: Responsible for addressing legal and other issues for policy development.

LOA 8—Personnel, Pay, and Financial Support: Responsible for addressing compensation and benefit issues.

Some of the key efforts initiated out of the LOAs included the establishment of an integrated disability evaluation system, care coordination programs, and steps towards the electronic exchange of DOD and VA health records—a responsibility that was later assumed by the Interagency Program Office.

DOD/VA Integrated Disability Evaluation System. Through LOA 1, DOD and VA jointly began to develop and pilot IDES to improve the disability evaluation process by eliminating duplication in DOD’s and VA’s separate evaluation systems and expediting the receipt of VA benefits. Specifically, IDES merges DOD’s and VA’s separate medical exams for servicemembers into a single exam process; consolidates DOD’s and VA’s separate disability rating decisions into a single VA rating decision; and provides staff to perform outreach and nonclinical case management and explain VA results and processes to servicemembers. By October 2011, DOD and VA had fully deployed IDES at 139 MTFs in the United States and several other countries.

Care Coordination Programs. LOA 3 took the lead role in addressing problems with uncoordinated case management for recovering servicemembers and veterans through the establishment of two care coordination programs—the FRCP and the RCP. The FRCP was based on a recommendation from the Dole-Shalala Commission that a single individual—a recovery coordinator—would work with existing DOD and VA case managers to ensure that servicemembers had the resources needed for their care. LOA 3 designed the FRCP to assist “severely” wounded, ill, and injured OEF and OIF servicemembers, veterans, and their families with access to care, services, and benefits. This population includes servicemembers and veterans who suffer from traumatic brain injuries, amputations, burns, spinal cord injuries, visual impairment, and PTSD. The program uses federal recovery coordinators to monitor and coordinate clinical services, including facilitating and coordinating medical appointments, and nonclinical services, such as providing assistance with obtaining financial benefits or special accommodations, needed by program enrollees and their families. Federal recovery coordinators, who are senior-level registered nurses and licensed clinical social workers, were intended to serve as the single point of contact among all of the case managers of DOD, VA, and other governmental and nongovernmental programs that provide services directly to servicemembers and veterans. Although the FRCP was designed as a joint program, it is administered by VA, and the federal recovery coordinators are VA employees.

LOA 3 subsequently developed the RCP in response to a requirement in the NDAA 2008. The RCP is a DOD-specific program that uses recovery care coordinators to coordinate nonclinical services and resources for “seriously” wounded, ill, and injured servicemembers who may return to active duty, unlike those categorized as “severely” wounded, ill, and injured, who are not likely to return to duty and would be served by the FRCP. The military services were responsible for separately implementing the RCP through each of their existing wounded warrior programs as a means of providing care coordination services to program enrollees.

Electronic Sharing of Health Records. LOA 4 was focused on addressing issues related to the electronic exchange of DOD and VA health records. However, this effort was superseded by the NDAA 2008, which required the establishment of the Interagency Program Office to serve as a single point of accountability for both departments in the development and implementation of interoperable electronic health records.DOD and VA retained the responsibility for the development and Although management of the information technology systems, the Interagency Program Office was responsible for ensuring the implementation of an electronic health records system or capabilities that allowed for the complete sharing of health care information for the provision of clinical care. In October 2011, the Interagency Program Office also became accountable for DOD’s and VA’s work on developing an integrated electronic health records system that both departments would use for their beneficiaries.

Additional Efforts by DOD and VA to Address Problems Facing Recovering Servicemembers and Veterans

In addition to the Senior Oversight Committee’s efforts, DOD, its military services, and VA developed or modified a number of programs and initiatives to assist recovering servicemembers and veterans in navigating the recovery care continuum.

Military Services’ Wounded Warrior Programs. The military services’ wounded warrior programs were established to assist recovering servicemembers during their recovery, rehabilitation, and initial reintegration back to active duty or to civilian life. Most of these programs provide nonclinical case management services to the recovering servicemembers; that is, they help to resolve issues related to finances, benefits and compensation, administrative and personnel paperwork, housing, and transportation. In addition, the wounded warrior programs serve as the central point of access to other types of services or resources that support recovering servicemembers, such as clinical case management, care coordination, and career, education, and readiness services. (See table 1.) If a wounded warrior program does not directly provide a service or resource, it can facilitate servicemembers’ access to that service or resource. Although the wounded warrior programs were intended mainly to provide services to recovering servicemembers, all but one of the programs continue to assist individuals after they have transitioned to veteran status.

VA Transition Programs. VA’s Liaison for Healthcare Program and its OEF/OIF/OND Care Management Program assist recovering servicemembers with transitioning from DOD’s to VA’s health care system. As of August 2012, the Liaison for Healthcare Program employed 33 liaisons at 18 MTFs nationwide. After a DOD or VA treatment team determines that a recovering servicemember is medically ready to transition to a VAMC, a VA liaison facilitates the transfer from an MTF to a VAMC closest to their homes or to the most appropriate locations for the specialized services their medical condition requires. VA liaisons follow recovering servicemembers as they enter the VA health care system, ensuring that their first VA appointments are scheduled. Thereafter, the VA OEF/OIF/OND Care Management Program team assigned to each recovering individual coordinates the individual’s care at the VAMC and provides ongoing follow-up.OEF/OIF/OND Care Management Program team in place to coordinate patient care activities.

DOD and VA Have Not Fully Resolved Persistent Problems with Case Management and Care Coordination, Disability Evaluation Systems, and Electronic Sharing of Health Records

Recovering Servicemembers and Veterans Do Not Always Have Access to the Case Management and Care Coordination Programs Designed to Assist Them

Recovering servicemembers’ access to case management and care coordination programs has been impeded by two main factors—(1) the limited ability to identify and refer those servicemembers who could benefit from enrollment in the programs along with officials’ reluctance to refer them, and (2) variations in eligibility criteria among the military services’ wounded warrior programs, resulting in access disparities for similarly situated recovering servicemembers.

We found that referrals may be lacking or delayed (1) from military service unit commanders to wounded warrior programs; (2) from wounded warrior programs to the FRCP; and (3) for certain groups of servicemembers, such as those with “invisible injuries” as well as members of the National Guard and Reserve.

Referral to the military services’ wounded warrior programs. The military services’ wounded warrior programs primarily use referrals to identify recovering servicemembers that might be eligible for enrollment. However, we found that the methods for referral, which include casualty reports and direct referrals, are imprecise, such that all servicemembers who could benefit from being enrolled in these programs are not necessarily identified and referred.

Officials from three wounded warrior programs told us that casualty reports are the primary method for receiving referrals. Casualty reports are initial alerts to military personnel, including wounded warrior program officials, that a servicemember has been injured. These reports can be initiated by unit commands or other military personnel as a method of referral to the wounded warrior programs. However, wounded warrior program officials from four wounded warrior programs told us that casualty reports are not created after every injury or may be created late in a servicemember’s recovery. In particular, some of these officials said that military service unit command staff may delay or not create casualty reports for servicemembers not injured in combat, such as for injuries that occur stateside or while on leave, because servicemembers’ units may not find out about such incidents immediately.

We found that referrals by unit command staff are most likely, because they have the most knowledge about servicemembers’ conditions, injuries, and treatment locations. their recovery as a result of staying in their units and not being referred to a wounded warrior program earlier. For example, a recovering servicemember told us that despite having been recently discharged from a hospital for arm injuries, he was required to operate a floor buffing machine in his unit, which was difficult for him as a result of his injuries. He did not receive rehabilitative treatment for his injuries until he was assigned to a wounded warrior program. Furthermore, we found that most of the military services’ wounded warrior programs do not always track the number of referrals to their programs, including data on whether or not servicemembers referred to the programs were actually enrolled. (See table 14 in app. I for additional information about referral data.) Without this information, it is not clear whether all those who could benefit from a wounded warrior program are being enrolled.

Referral to the FRCP. In addition to problems with referrals to wounded warrior programs, wounded warrior program officials sometimes delay or fail to make referrals of potentially eligible servicemembers to the FRCP, which coordinates care across the departments and throughout the recovery care continuum. As we have previously reported, the FRCP relies predominantly on referrals from other sources, including wounded warrior program officials and clinical treatment teams, because it does not have a systematic way to identify potential enrollees. Referrals to the FRCP are important because federal recovery coordinators are intended to provide continuity of care throughout servicemembers’ recovery, starting with their initial treatment at an MTF and throughout the recovery care continuum. They can also assist in facilitating recovering servicemembers’ access to VA services and benefits while servicemembers are still on active duty, according to VA officials. However, we found that officials from wounded warrior programs view the jointly created and established FRCP as a VA program and, therefore, delay their referrals until it is certain that the servicemember will become a veteran.

Referrals for certain servicemember populations. We found that certain servicemember populations may be at greater risk for not being identified for DOD and VA case management and care coordination programs.

Specifically, according to wounded warrior program officials, servicemembers who have undiagnosed, “invisible” wounds, such as PTSD and TBI, may be at greater risk of not being referred to a wounded warrior program or the FRCP until it becomes apparent that the servicemember cannot be deployed. For example, a servicemember told us that although he was experiencing anxiety every time he put on his uniform, it was not until he had a severe anxiety attack, as a result of his PTSD, that he was hospitalized and then referred to a wounded warrior program. According to officials representing military advocacy organizations, National Guard and Reserve servicemembers may be particularly reluctant to identify injuries and illnesses because they are eager to return home and do not want to be delayed at the installation for an evaluation of any conditions they may have. However, these officials said that when these servicemembers have been deactivated and problems manifest themselves later on, they may experience difficulties establishing that their injuries or illnesses are a result of their service in the military, which could make it difficult for them to access services and programs provided by DOD and VA.

Because of variations in eligibility criteria among the military services’ wounded warrior programs, DOD cannot assure that similarly situated servicemembers have equitable access to these programs, leading to disparities in the level of assistance provided across the military services. (See table 2.) For example, servicemembers can only be eligible for the Air Force Wounded Warrior Program if they have a combat-related injury or illness, whereas servicemembers with combat or non-combat-related injuries or illnesses can be eligible for the Army’s Warrior Transition Units.

As a result of these differences in eligibility criteria, recovering servicemembers in one military service may qualify for entry in their wounded warrior program while similarly situated servicemembers in another military service do not have access to their program. Consequently, according to wounded warrior program officials, some recovering servicemembers do not have access to services that would otherwise be available to them, including the RCP and Operation Warfighter. Additionally, because wounded warrior programs facilitate access to other programs and services, including the VA Liaison for Healthcare Program and the Warrior Athlete Reconditioning Program, not being eligible for a particular wounded warrior program could preclude a servicemember from receiving the services of these other programs. Military coalition officials who advocate for recovering servicemembers and their families told us the lack of standardization across similar programs, such as the military services’ wounded warrior programs, is one of the main reasons recovering servicemembers “fall through the cracks” or do not get the services that they need when they are navigating the recovery care continuum.

DOD is aware of inconsistencies in eligibility criteria among the military services’ wounded warrior programs and the potential for disparities in the provision of services and assistance that may result. DOD has not taken action to correct this, however, despite the identification of this issue as a potential problem for recovering servicemembers by a congressionally mandated DOD task force. Specifically, in its 2011 annual report to congressional committees, the Recovering Warrior Task Force noted that as a result of differences in eligibility criteria among the military services, certain subpopulations of recovering servicemembers may be at a disadvantage. In response to this report, DOD stated that although there are no DOD-wide criteria for entry into wounded warrior programs, the individual military services already have policies in place as a result of the flexibility given to them by DOD.

Delays in DOD’s and VA’s Integrated Disability Evaluation System Persist, Limiting Recovering Servicemembers’ Ability to Plan for Their Future

Although IDES provides improved timeliness over the separate DOD and VA disability evaluation systems, processing times have continued to increase since its implementation in November 2007, resulting in frustration and uncertainty for servicemembers going through the process. In a May 2012 hearing, we testified that the average number of days for servicemembers to complete the IDES process and receive VA benefits increased from 283 in fiscal year 2008 to 394 in fiscal year 2011 for active duty cases (compared to the goal of 295 days) and from 297 to 420 for reserve cases, respectively (compared to the goal of 305 days).

As we have previously testified, other reasons that could impact the increase in IDES processing times include large case loads and insufficient staff to complete a stage of IDES in a timely manner. the status of their case. For example, a servicemember told us that after going through the IDES process, receiving a rating, and filing an appeal over a year ago, he still did not know the status of his case, negatively affecting his ability to plan for his future. Similarly, a wounded warrior program official also told us that her program has had several servicemembers lose job opportunities because they applied for positions thinking that they would be through the IDES process by a certain date, but when that date was pushed back, the employers rescinded their offers.

Wounded warrior program officials from some of the sites we visited told us that extended waiting periods resulting from the disability process also may lead to some recovering servicemembers engaging in negative behavior, including drug use. Wounded warrior program officials told us that after waiting for so long in the wounded warrior barracks due to the lengthy disability process, servicemembers can get depressed, resist or just stop going to medical appointments, and stop working on their recovery. Similarly, the DOD Inspector General has reported that lengthy IDES processing times has contributed to a negative and even counterproductive environment, which was not conducive to servicemembers’ recovery and transition. To prevent these problems, we found that two wounded warrior programs require recovering servicemembers to participate in programs such as the Warrior Athlete Reconditioning Program and Operation Warfighter. A recovering servicemember told us that soon after being assigned to the wounded warrior program, he was referred to the Warrior Athlete Reconditioning Program, which gave him something to do other than “sitting around.” Another recovering servicemember told us that the Warrior Athlete Reconditioning Program is an effective motivator for recovery.

Conversely, the servicemembers could take actions that may impact their own processing times in IDES and, therefore, their length of stay in a wounded warrior program. We found that some servicemembers may appeal their disability decisions to prolong their own recovery and transition out of the military. According to wounded warrior program officials from some of the sites we visited, some servicemembers resist their transfer out of the wounded warrior program and the military because they want to continue to take advantage of the opportunities and services available to them, including the financial security of a regular paycheck. For example, a wounded warrior program official and a VA official told us that some servicemembers will purposefully miss appointments to delay the IDES process because they feel that they are not ready to leave the program.

DOD and VA Have Yet to Develop Sufficient Capability to Electronically Share Health Records, Potentially Delaying Servicemembers’ Receipt of Coordinated Care and Benefits

The departments have not yet developed sufficient capability to electronically share servicemembers’ and veterans’ complete health records, which can delay the receipt of care and benefits for recovering servicemembers and veterans. As we have previously reported, for over a decade DOD and VA have undertaken several efforts to improve the ability of their information technology systems to electronically share health records. For example, the Federal Health Information Exchange, which was started in 2001 and completed in 2004, allows DOD to electronically transfer servicemembers’ health information to VA when they leave active duty. In addition, the departments’ Bidirectional Health Information Exchange was established in 2004 to allow clinicians in both departments to view limited health information on patients who receive care from both departments. More recently, the departments have undertaken two new joint initiatives, the Virtual Lifetime Electronic Record and an integrated electronic health records system, in an effort to increase electronic health record interoperability and modernize their systems.

We found that although DOD and VA care providers were expected to have access to some electronic health record information across the departments, the DOD and VA care providers that we spoke to still did not have the ability to electronically share complete health records for recovering servicemembers who were transferring between DOD’s and VA’s health care systems, and therefore they had to use other methods.

For example, wounded warrior program and VA officials told us that they had to resort to copying and faxing recovering servicemembers’ health records to VAMC staff in preparation for a servicemember’s transition from DOD’s to VA’s health care system because there was not an automatic, electronic way to transfer them. In addition to copying and faxing health records, according to VA officials we spoke with, DOD and VA staff may hold a video-teleconference between the transferring MTF and receiving VA health care facilities to exchange information.

In addition, wounded warrior program and VA officials who help servicemembers transition from DOD to VA told us that they only share with VA facilities the health records necessary for the treatment of a recovering servicemember’s current condition. As a result, servicemembers’ and veterans’ complete health records are not always shared between departments when transferring facilities, and ultimately, the responsibility to collect and provide a complete health record to the VA facility can fall on the recovering servicemember and veteran. A VA official told us that this process can be complicated because DOD separately maintains servicemembers’ inpatient, outpatient, and behavioral health records and does not have a single database that can identify all of the medical facilities where a servicemember received treatment. Further, according to VA and DOD officials, delaying the collection and assembly of a servicemember’s complete medical history until the start of the disability process could result in servicemembers having to be reexamined when they are demobilized, needing to establish that their injuries were connected to their time in the military, thus possibly delaying a servicemember’s or veteran’s receipt of VA benefits.

Both departments have needed to create programs and provide staff to assist recovering servicemembers during their transition from a DOD MTF to a VAMC. For example, VA Liaisons and DOD nurse case managers help recovering servicemembers transition from DOD to VA by assembling their health records and sharing them with the VAMC where the servicemember will be receiving treatment. According to DOD and VA staff that assist servicemembers in their transition from one system to another, DOD nurse case managers at installations that do not have VA Liaisons do not always have the same knowledge of VA services and benefits, and may not be informed of the appropriate referral methods or contacts used by VA Liaisons to provide a servicemember with a seamless transition to a VAMC. A DOD official told us that at locations where the VA Liaison program is not available, the transition process for recovering servicemembers from DOD to VA is more difficult. This official understood how to properly transfer servicemembers’ records from the DOD facility to the receiving VA facility only because of past VA experience.

DOD and VA Have Not Fully Resolved Long-standing Problems Due to Deficiencies in Leadership and Oversight, Resources, and Collaboration

Lack of Leadership and Oversight Has Limited DOD’s and VA’s Ability to Effectively Manage Programs for Recovering Servicemembers and Veterans

The lack of leadership and program oversight has limited DOD’s and VA’s ability to effectively manage programs created to serve recovering servicemembers and veterans. Two bodies established to oversee these programs, the Senior Oversight Committee and the Office of Wounded Warrior Care and Transition Policy (WWCTP), lacked consistent leadership attention and oversight capabilities. In addition, DOD does not have a central office that oversees or collects common data on the military services’ wounded warrior programs.

The Joint Executive Council was established by law in November 2003 to provide senior leadership for collaboration and resource sharing between DOD and VA. Through a joint strategic planning process, the Joint Executive Council recommends to the Secretaries the strategic direction for the joint coordination and sharing efforts between the two departments and oversees the implementation of those efforts. high-level leadership participation without substitution of lower-ranking rapid policy development and quick decision making, and rigorous monitoring to hold the military services and the two departments accountable for needed actions.

Sustaining the Senior Oversight Committee’s original momentum over time became difficult, and its waning influence and effectiveness became evident in a number of ways:

Starting in December 2008, the Senior Oversight Committee experienced leadership changes, including the departure of its cochairs, the Deputy Secretaries, as well as turnover in some of its key staff. According to a former Senior Oversight Committee executive, the personal commitment and strong relationship between the Deputy Secretaries who initially cochaired the Senior Oversight Committee served as a unifying and confidence building force that was not replicated by subsequent leadership, while leadership turnover in the DOD offices supporting the Senior Oversight Committee negatively impacted its ability to function effectively.

As we have previously reported, the Senior Oversight Committee also began to encounter challenges when DOD “disrupted the unity of command” by changing the organizational structure of the committee and realigning and incorporating the committee’s staff and responsibilities into existing or newly created DOD and VA offices, such as WWCTP.us that the new staffing arrangement did not adequately support the committee’s efforts, and VA did not provide full-time staff members to support the committee, as it had in the past. Later in October 2008, VA established the Office of VA/DOD Collaboration Services, and VA supported Senior Oversight Committee efforts, along with broader collaboration efforts, through this separate office.

Officials formerly involved with the committee told

The committee began meeting less frequently. For example, in contrast to weekly meetings held during its initial year of operation, in fiscal year 2011, the committee met less than 11 hours in total.

Top DOD leadership no longer consistently attended Senior Oversight Committee meetings. According to a former Senior Oversight Committee official, the second Deputy Secretary of Defense to cochair the committee sent the Deputy Undersecretary of Defense for Personnel and Readiness to represent DOD in his place.

The Senior Oversight Committee no longer made relatively quick decisions. According to former Senior Oversight Committee executive and support staff, frequent substitutions by lower-ranking officials at Senior Oversight Committee meetings no longer allowed for quick decision making and transformed Senior Oversight Committee meetings into informational briefings.

The Senior Oversight Committee no longer tracked or monitored progress of its policy initiatives or assigned tasks. According to a former LOA cochair and a cognizant support staff member, by 2011 the Senior Oversight Committee was no longer routinely using a tracking mechanism to hold the departments accountable for completing appointed tasks. Later that year, the Recovering Warrior Task Force reported that the Senior Oversight Committee no longer had a formal mechanism for assessing the status of the committee’s initiatives and goals, leaving no way to determine whether initiatives or goals had been partially or fully implemented or met.

In its September 2011 report, the Recovering Warrior Task Force recommended combining the Senior Oversight Committee and Joint Executive Council to improve effectiveness and reduce redundancies as both entities had similar membership and operating structures. In January 2012, the Joint Executive Council cochairs agreed to consolidate the two groups. The Senior Oversight Committee’s working groups for care coordination and the integrated disability evaluation system were realigned within the Joint Executive Council, and a Wounded, Ill, and Injured Council was established under the Joint Executive Council to oversee emerging issues for recovering servicemembers and veterans.

Whether the Joint Executive Council can effectively address the issues once managed by the Senior Oversight Committee has yet to be seen. Several DOD and VA officials expressed concern to us about the ability of the Joint Executive Council to focus on rapid, short-term policy decision making rather than the longer-term strategic planning role that it has traditionally played. For example, according to a DOD official, historically, the Joint Executive Council has not been able to drive policy decision making, and therefore, issues that should have been decided by the Joint Executive Council were taken directly to the Secretaries for resolution, raising doubts about the ability of the Joint Executive Council to function effectively. A former Senior Oversight Committee executive noted that the Joint Executive Council cochairs are not of equivalent rank, another challenge that may serve as a barrier to the council’s ability to make decisions and drive policy changes. Specifically, the VA cochair is the Deputy Secretary, who has control over all relevant offices within VA, while the DOD cochair is the Deputy Undersecretary of Defense for Personnel and Readiness, whose responsibilities include establishing health and benefit policies affecting recovering servicemembers and directing the military services to comply with such policies but lacks authority in enforcing the military services’ implementation of these policies. The Recovering Warrior Task Force also cited concerns about the rank of the DOD cochair of the Joint Executive Council, stating that a higher level of leadership is needed to sustain departmental attention on key initiatives such as IDES and electronic health records. Furthermore, as of August 2012, DOD officials told us that the Joint Executive Council is operating under the original procedures that were in place prior to the entities merging. As a result, it is unclear at this time how the Joint Executive Council will provide oversight and accountability for issues once addressed by the Senior Oversight Committee.

In 2008, WWCTP became responsible for overseeing the RCP among other programs that provide assistance to recovering servicemembers. However, WWCTP’s ability to oversee the RCP, including its ability to monitor program performance and ensure compliance with DOD policy, is limited by its lack of operational authority, such as budget and tasking authority, over the military services that implement the program. According to WWCTP officials, this lack of operational authority challenges WWCTP’s ability to direct the military services on their implementation of the program. For example, although WWCTP has been responsible for RCP oversight since 2008, the office was not able to collect basic program data, such as monthly enrollment numbers, on a consistent basis until October 2011. According to a WWCTP official, although WWCTP requested monthly data submissions from the military services, the information was provided on an ad hoc basis; sometimes the services would submit it, and other times they would not. Data- collection efforts still remain a challenge for WWCTP. For example, the Army’s Wounded Warrior Program, which serves as the Army’s care coordination program, only agrees to share partial data with WWCTP, arguing that the Army is only obligated to share data on servicemembers served by WWCTP-contracted personnel.

Getting the military services to implement consistent care coordination policies also poses a challenge for WWCTP. WWCTP officials said that while WWCTP can develop policy to guide the military services, the military services may interpret that policy and implement their programs differently. Consequently, some DOD officials assert that the military services have not consistently implemented the RCP in accordance with DOD policy—an observation that is shared by the Recovering Warrior Task Force. DOD policy requires that care coordination should be provided to those who are “seriously” and “severely” wounded, ill, and injured, but the Army only provides care coordination to recovering servicemembers who are “severely” wounded, ill, and injured. As a result, some servicemembers who could benefit from having someone coordinate their care and benefits as they navigate the recovery care continuum do not have access to those services.

Some WWCTP officials with whom we spoke expressed the view that the military services have been inconsistent in their cooperation with WWCTP, with cooperation being better on issues that represent priorities of top leadership. Specifically, WWCTP officials told us that top DOD leadership has not been pressured to resolve lingering care coordination issues as much as other more visible issues, such as IDES and electronic medical record interoperability problems confronting the departments. Consequently, WWCTP officials said that the military services cooperate with WWCTP’s efforts to oversee IDES and to monitor whether the military services achieve their goals for timely completion of the IDES process. Although these goals have not consistently been achieved,officials told us that military service cooperation has not been an impediment to overseeing IDES as it has been for overseeing care coordination. Conversely, the military services have not been as inclined to cooperate with WWCTP on its oversight of the RCP relative to these other issues.

In addition to limited operational authority over the military services, turnover in leadership and other staffing changes have also limited WWCTP’s ability to provide consistent direction and oversight for the RCP, according to WWCTP officials. Specifically:

Three different DOD officials have led WWCTP since its inception in 2008. According to WWCTP staff, each of these officials had different visions and priorities for the office, which led to disruptions in RCP oversight. For example, a major oversight initiative—to collect satisfaction survey data across the RCP—was abandoned when a new official was appointed. In addition, the RCP has been led by three different directors, with the most recent director leaving in June 2012.

In September through December 2011, WWCTP’s contracted staffing was temporarily reduced by 70 percent when a contract expired and was not immediately renewed, according to DOD. Staff reductions primarily impacted WWCTP’s ability to oversee the RCP, since many RCP support staff members were lost. For example, according to a WWCTP official, the office was no longer able to make monitoring visits to the RCP program sites. However, in July 2012 a contract was awarded that allowed WWCTP to engage additional staff to support the RCP, according to a WWCTP official.

In June 2012, DOD changed the name of the WWCTP office to the Office of Warrior Care Policy and moved it under the Assistant Secretary of Defense for Health Affairs. According to a DOD official, the change was made as part of a realignment of DOD’s organizational structure in response to statutory requirements. An official in Health Affairs said that the move will be beneficial because it will provide greater access to resources, including human resources and information technology, among others. However, it is too early to determine the full effect of this change.

There is currently no central office or authority that oversees or collects common data on the military services’ wounded warrior programs, preventing DOD from both assessing how well the programs are working across the department and leveraging the strengths of each program by sharing proven best practices across the military services.

Each of the military service Secretaries created their own wounded warrior programs to meet their military service’s unique needs. Because each service developed its own policy to govern its wounded warrior programs and no central, unified DOD policy exists to govern these programs, no central DOD office—such as WWCTP—may direct how these programs operate. This lack of central oversight over the wounded warrior programs has been one of the main reasons for the large discrepancies between these programs. The 2011 Recovering Warrior Task Force report recommended that the Secretary of Defense enforce the existing policy guidance regarding the Army’s and Marines’ wounded warrior transition units’ entrance criteria. However, in its response to this recommendation, DOD supported the military service Secretaries’ discretion in establishing their own policies in this regard, saying that there is no central DOD policy on the establishment of transition units and entrance criteria, and that the policies were established by the Secretaries for their specific populations.

While no common data are collected on the performance of wounded warrior programs across the military services, each individual program has initiated internal efforts to collect and analyze performance data. The type and quality of data vary by program, however. For example, the largest of the wounded warrior programs, the Army Warrior Care and Transition Program, has collected wounded warrior program performance survey data on a continuous basis since March 2007 and has developed outcome measures to determine the impact of its services. However, smaller programs, such as the Air Force Wounded Warrior Program and the United States Special Operations Command’s Care Coalition have measured baseline program satisfaction levels, but they do not have additional years of survey data to monitor any changes over time. (See table 3 for information about the types of performance data collected by each of the wounded warrior programs.)

Some DOD officials with whom we spoke questioned why common measures have not been developed. For example, a DOD official in charge of wounded warrior care at an MTF suggested developing a measurement tool to determine what aspects of the programs help recovering servicemembers. Another DOD official involved with wounded warrior program performance measurement commented that it is common practice for DOD to share performance measurement practices and standard metrics across the military services.

In September 2011, citing wide disparity across the military services in their implementation of wounded warrior programs and policies, the Recovering Warrior Task Force made four recommendations for creating common standards to ensure parity in the programs and services provided to recovering servicemembers across DOD. For example, the first recommendation called for a common nomenclature, or consistent definitions to be used in DOD policy to identify recovering servicemembers who may require and be eligible for assistance. The task force concluded that common definitions are needed to promote consistent levels of care among the military services and would better enable DOD to compare across programs and identify best practices. In its response to the task force, DOD acknowledged that some of these recommendations were valid and that DOD should take actions to address them. However, at the time of the Recovering Warrior Task Force’s 2012 report, these recommendations had not been implemented, and the task force is continuing to follow DOD’s efforts to implement Moreover, even if DOD decided to take some actions in this them.regard, it is unclear who would have responsibility for addressing them, since there is no central oversight office or authority for these programs.

Insufficient Staffing and Budget Control Have Contributed to DOD’s and VA’s Inability to Resolve Delays with Disability Determinations and Electronically Share Health Records

In addition to problems with leadership and oversight of care coordination and case management programs, DOD and VA have a longstanding track record of insufficient staffing to address delays in disability determinations and insufficient staffing and control over the budget to oversee the development of systems with improved capabilities for electronically sharing health records.

Insufficient staffing across both departments has affected DOD’s and VA’s ability to reduce disability determination delays and meet their IDES timeliness goals. We raised concerns about staffing in 2010, when we reported that DOD and VA did not sufficiently staff many key positions in the IDES process, including DOD board liaisons, who counsel servicemembers and ensure that documentation submitted for consideration is complete and accurate, and medical evaluation board physicians, who review medical and service records to identify conditions that limit a servicemember’s ability to serve in the military. In 2012, we continued to report evidence of staffing shortages, including high caseloads for DOD board liaisons and VA case managers as well as insufficient numbers of physicians to write narrative summaries needed to complete the medical evaluation board stage of the IDES process in a Some recovering servicemembers told us they do not timely manner.receive sufficient support from their DOD board liaisons, and that there are not enough liaisons to efficiently meet the needs of all the recovering servicemembers going through the IDES process.

Delays in the disability determination process are expected to continue. VA anticipates a much larger caseload of all disability and other benefit claims in the near future, not just those claims associated with IDES cases. Specifically, a high-level VA official told us that new laws, such as the Veterans Opportunity to Work Act, will encourage all transitioning servicemembers—not just those going through the IDES process—to claim VA benefits. This official also told us that DOD and VA have a much larger problem to address as a surge of 300,000 servicemembers begin to transition into the VA system as troops return home from Iraq and Afghanistan. Without adequate planning and adequate resources, these servicemembers may experience much longer processing times in the disability benefits systems.

DOD and VA are working to address staffing challenges in some of the IDES processes that are most delayed. We have previously reported that the Army, for example, is in the midst of a major hiring initiative to increase staffing dedicated to its medical evaluation boards, which will include additional DOD board liaisons and medical evaluation board physician positions. Additionally, VA officials said that the agency has added staffing to its IDES rating sites to handle the demand for preliminary disability ratings, rating reconsiderations, and final benefit decisions, which has increased the number of preliminary VA ratings completed and slightly improved processing times. But it is too early to tell the extent to which VA’s efforts will continue to improve processing times.

The Interagency Program Office was established by law single point of accountability for joint DOD and VA efforts to implement fully interoperable electronic health record systems or capabilities, but this office was not given sufficient staffing or budget control by DOD and VA to effectively facilitate the departments’ efforts. According to an Interagency Program Office official, the office was never fully staffed and was challenged by a high degree of turnover in staffing and leadership that served in a temporary or acting capacity.

The Interagency Program Office’s initial charter limited its ability to exercise authority over DOD and VA. Specifically, the charter stated that control of the budget, contracts, and technical development remained wholly within the two departments’ program offices. The charter conveyed no authority in these areas to the Interagency Program Office. As a former Interagency Program Office official testified in July 2011, the office lacked control of budgeting and contracting necessary to achieve its intended purpose, and without this, it could not sufficiently oversee the departments’ efforts and compliance with the requirements in NDAA 2008. As a result, each department continued to pursue separate strategies, rather than a unified interoperable approach, according to this former official.

See Pub. L. No. 110-181, § 1635, 122 Stat. 3, 460-63 (2008).

The Interagency Program Office was rechartered in October 2011 and provided an expanded staff and new authorities under the charter, including control over the budget. According to Interagency Program Office officials, when hiring under the new charter is completed, the office will have a staff of 236 personnel, more than seven times the number of In addition, the staff originally allotted to the office by DOD and VA.charter provides the Interagency Program Office with the authority to lead, oversee, and manage budget and contracting for electronic health record sharing efforts. According to Interagency Program Office officials, budget control is the essential component for overseeing progress and ensuring accountability for the departments’ efforts.

With the enhanced charter, as well as plans for an expanded staff to oversee the implementation of a single joint electronic health record system, the Interagency Program Office will have more resources to draw upon and support department interoperability initiatives. However, it is still too early to determine whether this investment of resources will be sufficient to meet the office’s goals for 2017. provision of additional resources, Interagency Program Office officials told us that as of July 2012, the office is staffed at approximately 48 percent and that hiring additional staff in time to meet appointed implementation deadlines remains one of its biggest challenges.

Despite Repeated Attempts, DOD and VA Have Failed to Effectively Collaborate to Align Their Care Coordination Programs; New Efforts Are Under Way

According to DOD and VA officials, the departments have identified 54 joint capabilities that will be implemented by the end of fiscal year 2017. will depend upon achieving cooperation between the departments—which has been elusive for many years—as well as with the military services.

With the creation of the RCP, the FRCP was no longer the single point of contact with respect to servicemembers’ care coordination, and early on, there were concerns and some confusion about how the FRCP and the RCP would align without creating overlapping and duplicative services. Shortly after the RCP was established, DOD sent a report to congressional committees outlining a medical category assignment process that was based on the severity of each servicemember’s medical condition, along with input from the servicemember and his or her unit commander, to determine whether servicemembers would be directed to either the FRCP or to the RCP for care coordination services. In concept, the medical category assignment process would have resulted in wounded, ill, and injured servicemembers being assigned to one of three categories: “mild,” “serious,” or “severe.” Under this approach, the FRCP would provide care coordination services for “severely” wounded, ill, and injured servicemembers and the RCP would serve those who were “seriously” wounded, ill, and injured. (See app. II for additional information on the intended medical category assignment process for DOD and VA care coordination programs.)

Despite DOD’s attempt to define the populations served by the FRCP and the RCP, neither the military services’ wounded warrior programs, which implement the RCP, nor VA, which administers the FRCP, implemented DOD’s assignment process. Instead, these programs expanded their enrollment to include both “seriously” and “severely” recovering servicemembers and veterans, which resulted in both programs serving the same populations, thereby setting up the likelihood of overlap and duplication of services. As we have previously reported, this duplication issue is compounded by the numerous other programs that also provide services to recovering servicemembers and veterans and have overlapping roles as well. It is not uncommon for recovering servicemembers to be enrolled in more than one case management or care coordination program and end up with multiple care coordinators and case managers—each of whom develop different care plans for the same servicemember. The care plans may even conflict with one another, which could conceivably adversely affect the servicemember’s recovery process. In fact, in the course of previous work, we found instances where inadequate information exchange and poor coordination between these programs resulted not only in duplication of effort and overlap of services, but also confusion and frustration for servicemembers and their families. In addition, DOD and VA officials acknowledge that the multiplicity of care coordination and case management programs causes confusion even among members of care coordination teams. In October 2011, we recommended that the Secretaries of Defense and Veterans Affairs direct the Senior Oversight Committee to expeditiously develop and implement a plan to strengthen functional integration across all DOD and VA care coordination and case management programs to reduce redundancy and overlap.

Although DOD and VA have not yet aligned care coordination policy for the FRCP and RCP, we have found indications that care coordinators and case managers at some locations have been cooperating to some degree and trying to work more closely with one another. In the course of our visits to 11 DOD and VA facilities during this review, we found that care coordinators and case managers in many locations had attempted—with some success—to clarify their roles and to limit the degree of overlap and duplication in the services they provide to recovering servicemembers and veterans. However, such local attempts to improve the degree of cooperation and coordination among the programs are not systemic and depend on individual personalities and circumstances. They may not be sustainable without agreement by DOD and VA and the alignment of policy governing case management and care coordination programs.

Another critical issue on which DOD and VA have disagreed pertains to the stage in a servicemember’s recovery when the FRCP should get involved in the coordination of services. Because the FRCP depends on referrals from other programs as a basis for becoming involved with recovering servicemembers, this can be a significant issue. Currently, neither DOD nor VA policy clearly defines when referrals are to be made; consequently, most wounded warrior programs delay referrals to the FRCP until it becomes clear that the servicemember will be separated from the military. Senior DOD officials stated that wounded warrior program officials justify this practice on the basis that referring a recently wounded servicemember to the FRCP—a VA-operated program—sends a negative message to a recovering servicemember that his or her military career has ended, even though the FRCP was designed as a joint program. Additionally, the belief among the military that they should “take care of their own,” contributes to the reluctance to involve the FRCP. On their part, VA maintains that its point of engagement should be in the early stage of medical treatment to build rapport and trust and to begin coordinating the services needed by severely wounded servicemembers.

Despite multiple efforts over the last several years to align their care coordination and case management programs, DOD and VA have failed to implement lasting measures to resolve underlying problems concerning the aligning of roles and responsibilities of the FRCP, RCP, and case management programs. Previous attempts include the following:

December 2010. The Senior Oversight Committee directed its case management work group to perform a feasibility study of recommendations on the governance, roles, and mission of DOD and VA care coordination. However, no action was taken by the committee and care coordination was subsequently removed from the Senior Oversight Committee’s agenda as other issues were given higher priority.

March 2011. WWCTP sponsored a joint summit that included officials from VA and the military services to review DOD and VA care coordination issues. Although this collaboration resulted in the development of five recommendations related to care coordination, no agreement was reached by the departments to jointly implement them. A DOD participant told us that VA did not agree with the recommendations, and a VA official involved in the summit concurred, alleging that the recommendations appeared to suggest eliminating overlap and duplication between the FRCP and RCP by ending the FRCP.

May 2011. Concerned with overlap and duplication between the DOD and VA care coordination programs, the House Committee on Veterans Affairs, Subcommittee on Health directed the Deputy Secretaries of DOD and VA to provide an analysis of how the FRCP and RCP could be integrated under a “single umbrella” by June 20, 2011. In the absence of such a response, the subcommittee scheduled a congressional hearing and requested that options for addressing this issue be presented. Following the notification of the hearing, the departments developed a joint letter and submitted it to the subcommittee in September 2011. This letter, however, did not identify or outline options for aligning the FRCP and the RCP. In a hearing held by the subcommittee in early October 2011, neither VA nor DOD outlined definitive plans to address this issue.

September 2011. The Recovering Warrior Task Force issued the first of four annual reports that included 21 recommendations, including a recommendation that the roles of care coordinators be clarified. In DOD’s official response to congressional committees, the Under Secretary of Defense stated that the department would implement the Recovering Warrior Task Force’s recommendations. However, a Recovering Warrior Task Force member stated that the Recovering Warrior Task Force concluded that in most cases DOD has not made significant changes to its programs to achieve the outcomes intended by the recommendations. In August 2012, the Recovering Warrior Task Force reported that DOD has fully implemented only 2 of the 21 recommendations. However, a DOD official whose office is responsible for coordinating DOD’s responses to the Recovering Warrior Task Force’s recommendations stated that DOD is in the process of addressing several more of the 2011 Recovering Warrior Task Force recommendations.

October 2011–April 2012. VA declined DOD’s requests to discuss care coordination and case management policy issues during this period, according to DOD and VA senior officials, because VA had established its own task force to conduct an internal review of its care coordination and case management activities, including the FRCP. After completing its initial assessment, VA briefed WWCTP officials on the process it was using to review its care coordination and case management activities, but chose not to discuss realignment of the FRCP and RCP at that time, according to DOD officials who attended this briefing. Instead, the VA Chief of Staff said that he approached the Army’s Warrior Transition Command—which has the largest number of recovering servicemembers—to propose developing guidelines for better integrating Army’s wounded warrior program with the FRCP, including identifying when the Army’s wounded warrior programs should refer a recovering servicemember to the FRCP, and replacing multiple care coordination plans with a single, comprehensive planning document. However, a high-level DOD official criticized this initiative as a tactic to minimize central input from the Office of the Secretary of Defense and pointed out that this effort would result in an agreement with only a single military branch. In contrast, VA’s Chief of Staff told us that VA took this approach in the hope that if an agreement could be reached with Army, the other military branches would follow suit.

More recently, in May 2012, VA and DOD developed a new task force, the VA/DOD Warrior Care and Coordination Task Force, which represents an effort to comprehensively address problems caused by the lack of integration between DOD’s and VA’s care coordination and case management programs. The task force has developed recommendations that are intended to achieve a coordinated, interdepartmental approach to care coordination and case management programs, according to a task force official. On August 10, 2012, the task force presented the following recommendations to the Joint Executive Council for its consideration: establish and charter an interagency governance structure responsible for coordinating VA and DOD policy, establish and charter an interagency care coordination community of align the FRCP to function in a consultant and resource-facilitator role, clarify the lead coordinator role and responsibilities for executing a recovering servicemember’s comprehensive plan, identify the business requirements for technical tools to support the interagency comprehensive plan, and accelerate existing information-sharing efforts for care coordination.

The Joint Executive Council provisionally approved the six recommendations, but withheld final approval pending receipt of additional information from the task force, such as an estimate of resources required to implement the recommendations, as well as details of the proposed interagency governance structure. The Joint Executive Council instructed the task force to present the additional information to them in another decision briefing, which was scheduled for September 20, 2012. Absent final approval from the Joint Executive Council, the task force’s next step was to hold a status briefing for the DOD and VA Secretaries on September 10, 2012, to discuss the task force’s recommended course of action for care coordination.

Given the inability of past task forces to effect changes that better align DOD and VA care coordination and case management policies, it is too soon to determine the full effect of the departments’ efforts to manage care coordination services regarding outcomes for recovering servicemembers and veterans. Although VA and DOD appear to be moving in a positive direction on care coordination, notable barriers remain:

There is concern as to whether the Joint Executive Council can effectively lead the effort to realign VA’s and DOD’s care coordination policy. Some high-ranking and cognizant DOD officials we talked with expressed concerns that the recently merged Joint Executive Council may not have the capability to effectively monitor the actions taken by DOD and VA to implement the task force’s recommendations. Some officials we talked with viewed the council as taking too long to resolve issues due to both the infrequency of its meetings and the difficulties DOD and VA members have in agreeing with one another.

Following approval of its recommended course of action, task force documents indicate that a detailed plan will be completed by July 2013. VA’s task force cochair stated that some aspects of the planned changes could take years to implement, particularly as they transition existing enrollees of programs affected by significant revisions. For example, VA intends to conduct a case-by-case review of every FRCP enrollee before modifying the FRCP to function in a consultant and resource-facilitator role, according to VA’s Task Force cochair.

One of the most fundamental challenges to resolving care coordination problems is the issue of obtaining the cooperation of the military services to implement a new approach to care coordination and case management, especially in light of past difficulties of working in concert with DOD and VA programs and policies. DOD and VA leadership officials stated that even if new solutions and policies were to be approved by the departments, changes would be made only if the individual military services implement the new policies as directed by the Secretary of Defense. Several DOD and VA officials identified concurrence and support of the military services as the most difficult element to achieve. Ultimately, the military services’ compliance with the departments’ agreed-upon strategy for care coordination and case management programs will determine how seamlessly recovering servicemembers and veterans will be able to navigate the recovery care continuum.

Conclusions

The deficiencies exposed at Walter Reed in 2007 served as a catalyst compelling DOD and VA to address a host of problems that complicate the course of a wounded, ill, and injured servicemember’s recovery, rehabilitation, and return to active duty or civilian life. We believe strongly and have reported already that fixing the long-standing and complex problems highlighted in the wake of the Walter Reed media accounts as expeditiously as possible is critical to ensuring high-quality care for returning servicemembers and veterans. We continue to believe that the departments’ success ultimately depends on sustained attention, systematic oversight, and sufficient resources from both DOD and VA. However, this has not yet occurred, and as a result, after 5 years, recovering servicemembers and veterans are still facing problems as they navigate the recovery care continuum, including access to some of the programs designed to assist them. The transition period from DOD’s to VA’s health care system is particularly critical, as servicemembers continue to experience delays in the disability evaluation system and the departments continue to use methods other than a common information technology system to share servicemembers’ health information. Until these problems are resolved, recovering servicemembers and veterans may still face difficulties getting the services they need to maximize their potential when they return to active duty or transition to civilian life.

Initially, departmental leadership exhibited focus and commitment— through the Senior Oversight Committee—to addressing problems related to case management and care coordination, disability evaluation systems, and data sharing between DOD and VA. However, over time, waning leadership attention, a failure to oversee critical wounded warrior functions and programs, limited resources, and the inability to achieve a collaborative environment— particularly with care coordination—have impeded the departments’ ability to fully resolve these problems. A key element in resolving current care coordination issues in particular is eliciting the cooperation of the military services, which are responsible for implementing various wounded warrior programs and ensuring that these programs operate as intended—which has sometimes not been the case, as with the RCP. Also, absent clear direction and central oversight and accountability among the military services’ wounded warrior programs, true cooperation and program effectiveness may be in jeopardy.

We believe that at the heart of the problem is the need for strong and unwavering leadership to bring about changes that best serve our nation’s recovering servicemembers and veterans. This leadership should be united across both DOD and VA and centered on the individual servicemember’s or veteran’s recovery. Many task forces—including the VA/DOD Warrior Care and Coordination Task Force and the Recovering Warrior Task Force—have already attempted to bring a spirit of cooperativeness and clear direction and purpose among the different programs providing services to this population. However, to date, these efforts have not fully resolved key issues, and our nation’s recovering servicemembers and veterans continue to face obstacles and challenges, especially as they transition from DOD’s to VA’s health care system. Certainly, the fluidity and focus of the departments’ leadership over the last several years, especially related to care coordination, have added to the challenges of developing consistent policy, effective oversight, and mechanisms to monitor progress and hold programs accountable. The departments have recently taken steps to improve problems related to care coordination, disability evaluations, and the electronic sharing of health records, through concerted efforts to coordinate on policy, increase staffing resources, and provide control over the budget, respectively. However, it is too early to determine the effectiveness of these efforts, and sustained leadership attention will be critical to their success. The need to fully resolve remaining problems is urgent as there will be an increasing demand for services from both DOD and VA as the current conflicts come to an end. If not resolved now, these same problems will persist into the future for recovering servicemembers and veterans.

Recommendations for Executive Action

To ensure that servicemembers have equitable access to the military services’ wounded warrior programs, including the RCP, and to establish central accountability for these programs, we recommend that the Secretary of Defense establish or designate an office to centrally oversee and monitor the activities of the military services’ wounded warrior programs to include the following:

Develop consistent eligibility criteria to ensure that similarly situated recovering servicemembers from different military services have uniform access to these programs.

Direct the military services’ wounded warrior programs to fully comply with the policies governing care coordination and case management programs and any future changes to these policies.

Develop a common mechanism to systematically monitor the performance of the wounded warrior programs—to include the establishment of common terms and definitions—and report this information on a biannual basis to the Armed Services Committees of the House of Representatives and the Senate.

To ensure that persistent challenges with care coordination, disability evaluation, and the electronic sharing of health records are fully resolved, we recommend that the Secretaries of Defense and Veterans Affairs ensure that these issues receive sustained leadership attention and collaboration at the highest levels with a singular focus on what is best for the individual servicemember or veteran to ensure continuity of care and a seamless transition from DOD to VA. This should include holding the Joint Executive Council accountable for ensuring that key issues affecting recovering servicemembers and veterans get sufficient consideration, including recommendations made by the Warrior Care and Coordination Task Force and the Recovering Warrior Task Force; developing mechanisms for making joint policy decisions; involving the appropriate decision-makers for timely implementation of policy; and establishing mechanisms to systematically oversee joint initiatives and ensure that outcomes and goals are identified and achieved.

Agency Comments and Our Evaluation

DOD and VA reviewed a draft of this report and provided comments, which are reprinted in appendixes III and IV. DOD and VA also provided technical comments, which we incorporated as appropriate.

DOD concurred with specific components of our first recommendation regarding the establishment of central accountability for the military services’ wounded warrior programs. In particular, DOD agreed that a single office should have oversight responsibility for the military services’ wounded warrior programs and that these programs should fully comply with the policies governing care coordination and case management programs and any future changes to these policies.

However, DOD only partially concurred with other components of our first recommendation—that DOD develop consistent eligibility criteria for enrollment in wounded warrior programs and that DOD establish a common mechanism to systematically monitor the performance of these programs. In its comments, DOD explained that the three military service Secretaries should have the ability to control entrance criteria into their wounded warrior programs and added that it does not believe that differences in eligibility criteria for these programs results in noticeable differences in access to these programs by recovering servicemembers or their families. DOD did not offer a rationale, however, as to why the military service Secretaries should unilaterally determine eligibility criteria for their wounded warrior programs, other than to suggest that flexibility is important and necessary. Moreover, as we have reported, DOD does not systematically assess or monitor these programs across the department, and as a result, we believe that DOD has no basis to assert that there are no noticeable differences in access to these programs. Overall, we believe that similarly situated wounded, ill, and injured servicemembers should be given the same access to wounded warrior programs and the assistance these programs provide, regardless of their branch of military service.

With respect to developing a common mechanism to systematically monitor the performance of the wounded warrior programs, DOD responded that the Interagency Care and Coordination Committee will conduct an inventory of all wounded warrior programs to identify duplication and areas for gaining efficiencies. In commenting on our recommendation to also report its performance information on the wounded warrior programs to the Armed Services Committees on a biannual basis, DOD stated that the department reports progress through the Joint Executive Council’s annual strategic planning report and any additional reporting would be redundant and of limited value. We disagree. The Joint Executive Council’s strategic planning and annual reports focus on joint efforts between the departments and do not report on the performance of the military services’ wounded warrior programs. Therefore, we do not believe that the performance information on the wounded warrior programs would be redundant or of limited value given that the department itself is currently unable to systematically determine how well these programs are functioning. As we reported, one of the key problems hindering a department-wide assessment of these programs is the lack of common terms and definitions used by the military services. Although DOD acknowledges that this is an issue, it asserts that it has instituted some common definitions through the Senior Oversight Committee and through its instruction for the RCP and that it will work towards a common understanding and use of these approved definitions. Although we are aware of efforts to define some terms, on the basis of our work, it does not appear that the military services are using them consistently. Therefore, substantial progress towards a common understanding and use will be critical to the department’s ability to oversee these programs.

DOD did not respond directly to our recommendation for developing a common mechanism for performance measurement, which we found is not systematically conducted across the wounded warrior programs. During our collection of performance data from the wounded warrior programs, we found that the programs vary in their ability to report performance outcome measures on the basis of what each program chooses to track. In addition, we found that some of the programs had difficulty reporting basic data, such as enrollment numbers, and only compiled these data following our request—sometimes taking about 5 months to do so. Lastly, our recommendation is consistent with the call of the Interagency Care and Coordination Committee that the military programs develop more useful quantitative and qualitative metrics that would effectively demonstrate their performance. Until DOD takes the necessary steps to assess these programs department-wide, it will never know with certitude whether these programs are meeting the needs of its recovering servicemember population.

DOD and VA both concurred with our second recommendation that the departments ensure that care coordination, disability evaluation, and electronic health record sharing receive sustained leadership attention and collaboration at the highest levels, with a singular focus on what is best for the individual servicemember or veteran to ensure continuity of care and a seamless transition from DOD to VA.

In addition to its comments on our recommendation, VA asserted that the care coordination challenges facing both departments are broader and more complex than issues concerning just the FRCP and RCP and that our overall analysis and conclusions are over simplified. VA stated that through its recently formed task force, both departments identified over 40 programs that provide some level of coordination or management of care and services across the continuum of care and acknowledged that there is no common operational picture that facilitates collaborative planning or situational awareness. We agree that the care coordination challenges are broader and more complex than the FRCP and RCP. Specifically, in October 2011, we recommended that the departments strengthen functional integration across all care coordination and case Similarly, management programs to reduce redundancy and overlap.our current recommendation is broad and does not focus exclusively on these two programs as our review also included other programs, such as the military services’ wounded warrior programs, VA’s Liaison for Healthcare Program, and VA’s OEF/OIF/OND Care Management Program. The scope of our review was directed by Congress, who required us to report on the progress DOD and VA in implementing the programs involved with the care, management, and transition of wounded, ill, and injured servicemembers that they established. Our specific discussion of the FRCP and RCP served to illustrate, until recently, a continued lack of collaboration between the departments to better align these programs and better serve recovering servicemembers and veterans. Furthermore, during detailed discussions with top-level VA and DOD officials, they focused on the FRCP and RCP issue as the main sticking point in achieving coordination and cooperation among the two departments with respect to care coordination and case management. We are encouraged that the departments are now taking steps to identify all programs that need better alignment and integration. However, as we have stated, the key to resolving this and other problems is the need for strong and unwavering leadership that is united across both departments and focused on the individual servicemember’s or veteran’s recovery.

VA also suggested further clarifications to our report.

VA suggested that we clarify that while the VA Liaison for Healthcare Program facilitates the transfer of recovering servicemembers from DOD’s to VA’s health care system, it is a DOD or VA treatment team that determines if the servicemember is medically ready to begin the transition process. VA also suggested that we add that that the OEF/OIF/OND Care Management Program screens all returning combat veterans for case management services. We incorporated VA’s suggested changes.

VA disagrees with a DOD-attributed statement that the Joint Executive Council historically has not driven policy decision making and that, at times, decisions were taken directly to the DOD and VA Secretaries for resolution. The statement that we attribute to the DOD official relates to the period prior to the integration of the Senior Oversight Committee with the Joint Executive Council. As mentioned in the report, it is too early to ascertain whether the newly merged Joint Executive Council will be able to make decisions and drive policy changes in DOD and VA.

VA provided clarification about how the Joint Executive Council is currently providing oversight and accountability for wounded warrior issues that were once addressed by the Senior Oversight Committee. We recognize the effort that the Joint Executive Council is now making to track wounded warrior issues, including the integrated disability evaluation system and care coordination. However, we have not had the opportunity to review this tracking mechanism now in place to comment on its effectiveness.

VA asserts that the size of the overlap between the FRCP and RCP population is fairly small. Although the number of seriously injured servicemembers may be comparatively small, this situation has been and continues to be a major concern in that these individuals and their families represent a highly vulnerable population. Further, during our review, one high-level DOD official we spoke with characterized the FRCP/RCP overlap as the most difficult policy issue to resolve. While we understand that DOD and VA now intend to harmonize care coordination policies within a broader context of interdepartmental care coordination and case management practice, many of the proposed revisions—including the role to be played by the FRCP— are neither fully developed nor implemented by the separate DOD and VA programs at this time.

In our report, we explain that VA declined DOD’s requests to discuss care coordination and case management policy issues—for the better part of 1 year—on the basis that VA was conducting an internal review of its care coordination and case management activities. In its comments, VA stated that the use of the word “decline” is misleading, and suggested that we change our text to state that VA asked DOD to defer collaboration until the internal review was conducted. Despite VA’s characterization that our statement is misleading, we maintain that this finding was based on remarks made by high-level DOD officials that were subsequently corroborated by senior VA officials.

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

If you or your staff members have any questions about this report, please contact me at (202) 512-7114 or williamsonr@gao.gov. Contact points for our Offices of Congressional Relations and Public Affairs may be found on the last page of this report. Key contributors to this report are listed in appendix V.

Appendix I: Enrollment and Populations for Select Department of Defense and Department of Veterans Affairs Programs

Both the Department of Defense (DOD) and the Department of Veterans Affairs (VA) operate care coordination and case management programs designed to assist servicemembers and veterans as they navigate the recovery care continuum, from acute medical treatment and stabilization, through rehabilitation, to reintegration—either back to active duty or to the civilian community as a veteran. This appendix describes selected DOD and VA programs and includes data on enrollment and population characteristics as well as the type of information each program tracks on referrals.

DOD Wounded Warrior Programs

Within DOD, each military service has established its own wounded warrior program or a complement of programs to assist wounded, ill, and injured servicemembers during their recovery and rehabilitation, and to help with the transition back to active duty or to civilian life. Wounded warrior programs range in size from the largest, the Army’s Warrior Transition Units and Community-Based Warrior Transition Units, with 18,762 enrollees served in fiscal year 2011, to the smallest, the Navy Safe Harbor Program, with 784 enrollees served in fiscal year 2011. (See table 4 for a list of the DOD wounded warrior programs and enrollment for fiscal year 2011.)

Programs differ in their organization and function. For example, two of the wounded warrior programs—the Army’s Warrior Transition Units and the Marine Corps Wounded Warrior Regiment—are organized under separate military commands, which means that wounded, ill, and injured servicemembers enrolled in these programs may be removed from their parent units or commands and assigned or attached to a separate unit or regiment that provides command and controlservicemember as well as administrative support. These servicemembers may be housed in separate barracks while receiving medical care and waiting to transition back to active duty or civilian life. The other wounded warrior programs do not assign or attach servicemembers to a separate command structure, but provide services while recovering servicemembers remain with their parent units. The services provided by the wounded warrior programs also vary. A servicemember may receive either case management or care coordination services or both, depending on how the military service’s wounded warrior program is structured. For example, the Navy Safe Harbor Program only provides care coordination services and does not have a case management component, whereas the Marine Corps Wounded Warrior Regiment provides all servicemembers with both case management and care coordination services. A further distinction is whether or not a program serves veterans as well as servicemembers. For example, the Army Warrior Transition Units do not serve veterans, but eligible veterans are served through the Army Wounded Warrior Program. The remainder of the wounded warrior programs continue to provide support to any enrollee who needs services even after the enrollee has transitioned to veteran status.

Army Warrior Care and Transition Program

The Army’s Warrior Care and Transition Program, which was established in May 2007, consists of two components that support the recovery process for wounded, ill, and injured servicemembers—the Warrior Transition Unitsoperates a number of warrior transition units located at Army installations across the country. Recovering servicemembers who are attached or assigned to a warrior transition unit generally are housed in barracks and receive medical care, rehabilitative services, professional development and clinical and nonclinical case management services in order to help and the Army Wounded Warrior Program. The Army them in their transition back to active duty or to the civilian community. Army Warrior Transition Units vary in size and functionality, including community-based warrior transition units, which primarily serve Reserve Component servicemembers. In fiscal year 2011, there were a total of 14,906 recovering servicemembers assigned or attached to 29 warrior transition units and 3,856 recovering servicemembers assigned or attached to 10 community-based warrior transition units. (See table 5.) According to Army policy, recovering servicemembers assigned or attached to the units are expected to require 6 months or more of rehabilitative care or require complex medical management. was established in April 2004 to The Army Wounded Warrior Program assist severely wounded, ill, and injured servicemembers, their families, and caregivers. Army Wounded Warrior Program enrollees are assigned an Advocate who provides nonclinical care coordination services, which include assisting enrollees with benefit information, career guidance, finances, and the integrated disability evaluation system (IDES) process. Recovering servicemembers are eligible for Army Wounded Warrior Program services if they have, or are expected to receive, an Army disability rating of 30 percent or greater in one or more specific categories or a combined rating of 50 percent or greater for conditions that are the result of combat or are combat-related. The most severely wounded, ill, or injured servicemembers who are assigned to warrior transition units are also enrolled in the Army Wounded Warrior Program. The Army Wounded Warrior Program also provides services to veterans. In fiscal year 2011, nearly three-fourths of the population (6,953) were veterans. (See table 6.)

The Army Wounded Warrior Program was originally named the Disabled Soldier Support System.

Army Wounded Warrior Program officials said that the program does not specifically track whether or when an enrollee transitions to veteran status because it has no impact on enrollees’ eligibility for the program and whether they leave the program. Rather, these data have been derived by the program by counting the number of enrolled servicemembers who received a certificate of release or discharge from active duty within each fiscal year. Enrollees considered to have “left for other reasons” include those who died while enrolled in the Army Wounded Warrior Program.

Navy Safe Harbor Program

The Navy Safe Harbor Program office was established in 2005. Over time, this office expanded its reach and mission, and in 2008 the program became responsible for nonclinical care coordination and oversight of all severely (and high-risk nonseverely) wounded, ill, and injured Sailors and Recovering servicemembers enrolled in the program Coast Guardsmen.are assigned to nonmedical care managers who are geographically dispersed at major military treatment facilities and Veterans Affairs polytrauma medical centers. The program’s nonmedical care managers assist enrollees with services such as pay and personnel, legal, housing, as well as education and training benefits. In addition, enrollees obtain support from centrally located experts in transition and benefits assistance, such as a liaison to the Department of Labor and a Navy Staff Judge Advocate. Recovering servicemembers enrolled in the program are enrolled for life and, if desired, receive support from Navy Safe Harbor personnel after they transition to veteran status. (See table 7.)

The Air Force Warrior and Survivor Care Program supports wounded, ill, and injured servicemembers through its Air Force Wounded Warrior Program and the Air Force Recovery Care Program. The Air Force Wounded Warrior Program was established in June 2005 to provide nonclinical case management to Airmen, Air National Guard, and Reserve Component servicemembers who have combat-related illnesses or injuries. Each enrolled servicemember is assigned a nonmedical care manager, who serves as an advocate for enrollees to obtain services from agencies and organizations that support the needs of enrolled servicemembers, their families and caregivers. The Air Force Wounded Warrior Program continues to provide services to enrollees once they transition to veteran status. (See table 8.)

The Air Force Recovery Care Program was established in November 2008 to provide nonclinical care coordination services for seriously ill and injured Airmen, Air National Guard, and Reserve Component servicemembers. Each enrolled servicemember is assigned a care coordinator who oversees the coordination of services and assists enrollees’ with nonclinical needs, such as employment and benefits. These care coordinators also work with enrolled servicemembers to develop their recovery plans and career goals. Enrollees who have combat-related illness or injuries are concurrently enrolled in the Air Force Wounded Warrior Program. For example, in fiscal year 2011, almost 300 Air Force Recovery Care Program enrollees were also either tracked or actively assisted by the Air Force Wounded Warrior Program. (See table 9.)

The Marine Corps established the Wounded Warrior Regiment in May 2007 to provide and facilitate assistance to wounded, ill, and injured Marines and their family members throughout the recovery process. The Wounded Warrior Regiment is a single command that oversees nonmedical care for the total Marine force, including Active Duty, Reserve, retired, and veteran Marines. The regiment enrolls Marines regardless of whether they have combat- or non-combat-related conditions. The regiment commands the operation of two wounded warrior battalions and 14 detachments located at 12 principal military treatment facilities and four Veterans Affairs polytrauma medical centers across the United States and overseas. A Marine enrolled in the regiment can either stay with his or her parent unit and be supported by the regiment, or be assigned or attached to one of the regiment’s battalions and detachments, depending on their specific needs. Generally, Marines who require more than 90 days of medical treatment or rehabilitation are assigned or attached to a battalion or detachment. The District Injured Support Cells Program is the component of the Wounded Warrior Regiment that provides services to veterans. District Injured Support Coordinators are located at 30 sites across the United States to provide support, including nonmedical care management to its enrollees. In fiscal year 2011, the District Injured Support Coordinators provided support to 1,488 veterans. (See table 10.)

The United States Special Operations Command established the Care Coalition in August 2005 to track, support, and advocate for Special Operations Force’s wounded, ill, and injured servicemembers regardless of their duty status or whether their conditions are combat-related. (See table 11.) All enrollees are assigned an Advocate and are entitled to advocate services for life. Advocates assist enrollees with health care and financial benefits, transition processes, and link enrollees with needed government and nongovernment resources. Because the United States Special Operations Command’s Care Coalition serves servicemembers from across the military services, it serves as a liaison with, and complements, the military services’ wounded warrior programs. United States Special Operations Command’s Care Coalition enrollees are often concurrently enrolled in their own military service’s wounded warrior program. However, according to a Care Coalition official, the Care Coalition serves as the lead program for case management and care coordination for dually enrolled servicemembers.

VA Case Management and Care Coordination Programs

VA operates a number of case management and care coordination programs that provide assistance to recovering servicemembers and veterans, including the Operation Enduring Freedom/Operation Iraqi Freedom/Operation New Dawn (OEF/OIF/OND) Care Management Program and the Federal Recovery Coordination Program (FRCP). These two programs assist wounded servicemembers and veterans to navigate the recovery care continuum.

OEF/OIF/OND Care Management Program

The OEF/OIF/OND Care Management Program was established in March 2007 to provide case management to wounded, ill, and injured servicemembers and veterans who screen positive for the need for case management or request case management services. (See table 12). Each of VA’s 152 Medical Centers (VAMC) has an OEF/OIF/OND Care Management team in place to manage patient care activities and ensure that servicemembers and veterans are receiving patient-centered, integrated care and benefits. Members of the OEF/OIF/OND Care Management team include: a Program Manager, Clinical Case Managers, and a Transition Patient Advocate.

The FRCP was established in January 2008. Developed as a joint program by DOD and VA, but administered by VA, the program was designed to provide care coordination services to servicemembers and veterans who were “severely” wounded, ill, and injured after September 11, 2001. (See table 13.) The program uses federal recovery coordinators to monitor and coordinate clinical services, including facilitating and coordinating medical appointments, and nonclinical services, such as providing assistance with obtaining financial benefits or special accommodations, needed by program enrollees and their families. Federal recovery coordinators serve as the single point of contact among all of the case managers of DOD, VA, and other governmental and private case management programs that provide services directly to servicemembers and veterans.

Referral Information Tracked by DOD and VA Case Management and Care Coordination Programs

DOD and VA case management and care coordination programs primarily identify servicemembers and veterans who may be eligible for enrollment through referrals. Tracking referral information, including the number of those who were referred and enrolled or not enrolled in the program, may indicate whether the programs are identifying those who could benefit from their services. However, fewer than half of the DOD and VA case management and care coordination programs that we reviewed track this type of referral information. (See table 14.)

Appendix II: Medical Category Assignment Process for Care Coordination Programs

The Senior Oversight Committee intended for the Federal Recovery Coordination Program (FRCP) and the Recovery Coordination Program (RCP) to be complementary programs, specifically identifying which population of wounded, ill, and injured servicemembers would be assigned to the two programs. On the basis of work done for the committee, the Department of Defense (DOD) sent a report to congressional committees in 2008 outlining a medical category assignment process based on the severity of each servicemember’s medical condition, along with input from the servicemember and his or her unit commander, to determine whether servicemembers would be directed either to the FRCP or to the RCP programs for care coordination services.

In concept, the medical category assignment process would have resulted in wounded, injured, or ill servicemembers being assigned to one of three categories. Servicemembers designated as Category 1 were those who were found to have mild injury or illness, who were expected to return to duty in less than 180 days of medical treatment, and primarily received local outpatient and short-term inpatient treatment and rehabilitation. Servicemembers designated as Category 2 were those with serious injury or illness, who were unlikely to return to duty in less than 180 days, and may be medically separated from the military. Servicemembers designated as Category 3 were those with severe injury or illness, who were highly unlikely to return to duty, and were most likely to be medically separated from the military. The category designation was intended to be used to determine whether the recovering servicemember was subsequently referred to a care coordination program, in that Category 1 servicemembers would not be referred to a care coordination program, unless their medical or psychological conditions worsen; Category 2 servicemembers would be referred to the RCP; and Category 3 servicemembers would be referred to the FRCP. (See fig. 3.)

Appendix III: Comments from the Department of Defense

Appendix IV: Comments from the Department of Veterans Affairs

Appendix V: GAO Contact and Staff Acknowledgments

GAO Contact

Staff Acknowledgments

In addition to the contact name above, Bonnie Anderson, Assistant Director; Mark Bird, Assistant Director; Michele Grgich, Assistant Director; Jennie Apter; Frederick Caison; Heather Collins; Dan Concepcion; Melissa Jaynes; Deitra Lee; Mariel Lifshitz; Lisa Motley; Elise Pressma; and Greg Whitney made key contributions to this report.

Related GAO Products

Military Disability System: Improved Monitoring Needed to Better Track and Manage Performance. GAO-12-676. Washington, D.C.: August 28, 2012.

Military Disability System: Preliminary Observations on Efforts to Improve Performance. GAO-12-718T. Washington, D.C.: May 23, 2012.

More Efficient and Effective Government: Opportunities to Reduce Duplication, Overlap and Fragmentation, Achieve Savings, and Enhance Revenue. GAO-12-449T. Washington, D.C.: February 28, 2012. 2012 Annual Report: Opportunities to Reduce Duplication, Overlap and Fragmentation, Achieve Savings, and Enhance Revenue. GAO-12-342SP. Washington, D.C.: February 28, 2012.

DOD and VA Health Care: Action Needed to Strengthen Integration across Care Coordination and Case Management Programs. GAO-12-129T. Washington, D.C.: October 6, 2011.

VA and DOD Health Care: First Federal Health Care Center Established, but Implementation Concerns Need to Be Addressed. GAO-11-570. Washington, D.C.: July 19, 2011.

Federal Recovery Coordination Program: Enrollment, Staffing, and Care Coordination Pose Significant Challenges. GAO-11-572T. Washington, D.C.: May 13, 2011.

Information Technology: Department of Veterans Affairs Faces Ongoing Management Challenges. GAO-11-663T. Washington, D.C.: May 11, 2011.

Military and Veterans Disability System: Worldwide Deployment of Integrated System Warrants Careful Monitoring. GAO-11-633T. Washington, D.C.: May 4, 2011.

DOD and VA Health Care: Federal Recovery Coordination Program Continues to Expand but Faces Significant Challenges. GAO-11-250. Washington, D.C.: March 23, 2011.

Electronic Health Records: DOD and VA Should Remove Barriers and Improve Efforts to Meet Their Common System Needs. GAO-11-265. Washington, D.C.: February 2, 2011.

Military and Veterans Disability System: Pilot Has Achieved Some Goals, but Further Planning and Monitoring Needed. GAO-11-69. Washington, D.C.: December 6, 2010.

Military and Veterans Disability System: Preliminary Observations on Evaluation and Planned Expansion of DOD/VA Pilot. GAO-11-191T. Washington, D.C.: November 18, 2010.

Electronic Health Records: DOD and VA Interoperability Efforts Are Ongoing; Program Office Needs to Implement Recommended Improvements. GAO-10-332. Washington, D.C.: January 28, 2010.

Electronic Health Records: DOD and VA Efforts to Achieve Full Interoperability Are Ongoing; Program Office Management Needs Improvement. GAO-09-775. Washington, D.C.: July 28, 2009.

Recovering Servicemembers: DOD and VA Have Jointly Developed the Majority of Required Policies but Challenges Remain. GAO-09-728. Washington, D.C.: July 8, 2009.

Recovering Servicemembers: DOD and VA Have Made Progress to Jointly Develop Required Policies but Additional Challenges Remain. GAO-09-540T. Washington, D.C.: April 29, 2009.

Army Health Care: Progress Made in Staffing and Monitoring Units that Provide Outpatient Case Management, but Additional Steps Needed. GAO-09-357. Washington, D.C.: April 20, 2009.

Electronic Health Records: DOD’s and VA’s Sharing of Information Could Benefit from Improved Management. GAO-09-268. Washington, D.C.: January 28, 2009.

Electronic Health Records: DOD and VA Have Increased Their Sharing of Health Information, but More Work Remains. GAO-08-954. Washington, D.C.: July 28, 2008.

DOD and VA: Preliminary Observations on Efforts to Improve Care Management and Disability Evaluations for Servicemembers. GAO-08-514T. Washington, D.C.: February 27, 2008.

DOD and VA: Preliminary Observations on Efforts to Improve Health Care and Disability Evaluations for Returning Servicemembers. GAO-07-1256T. Washington, D.C.: September 26, 2007.

DOD and VA Health Care: Challenges Encountered by Injured Servicemembers during Their Recovery Process. GAO-07-589T. Washington, D.C.: March 5, 2007.