DOD and VA Health Care: Federal Recovery Coordination Program Continues to Expand but Faces Significant Challenges
Released: 2011-03-23T00:00:00

Letter

Background

Servicemembers wounded in recent conflicts are surviving injuries that would have been fatal in past conflicts, in part because of advanced protective equipment and medical treatment. However, the severity of their injuries can result in a lengthy transition from patient status back to active duty or to veteran status. Most severely wounded servicemembers from the conflicts in Iraq and Afghanistan initially are evacuated to Landstuhl Regional Medical Center in Germany for treatment. From there, they are usually transported to military treatment facilities in the United States, with most of the severely wounded admitted to Walter Reed Army Medical Center, the National Naval Medical Center, or Brooke Army Medical Center.

Acute medical treatment and stabilization is the first of three phases in the “continuum of care” experienced by severely wounded servicemembers. The second phase of the continuum is rehabilitation at a DOD, VA, or civilian facility. (The recovery needs of some servicemembers receiving rehabilitation may require their return to a medical center for acute medical care, such as surgical procedures.) The third phase of the continuum is reintegration—either return to active duty or to the civilian community as a veteran, where they may receive health care from DOD, VA, or civilian providers.

FRCP Enrollees

From January 2008—when FRCP enrollment began—through September 2010, the FRCP provided services to a total of 1,268 servicemembers and veterans. As of September 2010, the program had 607 active enrollees, ranging in age from 19 to 61 years, with a median age of 27 years. About half of the enrollees were or had been married. Fifty-eight percent had designated another person as his or her primary caregiver, and 38 percent had delegated legal authority to another person. (See table 1 for additional demographic information about current FRCP enrollees.)

FRC Activities

FRCs are senior-level registered nurses and licensed social workers whose principal role is to coordinate services with case managers rather than provide services directly to enrollees. FRCs are expected to serve as the single point of contact for the enrollees and their families and to assist the enrollees in a number of ways. FRCP care coordination guidelines identify FRC activities, which are outlined in table 2.

According to FRCP policy, the FRC’s primary responsibility is to develop and monitor progress of each enrollee as detailed in that person’s Federal Individual Recovery Plan, which is created and implemented by the FRC with input from the enrollee and his or her family and clinical team. This plan is to be a comprehensive, client-centered plan that sets individualized goals for recovery and is intended to guide and support the enrollee through the continuum of care. FRCs update Federal Individual Recovery Plans to reflect changing conditions or enrollee goals.

Based on their diagnoses and other factors, enrollees are likely to require a complex array of clinical and nonclinical services from multiple providers and facilities. (See table 3.) In providing care coordination services, the FRC may engage with an enrollee’s health care providers, other care coordinators, and case managers, such as those with the military services’ wounded warrior programs. As care coordinators, FRCs are generally not expected to directly provide the services needed by enrollees. However, FRCs may provide services directly to enrollees in certain situations, such as when they cannot determine whether a case manager has taken care of an issue for an FRCP enrollee, when asked to resolve complex problems, or when making complicated arrangements, for example, identifying and arranging admission to a substance abuse treatment program for a veteran who was beginning to develop violent behaviors and had refused to complete a VA drug rehabilitation treatment program.

Problems Identifying Potential Enrollees and Reviewing Enrollment Decisions Make It Unclear Whether Those Needing FRCP Services Are Enrolled

It is unclear whether all of the eligible “severely wounded, ill, and injured” servicemembers and veterans who could benefit from the FRCP are being enrolled in the program. The FRCP cannot readily identify these individuals because the “severely wounded, ill, and injured” classification is not captured in existing data sources. Additionally, the program’s broad eligibility criteria cannot be used systematically to identify potentially eligible servicemembers and veterans. Instead, the FRCP must rely on referrals from others to identify these individuals, although the program has also taken steps to identify potential enrollees through the FRCs’ efforts at medical facilities and through a “look back” initiative to identify eligible veterans who were wounded prior to program implementation. In addition, the FRCs must exercise judgment in applying the program’s criteria for enrollment determinations, and FRCP leadership does not systematically review these decisions to ensure that these criteria are applied appropriately so that referred individuals who could benefit from the program are enrolled, and that individuals who could be served by less intensive services are referred to other programs.

The FRCP’s Potential Enrollee Population Cannot Be Readily Identified from Existing Data Sources, but the FRCP Has Taken a Number of Steps to Identify Potentially Eligible Individuals

FRCP officials have experienced difficulties in identifying the potentially eligible population of “severely wounded, ill, or injured” servicemembers and veterans, and as a result, it is unclear whether all of these individuals who could benefit from care coordination services are enrolled in the program. The Senior Oversight Committee, which created the FRCP, developed a three-level care categorization system to differentiate the population of wounded servicemembers and veterans for different programs based on the severity of their conditions. In this system, Category 1 servicemembers are those with mild wounds, illnesses, or injuries who are expected to return to duty in less than 180 days; Category 2 servicemembers are those with serious wounds, illnesses, or injuries who are unlikely to return to duty in less than 180 days and possibly may be medically separated from the military; and Category 3 servicemembers are severely wounded, ill, or injured individuals whose medical conditions are highly likely to prevent their return to duty and also likely to result in medical separation from the military.

Individuals who fall under category 3 may be considered for enrollment into the FRCP, while individuals falling under categories 1 or 2 may qualify for other types of programs. However, according to the FRCP Executive Director, these are administrative categories that are not captured in existing VA or DOD medical or benefits data systems or included in medical or benefits records. As a result, the FRCP cannot use this classification to systematically identify the population of potentially eligible severely wounded servicemembers and veterans using available data sources. In addition, the FRCP Executive Director and FRCs told us that the broad eligibility criteria developed for the FRCP must be used on a case-by-case basis to identify potentially eligible individuals for the program because these criteria require some judgment. Therefore, the criteria cannot be used systematically to identify the program’s potentially eligible population. These criteria include both specific medical diagnoses and requirements that are somewhat subjective, such as whether an individual may benefit from a recovery plan. To decide whether potential enrollees may benefit from a recovery plan, FRCs reported that they evaluate the complexity of a situation by examining issues such as future medical needs, family dynamics, and any financial or legal problems— information that is not readily available in any one data source.

As a result, to identify potentially eligible individuals, the FRCP relies on referrals from others, including program officials and medical facility staff. Sources of referrals include, for example, wounded warrior program staff, Recovery Care Coordinators, and clinical treatment teams. Of the program officials and medical facility staff we spoke with who discussed referrals, more than half (25 of 47) had made a referral to the program. However, more than half (15 of 27) of the program officials and medical facility staff we interviewed who responded to questions on eligibility also felt that the FRCP eligibility criteria were unclear. In addition to relying on referrals, the FRCs also take steps to identify potential enrollees. Some FRCs stated that they review their facility’s list of incoming severely wounded servicemembers and attend weekly multidisciplinary team meetings where hospital officials and medical staff discuss severely wounded patients’ cases.

In an attempt to ensure that eligible veterans who were wounded prior to the program’s inception are enrolled in the program, the FRCP conducted a “look back” initiative in May 2010. Because no single data source contains sufficient information, the FRCP Executive Director told us that she combined five DOD and VA data sets and used multiple “proxy” factors to narrow the data from 40,000 veterans’ records to the final list of potentially eligible veterans. For example, the Veterans Benefits Administration’s 100 percent disability compensation list and medical diagnostic codes were used to help identify this population. Based on this analysis, the FRCP Executive Director reported that the program contacted approximately 300 potential enrollees to determine whether they could benefit from an FRC’s assistance. As a result, 35 of those severely wounded veterans will be further evaluated for potential enrollment.

According to the FRCP Executive Director, this analysis was prioritized to focus on severely wounded veterans who were most likely to need FRC assistance. The Executive Director told us that, as a result, the list was not comprehensive—for example, the program did not contact veterans who were already enrolled in VA’s OEF/OIF Care Management Program under the assumption that they were already receiving adequate case management. Additionally, the FRCP Executive Director told us that identifying 35 veterans indicated that the FRCP is not reaching all potentially eligible veterans through its normal referral process or that information about the program is not reaching severely wounded veterans. The FRCP Executive Director added that once it is complete, this effort will be assessed to determine whether another “look back” is needed, but as of February 2011, leadership officials had not yet determined whether they would conduct a subsequent “look back.”

Enrollment Decisions Require FRC Judgment, and FRCP Leadership Does Not Systematically Review These Decisions to Ensure That Referred Individuals Who Could Benefit Are Enrolled

Following the identification of potentially eligible servicemembers and veterans, FRCs use a more thorough application of the program’s eligibility criteria to evaluate these individuals for enrollment. The eligibility criteria are broad and require FRCs to exercise judgment with their enrollment decisions. However, FRCP leadership does not systematically review these decisions to ensure that referred individuals who could benefit from the program are enrolled while those requiring less intensive services are referred to other programs.

Eligibility criteria for the program—developed by the Senior Oversight Committee—specify that enrollees be receiving acute care in a military treatment facility; be diagnosed or referred for one or more of the following: spinal cord injury, burns, amputation, visual impairment, traumatic brain injury, or post-traumatic stress disorder; be considered at risk for psychosocial complication; or may benefit from a recovery plan.

Because some of these criteria are subjective, particularly whether an individual is at risk for psychosocial complications or would benefit from a recovery plan, the FRCs must use their judgment when deciding whether an individual should be enrolled in the program. According to the FRCP Executive Director, the program’s criteria are intended to provide guidance for the FRCs, giving them the flexibility to enroll severely wounded servicemembers and veterans, rather than being restrictive. The Executive Director added that FRCs strive to enroll severely wounded servicemembers and veterans in cases where having an FRC can add value to existing case management efforts.

To evaluate servicemembers and veterans for program eligibility, FRCs must make subjective assessments of the impact their care coordination efforts could have on potential enrollees. This involves FRCs making assessments of the severity of potential enrollees’ medical conditions to determine future medical needs—such as rehabilitation—and nonmedical issues—such as caregiver status. FRCs obtain information from a number of sources, including DOD and VA medical records, as well as records from private sector providers. They may also discuss potential enrollees’ situations with members of multidisciplinary teams providing medical treatment, family members, and the potential enrollees. At the end of the evaluation period, the FRC will consider a potential enrollee’s need for care coordination based on the collected information and determine whether the individual should be enrolled in the program, provided temporary assistance, or referred to another program.

While it is necessary for FRCs to use their judgment in making enrollment decisions, the FRCP does not systematically review the factors and reasons for enrolling, providing temporary assistance, or referring potentially eligible servicemembers and veterans to other programs. Systematic review could involve the use of a defined protocol for the review of eligibility decisions made by FRCs. According to federal internal control standards, agencies should establish ongoing internal control activities to provide reasonable assurance that decisions are consistent with applicable criteria—in this case, criteria designed to ensure that those in need of care coordination services are enrolled in the program. While the FRCs indicate in their data management system—the Veterans Tracking Application—whether they decided to enroll an individual, FRCP leadership told us they do not require that the FRCs record the factors they considered to support this decision. Additionally, FRCP leadership told us that while they closely review all enrollment decisions made by new FRCs, they do not perform similar reviews of decisions made by more experienced FRCs. Instead, FRCP leadership and experienced FRCs discuss the FRCs’ recommended actions on newly referred individuals as part of weekly telephone conversations. However, FRCP officials acknowledged that these discussions with the FRCs may not be comprehensive and that there is no section in the Veterans Tracking Application dedicated to recording these discussions. Without specific documentation of the factors the FRCs considered when making their enrollment decisions and absent internal controls and systematic oversight of much of the enrollment process, it is difficult to determine whether severely wounded servicemembers and veterans who are referred and could benefit from the program are actually enrolled and severely wounded servicemembers and veterans who could be served by less intensive services are referred to other programs. Additionally, this issue could become even more problematic as the program’s enrollment continues to increase and FRCP leadership has to review more enrollment decisions.

The FRCP Faces Challenges in Determining Staffing Needs and Has Not Clearly Defined or Documented Its Processes for Managing FRCs’ Caseloads, Making Staffing Decisions, and Placing FRCs

Several challenges confront the FRCP in determining staffing needs for the program, including how to manage FRCs’ caseloads, deciding when VA should hire FRCs, and determining where to place them in the field to best serve current and potential enrollees. The FRCP has not established a formal caseload size for FRCs because there are no comparable criteria upon which to determine caseload size because of the program’s unique care coordination activities. Also, while establishing an appropriate caseload size for FRCs may help FRCP leadership determine how many FRCs VA should hire, it remains difficult for FRCP leadership to determine when VA should hire FRCs. Finally, the FRCP lacks a clear and consistent rationale for making decisions about where to place FRCs in the field.

FRCs Have Expressed Concerns about Heavy Caseloads, and the FRCP Is Developing a Workload Assessment Tool That Should Help Address This Concern

The FRCs we spoke with expressed concerns about the high number of enrollees assigned to them and cited the need for improved caseload management. Specifically, 11 of the 15 FRCs we interviewed identified inadequate caseload management as a concern. Eight of these FRCs expressed concerns about the large number of cases assigned to them. As of September 30, 2010, FRCs’ caseloads ranged from 25 to 48, with two- thirds of the FRCs (10 of 15) having caseloads that exceeded the informal target ratio of 1 FRC for every 30 enrollees established by the FRCP Executive Director to manage FRC caseloads. Some FRCs told us that the large number of cases required them to work long hours and sometimes forced them to limit the amount of time that they could devote to an enrollee. In addition, more than half of the FRCs (8 of 15) expressed concerns that FRCP leadership does not adequately account for the services required by existing enrollees in their caseloads when assigning new cases. For example, one FRC told us that the types of cases assigned to her were stressful. She indicated that she had been assigned two enrollees with terminal conditions because she was skilled at managing the issues related to these types of cases, but she is now reluctant to take another terminally ill enrollee because it is emotionally draining to deal with end-of-life issues. However, an FRCP leadership official told us that FRCs have the flexibility to forward a referral to the FRCP central office for assignment to another FRC as a means of managing their existing caseloads.

According to the FRCP Executive Director, an appropriate caseload is difficult to determine because care coordination is a new type of function, and there are no comparable criteria against which to measure and base caseload size for this program because of its unique activities. Additionally, the FRCs’ caseloads are dynamic in that the needs of each enrollee differ and may change over time. For example, out of a caseload of 30 clients, 5 may need intensive crisis management, while the remaining 25 enrollees may only need periodic contact or limited services. However, as noted by FRCP leadership and some FRCs, the needs of these enrollees, and consequently, the time required of an FRC, may change as enrollees move through different stages of the continuum of care.

As a means of managing FRCs’ caseloads, the FRCP Executive Director cited two actions in particular that FRCP leadership uses to assess and manage FRC caseloads.

FRCP leadership uses an informal FRC-to-enrollee target ratio of 1 to 30 (with a targeted range of 25 to 35 enrollees per FRC), which is based on the FRCP Executive Director’s experience in managing the program over time.

Weekly telephone calls with each FRC are used by FRCP leadership to discuss issues related to their assigned cases and to gauge workload burden.

The FRCP Executive Director told us that the program is developing a customized workload assessment tool to help balance FRCs’ caseloads— in other words, to ensure that an FRC’s caseload mix is manageable. The objective of the workload assessment tool is to identify specific enrollee characteristics, such as medical diagnosis, and to correlate each characteristic with the amount of time an FRC would be required to spend on addressing issues related to it. One method being considered is the assignment of a point value to each identified enrollee characteristic. Adding up the number of points for the characteristics of all enrollees in an FRC’s caseload would provide an estimate of that FRC’s workload burden. However, according to the FRCP Executive Director, the development of such a tool has been difficult, primarily because the enrollee characteristics that existing workload assessment tools use to determine how much time it takes to address an issue are not relevant to the care coordination activities that FRCs perform. As a result, program leadership continues to consider different methods of assessing FRCs’ workloads, including measurement tools that have already been validated for other purposes, to identify a method that could potentially be relevant for the program. The FRCP Executive Director is uncertain how long it will take to develop a workload assessment tool and has not established timelines to complete this effort. Without a workload assessment tool, the program does not have the data it needs to develop a more comprehensive caseload management strategy and to better determine appropriate caseload size for FRCs.

FRCP Staffing Decisions Are Based on Ongoing Program Monitoring Efforts, but This Process Has Not Been Clearly Defined or Documented

While establishing appropriate FRC caseloads should help FRCP leadership better determine how many FRCs VA should hire, determining when VA should hire FRCs has been another staffing challenge. Currently, the FRCP Executive Director’s decisions about when VA should hire FRCs are based on various ongoing monitoring efforts. The FRCP Executive Director told us that staffing decisions regarding FRCs are difficult to make because the FRCP cannot predict the number of potentially eligible servicemembers and veterans, which is affected by the OEF/OIF conflicts. In the absence of being able to project the number of potentially eligible servicemembers and veterans, the FRCP Executive Director said she uses other methods to predict future trends and guide the staffing process. One method involves monitoring FRCs’ workloads as an indicator that workload levels are increasing and new FRCs are needed. In this regard, the FRCP Executive Director told us that FRCP leadership conducts weekly telephone calls with each FRC to discuss issues related to their caseloads. The FRCP Executive Director told us that another method she uses to predict staffing needs is through the analysis of the number of new referrals and enrollment rates in the program, which she uses to create a quarterly report that highlights the projected number of FRCs that the program may need. For example, the average number of new referrals grew from 25 a month in 2008 to 35 a month in 2009. VA hired five FRCs in January 2010 in part because of this increase in the number of referrals and the expected resulting increase in the number of enrolled servicemembers and veterans. The FRCP Executive Director told us that the referral data collected in 2010 show that the number of new referrals continued to increase and averaged 50 a month, which indicates a continuing need for more FRCs. According to the FRCP Executive Director, she routinely shares this information with the Secretary of Veterans Affairs as advance notice that a request for additional FRCs may be forthcoming because it takes about 6 months for VA to hire a new FRC. The FRCP Executive Director told us that the program’s ongoing monitoring efforts are the most logical approach for determining when and how many FRCs VA should hire in the absence of knowing the number of potentially eligible servicemembers and veterans.

While these methods appear to be reasonable given the lack of overall data on the numbers of severely wounded servicemembers and veterans, the staffing process is not well documented. Internal control standards applicable to all federal agencies state that an agency should effectively communicate its policies and procedures by providing clear documentation that is readily available for examination. Consistent with this internal control standard, we would expect the FRCP to have documented procedures outlining its process for making staffing decisions. FRCP leadership documented staffing projections for fiscal year 2010 in the program’s annual operating plan, citing that ongoing analysis of referrals and enrollment rates was important in making those projections. However, the process used by program leadership—specifically how the referral and enrollment data are used in making staffing decisions—has not been clearly defined or documented in the operating plan or any of the other program policies or procedures. By documenting this information, the FRCP would have greater assurance that the process developed by the current leadership will be maintained during management changes.

The FRCP Lacks a Clear and Consistent Rationale for Making FRC Placement Decisions

Deciding where to place FRCs to best serve current and potential enrollees’ needs is another key staffing issue, despite the fact that FRCs often coordinate services for enrollees who are located throughout the country and may not be receiving care at the facility where their assigned FRC is located. The FRCP’s basis for making decisions about where to place FRCs has varied over time, and the program currently lacks a clear and consistent rationale for making FRC placement decisions. As of September 2010, 20 FRCs were located at 10 facilities. (See fig. 1.)

When the FRCP began operating in 2008, eight FRCs were placed at the three military treatment facilities where the majority of severely wounded servicemembers were receiving treatment. According to the FRCP Executive Director, the placement of FRCs at military treatment facilities helped with the identification of servicemembers who could benefit from FRCP services. In addition, some FRCs told us that being located at the military treatment facilities allowed them to develop relationships with the enrollees, their families, and the case managers who would be providing direct services to the enrollees. However, as the program expanded, placement of some FRCs was not based on a rationale or an analysis of where FRCs could provide the maximum benefit to severely wounded servicemembers and veterans. For example, some DOD and VA officials we spoke with expressed concerns about the FRCP’s placement decisions, particularly the placement of FRCs at facilities that do not treat a large population of severely wounded servicemembers or veterans. DOD officials told us that it was not clear why there were FRCs assigned to a military treatment facility that typically does not treat severely wounded servicemembers. Similarly, a VA medical center official stated that it was unclear why FRCs were initially placed at two VA medical centers that had few FRCP enrollees being treated there, rather than at VA medical centers where a significant number of severely wounded veterans may be receiving treatment. There was no official FRCP documentation that explained the basis for these decisions, which were made by FRCP officials who are no longer with the program.

After the FRCP leadership changed in July 2008, decisions to place FRCs have been based on several factors. According to the FRCP Executive Director, some placement decisions focused on ensuring that enough FRCs were in place to meet the demands of the FRCP workload by replacing FRCs who had left the program and by adding FRCs at facilities where only one FRC was located. She explained that where possible, it is helpful to have at least two FRCs at each facility so that there can be backup support, particularly for administrative purposes such as coverage, when an FRC is on leave. However, the FRCP Executive Director told us that more recently—from March 2010 through September 2010—FRC placement decisions have primarily been based on requests or recommendations from DOD and VA officials. For example, in June 2010, the FRCP relocated an FRC to a military wounded warrior program headquarters facility in response to a request from the program’s director. FRCP officials have also decided to place some new FRCs at two VA medical centers where servicemembers and veterans with polytrauma injuries receive care, based on recommendations from DOD and VA officials.

The FRCP Executive Director explained that the FRCP had not established a systematic rationale for FRC placement because the program initially lacked the data upon which to base these determinations. Additionally, she told us that every placement of an FRC at a VA or DOD facility is a negotiation and depends on the facility’s ability to accommodate an FRC, including the provision of work space and equipment. However, she told us that she and other FRCP leadership officials have begun to think about how to improve the FRCP’s process for deciding where to place FRCs. In August 2010, the FRCP Executive Director explained that a planned update of the Veterans Tracking Application would collect additional information that would allow FRCP officials to identify the location of individuals who refer potential enrollees. She anticipates being able to use these data to identify the locations and facilities where the most referrals are being made. According to the FRCP Executive Director, this information along with other factors, such as placement recommendations from DOD and VA officials, could be used in making future placement decisions. However, as of December 2010, she had not established a specific time frame for this effort. Developing a clear and consistent rationale for placing FRCs, which includes a systematic analysis of program data, should help ensure that FRCs are located where they could provide the maximum benefit to current and potential enrollees.

The FRCP Faces Challenges That Limit Its Ability to Coordinate Care but Is Taking Steps to Address Them

FRCs and others identified challenges that can limit the FRCP’s efforts to coordinate the services needed by severely wounded servicemembers and veterans. One challenge involves limitations on the FRCP’s ability to share information with the large number of programs that provide care coordination and case management services to wounded servicemembers and veterans. These limitations—which are the result of restrictions on the disclosure of enrollee information and data systems’ incompatibility— have sometimes resulted in confusion and the duplication of services for enrollees. Efforts by the FRCP to improve information sharing are ongoing. Another challenge is that FRCs often have difficulty obtaining resources from the facilities at which they are located—such as telephones, computers, and private office space—that they need to perform their care coordination activities, including communicating with enrollees across the country. This can affect the quality of services to enrollees, and the FRCP is working to resolve these logistical issues.

Coordination among the FRCP and DOD and VA Case Management Programs Is Impeded by Limitations on Their Ability to Share Information, and Efforts to Address These Limitations Are Ongoing

Coordination among DOD and VA programs that provide care coordination and case management is difficult because of the large number of such programs that exist to address the needs of wounded servicemembers and veterans and the limitations in the ability of these programs to share information. Although these programs vary in terms of the severity of the injuries among the servicemembers or veterans they serve and the specific types of services they coordinate, many programs have similar functions. (See table 4.)

For the purposes of this table, we have categorized the severity of enrollees’ injuries according to the injury categories established by the DOD and VA Wounded, Ill, and Injured Senior Oversight Committee. Servicemembers with mild wounds, illness, or injury are expected to return to duty in less than 180 days; those with serious wounds, illness, or injury are unlikely to return to duty in less than 180 days and possibly may be medically separated from the military; and those who are severely wounded, ill, or injured are highly unlikely to return to duty and also likely to medically separate from the military. These categories are not necessarily used by the programs themselves.

The military wounded warrior programs are the Army Wounded Warrior Program, Marine Wounded Warrior Regiment, Navy Safe Harbor, Air Force Warrior and Survivor Care Program, and Special Operations Command’s Care Coalition.

An FRC placed at Special Operations Command’s Care Coalition headquarters coordinates clinical and nonclinical care for Care Coalition and other FRCP enrollees.

OEF/OIF refers to Operation Enduring Freedom and Operation Iraqi Freedom.

An OEF/OIF care manager supervises the case managers and transition patient advocates and may also maintain a caseload of wounded veterans.

According to VA, in some instances, patients are transferred to VA medical facilities while still in the acute phase of the care continuum and may receive services from VA care management or polytrauma program staff.

Many recovering servicemembers and veterans are enrolled in more than one program. For example, in September 2010, approximately 84 percent of FRCP enrollees were also enrolled in a military service wounded warrior program. According to one FRC, his enrollees have, on average, eight case managers who are affiliated with different programs. Individuals enrolled in multiple programs may have recovery plans or goals that have been developed by different programs. Moreover, some case managers of other programs consider themselves to be the single point of contact for their enrollees, even those enrolled in the FRCP. Because the majority of FRCP enrollees are enrolled in more than one program, there is a high likelihood that without adequate information exchange and coordination, FRCs and case managers could duplicate one another’s efforts, confuse enrollees and families, waste resources, or mistakenly believe that someone else has taken care of a task for an enrollee. The extent of overlap and the lack of information sharing by the FRCP have prompted some programs to limit FRCs’ involvement with servicemembers when they are receiving initial medical treatment at a military treatment facility. At two of the military treatment facilities we visited, for example, a military program serving wounded servicemembers delays referrals to the FRCP until a servicemember approaches the point when he or she is preparing to transition to another facility or VA.

Information Disclosure Requirements Limited the FRCP’s Information Sharing with DOD’s Wounded Warrior Programs

Prior to January 2011, VA had not completed public disclosure actions necessary to enable the sharing of information from the Veterans Tracking Application, the information system used by the FRCP that contains each enrollee’s personal information and Federal Individual Recovery Plan. As a result, VA management had advised the FRCP that the program could not provide staff of non-VA programs (such as those affiliated with DOD) with its enrollees’ personally identifiable information, such as names, addresses, Social Security numbers, and details of Federal Individual Recovery Plans. Specifically, VA had not completed the System of Records Notification process for the Veterans Tracking Application, a process required by the Privacy Act of 1974 that requires federal agencies to publish in the Federal Register a notice of the existence, purpose, and routine uses of every “system of records” that contains information that may be linked to individuals.

Although this limitation did not prevent FRCs from performing their care coordination responsibilities, it has been a source of frustration for others. Specifically, officials of several of DOD’s wounded warrior programs contend that the inability to receive enrollment information from the FRCP has caused difficulties. The director of one program, for example, told us that not having the names of servicemembers enrolled in the FRCP resulted in a situation in which an FRC and a wounded warrior program Recovery Care Coordinator were not aware that the other was involved in coordinating care for the same servicemember and had unknowingly established conflicting recovery goals for this individual. In this case, a servicemember with multiple amputations was advised by his FRC to separate from the military in order to receive needed services from VA, whereas his Recovery Care Coordinator set a goal of remaining on active duty. These conflicting goals caused considerable confusion for this servicemember and his family. Furthermore, leadership officials of two of the military services’ wounded warrior programs told us that they have instructed their staff not to make referrals to the FRCP to avoid confusion and potential duplication of activities, citing issues associated with information sharing.

In August 2010, prompted by the FRCP, VA initiated the public-disclosure process to facilitate information sharing. In December 2010, VA published a notice in the Federal Register that describes the compilation of information in the Veterans Tracking Application and routine uses of that information. VA received no comments on the notice during the public comment period, which ended on January 10, 2011. The new system of records became effective on that date and the FRCP was able to share certain enrollee information, such as the names of enrollees, with DOD programs.

DOD and VA Data System Incompatibility Impedes Information Sharing among the FRCP and DOD’s Wounded Warrior Programs

Another factor that limits information sharing is the inability of the information systems used by the FRCP, the DOD Recovery Coordination Program, and the five military services’ wounded warrior programs to exchange information directly with one another. As a result, FRCs cannot readily access information from data systems used by case management programs about their enrollees and information about an individual cannot be easily transferred among systems. To help address this issue, the FRCP has spearheaded an effort, known as the Information Sharing Initiative, to identify an approach for the direct exchange of information between DOD and VA care coordination and case management information systems in the future. The FRCP Executive Director explained that this initiative primarily includes identifying the data that need to be exchanged as well as identifying the data systems where these data originate and subsequently developing a technical solution to electronically exchange this information. Further, she noted that the Information Sharing Initiative is a grassroots effort and that work on the initiative has been performed by DOD and VA employees in addition to their normal duties, making a completion date difficult to estimate. An official from the Interagency Program Office, which oversees major information technology initiatives jointly undertaken by DOD and VA, said that the Information Sharing Initiative was a well-considered initial step but notes that the ultimate goal of direct information exchange among programs’ information systems faces daunting challenges, such as resolving conflicting DOD and VA policies pertaining to information exchange. We have previously reported on DOD’s and VA’s efforts to electronically exchange health care information, including the departments’ progress toward increasing their capabilities to share medical and nonmedical history and physical exam data. We have found that despite the departments’ progress, their efforts to meet clinicians’ evolving needs to exchange health information and to create a single lifetime electronic record for each servicemember, which is intended to streamline the transition of electronic records between the two departments, are ongoing.

Recognizing that these limitations on information sharing exist, the FRCP is also taking steps to emphasize FRCs’ principal role of coordinating with case managers rather than providing services to enrollees themselves, which should help prevent unintentional duplication of effort. Because FRCs may provide a direct service in some instances, proper information sharing is necessary so that staff from multiple programs may not unknowingly perform the same task for an enrollee. For example, an FRC told us that in one instance there were five case managers working on the same life insurance issue for an individual. According to the FRCP Executive Director, the Federal Individual Recovery Plan process has been improved to encourage coordination by FRCs and also to reinforce their primary role as care coordinators. To accomplish these objectives, in January 2011 the FRCP upgraded the Veterans Tracking Application, in which Federal Individual Recovery Plans are maintained, by adding a record of the names of the case managers who are responsible for completing activities linked to enrollees’ planning goals. In addition, the Veterans Tracking Application began displaying indicators to inform each FRC about the completion status of every goal-related activity planned for each enrollee, based on the completion dates that the FRCs put into the system. The FRCP Executive Director believes that such an indicator system, when linked to the names of the case managers who are responsible for completing the activities, will reinforce the FRCs’ care coordination role by encouraging them to actively follow up with others on the status of individual tasks rather than taking on these tasks themselves.

FRCs Face Difficulties in Obtaining Access to Equipment, Technology Support, and Work Space at Their Medical Facilities, but FRCP Leadership Is Taking Steps to Remedy These Issues

FRCs and others identified several types of logistical problems that have affected the FRCs’ ability to carry out their responsibilities in dealing with FRCP enrollees and coordinating with wounded warrior programs. These issues center around three specific areas: provision of equipment (such as computers, printers, landline telephones, and BlackBerrys), technology support (such as equipment maintenance, software upgrades, and systems security), and private work space at the medical facilities.

Provision of equipment. Most of the FRCs’ work is done using computers, accessing data management systems, and communicating with enrollees and DOD and VA facility staff by e-mail and phone. However, about half of the FRCs told us that they have been hindered in their ability to perform their care coordination responsibilities by the lack of appropriate technology resources at the facilities at which they work. Some FRCs expressed frustration with delays in obtaining appropriate computer or communications equipment when they first reported to their facilities, and this experience was echoed by nearly all of the FRCs hired in January 2010. For example, one FRC said she waited more than 6 weeks at the facility to receive a DOD computer and landline telephone. Another FRC reported that he has found that e-mail is an effective mode of communication with enrollees with traumatic brain injuries because he can provide detailed instructions to them, but when he was hired he did not receive a DOD computer and a landline telephone with long-distance calling capability for 8 months. Consequently, he had to resort to mailing letters and brochures to current and potential enrollees.

Technology support. In addition to the lack of equipment, some FRCs cited the lack of technology support as a factor that hindered their care coordination activities. Technological support includes functions such as connectivity to information systems, installing security systems, and equipment upgrading and repair. An FRCP deputy director told us that the lack of such support is often experienced by new FRCs, but it is also an ongoing issue for many, especially after a facility computer system is upgraded and the FRCs’ equipment becomes incompatible. Additionally, several FRCs have had difficulty with their BlackBerrys, either because the facility was unable to install a security patch needed to access e-mails or because poor reception made the device unusable. Some FRCs also reported their inability to access DOD medical records (although this issue is beyond the scope of a single program to address)—for example, FRCs located at VA medical centers must ask FRCs at military treatment facilities to access enrollees’ DOD records and then fax them to the FRCs at the VA medical centers. Finally, FRCP officials noted that equipment repair has been a problem for some FRCs—one FRC told us that she had to use a malfunctioning laptop computer issued to her by the local VA medical center for 8 months.

Work space. Some FRCs noted that they had been assigned work space at the facility that was unsuitable for conducting sensitive conversations with enrollees, family members, and coworkers. At a major medical center, we observed that FRCs were located in tightly spaced cubicles that allowed nearby staff to easily overhear their conversations. A recently transferred FRC told us that when she arrived at her new medical center, she found that she had no office and had been located in an open room that serves as the call center for triage nurses. Lacking the privacy needed to make confidential calls to her enrollees, this FRC resorted to making sensitive phone calls from her car in the parking lot. At another treatment facility, an FRC who shared an office with staff from another program had to take phone calls with enrollees in the stairwell in order to have privacy. Finally, two recently hired FRCs were not only placed in the same office but also had to share the same desk.

The provision of equipment, technology support, and work space is covered by memoranda of agreement between the FRCP and the DOD and VA facilities where FRCs are located. However, an FRCP deputy director told us that obtaining compliance with the memoranda of agreement at some facilities is an ongoing challenge and that equipment maintenance and systems upgrades are persistent issues for all FRCs. In some instances, after FRCs had made repeated requests for needed resources without result, the FRCP Executive Director intervened with medical center officials or through the Senior Oversight Committee to obtain a resolution. A leadership official for a wounded warrior program told us that some military medical centers have difficulty satisfying requests for equipment and space from programs such as the FRCP because these facilities house and support various DOD and VA support programs and all make requests for resources. This official pointed out that at one military treatment facility, a military case manager was relocated in order to make an office available to an FRC. An FRCP deputy director added that given the frequent turnover of military staff, medical center officials are sometimes unaware that their facility is responsible for providing resources and services to FRCs.

FRCP officials reviewed existing memoranda of agreement between the FRCP and DOD and VA medical facilities to determine where improvements could be made to ensure that the FRCs have the tools and privacy required to do their work. The program has developed three new templates for memoranda of agreement that will be used when FRCs are located in new settings: one each for military treatment facilities, VA medical centers where servicemembers and veterans with polytrauma injuries receive care, and military wounded warrior programs. These new memoranda are more detailed than the previous versions, and they identify who is responsible for providing specific resources and services. The FRCP is using the revised agreements in its negotiations for logistical support for newly placed FRCs at two VA medical centers and with the Special Operations Command wounded warrior program. Following implementation of the new memoranda of agreement, the FRCP plans to revise existing agreements to make them consistent with the newer versions, but no specific timetable has been established to complete these revisions.

Conclusions

Since its inception, the FRCP has increased the number of enrollees, enlarged its staff considerably, and expanded the number of locations where FRCs are assigned. However, the program faces significant challenges as it matures. As the first joint care coordination program for DOD and VA, the FRCP represents a new paradigm in patient support for the departments. Because of its unprecedented nature, the program cannot refer to preexisting data or policies and procedures to manage the program, and as a result, FRCP leadership had to develop management processes as the program was being implemented and has largely relied on informal processes to oversee and manage key aspects of the program. However, now that the program has been operating for several years and continues to grow, it has become apparent that the program would benefit from more definitive management processes to strengthen program oversight and decision making.

While the program has overcome some early setbacks and has established processes related to enrollment and staffing, these processes are not clearly documented or systematic. Because enrollment decisions are not well documented or systematically reviewed by FRCP leadership, it is unclear whether referred servicemembers and veterans who need FRC services are being enrolled in the program. Additionally, as the number of individuals enrolled in the program steadily increases, it will be important for the FRCP to appropriately balance FRCs’ workload to ensure that enrollees receive the services they need and to prevent FRC burnout. While program leadership recognizes this issue and is developing a customized workload tool, there is no firm timeline for the completion of this effort. The FRCP also needs clearly documented processes and criteria for guiding staffing and placement decisions. Without this, it will be difficult to provide continuity to subsequent program leadership and to place FRCs where they would best serve the needs of current and future enrollees.

Some of the daunting challenges facing FRCs and the program are beyond the capability of the program’s leadership to resolve. The exchange of information among DOD and VA data systems, in particular, has been a long-standing issue and will require interdepartmental action. Similarly, the duplication of effort resulting from the proliferation and overlap of DOD and VA programs that support recovering servicemembers and veterans can best be resolved through interdepartmental coordination and action.

Recommendations for Executive Action

We recommend that the Secretary of Veterans Affairs direct the Executive Director of the FRCP to take four actions: 1. Ensure that referred servicemembers and veterans who need FRC services are enrolled in the program by establishing adequate internal controls regarding the FRCs’ enrollment decisions. To accomplish this, the FRCP leadership should require FRCs to record in the Veterans Tracking Application the factors they consider in making an enrollment decision, develop and implement a methodology and protocol for assessing the appropriateness of enrollment decisions, and refine the methodology as needed. 2. Complete development of the FRCP’s workload assessment tool that will enable the program to assess the complexity of services needed by enrollees and the amount of time required to provide services to improve the management of FRCs’ caseloads. 3. Clearly define and document the FRCP’s decision-making process for determining when and how many FRCs VA should hire to ensure that subsequent FRCP leadership can understand the methods currently used to make staffing decisions. 4. Develop and document a clear rationale for the placement of FRCs, which should include a systematic analysis of data, such as referral locations, to ensure that future FRC placement decisions are strategic in providing maximum benefit for the program’s population.

Agency Comments and Our Evaluation

DOD and VA each provided comments on a draft of this report. In its comments, DOD stated that it continues to work with VA to fully integrate their efforts and to increase collaboration between the two departments. (DOD’s comments are reprinted in app. II.) In its comments, VA stated that it generally agrees with GAO’s conclusions and concurs with our recommendations to the Secretary. (VA’s comments are reprinted in app. III.) VA’s responses to each of our recommendations are as follows: To ensure that referred servicemembers and veterans who need FRC services are enrolled in the program, VA indicated that the FRCP will document decisions and factors used to assess a potential enrollee’s eligibility for the program. In addition, the program will establish clear documentation requirements according to a defined protocol within the program’s data management system.

To complete the development of the FRCP’s workload assessment tool, VA indicated that the FRCP will continue field-testing a new assessment tool, which will require at least a year to complete.

To document the decision-making process for determining when and how many FRCs VA should hire, VA stated that the FRCP will clearly document the current process used for making staffing decisions. In addition, the staffing processes and plans will be updated annually in the FRCP business operation planning document.

To develop and document a clear rationale for the placement of FRCs, VA indicated that the FRCP will develop an FRC placement strategy based upon a systematic analysis of data over the next 6 months. This process will be documented and updated annually in the FRCP business operation planning document.

VA provided an additional comment regarding the progress made toward the exchange of data between VA and DOD’s wounded warrior information systems. VA stated that it anticipates that an initial set of data will be available for exchange between VA and DOD by the end of fiscal year 2011. The departments plan to expand the exchange of data to support improved collaboration on care plans in fiscal year 2012.

We are sending copies of this report to the Secretary of Defense and the Secretary of Veterans Affairs and other interested parties. The report also is available at no charge on the GAO Web site at http://www.gao.gov.

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

Appendix I: The Use of Software to Analyze Testimonial Evidence

To conduct a content analysis of our interviews with program officials and medical facility staff, we used a qualitative data analysis software package. The software facilitated our analysis of over 150 of the 170 interviews we conducted and helped us to identify and quantify interviewees’ responses on various topics. The program’s coding capabilities allowed us to group our interviewees’ responses into categories. It also provided a centralized location where all of our documents could be reviewed and analyzed.

We took a number of steps to ensure that our analysis was methodologically sound. First, we defined categories to organize the views of the Department of Defense and the Department of Veterans Affairs program officials and medical facility staff by specific topics, including the Federal Recovery Coordination Program’s (FRCP) eligibility criteria, the interviewees’ interactions with the Federal Recovery Coordinators (FRC), overlap and duplication of activities among the FRCP and the case management programs with which the FRCs interacted, knowledge of the FRC role, and challenges faced by the FRCs. These categories were chosen based on themes we heard during our interviews with the program officials and medical facility staff. We conducted an intercoder reliability check to ensure the accuracy of the category definitions. To do this, two analysts coded a sample of 15 interviews into the categories. A methodologist compared the analyses to determine where inconsistencies occurred and, as a result, what categories needed more specific definitions.

Once the category definitions were finalized, the same two analysts divided the categories among them and coded their categories for all of the interview documents. When the coding was completed, both analysts reviewed every code made by the other analyst and indicated whether they agreed or disagreed with the code. Changes were then made accordingly. We subsequently analyzed the interviewees’ responses based on the defined categories. This analysis allowed us to quantify interviewees’ responses within each category.

Appendix II: Comments from the Department of Defense

Appendix III: Comments from the Department of Veterans Affairs

Appendix IV: GAO Contact and Staff Acknowledgments

Staff Acknowledgments

In addition to the contact named above, Bonnie Anderson, Assistant Director; Susannah Bloch; Frederick Caison; Elizabeth Conklin; Cynthia Gilbert; Deitra Lee; Lisa Motley; Kristina Martin; Steven Putansu; and Suzanne Worth made key contributions to this report.