In June 2007, the Army began establishing WTUs at United States military installations with MTFs that were providing medical care to 35 or more eligible servicemembers. As of January 2009, the Army was operating 33 of these WTUs. (See fig. 1.) The Army has also established WTUs at locations in Germany—Bavaria, Heidelberg, and Landstuhl. For servicemembers with less complex medical needs, the Army uses its existing network of community-based health care organizations, which it now refers to as community-based WTUs. The community-based WTUs allow servicemembers to live at home and receive medical care while remaining on active duty. A servicemember was eligible for placement in a WTU if he or she required more than 6 months of medical treatment and required complex case management. Army guidance specifies that the mission of servicemembers assigned to a WTU is to heal and transition—return to duty or to civilian life—and while WTU servicemembers may have work assignments in the unit, this work may not take precedent over the servicemembers’ treatment. WTUs have a defined staffing structure that includes leadership positions of commanders and platoon sergeants, as well as administrative staff, such as human resources and financial management specialists. Within each unit, the servicemember is assigned to a team of three key staff—the Triad of Care—who provide case management services to ensure continuity of care. (See fig. 2.) Servicemembers in the WTUs vary by the type of medical condition for which they are receiving care and include Army active component, Reserve, and National Guard servicemembers. Active component servicemembers comprise about two-thirds of the WTU population, and active duty Reserve and National Guard servicemembers collectively comprise about one-third. As of December 1, 2008, about 60 percent of servicemembers in WTUs had been wounded in combat or had incurred a noncombat injury or illness during OEF or OIF, which may have resulted in burns, amputations, or other types of conditions. The remaining servicemembers in the units included those who may have been referred to the WTU for completion of the disability evaluation process; those who incurred a noncombat injury, such as during a training exercise; and those who incurred a noncombat illness such as cancer that required complex case management. The Army has issued additional WTU policies aimed at reducing staffing shortfalls, modifying the staffing model, and revising servicemember entry and exit criteria. To reduce staffing shortfalls, the Army issued policies designed to ensure that WTUs achieve and maintain staffing at required staff-to-servicemember ratios. The Army also implemented a revised WTU staffing model that includes new staff-to-servicemember ratios for two of the three Triad of Care positions. In addition, the Army issued policies to revise its criteria for servicemembers entering and leaving WTUs—a policy that affects population size and staffing needs. Although the Army had increased the number of staff being assigned to the WTUs, staffing shortfalls continued through June 2008. When we last reported on the Army’s progress in staffing the WTUs in February 2008, the Army had established a goal of having at least 90 percent of Triad of Care staff positions filled to meet the staff-to-servicemember ratios that it had established for its WTUs. These ratios were 1:200 for primary care managers; 1:18 for nurse case managers at Army medical centers that normally see servicemembers with more acute conditions and 1:36 for other types of Army medical treatment facilities; and 1:12 for squad leaders. At that time, the Army had 1,141 Triad of Care staff for its WTUs, and 11 WTUs had less than 90 percent of needed staff for one or more Triad of Care positions—representing a total shortfall of 64 staff. As of June 25, 2008, WTU Triad of Care staff had increased to 1,328, but because the size of the WTU servicemember population continued to grow and increase staffing needs, 21 WTUs were not meeting this goal and had staffing shortfalls in 108 Triad of Care positions. However, it is important to note that WTU staffing shortfalls represent a specific point in time. WTU staffing needs may vary daily based on both the number of servicemembers entering and exiting the WTUs and with fluctuations in the number of Triad of Care staff, who may deploy or otherwise be reassigned or leave. To address challenges in fully staffing the WTUs, including Triad of Care positions, the Army issued new policies in July 2008 for staffing the WTUs. The Army’s new policies included a requirement that local leadership— WTU commanders, MTF commanders, and senior installation commanders—fill 100 percent of WTU staff shortages, including those related to the Triad of Care, by July 14, 2008. For example, commanders were directed to fill the positions using personnel present on the installation, such as physicians and nurses who work in the MTFs, and to ensure continued 100 percent staffing from July 14, 2008, forward. As of August 2008, after the implementation of these new staffing policies, Army data indicated that Triad of Care staffing shortfalls had been reduced considerably, and the Army had generally met its goal of 100 percent staffing of its WTUs, with only a few exceptions. As of August 25, 2008, four WTUs had staffing shortfalls in four Triad of Care positions total—Balboa was missing one nurse case manager, Fort Belvoir was missing one squad leader, and Fort Drum and Fort Irwin were each missing one primary care manager. On October 16, 2008, the Army implemented revisions to its WTU staffing model, including changes to two of its Triad of Care staff-to- servicemember ratios. (See fig. 3.) These policy changes were based on a study initiated by the Army in February 2008 that found that some of the existing staff-to-servicemember ratios were not adequate for providing an appropriate level of care to servicemembers in WTUs. The study team recommended changes to the Triad of Care staffing ratios for nurse case managers and squad leaders. The team also recommended realigning existing medical and administrative support staff in the WTU to provide direct assistance to the nurse case manager and hiring new staff to support the primary care manager. The Army applied the revised ratios to all the WTUs except Walter Reed Army Medical Center. Army officials told us that the study team excluded Walter Reed from its review because the population receiving care at Walter Reed has more complex medical needs than the population at other WTUs. As a result, Walter Reed is continuing to operate under its original staff-to-servicemember ratios—1:200 for primary care managers, 1:18 for nurse case managers, and 1:12 for squad leaders. Despite the servicemember population at Walter Reed having more complex medical needs, these ratios are not much different than the revised ratios established for other WTUs. According to WTU officials from Walter Reed, Triad of Care staff who work with servicemembers with more complex medical needs generally require higher staff-to-servicemember ratios, but an assessment of acuity—the complexity of servicemembers’ needs—is necessary for determining the exact ratios that would be appropriate for Triad of Care positions at this location. Army officials told us that the Army currently does not have a plan for conducting a study of Walter Reed’s staffing model because this facility is scheduled to close in 2011 under Base Realignment and Closure 2005. According to Army officials, the WTU at Walter Reed will be moved to the newly established Walter Reed National Military Medical Center in Bethesda, Maryland. The WTU servicemember population from Walter Reed will be dispersed among the WTU at the new medical center and the WTUs at Fort Belvoir and Fort Meade. Nonetheless, the Army had made considerable progress in meeting the new WTU staff-to-servicemember ratios for the Triad of Care positions. On January 12, 2009, 4 of the 32 WTUs in the United States (excluding Walter Reed Army Medical Center) had a total shortfall of seven Triad of Care positions—three primary care managers and four squad leaders. Walter Reed, which continued to operate under its original Triad of Care staff-to- servicemember ratios, did not have any shortfalls. In July 2008, the Army also implemented policies revising WTU servicemember entry and exit criteria to increase emphasis on servicemembers needing complex case management. The revised policies stated that feedback from WTU officials, MTF commanders, and other senior officials indicated that many servicemembers in WTUs did not need the complex case management that the units provided. For example, officials from one WTU we visited told us that the WTUs included servicemembers who had conditions that were not complex, such as a broken leg, or who were waiting to finish the Army’s disability evaluation process and no longer had medical appointments. Army officials indicated that the growth of the WTU population—partially due to the inclusion of servicemembers who did not need complex case management—had impeded its ability to achieve and maintain staff for its Triad of Care positions in accordance with its staff-to-servicemember ratios. The Army’s July 2008 policies modified WTU entry and exit criteria specifically for active component servicemembers. These revised criteria do not apply to Reserve and National Guard servicemembers, who comprise about one-third of the WTU population.