Military Health Care: Army Needs to Improve Oversight of Warrior Transition Units
Released: 2016-07-12T00:00:00

Letter

Background

Evolution of the Army’s Approach for Caring for Wounded Soldiers

Due to improved battlefield medicine, soldiers who might have died in past conflicts are now surviving, many with multiple serious injuries that require extensive outpatient rehabilitation, such as amputations, burns, and traumatic brain injuries. Prior to the establishment of WTUs, the Army provided care for soldiers recovering from serious medical conditions through Medical Hold and Holdover Units. According to Army documents, the previous system did not have a uniform structure and exhibited varying levels of resources. For example, some units fell under the command of the local military treatment facility, while others fell under the command of the local installation. In addition, the Army did not have a uniform system of staffing, as the relevant command had to resource the units by reassigning personnel from other missions and functions. Further, the increased workload associated with care for these soldiers at the local military treatment facility was not reflected in increased staffing levels or resources.

In response to congressional interest and media coverage regarding inadequate and substandard care for Army soldiers recovering from serious medical conditions at the former Walter Reed Army Medical Center, the Army in 2007 developed its Army Medical Action Plan. This plan laid out a series of steps to address the problems highlighted at Walter Reed and other facilities, including the establishment of the WTU program. According to Army documents, the primary differences between the previous system of Medical Hold and Holdover Units and the WTU program was the establishment of (1) a uniform structure and ratios of staff to WTU soldiers by specialty and (2) a program (the Comprehensive Transition Plan) to facilitate the soldiers’ transition to either a return to the force or separation from the Army.

The central structure of the WTU program is the Triad of Care model, which includes a primary care manager, a nurse case manager, and a squad leader or platoon sergeant, who direct and supervise the WTU soldiers’ healing process. Along with these Triad of Care key staff, there are other medical and nonmedical providers—such as social workers and occupational therapists—who work together to develop a plan of care specific to each soldier. The plan of care is intended to address the soldiers’ medical needs and support their transition either back to duty or to separation from the Army. This staffing model formalized the relationship between some of the same positions that had existed in the prior Medical Hold and Holdover Units’ and established ratios for the number of WTU soldiers that were to be under the care of each of the Triad of Care’s key staff. Figure 1 provides position descriptions and staffing ratios for the Triad of Care model.

Trends in the Population of Soldiers in the WTU Program

In 2007, the Army began establishing individual WTUs at geographically dispersed locations to serve active-duty, Army Reserve, and Army National Guard soldiers needing this type of assistance. Figure 2 shows trends in the WTU soldier population over time. In line with this reduction in population, the Army reduced the number of WTUs from a high of 45 in 2008 to 25 in 2014, with plans to inactivate another 11 by August 2016. At that point, the Army will have 14 WTUs remaining.

The Army uses an annual process known as a Strategic Posture Review to determine the required capability and capacity for each WTU location and for WTUs across the Army enterprise, such as determinations for the number of WTUs. This process includes estimating the future population of WTU soldiers using a model validated by the Army and then applying the estimated population to the current capacity of WTUs based on established ratios of the numbers of WTU soldiers to the numbers of primary care managers, nurse case managers, and squad leaders. If excess capacity is identified, the Warrior Transition Command reviews a series of criteria to determine which WTUs should remain open. For example, as part of the most recent review that recommended the inactivation of 11 sites, Army officials stated that they had selected sites to remain open that were co-located with force projection platforms and the best Army medical facilities. These recommendations are ultimately approved by senior Army officials.

The ability to reverse these inactivations if demand for WTUs were to rise in the future was a key planning consideration in the decision to inactivate 11 WTUs by August 2016. As a result, the Army has issued policy to maintain control and oversight of former WTU facilities at inactivating locations. For example, the policy requires that the Installation Management Command conduct annual inspections of inactivated WTU facilities to ensure that compliance with Army standards for WTU facilities. The same policy calls for the Army’s Installation Management Command to be prepared to return deactivated facilities to WTU program use within 180 days of notification of the unit’s reactivation.

Transition Process

While assigned to the WTU program, soldiers are to work toward meeting the goals identified in their individualized Comprehensive Transition Plan. This standardized framework has six main phases: (1) in- processing, (2) goal setting, (3) transition review, (4) rehabilitation, (5) reintegration, and (6) post-transition. As part of the Comprehensive Transition Plan and in addition to attending medical appointments, soldiers might, depending on their needs, undergo physical rehabilitation, meet with behavioral health therapists, participate in adaptive sports and reconditioning programs, participate in internships and training, and prepare to transition out of the WTU program. The last phase, post- transition, occurs after a soldier has left the WTU program.

The point in the WTU soldiers’ rehabilitation process when it can be determined whether or not further medical care will cause a soldier to be found fit for duty is called the medical retention determination point. During their stay, WTU soldiers take part in activities to help them transition either back to the Army or to separate from the Army. For WTU soldiers who are returning to the Army, these activities could include taking Army career-related education or training, including college courses and other soldier development classes. For WTU soldiers who are transitioning out of the Army, these activities could include going through the disability evaluation systems, as well as participating in education and readiness opportunities that fit with the soldiers’ career goals. See appendix II for additional information concerning trends in WTU soldiers’ separation from the Army and in WTU soldiers’ lengths of stay in the WTU program.

The Army Has Not Assessed the Effectiveness of the Triad of Care Model despite the Change in the Composition of Diagnoses among WTU Soldiers

The Army has not assessed the effectiveness of the Triad of Care model, the core structure of the WTU program and consisting of a team of three key staff that provide medical case management. The Army designed the Triad of Care model at a time when WTU soldiers’ diagnoses were primarily for physical conditions. However, since then, the composition of diagnoses has changed significantly. Despite this change, the Army has not assessed its approach for managing soldiers’ medical care. The five WTUs we visited reported having taken ad-hoc measures to help meet the increase in behavioral health needs in the absence of such an assessment. For example, medical officials at each of the five WTUs that we visited told us that they include social workers as a fourth member of the Triad of Care staff.

Composition of Diagnoses among WTU Soldiers Has Changed Significantly

The Army established the Triad of Care model at a time when WTU soldiers’ diagnoses were primarily for physical conditions. Since then, the composition of diagnoses has changed significantly. Specifically, in 2008, the first full year of the WTU program, about 36 percent of the 12,228 WTU soldiers had a behavioral health diagnosis, while in 2015, over half of the 2,628 soldiers, about 52 percent, had such a diagnosis. According to Warrior Transition Command officials, these diagnoses include post-traumatic stress disorder diagnoses and all behavioral health or psychiatric diagnoses that are not categorized as post-traumatic stress disorder, such as major depression, anxiety disorder, panic disorder, and schizophrenia.

Our analysis of these data showed that in 2008, 2,553 of 12,228 WTU soldiers (about 21 percent) entered the WTU program with a behavioral health issue as their primary diagnosis, compared with 830 of the 2,628 WTU soldiers in 2015 (about 32 percent). Moreover, over that same time frame, 4,424 of 12,228 WTU soldiers (about 36 percent) entered the WTU program with a behavioral health issue as their primary, secondary, or tertiary diagnosis, compared with 1,355 of 2,628 WTU soldiers in 2015 (about 52 percent). Warrior Transition Command officials stated that the greater prevalence of behavioral health issues is likely related to the Army’s efforts to de-stigmatize behavioral health issues. They told us that, as a result, it has now become acceptable for soldiers to notify medical personnel when these issues arise, impacting the number of soldiers being recognized and coming forward for assistance with behavioral health diagnoses.

The Warrior Transition Command Has Not Assessed Whether Army- wide Changes to the Triad of Care Model Are Needed to Respond to the Change in the Composition of Diagnoses

While the Army conducts reviews and inspections of the WTU program and WTUs, it has not assessed the effectiveness of the Triad of Care model, in light of the change in the composition of diagnoses. Warrior Transition Command senior officials told us that validation reviews of the population and staffing models have been conducted on an approximately 3-year basis and that periodic unit inspections have also been conducted.

Validation reviews. The U.S. Army Manpower Analysis Agency conducts validation reviews of the Warrior Transition Command’s population and staffing models within the WTUs. These reviews examine, among other things, the staffing ratios for different types of personnel (including for members of the Triad of Care).

Unit inspections. The Warrior Transition Command conducts inspections of each WTU under the Organizational Inspection Program, inspections that are to assess numerous aspects of each WTU’s operations and provide an avenue for other concerns to be raised. These inspections generally include a pre-questionnaire to WTU soldiers, their family members, and staff; a process evaluation to determine a WTU’s adherence to policies and procedures; and an after-action review with a WTU’s leadership and staff to rate the inspection process.

According to Warrior Transition Command officials, these reviews and inspections should indicate whether changes are needed to the Triad of Care model. However, we found that while both validation reviews and unit inspections assess important aspects of the Army’s approach to care, neither has specifically assessed whether changes are needed to the Triad of Care model to address, for example, the greater prevalence of WTU soldiers’ behavioral health needs. The Army designed the Triad of Care model at a time when the preponderance of injuries among WTU soldiers were physical. Since that time, the Army has not assessed whether these significant changes to the WTU soldier population’s diagnoses have impacted its approach for managing soldiers’ medical care. Federal standards for internal control state that management should analyze relevant risks associated with achieving a program’s objectives. The increasing prevalence of behavioral health diagnoses in WTU soldiers and the resulting increase in soldiers’ need for behavioral health services needs is one such relevant risk.

In the absence of an assessment by the Warrior Transition Command, officials from each of the five WTUs we visited told us that they have taken various ad-hoc steps to meet the challenges posed by the increasing prevalence of behavioral health diagnoses. For example, medical officials at each of the WTUs we visited told us that they include social workers as an additional member of the Triad of Care model in response to the need for specialized medical case management. While social workers have always played a role in the WTUs’ interdisciplinary team, officials at these WTUs told us that the greater prevalence of behavioral health diagnoses among soldiers warranted a greater role for social workers, who serve as the WTUs’ behavioral health experts. Further, senior officials at several of these WTUs told us that they now refer to their model as the “Quad of Care” or “Square of Care” in response to the social workers’ inclusion. In addition, at four of the five WTUs, social workers told us that they have been directly providing certain types of behavioral health care to soldiers, such as therapy sessions, in part because obtaining behavioral health appointments at the local military treatment facility can be difficult. Medical officials from one of these four WTUs also told us that, in addition to providing the social workers’ therapy sessions, the unit borrows a psychiatrist from the local military treatment facility 2 days each week to provide behavioral health care. At the remaining WTU, the local military treatment facility contracted for a full-time psychiatrist in order to meet soldiers’ need for behavioral health services.

While these local adaptations represent efforts to meet an immediate need, they are not supported by analysis of whether the Triad of Care model must change to meet the increasing behavioral health needs of the WTU soldier population. For example, the differing approaches of various WTUs, with some making greater use of social workers and others turning to psychiatrists, merits review and assessment by the Army to determine which approach best benefits WTU soldiers. Assessing the Triad of Care model in light of changes in, for example, the prevalence of behavioral health conditions would position the Army to better determine how to meet WTU soldiers’ medical needs.

The Army Faces Challenges in Overseeing the Selection of Certain WTU Staff, in Evaluating Their Training, and in Adjusting Staff Levels if Needed

The Army has established selection processes and updated its selection criteria to require additional information about potential squad leaders and platoon sergeants for its WTUs, but the Army is not monitoring full adherence to policy, specifically the requirement to interview candidates for these positions. Further, while the Army had made improvements to its training program, the program does not incorporate a post-training assessment on the application of training to the work environment. In addition, the Army has not developed a plan that explains how to meet any potential increases in demand for staff, if needed, at the WTUs.

The Army Has Established Selection Processes and Updated Its Selection Criteria

The Army has established processes to select WTU squad leaders and platoon sergeants, and has updated its selection criteria to require greater experience and additional screening. WTU squad leaders and platoon sergeants are selected by various methods based on whether they are active duty or members of the reserve components, and the senior Commander at the installation is the final approval authority for all assignments. WTU positions are designed to be representative of the entire Army, with a mix of military occupational specialties and all three active and reserve components. Prior to selection, squad leaders and platoon sergeants must meet minimum grade, experience, and training qualifications.

Squad leader and platoon sergeant positions can be filled by personnel sourced through one of the following: from the installation where the WTU is located; the Human Resources Command; and, for reserve component soldiers, the Tour of Duty system. Senior Commanders can identify personnel from the installation where the WTU is located to interview for squad leader and platoon sergeant positions. If senior Commanders are unable to identify staff at the installation, a request is sent to the Human Resources Command to identify personnel to be screened and sent to the WTU program. Using the Tour of Duty system, reserve component personnel can apply for open squad leader and platoon sergeant positions, and local Commanders and their selection panels interview and select the best-qualified candidates. Figure 3 shows the three sources and the processes for filling the squad leader and platoon sergeant positions.

In November 2015, the Army updated its selection policy for WTU squad leaders and platoon sergeants. The November 2015 policy increases the minimum grade and experience requirements and identifies minimum training requirements. According to WTC officials, the updated requirements give WTU squad leaders and platoon sergeants more experience to draw from when working with WTU soldiers. In addition, the policy identifies squad leaders and platoon sergeants as positions of significant trust and authority. Through this designation, the Army requires more screening, including through the use of records concerning police encounters, substance abuse, sex offender status, and behavioral health and records held by Army personnel offices.

The updated policy also requires WTU squad leaders and platoon sergeants to have previously served successfully in a grade-equivalent leadership position and to meet minimum grade and training requirements. For example, potential squad leaders are required to hold the minimum grade of E-6 and to have completed the Advanced Leader Course, and potential platoon sergeants are required to hold the minimum grade of E-7 and have completed the Senior Leader Course. Table 1 lists the WTU program selection criteria for squad leaders and platoon sergeants before and after November 2015.

The Army Is Not Monitoring Full Adherence to Selection Policy Requirement

Although the Army has updated its policy for selecting squad leaders and platoon sergeants, the Warrior Transition Command is not monitoring full adherence to this policy, specifically the requirement to interview candidates for these positions. According to the policy effective before November 2015, Commanders or their staff selection panels are required to review the records of candidates and interview them to validate whether a candidate possesses the required skills and attributes to work as WTU staff. This provision did not change with the new regulation effective November 2015. However, the Army does not have a mechanism in place to monitor whether the interviews are conducted.

According to Warrior Transition Command guidance, the WTU selection process for squad leaders and platoon sergeants is important to ensure the selection of individuals who are best suited for the position. Warrior Transition Command officials stated that squad leader and platoon sergeant positions within the WTU are categorized as “broadening positions” because they reflect responsibilities and duties outside of their Army military occupational specialty. Candidates for these positions are drawn from a mix of Army occupations, such as infantry or transportation corps, and the selection process, including interviews, is intended to ensure the suitability of the staff selected for the position. Warrior Transition Command guidance recommends using the structured interview process when evaluating candidates to significantly improve the likelihood of selecting good candidates. A structured interviewed process involves the WTU Commander or a staff selection board asking the same questions of each candidate and scoring the answers using a pre- developed rating scale. The guidance explains that interviewing provides Commanders and their selection panels the ability to learn more about the candidate and gives candidates the opportunity to demonstrate their responses to situational job scenarios such as supervising WTU soldiers with behavioral health issues.

The Warrior Transition Command, which is responsible for oversight of the WTU program and operations, has not monitored whether units adhere to the requirement to interview squad leaders and platoon sergeants for WTU positions. The Warrior Transition Command directs the Army Human Resource Action Branch to conduct a quarterly analysis of a random sample of squad leader and platoon sergeants’ records to validate that candidates meet, for example, minimum grade and experience requirements. However, this quarterly analysis does not include validation of whether the selection process was followed as required, including whether the candidate was interviewed. At four of the five WTUs we visited, squad leaders and platoon sergeants told us that they were not interviewed prior to assuming their positions. In contrast, senior officials at three of the five WTUs we visited stated that they believed that interviews for squad leaders and platoon sergeants are conducted. However, in the absence of a mechanism to monitor this, the Army does not have assurance that the interviews are being conducted. When questioned why some interviews may not be conducted, Warrior Transition Command officials stated that the interviews were encouraged, which stands in contrast to the stated policy.

Federal internal control standards state that management should design control activities to achieve objectives and respond to risks. Although both the regulations effective as of November 2015 and before November 2015 state that Commanders or their staff selection panels will interview and review the records of candidates to validate whether a candidate possesses the required skills and attributes to work as WTU squad leaders and platoon sergeants, there is no internal control procedure to monitor full adherence to this requirement. By not monitoring full adherence to this requirement, the Army does not have assurance that squad leaders and platoon sergeants being selected are well suited to carry out the sensitive mission of the WTUs.

The Army Has Made Efforts to Improve Training, but Does Not Incorporate a Key Post- Training Assessment

The Army Medical Department Center and School has made efforts to make improve WTU training for squad leaders and platoon sergeants, but the program does not incorporate a post-training assessment of the application of training to the work environment. At three of the five sites we visited, WTU squad leaders and platoon sergeants, along with other WTU staff, expressed concerns regarding squad leader and platoon sergeants’ training. While the Army has implemented several practices to incorporate feedback from participants and other WTU professionals into its training program for squad leaders and platoon sergeants, these efforts may not fully address the concerns.

Currently, according to school officials, the Army Medical Department Center and School offers a 3-week residential training course that squad leaders and platoons sergeants must take within 90 days of assuming their duties. Prior to attending the residence course, staff must complete a staff orientation distance learning course. In the first week of residence training, squad leaders and platoon sergeants are required to take the Cadre Resilience Course, designed to assist those caring for wounded, ill, and injured soldiers and their families. According to Army Medical Department Center and School officials, the second and third weeks of training are designed specifically for the WTU and include information related to, for example, communication skills, behavioral health issues, the Comprehensive Transition Program, the case management system, and role-playing activities. Army Medical Department Center and School officials stated that the vast majority of squad leaders and platoon sergeants come to the course with little to no knowledge of the WTU concept. Army Medical Department Center and School officials also stated that the training is designed to provide a foundation for squad leaders and platoon sergeants to be able to perform their duties, and is not intended to provide them with expert-level proficiency.

While the WTU training program is extensive, WTU squad leaders and platoon sergeants at three of the five sites we visited stated that they were not sufficiently prepared for their positions after taking the required training. Specifically, squad leaders and platoon sergeants stated that their training did not address the actual requirements of their positions, such as the use of data systems and other day-to-day responsibilities. Squad leaders and platoon sergeants expressed frustration with their training, noting that there is no military occupational specialty similar to their positions, and that their roles and responsibilities were unfamiliar and dissimilar to anything in their prior Army experience. Candidates for these positions are drawn from a mix of Army occupations, such as infantry or transportation corps, and new squad leaders and platoon sergeants may have no background working with soldiers with issues typical of the WTU population, such as behavioral health issues. Other WTU staff at these sites, such as nurse case managers, social workers, and a WTU Commander stated that they also believe that current training does not sufficiently prepare squad leaders and platoon sergeants for their duties. For example, they noted that in some instances squad leaders and platoon sergeants did not have a sufficient understanding of behavioral health issues to be charged with responsibility for individuals having these issues.

Our prior work on assessing strategic training efforts summarizes attributes of effective training and development programs, including those related to the evaluation of agency training and development efforts. Such attributes include how the agency incorporates evaluation feedback into the planning, design, and implementation of its training and development efforts. According to school officials, the Army Medical Department Center and School currently uses end-of-course surveys and feedback from focus groups, WTU leadership, and staff to collect information on the effectiveness of the courses offered and make changes to course curricula. In addition, Army Medical Department Center and Schools officials stated that the Warrior Transition Command provides feedback from its Organizational Inspection Program regarding training. Warrior Transition Command officials stated that they send questionnaires prior to their Organizational Inspection Program and ask questions during informal feedback sessions regarding the effectiveness of squad leader and platoon sergeant training. These officials stated that they believe their current approach provides sufficient feedback to improve the training program.

While these efforts represent attempts to improve training through feedback, they do not assess the application of training to the work environment. Our prior work emphasizes that agencies should use analytical approaches appropriate for assessing training and development programs, such as assessing the application of training to the work environment. Application of training to the work environment assesses expected changes in behavior that trainees should exhibit on the job because of the training. Army Medical Department Center and School officials stated that the WTUs do not evaluate training of squad leaders and platoon sergeant through assessments of how well they are able to apply their training to the work environment. These officials noted that they have previously proposed such an assessment to the Warrior Transition Command as the Warrior Transition Command is responsible for post-training assessments of staff. Army Medical Department Center and School officials noted that 90 days post-training would be an opportune time to collect information on the application of squad leaders and platoon sergeants’ training to the work environment. However, no action has been taken to date.

Without information that could be obtained from conducting post-training assessments, the Army Medical Department Center and School may miss a valuable opportunity to improve its programs by incorporating useful information concerning the practical application of training. Similarly, the Warrior Transition Command and WTUs may miss a valuable opportunity to further assess the performance of the squad leaders and platoon sergeants for the benefit of WTU soldiers.

The Army Has Not Developed Plans for Adjusting Staff Levels to Meet Any Potential Increases in Demand for WTUs

The Army has not developed plans for increasing its WTU staff levels in the event of increased demand for WTUs. A key planning consideration in the decision to inactivate 11 WTUs by August 2016 was the Army’s ability to reverse these changes in the event that the demand for the Army’s WTU program was to increase. The Army’s guidance highlights the importance of reversibility, and establishes a number of relevant policies, for example, to maintain control of inactive WTU facilities. According to the Warrior Transition Command, the enduring 14 WTUs, if staffed by a full complement of 1,475 staff, could manage up to 4,400 WTU soldiers. With additional staff, the facilities at the enduring WTUs could support up to 8,100 WTU soldiers. In line with this projection, the Army has outlined plans for “expansion companies” at its enduring locations, with the exception of Walter Reed National Military Medical Center and Brooke Army Medical Center, that could operate on a temporary basis for a period of 2 years, with an assessment after the first 9 months to determine whether the company should be added to the unit’s permanent staffing document. Each expansion company would require 55 WTU personnel and could manage the care of up to 200 WTU soldiers.

While these plans represent positive steps toward planning for a potential increase in WTU numbers, the Army has not addressed how it would staff the expansion companies at these enduring WTUs, or at any of the 11 inactivating WTUs, if the need arises. Warrior Transition Command officials stated that any change in the need for staff would be gradual. In addition, the Warrior Transition Command’s population projection model takes account of deployment cycles and could possibly anticipate a spike in WTU admissions due to an increased operational tempo. However, upswings in deployments and operational tempo could create spikes in WTU soldier admissions, possibly resulting in the need to expand WTU staff at a pace that is greater than the Army’s current expectations.

Regardless of the pace of any increase, the Army could face challenges in its efforts to staff these units with appropriately selected and screened personnel in a timely manner. As previously noted, the Warrior Transition Command recently updated its selection requirements for squad leaders and platoon sergeants. As the Warrior Transition Command implements requirements for squad leaders and platoon sergeants to undergo background checks and behavioral health records checks, effects from these changes could result in an increase in the time required to select WTU staff. The Warrior Transition Command has emphasized the importance of the screening and selection process, noting that it is central to the integrity of the WTU program and the duty to care for WTU soldiers. In addition, WTUs are staffed by a number of other professionals, including primary care managers, nurse case managers, social workers, and transition coordination specialists, and hiring well- qualified candidates for these positions will also take time. For example, after WTU nurse case managers attend a 3-week training course, they must then complete a 4-week preceptorship at their assigned WTU before they can manage a normal caseload of 20 WTU soldiers. Army guidance notes the possibility of hiring term or temporary employees to address any gaps. However, such an approach could negatively impact the continuity of care, a central principle of the Army’s approach to WTU care, because of turnover in key WTU staff.

To handle any sudden increase in demand, WTUs also could potentially increase their ratios of squad leaders, nurse case managers, or primary care managers to WTU soldiers to accommodate the additional demand, but this too could have negative effects due to the heavier case workloads that would result for these individuals. Warrior Transition Command officials stated that they regularly monitor the ratios of these team members to WTU soldiers, and the regulation underscores the relationship between adhering to these ratios and the quality of care provided. Further, officials such as squad leaders, platoon sergeants, social workers, and nurse case managers at the five WTUs we visited stated that the current ratios may be too high. At one site we visited, officials have changed local policy to lower the ratio of squad leaders to WTU soldiers.

Federal internal control standards emphasize the need for control activities, such as the management of human capital, to maintain a continuity of needed skills and abilities. While the Army’s recently issued policy does not require the Warrior Transition Command to develop a plan for increasing its staff levels in response to future demand, the policy states that the Warrior Transition Command should “be prepared to reactivate previously inactivated WTUs.” Senior Warrior Transition Command officials told us that this is an implied requirement for a plan related to staffing. However, they stated that they have not yet taken steps to address this issue. Absent such a plan, the Army does not have assurance that it can, with limited notice, expand its staffing to effectively carry out the WTU mission.

The Army Does Not Track Instances in Which Commanders Have Made Exceptions to WTU Admittance Criteria and Has Not Analyzed Proposed Changes to Criteria for the Reserve Component

The Army has implemented a structured process for reviewing the eligibility of soldiers to be admitted to WTUs, but it does not track instances in which Commanders have made exceptions to these criteria for active-duty soldiers. In addition, Warrior Transition Command and Army Reserve officials stated that they came to an agreement that admittance criteria for members of the reserve component will not change until a WTU-alternative program is expanded to the Army Reserve. However, the Army has not yet examined the costs and benefits of expanding this alternative program relative to the current system.

The Army Does Not Track Instances in Which Commanders Have Made Exceptions to WTU Admittance Criteria for the Active-Duty Component

According to Warrior Transition Command officials, the Army does not track instances in which individual WTUs have made exceptions to the Army’s WTU admittance criteria for active-duty soldiers. While the Army has established a structured process for reviewing the eligibility of soldiers to enter WTUs, Warrior Transition Command officials stated that the senior mission Commander at the relevant installation can choose to admit soldiers to WTUs outside of this process by approving an exception to the eligibility criteria.

Army regulations state that for admittance into the WTU program, active- duty component soldiers must either (1) need care requiring 6 months or more of treatment or (2) have a significant behavioral health issue that presents a danger to themselves or others. The Army’s structured process for reviewing the eligibility of soldiers to enter WTUs comprises the requirement that the WTU Commander, local hospital Commander, and senior mission Commander compare potential WTU soldiers’ medical case history with the WTU admittance criteria and decide whether soldiers are eligible. Warrior Transition Command officials stated that senior mission Commanders are able to approve exceptions to the criteria under a variety of circumstances, such as the need for soldiers stationed overseas to process disability status through DOD’s Integrated Disability Evaluation System.

Officials at the Warrior Transition Command could not provide data of how often exceptions to WTU admittance criteria were approved. Officials noted that admitting soldiers who do not meet admittance criteria can be appropriate in some situations. For example, the Department of Defense and the Veterans Affairs system for assessing individuals’ medical fitness for service and level of service-related disability, known as the Integrated Disability Evaluation System, is available only to soldiers in the continental United States, and soldiers stationed overseas can be transferred to a military treatment facility in the continental United States with an associated WTU to complete this process. WTU soldiers who will not be returning to duty normally go through this process while in the WTU.

Officials at our site visits expressed concern related to instances in which soldiers were far into the Integrated Disability Evaluation System process, near to the point of separation from the Army, and were assigned to a WTU to stay for fewer than 6 months, sometimes for fewer than 30 days. By virtue of the fact that a soldier is in the late stages of the Integrated Disability Evaluation System process, the soldier is unlikely to be in the Army for the standard admittance criteria period of 6 months or more of care. At three of the five sites we visited, a variety of WTU officials, such as nurse case managers, squad leaders, and social workers, among others, expressed concern about this issue. Officials at these locations noted that this was not the best use of WTU resources, and that such soldiers did not have the necessary time to benefit from the medical and career opportunities that the WTU program provides.

According to Warrior Transition Command officials, they do not track instances in which individual WTUs make exceptions to the Army’s admittance criteria because application of the eligibility criteria is the responsibility of the senior mission Commander on the relevant installation. Standards for Internal Control in the Federal Government state that management should design control activities to achieve objectives. These control activities might include performing top-level reviews, for example, to ensure that performance is consistent with the WTU program’s goals. However, by not tracking this information, the Army does not know how frequently such exceptions are made and cannot ensure the best use of resources.

The Army Has Not Yet Examined the Costs and Benefits of Expanding a WTU-Alternative Program for Army Reserve Soldiers

The Army is planning to expand an alternative WTU program to the Army Reserve, but it has not yet examined the costs and benefits of this expansion. Specifically, the Army has not yet estimated the costs and benefits of expanding the Reserve Component Managed Care program, which currently treats only National Guard soldiers with low-acuity, low- risk, non-complex medical needs. In addition, the Army has not compared the cost of expanding this program with maintaining the status quo for soldiers with similar low-acuity, low-risk, non-complex medical needs. Army Reserve officials have confirmed their intention to participate in the program, but have not yet established a timeline for its introduction.

Currently, active-duty soldiers must need care lasting 6 months or longer to be admitted to a WTU. In contrast, reserve component soldiers must need care lasting 30 days or longer. If reserve component soldiers meet this threshold, they can be considered for admittance to a WTU Community Care Unit if their medical needs are low-acuity, low-risk, and non-complex. Warrior Transition Command and Army Reserve officials stated that expansion of the Reserve Component Managed Care program to the Army Reserve would be necessary if the Warrior Transition Command were to change current WTU admittance policy, specifically by applying the more stringent criteria for active-duty soldiers to members of the reserve components. However, during the course of our review, Warrior Transition Command officials stated that they came to an agreement with the Army Reserve that admittance criteria will not change until the Reserve Component Managed Care program is expanded to the Army Reserve.

A senior Army Reserve official stated that the lower threshold for members of the reserve components stems from requirements under law and DOD instructions for such soldiers to remain in active federal service for the purposes of disability evaluation or medical treatment. Senior officials at the Warrior Transition Command noted that active-duty soldiers needing fewer than 6 months of care can, instead of being assigned to a WTU, remain with their line unit and receive medical care in that setting. Meanwhile, reserve component soldiers must demobilize as their active-duty orders end and, while they can receive DOD-funded medical care for a period of time, cannot continue to receive their active- duty pay and other benefits. The 30-day treatment threshold therefore allows those soldiers to enter the WTU, whereas active-duty soldiers with similar short-term care needs can remain with their unit. Table 2 summarizes the admittance criteria for the WTU program and for the WTU-alternative program.

Warrior Transition Command and Army Reserve officials told us that were the more stringent active-duty criteria to be applied to members of the reserve components, those Army Reserve soldiers needing fewer than 6 months of care would not be eligible for the WTU program, and would not be able to receive their active duty pay while receiving short-term medical treatment. According to Warrior Transition Command and Army Reserve officials, access to active-duty pay is important because these soldiers may not be medically able to return to civilian employment while receiving medical care. Warrior Transition Command officials acknowledged that this would put Army Reserve soldiers at a disadvantage compared with active component soldiers. National Guard soldiers, meanwhile, could potentially access the Reserve Component Managed Care Program, which provides an alternative to WTUs for soldiers needing 179 days or fewer of low-acuity, low-risk medical care while on active-duty orders, entitling soldiers to active duty pay and benefits. Army Reserve or National Guard soldiers with low-acuity, low-risk, non-complex conditions can also be assigned to a WTU Community Care Unit, in which soldiers are not physically located at a WTU, but receive remote medical case management from their assigned WTU and receive medical care in their local area, either in a military treatment facility or from a provider in the TRICARE network. To be eligible, soldiers must not be in need of complex medical case management, and must meet behavioral health- risk standards. According to Army data, as of February 2016, there were 155 Army Reserve soldiers in 11 Community Care Units across the United States.

Army Reserve officials told us that they are in the early planning stages of considering Reserve Component Managed Care expansion, and that no cost estimates of such an expansion have yet been developed. As in the National Guard, the active duty Army would pay for active duty pay and medical care costs for the reservists in this program. However, officials told us that the Army Reserve would incur costs because of the need to tender a contract for nurse case managers for the program. Unlike the National Guard, the Army Reserve does not currently have a large network of contracted nurse case managers charged with improving medical readiness. While the National Guard is able to utilize its existing nurse case manager contract to service the program, officials stated that the Army Reserve would incur new costs in procuring these services. Further, Army officials have not yet articulated why expansion of the Reserve Component Managed Care is preferable to any alternatives, such as the continued use of WTU Community Care Units, especially in light of the alternative program’s increased costs. One official told us that this may stem from a desire to limit the time that reserve component personnel spend in the WTU program.

Our Business Process Reengineering Assessment Guide states that when considering program changes, officials should develop a performance-based analysis of the benefits and costs for each alternative, followed by a formal business case analysis making the case for a change. In this case, such an analysis could assess the costs and benefits of expanding the Reserve Component Managed Care program to the Army Reserve with alternatives, such as the option of continuing the current system of Community Care Units. As noted above, the Army Reserve is in the early stages of considering Reserve Component Managed Care expansion and no cost estimate has yet been conducted. Senior officials from Warrior Transition Command and the Army Reserve stated that expansion of the Reserve Component Managed Care program requires fewer resources than WTUs and soldiers in this program, on average, demonstrate shorter lengths of stay than soldiers in WTUs or Community Care Units. However, without conducting a cost-benefit analysis to analyze such factors, the Army Reserve may continue with plans to expand the Reserve Component Managed Care program and incur significant costs without clearly articulated benefits.

The Army Cannot Ensure Full Oversight of Soldiers’ Complaints

The Army has several methods that WTU soldiers can use to register a complaint or express a concern about the WTU program, medical care, or other issues. Although Army Medical Command oversees five complaint methods available to WTU soldiers, it does not have an approach to ensure that the Warrior Transition Command, which is charged with oversight of the WTU program, has access to all of this information. Standards for Internal Control in the Federal Government state that information should be communicated to management and others who need it in such a way that they can carry out their responsibilities. However, absent information on potential challenges with the WTU program, the Warrior Transition Command cannot fully carry out its oversight and policy development responsibilities.

The Army has the following methods, among others, by which WTU soldiers can register a complaint: the WTU chain of command;

WTU town hall meetings, to be held at least quarterly at the Commander’s discretion in order for the Commander to address the WTU soldiers and listen to their concerns; the local Army ombudsman, who is independent from WTU command and located at most WTU sites; a toll-free hotline, including the Wounded Soldier and Family Hotline managed by the Army Medical Command’s Medical Assistance Group, which oversees both the hotline and the Ombudsman program; and, the WTU chaplain, a confidential source within the command.

The Army Medical Command, with direct purview over Warrior Transition Command and the WTUs, oversees these five complaint methods. Local WTU Commanders, who coordinate with military treatment facility Commanders, manage their respective town hall meetings, and are part of the WTU chain of command. The Army Medical Command’s Medical Assistance Group oversees both the hotline and the Ombudsman program. The Regional Medical Commands, which report to Army Medical Command, provide chaplain support to the WTUs. The chaplain corps adheres to standards of privileged and confidential communications but, according to chaplains contacted throughout our review, they can provide general and trend information to Commanders.

According to the Army’s Warrior Transition Regulation, the Warrior Transition Command provides centralized oversight, guidance, and advocacy in support of WTU soldiers and their families, including policy development and oversight of the WTUs’ daily operations. In addition, the regulation states that WTU soldiers and their families are to be assisted through effective collaboration efforts, proactive communication, responsive policy, and program oversight. However, information from the three of the five complaint methods—chain of command, town hall meetings, and chaplains—that Army Medical Command has purview over may not be shared with the Warrior Transition Command, which therefore may not be able to sufficiently identify and address systemic issues. Warrior Transition Command officials stated that they do not generally receive information about complaints from these complaint methods and that complaints are mostly handled by the local chain of command, which has the responsibility to investigate and resolve these complaints.

WTU staff at four sites we visited said they handle complaints locally as much as possible, and infrequently contact senior leadership or the Warrior Transition Command with complaints information. In interviews with WTU staff at three of the sites we visited, officials stated that town halls may provide useful information to local leadership and referrals to other methods, but information from them typically is not forwarded to senior leadership. If complaints are expressed and resolved locally and information about them is not communicated further, senior leaders would remain unaware, and, if present at multiple WTUs, their possible systemic nature might go unidentified. In addition, at least one local senior official at a site we visited expressed a lack of confidence in the town hall system, stating that it yielded no useful information. Further, while Army chaplains are bound by confidentiality rules concerning communication between them and any soldier or family member, chaplains can share general information with local Commanders and regional medical commands, such as data on trends in the types of issues discussed, and such information can provide valuable insight into the issues concerning WTU soldiers.

The Warrior Transition Command does receive consistent information from some complaint methods, specifically from the two managed by the Ombudsman program. According to its operating procedures, the Ombudsman program provides information on issues reported by soldiers to local ombudsmen and the toll-free hotline through weekly reports to the Army’s Office of the Surgeon General and the Warrior Transition Command, as well as daily reports on WTU-related issues to the Warrior Transition Command’s Commander and staff. However, the Ombudsman program’s complaints information represents only two complaint methods identified by the Warrior Transition Command and does not present complete information about possible concerns raised by WTU soldiers. For example, ombudsman data would not include complaints from town hall meetings or the WTU chain of command unless WTU soldiers had repeated their complaints to the local ombudsman or toll-free hotline.

While the Warrior Transition Command receives information from the two programs run by the Ombudsman program, it does not consistently receive information from the other three methods of expressing complaints. Standards for Internal Control in the Federal Government state that information should be communicated to management and others who need it in such a way that they can carry out their responsibilities. The Warrior Transition Command, as the entity which provides strategic oversight and policy development support for the WTU program, provides a focal point for coordination and support for the program, and requires relevant information from the complaint methods to inform its oversight responsibilities. Quality information and effective communication about relevant complaints from all WTUs would enable the Warrior Transition Command and the Army to identify and implement necessary policy or program changes. However, the Army does not have an approach to ensure relevant complaints information from the various methods it presents to WTU soldiers is communicated to appropriate senior leadership, such as the Warrior Transition Command. In addition, the Army has not clarified which complaints information is important for WTU program management and oversight. Warrior Transition Command officials stated that they engage on a policy level when there is a trend or ongoing problem, but did not explain how it would identify such systemic issues absent relevant information from available complaint methods. Given this, the Army cannot ensure that the Warrior Transition Command has relevant, reliable, and timely information necessary to achieve its objectives for oversight of and policy development for the WTU program and may not be able to identify and address potential systemic issues concerning the WTUs.

Conclusions

The Army has taken the following steps that signify its commitment to strengthening its WTU program and not repeating some of the mistakes made which led to the crisis of care at the former Walter Reed Army Medical Center: WTUs are staffed with standard ratios of WTU soldiers to providers; soldiers’ transition through the WTUs follows a structured process; minimum standards for squad leaders and platoon sergeants are being strengthened; and WTU soldiers have a range of methods for expressing complaints. These changes represent efforts to develop policy for the WTU program to help ensure quality of care and soldiers’ trust in the program. However, the Army has not assessed how fundamental aspects of the WTUs, such as the Triad of Care model, are impacted by the changing composition of diagnoses for WTU soldiers, particularly the increasing prevalence of behavioral health diagnoses. Additionally, in areas ranging from screening requirements for WTU staff, WTU soldiers’ admittance criteria, and the complaints process, the Army has yet to implement management controls to ensure that its policies are maintained and implemented in practice. As the Warrior Transition Command moves toward its transition to becoming a directorate within the Army Medical Command, it will be important that its successor organization increase oversight of the program to maintain the commitment to high-quality care for WTU soldiers.

Recommendations for Executive Action

To increase oversight of the Army’s Warrior Transition Unit program, we recommend that the Secretary of the Army direct the Army Surgeon General to take the following six actions:

Assess the Triad of Care model’s effectiveness in light of the changes in WTU diagnoses and take the appropriate action.

Exercise oversight responsibility to track full adherence to selection processes for squad leaders and platoon sergeants, including the requirement to conduct interviews for these positions.

Develop a mechanism to conduct post-training assessments on squad leaders and platoon sergeants’ application of training to the work environment and incorporate the results into the training program.

Develop plans to adjust staff levels, if needed, to accommodate a potential future surge in demand.

Establish a process that assigns oversight responsibility for tracking instances in which Commanders make exceptions to WTU entrance criteria so that the Army Surgeon General is aware of the extent Commanders’ decisions are consistent with program goals.

Develop and implement an approach and associated procedures for providing senior leadership, such as the Warrior Transition Command, with complaints information concerning the WTU program and WTU soldiers.

To help ensure the best use of resources for managing the medical care of soldiers recovering from serious medical conditions, we recommend that the Secretary of the Army direct the Chief of the Army Reserve, in conjunction with the Army Surgeon General, to take the following action:

Develop an analysis that compares the costs and benefits of maintaining the current system of Community Care Units with the costs and benefits of expanding the Reserve Component Managed Care program.

Agency Comments

In written comments on a draft of this report, DOD concurred with our seven recommendations to increase oversight of the Army’s Warrior Transition Unit program and to help ensure the best use of resources for managing the medical care of Army Reserve soldiers recovering from serious medical conditions. DOD’s comments are reprinted in appendix III.

We are sending copies of this report to the appropriate congressional committees, the Secretary of Defense, the Deputy Secretary of Defense, the Secretary of the Army, the Army Surgeon General, and the Chief of the Army Reserve. In addition, the report is available at no charge on the GAO website at http://www.gao.gov.

If you or your staff have any questions regarding this report, please contact me at (202) 512-3604 or farrellb@gao.gov. Contact points for our Offices of Congressional Relations and Public Affairs may be found on the last page of this report. GAO staff who made key contributions to this report are listed in appendix IV.

Appendix I: Scope and Methodology

To address the objectives for this review, we reviewed policies governing the Army’s Warrior Transition Unit (WTU) program, including the Army Medical Action Plan; analyzed program documents and data; and interviewed officials from the Warrior Transition Command, the Office of the Army Surgeon General, and other Army offices with responsibilities for medical and personnel management. We conducted site visits to 5 of the WTUs existing during the course of our review, which we selected based on the mix of active-duty and reserve components, the number of complaints reported to the ombudsman, and geographic dispersion. The sites we visited were Walter Reed National Military Medical Center in Bethesda, MD; Joint Base San Antonio in San Antonio, TX; Fort Hood in Killeen, TX; Fort Carson in Colorado Springs, CO; and Fort Eustis in Newport News, VA. At each site, we conducted interviews with squad leaders, command staff, nurse case managers, social workers, and other professionals. The results of these site visits are non-generalizable but provide useful information on WTU program operations and relevant issues.

To determine the extent to which the Army has assessed the effectiveness of the Triad of Care staffing model for managing WTU soldiers’ care, we compared policy and other documents concerning the use of the Triad of Care model with federal internal control standards, which emphasize the need for management to identify and analyze relevant risks associated with achieving defined objectives. To identify changes in the WTU population over time, we analyzed aggregate data from the Warrior Transition Command on WTU soldiers’ medical diagnoses upon entry into the WTU program from June 1, 2007 through December 2015. We did not request or have access to any individual WTU soldier’s information, including an individual soldier’s medical records or diagnoses. We decided not to present data for soldiers who entered a WTU in 2007 because it did not represent a full year of the program. We found these data to be sufficiently reliable to show the prevalence of behavioral health diagnoses at the time of the soldier’s entry into the WTU program. We made this determination based on a data reliability questionnaire filled out by Army officials, logic tests of the data, and our conversations with Warrior Transition Command officials about how the data were captured, stored, and checked for accuracy. We also reviewed relevant documentation related to the Warrior Transition Command’s most recent unit inspections conducted at each of the five individual WTUs we visited (one WTU inspected in 2011, one WTU inspected in 2014, and the remaining three inspected in 2015), and observed one of these inspections in process to determine what types of information were analyzed by the Warrior Transition Command. We spoke with Warrior Transition Command officials about the Triad of Care model, changes in the WTU soldier population, and their WTU inspections. We also interviewed officials at each of the five WTUs we visited about the Triad of Care model and the management of their soldiers’ care.

To determine the extent to which the Army’s has established processes to oversee its WTU personnel selection, assess the training of these personnel, and adjust staff levels, we interviewed officials from the Warrior Transition Command, the Human Resources Command, and officials at various levels at each of the sites we visited concerning their views of the selection of squad leaders and platoon sergeants. We also interviewed officials at the Army Medical Department Center and School regarding the WTU training program. We compared current and past Army policies regarding the selection and training of squad leaders and platoon sergeants and reviewed the content of our discussions with squad leaders and platoon sergeants at various sites we visited. We reviewed federal internal control standards which state that management should demonstrate a commitment to recruit, develop, and retain competent individuals and our prior work which summarizes the attributes of effective training, including the need to ensure that training goals and strategies are aligned with organizational goals and attributes of effective training and development programs. Though WTU policies address issues related to staff in various roles, collectively referred to as “cadre,” we decided to focus on the selection and training of squad leaders and platoon sergeants based on the content of our discussions with officials at each of our site visits. We also discussed the Army’s ability to adjust WTU staff levels with officials from the Warrior Transition Command. We reviewed the Army’s policy in this area and the principle in federal internal control standards that states that agencies need to demonstrate a commitment to competence through succession and contingency plans and to establish control activities, such as for the management of human capital, to maintain a continuity of needed skills and abilities.

To determine the extent to which the Army has assessed adherence to WTU program admittance criteria and the impact of any changes to these criteria for the active-duty and reserve components, we reviewed policies and procedures for admitting soldiers into the WTU program, including any proposed changes to the admittance criteria and discussed the application of these policies and procedures with officials at each of the sites we visited and with officials from the Warrior Transition Command. We compared these policies and procedures with federal internal control standards which require that management design control activities, such as establishing and reviewing performance measures and indicators, to achieve objectives and respond to risks, and noted any differences. In addition, we reviewed documentation concerning the Army’s Reserve Component Managed Care program, a WTU-alternative program, and its proposed introduction to the Army Reserve, and discussed this information, including estimated costs, with officials from the Army Reserve and the Warrior Transition Command. We compared plans for the introduction of the program to the Army Reserve with the requirement in our Business Process Reengineering Assessment Guide for a performance-based analysis of benefits and costs for each alternative when considering program changes, and noted any differences.

To determine whether the Army had instituted methods to address the complaints of WTU soldiers, we analyzed information on the Army’s approach to handling complaints by WTU soldiers. We interviewed program staff and officials regarding the Army’s approach and reviewed related Army documentation, such as Army policies on its WTU and chaplain corps programs. We compared the Army’s approach for handling complaints with federal internal control standards which state that information should be communicated to management and others who need it in such a way that they can carry out their responsibilities.

We analyzed data regarding the number of soldiers in a WTU over time, the date when they entered a WTU, and their average length of stay from 2007 to 2015. We found the data on the number of soldiers in a WTU over time to be sufficiently reliable to present monthly changes in the WTU soldiers’ census. For the data on when a soldier entered a WTU and their lengths of stay, we determined that the 2007 and 2008 data were unreliable because of missing data. We also chose not to report data on when a soldier entered a WTU and their lengths of stay for 2015 because of the large number of soldiers that were still in the WTU program when the data were reported by Warrior Transition Command officials. Other than these exceptions, we found the data to be sufficiently reliable for showing WTU soldiers’ lengths of stay from the time of entry in the WTU program to the time of (1) exiting the WTU and (2) until they had reached their medical retention decision point. For each type of data, we made these determinations based on a data reliability questionnaire filled out by Army officials, logic tests of the data, and our conversations with Warrior Transition Command officials about how the data were captured, stored, and checked for accuracy.

We conducted this performance audit from August 2015 to July 2016 in accordance with generally accepted government auditing standards. Those standards require that we plan and perform the audit to obtain sufficient, appropriate evidence to provide a reasonable basis for our findings and conclusions based on our audit objectives. We believe that the evidence obtained provides a reasonable basis for our findings and conclusions based on our audit objectives.

Appendix II: Trends in Warrior Transition Unit Soldiers’ Separation from the Army and Lengths of Stay in the Warrior Transition Unit Program

Of the Army soldiers who entered a Warrior Transition Unit (WTU) between 2008 and the end of 2015, generally a higher percentage separated from the Army than returned to the Army (see fig. 4).

WTU soldiers’ length of stay—from entry in the WTU until separation— peaked for soldiers who entered in 2009 and has generally decreased since then. For example, the average length of stay was 407 days for those soldiers who entered a WTU in 2009, and that number decreased to 308 for those who entered a WTU in 2014. In addition, WTU soldiers in the active component generally had shorter lengths of stay than those in the Army National Guard or Army Reserve (see fig. 5).

Similarly, the average length of time between a WTU soldier’s entrance into the WTU program and the medical retention determination point has significantly decreased. For example, the average length of time to reach the medical retention determination point has decreased by about 45 percent for those soldiers who had entered a WTU in 2009 as compared with those who entered a WTU in 2014 (see fig.6).

Appendix III: Comments from the Department of Defense

Appendix IV: GAO Contact and Staff Acknowledgments

GAO Contact

Staff Acknowledgments

In addition to the contact named above, Lori Atkinson, Assistant Director; Rebekah Boone; Nicole Collier; Mae Jones; Amie Lesser; Jeffrey Mayhew; Michael Silver; Adam Smith; and Sabrina Streagle made key contributions to this report.

Related GAO Products

Military and Veteran Support: DOD and VA Programs That Address the Effects of Combat and Transition to Civilian Life. GAO-15-24. Washington, D.C.: November 7, 2014.

Recovering Servicemembers and Veterans: Sustained Leadership Attention and Systematic Oversight Needed to Resolve Persistent Problems Affecting Care and Benefits. GAO-13-5. Washington, D.C.: November 16, 2012.

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.

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.