oversight

Recovering Servicemembers and Veterans: Sustained Leadership Attention and Systematic Oversight Needed to Resolve Persistent Problems Affecting Care and Benefits

Published by the Government Accountability Office on 2012-11-16.

Below is a raw (and likely hideous) rendition of the original report. (PDF)

                             United States Government Accountability Office

GAO                          Report to Congressional Committees




November 2012
                             RECOVERING
                             SERVICEMEMBERS
                             AND VETERANS
                             Sustained Leadership
                             Attention and
                             Systematic Oversight
                             Needed to Resolve
                             Persistent Problems
                             Affecting Care and
                             Benefits
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GAO-13-5
                                               November 2012

                                               RECOVERING SERVICEMEMBERS AND
                                               VETERANS
                                               Sustained Leadership Attention and Systematic
Highlights of GAO-13-5, a report to
                                               Oversight Needed to Resolve Persistent Problems
congressional committees                       Affecting Care and Benefits



Why GAO Did This Study                         What GAO Found
The National Defense Authorization             Deficiencies exposed at Walter Reed Army Medical Center in 2007 served as a
Act for Fiscal Year 2008 required DOD          catalyst compelling the Departments of Defense (DOD) and Veterans Affairs
and VA to jointly develop and                  (VA) to address a host of problems for wounded, ill, and injured servicemembers
implement policy on the care,                  and veterans as they navigate through the recovery care continuum. This
management, and transition of                  continuum extends from acute medical treatment and stabilization, through
recovering servicemembers. It also             rehabilitation to reintegration, either back to active duty or to the civilian
required GAO to report on DOD’s and            community as a veteran. In spite of 5 years of departmental efforts, recovering
VA’s progress in addressing these              servicemembers and veterans are still facing problems with this process and may
requirements. This report specifically
                                               not be getting the services they need. Key departmental efforts included the
examines (1) the extent to which DOD
                                               creation or modification of various care coordination and case management
and VA have resolved persistent
problems facing recovering
                                               programs, including the military services’ wounded warrior programs. However,
servicemembers and veterans as they            these programs are not always accessible to those who need them due to the
navigate the recovery care continuum,          inconsistent methods, such as referrals, used to identify potentially eligible
and (2) the reasons DOD and VA                 servicemembers, as well as inconsistent eligibility criteria across the military
leadership have not been able to fully         services’ wounded warrior programs. The departments also jointly established an
resolve any remaining problems. To             integrated disability evaluation system to expedite the delivery of benefits to
address these objectives, GAO visited          servicemembers. However, processing times for disability determinations under
11 DOD and VA medical facilities               the new system have increased since 2007, resulting in lengthy wait times that
selected for population size and range         limit servicemembers’ ability to plan for their future. Finally, despite years of
of available resources and met with            incremental efforts, DOD and VA have yet to develop sufficient capabilities for
servicemembers and veterans to                 electronically sharing complete health records, which potentially delays
identify problems they continue to face.       servicemembers’ receipt of coordinated care and benefits as they transition from
GAO also reviewed documents related            DOD’s to VA’s health care system.
to specific DOD and VA programs that
assist recovering servicemembers and           Collectively, a lack of leadership, oversight, resources, and collaboration has
veterans and interviewed the                   contributed to the departments’ inability to fully resolve problems facing
leadership and staff of these programs         recovering servicemembers and veterans. Initially, departmental leadership
to determine why problems have not             exhibited focus and commitment—through the Senior Oversight Committee—to
been fully resolved.                           addressing problems related to case management and care coordination,
                                               disability evaluation systems, and data sharing between DOD and VA. However,
What GAO Recommends                            the committee’s oversight waned over time, and in January 2012, it was merged
GAO recommends that DOD provide                with the VA/DOD Joint Executive Council. Whether this council—which has
central oversight of the military              primarily focused on long-term strategic planning—can effectively address the
services’ wounded warrior programs             shorter-term policy focused issues once managed by the Senior Oversight
and that DOD and VA sustain high-              Committee remains to be seen. Furthermore, DOD does not provide central
level leadership attention and                 oversight of the military services’ wounded warrior programs, preventing it from
collaboration to fully resolve identified      determining how well these programs are working across the department.
problems. DOD partially concurred with         However, despite these shortcomings, the departments continue to take steps to
the recommendation for central                 resolve identified problems, such as increasing the number of staff involved with
oversight of the wounded warrior               the electronic sharing of health records and the integrated disability evaluation
programs, citing issues with common            process. Additionally, while the departments’ previous attempts to collaborate on
eligibility criteria and systematic            how to resolve case management and care coordination problems have largely
monitoring. DOD and VA both                    been unsuccessful, a joint task force established in May 2012 is focused on
concurred with the recommendation for          resolving long-standing areas of disagreement between VA, DOD, and the
sustained leadership attention.
                                               military services. However, without more robust oversight and military service
View GAO-13-5. For more information, contact   compliance, consistent implementation of policies that result in more effective
Randall B. Williamson at (202) 512-7114 or     case management and care coordination programs may be unattainable.
williamsonr@gao.gov.

                                                                                       United States Government Accountability Office
Contents


Letter                                                                                               1
                       Background                                                                    6
                       DOD and VA Have Not Fully Resolved Persistent Problems with
                         Case Management and Care Coordination, Disability Evaluation
                         Systems, and Electronic Sharing of Health Records                         15
                       DOD and VA Have Not Fully Resolved Long-standing Problems
                         Due to Deficiencies in Leadership and Oversight, Resources, and
                         Collaboration                                                             26
                       Conclusions                                                                 44
                       Recommendations for Executive Action                                        45
                       Agency Comments and Our Evaluation                                          46

Appendix I             Enrollment and Populations for Select Department of Defense and
                       Department of Veterans Affairs Programs                                     54



Appendix II            Medical Category Assignment Process for Care Coordination
                       Programs                                                                    77



Appendix III           Comments from the Department of Defense                                     79



Appendix IV            Comments from the Department of Veterans Affairs                            85



Appendix V             GAO Contact and Staff Acknowledgments                                       92



Related GAO Products                                                                               93



Tables
                       Table 1: Military Services’ Wounded Warrior Programs: Types of
                                Services Provided                                                  13
                       Table 2: Eligibility Criteria for Military Services’ Wounded Warrior
                                Programs                                                           19


                       Page i                           GAO-13-5 Recovering Servicemembers and Veterans
          Table 3: Military Services’ Wounded Warrior Program Efforts to
                   Measure Program Performance                                       33
          Table 4: Military Services’ Wounded Warrior Programs: Enrollment
                   for Fiscal Year 2011                                              55
          Table 5: Army Warrior Care and Transition Program Enrollment
                   Populations and Characteristics, Fiscal Years 2008 through
                   2011                                                              58
          Table 6: Army Wounded Warrior Program Enrollment Populations
                   and Characteristics, Fiscal Years 2008 through 2011               60
          Table 7: Navy Safe Harbor Program Enrollment Populations and
                   Characteristics, Fiscal Years 2008 through 2011                   62
          Table 8: Air Force Wounded Warrior Program Enrollment
                   Populations and Characteristics, Fiscal Years 2008 through
                   2011                                                              64
          Table 9: Air Force Recovery Care Program Enrollment Populations
                   and Characteristics, Fiscal Years 2008 through 2011               65
          Table 10: Marine Corps Wounded Warrior Regiment Enrollment
                   Populations and Characteristics, Fiscal Years 2008 through
                   2011                                                              67
          Table 11: United States Special Operations Command’s Care
                   Coalition Enrollment Populations and Characteristics,
                   Fiscal Years 2008 through 2011                                    69
          Table 12: Operation Enduring Freedom/Operation Iraqi Freedom/
                   Operation New Dawn (OEF/OIF/OND) Care Management
                   Program Enrollment Populations and Characteristics,
                   Fiscal Years 2008 through 2011                                    71
          Table 13: Federal Recovery Coordination Program (FRCP)
                   Enrollment Populations and Characteristics, Fiscal Years
                   2008 through 2011                                                 73
          Table 14: Referral Information Routinely Tracked by DOD and VA
                   Case Management and Care Coordination Programs                    75


Figures
          Figure 1: Timeline of Key Events in the 2-Year Period Following the
                   Walter Reed Army Medical Center Media Reports                       8
          Figure 2: Original Senior Oversight Committee Organizational
                   Chart, including the Lines of Action (LOA) Workgroups               9
          Figure 3: The Department of Defense’s Vision of the Assignment
                   Process for the Recovery Coordination Program and the
                   Federal Recovery Coordination Program                             78




          Page ii                         GAO-13-5 Recovering Servicemembers and Veterans
Abbreviations

DOD                                      Department of Defense
Dole-Shalala Commission                  President’s Commission on Care for
                                           America’s Returning Wounded
                                           Warriors
FRCP                                     Federal Recovery Coordination
                                           Program
IDES                                     Integrated disability evaluation system
LOA                                      Line of Action
MTF                                      military treatment facility
NDAA 2008                                National Defense Authorization Act for
                                           Fiscal Year 2008
OEF                                      Operation Enduring Freedom
OIF                                      Operation Iraqi Freedom
OND                                      Operation New Dawn
PTSD                                     posttraumatic stress disorder
RCP                                      Recovery Coordination Program
Recovering Warrior Task Force            Department of Defense Task Force on
                                           the Care, Management, and
                                           Transition of Recovering Wounded,
                                           Ill, and Injured Members of the
                                           Armed Forces
Senior Oversight Committee               Wounded, Ill, and Injured Senior
                                           Oversight Committee
TBI                                      traumatic brain injury
VA                                       Department of Veterans Affairs
VAMC                                     Department of Veterans Affairs Medical
                                           Center
WWCTP                                    Office of Wounded Warrior Care and
                                         Transition Policy



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Page iii                               GAO-13-5 Recovering Servicemembers and Veterans
United States Government Accountability Office
Washington, DC 20548




                                   November 16, 2012

                                   Congressional Committees

                                   A series of media reports in early 2007 disclosed troublesome
                                   deficiencies in the provision of outpatient services at Walter Reed Army
                                   Medical Center in Washington, D.C. 1 These reports prompted broader
                                   questions about whether the Departments of Defense (DOD) and
                                   Veterans Affairs (VA) were fully prepared to meet the needs of the
                                   growing number of servicemembers and veterans returning from recent
                                   conflicts. Several review groups were subsequently tasked with
                                   investigating the reported problems and identifying recommendations. 2
                                   These groups identified common areas of concern including: inadequate
                                   case management to ensure continuity of care, 3 confusing disability
                                   evaluation systems, and insufficient sharing of servicemembers’ health
                                   records and other data between DOD and VA—all long-standing
                                   problems that we have reported on extensively. 4

                                   To elevate the response to concerns raised by these review groups, DOD
                                   and VA established the Wounded, Ill, and Injured Senior Oversight
                                   Committee (Senior Oversight Committee) in May 2007. The committee
                                   was intended to operate on a short-term basis to review and implement



                                   1
                                    “Soldiers Face Neglect, Frustration at Army’s Top Medical Facility,” Washington Post
                                   (Washington, D.C.: Feb. 18, 2007); “The Other Walter Reed: The Hotel Aftermath,”
                                   Washington Post (Washington, D.C.: Feb. 19, 2007); and “Hospital Investigates Former
                                   Aid Chief,” Washington Post (Washington, D.C.: Feb. 20, 2007).
                                   2
                                    Independent Review Group, Rebuilding the Trust: Report on Rehabilitative Care and
                                   Administrative Processes at Walter Reed Army Medical Center and National Naval
                                   Medical Center (Arlington, Va.: April 2007); Task Force on Returning Global War on Terror
                                   Heroes, Report to the President (April 2007); President’s Commission on Care for
                                   America’s Returning Wounded Warriors, Serve, Support, Simplify (July 2007); Veterans’
                                   Disability Benefits Commission, Honoring the Call to Duty: Veterans’ Disability Benefits in
                                   the 21st Century (October 2007); and Department of Defense Office of the Inspector
                                   General, Department of Veterans Affairs Office of the Inspector General, DOD/VA Care
                                   Transition Process for Service Members Injured in OIF/OEF (June 2008).
                                   3
                                    According to the Case Management Society of America, case management is defined as
                                   a collaborative process of assessment, planning, facilitation, and advocacy for options and
                                   services to meet an individual’s health needs through communication and available
                                   resources to promote high quality, cost-effective outcomes.
                                   4
                                    See list of related GAO products at the end of this report.




                                   Page 1                                  GAO-13-5 Recovering Servicemembers and Veterans
the recommendations made by the various review groups and improve
seamlessness in the provision of care for recovering servicemembers and
veterans. 5 It was cochaired by the Deputy Secretaries of Defense and
Veterans Affairs and included the military service Secretaries and other
high-ranking officials within the departments. Congress subsequently
passed the National Defense Authorization Act for Fiscal Year 2008
(NDAA 2008) requiring the Secretary of Defense and the Secretary of
Veterans Affairs to jointly develop and implement policy, to the extent
feasible, to improve the care, management, and transition of recovering
servicemembers. 6 Because of its related ongoing work, the Senior
Oversight Committee also assumed responsibility for addressing these
requirements.

Despite actions taken by DOD and VA to address the problems identified
at Walter Reed in 2007, concerns remain that recovering servicemembers
and veterans continue to face many of the same problems as they did in
2007 navigating the recovery care continuum, from acute medical
treatment and stabilization, through rehabilitation, to reintegration—either
back to active duty or to the civilian community as a veteran. In 2009,
Congress required DOD to establish a task force to assess the
effectiveness of DOD programs and policies developed to assist
recovering servicemembers and to make recommendations for
continuous improvements of such policies and programs. 7 The DOD Task
Force on the Care, Management, and Transition of Recovering Wounded,
Ill, and Injured Members of the Armed Forces—referred to as the
Recovering Warrior Task Force—issued its first report in September
2011; 8 it contained 21 recommendations on a variety of issues affecting
recovering servicemembers. 9 Additionally, congressional committees held


5
 In this report, we will use the term “recovering servicemembers” to denote wounded, ill,
and injured servicemembers.
6
Pub. L. No. 110-181, § 1611, 122 Stat. 3, 433 (2008).
7
 National Defense Authorization Act for Fiscal Year 2010, Pub. L. No. 111-84, § 724,
123 Stat. 2190, 2389 (2009).
8
 Department of Defense Task Force on the Care, Management, and Transition of
Recovering Wounded, Ill, and Injured Members of the Armed Forces, Department of
Defense Recovering Warrior Task Force 2010-2011 Annual Report (September 2011).
9
 To understand how VA interacts with servicemembers, the Recovering Warrior Task
Force reviewed VA programs, including those that assist servicemembers with the
transition from DOD’s to VA’s health care system.




Page 2                                 GAO-13-5 Recovering Servicemembers and Veterans
multiple hearings in 2010 and 2011 that highlighted ongoing difficulties
facing these servicemembers and veterans, including issues with
duplication and poor coordination among case management and care
coordination programs, 10 delays in completing the disability evaluation
process, and the lack of full interoperability between DOD’s and VA’s
computer systems. 11

The NDAA 2008 required that we report on DOD’s and VA’s progress in
developing and implementing joint policy on issues related to the care,
management, and transition of recovering servicemembers. 12 As
discussed with the committees of jurisdiction, we have reviewed and
reported on the departments’ progress with respect to various topic areas.
This review, which is focused on the continuity of care for recovering
servicemembers and veterans, is the latest in our body of work. 13 In this
review, we are reporting on

1. the extent to which DOD and VA have resolved persistent problems
   facing recovering servicemembers and veterans as they navigate the
   recovery care continuum and
2. the reasons DOD and VA leadership have not been able to fully
   resolve any remaining problems.



10
  According to the National Coalition on Care Coordination, care coordination is a client-
centered, assessment-based interdisciplinary approach to integrating health care and
social support services in which an individual’s needs and preferences are assessed, a
comprehensive care plan is developed, and services are managed and monitored by an
identified care coordinator.
11
  See Hearing on the Federal Recovery Coordination Program: From Concept to Reality,
Subcommittee on Health, Committee on Veterans’ Affairs, House of Representatives
(May 13, 2011); and Review of the VA and DOD Integrated Disability Evaluation System,
Hearing before the Committee on Veterans’ Affairs, United States Senate (Nov. 18, 2010).
12
 Pub. L. No. 110-181, § 1615(d), 122 Stat. 2, 447.
13
  GAO has produced a body of work assessing progress made to improve care,
management, and transition of recovering servicemembers, including: Recovering
Servicemembers: DOD and VA Have Made Progress to Jointly Develop Required Polices
but Additional Challenges Remain, GAO-09-540T (Washington, D.C.: Apr. 29, 2009);
Recovering Servicemembers: DOD and VA Have Jointly Developed the Majority of
Required Policies but Challenges Remain, GAO-09-728 (Washington, D.C.: July 8, 2009);
DOD and VA Health Care: Federal Recovery Coordination Program Continues to Expand
but Faces Significant Challenges, GAO-11-250 (Washington, D.C.: Mar. 23, 2011); DOD
and VA Health Care: Action Needed to Strengthen Integration across Care Coordination
and Case Management Programs, GAO-12-129T (Washington, D.C.: Oct. 6, 2011).




Page 3                                  GAO-13-5 Recovering Servicemembers and Veterans
To respond to these objectives, we interviewed the directors of the
following case management and care coordination programs, 14 including

•    the Army Warrior Care and Transition Command’s Warrior Transition
     Units and the Army Wounded Warrior Program,

•    the Navy Safe Harbor Program,

•    the Air Force Recovery Care Program and the Air Force Wounded
     Warrior Program,

•    the Marine Corps Wounded Warrior Regiment,

•    the United States Special Operations Command’s Care Coalition,

•    the Federal Recovery Coordination Program, and

•    VA’s Operation Enduring Freedom/Operation Iraqi Freedom/
     Operation New Dawn (OEF/OIF/OND) Care Management Program.

We collected data for each of these programs, such as the number of
enrollees over time. (See app. I for data on enrollment and population
characteristics for these programs.) We also reviewed documents
describing the scope, mission, and leadership of these selected
programs.

In addition, we took the following steps to determine the extent to which
DOD and VA have resolved persistent problems affecting recovering
servicemembers and veterans along the recovery care continuum:

•    We visited a judgmental sample of 11 DOD military treatment facilities
     (MTF) and VA Medical Centers (VAMC) to identify variations in how
     care coordination and case management programs are being
     operated at the local level. We focused on Army and Marine Corps
     MTFs because, collectively, the wounded warrior programs for these
     military services serve more than 70 percent of the wounded, ill, and
     injured servicemember and veteran population. We selected facilities


14
  We selected key care coordination and case management programs that provide
assistance to recovering servicemembers and veterans—many of which were created or
modified after Walter Reed media reports. These programs have also been the subject of
prior reviews by GAO and others.




Page 4                               GAO-13-5 Recovering Servicemembers and Veterans
      that provide or have access to significant medical and rehabilitation
      resources as well as facilities that have fewer medical or rehabilitation
      resources. The sites we visited included MTFs at Fort Bragg (N.C.),
      Fort Knox (Ky.), Fort Carson (Colo.), Fort Belvoir (Va.), Fort Meade
      (Md.), Walter Reed National Military Medical Center (Md.), Camp
      Lejeune (N.C.), and Quantico (Va.), and VAMCs in Richmond,
      Virginia; Denver, Colorado; and the District of Columbia. At these
      facilities, we met with local leadership officials and the officials
      responsible for managing the facilities’ case management and care
      coordination programs, and we obtained information on how these
      programs were working as well as the types of problems that
      recovering servicemembers and veterans continue to face. While at
      these facilities, we met with recovering servicemembers and veterans
      to obtain information about their experiences.

•     We interviewed officials from military and veteran advocacy groups to
      obtain their members’ perspective on any problems that persist in
      navigating the recovery care continuum.

•     We interviewed the director of the VA Liaison for Healthcare Program
      to understand VA’s role in assisting recovering servicemembers’
      transition from DOD’s to VA’s health care system.

•     We met with members of the Recovering Warrior Task Force,
      reviewed relevant task force documentation, and attended its public
      meetings to obtain information about problems they identified that
      affect recovering servicemembers and veterans.

•     We reviewed published and ongoing studies and GAO reports 15
      describing problems that recovering servicemembers and veterans
      face, including issues related to the disability evaluation system and
      the electronic sharing of health records between DOD and VA.

To identify the reasons why DOD and VA leadership have not fully
resolved any remaining problems facing recovering servicemembers and
veterans, we reviewed relevant documentation to identify the roles of
DOD and VA offices that coordinate or oversee case management or
care coordination programs, their placement within their respective
departments, and whether and how these offices monitor the


15
    See list of related GAO products.




Page 5                                  GAO-13-5 Recovering Servicemembers and Veterans
             performance of the programs we reviewed. We also obtained information
             about organizational and program changes, including officials’ views
             about the potential impact of these changes. We also interviewed key
             DOD and VA leadership officials, such as the Deputy Assistant Secretary
             of Defense for Wounded Warrior Care and Transition Policy, VA’s Chief
             of Staff, and former and current officials from the departments’
             coordinating and oversight offices, including the Senior Oversight
             Committee, DOD’s Office of Wounded Warrior Care and Transition
             Policy, the Interagency Program Office, and the VA/DOD Collaboration
             Service, which is an office within VA. To obtain information about recent
             efforts DOD and VA have initiated to address problems facing
             servicemembers and veterans, we interviewed DOD and VA officials
             participating in these activities, including officials involved in the DOD and
             VA Warrior Care and Coordination Taskforce. We also reviewed the
             documentation available regarding the departments’ recent efforts;
             however, we predominately relied on testimonial evidence provided by
             these officials.

             The NDAA 2008 also requires us to certify whether we had timely access
             to sufficient information to make informed judgments on the matters
             covered by our report. We were provided sufficient information in a timely
             manner to assess the extent to which DOD and VA have resolved
             persistent problems facing recovering servicemembers and veterans as
             they navigate the recovery care continuum and the reasons DOD and VA
             leadership have not been able to fully resolve any remaining problems.

             We conducted this performance audit from July 2011 through September
             2012 in accordance with generally accepted government auditing
             standards. Those standards require that we plan and perform the audit to
             obtain sufficient, appropriate evidence to provide a reasonable basis for
             our findings and conclusions based on our audit objectives. We believe
             that the evidence obtained provides a reasonable basis for our findings
             and conclusions based on our audit objectives.


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




             Page 6                            GAO-13-5 Recovering Servicemembers and Veterans
Review Groups Identified     Following the revelations at Walter Reed, several review groups noted
Problems across the          significant problems that may arise during servicemembers’ recovery from
Recovery Care Continuum      wounds, illnesses, and injuries. 16 Some of these problems involve the
                             provision of appropriate medical care, while others involve the acquisition
                             of needed DOD and VA benefits. In 2007, one of the review groups, the
                             President’s Commission on Care for America’s Returning Wounded
                             Warriors—commonly referred to as the Dole-Shalala Commission—noted
                             that recovering servicemembers depend on the effective and efficient
                             provision of medical services and benefits across the recovery care
                             continuum, 17 which is separated into three phases:

                             •    recovery, when wounded, ill, and injured servicemembers are
                                  stabilized and receive acute inpatient medical treatment at an MTF,
                                  VAMC, or private medical facility;

                             •    rehabilitation, when recovering servicemembers with complex trauma,
                                  such as missing limbs, receive medical and rehabilitative care; and

                             •    reintegration, when servicemembers either return to active duty or to
                                  the civilian community as veterans.

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


Initial Efforts to Address   DOD and VA took a number of steps to address the problems identified
Problems Were                by the review groups that investigated the issues raised by the Walter
Coordinated by the Senior    Reed media reports. As an initial step, the departments established the
Oversight Committee

                             16
                               The terms “wounded, ill, and injured” are used by DOD and VA as general
                             classifications of servicemembers or veterans with regard to their medical condition.
                             “Wounded” generally means any injury inflicted by an external force during combat. “Ill
                             and injured” refers to any illness or injury in the line of duty that may render the
                             servicemember medically unfit to perform the duties of his or her office, grade, rank, or
                             rating.
                             17
                              President’s Commission on Care for America’s Returning Wounded Warriors, Serve,
                             Support, Simplify.




                             Page 7                                  GAO-13-5 Recovering Servicemembers and Veterans
                                        Senior Oversight Committee to coordinate and oversee DOD’s and VA’s
                                        efforts to jointly resolve these problems. Through this committee, DOD
                                        and VA created programs and initiatives to assist recovering
                                        servicemembers and veterans as they navigate the recovery care
                                        continuum. Key efforts included the establishment of the integrated
                                        disability evaluation system (IDES), the Federal Recovery Coordination
                                        Program (FRCP), the Recovery Coordination Program (RCP), and the
                                        Interagency Program Office. (See fig. 1.)

Figure 1: Timeline of Key Events in the 2-Year Period Following the Walter Reed Army Medical Center Media Reports




                                        a
                                         Several review groups, including the Dole-Shalala Commission, were tasked with investigating the
                                        problems reported at Walter Reed Army Medical Center in Washington, D.C., and identifying
                                        recommendations. The other review groups included the Independent Review Group, Rebuilding the
                                        Trust: Report on Rehabilitative Care and Administrative Processes at Walter Reed Army Medical
                                        Center and National Naval Medical Center (Arlington, Va.: April 2007); Task Force on Returning
                                        Global War on Terror Heroes, Report to the President (April 2007); Veterans’ Disability Benefits
                                        Commission, Honoring the Call to Duty: Veterans’ Disability Benefits in the 21st Century (October
                                        2007); and Department of Defense Office of the Inspector General, Department of Veterans Affairs
                                        Office of the Inspector General, DOD/VA Care Transition Process for Service Members Injured in
                                        OIF/OEF (June 2008).


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



                                        Page 8                                    GAO-13-5 Recovering Servicemembers and Veterans
Figure 2: Original Senior Oversight Committee Organizational Chart, including the Lines of Action (LOA) Workgroups




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

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

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

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

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

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



                                        Page 9                              GAO-13-5 Recovering Servicemembers and Veterans
•    LOA 6—”Clean Sheet” Review: Developed recommendations to
     improve care and benefits without the constraints of existing laws,
     regulations, organizational roles, personnel constraints, or budgets.

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

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

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

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

Care Coordination Programs. LOA 3 took the lead role in addressing
problems with uncoordinated case management for recovering
servicemembers and veterans through the establishment of two care
coordination programs—the FRCP and the RCP. The FRCP was based
on a recommendation from the Dole-Shalala Commission that a single
individual—a recovery coordinator—would work with existing DOD and
VA case managers to ensure that servicemembers had the resources
needed for their care. LOA 3 designed the FRCP to assist “severely”
wounded, ill, and injured OEF and OIF 18 servicemembers, veterans, and


18
  OEF, which began in October 2001, supports combat operations in Afghanistan and
other locations, and OIF, which began in March 2003, supports combat operations in Iraq
and other locations. Since September 1, 2010, OIF is referred to as Operation New Dawn
(OND).




Page 10                               GAO-13-5 Recovering Servicemembers and Veterans
their families with access to care, services, and benefits. This population
includes servicemembers and veterans who suffer from traumatic brain
injuries, amputations, burns, spinal cord injuries, visual impairment, and
PTSD. The program uses federal recovery coordinators to monitor and
coordinate clinical services, including facilitating and coordinating medical
appointments, and nonclinical services, such as providing assistance with
obtaining financial benefits or special accommodations, needed by
program enrollees and their families. Federal recovery coordinators, who
are senior-level registered nurses and licensed clinical social workers,
were intended to serve as the single point of contact among all of the
case managers of DOD, VA, and other governmental and
nongovernmental programs 19 that provide services directly to
servicemembers and veterans. Although the FRCP was designed as a
joint program, it is administered by VA, and the federal recovery
coordinators are VA employees.

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

Electronic Sharing of Health Records. LOA 4 was focused on addressing
issues related to the electronic exchange of DOD and VA health records.
However, this effort was superseded by the NDAA 2008, 20 which required
the establishment of the Interagency Program Office to serve as a single
point of accountability for both departments in the development and
implementation of interoperable electronic health records. 21 Although
DOD and VA retained the responsibility for the development and


19
  Federal Recovery Coordinators are intended to coordinate all care and benefits for their
enrollees, including coordinating assistance from private sector programs.
20
 Pub. L. No. 110-181, § 1635, 122 Stat. 3, 460-63.
21
  Interoperability is the ability of two or more systems or components to exchange
information and to use the information that has been exchanged.




Page 11                                GAO-13-5 Recovering Servicemembers and Veterans
                            management of the information technology systems, the Interagency
                            Program Office was responsible for ensuring the implementation of an
                            electronic health records system or capabilities that allowed for the
                            complete sharing of health care information for the provision of clinical
                            care. In October 2011, the Interagency Program Office also became
                            accountable for DOD’s and VA’s work on developing an integrated
                            electronic health records system that both departments would use for
                            their beneficiaries.


Additional Efforts by DOD   In addition to the Senior Oversight Committee’s efforts, DOD, its military
and VA to Address           services, and VA developed or modified a number of programs and
Problems Facing             initiatives to assist recovering servicemembers and veterans in navigating
                            the recovery care continuum.
Recovering
Servicemembers and          Military Services’ Wounded Warrior Programs. The military services’
Veterans                    wounded warrior programs were established to assist recovering
                            servicemembers 22 during their recovery, rehabilitation, and initial
                            reintegration back to active duty or to civilian life. Most of these programs
                            provide nonclinical case management services to the recovering
                            servicemembers; that is, they help to resolve issues related to finances,
                            benefits and compensation, administrative and personnel paperwork,
                            housing, and transportation. In addition, the wounded warrior programs
                            serve as the central point of access to other types of services or
                            resources that support recovering servicemembers, such as clinical case
                            management, care coordination, and career, education, and readiness
                            services. (See table 1.) If a wounded warrior program does not directly
                            provide a service or resource, it can facilitate servicemembers’ access to
                            that service or resource. Although the wounded warrior programs were
                            intended mainly to provide services to recovering servicemembers, all but
                            one of the programs continue to assist individuals after they have
                            transitioned to veteran status.




                            22
                              Recovering servicemembers include those who are wounded, ill, or injured in a combat
                            zone or due to an incident that occurred in the United States or overseas while in active
                            status.




                            Page 12                                GAO-13-5 Recovering Servicemembers and Veterans
Table 1: Military Services’ Wounded Warrior Programs: Types of Services Provided

                                                                                     Types of services provided
                                                                                                                                      Career,
Military services’ wounded                       Clinical case                  Nonclinical case                      Care        education, and
                                                                                                                                              a
warrior program                                  management                      management                        coordination     readiness
Army
    Army Warrior Care and Transition                                                                                                  
    Program: Warrior Transition Units and
    Community-Based Warrior Transition
          b
    Units
    Army Warrior Care and Transition                                                                                                   
    Program: Army Wounded Warrior
    Program
Navy/Coast Guard
    Navy Safe Harbor Program                                                                                                           
Air Force
    Air Force Wounded Warrior Program                                                                                                  
    Air Force Recovery Care Program                                                                                                    
Marine Corps
    Marine Corps Wounded Warrior                                                                                                      
    Regiment
United States Special Operations Command
    United States Special Operations                                                                                                  
    Command’s Care Coalition
                                            Source: GAO analysis of military services’ wounded warrior program information.

                                            Notes: The characteristics listed in this table are general characteristics of each program; individual
                                            circumstances may affect the services provided by specific programs. For the purposes of this report,
                                            clinical case management services include services such as scheduling medical appointments and
                                            providing outreach education about medical conditions such as PTSD. Nonclinical case management
                                            services include services such as assisting servicemembers with financial benefits and accessing
                                            accommodations for families.
                                            a
                                             Career, education, and readiness services are provided through programs such as the Warrior
                                            Athlete Reconditioning Program and DOD’s Operation Warfighter Program and Education and
                                            Employment Initiative. The Warrior Athlete Reconditioning Program enhances recovery by engaging
                                            wounded, ill, and injured servicemembers in individualized physical and cognitive activities outside of
                                            traditional therapy settings. Operation Warfighter is a federal internship program for wounded, ill, and
                                            injured servicemembers that places them in supportive work settings to prepare them to return to
                                            active duty or to transition into jobs in the government or private sector. To access the Operation
                                            Warfighter Program a recovering servicemember has to be enrolled in a military service wounded
                                            warrior program. In addition, the military services’ wounded warrior programs facilitate access to other
                                            programs such as the Warrior Athlete Reconditioning Program.
                                            b
                                             A warrior transition unit is technically an Army brigade, battalion, or company that provides command
                                            and control, administrative support, primary care and case management and other services to
                                            support soldiers and their families during recovery, rehabilitation, and transition back to active duty or
                                            to civilian life. For the purposes of this report, we are categorizing it as a wounded warrior program.




                                            Page 13                                                  GAO-13-5 Recovering Servicemembers and Veterans
VA Transition Programs. VA’s Liaison for Healthcare Program and its
OEF/OIF/OND Care Management Program assist recovering
servicemembers with transitioning from DOD’s to VA’s health care
system. As of August 2012, the Liaison for Healthcare Program employed
33 liaisons at 18 MTFs nationwide. 23 After a DOD or VA treatment team
determines that a recovering servicemember is medically ready to
transition to a VAMC, a VA liaison facilitates the transfer from an MTF to
a VAMC closest to their homes or to the most appropriate locations for
the specialized services their medical condition requires. VA liaisons
follow recovering servicemembers as they enter the VA health care
system, ensuring that their first VA appointments are scheduled.
Thereafter, the VA OEF/OIF/OND Care Management Program team
assigned to each recovering individual coordinates the individual’s care at
the VAMC and provides ongoing follow-up. 24 Each VAMC has an
OEF/OIF/OND Care Management Program team in place to coordinate
patient care activities.




23
  According to a VA official, in fiscal year 2013, VA will hire 10 additional liaisons and
expand the number of MTFs where liaisons will be located to 21.
24
  The VA OEF/OIF/OND Care Management Program screens all returning combat
veterans to determine if case management services are required.




Page 14                                  GAO-13-5 Recovering Servicemembers and Veterans
DOD and VA Have
Not Fully Resolved
Persistent Problems
with Case
Management and Care
Coordination,
Disability Evaluation
Systems, and
Electronic Sharing of
Health Records
Recovering                      Recovering servicemembers’ access to case management and care
Servicemembers and              coordination programs has been impeded by two main factors—(1) the
Veterans Do Not Always          limited ability to identify and refer those servicemembers who could
                                benefit from enrollment in the programs along with officials’ reluctance to
Have Access to the Case         refer them, and (2) variations in eligibility criteria among the military
Management and Care             services’ wounded warrior programs, resulting in access disparities for
Coordination Programs           similarly situated recovering servicemembers. 25
Designed to Assist Them
Recovering Servicemembers       We found that referrals may be lacking or delayed (1) from military
Are Not Always Identified and   service unit commanders to wounded warrior programs; (2) from
Referred to Programs That May   wounded warrior programs to the FRCP; and (3) for certain groups of
Benefit Them                    servicemembers, such as those with “invisible injuries” as well as
                                members of the National Guard and Reserve.

                                Referral to the military services’ wounded warrior programs. The military
                                services’ wounded warrior programs primarily use referrals to identify
                                recovering servicemembers that might be eligible for enrollment.
                                However, we found that the methods for referral, which include casualty
                                reports and direct referrals, are imprecise, such that all servicemembers




                                25
                                  Not all wounded, ill, and injured servicemembers and veterans are eligible for access to
                                these programs. Most military service wounded warrior programs only serve those who
                                are “seriously” and “severely” wounded, ill, and injured.




                                Page 15                                GAO-13-5 Recovering Servicemembers and Veterans
who could benefit from being enrolled in these programs are not
necessarily identified and referred.

Officials from three wounded warrior programs told us that casualty
reports are the primary method for receiving referrals. 26 Casualty reports
are initial alerts to military personnel, including wounded warrior program
officials, that a servicemember has been injured. These reports can be
initiated by unit commands or other military personnel as a method of
referral to the wounded warrior programs. However, wounded warrior
program officials from four wounded warrior programs told us that
casualty reports are not created after every injury or may be created late
in a servicemember’s recovery. In particular, some of these officials said
that military service unit command staff may delay or not create casualty
reports for servicemembers not injured in combat, such as for injuries that
occur stateside or while on leave, because servicemembers’ units may
not find out about such incidents immediately.

According to wounded warrior program officials, referrals to wounded
warrior programs also can be made directly from unit command staff and
other sources, including staff at the MTF where a recovering
servicemember is receiving treatment or through self-referrals. 27 These
referrals also may not be made in a timely manner. Specifically, unit
command staff may not refer potentially eligible servicemembers to
wounded warrior programs because either they want to “take care of their
own” or because they are not well informed about the programs and the
services they provide, according to wounded warrior program officials.
For example, a wounded warrior program official told us that he identified
a servicemember who had sustained a gunshot wound to the head but
was still assigned to his combat unit. This official explained that even
though the servicemember was receiving treatment, he could have
benefited from being enrolled in the wounded warrior program because of
the additional assistance it provides, including nonclinical case
management and care coordination services. Additionally, several
recovering servicemembers told us that they encountered difficulties in



26
  Casualty reports, including personnel casualty reports, are electronic messages that
contain casualty information including type of injury, where the injury occurred, and
location of the injured servicemember.
27
 We found that referrals by unit command staff are most likely, because they have the
most knowledge about servicemembers’ conditions, injuries, and treatment locations.




Page 16                                GAO-13-5 Recovering Servicemembers and Veterans
their recovery as a result of staying in their units and not being referred to
a wounded warrior program earlier. For example, a recovering
servicemember told us that despite having been recently discharged from
a hospital for arm injuries, he was required to operate a floor buffing
machine in his unit, which was difficult for him as a result of his injuries.
He did not receive rehabilitative treatment for his injuries until he was
assigned to a wounded warrior program. Furthermore, we found that most
of the military services’ wounded warrior programs do not always track
the number of referrals to their programs, including data on whether or
not servicemembers referred to the programs were actually enrolled. (See
table 14 in app. I for additional information about referral data.) Without
this information, it is not clear whether all those who could benefit from a
wounded warrior program are being enrolled.

Referral to the FRCP. In addition to problems with referrals to wounded
warrior programs, wounded warrior program officials sometimes delay or
fail to make referrals of potentially eligible servicemembers to the FRCP,
which coordinates care across the departments and throughout the
recovery care continuum. As we have previously reported, the FRCP
relies predominantly on referrals from other sources, including wounded
warrior program officials and clinical treatment teams, because it does not
have a systematic way to identify potential enrollees. 28 Referrals to the
FRCP are important because federal recovery coordinators are intended
to provide continuity of care throughout servicemembers’ recovery,
starting with their initial treatment at an MTF and throughout the recovery
care continuum. They can also assist in facilitating recovering
servicemembers’ access to VA services and benefits while
servicemembers are still on active duty, according to VA officials. 29
However, we found that officials from wounded warrior programs view the
jointly created and established FRCP as a VA program and, therefore,
delay their referrals until it is certain that the servicemember will become
a veteran.

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


28
 GAO-11-250.
29
  Servicemembers are eligible for certain VA benefits while still on active duty, including
access to treatment at specialized VA facilities and grants for home and car modifications.




Page 17                                GAO-13-5 Recovering Servicemembers and Veterans
                                   Specifically, according to wounded warrior program officials,
                                   servicemembers who have undiagnosed, “invisible” wounds, such as
                                   PTSD and TBI, may be at greater risk of not being referred to a wounded
                                   warrior program or the FRCP until it becomes apparent that the
                                   servicemember cannot be deployed. For example, a servicemember told
                                   us that although he was experiencing anxiety every time he put on his
                                   uniform, it was not until he had a severe anxiety attack, as a result of his
                                   PTSD, that he was hospitalized and then referred to a wounded warrior
                                   program. According to officials representing military advocacy
                                   organizations, National Guard and Reserve servicemembers may be
                                   particularly reluctant to identify injuries and illnesses because they are
                                   eager to return home and do not want to be delayed at the installation for
                                   an evaluation of any conditions they may have. However, these officials
                                   said that when these servicemembers have been deactivated and
                                   problems manifest themselves later on, they may experience difficulties
                                   establishing that their injuries or illnesses are a result of their service in
                                   the military, which could make it difficult for them to access services and
                                   programs provided by DOD and VA.

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




                                   Page 18                           GAO-13-5 Recovering Servicemembers and Veterans
Table 2: Eligibility Criteria for Military Services’ Wounded Warrior Programs

Military services’ wounded warrior program              Eligibility criteria
Army
    Army Warrior Care and Transition Program:           Serves servicemembers who require at least 6 months of rehabilitative care
                                                                                       a
    Warrior Transition Units and Community-Based        and complex medical management
    Warrior Transition Units
    Army Warrior Care and Transition Program:           Serves “severely” wounded, ill, and injured servicemembers in the warrior
    Army Wounded Warrior Program                        transition units who have, or are expected to receive, a physical evaluation
                                                                         b
                                                        disability rating of 30 percent or greater in one or more specific categories or a
                                                        combined rating of 50 percent or greater for conditions that are combat-related
Navy/Coast Guard
    Navy Safe Harbor Program                            Serves “seriously” wounded, ill, and injured sailors and coast guardsmen not
                                                        likely to return to duty in 180 days and likely to be medically retired, as well as
                                                        high-risk wounded, ill, and injured sailors that have less serious health
                                                        concerns
Air Force
    Air Force Wounded Warrior Program                   Serves servicemembers with a combat-related injury or illness that requires
                                                                      c
                                                        long-term care as well as examinations to determine fitness for duty
                                                                                                                            d
    Air Force Recovery Care Program                     Serves all servicemembers who are “seriously” ill and injured either in a
                                                        combat-related incident or in a non-combat-related incident
Marine Corps
    Marine Corps Wounded Warrior Regiment               Serves wounded, ill, and injured servicemembers who require more than 90
                                                        days of medical treatment or rehabilitation. A recovering servicemember also
                                                        may be assigned to the Wounded Warrior Regiment when:
                                                        •   the unit command cannot support transportation requirements to the
                                                            military treatment facility,
                                                        •   the Marine cannot serve a function in the unit command due to his/her
                                                            injuries or illness, or
                                                        •   the Marine has three or more medical appointments per week.
United States Special Operations Command
    United States Special Operations Command’s          Assists Special Forces servicemembers who are
    Care Coalition                                      •   wounded, injured, or ill evacuated from a combat area;
                                                        •   wounded, injured, or ill returned to duty or redeployed; or
                                                        •   injured or ill whose injury or illness is not combat-related.
                                          Source: GAO analysis of military services’ wounded warrior program information.
                                          a
                                           Reservists in need of definitive medical treatment for conditions caused or aggravated while on
                                          active duty or training status are also eligible.
                                          b
                                           After medical examinations are conducted to determine a servicemember’s ability to continue to
                                          serve in the military, decisions are made about the servicemember’s fitness for duty and about a
                                          servicemember’s disability rating, which determines the DOD and VA benefits he or she can receive.
                                          c
                                            According to an Air Force Wounded Warrior Program official, the program does not define long-term
                                          care or provide criteria related to the time needed for recovery.
                                          d
                                           According to an Air Force Recovery Care Program official, a servicemember is designated as
                                          “seriously’ ill or injured on the basis of a medical diagnosis made by Air Force medical staff when
                                          referred to the program; the program does not make this designation.




                                          Page 19                                                  GAO-13-5 Recovering Servicemembers and Veterans
As a result of these differences in eligibility criteria, recovering
servicemembers in one military service may qualify for entry in their
wounded warrior program while similarly situated servicemembers in
another military service do not have access to their program.
Consequently, according to wounded warrior program officials, some
recovering servicemembers do not have access to services that would
otherwise be available to them, including the RCP and Operation
Warfighter. 30 Additionally, because wounded warrior programs facilitate
access to other programs and services, including the VA Liaison for
Healthcare Program and the Warrior Athlete Reconditioning Program, 31
not being eligible for a particular wounded warrior program could preclude
a servicemember from receiving the services of these other programs. 32
Military coalition officials who advocate for recovering servicemembers
and their families told us the lack of standardization across similar
programs, such as the military services’ wounded warrior programs, is
one of the main reasons recovering servicemembers “fall through the
cracks” or do not get the services that they need when they are
navigating the recovery care continuum.

DOD is aware of inconsistencies in eligibility criteria among the military
services’ wounded warrior programs and the potential for disparities in the
provision of services and assistance that may result. DOD has not taken
action to correct this, however, despite the identification of this issue as a
potential problem for recovering servicemembers by a congressionally
mandated DOD task force. Specifically, in its 2011 annual report to



30
  Operation Warfighter is a DOD-sponsored internship program for wounded, ill, and
injured servicemembers who are at MTFs. Operation Warfighter is designed to provide
recuperating servicemembers with meaningful activity outside of the hospital environment
that assists in their wellness and offers a formal means of transition back to the civilian
workforce. Open to active duty, National Guard and Reserve components, Operation
Warfighter represents an opportunity for servicemembers in a medical hold status to build
their resumes, explore employment interests, develop job skills, and gain valuable work
experience that will prepare them for the future (see www.militaryhomefront.dod.mil).
31
  The Warrior Athlete Reconditioning program provides recreational activities and
competitive athletic opportunities to recovering servicemembers to improve their physical
and mental quality of life throughout the continuum of recovery and transition. The
program is designed to enhance recovery by engaging recovering servicemembers in
physical and cognitive activities outside of traditional therapy settings.
32
  Servicemembers do not have to be enrolled in or attached to a wounded warrior
program to participate in the VA Liaison for Healthcare Program or the Warrior Athlete
Reconditioning Program.




Page 20                                GAO-13-5 Recovering Servicemembers and Veterans
                             congressional committees, the Recovering Warrior Task Force noted that
                             as a result of differences in eligibility criteria among the military services,
                             certain subpopulations of recovering servicemembers may be at a
                             disadvantage. 33 In response to this report, DOD stated that although there
                             are no DOD-wide criteria for entry into wounded warrior programs, the
                             individual military services already have policies in place as a result of the
                             flexibility given to them by DOD.


Delays in DOD’s and VA’s     Although IDES provides improved timeliness over the separate DOD and
Integrated Disability        VA disability evaluation systems, processing times have continued to
Evaluation System Persist,   increase since its implementation in November 2007, resulting in
                             frustration and uncertainty for servicemembers going through the
Limiting Recovering          process. In a May 2012 hearing, 34 we testified that the average number of
Servicemembers’ Ability to   days for servicemembers to complete the IDES process and receive VA
Plan for Their Future        benefits increased from 283 in fiscal year 2008 to 394 in fiscal year 2011
                             for active duty cases (compared to the goal of 295 days) and from 297 to
                             420 for reserve cases, respectively (compared to the goal of 305 days). 35

                             While there are many reasons for increases in processing times, 36
                             recovering servicemembers and wounded warrior program officials told
                             us that extended timelines in the IDES process and the lack of a firm
                             completion date limits recovering servicemembers’ ability to plan for their
                             future. Several recovering servicemembers said that not being given a
                             timeframe for completion of the IDES process is frustrating, particularly
                             when their own providers are unable to obtain additional information on



                             33
                               Recovering Warrior Task Force, Department of Defense Recovering Warrior Task Force
                             2010-2011 Annual Report.
                             34
                               GAO, Military Disability System: Preliminary Observations on Efforts to Improve
                             Performance, GAO-12-718T (Washington, D.C.: May 23, 2012). For additional
                             information about IDES, see reports listed on the related products page.
                             35
                               The fiscal year 2008 and 2011 averages include only those servicemembers who
                             completed IDES and received VA benefits. The averages do not include other outcomes,
                             such as servicemembers who were found fit and returned to duty. Not all reservists
                             complete the VA benefit phase and thus DOD does not apply the 30-day goal for this
                             phase to reservists. For those reservists who do go through the VA benefits phase, this
                             time is reflected in the overall time in IDES.
                             36
                               As we have previously testified, other reasons that could impact the increase in IDES
                             processing times include large case loads and insufficient staff to complete a stage of
                             IDES in a timely manner.




                             Page 21                                GAO-13-5 Recovering Servicemembers and Veterans
the status of their case. For example, a servicemember told us that after
going through the IDES process, receiving a rating, and filing an appeal
over a year ago, he still did not know the status of his case, negatively
affecting his ability to plan for his future. Similarly, a wounded warrior
program official also told us that her program has had several
servicemembers lose job opportunities because they applied for positions
thinking that they would be through the IDES process by a certain date,
but when that date was pushed back, the employers rescinded their
offers.

Wounded warrior program officials from some of the sites we visited told
us that extended waiting periods resulting from the disability process also
may lead to some recovering servicemembers engaging in negative
behavior, including drug use. Wounded warrior program officials told us
that after waiting for so long in the wounded warrior barracks due to the
lengthy disability process, servicemembers can get depressed, resist or
just stop going to medical appointments, and stop working on their
recovery. Similarly, the DOD Inspector General has reported that lengthy
IDES processing times has contributed to a negative and even
counterproductive environment, which was not conducive to
servicemembers’ recovery and transition. 37 To prevent these problems,
we found that two wounded warrior programs require recovering
servicemembers to participate in programs such as the Warrior Athlete
Reconditioning Program and Operation Warfighter. A recovering
servicemember told us that soon after being assigned to the wounded
warrior program, he was referred to the Warrior Athlete Reconditioning
Program, which gave him something to do other than “sitting around.”
Another recovering servicemember told us that the Warrior Athlete
Reconditioning Program is an effective motivator for recovery.

Conversely, the servicemembers could take actions that may impact their
own processing times in IDES and, therefore, their length of stay in a
wounded warrior program. We found that some servicemembers may
appeal their disability decisions to prolong their own recovery and
transition out of the military. According to wounded warrior program



37
 Department of Defense Office of the Inspector General, Special Plans and Operations,
Assessment of DOD Wounded Warrior Matters-Camp Lejeune (March 2012) and
Department of Defense Office of the Inspector General, Special Plans and Operations,
Assessment of DOD Wounded Warrior Matters-Wounded Warrior Battalion-West
Headquarters and Southern California Units (August 2012).




Page 22                              GAO-13-5 Recovering Servicemembers and Veterans
                          officials from some of the sites we visited, some servicemembers resist
                          their transfer out of the wounded warrior program and the military
                          because they want to continue to take advantage of the opportunities and
                          services available to them, including the financial security of a regular
                          paycheck. For example, a wounded warrior program official and a VA
                          official told us that some servicemembers will purposefully miss
                          appointments to delay the IDES process because they feel that they are
                          not ready to leave the program.


DOD and VA Have Yet to    The departments have not yet developed sufficient capability to
Develop Sufficient        electronically share servicemembers’ and veterans’ complete health
Capability to             records, which can delay the receipt of care and benefits for recovering
                          servicemembers and veterans. As we have previously reported, for over a
Electronically Share      decade DOD and VA have undertaken several efforts to improve the
Health Records,           ability of their information technology systems to electronically share
Potentially Delaying      health records. 38 For example, the Federal Health Information Exchange,
Servicemembers’ Receipt   which was started in 2001 and completed in 2004, allows DOD to
of Coordinated Care and   electronically transfer servicemembers’ health information to VA when
Benefits                  they leave active duty. In addition, the departments’ Bidirectional Health
                          Information Exchange was established in 2004 to allow clinicians in both
                          departments to view limited health information on patients who receive
                          care from both departments. More recently, the departments have
                          undertaken two new joint initiatives, the Virtual Lifetime Electronic Record
                          and an integrated electronic health records system, in an effort to
                          increase electronic health record interoperability and modernize their
                          systems.

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


                          38
                            See, for example, GAO, Electronic Health Records: DOD and VA Efforts to Achieve Full
                          Interoperability Are Ongoing; Program Office Management Needs Improvement,
                          GAO-09-775 (Washington, D.C.: July 28, 2009); Electronic Health Records: DOD and VA
                          Interoperability Efforts Are Ongoing; Program Office Needs to Implement Recommended
                          Improvements, GAO-10-332 (Washington, D.C.: Jan. 28, 2010) and Electronic Health
                          Records: DOD and VA Should Remove Barriers and Improve Efforts to Meet Their
                          Common System Needs, GAO-11-265 (Washington, D.C.: Feb. 2, 2011).




                          Page 23                              GAO-13-5 Recovering Servicemembers and Veterans
For example, wounded warrior program and VA officials told us that they
had to resort to copying and faxing recovering servicemembers’ health
records to VAMC staff in preparation for a servicemember’s transition
from DOD’s to VA’s health care system because there was not an
automatic, electronic way to transfer them. In addition to copying and
faxing health records, according to VA officials we spoke with, DOD and
VA staff may hold a video-teleconference between the transferring MTF
and receiving VA health care facilities to exchange information.

In addition, wounded warrior program and VA officials who help
servicemembers transition from DOD to VA told us that they only share
with VA facilities the health records necessary for the treatment of a
recovering servicemember’s current condition. As a result,
servicemembers’ and veterans’ complete health records are not always
shared between departments when transferring facilities, and ultimately,
the responsibility to collect and provide a complete health record to the
VA facility can fall on the recovering servicemember and veteran. 39 A VA
official told us that this process can be complicated because DOD
separately maintains servicemembers’ inpatient, outpatient, and
behavioral health records and does not have a single database that can
identify all of the medical facilities where a servicemember received
treatment. Further, according to VA and DOD officials, delaying the
collection and assembly of a servicemember’s complete medical history
until the start of the disability process could result in servicemembers
having to be reexamined when they are demobilized, needing to establish
that their injuries were connected to their time in the military, thus possibly
delaying a servicemember’s or veteran’s receipt of VA benefits.

Both departments have needed to create programs and provide staff to
assist recovering servicemembers during their transition from a DOD MTF
to a VAMC. For example, VA Liaisons and DOD nurse case managers
help recovering servicemembers transition from DOD to VA by
assembling their health records and sharing them with the VAMC where
the servicemember will be receiving treatment. According to DOD and VA


39
  DOD policy requires that, upon retirement, discharge, or end of active obligated service,
records be transferred to the VA Records Management Center if the servicemember is not
applying for VA benefits or the appropriate VA Regional Office if the servicemember has
applied or plans to apply for VA benefits. Department of Defense, Service Treatment
Record (STR) and Non-Service Treatment Record (NSTR) Life Cycle Management, DOD
Instruction 6040.45, Enclosure 3, (Oct. 28, 2010). The transfer of records from DOD to a
VA medical facility is achieved under different procedures.




Page 24                                GAO-13-5 Recovering Servicemembers and Veterans
staff that assist servicemembers in their transition from one system to
another, DOD nurse case managers at installations that do not have VA
Liaisons do not always have the same knowledge of VA services and
benefits, and may not be informed of the appropriate referral methods or
contacts used by VA Liaisons to provide a servicemember with a
seamless transition to a VAMC. A DOD official told us that at locations
where the VA Liaison program is not available, the transition process for
recovering servicemembers from DOD to VA is more difficult. This official
understood how to properly transfer servicemembers’ records from the
DOD facility to the receiving VA facility only because of past VA
experience.




Page 25                         GAO-13-5 Recovering Servicemembers and Veterans
DOD and VA Have
Not Fully Resolved
Long-standing
Problems Due to
Deficiencies in
Leadership and
Oversight, Resources,
and Collaboration
Lack of Leadership and         The lack of leadership and program oversight has limited DOD’s and VA’s
Oversight Has Limited          ability to effectively manage programs created to serve recovering
DOD’s and VA’s Ability to      servicemembers and veterans. Two bodies established to oversee these
                               programs, the Senior Oversight Committee and the Office of Wounded
Effectively Manage             Warrior Care and Transition Policy (WWCTP), 40 lacked consistent
Programs for Recovering        leadership attention and oversight capabilities. In addition, DOD does not
Servicemembers and             have a central office that oversees or collects common data on the
Veterans                       military services’ wounded warrior programs.

Strength of Senior Oversight   Before the Senior Oversight Committee was consolidated into the Joint
Committee Leadership Waned     Executive Council 41 in early 2012, it had already lost many of the
                               characteristics that had made it a strong decision making and oversight
                               body for the programs and initiatives created to assist recovering
                               servicemembers and veterans. What had originally made it strong were




                               40
                                 In 2008, DOD established the Office of Transition Policy and Care Coordination which
                               was renamed the Office of Wounded Warrior Care and Transition Policy (WWCTP).
                               Reporting to the Under Secretary of Defense for Personnel and Readiness, up until June
                               2012, WWCTP served as a single, centralized office for developing policy, coordinating
                               interagency collaboration, and conducting outreach to address the broad set of issues
                               confronted by wounded, ill and injured service members and their families. WWCTP also
                               provided program oversight for the integrated disability evaluation system process and
                               care coordination.
                               41
                                 The Joint Executive Council was established by law in November 2003 to provide senior
                               leadership for collaboration and resource sharing between DOD and VA. Through a joint
                               strategic planning process, the Joint Executive Council recommends to the Secretaries
                               the strategic direction for the joint coordination and sharing efforts between the two
                               departments and oversees the implementation of those efforts.




                               Page 26                               GAO-13-5 Recovering Servicemembers and Veterans
•     high-level leadership participation without substitution of lower-ranking
      officials,

•     rapid policy development and quick decision making, and

•     rigorous monitoring to hold the military services and the two
      departments accountable for needed actions.

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

•     Starting in December 2008, the Senior Oversight Committee
      experienced leadership changes, including the departure of its
      cochairs, the Deputy Secretaries, 42 as well as turnover in some of its
      key staff. According to a former Senior Oversight Committee
      executive, the personal commitment and strong relationship between
      the Deputy Secretaries who initially cochaired the Senior Oversight
      Committee served as a unifying and confidence building force that
      was not replicated by subsequent leadership, while leadership
      turnover in the DOD offices supporting the Senior Oversight
      Committee negatively impacted its ability to function effectively.

•     As we have previously reported, the Senior Oversight Committee also
      began to encounter challenges when DOD “disrupted the unity of
      command” by changing the organizational structure of the committee
      and realigning and incorporating the committee’s staff and
      responsibilities into existing or newly created DOD and VA offices,
      such as WWCTP. 43 Officials formerly involved with the committee told
      us that the new staffing arrangement did not adequately support the
      committee’s efforts, and VA did not provide full-time staff members to
      support the committee, as it had in the past. Later in October 2008,
      VA established the Office of VA/DOD Collaboration Services, and VA
      supported Senior Oversight Committee efforts, along with broader
      collaboration efforts, through this separate office.




42
 With the change of presidential administration in January 2009, the Deputy Secretary of
Defense and Deputy Secretary of Veterans Affairs were replaced.
43
    GAO-09-728.




Page 27                               GAO-13-5 Recovering Servicemembers and Veterans
•   The committee began meeting less frequently. For example, in
    contrast to weekly meetings held during its initial year of operation, in
    fiscal year 2011, the committee met less than 11 hours in total.

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

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

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

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

Whether the Joint Executive Council can effectively address the issues
once managed by the Senior Oversight Committee has yet to be seen.
Several DOD and VA officials expressed concern to us about the ability of
the Joint Executive Council to focus on rapid, short-term policy decision



Page 28                           GAO-13-5 Recovering Servicemembers and Veterans
                            making rather than the longer-term strategic planning role that it has
                            traditionally played. For example, according to a DOD official, historically,
                            the Joint Executive Council has not been able to drive policy decision
                            making, and therefore, issues that should have been decided by the Joint
                            Executive Council were taken directly to the Secretaries for resolution,
                            raising doubts about the ability of the Joint Executive Council to function
                            effectively. A former Senior Oversight Committee executive noted that the
                            Joint Executive Council cochairs are not of equivalent rank, another
                            challenge that may serve as a barrier to the council’s ability to make
                            decisions and drive policy changes. Specifically, the VA cochair is the
                            Deputy Secretary, who has control over all relevant offices within VA,
                            while the DOD cochair is the Deputy Undersecretary of Defense for
                            Personnel and Readiness, whose responsibilities include establishing
                            health and benefit policies affecting recovering servicemembers and
                            directing the military services to comply with such policies but lacks
                            authority in enforcing the military services’ implementation of these
                            policies. The Recovering Warrior Task Force also cited concerns about
                            the rank of the DOD cochair of the Joint Executive Council, stating that a
                            higher level of leadership is needed to sustain departmental attention on
                            key initiatives such as IDES and electronic health records. 44 Furthermore,
                            as of August 2012, DOD officials told us that the Joint Executive Council
                            is operating under the original procedures that were in place prior to the
                            entities merging. As a result, it is unclear at this time how the Joint
                            Executive Council will provide oversight and accountability for issues
                            once addressed by the Senior Oversight Committee.

WWCTP Lacks Authority and   In 2008, WWCTP became responsible for overseeing the RCP among
Leadership to Provide       other programs that provide assistance to recovering servicemembers.
Oversight for Care          However, WWCTP’s ability to oversee the RCP, including its ability to
Coordination                monitor program performance and ensure compliance with DOD policy, is
                            limited by its lack of operational authority, such as budget and tasking
                            authority, over the military services that implement the program.
                            According to WWCTP officials, this lack of operational authority
                            challenges WWCTP’s ability to direct the military services on their
                            implementation of the program. For example, although WWCTP has been
                            responsible for RCP oversight since 2008, the office was not able to
                            collect basic program data, such as monthly enrollment numbers, on a


                            44
                             Department of Defense Task Force on the Care, Management, and Transition of
                            Recovering Wounded, Ill, and Injured Members of the Armed Forces, Department of
                            Defense Recovering Warrior Task Force 2011-2012 Annual Report (August 2012).




                            Page 29                             GAO-13-5 Recovering Servicemembers and Veterans
consistent basis until October 2011. According to a WWCTP official,
although WWCTP requested monthly data submissions from the military
services, the information was provided on an ad hoc basis; sometimes
the services would submit it, and other times they would not. Data-
collection efforts still remain a challenge for WWCTP. For example, the
Army’s Wounded Warrior Program, which serves as the Army’s care
coordination program, only agrees to share partial data with WWCTP,
arguing that the Army is only obligated to share data on servicemembers
served by WWCTP-contracted personnel.

Getting the military services to implement consistent care coordination
policies also poses a challenge for WWCTP. WWCTP officials said that
while WWCTP can develop policy to guide the military services, the
military services may interpret that policy and implement their programs
differently. Consequently, some DOD officials assert that the military
services have not consistently implemented the RCP in accordance with
DOD policy—an observation that is shared by the Recovering Warrior
Task Force. 45 DOD policy requires that care coordination should be
provided to those who are “seriously” and “severely” wounded, ill, and
injured, but the Army only provides care coordination to recovering
servicemembers who are “severely” wounded, ill, and injured. 46 As a
result, some servicemembers who could benefit from having someone
coordinate their care and benefits as they navigate the recovery care
continuum do not have access to those services.

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



45
  Recovering Warrior Task Force, Department of Defense Recovering Warrior Task Force
2011-2012 Annual Report.
46
  Department of Defense, Recovery Coordination Program, DOD Instruction 1300.24,
(Dec. 1, 2009).




Page 30                             GAO-13-5 Recovering Servicemembers and Veterans
process. Although these goals have not consistently been achieved, 47 the
officials told us that military service cooperation has not been an
impediment to overseeing IDES as it has been for overseeing care
coordination. Conversely, the military services have not been as inclined
to cooperate with WWCTP on its oversight of the RCP relative to these
other issues.

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

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

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

•     In June 2012, DOD changed the name of the WWCTP office to the
      Office of Warrior Care Policy and moved it under the Assistant
      Secretary of Defense for Health Affairs. According to a DOD official,
      the change was made as part of a realignment of DOD’s
      organizational structure in response to statutory requirements. 48 An


47
 See GAO, Military and Veterans Disability System: Pilot Has Achieved Some Goals, but
Further Planning and Monitoring Needed, GAO-11-69 (Washington, D.C.: Dec . 6, 2010);
Military and Veterans Disability System: Worldwide Deployment of Integrated System
Warrants Careful Monitoring, GAO-11-633T (Washington, D.C.: May 4, 2011); and
GAO-12-718T.
48
    See Pub. L. No. 111-84, § 906, 123 Stat. 2190, 2425 (2009).




Page 31                                 GAO-13-5 Recovering Servicemembers and Veterans
                               official in Health Affairs said that the move will be beneficial because it
                               will provide greater access to resources, including human resources
                               and information technology, among others. However, it is too early to
                               determine the full effect of this change.

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

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

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




                           Page 32                           GAO-13-5 Recovering Servicemembers and Veterans
Table 3: Military Services’ Wounded Warrior Program Efforts to Measure Program Performance

                                                                                       Performance metrics:
                                          Satisfaction surveys:                         Measures whether                          Outcome measures:
Military services’ wounded                 Measures customer                           program meets target                    Measures whether program
warrior program                         satisfaction with program                          output goals                         achieves desired impact
Army
    Army Warrior Care and Transition                                                                                                              
    Program
    Army Wounded Warrior Program                                                                                                                  
Navy/Coast Guard
    Navy Safe Harbor Program                                                                          
Air Force
                                                            a
    Air Force Wounded Warrior Program                     
                                                            a
    Air Force Recovery Care Program                                                                   
Marine Corps
    Marine Corps Wounded Warrior                                                                                                                  
    Regiment
United States Special
Operations Command
                                                                                                         b
    United States Special Operations                                                                 
    Command’s Care Coalition
                                        Source: GAO analysis of interviews with military services’ wounded warrior program officials and program documentation.
                                        a
                                        Although the Air Force Wounded Warrior and Recovery Care Programs’ initial satisfaction survey
                                        was completed in October 2011, the survey results have not been released as of August 9, 2012.
                                        b
                                        The United States Special Operations Command’s Care Coalition has performance metrics for its
                                        Recovery Program.


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

                                        In September 2011, citing wide disparity across the military services in
                                        their implementation of wounded warrior programs and policies, the
                                        Recovering Warrior Task Force made four recommendations for creating




                                        Page 33                                                  GAO-13-5 Recovering Servicemembers and Veterans
                            common standards to ensure parity in the programs and services
                            provided to recovering servicemembers across DOD. 49 For example, the
                            first recommendation called for a common nomenclature, or consistent
                            definitions to be used in DOD policy to identify recovering
                            servicemembers who may require and be eligible for assistance. The task
                            force concluded that common definitions are needed to promote
                            consistent levels of care among the military services and would better
                            enable DOD to compare across programs and identify best practices. In
                            its response to the task force, DOD acknowledged that some of these
                            recommendations were valid and that DOD should take actions to
                            address them. However, at the time of the Recovering Warrior Task
                            Force’s 2012 report, these recommendations had not been implemented,
                            and the task force is continuing to follow DOD’s efforts to implement
                            them. 50 Moreover, even if DOD decided to take some actions in this
                            regard, it is unclear who would have responsibility for addressing them,
                            since there is no central oversight office or authority for these programs.


Insufficient Staffing and   In addition to problems with leadership and oversight of care coordination
Budget Control Have         and case management programs, DOD and VA have a longstanding track
Contributed to DOD’s and    record of insufficient staffing to address delays in disability determinations
                            and insufficient staffing and control over the budget to oversee the
VA’s Inability to Resolve   development of systems with improved capabilities for electronically
Delays with Disability      sharing health records. 51
Determinations and
Electronically Share
Health Records




                            49
                              Recovering Warrior Task Force, Department of Defense Recovering Warrior Task Force
                            2010-2011 Annual Report.
                            50
                              Recovering Warrior Task Force, Department of Defense Recovering Warrior Task Force
                            2011-2012 Annual Report.
                            51
                              See GAO-11-69; GAO-11-633T; GAO-12-718T; Electronic Health Records: DOD and
                            VA Have Increased Their Sharing of Health Information, but More Work Remains,
                            GAO-08-954 (Washington, D.C.: July 28, 2008); Electronic Health Records: DOD’s and
                            VA’s Sharing of Information Could Benefit from Improved Management, GAO-09-268
                            (Washington, D.C.: Jan. 28, 2009); Information Technology: Challenges Remain for VA’s
                            Sharing of Electronic Health Records with DOD, GAO-09-427T (Washington, D.C.:
                            Mar. 12, 2009); GAO-09-775; and GAO-10-332.




                            Page 34                              GAO-13-5 Recovering Servicemembers and Veterans
Insufficient Staffing       Insufficient staffing across both departments has affected DOD’s and
Contributed to Delays in    VA’s ability to reduce disability determination delays and meet their IDES
Disability Determinations   timeliness goals. We raised concerns about staffing in 2010, when we
                            reported that DOD and VA did not sufficiently staff many key positions in
                            the IDES process, including DOD board liaisons, who counsel
                            servicemembers and ensure that documentation submitted for
                            consideration is complete and accurate, and medical evaluation board
                            physicians, who review medical and service records to identify conditions
                            that limit a servicemember’s ability to serve in the military. 52 In 2012, we
                            continued to report evidence of staffing shortages, including high
                            caseloads for DOD board liaisons and VA case managers as well as
                            insufficient numbers of physicians to write narrative summaries needed to
                            complete the medical evaluation board stage of the IDES process in a
                            timely manner. 53 Some recovering servicemembers told us they do not
                            receive sufficient support from their DOD board liaisons, and that there
                            are not enough liaisons to efficiently meet the needs of all the recovering
                            servicemembers going through the IDES process.

                            Delays in the disability determination process are expected to continue.
                            VA anticipates a much larger caseload of all disability and other benefit
                            claims in the near future, not just those claims associated with IDES
                            cases. Specifically, a high-level VA official told us that new laws, such as
                            the Veterans Opportunity to Work Act, 54 will encourage all transitioning
                            servicemembers—not just those going through the IDES process—to
                            claim VA benefits. This official also told us that DOD and VA have a much
                            larger problem to address as a surge of 300,000 servicemembers begin
                            to transition into the VA system as troops return home from Iraq and
                            Afghanistan. Without adequate planning and adequate resources, these
                            servicemembers may experience much longer processing times in the
                            disability benefits systems.

                            DOD and VA are working to address staffing challenges in some of the
                            IDES processes that are most delayed. We have previously reported that
                            the Army, for example, is in the midst of a major hiring initiative to
                            increase staffing dedicated to its medical evaluation boards, which will


                            52
                             GAO-11-69.
                            53
                             GAO-12-718T.
                            54
                              Veterans Opportunity to Work (VOW) to Hire Heroes Act, Pub. L. No. 112-56, tit. II, 125
                            Stat. 712 (2011).




                            Page 35                                GAO-13-5 Recovering Servicemembers and Veterans
                              include additional DOD board liaisons and medical evaluation board
                              physician positions. 55 Additionally, VA officials said that the agency has
                              added staffing to its IDES rating sites to handle the demand for
                              preliminary disability ratings, rating reconsiderations, and final benefit
                              decisions, which has increased the number of preliminary VA ratings
                              completed and slightly improved processing times. But it is too early to tell
                              the extent to which VA’s efforts will continue to improve processing times.

Lack of Staffing and Budget   The Interagency Program Office was established by law 56 to serve as a
Control Limited Progress on   single point of accountability for joint DOD and VA efforts to implement
Electronic Health Records     fully interoperable electronic health record systems or capabilities, but this
Sharing                       office was not given sufficient staffing or budget control by DOD and VA
                              to effectively facilitate the departments’ efforts. According to an
                              Interagency Program Office official, the office was never fully staffed and
                              was challenged by a high degree of turnover in staffing and leadership
                              that served in a temporary or acting capacity.

                              The Interagency Program Office’s initial charter limited its ability to
                              exercise authority over DOD and VA. Specifically, the charter stated that
                              control of the budget, contracts, and technical development remained
                              wholly within the two departments’ program offices. The charter conveyed
                              no authority in these areas to the Interagency Program Office. As a
                              former Interagency Program Office official testified in July 2011, the office
                              lacked control of budgeting and contracting necessary to achieve its
                              intended purpose, and without this, it could not sufficiently oversee the
                              departments’ efforts and compliance with the requirements in NDAA
                              2008. 57 As a result, each department continued to pursue separate
                              strategies, rather than a unified interoperable approach, according to this
                              former official.




                              55
                               GAO, Military System: Improved Monitoring Needed to Better Track and Manage
                              Performance. GAO-12-676 (Washington, D.C.: Aug. 28, 2012).
                              56
                                   See Pub. L. No. 110-181, § 1635, 122 Stat. 3, 460-63 (2008).
                              57
                                Legislative Hearing on H.R. 2383, H.R. 2388, H.R. 2243 and H.R. 2470, Before the
                              Subcommittee on Oversight and Investigations of the Committee on Veterans Affairs,
                              112th Cong. (July 20, 2011) (statement of Debra M. Filippi, former Director, U.S.
                              Department of Defense/U.S. Department of Veterans Affairs Interagency Program Office).




                              Page 36                                  GAO-13-5 Recovering Servicemembers and Veterans
                             The Interagency Program Office was rechartered in October 2011 and
                             provided an expanded staff and new authorities under the charter,
                             including control over the budget. According to Interagency Program
                             Office officials, when hiring under the new charter is completed, the office
                             will have a staff of 236 personnel, more than seven times the number of
                             staff originally allotted to the office by DOD and VA. 58 In addition, the
                             charter provides the Interagency Program Office with the authority to
                             lead, oversee, and manage budget and contracting for electronic health
                             record sharing efforts. According to Interagency Program Office officials,
                             budget control is the essential component for overseeing progress and
                             ensuring accountability for the departments’ efforts.

                             With the enhanced charter, as well as plans for an expanded staff to
                             oversee the implementation of a single joint electronic health record
                             system, the Interagency Program Office will have more resources to draw
                             upon and support department interoperability initiatives. However, it is still
                             too early to determine whether this investment of resources will be
                             sufficient to meet the office’s goals for 2017. 59 For example, despite the
                             provision of additional resources, Interagency Program Office officials told
                             us that as of July 2012, the office is staffed at approximately 48 percent
                             and that hiring additional staff in time to meet appointed implementation
                             deadlines remains one of its biggest challenges.


Despite Repeated             Since the inception of the RCP in 2008, the FRCP and RCP care
Attempts, DOD and VA         coordination programs have conflicted with one another and with other
Have Failed to Effectively   case management programs that provide services to recovering
                             servicemembers and veterans. Conflicting issues have arisen as to what
Collaborate to Align Their   populations they serve, the specific services each would provide, and
Care Coordination            when each program would get involved in the servicemembers’ recovery
Programs; New Efforts Are    process. Aligning and integrating these programs with one another—
Under Way                    especially the FRCP with the RCP—has proven to be a major challenge
                             for DOD and VA. While the departments are developing an interagency
                             strategy for minimizing duplication between DOD’s and VA’s care
                             coordination and case management programs, the success of this effort



                             58
                               As we reported in 2008, the Interagency Program Office was in the process of recruiting
                             about 30 permanent staff members (see GAO-08-954).
                             59
                               According to DOD and VA officials, the departments have identified 54 joint capabilities
                             that will be implemented by the end of fiscal year 2017.




                             Page 37                                GAO-13-5 Recovering Servicemembers and Veterans
will depend upon achieving cooperation between the departments—which
has been elusive for many years—as well as with the military services.

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

Despite DOD’s attempt to define the populations served by the FRCP and
the RCP, neither the military services’ wounded warrior programs, which
implement the RCP, nor VA, which administers the FRCP, implemented
DOD’s assignment process. Instead, these programs expanded their
enrollment to include both “seriously” and “severely” recovering
servicemembers and veterans, which resulted in both programs serving
the same populations, thereby setting up the likelihood of overlap and
duplication of services. As we have previously reported, this duplication
issue is compounded by the numerous other programs that also provide
services to recovering servicemembers and veterans and have
overlapping roles as well. It is not uncommon for recovering
servicemembers to be enrolled in more than one case management or
care coordination program and end up with multiple care coordinators and
case managers—each of whom develop different care plans for the same
servicemember. The care plans may even conflict with one another,
which could conceivably adversely affect the servicemember’s recovery
process. In fact, in the course of previous work, we found instances
where inadequate information exchange and poor coordination between




Page 38                          GAO-13-5 Recovering Servicemembers and Veterans
these programs resulted not only in duplication of effort and overlap of
services, but also confusion and frustration for servicemembers and their
families. 60 In addition, DOD and VA officials acknowledge that the
multiplicity of care coordination and case management programs causes
confusion even among members of care coordination teams. In October
2011, we recommended that the Secretaries of Defense and Veterans
Affairs direct the Senior Oversight Committee to expeditiously develop
and implement a plan to strengthen functional integration across all DOD
and VA care coordination and case management programs to reduce
redundancy and overlap.

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

Another critical issue on which DOD and VA have disagreed pertains to
the stage in a servicemember’s recovery when the FRCP should get
involved in the coordination of services. Because the FRCP depends on
referrals from other programs as a basis for becoming involved with
recovering servicemembers, this can be a significant issue. Currently,
neither DOD nor VA policy clearly defines when referrals are to be made;
consequently, most wounded warrior programs delay referrals to the
FRCP until it becomes clear that the servicemember will be separated
from the military. Senior DOD officials stated that wounded warrior
program officials justify this practice on the basis that referring a recently
wounded servicemember to the FRCP—a VA-operated program—sends
a negative message to a recovering servicemember that his or her
military career has ended, even though the FRCP was designed as a joint



60
 GAO-12-129T.




Page 39                          GAO-13-5 Recovering Servicemembers and Veterans
program. Additionally, the belief among the military that they should “take
care of their own,” contributes to the reluctance to involve the FRCP. On
their part, VA maintains that its point of engagement should be in the
early stage of medical treatment to build rapport and trust and to begin
coordinating the services needed by severely wounded servicemembers.

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

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

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

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


Page 40                          GAO-13-5 Recovering Servicemembers and Veterans
•    September 2011. The Recovering Warrior Task Force issued the first
     of four annual reports that included 21 recommendations, including a
     recommendation that the roles of care coordinators be clarified. In
     DOD’s official response to congressional committees, the Under
     Secretary of Defense stated that the department would implement the
     Recovering Warrior Task Force’s recommendations. However, a
     Recovering Warrior Task Force member stated that the Recovering
     Warrior Task Force concluded that in most cases DOD has not made
     significant changes to its programs to achieve the outcomes intended
     by the recommendations. In August 2012, the Recovering Warrior
     Task Force reported that DOD has fully implemented only 2 of the 21
     recommendations. 61 However, a DOD official whose office is
     responsible for coordinating DOD’s responses to the Recovering
     Warrior Task Force’s recommendations stated that DOD is in the
     process of addressing several more of the 2011 Recovering Warrior
     Task Force recommendations.

•    October 2011–April 2012. VA declined DOD’s requests to discuss
     care coordination and case management policy issues during this
     period, according to DOD and VA senior officials, because VA had
     established its own task force to conduct an internal review of its care
     coordination and case management activities, including the FRCP. 62
     After completing its initial assessment, VA briefed WWCTP officials on
     the process it was using to review its care coordination and case
     management activities, but chose not to discuss realignment of the
     FRCP and RCP at that time, according to DOD officials who attended
     this briefing. Instead, the VA Chief of Staff said that he approached
     the Army’s Warrior Transition Command—which has the largest
     number of recovering servicemembers—to propose developing
     guidelines for better integrating Army’s wounded warrior program with
     the FRCP, including identifying when the Army’s wounded warrior
     programs should refer a recovering servicemember to the FRCP, and
     replacing multiple care coordination plans with a single,
     comprehensive planning document. However, a high-level DOD
     official criticized this initiative as a tactic to minimize central input from


61
  The Recovery Warrior Task Force also reported that DOD has partially addressed an
additional 6 recommendations and noted that 13 recommendations remain open.
62
  Responding to a recommendation of a consulting firm that advised VA on its care
coordination and case management policy, the VA Chief of Staff directed that VA conduct
a department-wide inventory and review of its existing care coordination and case
management programs and personnel.




Page 41                               GAO-13-5 Recovering Servicemembers and Veterans
     the Office of the Secretary of Defense and pointed out that this effort
     would result in an agreement with only a single military branch. In
     contrast, VA’s Chief of Staff told us that VA took this approach in the
     hope that if an agreement could be reached with Army, the other
     military branches would follow suit.

More recently, in May 2012, VA and DOD developed a new task force,
the VA/DOD Warrior Care and Coordination Task Force, which
represents an effort to comprehensively address problems caused by the
lack of integration between DOD’s and VA’s care coordination and case
management programs. The task force has developed recommendations
that are intended to achieve a coordinated, interdepartmental approach to
care coordination and case management programs, according to a task
force official. On August 10, 2012, the task force presented the following
recommendations to the Joint Executive Council for its consideration:

•    establish and charter an interagency governance structure
     responsible for coordinating VA and DOD policy,

•    establish and charter an interagency care coordination community of
     practice, 63

•    align the FRCP to function in a consultant and resource-facilitator role,

•    clarify the lead coordinator role and responsibilities for executing a
     recovering servicemember’s comprehensive plan,

•    identify the business requirements for technical tools to support the
     interagency comprehensive plan, and

•    accelerate existing information-sharing efforts for care coordination.

The Joint Executive Council provisionally approved the six
recommendations, but withheld final approval pending receipt of
additional information from the task force, such as an estimate of
resources required to implement the recommendations, as well as
details of the proposed interagency governance structure. The Joint



63
  Communities of practice are groups of people who engage, through regular interaction
with one another, in a process of collective learning in a shared domain of human
endeavor.




Page 42                               GAO-13-5 Recovering Servicemembers and Veterans
Executive Council instructed the task force to present the additional
information to them in another decision briefing, which was scheduled for
September 20, 2012. Absent final approval from the Joint Executive
Council, the task force’s next step was to hold a status briefing for the
DOD and VA Secretaries on September 10, 2012, to discuss the task
force’s recommended course of action for care coordination.

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

•     There is concern as to whether the Joint Executive Council can
      effectively lead the effort to realign VA’s and DOD’s care coordination
      policy. Some high-ranking and cognizant DOD officials we talked with
      expressed concerns that the recently merged Joint Executive Council
      may not have the capability to effectively monitor the actions taken by
      DOD and VA to implement the task force’s recommendations. Some
      officials we talked with viewed the council as taking too long to resolve
      issues due to both the infrequency of its meetings 64 and the difficulties
      DOD and VA members have in agreeing with one another.

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

•     One of the most fundamental challenges to resolving care
      coordination problems is the issue of obtaining the cooperation of the
      military services to implement a new approach to care coordination
      and case management, especially in light of past difficulties of working
      in concert with DOD and VA programs and policies. DOD and VA


64
    The Joint Executive Council meets on a bimonthly basis.




Page 43                                 GAO-13-5 Recovering Servicemembers and Veterans
                  leadership officials stated that even if new solutions and policies were
                  to be approved by the departments, changes would be made only if
                  the individual military services implement the new policies as directed
                  by the Secretary of Defense. Several DOD and VA officials identified
                  concurrence and support of the military services as the most difficult
                  element to achieve. Ultimately, the military services’ compliance with
                  the departments’ agreed-upon strategy for care coordination and case
                  management programs will determine how seamlessly recovering
                  servicemembers and veterans will be able to navigate the recovery
                  care continuum.

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

              Initially, departmental leadership exhibited focus and commitment—
              through the Senior Oversight Committee—to addressing problems related
              to case management and care coordination, disability evaluation systems,
              and data sharing between DOD and VA. However, over time, waning
              leadership attention, a failure to oversee critical wounded warrior
              functions and programs, limited resources, and the inability to achieve a
              collaborative environment— particularly with care coordination—have
              impeded the departments’ ability to fully resolve these problems. A key
              element in resolving current care coordination issues in particular is



              Page 44                           GAO-13-5 Recovering Servicemembers and Veterans
                      eliciting the cooperation of the military services, which are responsible for
                      implementing various wounded warrior programs and ensuring that these
                      programs operate as intended—which has sometimes not been the case,
                      as with the RCP. Also, absent clear direction and central oversight and
                      accountability among the military services’ wounded warrior programs,
                      true cooperation and program effectiveness may be in jeopardy.

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


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




                      Page 45                          GAO-13-5 Recovering Servicemembers and Veterans
                     •   Develop consistent eligibility criteria to ensure that similarly situated
                         recovering servicemembers from different military services have
                         uniform access to these programs.

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

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

                     To ensure that persistent challenges with care coordination, disability
                     evaluation, and the electronic sharing of health records are fully resolved,
                     we recommend that the Secretaries of Defense and Veterans Affairs
                     ensure that these issues receive sustained leadership attention and
                     collaboration at the highest levels with a singular focus on what is best for
                     the individual servicemember or veteran to ensure continuity of care and
                     a seamless transition from DOD to VA. This should include holding the
                     Joint Executive Council accountable for

                     •   ensuring that key issues affecting recovering servicemembers and
                         veterans get sufficient consideration, including recommendations
                         made by the Warrior Care and Coordination Task Force and the
                         Recovering Warrior Task Force;

                     •   developing mechanisms for making joint policy decisions;

                     •   involving the appropriate decision-makers for timely implementation of
                         policy; and

                     •   establishing mechanisms to systematically oversee joint initiatives and
                         ensure that outcomes and goals are identified and achieved.


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




                     Page 46                           GAO-13-5 Recovering Servicemembers and Veterans
DOD concurred with specific components of our first recommendation
regarding the establishment of central accountability for the military
services’ wounded warrior programs. In particular, DOD agreed that a
single office should have oversight responsibility for the military services’
wounded warrior programs and that these programs should fully comply
with the policies governing care coordination and case management
programs and any future changes to these policies.

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

With respect to developing a common mechanism to systematically
monitor the performance of the wounded warrior programs, DOD
responded that the Interagency Care and Coordination Committee will
conduct an inventory of all wounded warrior programs to identify
duplication and areas for gaining efficiencies. In commenting on our
recommendation to also report its performance information on the
wounded warrior programs to the Armed Services Committees on a
biannual basis, DOD stated that the department reports progress through
the Joint Executive Council’s annual strategic planning report and any
additional reporting would be redundant and of limited value. We
disagree. The Joint Executive Council’s strategic planning and annual
reports focus on joint efforts between the departments and do not report
on the performance of the military services’ wounded warrior programs.
Therefore, we do not believe that the performance information on the


Page 47                           GAO-13-5 Recovering Servicemembers and Veterans
wounded warrior programs would be redundant or of limited value given
that the department itself is currently unable to systematically determine
how well these programs are functioning. As we reported, one of the key
problems hindering a department-wide assessment of these programs is
the lack of common terms and definitions used by the military services.
Although DOD acknowledges that this is an issue, it asserts that it has
instituted some common definitions through the Senior Oversight
Committee and through its instruction for the RCP and that it will work
towards a common understanding and use of these approved definitions.
Although we are aware of efforts to define some terms, on the basis of
our work, it does not appear that the military services are using them
consistently. Therefore, substantial progress towards a common
understanding and use will be critical to the department’s ability to
oversee these programs.

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

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




Page 48                          GAO-13-5 Recovering Servicemembers and Veterans
In addition to its comments on our recommendation, VA asserted that the
care coordination challenges facing both departments are broader and
more complex than issues concerning just the FRCP and RCP and that
our overall analysis and conclusions are over simplified. VA stated that
through its recently formed task force, both departments identified over
40 programs that provide some level of coordination or management of
care and services across the continuum of care and acknowledged that
there is no common operational picture that facilitates collaborative
planning or situational awareness. We agree that the care coordination
challenges are broader and more complex than the FRCP and RCP.
Specifically, in October 2011, we recommended that the departments
strengthen functional integration across all care coordination and case
management programs to reduce redundancy and overlap. 65 Similarly,
our current recommendation is broad and does not focus exclusively on
these two programs as our review also included other programs, such as
the military services’ wounded warrior programs, VA’s Liaison for
Healthcare Program, and VA’s OEF/OIF/OND Care Management
Program. The scope of our review was directed by Congress, who
required us to report on the progress DOD and VA in implementing the
programs involved with the care, management, and transition of
wounded, ill, and injured servicemembers that they established. Our
specific discussion of the FRCP and RCP served to illustrate, until
recently, a continued lack of collaboration between the departments to
better align these programs and better serve recovering servicemembers
and veterans. Furthermore, during detailed discussions with top-level VA
and DOD officials, they focused on the FRCP and RCP issue as the main
sticking point in achieving coordination and cooperation among the two
departments with respect to care coordination and case management.
We are encouraged that the departments are now taking steps to identify
all programs that need better alignment and integration. However, as we
have stated, the key to resolving this and other problems is the need for
strong and unwavering leadership that is united across both departments
and focused on the individual servicemember’s or veteran’s recovery.




65
 GAO-12-129T.




Page 49                        GAO-13-5 Recovering Servicemembers and Veterans
VA also suggested further clarifications to our report.

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

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

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

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




Page 50                          GAO-13-5 Recovering Servicemembers and Veterans
•   In our report, we explain that VA declined DOD’s requests to discuss
    care coordination and case management policy issues—for the better
    part of 1 year—on the basis that VA was conducting an internal
    review of its care coordination and case management activities. In its
    comments, VA stated that the use of the word “decline” is misleading,
    and suggested that we change our text to state that VA asked DOD to
    defer collaboration until the internal review was conducted. Despite
    VA’s characterization that our statement is misleading, we maintain
    that this finding was based on remarks made by high-level DOD
    officials that were subsequently corroborated by senior VA officials.


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

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




Randall B. Williamson
Director, Health Care




Page 51                           GAO-13-5 Recovering Servicemembers and Veterans
List of Committees

The Honorable Carl Levin
Chairman
The Honorable John McCain
Ranking Member
Committee on Armed Services
United States Senate

The Honorable Patty Murray
Chairman
The Honorable Richard Burr
Ranking Member
Committee on Veterans’ Affairs
United States Senate

The Honorable Daniel Inouye
Chairman
The Honorable Thad Cochran
Ranking Member
Subcommittee on Defense
Committee on Appropriations
United States Senate

The Honorable Tim Johnson
Chairman
The Honorable Mark Kirk
Ranking Member
Subcommittee on Military Construction, Veterans Affairs,
 and Related Agencies
Committee on Appropriations
United States Senate

The Honorable Howard McKeon
Chairman
The Honorable Adam Smith
Ranking Member
Committee on Armed Services
House of Representatives




Page 52                          GAO-13-5 Recovering Servicemembers and Veterans
The Honorable Jeff Miller
Chairman
The Honorable Bob Filner
Ranking Member
Committee on Veterans’ Affairs
House of Representatives

The Honorable C.W. Bill Young
Chairman
The Honorable Norman Dicks
Ranking Member
Subcommittee on Defense
Committee on Appropriations
House of Representatives

The Honorable John Culberson
Chairman
The Honorable Sanford Bishop
Ranking Member
Subcommittee on Military Construction, Veterans Affairs,
 and Related Agencies
Committee on Appropriations
House of Representatives




Page 53                          GAO-13-5 Recovering Servicemembers and Veterans
Appendix I: Enrollment and Populations for
                   Appendix I: Enrollment and Populations for
                   Select Department of Defense and Department
                   of Veterans Affairs Programs


Select Department of Defense and
Department of Veterans Affairs Programs
                   Both the Department of Defense (DOD) and the Department of Veterans
                   Affairs (VA) operate care coordination 1 and case management 2 programs
                   designed to assist servicemembers and veterans as they navigate the
                   recovery care continuum, from acute medical treatment and stabilization,
                   through rehabilitation, to reintegration—either back to active duty or to the
                   civilian community as a veteran. This appendix describes selected DOD
                   and VA programs and includes data on enrollment and population
                   characteristics as well as the type of information each program tracks on
                   referrals.


                   Within DOD, each military service has established its own wounded
DOD Wounded        warrior program or a complement of programs 3 to assist wounded, ill, and
Warrior Programs   injured servicemembers during their recovery and rehabilitation, and to
                   help with the transition back to active duty or to civilian life. 4 Wounded
                   warrior programs range in size from the largest, the Army’s Warrior
                   Transition Units and Community-Based Warrior Transition Units, with
                   18,762 enrollees served in fiscal year 2011, to the smallest, the Navy
                   Safe Harbor Program, with 784 enrollees served in fiscal year 2011. (See
                   table 4 for a list of the DOD wounded warrior programs and enrollment for
                   fiscal year 2011.)


                   1
                    According to the National Coalition on Care Coordination, care coordination is a client-
                   centered, assessment-based interdisciplinary approach to integrating health care and
                   social support services in which an individual’s needs and preferences are assessed, a
                   comprehensive care plan is developed, and services are managed and monitored by an
                   identified care coordinator.
                   2
                    According to the Case Management Society of America, case management is defined as
                   a collaborative process of assessment, planning, facilitation, and advocacy for options and
                   services to meet an individual’s health needs through communication and available
                   resources to promote high quality, cost-effective outcomes.
                   3
                    Military services operate multiple programs that are specialized to serve different
                   populations, such as the severely wounded or surviving family members. For example,
                   within the Air Force’s Warrior and Survivor Care Program, the Air Force operates three
                   distinct programs: (1) the Air Force Wounded Warrior Program to serve those who were
                   injured in combat; (2) the Air Force Recovery Care Program to serve other seriously and
                   severely wounded, ill, and injured; and (3) the Air Force Survivor Assistance Program, to
                   serve surviving family members or caregivers of wounded, ill, and injured
                   servicemembers.
                   4
                    For the purpose of this appendix we will be discussing seven of the case management
                   and care coordination programs established by the military services to assist recovering
                   servicemembers and veterans with recovery, rehabilitation, and transition either back to
                   military service or to civilian life.




                   Page 54                                GAO-13-5 Recovering Servicemembers and Veterans
                                           Appendix I: Enrollment and Populations for
                                           Select Department of Defense and Department
                                           of Veterans Affairs Programs




Table 4: Military Services’ Wounded Warrior Programs: Enrollment for Fiscal Year 2011

Military services’ wounded warrior program                                                                      Number enrolled, as of fiscal year 2011
Army
    Army Warrior Care and Transition Program: Warrior Transition Units and
                                            a,b
    Community-Based Warrior Transition Units                                                                                                    18,762
                                                                                                 b
    Army Warrior Care and Transition Program: Army Wounded Warrior Program                                                                       9,738
Navy/Coast Guard
                               c
    Navy Safe Harbor Program                                                                                                                       784
Air Force
                                       d
    Air Force Wounded Warrior Program                                                                                                            1,386
    Air Force Recovery Care Program                                                                                                              1,804
Marine Corps
                                               e,f
    Marine Corps Wounded Warrior Regiment                                                                                                        2,155
                                               g
United States Special Operations Command
    United States Special Operations Command’s Care Coalition                                                                                    4,570
                                           Source: GAO analysis of military services’ wounded warrior program information.
                                           a
                                            Enrollment data include servicemembers who were in the Army Warrior Care and Transition
                                           Program at any point during the fiscal year, not the population on a specific date.
                                           b
                                            Enrollees may include servicemembers who are dually enrolled in the Army Warrior Care and
                                           Transition Program and Army Wounded Warrior Program.
                                           c
                                            Enrollment numbers represent all enrollees being served by the program as of December 31, rather
                                           than as of the end of each fiscal year.
                                           d
                                            Servicemembers may be dually enrolled in the Air Force Wounded Warrior Program and the Air
                                           Force Recovery Care Program. The enrollment data presented here only reflect servicemembers who
                                           are enrolled in the Air Force Wounded Warrior Program.
                                           e
                                            According to a Wounded Warrior Regiment official, the Wounded Warrior Regiment does not have
                                           “enrollees,” rather the program assigns and attaches Marines to the program.
                                           f
                                           Total enrollment does not include Wounded Warrior Regiment enrollees who are not assigned or
                                           attached to a Wounded Warrior Regiment site. Many wounded, ill, and injured Marines are supported
                                           by the Wounded Warrior Regiment while remaining with their parent unit.
                                           g
                                             Enrollees of the United States Special Operations Command’s Care Coalition Recovery Program
                                           may also be enrolled in a military service’s wounded warrior program on the basis of their branch of
                                           service, but the United States Special Operations Command’s Care Coalition Recovery Program
                                           takes the lead for providing nonclinical case management.


                                           Programs differ in their organization and function. For example, two of the
                                           wounded warrior programs—the Army’s Warrior Transition Units and the
                                           Marine Corps Wounded Warrior Regiment—are organized under
                                           separate military commands, which means that wounded, ill, and injured
                                           servicemembers enrolled in these programs may be removed from their
                                           parent units or commands and assigned or attached to a separate unit or




                                           Page 55                                                   GAO-13-5 Recovering Servicemembers and Veterans
                        Appendix I: Enrollment and Populations for
                        Select Department of Defense and Department
                        of Veterans Affairs Programs




                        regiment that provides command and control 5 over the recovering
                        servicemember as well as administrative support. These servicemembers
                        may be housed in separate barracks while receiving medical care and
                        waiting to transition back to active duty or civilian life. The other wounded
                        warrior programs do not assign or attach servicemembers to a separate
                        command structure, but provide services while recovering
                        servicemembers remain with their parent units. The services provided by
                        the wounded warrior programs also vary. A servicemember may receive
                        either case management or care coordination services or both, depending
                        on how the military service’s wounded warrior program is structured. For
                        example, the Navy Safe Harbor Program only provides care coordination
                        services and does not have a case management component, whereas
                        the Marine Corps Wounded Warrior Regiment provides all
                        servicemembers with both case management and care coordination
                        services. A further distinction is whether or not a program serves veterans
                        as well as servicemembers. For example, the Army Warrior Transition
                        Units do not serve veterans, but eligible veterans are served through the
                        Army Wounded Warrior Program. The remainder of the wounded warrior
                        programs continue to provide support to any enrollee who needs services
                        even after the enrollee has transitioned to veteran status.


Army Warrior Care and   The Army’s Warrior Care and Transition Program, which was established
Transition Program      in May 2007, 6 consists of two components that support the recovery
                        process for wounded, ill, and injured servicemembers—the Warrior
                        Transition Units 7 and the Army Wounded Warrior Program. The Army
                        operates a number of warrior transition units located at Army installations
                        across the country. Recovering servicemembers who are attached or
                        assigned to a warrior transition unit generally are housed in barracks and
                        receive medical care, rehabilitative services, professional development
                        and clinical and nonclinical case management services in order to help


                        5
                         DOD defines command and control as the exercise of authority and direction by a
                        properly designated commander over assigned and attached forces in the
                        accomplishment of the mission.
                        6
                         The program was originally named the Army Medical Action Plan.
                        7
                         Warrior Transition Units are technically an Army brigade, battalion, or company that
                        provides command and control, administrative support, primary care and case
                        management and other services to promote readiness of soldiers and family to transition
                        back to active duty or to civilian life. For the purposes of this report, we are categorizing it
                        as a wounded warrior program.




                        Page 56                                   GAO-13-5 Recovering Servicemembers and Veterans
Appendix I: Enrollment and Populations for
Select Department of Defense and Department
of Veterans Affairs Programs




them in their transition back to active duty or to the civilian community.
Army Warrior Transition Units vary in size and functionality, including
community-based warrior transition units, 8 which primarily serve Reserve
Component servicemembers. 9 In fiscal year 2011, there were a total of
14,906 recovering servicemembers assigned or attached to 29 warrior
transition units and 3,856 recovering servicemembers assigned or
attached to 10 community-based warrior transition units. (See table 5.)
According to Army policy, recovering servicemembers assigned or
attached to the units are expected to require 6 months or more of
rehabilitative care or require complex medical management.

The Army Wounded Warrior Program 10 was established in April 2004 to
assist severely wounded, ill, and injured servicemembers, their families,
and caregivers. Army Wounded Warrior Program enrollees are assigned
an Advocate who provides nonclinical care coordination services, which
include assisting enrollees with benefit information, career guidance,
finances, and the integrated disability evaluation system (IDES) process.
Recovering servicemembers are eligible for Army Wounded Warrior
Program services if they have, or are expected to receive, an Army
disability rating of 30 percent or greater in one or more specific categories
or a combined rating of 50 percent or greater for conditions that are the
result of combat or are combat-related. The most severely wounded, ill, or
injured servicemembers who are assigned to warrior transition units are
also enrolled in the Army Wounded Warrior Program. The Army Wounded
Warrior Program also provides services to veterans. In fiscal year 2011,
nearly three-fourths of the population (6,953) were veterans. (See
table 6.)




8
 The Community-based Warrior Transition Unit Program allows servicemembers to live at
home and perform duty at a location near home while receiving medical care.
9
 Warrior transition units and community-based warrior transition units serve Active
Component servicemembers as well as servicemembers in National Guard and Reserve
Components, but do not serve veterans.
10
 The Army Wounded Warrior Program was originally named the Disabled Soldier
Support System.




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




Table 5: Army Warrior Care and Transition Program Enrollment Populations and Characteristics, Fiscal Years 2008 through
2011

                                                                                               Fiscal year
                                                                                  2008         2009           2010        2011
Program enrollment for Warrior Transition Units and
Community-Based Warrior Transition Units
                     a,b
Total enrollment                                                                20,878       19,238          18,647     18,762
    Active Duty                                                                 13,558       11,771           9,560       9,160
                           c
    National Guard                                                               4,761         4,839          5,860       5,857
                 c
    Reservists                                                                   2,559         2,628          3,227       3,745
Population characteristics
                                               d
    Enrollees with combat-related conditions                                     2,523         2,033          1,788       1,984
                                                         e
    Enrollees with non-combat-related conditions                                18,355       17,205          16,859     16,778
Enrollees who left the program
                                   f
    Returned to active duty                                                      4,366         4,279          4,664       5,349
                                       g
    Transitioned to veteran status                                               5,125         5,938          4,027       3,448
                               h
    Left for other reasons                                                         146          200            159         148
Referrals
                                                             i
Total number of servicemembers referred to the program                          20,878       19,238          18,647     18,762
Warrior Transition Unit enrollment
                                                   a,b
Total enrollment in Warrior Transition Units                                    18,038       16,203          14,921     14,906
    Active Duty                                                                 13,511       11,686           9,456       9,058
                           c
    National Guard                                                               2,864         2,807          3,336       3,354
                 c
    Reservists                                                                   1,663         1,710          2,129       2,494
Population characteristics
                                               d
    Enrollees with combat-related conditions                                     2,231         1,798          1,569       1,760
                                                         e
    Enrollees with non-combat-related conditions                                15,807       14,405          13,352     13,146
Enrollees who left the program
                                   f
    Returned to active duty                                                      3,613         3,653          3,803       4,259
                                       g
    Transitioned to veteran status                                               4,706         5,445          3,700       3,167
                               h
    Left for other reasons                                                         139          184            146         135
Community-Based Warrior Transition Unit enrollment
                                                                 a,b,j
Total enrollment in Community-Based Warrior Transition Units                     2,840         3,035          3,726       3,856
    Active Duty                                                                     47            85           104         102
                           c
    National Guard                                                               1,897         2,032          2,524       2,503
                 c
    Reservists                                                                     896          918           1,098       1,251




                                           Page 58                               GAO-13-5 Recovering Servicemembers and Veterans
                                           Appendix I: Enrollment and Populations for
                                           Select Department of Defense and Department
                                           of Veterans Affairs Programs




                                                                                                                    Fiscal year
                                                                                                    2008            2009          2010         2011
Population characteristics
                                               d
    Enrollees with combat-related conditions                                                          292            235           219          224
                                                   e
    Enrollees with non-combat-related conditions                                                   2,548            2,800         3,507       3,632
Enrollees who left the program
                                 f
    Returned to active duty                                                                           753            626           861        1,090
                                     g
    Transitioned to veteran status                                                                    419            493           327          281
                             h
    Left for other reasons                                                                               7            16            13            13
                                           Source: GAO analysis of Army Warrior Care and Transition Program data.

                                           Notes: The Army Warrior Care and Transition Program’s Warrior Transition Units and Community-
                                           Based Warrior Transition Units serve Active, Guard, and Reserve Component servicemembers. The
                                           program does not serve veterans.
                                           a
                                            Enrollment data include servicemembers who were in the Army Warrior Care and Transition
                                           Program at any point during the fiscal year, not the population on a specific date.
                                           b
                                            Enrollees may include servicemembers who are dually enrolled in the Army Warrior Care and
                                           Transition Program and the Army Wounded Warrior Program.
                                           c
                                            National Guard and Reservists enrolled in the Army Warrior Care and Transition Program must be
                                           on active-duty orders in order to participate in the program.
                                           d
                                            Enrollees with combat-related conditions only include those enrollees medically evacuated from a
                                           combat zone with identified battle injuries. Other combat-related conditions, such as posttraumatic
                                           stress disorder, may not have required medical evacuation from a combat zone and therefore would
                                           not be captured in the data provided. In addition, prior battle injuries not related to the
                                           servicemember’s current medical diagnosis would also be excluded from the data. Battle injury is
                                           defined as damage or harm sustained by personnel during or as a result of battle conditions.
                                           e
                                            Enrollees with non-combat-related conditions include all enrollees who were not medically evacuated
                                           from a combat zone and those who are identified as having nonbattle injuries.
                                           f
                                           Enrollees who exit the program by returning to duty also include Guard or Reserve Components who
                                           are released from active duty, but not medically separated from military service.
                                           g
                                           Enrollees who transition to veteran status include only enrollees who are medically separated from
                                           military service.
                                           h
                                            Enrollees are considered to have left the Army Warrior Care and Transition Program’s Warrior
                                           Transition Units for “other” reasons, including death or as a result of military legal actions. This
                                           category also includes those enrollees with incomplete information about why they left the program.
                                           i
                                            According to Army Warrior Care and Transition Program officials, the program only tracks referral
                                           information for program enrollees. Therefore, the program does not have data on servicemembers
                                           who were referred, but never enrolled into the program.
                                           j
                                             The Army’s Community-Based Warrior Transition Units are populated only by servicemembers who
                                           transfer to the Community-Based Units from their original assignment to a Warrior Transition Unit.
                                           According to Army Warrior Care and Transition Program officials, the first 60 days of recovery are
                                           typically spent in a Warrior Transition Unit. After the initial recovery period, a decision is made about
                                           whether the servicemember should be transferred to a community-based unit. Data provided in the
                                           table reflect the most recent location recorded for each enrollee.




                                           Page 59                                                GAO-13-5 Recovering Servicemembers and Veterans
                                            Appendix I: Enrollment and Populations for
                                            Select Department of Defense and Department
                                            of Veterans Affairs Programs




Table 6: Army Wounded Warrior Program Enrollment Populations and Characteristics, Fiscal Years 2008 through 2011

                                                                                                                     Fiscal year
                                                                                                          2008       2009       2010       2011
Program enrollment for Army Wounded Warrior Program
                   a,b
Total enrollment                                                                                          3,813     6,473      8,454      9,738
    Servicemembers                                                                                        2,037     3,377      3,354      2,785
        Active Duty                                                                                       1,249     2,252      1,954      1,210
                         c
        National Guard                                                                                     562        794          985    1,091
                     c
        Reservists                                                                                         226        331          415       484
    Veterans                                                                                              1,776     3,096      5,100      6,953
Population characteristics
    Enrollees with combat-related conditions                                                              3,233     5,503      7,082      8,001
    Enrollees with non-combat-related conditions                                                           544        875      1,104      1,184
                                                                                                 d
    Enrollees with conditions not classified as either combat- or non-combat-related                         36        95          268       553
Enrollees who changed duty status or left the program
                                 e
    Returned to active duty                                                                                117         80           59        47
                                     f
    Transitioned to veteran status                                                                         958      1,574      1,539      1,100
                             g
    Left for other reasons                                                                                   10        24           21            3
Referrals and assists
Total number of servicemembers referred to the program                                                    3,106     4,199      3,993      3,364
    Servicemembers referred and enrolled in the program                                                   2,037     3,377      3,354      2,785
                                                                                      h
    Servicemembers referred and assisted, but not enrolled in the program                                  969        822          639       579
Total number of veterans referred to the program                                                          2,568     3,617      5,554      7,291
    Veterans referred and enrolled in the program                                                         1,776     3,096      5,100      6,953
    Veterans referred and assisted, but not enrolled in the program                                        792        521          454       338
                                            Source: GAO analysis of Army Wounded Warrior Program data.
                                            a
                                             Enrollment data include servicemembers and veterans who were served by the program at any point
                                            during the fiscal year, not the population being served on a specific date.
                                            b
                                             Enrollees also may be enrolled in the Army’s Warrior Transition Units or Community-Based Warrior
                                            Transition Units.
                                            c
                                             Enrollment is counted in this category only for National Guard and Reservists who were on active
                                            duty orders during the designated fiscal year. According to Army Wounded Warrior Program officials,
                                            National Guard and Reservists who were demobilized previous to the designated fiscal year are
                                            considered veterans.
                                            d
                                             Enrollees considered to have “conditions not classified as either combat- or non-combat-related”
                                            include enrollees who have yet to complete the physical disability evaluation process and therefore
                                            do not have verification of whether or not their conditions are combat-related.
                                            e
                                             Army Wounded Warrior Program officials said that the program does not specifically track whether or
                                            when an enrollee returns to active duty. However, data on duty status are available for those
                                            enrollees who are also enrolled in the Army’s Warrior Transition Units or Community-Based Warrior
                                            Transition Unit, as provided in the table.




                                            Page 60                                              GAO-13-5 Recovering Servicemembers and Veterans
                           Appendix I: Enrollment and Populations for
                           Select Department of Defense and Department
                           of Veterans Affairs Programs




                           f
                           Army Wounded Warrior Program officials said that the program does not specifically track whether or
                           when an enrollee transitions to veteran status because it has no impact on enrollees’ eligibility for the
                           program and whether they leave the program. Rather, these data have been derived by the program
                           by counting the number of enrolled servicemembers who received a certificate of release or
                           discharge from active duty within each fiscal year.
                           g
                            Enrollees considered to have “left for other reasons” include those who died while enrolled in the
                           Army Wounded Warrior Program.
                           h
                            The data include those enrollees who were later found ineligible for the program and were
                           disenrolled, but assisted during their initial period of enrollment. These ineligible enrollees were not
                           included in the program’s count of total enrollees. Additionally, some servicemembers who were
                           referred to the Wounded Warrior Program and provided short-term, informal assistance are not
                           included in the data because they are not tracked by the program.




Navy Safe Harbor Program   The Navy Safe Harbor Program office was established in 2005. Over
                           time, this office expanded its reach and mission, and in 2008 the program
                           became responsible for nonclinical care coordination and oversight of all
                           severely (and high-risk nonseverely) wounded, ill, and injured Sailors and
                           Coast Guardsmen. 11 Recovering servicemembers enrolled in the program
                           are assigned to nonmedical care managers who are geographically
                           dispersed at major military treatment facilities and Veterans Affairs
                           polytrauma medical centers. The program’s nonmedical care managers
                           assist enrollees with services such as pay and personnel, legal, housing,
                           as well as education and training benefits. In addition, enrollees obtain
                           support from centrally located experts in transition and benefits
                           assistance, such as a liaison to the Department of Labor and a Navy Staff
                           Judge Advocate. Recovering servicemembers enrolled in the program are
                           enrolled for life and, if desired, receive support from Navy Safe Harbor
                           personnel after they transition to veteran status. (See table 7.)




                           11
                             According to Navy Safe Harbor Program officials, the program evolved from the Navy’s
                           preexisting Military Severely Injured Center & Casualty Office.




                           Page 61                                       GAO-13-5 Recovering Servicemembers and Veterans
                                           Appendix I: Enrollment and Populations for
                                           Select Department of Defense and Department
                                           of Veterans Affairs Programs




Table 7: Navy Safe Harbor Program Enrollment Populations and Characteristics, Fiscal Years 2008 through 2011

                                                                                                                          Fiscal year
                                                                                                                2008      2009       2010      2011
Program enrollment for Navy Safe Harbor Program
                   a
Total enrollment                                                                                                  255      434          576     784
    Servicemembers                                                                                                144      236          271     391
        Active Duty                                                                                                77      129          152     254
        Reservists                                                                                                 67      107          119     137
    Veterans                                                                                                      111      198          305     393
Population characteristics
    Enrollees with combat-related conditions                                                                      130      166          193     239
    Enrollees with non-combat-related conditions                                                                  125      268          383     545
Enrollees who changed duty status or left the program
    Returned to active duty                                                                                       ND        ND          ND     113
                                                                                                                                 b         b
    Transitioned to veteran status                                                                                ND        91       338        142
    Left for other reasons                                                                                          0        0           0       1
Referrals and assists
                                                                                      c
Total number of servicemembers and veterans referred to the program                                               304      296          370     475
    Servicemembers and veterans referred and enrolled in the program                                              255      179          142     208
    Servicemembers and veterans referred and assisted, but not enrolled in the program                             74      417          330     199
    Servicemembers and veterans referred but not enrolled in or assisted by the program                             0        0           2       73

                                           Legend: ND indicates that no data are available.
                                           Source: GAO analysis of Navy Safe Harbor Program data.
                                           a
                                            Enrollment numbers represent all enrollees being served by the program as of December 31, rather
                                           than as of the end of each fiscal year.
                                           b
                                            According to a Navy Safe Harbor Program official, the database used to capture information about
                                           the duty status of enrollees did not have the ability to track dates when servicemembers transitioned
                                           to veteran status until the system was upgraded in 2010. At that point, the program moved all
                                           enrollees who had previously medically retired to a veteran status. Therefore, the number of enrollees
                                           who transitioned to veteran status in fiscal year 2010 includes both servicemembers who transitioned
                                           to veteran status within the fiscal year and servicemembers who transitioned to veteran status during
                                           the previous fiscal years.
                                           c
                                            The database used to capture referral information for the Navy Safe Harbor Program does not
                                           distinguish servicemembers from veterans referred to the program. Rather, the referral information
                                           provided for servicemembers also includes any veterans who were referred to the program.




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                        of Veterans Affairs Programs




Air Force Warrior and   The Air Force Warrior and Survivor Care Program supports wounded, ill,
Survivor Care Program   and injured servicemembers through its Air Force Wounded Warrior
                        Program and the Air Force Recovery Care Program. 12 The Air Force
                        Wounded Warrior Program was established in June 2005 to provide
                        nonclinical case management to Airmen, Air National Guard, and
                        Reserve Component servicemembers who have combat-related illnesses
                        or injuries. Each enrolled servicemember is assigned a nonmedical care
                        manager, who serves as an advocate for enrollees to obtain services
                        from agencies and organizations that support the needs of enrolled
                        servicemembers, their families and caregivers. The Air Force Wounded
                        Warrior Program continues to provide services to enrollees once they
                        transition to veteran status. (See table 8.)

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




                        12
                          The Air Force Warrior and Survivor Care Program’s Survivor Assistance Program
                        primarily provides services to the families of wounded, ill, and injured servicemembers.




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Table 8: Air Force Wounded Warrior Program Enrollment Populations and Characteristics, Fiscal Years 2008 through 2011

                                                                                                                     Fiscal year
                                                                                                              2008   2009          2010    2011
Program enrollment for Air Force Wounded Warrior Program
                   a
Total enrollment                                                                                               194    451           836    1,386
    Servicemembers                                                                                             160    388           703    1,143
        Active Duty                                                                                            103    256           463     783
        National Guard                                                                                          32     60           123     194
        Reservists                                                                                              25     72           117     166
    Veterans                                                                                                    34     63           133     243
Population characteristics
        Enrollees with combat-related conditions                                                               187    442           804    1,327
        Enrollees with non-combat-related conditions                                                            7       9            32       59
Enrollees who changed duty status or left the program
    Returned to active duty                                                                                     4      22            65     128
    Transitioned to veteran status                                                                             157    329           532     786
Referrals and assists
Total number of servicemembers referred to the program                                                         146    357           724    1,176
    Servicemembers referred and enrolled in the program                                                        145    337           645    1,071
                                                                                       b
    Servicemembers referred and assisted, but not enrolled in the program                                       1      20            79     105
    Servicemembers referred but not enrolled in or assisted by the program                                      0       0            0         0
Total number of veterans referred to the program                                                                34     63           133     243
    Veterans referred and enrolled in the program                                                               34     63           133     243
    Veterans referred and assisted, but not enrolled in the program                                            NA      NA           NA       NA
    Veterans referred but not enrolled in or assisted by the program                                            0       0            0         0

                                            Legend: NA indicates that the category is not applicable to the program.
                                            Source: GAO analysis of Air Force Wounded Warrior Program data.
                                            a
                                             Servicemembers may be dually enrolled in the Air Force Recovery Care Program and the Air Force
                                            Wounded Warrior Program. The enrollment data presented here only reflect servicemembers who are
                                            enrolled in the Air Force Wounded Warrior Program.
                                            b
                                             According to Air Force Wounded Warrior Program officials, because the program only serves
                                            servicemembers with combat-related conditions, most referrals come from casualty reports and the
                                            disability evaluation process, where it is determined whether a servicemember’s wound, illness, and
                                            injury are combat-related. Once the determination is made, servicemembers are enrolled into the
                                            program.




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Table 9: Air Force Recovery Care Program Enrollment Populations and Characteristics, Fiscal Years 2008 through 2011

                                                                                                               Fiscal year
                                                                                                2008           2009          2010              2011
Program enrollment for Air Force Recovery Care Program
                   a
Total enrollment                                                                                  ND            ND             ND             1,804
    Servicemembers                                                                                ND            ND             ND                ND
        National Guard                                                                            ND            ND             ND                ND
        Reservists                                                                                ND            ND             ND                ND
    Veterans                                                                                      ND            ND             ND                ND
             b
    Others                                                                                        ND            ND             ND               251
Population characteristics
    Enrollees with combat-related conditions                                                      ND            ND             ND               316
Enrollees with non-combat-related conditions                                                      ND            ND             ND               782
Enrollees who changed duty status or left the program
    Returned to active duty                                                                       ND            ND             ND               288
    Transitioned to veteran status                                                                ND            ND             ND               394
    Left for other reasons                                                                        ND            ND             ND                ND
Referrals and assists
Total number of servicemembers referred to the program                                            ND            ND             ND             1,804

                                           Legend: ND indicates that no data are available.
                                           Source: GAO analysis of Air Force Recovery Care Program data.

                                           Notes: According to Air Force Recovery Care Program officials, the program did not routinely track
                                           certain data about the program, because these data were not required to be collected by the DOD
                                           policy that governs the program. In addition, the original Air Force Recovery Care program
                                           requirements did not include provisions for data collection. The officials told us that a data-collection
                                           tool is being developed and that requirements for data collection would be finalized by the beginning
                                           of July 2012. The officials anticipate the new tool will be operational by January 2013.
                                           a
                                               Enrollees may also be enrolled in the Air Force’s Wounded Warrior Program.
                                           b
                                               The Air Force Recovery Care Program serves some servicemembers from other military services.



Marine Corps Wounded                       The Marine Corps established the Wounded Warrior Regiment in May
Warrior Regiment                           2007 to provide and facilitate assistance to wounded, ill, and injured
                                           Marines and their family members throughout the recovery process. The
                                           Wounded Warrior Regiment is a single command that oversees
                                           nonmedical care for the total Marine force, including Active Duty,
                                           Reserve, retired, and veteran Marines. The regiment enrolls Marines
                                           regardless of whether they have combat- or non-combat-related
                                           conditions. The regiment commands the operation of two wounded
                                           warrior battalions and 14 detachments located at 12 principal military
                                           treatment facilities and four Veterans Affairs polytrauma medical centers



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across the United States and overseas. A Marine enrolled in the regiment
can either stay with his or her parent unit and be supported by the
regiment, or be assigned or attached to one of the regiment’s battalions
and detachments, depending on their specific needs. Generally, Marines
who require more than 90 days of medical treatment or rehabilitation are
assigned or attached to a battalion or detachment. The District Injured
Support Cells Program is the component of the Wounded Warrior
Regiment that provides services to veterans. 13 District Injured Support
Coordinators are located at 30 sites across the United States to provide
support, including nonmedical care management to its enrollees. In fiscal
year 2011, the District Injured Support Coordinators provided support to
1,488 veterans. (See table 10.)




13
 District Injured Support Coordinators may also provide support to Reserve and Active
Duty Marines in remote locations away from military or other federal resources.




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Table 10: Marine Corps Wounded Warrior Regiment Enrollment Populations and Characteristics, Fiscal Years 2008 through
2011

                                                                                                                      Fiscal year
                                                                                                           2008       2009          2010       2011
Program enrollment for Marine Corps Wounded Warrior Regiment
                   a,b
Total enrollment                                                                                             810       725           634      2,155
    Servicemembers                                                                                           810       725           634        667
        Active Duty                                                                                          712       633          494         517
        Reservists                                                                                               98     92           140        150
                                                                         c
    Veterans served through District Injured Support Coordinators                                                ND    ND            ND       1,488
Population characteristics
                                               d
    Enrollees with combat-related conditions                                                                 216       105           115        224
                                                   e
    Enrollees with non-combat-related conditions                                                             594       620           519        443
Enrollees who changed duty status or left the program
    Returned to active duty                                                                                      35     38            84          94
    Transitioned to veteran status                                                                           149       266          311         366
                             e
    Left for other reasons                                                                                       ND    ND            ND          ND
Referrals
                                                                  f
Total number of servicemembers referred to the program                                                           ND    ND            ND          ND
                                                                                           g
Total number of veterans referred to District Injured Support Coordinators                                       ND    ND            ND          ND

                                           Legend: ND indicates that no data are available.
                                           Source: GAO analysis of Marine Corps Wounded Warrior Regiment data.
                                           a
                                            According to a Wounded Warrior Regiment official, the Wounded Warrior Regiment does not have
                                           “enrollees,” rather the program assigns and attaches Marines to the program.
                                           b
                                            Total enrollment does not include Wounded Warrior Regiment enrollees who are not assigned or
                                           attached to a Wounded Warrior Regiment site. Many wounded, ill, and injured Marines are supported
                                           by the Wounded Warrior Regiment while remaining with their parent unit.
                                           c
                                             The District Injured Support Coordinators provide outreach and services to Reserve and veteran
                                           Marines located across the country.
                                           d
                                            The data in this category do not include Marines attached to the Wounded Warrior Regiment who
                                           may have been wounded, fallen ill, or injured in a combat zone, but who were not medically
                                           evacuated from a combat zone.
                                           e
                                            Although the Wounded Warrior Regiment was not able to provide data on the number of enrollees
                                           who left the Wounded Warrior Regiment for reasons other than returning to duty or transitioning to
                                           veteran status, according to a Wounded Warrior Regiment official, Marines attached to the Wounded
                                           Warrior Regiment have left the program for other reasons such as death or as a result of military legal
                                           actions taken against the Marine.
                                           f
                                            According to a Marine Corps Wounded Warrior Regiment official, although a policy exists requiring
                                           referral information to be collected, the policy was not always enforced. According to this official, as of
                                           fiscal year 2012, the data are routinely collected.
                                           g
                                           According to a Marine Corps Wounded Warrior Regiment official, the District Injured Support
                                           Coordinators initially served veterans on an ad hoc basis, so referral information was not collected.




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




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Table 11: United States Special Operations Command’s Care Coalition Enrollment Populations and Characteristics, Fiscal
Years 2008 through 2011

                                                                                                                                     Fiscal year
                                                                                                                    2008             2009      2010      2011
Program enrollment for United States Special Operations Command’s Care Coalition
                   a                                                                                                      b              b
Total enrollment                                                                                                  2,277          2,532        3,447      4,570
    Servicemembers                                                                                                 1,594             1,741    2,475      3,518
        National Guard                                                                                               113              127          154    228
        Reservists                                                                                                   193              196          206    232
    Veterans                                                                                                         654              722          838    893
             c
    Others                                                                                                           152              192          262    287
Population characteristics
                                               d
    Enrollees with combat-related conditions                                                                       1,693             1,803    2,415      2,879
                                                   d
    Enrollees with non-combat-related conditions                                                                     736              839     1,256      1,859
Enrollees who changed duty status
                           e
    Returned to active duty                                                                                            31              32           38     46
                                     e
    Transitioned to veteran status                                                                                       4             23           24     48
Referrals
                                                                  f
Total number of servicemembers referred to the program                                                                ND               ND          ND      ND
                                                       f
Total number of veterans referred to the program                                                                      ND               ND          ND      ND

                                           Legend: ND indicates that no data are available.
                                           Source: GAO analysis of United States Special Operations Command’s Care Coalition data.
                                           a
                                            Enrollees of the United States Special Operations Command’s Care Coalition Recovery Program
                                           may also be enrolled in a military service’s wounded warrior program on the basis of their branch of
                                           service, but the United States Special Operations Command’s Care Coalition Recovery Program
                                           takes the lead for providing nonclinical case management.
                                           b
                                            According to a United States Special Operations Command’s Care Coalition official, because of a
                                           change in the data system used to track enrollment, enrollment numbers provided for fiscal year 2008
                                           include enrollees served by the program between October 1, 2007, and May 28, 2009. Enrollment
                                           numbers provided for fiscal year 2009 include an additional 255 servicemembers and veterans who
                                           enrolled in the program between May 28, 2009, and September 30, 2009.
                                           c
                                            Others enrolled include civilians, surviving family members, and records with unknown information.
                                           According to a United States Special Operations Command’s Care Coalition official, the program
                                           continues to provide and track services to surviving family members after an enrolled servicemember
                                           or veteran has died.
                                           d
                                            According to a United States Special Operations Command’s Care Coalition official, data provided
                                           on enrollees with either combat- or non-combat-related conditions also include some servicemembers
                                           who were either killed in action or died while enrolled in the program, and therefore were excluded
                                           from the total enrollment data. In addition, officials stated that the exact count for non-combat-related
                                           conditions may not be accurate, due to inaccuracies in record keeping.
                                           e
                                            According to a United States Special Operations Command’s Care Coalition official, the program did
                                           not begin tracking enrollee transition status and transition dates in an accessible format until January
                                           2012. Therefore, information about the duty status and transition status is being updated by hand as
                                           an individual record is reviewed by program personnel, and the information provided may not be
                                           accurate.




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                     f
                      According to a United States Special Operations Command’s Care Coalition official, the program has
                     several methods of receiving referrals, but its primary source of referrals comes from casualty reports.
                     The program does not track referral information because the Care Coalition does not have a field in
                     its database to track this information. However, this official said that the Care Coalition could access
                     this information by contacting the military services.



                     VA operates a number of case management and care coordination
VA Case Management   programs that provide assistance to recovering servicemembers and
and Care             veterans, including the Operation Enduring Freedom/Operation Iraqi
                     Freedom/Operation New Dawn (OEF/OIF/OND) Care Management
Coordination         Program and the Federal Recovery Coordination Program (FRCP). 14
Programs             These two programs assist wounded servicemembers and veterans to
                     navigate the recovery care continuum.


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




                     14
                       In addition, the Department of Veterans Affairs operates other dedicated programs and
                     systems of care including Polytrauma/Traumatic Brain Injury, Spinal Cord Injury and
                     Diseases, Visual Impairment, and Mental Health that provide specialized lifelong clinical
                     care and care management for these special cohorts of veterans.




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Table 12: Operation Enduring Freedom/Operation Iraqi Freedom/ Operation New Dawn (OEF/OIF/OND) Care Management
Program Enrollment Populations and Characteristics, Fiscal Years 2008 through 2011

                                                                                                                      Fiscal year
                                                                                                                 a          a
                                                                                                          2008       2009           2010        2011
                   b
Total enrollment                                                                                          2,463      7,048      49,145        50,255
                       c
    Servicemembers                                                                                          152        590       2,069         2,505
    Veterans                                                                                              1,136      4,212      31,831        29,848
             d
    Others                                                                                                1,175      2,246      15,245        17,902
Population characteristics
                                                e
    Enrollees with combat-related conditions                                                              1,214      2, 470      7,165         6,898
                                                     f
    Enrollees with non-combat-related conditions                                                            212        676       3,115         3,188
                                                                                               g
    Enrollees with conditions not classified as either combat- or non-combat-related                        200        880       4,820         4,072
Referrals
Total number of servicemembers and veterans referred to the program by
                              h
military treatment facilities                                                                             2,130      4,474       7,172         6,686
                                            Source: GAO analysis of OEF/OIF/OND Care Management Program data.
                                            a
                                             According to OEF/OIF/OND Care Management Program officials, 2008 and 2009 data only include
                                            severely wounded, ill, and injured because the database only tracked this subpopulation of the
                                            program, which was the initial focus of the program’s efforts. This population included, for example,
                                            those with severe burns, amputations, spinal cord injuries, or blindness, or more than one of these.
                                            Soon after the program was initiated, the Department of Veterans Affairs found that people returning
                                            from the conflicts in Iraq and Afghanistan required additional support, regardless of the severity of
                                            their injuries or illnesses. Therefore, policy was changed and the OEF/OIF/OND Care Management
                                            Program began tracking data on all those receiving case management services through their
                                            program.
                                            b
                                                Total enrollment includes those who serve or served in National Guard and Reserve Components.
                                            c
                                            The OEF/OIF/OND Care Management Program primarily serves veterans. Some servicemembers
                                            who are receiving treatment through a VA facility may also be enrolled in the program.
                                            d
                                                Others include enrollees with unknown military status.
                                            e
                                             Includes enrollees with battle injuries. According to OEF/OIF/OND Care Management Program
                                            officials, battle injuries are injuries sustained while in combat, such as a wound from an improvised
                                            explosive device.
                                            f
                                             Includes enrollees with nonbattle injuries. According to OEF/OIF/OND Care Management Program
                                            officials, nonbattle injuries can include injuries sustained in a combat zone that are not directly related
                                            to combat.
                                            g
                                             Includes enrollees with illnesses that may be classified as either combat-related or non-combat-
                                            related. According to OEF/OIF/OND Care Management Program officials, the program tracks whether
                                            an enrollee’s condition is a battle injury or a nonbattle injury, but not whether an illness is related to
                                            combat.
                                            h
                                             According to OEF/OIF/OND Care Management Program officials, servicemembers and veterans are
                                            either referred to the program by a military treatment facility or are screened into the program when a
                                            servicemember or veteran initially seeks VA services at a VA treatment facility.




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




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Table 13: Federal Recovery Coordination Program (FRCP) Enrollment Populations and Characteristics, Fiscal Years 2008
through 2011

                                                                                                              Fiscal year
                                                                                                  2008        2009         2010         2011
Program enrollment for the FRCP
Total enrollment                                                                                   177          522         823        1,022
    Servicemembers                                                                                 132          325         394          573
                         a
        National Guard                                                                               11          51           84          87
                     a
        Reservists                                                                                    7          30           45          63
    Veterans                                                                                         43         194         429          449
    Others                                                                                            2           3            0            0
Population characteristics
    Enrollees with combat-related conditions                                                        ND          ND           ND          ND
    Enrollees with non-combat-related conditions                                                    ND          ND           ND          ND
    Enrollees with conditions not classified as either combat- or non-combat-related                ND          ND           ND          ND
Referrals and assists
Total number of servicemembers referred to the program                                             179          257         268          362
    Servicemembers referred and enrolled in the program                                            132          194         222          293
    Servicemembers referred and assisted, but not enrolled in the program                           ND          ND           ND          ND
    Servicemembers referred but not enrolled in or assisted by the program                           47          63           46          68
Total number of veterans referred to the program                                                     44         171         165          119
    Veterans referred and enrolled in the program                                                    43         155         150           66
    Veterans referred and assisted, but not enrolled in the program                                 ND          ND           ND          ND
    Veterans referred but not enrolled in or assisted by the program                                  1          16           15          53

                                            Legend: ND indicates that no data are available.
                                            Source: GAO analysis of FRCP data.
                                            a
                                             According to an FRCP official, the total number of servicemembers who are active duty cannot be
                                            delineated because the National Guard and Reservist numbers are descriptive data points and do not
                                            designate whether the enrollee is active duty or veteran. In addition, not all National Guard and
                                            Reservists are included in the data due to database limitations that have since been resolved.




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




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Table 14: Referral Information Routinely Tracked by DOD and VA Case Management and Care Coordination Programs

                                                   Referral information
Program                                             routinely tracked     Types of referral information tracked, if any
Army
    Army Warrior Care and Transition Program:               √             Referral sources for program enrollees
    Warrior Transition Units and Community-
    Based Warrior Transition Units
    Army Warrior Care and Transition Program:               √             Total number of referrals made to the program
    Army Wounded Warrior Program                                          Number of those referred to the program who were
                                                                          enrolled into the program
                                                                          Number of those referred to the program who were
                                                                          enrolled and provided short-term assistance by the
                                                                          program, but who were later found ineligible for the
                                                                          program and disenrolled
                                                                          Number of those referred to the program who were not
                                                                          enrolled into the program
Navy/Coast Guard
                                                             a
    Navy Safe Harbor Program                                √             Total number of referrals made to the program
                                                                          Number of those referred to the program who were
                                                                          enrolled into the program
                                                                          Number of those referred to the program who were
                                                                          provided short-term assistance by the program, but not
                                                                          enrolled
                                                                          Number of those referred to the program who were not
                                                                          enrolled into the program or provided short-term
                                                                          assistance by the program
Air Force
    Air Force Wounded Warrior Program                                     According to Air Force Wounded Warrior Program
                                                                          officials, since the program only serves servicemembers
                                                                          with combat-related conditions, most referrals come
                                                                          from casualty reports and the disability evaluation
                                                                          process, where it is determined whether a
                                                                          servicemember’s wound, illness, or injury is combat-
                                                                          related.
    Air Force Recovery Care Program                                       None
Marine Corps
    Marine Corps Wounded Warrior Regiment                                 According to a Marine Corps Wounded Warrior
                                                                          Regiment official, although a policy exists requiring
                                                                          referral information to be collected, the policy was not
                                                                                            b
                                                                          always enforced.
United States Special Operations Command




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                                                    Referral information
Program                                              routinely tracked              Types of referral information tracked, if any
    United States Special Operations                                                According to a United States Special Operations
    Command’s Care Coalition                                                        Command’s Care Coalition official, the program does
                                                                                    not track referral information because there is no field in
                                                                                    its database to track this information. However,
                                                                                    according to this official, the program is able to access
                                                                                    this information from the individual military services.
Department of Veterans Affairs
    Operation Enduring Freedom/Operation Iraqi                    √                 Total number of referrals made to the program from
    Freedom/Operation New Dawn Care                                                 military treatment facilities
    Management Program
    Federal Recovery Coordination Program                         √                 Total number of referrals made to the program
                                                                                    Number of those referred to the program who were
                                                                                    enrolled into the program
                                                                                    Number of those referred to the program who were
                                                                                    provided short-term assistance by the program, but not
                                                                                    enrolled
                                                                                    Number of those referred to the program who are not
                                                                                    enrolled into the program or provided short-term
                                                                                    assistance by the program
                                         Source: GAO analysis of DOD and VA data.
                                         a
                                          According to a Navy Safe Harbor Program official, the database used to track referral information did
                                         not capture accurate data until it was upgraded in 2010.
                                         b
                                          According to a Marine Corps Wounded Warrior Program official, as of fiscal year 2012, data on
                                         referral information are routinely collected.




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Appendix II: Medical Category Assignment
              Appendix II: Medical Category Assignment
              Process for Care Coordination Programs



Process for Care Coordination Programs

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

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




              1
               DOD subsequently modified the 180-day criteria to “within a time specified by his or her
              military department” to accommodate different standards used by the Marine Corps and
              the Army.




              Page 77                                GAO-13-5 Recovering Servicemembers and Veterans
                                        Appendix II: Medical Category Assignment
                                        Process for Care Coordination Programs




Figure 3: The Department of Defense’s Vision of the Assignment Process for the Recovery Coordination Program and the
Federal Recovery Coordination Program




                                        Note: In this figure, solid arrows indicate typical or expected results and dashed arrows indicate
                                        alternative, but possible, outcomes.




                                        Page 78                                      GAO-13-5 Recovering Servicemembers and Veterans
Appendix III: Comments from the
              Appendix III: Comments from the Department
              of Defense



Department of Defense




              Page 79                               GAO-13-5 Recovering Servicemembers and Veterans
Appendix III: Comments from the Department
of Defense




Page 80                               GAO-13-5 Recovering Servicemembers and Veterans
Appendix III: Comments from the Department
of Defense




Page 81                               GAO-13-5 Recovering Servicemembers and Veterans
Appendix III: Comments from the Department
of Defense




Page 82                               GAO-13-5 Recovering Servicemembers and Veterans
Appendix III: Comments from the Department
of Defense




Page 83                               GAO-13-5 Recovering Servicemembers and Veterans
Appendix III: Comments from the Department
of Defense




Page 84                               GAO-13-5 Recovering Servicemembers and Veterans
Appendix IV: Comments from the
             Appendix IV: Comments from the Department
             of Veterans Affairs



Department of Veterans Affairs




             Page 85                             GAO-13-5 Recovering Servicemembers and Veterans
Appendix IV: Comments from the Department
of Veterans Affairs




Page 86                             GAO-13-5 Recovering Servicemembers and Veterans
Appendix IV: Comments from the Department
of Veterans Affairs




Page 87                             GAO-13-5 Recovering Servicemembers and Veterans
Appendix IV: Comments from the Department
of Veterans Affairs




Page 88                             GAO-13-5 Recovering Servicemembers and Veterans
Appendix IV: Comments from the Department
of Veterans Affairs




Page 89                             GAO-13-5 Recovering Servicemembers and Veterans
Appendix IV: Comments from the Department
of Veterans Affairs




Page 90                             GAO-13-5 Recovering Servicemembers and Veterans
Appendix IV: Comments from the Department
of Veterans Affairs




Page 91                             GAO-13-5 Recovering Servicemembers and Veterans
Appendix V: GAO Contact and Staff
                  Appendix V: GAO Contact and Staff
                  Acknowledgments



Acknowledgments

                  Randall B. Williamson, (202) 512-7114 or williamsonr@gao.gov
GAO Contact
                  In addition to the contact name above, Bonnie Anderson, Assistant
Staff             Director; Mark Bird, Assistant Director; Michele Grgich, Assistant Director;
Acknowledgments   Jennie Apter; Frederick Caison; Heather Collins; Dan Concepcion;
                  Melissa Jaynes; Deitra Lee; Mariel Lifshitz; Lisa Motley; Elise Pressma;
                  and Greg Whitney made key contributions to this report.




                  Page 92                             GAO-13-5 Recovering Servicemembers and Veterans
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Page 94                        GAO-13-5 Recovering Servicemembers and Veterans
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           Page 95                     GAO-13-5 Recovering Servicemembers and Veterans
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