VA and Defense Health Care: More Information Needed to Determine If VA Can Meet an Increase in Demand for Post-Traumatic Stress Disorder Services
Released: 2004-09-30T00:00:00

Letter

Background

PTSD can develop following exposure to life-threatening events, natural disasters, terrorist incidents, serious accidents, or violent personal assaults like rape. PTSD is the most prevalent mental disorder arising from combat. People who experience stressful events often relive the experience through nightmares and flashbacks, have difficulty sleeping, and feel detached or estranged. These symptoms may occur within the first 4 days after exposure to the stressful event or be delayed for months or years. Symptoms that appear within the first 4 days after exposure to a stressful event are generally diagnosed as acute stress reaction or combat stress. If the symptoms of acute stress reaction or combat stress continue for more than 1 month, PTSD is diagnosed.

PTSD services are provided in VA medical facilities and VA community settings. VA medical facilities offer PTSD services as well as other services, which range from complex specialty care, such as cardiac or spinal cord injury, to primary care. VA’s community settings include more than 800 community-based outpatient clinics and 206 Vet Centers. Community- based outpatient clinics are an extension of VA’s medical facilities and mainly provide primary care services. Vet Centers offer PTSD and family counseling, employment services, and a range of social services to assist veterans in readjusting from wartime military service to civilian life. Vet Centers also function as community points of access for many returning veterans, providing them with information and referrals to VA medical facilities. Vet Centers were established as entities separate from VA medical facilities to serve Vietnam veterans, who were reluctant to access health care provided in a federal building. As a result, Vet Centers are not located on the campuses of VA medical facilities.

VA has specialized PTSD programs that are staffed by clinicians who have concentrated their clinical work in the area of PTSD treatment. VA specialized PTSD programs are located in 97 VA medical facilities and provide services on an inpatient and outpatient basis. VA PTSD services include individual counseling, support groups, and drug therapy and can be provided in non-specialized clinics, such as general mental health clinics.

Veterans who served in any conflict after November 11, 1998 are eligible for VA health care services for any illness, including PTSD services, for 2 years from the date of separation from military service, even if the condition is not determined to be attributable to military service. This 2-year eligibility includes those Reserve and National Guard members who have left active duty and returned to their units. After 2 years, these veterans will be subject to the same eligibility rules as other veterans, who generally have to prove that a medical problem is connected to their military service or have relatively low incomes. In July 2004, VA reported that so far 32,684 or 15 percent of veterans who have returned from service in Iraq or Afghanistan, including Reserve and National Guard members, have accessed VA for various health care needs.

DOD and VA have formed a Seamless Transition Task Force with the goal of meeting the needs of servicemembers returning from Iraq and Afghanistan who will eventually become veterans and may seek health care from VA. To achieve this goal, DOD and VA plan to improve the sharing of information, including individual health information, between the two departments in order to enhance VA’s outreach efforts to identify and serve returning servicemembers, including Reserve and National Guard members, in need of VA health care services. Since April 2003, VA requires that every returning servicemember from the Iraq and Afghanistan conflicts who needs health care services receive priority consideration for VA health care appointments.

DOD Uses Two Approaches to Identify Servicemembers At Risk for PTSD

DOD uses two approaches to identify servicemembers who may be at risk of developing PTSD: the combat stress control program and the post- deployment health assessment questionnaire. DOD’s combat stress control program identifies servicemembers at risk for PTSD by training all servicemembers to identify the early onset of combat stress, which if left untreated, could lead to PTSD. DOD uses the post-deployment health assessment questionnaire to screen servicemembers for physical ailments and mental health issues commonly associated with deployments, including PTSD. The questionnaire contains four screening questions that were developed jointly by DOD and VA mental health experts to identify servicemembers at risk for PTSD.

DOD Trains Servicemembers to Identify Symptoms That Could Lead to PTSD

DOD’s combat stress control program identifies servicemembers at risk for PTSD by training all servicemembers to identify the early onset of combat stress symptoms, which if left untreated, could lead to PTSD. The program is based on the principle of promptly identifying servicemembers with symptoms of combat stress in a combat theater, with the goal of treating and returning them to duty. This principle is consistent with the views of PTSD experts, who believe that early identification and treatment of combat stress symptoms may reduce the risk of PTSD. To assist servicemembers in the combat theater, teams of DOD mental health professionals travel to units to reinforce the servicemembers’ knowledge of combat stress symptoms and to help identify those who may be at risk for combat stress or PTSD. The teams may include psychiatrists, psychologists, social workers, nurses, mental health technicians, and chaplains. DOD requires that the effectiveness of the combat stress control program be monitored on an annual basis.

DOD Uses the Post- Deployment Questionnaire to Identify Servicemembers At Risk for PTSD

DOD generally uses the post-deployment health assessment questionnaire, DD 2796, to identify servicemembers at risk for PTSD following deployment outside of the United States. (See app. II for a copy of the DD 2796.) DOD requires certain servicemembers deployed to locations outside of the United States to complete a DD 2796 within 30 days before leaving a deployment location or within 5 days after returning to the United States.This applies to all servicemembers returning from a combat theater, including Reserve and National Guard members.

The DD 2796 is a questionnaire used to determine the presence of any physical ailments and mental health issues commonly associated with deployments, any special medications taken during deployment, and possible environmental or occupational exposures. The DD 2796 includes the following four screening questions that VA and DOD mental health experts developed to identify servicemembers at risk for PTSD: Have you ever had any experience that was so frightening, horrible, or upsetting that, in the past month, you have had any nightmares about it or thought about it when you did not want to? tried hard not to think about it or went out of your way to avoid situations that remind you of it? were constantly on guard, watchful, or easily startled? felt numb or detached from others, activities, or your surroundings?

Once completed, the DD 2796 must be initially reviewed by a DOD health care provider, which could range from a physician to a medic or corpsman. Figure 1 illustrates DOD’s process for completion and review of the DD 2796. The form is then reviewed, completed, and signed by a health care provider, who can be a physician, physician assistant, nurse practitioner, or an independent duty medical technician or corpsman. This health care provider reviews the completed DD 2796 to identify any “yes” responses to the screening questions—including questions related to PTSD—that may indicate a need for further medical evaluation. The review is to take place in a face-to-face interview with the servicemember and be conducted either on an individual basis, as we observed at the Army’s Fort Lewis in Washington, or in a group setting, as we found at the Marine Corps’ Camp Lejeune in North Carolina. If a servicemember answers “yes” to a PTSD question, the health care provider is instructed to gather additional information from the servicemember and use clinical judgment to determine if the servicemember should be referred for further medical evaluation to a physician, physician’s assistant, nurse, or an independent duty medical technician.To document completion of the DD 2796, DOD requires that the questionnaire be placed in the servicemember’s permanent medical record and a copy sent to the Army Medical Surveillance Activity, which maintains a database of all servicemembers’ completed health assessment questionnaires.

The National Defense Authorization Act for Fiscal Year 1998 required DOD to establish a quality assurance program to ensure, among other things, that post-deployment mental health assessments are completed for servicemembers who are deployed outside of the United States. Completion of the DD 2796 is tracked as part of this quality assurance program. DOD delegated responsibility for developing procedures for the required quality assurance program to each of its uniform services. The uniform services have given unit commanders the responsibility to ensure completion of the DD 2796 by all servicemembers under their command. To ensure the DD 2796 is completed, one DOD official we interviewed told us that servicemembers would not be granted leave to go home until the DD 2796 was completed. Another official told us that Reserve and National Guard members would not be given their active duty discharge paperwork until the DD 2796 was completed.

VA Lacks Information Needed to Determine Whether It Can Meet an Increase in Demand for PTSD Services

VA does not have all the information it needs to determine whether it can meet an increase in demand for VA PTSD services. VA does not have a count of the total number of veterans currently receiving PTSD services at its medical facilities and Vet Centers. Without this information, VA cannot estimate the number of veterans its medical facilities and Vet Centers could treat for PTSD. VA could use demographic information it receives from DOD to broadly estimate the number of servicemembers who may access VA health care, including PTSD services. By assuming that 15 percent or more of returning servicemembers will develop PTSD, VA could use the demographic information to broadly estimate demand for PTSD services. However, predicting which veterans will seek VA care and at which facilities is inherently uncertain, particularly given that the symptoms of PTSD may not appear for years.

VA Does Not Have Information on the Total Number of Veterans Currently Receiving PTSD Services

VA does not have a count of the total number of veterans currently receiving PTSD services at its medical facilities and Vet Centers. Without this information, VA cannot estimate the number of additional veterans its facilities could treat for PTSD. On August 27, 2004, a Northeast Program Evaluation Center (NEPEC) official told us that a count of the total number of veterans with a diagnosis of PTSD who receive VA services at medical facilities could be obtained from VA’s existing database. However, this database does not include Vet Centers’ information because this information is kept separate from the medical facilities’ data.

VA publishes two reports that contain information on some of the veterans receiving PTSD services at its medical facilities. Neither report includes all veterans receiving PTSD services at VA medical facilities and Vet Centers. VA’s annual capacity report, which is required by law, provides data on VA’s most vulnerable populations, such as veterans with spinal cord injuries, blind veterans, and seriously mentally ill veterans with PTSD. The NEPEC annual report mainly provides data on veterans with a primary diagnosis of PTSD. VA has not developed a methodology that would allow it to count the number of veterans receiving PTSD services at its medical facilities and Vet Centers.

The PTSD data used in VA’s annual capacity report and the data used in NEPEC’s annual report are drawn from different—though not mutually exclusive—subgroups of veterans receiving PTSD services at VA’s medical facilities. VA developed criteria that allow it to determine which veterans should be included in each subgroup. VA’s criteria, which differ in each report, are based on the type and frequency of mental health services provided to veterans with PTSD at its medical facilities. (See Figure 2 for the veterans included in each of VA’s annual reports.)

Veterans who are receiving VA PTSD services may be counted in both reports, only counted in the NEPEC report, or not included in either report. For example, a veteran who is seriously mentally ill and has a primary diagnosis of PTSD is counted in both reports. On the other hand, a veteran who has a primary diagnosis of PTSD but is not defined as seriously mentally ill is counted in the NEPEC report but not in the capacity report. Finally, a veteran who is receiving PTSD services only at a Vet Center is not counted in either report.

Furthermore, both the VA OIG and VA’s Committee on Care of Veterans with Serious Mental Illness have found inaccuracies in the data used in VA’s annual capacity report.For example, OIG found inconsistencies in the PTSD program data reported by some VA medical facilities. OIG found that some medical facilities reported having active PTSD programs, although the facilities reported having no staff assigned to these programs. Additionally, the Committee on Care of Veterans with Serious Mental Illness, commenting on VA’s fiscal year 2002 capacity report, stated the data VA continues to use for reporting information on specialized programs are inaccurate and recommended changes in future reporting.22, 23 VA agreed with OIG that the data were inaccurate and is continuing to make changes to improve the accuracy of the data in its annual capacity report. VA’s fiscal year 2003 capacity report to Congress is currently undergoing review by OIG, which informed us that VA has not incorporated all of the changes necessary for OIG to certify that the report is accurate. OIG further stated that it will continue to oversee this process.

VA Has Information to Broadly Estimate Future Demand for PTSD Services

The Committee on Care of Severely Chronically Mentally Ill Veterans assesses VA’s capability to meet the rehabilitation and treatment needs of such veterans. See 38 U.S.C. § 7321. The Committee, established within VA, is generally referred to as the Committee on Care of Veterans with Serious Mental Illness.

Department of Veterans Affairs, Capacity Report Fiscal Year 2002 (Washington, D.C.: May 2003). predict the facilities or Vet Centers that could experience an increase in demand for care. By assuming that 15 percent or more of returning servicemembers will eventually develop PTSD, based on the predictions of mental health experts, VA could use the demographic information to broadly estimate the number of returning servicemembers who may need VA PTSD services and the VA facilities located closest to servicemembers’ homes. However, predicting which veterans will seek VA care and at which facilities is inherently uncertain, particularly given that the symptoms of PTSD may not appear for years.

VA headquarters received demographic information from DOD in September 2003; however, during our review we found that VA had not shared this information with its facilities. On July 21, 2004, VA provided this information to its medical facilities for planning future services for veterans returning from the Iraq and Afghanistan conflicts. However, VA did not provide the demographic information to Vet Centers. Officials at seven VA medical facilities told us that while the demographic information VA receives from DOD has limitations, it is the best national data currently available and would help them plan for new veterans seeking VA PTSD services.

Officials at six of the seven VA medical facilities we visited explained that while they are now able to keep up with the current number of veterans seeking PTSD services, they may not be able to meet an increase in demand for these services. In addition, some of the officials expressed concern about their ability to meet an increase in demand for VA PTSD services from servicemembers returning from Iraq and Afghanistan based on DOD’s demographic information. Officials are concerned because facilities have been directed by VA to give veterans of the Iraq and Afghanistan conflicts priority appointments for health care services, including PTSD service. As a result, VA medical facility officials estimate that follow-up appointments for veterans currently receiving care for PTSD may be delayed. VA officials estimate the delay may be up to 90 days. Veterans of the Iraq and Afghanistan conflicts will not be given priority appointments over veterans who have a service-connected disability and are currently receiving services.

Conclusions

While the VA OIG continues to oversee VA’s efforts to improve the accuracy of data in the capacity reports, VA does not have a report that counts all veterans receiving VA PTSD services. Although VA can use DOD’s demographic information to broadly estimate demand for VA PTSD services, VA does not know the number of veterans it now treats for PTSD at its medical facilities and Vet Centers. As a result, VA will be unable to estimate its capacity for treating additional veterans who choose to seek VA’s PTSD services, and therefore, unable to plan for an increase in demand for these services.

Recommendation for Executive Action

To help VA estimate the number of additional veterans it could treat for PTSD and to plan for the future demand for VA PTSD services from additional veterans seeking these services, we recommend that the Secretary of Veterans Affairs direct the Under Secretary for Health to determine the total number of veterans receiving VA PTSD services and provide facility-specific information to VA medical facilities and Vet Centers.

Agency Comments

In commenting on a draft of this report, VA concurred with our recommendation and acknowledged that more coordinated efforts are needed to improve its existing PTSD data. VA stated that it plans to aggregate, at the national level, the number of veterans receiving PTSD services at VA medical facilities and Vet Centers. We believe VA should provide these data to both its medical facilities and Vet Centers so they have the information needed to plan for future demand for PTSD services. In addition, VA provided two points of clarification. First, VA stated that it is in the process of developing a mental health strategic plan that will project demand by major diagnoses and identify where projected demand may exceed resource availability. VA stated that future revisions to the mental health strategic plan would include Vet Center data. Second, VA stated that it would seek additional information from DOD on servicemembers who have served in Iraq and Afghanistan to improve its provision of health care services to these new veterans. VA’s written comments are reprinted in appendix III. DOD concurred with the findings and conclusions in this report and provided technical comments, which we incorporated as appropriate. DOD’s written comments are reprinted in appendix IV.

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If you or your staff have any questions about this report, please call me at (202) 512-7101. Another contact and key contributors are listed in appendix V.

Scope and Methodology

To determine the approaches DOD uses to identify servicemembers who are at risk for PTSD, we reviewed directives on screening servicemembers deployed to locations outside of the United States, interviewed DOD officials, and visited a military installation for each of DOD’s uniformed services. At each of the military installations, we discussed with officials the steps taken by each of the uniformed services to implement DOD’s approaches, particularly the steps involved in completing the post- deployment health assessment questionnaire, DD 2796, as it relates to PTSD. How well the uniformed services implemented DOD’s approaches were reported in other GAO reports. The uniformed services included in our review were Army, Marines, Air Force, and Navy. We did not include the Coast Guard in this review because few Coast Guard servicemembers are involved in the Iraq and Afghanistan conflicts. The military installations visited were: Fort Lewis Army Base and Madigan Army Medical Center in Washington, Seymour Johnson Air Force Base in North Carolina, Camp Lejeune Marine Base and the Naval Hospital Camp Lejeune in North Carolina, and the Naval Medical Center San Diego in California. We also asked DOD officials whether they provide information to VA that could help VA plan how to meet the demand for VA PTSD services from servicemembers returning from the Iraq and Afghanistan conflicts.

To determine whether VA has the information it needs to determine whether it can meet an increase in demand for PTSD services, we interviewed PTSD experts from the National Center for PTSD established within VA and members of the Under Secretary for Health’s Special Committee on PTSD. We also visited three divisions of the National Center for PTSD: the Executive Division in White River Junction, Vermont; the Education Division in Palo Alto, California; and NEPEC in West Haven, Connecticut to review the Center’s reports on specialized PTSD programs.

We also reviewed VA’s fiscal year 2001 and 2002 annual reports on VA’s capacity to provide services to special populations, including veterans with PTSD, and NEPEC’s annual reports on specialized PTSD programs to determine the criteria VA uses to count the number of veterans receiving VA PTSD services. We reviewed the findings of VA’s Committee on Care of Veterans with Serious Mental Illness and the VA OIG, who have reported on the accuracy of VA’s annual capacity report to Congress on the number of veterans receiving specialized services, including PTSD services. We interviewed officials from each of these groups to clarify their findings. We did not include data from the annual capacity reports because the OIG reported that the data were not sufficiently reliable. We also interviewed the director of NEPEC to discuss the information included in NEPEC’s annual reports.

To determine whether VA facilities have the information needed to determine whether they can meet an increase in demand for PTSD services, we interviewed officials at 7 VA medical facilities, and 15 Vet Centers located near the medical facilities to discuss the number of veterans currently receiving VA PTSD services and the impact that an increase in demand would have on these services. We also discussed DOD’s demographic information with four of the seven medical facilities we visited. We contacted VA medical facilities located in Palo Alto and San Diego in California; Durham and Fayetteville in North Carolina; White River Junction, Vermont; West Haven, Connecticut; and Seattle, Washington. We also contacted Vet Centers located in Vista, San Diego, and San Jose in California; Raleigh, Charlotte, Greenville, Greensboro, and Fayetteville in North Carolina; South Burlington and White River Junction in Vermont; Hartford, Norwich, and New Haven in Connecticut; and Seattle and Tacoma in Washington.

Our work was conducted from May through September 2004 in accordance with generally accepted government auditing standards.

Department of Defense Post-Deployment Health Assessment Questionnaire DD-2796

Authority: 10 U.S.C. 136 Chapter 55. 1074f, 3013, 5013, 8013 and E.O. 9397 Principal Purpose: To assess your state of health after deployment outside the United States in support of military operations and to assist military healthcare providers in identifying and providing present and future medical care to you.

Routine Use: To other Federal and State agencies and civilian healthcare providers, as necessary, in order to provide necessary medical care and treatment.

Disclosure: (Military personnal and DoD civilian Employees Only) Voluntary. If not provided, healthcare WILL BE furnished, but comprehensive care may not be possible.

INSTRUCTIONS: Please read each question completely and carefully before marking your selections. Provide a response for each question. If you do not understand a question, ask the administrator.

Today's Date (dd/mm/yyyy)

DOB (dd/mm/yyyy)

Date of arrival in theater (dd/mm/yyyy)

Date of departure from theater (dd/mm/yyyy)

Asia (Other)

To what areas were you mainly deployed: (mark all that apply - list where/date arrived)

Occupational specialty during this deployment (MOS, NEC or AFSC)

Please answer all questions in relation to THIS deployment

1. Did your health change during this deployment?

4. Did you receive any vaccinations just before or during this deployment?

Smallpox (leaves a scar on the arm)

3. Did you have to spend one or more nights in a hospital as a patient during this deployment?

5. Did you take any of the following medications during this deployment? (mark all that apply)

PB (pyridostigmine bromide) nerve agent pill Pills to stay awake, such as dexedrine 6. Do you have any of these symptoms now or did you develop them anytime during this deployment?

7. Did you see anyone wounded, killed or dead during this deployment?

10. Are you currently interested in receiving help for a stress, emotional, alcohol or family problem? (mark all that apply)

11. Over the LAST 2 WEEKS, how often have you been bothered by any of the following problems?

8. Were you engaged in direct combat where you discharged your weapon?

Little interest or pleasure in doing things air )

9. During this deployment, did you ever feel that you were in great danger of being killed?

DD FORM 2796, APR 2003 12. Have you ever had any experience that was so frightening, horrible, or upsetting that, IN THE PAST MONTH, you ....

15. On how many days did you wear your MOPP over garments?

Have had any nightmares about it or thought about it when you did not want to?

Tried hard not to think about it or went out of your way to avoid situations that remind you of it?

16. How many times did you put on your gas mask because of alerts and NOT because of exercises?

Were constantly on guard, watchful, or easily startled?

Felt numb or detached from others, activities, or your surroundings?

17. Were you in or did you enter or closely inspect any destroyed military vehicles?

13. Are you having thoughts or concerns that ...

18. Do you think you were exposed to any chemical, biological, or radiological warfare agents during this deployment?

You may have serious conflicts with your spouse, family members, or close friends?

You might hurt or lose control with someone?

14. While you were deployed, were you exposed to:

(mark all that apply)

DEET insect repellent applied to skin Environmental pesticides (like area fogging)

Smoke from burning trash or feces Vehicle or truck exhaust fumes Fog oils (smoke screen)

Depleted Uranium (If yes, explain)

Post-Deployment Health Care Provider Review, Interview, and Assessment

After my interview/exam of the service member and review of this form, there is a need for further evaluation as indicated below. (More than one may be noted for patients with multiple problems. Further documentation of the problem evaluation to be placed in the service member's medical record.)

Date (dd/mm/yyyy)

End of Health Review

Comments from the Department of Veterans Affairs

Comments from the Department of Defense

GAO Contact and Staff Acknowledgments

GAO Contact

Acknowledgments

In addition to the contact named above Mary Ann Curran, Linda Diggs, Martha Fisher, Krister Friday, and Marion Slachta made key contributions to this report.

Related GAO Products

Defense Health Care: DOD Needs to Improve Force Health Protection and Surveillance Processes. GAO-04-158T, Washington, D.C.: October 16, 2003.

Defense Health Care: Quality Assurance Process Needed to Improve Force Health Protection and Surveillance. GAO-03-1041, Washington, D.C.: September 19, 2003.

Disabled Veterans’ Care: Better Data and More Accountability Needed to Adequately Assess Care. GAO/HEHS-00-57, Washington, D.C.: April 21, 2000.

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