[House Hearing, 112 Congress]
[From the U.S. Government Publishing Office]





   THE FEDERAL RECOVERY COORDINATION PROGRAM: FROM CONCEPT TO REALITY

=======================================================================

                                HEARING

                               before the

                         SUBCOMMITTEE ON HEALTH

                                 of the

                     COMMITTEE ON VETERANS' AFFAIRS
                     U.S. HOUSE OF REPRESENTATIVES

                      ONE HUNDRED TWELFTH CONGRESS

                             FIRST SESSION

                               __________

                              MAY 13, 2011

                               __________

                           Serial No. 112-13

                               __________

       Printed for the use of the Committee on Veterans' Affairs











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                     COMMITTEE ON VETERANS' AFFAIRS

                     JEFF MILLER, Florida, Chairman

CLIFF STEARNS, Florida               BOB FILNER, California, Ranking
DOUG LAMBORN, Colorado               CORRINE BROWN, Florida
GUS M. BILIRAKIS, Florida            SILVESTRE REYES, Texas
DAVID P. ROE, Tennessee              MICHAEL H. MICHAUD, Maine
MARLIN A. STUTZMAN, Indiana          LINDA T. SANCHEZ, California
BILL FLORES, Texas                   BRUCE L. BRALEY, Iowa
BILL JOHNSON, Ohio                   JERRY McNERNEY, California
JEFF DENHAM, California              JOE DONNELLY, Indiana
JON RUNYAN, New Jersey               TIMOTHY J. WALZ, Minnesota
DAN BENISHEK, Michigan               JOHN BARROW, Georgia
ANN MARIE BUERKLE, New York          RUSS CARNAHAN, Missouri
TIM HUELSKAMP, Kansas
Vacancy
Vacancy

            Helen W. Tolar, Staff Director and Chief Counsel

                                 ______

                         SUBCOMMITTEE ON HEALTH

                ANN MARIE BUERKLE, New York, Chairwoman

CLIFF STEARNS, Florida               MICHAEL H. MICHAUD, Maine, Ranking
GUS M. BILIRAKIS, Florida            CORRINE BROWN, Florida
DAVID P. ROE, Tennessee              SILVESTRE REYES, Texas
DAN BENISHEK, Michigan               RUSS CARNAHAN, Missouri
JEFF DENHAM, California              JOE DONNELLY, Indiana
JON RUNYAN, New Jersey

Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public 
hearing records of the Committee on Veterans' Affairs are also 
published in electronic form. The printed hearing record remains the 
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both printed and electronic versions of the hearing record, the process 
of converting between various electronic formats may introduce 
unintentional errors or omissions. Such occurrences are inherent in the 
current publication process and should diminish as the process is 
further refined.










                            C O N T E N T S

                               __________

                              May 13, 2011

                                                                   Page
The Federal Recovery Coordination Program: From Concept to 
  Reality........................................................     1

                           OPENING STATEMENTS

Chairwoman Ann Marie Buerkle.....................................     1
    Prepared statement of Chairwoman Buerkle.....................    28
Hon. Michael H. Michaud, Ranking Democratic Member...............     2
    Prepared statement of Congressman Michaud....................    28
                               __________

                               WITNESSES

U.S. Government Accountability Office, Randall B. Williamson, 
  Director, Health Care..........................................     3
    Prepared statement of Mr. Williamson.........................    29
U.S. Department of Veterans Affairs:
  Karen Guice, M.D., MPP, Executive Director, Federal Recovery 
    Coordination Program.........................................     4
    Prepared statement of Dr. Guice..............................    33
  Mary Ramos, Ph.D., RN, Federal Recovery Coordinator, San 
    Antonio, TX, Military Medical Center.........................    15
    Prepared statement of Dr. Ramos..............................    42
   Karen Gillette, RN, MSN, GNP, Federal Recovery Coordinator, 
    Providence, RI, Department of Veterans Affairs Medical Center    17
    Prepared statement of Ms. Gillette...........................    47
U.S. Department of Defense:
  Robert S. Carrington, Director, Recovery Care Coordination, 
    Office of Wounded Warrior Care and Transition Policy.........     6
    Prepared statement of Mr. Carrington.........................    38
  Colonel John L. Mayer, USMC, Commanding Officer, Marine Corps 
    Wounded Warrior Regiment.....................................    18
    Prepared statement of Colonel Mayer..........................    49
  Colonel Gregory Gadson, USA, Director, U.S. Army Wounded 
    Warrior Program..............................................    19
    Prepared statement of Colonel Gadson.........................    51
                               __________

Central Savannah River Area Wounded Warrior Care Projects, 
  Augusta, GA, James R. Lorraine, Executive Director.............    13
    Prepared statement of James R. Lorraine......................    40
                               __________

                       SUBMISSIONS FOR THE RECORD

Disabled American Veterans, Adrian Atizado, Assistant National 
  Legislative Director, statement................................    54
Military Officers Association of America, statement..............    57
Paralyzed Veterans of America, statement.........................    60
Wounded Warrior Project, statement...............................    62

 
   THE FEDERAL RECOVERY COORDINATION PROGRAM: FROM CONCEPT TO REALITY

                              ----------                              


                          FRIDAY, MAY 13, 2011

             U.S. House of Representatives,
                    Committee on Veterans' Affairs,
                                    Subcommittee on Health,
                                                    Washington, DC.
    The Subcommittee met, pursuant to notice, at 11:24 a.m., in 
Room 334, Cannon House Office Building, Hon. Ann Marie Buerkle 
[Chairwoman of the Subcommittee] presiding.
    Present: Representatives Buerkle, Runyan, Michaud, and 
Reyes.

            OPENING STATEMENT OF CHAIRWOMAN BUERKLE

    Ms. Buerkle. Good morning. Please let me begin by 
apologizing for having you all wait here for the last hour and 
a half. We had votes and we just finished that series of votes. 
My sincere apologies for the delay.
    I first of all want to thank all of you for being here this 
morning as we begin to examine the Federal Recovery 
Coordination Program (FRCP): From Concept to Reality.
    I am Ann Marie Buerkle and I am the Chairwoman of the 
Subcommittee on Health for the House Committee on Veterans' 
Affairs.
    Before we begin, I would like to first of all acknowledge 
all of the military that we have in our audience today and 
participating in our hearing. And I ask all of us to remember 
our active-duty men and women who are serving our Nation. To 
all of the veterans and to those who gave the ultimate 
sacrifice, we must never forget what our military has done for 
this Nation.
    This is the greatest Nation in the history of mankind and 
it is because of the service and the sacrifice of our military. 
So as we enjoy the freedom today to sit here and be assembled, 
we must always be aware and remember those who have served and 
are serving as we speak. Thank you.
    The Federal Recovery Coordination Program was the 
brainchild of the Commission of Care for America's Returning 
Wounded Warriors, commonly known as the Dole-Shalala 
Commission.
    The Commission, which was established in 2007, rightly 
recognized that navigating the complex maze of the U.S. 
Department of Defense (DoD) and the U.S. Department of Veterans 
Affairs (VA) care, benefits, and services can be a task of 
almost herculean effort for wounded warriors and their families 
at a time when all of their energies and focus should be on 
recovery.
    The Commission recommended that we swiftly develop a 
program to establish a single point of contact for wounded 
warriors and their families that would make the systems more 
manageable, eliminate delays and gaps in treatment and 
services, and break through VA and DoD jurisdictional 
boundaries to ensure a truly seamless transition.
    However, almost 4 years since DoD and VA signed a 
memorandum of understanding to establish the Federal Recovery 
Coordination Program, significant challenges persist in areas 
as fundamental as identifying potential enrollees, reviewing 
enrollment decisions, determining staffing needs, defining and 
managing caseloads, and making placement decisions.
    Further, it appears that rather than having the joint 
program envisioned by the Commission to advocate on behalf of 
the wounded warriors and ensure a comprehensive and seamless 
rehabilitation, recovery, and transition, we have two separate 
programs--a VA program that utilizes Federal Recovery 
Coordinators (FRCs) and a DoD program that utilizes Recovery 
Care Coordinators (RCCs).
    The intent was to streamline. The intent was to simplify. 
The intent was to serve the most seriously wounded, ill, and 
injured. But instead, there is duplication, there is 
bureaucracy, and there is confusion.
    This is unacceptable for any program that accepts tax 
dollars and taxpayer funding, but it is unforgivable in a 
program that serves our most severely-wounded servicemembers, 
veterans, and their families.
    I look forward to hearing from each of today's witnesses 
how they are going to solve these problems.
    At this time, I would like to recognize our Ranking Member, 
Mr. Michaud, for any comments he might have.
    [The prepared statement of Chairwoman Buerkle appears on
p. 28.]

          OPENING STATEMENT OF HON. MICHAEL H. MICHAUD

    Mr. Michaud. I want to thank you, Madam Chair, for having 
this very important hearing today. It certainly is important 
and an appropriate topic for this Subcommittee to hear.
    And because of the votes this morning, I would ask 
unanimous consent that my full opening statement be submitted 
for the record so we can get on and hear the panelists.
    [The prepared statement of Congressman Michaud appears on
p. 28.]
    Ms. Buerkle. Thank you, Mr. Michaud.
    I would like to now welcome the first panel to our witness 
table. With us this morning are Mr. Randall Williamson who is 
the Director of the Health Care Team for the U.S. Government 
Accountability Office (GAO); Dr. Karen Guice, the Executive 
Director of the Federal Recovery Coordination Program for the 
Department of Veterans Affairs; and Mr. Robert Carrington, 
Director, Recovery Care Coordination for the Department of 
Defense, Office of Wounded Warrior and Transition Policy.
    Thank you all very much for joining us this morning. And, 
again, I apologize for the delay. I am very much looking 
forward to our discussion.
    So, Mr. Williamson, without further delay, we will start 
with you.

  STATEMENTS OF RANDALL B. WILLIAMSON, DIRECTOR, HEALTH CARE, 
U.S. GOVERNMENT ACCOUNTABILITY OFFICE; KAREN GUICE, M.D., MPP, 
EXECUTIVE DIRECTOR, FEDERAL RECOVERY COORDINATION PROGRAM, U.S. 
   DEPARTMENT OF VETERANS AFFAIRS; AND ROBERT S. CARRINGTON, 
DIRECTOR, RECOVERY CARE COORDINATION, OFFICE OF WOUNDED WARRIOR 
     CARE AND TRANSITION POLICY, U.S. DEPARTMENT OF DEFENSE

               STATEMENT OF RANDALL B. WILLIAMSON

    Mr. Williamson. Thank you, Chairwoman Buerkle, Ranking 
Member Michaud, and Members of the Subcommittee.
    I am pleased to be here today to discuss GAO's recent 
report on the Federal Recovery Coordination Program, which aims 
to improve the continuity of care of severely-wounded, ill, or 
injured servicemembers and veterans including those who have 
suffered traumatic brain injuries (TBIs), amputations, burns, 
spinal cord injuries, and post-traumatic stress.
    While administered by the VA, it is designed to be a joint 
DoD and VA program. Currently the FRCP employs 22 recovery 
coordinators called FRCs in 12 locations nationwide and is 
serving over 700 active enrollees.
    Our report focused on challenges the program faces in 
identifying and enrolling those who need FRCP services, 
staffing and placement issues, and coordinating care for its 
clients.
    Regarding the first challenge, we found that it is not 
clear whether all those who could benefit from the program are 
being identified and enrolled in the FRCP. Because VA and DoD 
lack data that specifically designates servicemembers as 
severely wounded, FRCs have no systematic method to identify 
potential candidates for the program.
    Instead, FRCs must rely largely on referrals from 
clinicians and caseworkers and other programs. But this method 
isn't perfect because staff from other programs are often 
unclear about the eligibility criteria for the FRCP and because 
close cooperation and collaboration among the FRCP and other 
wounded warrior programs is sometimes missing. This in turn can 
affect the ability and willingness of other programs to refer 
servicemembers to FRCs.
    We also have recommended that FRCP strengthen its 
enrollment, workload management, and placement processes to 
best service its clients.
    Most pressing, however, is the need to improve 
collaboration and coordination among wounded warrior programs.
    Currently FRCs face daunting challenges coordinating with a 
large number of DoD and VA programs that support wounded 
servicemembers and veterans.
    For example, 84 percent of FRC enrollees are also enrolled 
in a military wounded warrior program. Coordination among these 
programs is paramount to minimize overlap, optimize information 
sharing, and prevent confusion among clients and their 
families.
    However, we found that considerable overlap does occur 
along with conflicting recovery plans on occasion. This adds to 
confusion among servicemembers and their families and it is 
just not in the best interest of a recovering servicemember.
    We found that problems with cooperation and collaboration 
occur for numerous reasons. For one, there are significant 
cultural differences between VA and DoD organizations. While 
the FRCP is a joint program, it is widely perceived as part of 
VA.
    A recurring theme, therefore, as we talk with military 
staff in other programs was we can take care of our own while 
they are recovering on active duty. We do not need the VA 
involved.
    Second, VA and DoD programs often cannot easily share 
information among themselves leading to duplication of effort 
and conflicting servicemember recovery goals among programs. 
This occurs largely due to IT issues that limit the transparent 
exchange of information between VA and DoD programs.
    Third, the point at which FRCs should become involved with 
a severely-wounded servicemember is blurred. Some in DoD would 
say that FRCs should not be involved until it is determined 
that the servicemember will likely be discharged. Conversely, 
FRCs contend that they should be engaged long before that to 
build rapport and trust with their clients and their families 
through the continuum of care.
    Finally, the primary point of contact once people are 
enrolled in the FRCP is ill defined. Case managers in military 
service programs often think they should be the point of 
contact while FRCs think they serve this role. This has 
prompted some recovering servicemembers to say I need a case 
manager to manage my case managers.
    In summary, while we offer ways to strengthen the 
management of the FRCP, the most pressing problem is improving 
the level of coordination and collaboration among the large 
number of DoD and VA programs that serve our wounded warriors.
    Achieving this will require efforts far beyond just what 
the FRCP can achieve by itself. In the end, without cooperation 
from the military services, the FRCP cannot function as 
intended. This dilutes the program's ability to best serve our 
wounded, ill, and injured servicemembers and veterans.
    That concludes my opening remarks.
    [The prepared statement of Mr. Williamson appears on p. 29.]

    Ms. Buerkle. Thank you, Mr. Williamson.
    Dr. Guice.

              STATEMENT OF KAREN GUICE, M.D., MPP

    Dr. Guice. Good morning, Chairwoman Buerkle and Ranking 
Member Michaud and Members of the Subcommittee.
    I request that my written statement be submitted for the 
record.
    The many investigations that followed the 2007 Washington 
Post article on Walter Reed raised concerns about the multiple 
transitions our wounded, ill, or injured servicemembers make as 
they recover from war zone to inpatient care, from one hospital 
to another, from a DoD facility to a VA polytrauma center, from 
inpatient to outpatient, and from a military career to veteran 
status.
    Each transition came with multiple providers and serial 
hand-offs. System navigation was left to the patient and family 
who were trying to adjust to the consequences of illness or 
injury. Access to accurate and timely information was difficult 
and, if available, often confusing. Perceived and real system 
barriers prevented access to entitlements.
    These observations led to the care coordination concept in 
order to create seamless synchronization of benefits and care 
as these servicemembers navigated our complex systems 
regardless of whether they returned to active duty or became a 
veteran. The Senior Oversight Committee (SOC) created FRCP to 
carry out this function.
    VA agreed with all four GAO recommendations and I will tell 
you the steps we have taken to address each one.
    The first recommendation called for adequate internal 
controls to ensure appropriate referral. As an interim 
solution, FRCs discuss all enrollment decisions with management 
and each decision is carefully documented.
    Our permanent solution is to include an eligibility 
protocol as we develop our intensity measurement tool.
    FRCP does not have visibility of all who might be eligible. 
As a voluntary referral program, we rely on outreach activities 
and demonstrated outcomes.
    FRCP conducted almost 200 outreach activities over the past 
2 years. We will exceed our target this year by 25 percent.
    Last year, the FRCP conducted a look-back project to 
identify veterans who might still benefit from care 
coordination. Through this process, we identified 35 
individuals who needed further evaluation and of those, six 
were subsequently enrolled.
    GAO recommended that FRCP should complete development of a 
workload assessment tool. Care coordination as implemented 
across and within Federal agencies by FRCP is a new concept. No 
guidelines or tools exist to accurately determine and balance a 
range of cases for this new function. We are developing our 
intensity measurement tool which will estimate the time and 
effort FRCs use to coordinate services for clients based on 
client attributes.
    GAO recommended that FRCP should better document hiring 
decisions. Given the uncertainty about the number of 
individuals who might need FRCs, we have pursued a scalable 
resource model based on the number of referrals, the rate of 
enrollment, and the number of clients made inactive.
    Once we complete the intensity measurement tool, we will 
substitute allowable average intensity points for the current 
benchmark range.
    GAO's final recommendation was that FRCP should develop and 
document a rationale for FRC placement. Initially FRCs were 
placed within military treatment facilities where significant 
numbers of wounded, ill, or injured servicemembers were 
located. As the program grows, we consider alternative 
locations.
    FRC placement is guided by four factors: Replacement for 
FRCs who leave the program; supplementation of existing FRCs 
based on documented need; the creation of a national FRCP 
network to optimize coordination; and specific requests for 
FRCs in order to better serve the wounded, ill, and injured 
servicemembers and veterans.
    Over the next 6 months, FRCP will develop a placement 
strategy based on a systematic analysis of our data. The actual 
placement of FRCs is based on a case-by-case negotiation for 
support and space.
    Many in DoD believe that FRCP is a redundant program, 
likely because the DoD's non-clinical Recovery Coordination 
Program (RCP) was modeled directly from FRCP including the 
design for the comprehensive recovery plan.
    Others, specifically the military services wounded warrior 
programs, say that FRCs should only provide support for 
veterans because they are not in the military services' chain 
of command.
    There is no shortage of military and VA programs to support 
servicemembers and veterans, so many, in fact, that our 
wounded, ill, and injured servicemembers, veterans, and their 
families are still confused by the number and types of case 
managers as well as by benefit eligibility criteria.
    FRCP was to be the single point of contact for these 
individuals through care and recovery, a single point of 
contact that would help them understand the complexities of 
medical care provided and the array of benefits and services 
available to assist recovery.
    Our families and clients tell us that the program works 
best when FRCs are included early in the servicemember's 
recovery and prior to the first transition, whether that 
transition is from inpatient to outpatient or from one facility 
to another.
    A single FRC stays with the client throughout all 
subsequent transitions, coordinating benefits and services as 
needed. This consistency is important for individuals with 
severe and complex conditions who require multiple DoD, VA, and 
private health providers and services.
    FRCs remain in contact with their clients as long as they 
are needed, whether for a lifetime or for a few weeks. FRCs' 
involvement is voluntary and collaborative.
    In closing, we understand that program evaluation, whether 
by Congress or by an investigative body such as GAO, is a vital 
part of program growth and maturation. We are grateful to GAO 
for their comprehensive review of the program and to the 
Members for this opportunity to discuss our continued 
challenges.
    Thank you and we look forward to your questions.
    [The prepared statement of Dr. Guice appears on p. 33.]
    Ms. Buerkle. Thank you, Dr. Guice.
    Mr. Carrington, you may proceed.

               STATEMENT OF ROBERT S. CARRINGTON

    Mr. Carrington. Good morning, Chairwoman Buerkle, Ranking 
Member Michaud, and Members of the Subcommittee.
    Thank you for the opportunity to be here this morning with 
Dr. Karen Guice from the VA and Randall Williamson from the 
GAO.
    Also joining me today from the Department of Defense are 
two of my Wounded Warrior Program leads, Colonel Mayer from the 
Marine Corps Wounded Warrior Regiment and Colonel Gadson from 
the Army's Wounded Warrior Program.
    I am pleased to discuss the role the Department of Defense 
in the VA's Federal Recovery Coordination Program or FRCP.
    While the FRCP was jointly developed in 2007 by DoD and VA 
leaders on the Senior Oversight Committee or SOC, the program 
itself continues to be solely administered and run by the VA.
    DoD operates the Recovery Coordination Program or RCP which 
was established later by Section 1611 of fiscal year 2008 
National Defense Authorization Act (NDAA).
    This program, which is actually run by the services, uses 
DoD trained recovery care coordinators or RCCs who focus on the 
non-medical care coordination issues of our recovering 
servicemembers and their families.
    They accomplish this by being an integral part of the 
recovery team, by being the central point of coordination to 
help ensure all needs are met, by establishing a personal 
relationship and using a comprehensive recovery plan in order 
to guide and focus the servicemember through all phases of 
recovery, rehabilitation, and reintegration.
    Within DoD, there are 146 RCCs and 170 advocates. Advocates 
are what the Army calls their RCCs, all of whom are placed in 
locations to best support the respective service wounded 
warrior programs.
    FRCs and RCCs serve similar functions but for different 
categories of wounded, ill, or injured servicemembers. RCCs are 
there from day one working as part of the individual service's 
Wounded Warrior Program team for all servicemembers regardless 
of their injury or illness. And FRCs' main focus is on 
servicemembers who have severe or catastrophic injuries or 
illness and are unlikely to return to duty and are likely to be 
medically separated.
    Practice has shown the services when, where, and how to 
best bring the FRC on to their recovery teams in order to 
transition the focus of the servicemember from being on active 
duty to being in a veteran status.
    Our DoD instruction, which follows the NDAA legislation, 
directs when an FRC will be added to join with the RCC and 
others to form a more complete recovery team for this category 
of servicemember.
    The FRC Program is effective at major military medical 
treatment facilities and at VA centers. At other locations 
where FRCs are not located, the services use other Veterans 
Health Administration (VHA) and Veterans Benefits 
Administration (VBA) liaisons and counselors to ensure that 
transitioning servicemembers and their family needs are met.
    As a twice deployed to both Iraq and most recently to 
Afghanistan DoD civilian, I can attest to the excellent, 
professional, and complete support of all my medical and non-
medical needs when I was medivacked from theater.
    From my personal experience, having gone through much of 
this myself and been providing this care coordination, I am 
confident that our programs work and that the needs of our 
wounded, ill, and injured servicemembers, their families, and 
in my case a deployed government civilian are being met.
    As discussed in my written statement, my office recently 
completed a 2\1/2\ day wounded warrior care coordination summit 
that included the chartered subgroup that focused entirely on 
the collaboration between VA and DoD care coordination 
programs.
    Actionable recommendations from the subgroup and the other 
subgroups are currently being actioned and have been presented 
to the overarching integrated product team or OIPT, are 
prepared to be briefed to the SOC, and will continue to be 
worked until these recommendations and policies are implemented 
in order ensure that best practices are implemented as we 
strive for excellence across our service programs.
    Also, in conjunction with the efforts of this summit, the 
SOC directed RCP and FRCP leadership to establish the joint 
DoD/VA Recovery Coordination Committee to identify ways to 
better collaborate and coordinate the efforts of FRCs and RCCs 
and to integrate FRCs where possible.
    We recently concluded our second day of meetings with 
representatives from across both departments and are now 
finalizing our recommendations on ways to improve the use of 
FRCs in the DoD Recovery Coordination Program.
    Since I came on board late last year, I have already taken 
actions within the DoD program in order to better integrate the 
VA's FRC Program. At our DoD provided training to all RCCs, we 
now include a module taught by the FRCP leadership in what FRCs 
are, what they do, and how to best use their talents.
    I also present a similar class in what RCCs are to the FRC 
training. At our next training in June, we will also include a 
lunchtime presentation from an FRC working in one of the major 
hospitals about their experiences.
    In conclusion, this Department is committed to working 
closely with the FRCP leadership to ensure a collaborative 
relationship exists between these two programs.
    Madam Chairwoman, this concludes my statement. I am happy 
to answer any questions. Thank you.
    [The prepared statement of Mr. Carrington appears on p. 38.]

    Ms. Buerkle. Thank you, Mr. Carrington.
    I will now yield myself 5 minutes for questions. I will 
begin with Mr. Williamson and with a general comment.
    It seems pretty clear to me that the intent of this program 
was to get DoD and VA together and form a single point of 
contact to assist the wounded warrior in his or her pursuit of 
services and care. What I hear this morning is that we still 
have silos after 4 years.
    My first question is to you, Mr. Williamson. If we are 
looking at an integrated program, why were these 
recommendations just directed at the VA rather than looking at 
the big picture?
    Mr. Williamson. Madam Chair, the VA administers the program 
and as such, Dr. Guice reports to the Secretary and the 
Secretary has the authority to take any action. So normally 
always when that happens, we always address our recommendations 
to the Secretary that can actually act on them.
    Ms. Buerkle. I hear what you are saying, but you mentioned 
that the VA administers the program. So it appears that, 
whether it is reality or perception, that this is the VA's 
problem and this is the VA's program.
    How can we integrate DoD into your recommendations? Is it 
possible?
    Mr. Williamson. I think that we are in the process of doing 
additional work, which will encompass all wounded warrior 
programs. And at that time, we will have, I am sure, some 
recommendations in that regard.
    I think that even though we do not have a recommendation 
focused strictly at DoD, I hope they have heard the need for 
all wounded warrior programs to work together, you know, play 
well in the same sandbox.
    Ms. Buerkle. Thank you.
    If you could provide us with what you are going to be 
working on and the recommendations as well as a time frame for 
when these will be accomplished----
    Mr. Williamson. Very good.
    [The Subcommittee staff received the information from GAO.]
    Ms. Buerkle [continuing]. I would appreciate it. Thank you.
    Dr. Guice, you mentioned in your testimony that the GAO 
recommended systematic oversight of enrollment decisions, 
complete development of a workload assessment tool, documented 
staffing decisions, and the development of a rationale for FRC 
placement. You mentioned that these were all in the works.
    Can you give us a time frame in which these four 
recommendations will be implemented?
    Dr. Guice. Probably the best time frame for all of them to 
be completed will be probably a year. The most critical and the 
most labor intensive of the solutions is development of our 
intensity tool.
    Because FRCs do a very unique job, this one of care 
coordination, and the needs of the individuals that they deal 
with vary over time and should vary over time and we hope 
diminish over time, their involvement with the clients will 
match that variation and that intensity of need.
    We just really do not have any way to accurately kind of 
account for that at the present time. We are in the process of 
developing this tool that we will use to create, rather than a 
typical caseload, you know, 1 to 4 or 1 to 20 or 1 to 200 
ratio, it will actually be based on points.
    So the intensity of the need of the client is really what 
drives the FRCs' interaction and time. And if we convert the 
traditional caseload management into something else, we think 
it will be a better fit for what this program does over a long 
period of time for each of its clients.
    That said, an assessment tool is a fairly cumbersome thing 
to do and it needs validity testing and reliability testing and 
integrated reliability.
    We are in the process of doing that. We had FRCs come to 
town and spend a couple of days. We have been doing it kind of 
iteratively over the entire time that I have been here and, 
again, assessing that wealth of data that we need in order to 
actually create this.
    So we think that we will probably have that which would be 
the final piece to comply with all of the recommendations. In 
the meantime, we continue to work. We have an equation now for 
staffing needs, which is based on the data elements that I put 
into my written statement. We are working on our placement 
strategy.
    We have now collected data in our data management system 
about exactly where our clients are, where they live, and where 
our referrals come from so that we can kind of look and match 
need. We also know that there is a need to put FRCs at 
polytraumas and we are currently recruiting three additional 
full-time equivalent FRCs to add to our portfolio of 25--to 
bring our portfolio up to 25.
    Ms. Buerkle. My time is running out and I will be yielding 
to the Ranking Member, but I would say that this need has been 
identified since 2007 and I am hearing now today this morning 
that it is going to take another year.
    And my question is, and hopefully I will have another 
opportunity to question this panel, what have you been doing 
since 2007 that now 4 years later we are hearing it is going to 
take another year?
    Dr. Guice. Well, in 2007 was when the program was actually 
given its operational parameters. The program actually really 
did not start until 2008 and as the program has grown--when I 
came close to 3 years ago, we only had 97 clients and seven 
FRCs. I think part of this is growing the portfolio of 
information to understand what drives the involvement of FRCs 
so that we can better balance the caseloads and the work that 
they need to do for that client.
    They are not case managers and it is a different paradigm. 
It is a pure coordination function and there just are not any 
tools to actually help us. And part of it was building the 
knowledge about what it takes, what drives the FRCs' time, and 
we can only get that with a little bit of time to actually 
understand, you know, if someone has a need for a TBI 
assistance program, you know, all the pieces that have to fit 
into getting that resource and aligning that with what the 
client needs. And we just needed the time to develop that 
information base.
    Ms. Buerkle. Thank you, Dr. Guice.
    I would now yield to the Ranking Member.
    Mr. Michaud. Thank you very much, Madam Chair.
    This is for GAO. What do you think the number one barrier 
is to fixing the problems that you identify in the report?
    Mr. Williamson. That is a tough one. I think breaking down 
the culture within DoD and VA so that they can play and can 
collaborate well, they can cooperate. That probably is the 
single most important thing.
    Mr. Michaud. And for the VA and DoD, what do you think it 
will take to break down that barrier, the culture that has been 
instilled in both agencies?
    Mr. Carrington. Quite frankly, we are more than willing to 
have a joint program. And our services that run these programs 
reach out to the available VA representatives that can help 
them take better care of their wounded, ill, and injured and 
their family members.
    Right now there are two separate programs and I think our 
services would tell you in short give us those FRCs, let us 
include them on our team, let us be responsible for them, let 
us put them under our leadership, let's have them focus on 
accomplishing our larger mission, and we would see probably 
more success than what the GAO reported.
    Dr. Guice. For me, the answer would have been if I had been 
given the task to create a joint program, I would not have put 
it in either department. I would have put it somewhere in 
between with joint ownership by both departments which includes 
joint funding.
    I think if you do not have that cooperation and level of 
side by side so that you are working the issues every day, you 
are working the challenges every day, and you have a uniting 
place where those dialogues and that function can occur, having 
it isolated in either department just will not work.
    I think if you look back to the Dole-Shalala Commission and 
now having this experience and look at their recommendation, 
they actually said put it with the Public Health Service. They 
said do not put it in either house. It will then become one or 
the other. It will not be joint.
    And so that was their recommendation. For a lot of reasons, 
that did not happen. And I think looking back on it, putting it 
in a joint space is more appropriate for what we are trying to 
achieve with all of this activity and programs.
    Mr. Michaud. So for everyone on the panel, do you think 
that the FRCPs and the RCP programs can be combined and still 
be effective? And if the programs are combined, what would have 
to change in order to do that?
    Dr. Guice. I think that people would have to sit down and 
talk about that. How does that change the current business 
model for FRCP? It would not be the same program as it is 
today. It would change a bit.
    The same thing for the Recovery Coordination Program and 
how it is currently operationalized. I think you would have to 
talk about how you are going to govern this, who is going to 
be, you know, sort of--how does the staffing work. It would 
take a lot of work, but I do not think that is an impossible 
task, sir. I think a few people and working it hard and truly 
trying to understand it could come up with a solution that 
might be workable.
    Mr. Williamson. I think also it may go beyond just the FRCP 
and the RCC. I think 4 years now after the Walter Reed 
situation, there have been a lot of resources thrown at helping 
the servicemember, wounded, ill, and injured servicemembers. 
And there are now over ten major wounded warrior programs. And 
I think it is time to step back and have an impartial look at 
this.
    Given the culture differences among DoD and VA or between 
DoD and the VA, I am just not sure you are going to get that 
kind of impartialness.
    Mr. Michaud. And, DoD, you want to comment on that?
    Mr. Carrington. I think services run their own unique 
programs based on their culture, philosophy, size of the 
population they are taking care of, and the ultimate goals of 
their wounded warriors and their families. And I think that 
should continue. I think we should recognize the goodness in 
that.
    I also believe that services do a very good job of their 
programs. They could do a better job as I described if we could 
better include the FRC into that team. We are already using 
their resources at some locations. Other locations use VBA, VHA 
resources. We agree that it is a team approach, the recovery 
team, but that takes care of all the needs medical and non-
medical for the recovering servicemember.
    Mr. Michaud. Great. My last question for the VA is, are you 
experiencing a high turnover rate of FRCs and, if so, do you 
think that hurts the program as well?
    Dr. Guice. Since I have been the Executive Director, I 
believe we have had two individuals, three individuals leave 
the program. That is over a period of 3 years. There was some 
turnover in the first 6 months of the program and that was, I 
think, people trying to figure out what the role was and then 
figuring out their skill set and their interests aligned with 
that.
    We currently have three slots that are open and we never 
have a shortage of applicants. I think the program has become 
recognized as a very unique and interesting place to work with 
a very deserving population of seriously-wounded, ill, and 
injured servicemembers that people want to be part of that.
    The three that have left since I have been here have been 
for personal reasons. One retired after 30 years in the VA. 
Another one had some family issues that had to take care of. 
Another one left for a different job opportunity that she was 
interested in.
    Mr. Michaud. Thank you.
    Thank you, Madam Chairman.
    Ms. Buerkle. Thank you, Mr. Michaud.
    At this time, I would like to thank the three panel members 
for testifying here this morning.
    We will have another hearing within the next few months in 
order to follow-up on this. I think that the intent of this was 
to help the wounded warriors when they are injured and when 
they come back home and need help to navigate through the 
system.
    Time is of the essence. They need our help now. They do not 
need it a year from now or 6 months from now. So I think we 
really need to approach this more urgently. We do not have the 
luxury of just waiting months and months in order to help our 
veterans.
    So with that, I thank you all very much, and I would invite 
the second panel to the table.
    Thank you all very much and welcome. Again, my apologies 
for the delay this morning. I apologize that you had to sit 
here and wait.
    Joining us on our second panel is Mr. James Lorraine, the 
Executive Director of the Central Savannah River Area Wounded 
Warrior Care Project. Prior to his position there, Mr. Lorraine 
worked with the U.S. Special Operations Command Care Coalition.
    Mr. Lorraine, thank you for joining us.
    We are also fortunate to have two Federal Recovery 
Coordinators with us today to explain their work, Dr. Mary 
Ramos who is currently stationed at the San Antonio, TX, 
Military Medical Center and Ms. Karen Gillette who is currently 
stationed at the Providence VA Medical Center in Providence, 
Rhode Island.
    Also on the panel is Colonel Gregory Gadson, the Director 
of the United States Army Wounded Warrior Care Program, and 
Colonel John Mayer, the Commanding Officer of the Marine Corps 
Wounded Warrior Regiment.
    Gentlemen, thank you very much for your service to this 
Nation and for being here this morning.
    Colonel Mayer, I understand that your family is here in our 
audience.
    Colonel Mayer. Yes, ma'am.
    Ms. Buerkle. If we could ask them to stand, we would like 
to recognize them.
    Colonel Mayer. They are sleeping.
    Ms. Buerkle. I hope that is not a commentary on our 
proceedings.
    Thank you all very much for being here this morning.
    Mr. Lorraine, we are going to start with you, please.

 STATEMENTS OF JAMES R. LORRAINE, EXECUTIVE DIRECTOR, CENTRAL 
SAVANNAH RIVER AREA WOUNDED WARRIOR CARE PROJECTS, AUGUSTA, GA; 
   MARY RAMOS, PH.D., RN, FEDERAL RECOVERY COORDINATOR, SAN 
   ANTONIO, TX, MILITARY MEDICAL CENTER, U.S. DEPARTMENT OF 
    VETERANS AFFAIRS; KAREN GILLETTE, RN, MSN, GNP, FEDERAL 
 RECOVERY COORDINATOR, PROVIDENCE, RI, DEPARTMENT OF VETERANS 
 AFFAIRS MEDICAL CENTER, U.S. DEPARTMENT OF VETERANS AFFAIRS; 
 COLONEL JOHN L. MAYER, USMC, COMMANDING OFFICER, MARINE CORPS 
   WOUNDED WARRIOR REGIMENT, U.S. DEPARTMENT OF DEFENSE; AND 
   COLONEL GREGORY GADSON, USA, DIRECTOR, U.S. ARMY WOUNDED 
              WARRIOR PROGRAM, U.S. DEPARTMENT OF
                            DEFENSE

                 STATEMENT OF JAMES R. LORRAINE

    Mr. Lorraine. Thank you, ma'am.
    Chairwoman Buerkle, Representative Michaud, distinguished 
Members of the Committee, thank you for the opportunity to 
speak with you today about the Federal Recovery Coordination 
Program.
    I would like to ask that my written statement be submitted 
for the record.
    Ms. Buerkle. So ordered.
    Mr. Lorraine. I would like to thank the Committee for its 
continuing efforts to support servicemembers and veterans and 
their families as they navigate through the complex web of 
government and non-government programs.
    I have been a member of the military community my entire 
life, a Reservist, active-duty servicemember, military spouse, 
retiree, government civilian, and veteran.
    In my previous position as the Founding Director of the 
United States Special Operations Command Care Coalition, an 
organization which advocates for over 4,000 wounded, ill, or 
injured special operations forces and has been recognized as 
the gold standard of non-clinical care management, I recognized 
a gap in my advocacy capabilities and incorporated a Federal 
recovery coordinator as a team member.
    This one Federal recovery coordinator dramatically improved 
how Special Operations provides transition care coordination 
and made my staff more efficient, more effective in support of 
the wounded warriors and our families throughout the Nation.
    It is essential that our military and veterans have strong 
advocates both government and non-government working together. 
One program by itself is not enough when it comes to supporting 
these heroes.
    I recently left government service to assume duties as the 
Executive Director of the Central Savannah River Area Wounded 
Warrior Care Project where my current position is to integrate 
services by strengthening community-based organizations that 
maximize the potential of government and non-government 
programs in Augusta, Georgia, and throughout the region. The 
Federal Recovery Coordination Program is one of these 
resources.
    From my experience, care coordinators require three 
attributes in order to be successful: The ability to anticipate 
needs; the authority to act; and the access to work as a team 
member.
    The first attribute, the ability to anticipate need, is 
much like a chess master thinking five to ten moves ahead. This 
assumes effectiveness and competence in various levels of the 
system.
    By design, the Federal recovery coordinator has the 
education credentials and experience to anticipate need by 
functioning at a high level of competence.
    We feel a certification program is necessary to prepare 
these coordinators to engage in a broad spectrum of Federal and 
local resources available in areas of not only health care but 
with a focus on behavioral health, family support, and access 
to benefits.
    The second attribute is the authority to act. In this 
complex environment of wounded warrior recovery, someone who 
can not act is an obstacle. Actions must occur at a strategic 
level to ensure case management is being accomplished, services 
are being provided, and Veterans Affairs' resources are being 
maximized in concert with government and non-government 
programs.
    The Federal recovery coordinator's authority should be 
strengthened from what it is today and remain subordinate to 
the Veterans Affairs' Central Office in order to influence 
actions across the Nation. This ability is unique and should be 
capitalized on by the Department of Defense service wounded 
warrior programs and strengthened by the Veterans Benefits 
Administration.
    The last attribute is to the access to work as a team. I 
believe this is the greatest challenge for the Federal Recovery 
Coordination Program. It is the most complex of the three 
attributes because it requires others to be inclusive, sharing 
of information, trust, and a great deal of time and coordinated 
and synchronized efforts.
    Federal recovery coordinators must function in a strategic 
coordination role working by, through, and with wounded warrior 
programs while also leveraging Veterans Affairs' case managers 
and benefits counselors.
    Lastly, the scope of the Federal Recovery Coordination 
Program should be expanded to assist not only those most severe 
cases, but those in combination of family dynamics, behavioral 
health issues, unemployment, homelessness where benefits 
anomalies inhibit their smooth transition to civilian life.
    In conclusion, we have three recommendations: Maintain a 
high credentialing standard, but augment with a nationally 
recognized certification; ensure coordinators have the 
authority to act on needs they have identified; make certain 
the Federal recovery coordinators have access to work as a team 
member by incorporating them early in the recovery process.
    There is currently a very positive feeling in the country 
towards the service and sacrifice of military, veterans, and 
their families and a desire to support them. One way to help is 
to utilize existing programs, especially at the local level.
    The Central Savannah River Area Wounded Warrior Care 
Project stands as a model for many communities throughout the 
Nation who are at the front line of helping our wounded, our 
veterans come home all the way from combat to fully 
reintegrated into our community.
    It is important to educate the military and their families 
about their transition, but it is frequently too late when the 
transition has occurred and life's daily pace takes over.
    Thank you for providing us the opportunity to brief before 
the Committee.
    [The prepared statement of Mr. Lorraine appears on p. 40.]
    Ms. Buerkle. Thank you, Mr. Lorraine, and thank you for 
your service to our country.
    Dr. Ramos.

               STATEMENT OF MARY RAMOS, PH.D., RN

    Dr. Ramos. Thank you.
    Good morning, Chairman Buerkle, Ranking Member Michaud, and 
Members of the Subcommittee. My name is Mary Ramos and I have 
been a Federal Recovery Coordinator located at San Antonio 
Military Medical Center for 3 years.
    I am honored to be here today and I would like to request 
my written statement be submitted for the record.
    Ms. Buerkle. So ordered.
    Dr. Ramos. In my position, I work hand in hand with those 
who touch the lives of my wounded, ill, and injured clients in 
order to facilitate the very best clinical and non-clinical 
outcomes.
    In explaining my role, I often say that I make sure that 
life details happen so that clients can concentrate on recovery 
and rehabilitation and so their families can support them as 
they adjust to a ``new normal.''
    A Federal recovery coordinator is the consummate team 
member with a unique role in the very complex matrix of care 
providers. The FRC role is one of overarching coordination. In 
operational terms, that means while others have a defined 
``lane,'' FRCs coordinate across ``lanes.'' We communicate with 
key members of the provider and support teams and in 
partnership assess whether there are interventions or bits of 
information that might assist in optimizing outcomes.
    There is a core of people supporting and coordinating care, 
but the preparation of an FRC is unique in that we are all at 
least master's prepared health care professionals with 
expertise and/or resources in all of the systems touching the 
recovering servicemember or veteran.
    There are others with more depth of knowledge in a single 
sphere, but the FRC has the background and experience to put 
each interfacing system into context. We help others to gain an 
understanding of how each issue has an impact on the clients 
and family.
    Our ultimate goal as nurses and social workers is 
maximizing independence and maximizing life care skill by 
providing support and education to our wounded, ill, and 
injured.
    FRCs at San Antonio or Brooke Army Medical Center (BAMC) 
usually introduce clients to the FRCP early in the initial 
hospitalization. While each client has a full complement of 
care providers in this phase of high acuity, non-clinical 
details can be addressed to facilitate future care and quality 
of life and anticipate upcoming needs.
    The FRC provides emotional support to the client and family 
and interfaces with the team regularly. The most important 
element the FRC contributes at the early treatment phase is the 
concept of seamless, long-term clinical and non-clinical care 
coordination. The FRC is a consistent person in the journey 
from acute care through community reintegration.
    It is true that when a client is in intensive care, he or 
she is not thinking about whether or not they will want to 
leave the service or whether or not they will seek funding to 
attend college, but the FRC can assure the client that when 
they are ready for those decisions, their FRC will be there 
supporting those decisions within a close professional 
relationship that has grown over time.
    The key to success in our collaborative role is 
communication and an understanding of the contribution of each 
team member.
    In the 3 years that I have been an FRC, global 
understanding of the role has grown. Each working contact 
increases knowledge about the program. The most effective 
advertisement for the FRCP is the success each of us has every 
day in working with clients. Personal contacts and professional 
relationships mean that referrals are facilitated.
    Each day as an FRC is an adventure in providing support 
that could in all likelihood otherwise fall through the cracks 
given the complexity of some of these cases. Much of what I 
provide is not quantifiable and some of what I provide would 
possibly not be missed by a client who did not anticipate a 
sound safety net.
    However, I have come to realize that an intimate 
understanding of a servicemember's or veteran's perspective of 
every-day life with an overlapping and possibly complicated 
delivery system equips me to find that perhaps small 
intervention that improves the quality of life for those who 
risked everything for my freedom and for my grandchildren's 
freedom.
    I have never served in battle, but I am honored to bring 
every minute of my personal and professional experience to bear 
in caring for those who have borne the battle.
    Thank you for inviting me here to testify today to discuss 
our program. My colleagues and I are prepared to answer your 
questions.
    [The prepared statement of Dr. Ramos appears on p. 42.]
    Ms. Buerkle. Thank you, Dr. Ramos.
    Ms. Gillette.

           STATEMENT OF KAREN GILLETTE, RN, MSN, GNP

    Ms. Gillette. Good morning, Chairwoman Buerkle, Ranking 
Member Michaud, and Members of the Committee.
    My name is Karen Gillette and I am a Federal recovery 
coordinator from Providence, Rhode Island.
    Thank you for inviting me today to tell you what I do as an 
FRC and to assist recovering servicemembers, veterans, and 
their families as they heal and return home.
    My testimony will focus on my roles and responsibilities in 
service of my clients.
    Thank you for allowing me to submit my written testimony 
regarding my role.
    I have been an FRC for 3 years. I currently have a caseload 
of 55 clients. Thirteen of those clients are currently active 
duty, 42 are veterans. Some of my clients have been recently 
injured and are still being treated at military treatment 
facilities while others are receiving care at private 
rehabilitation facilities.
    I have clients, now veterans, who were injured several 
years ago and continue to need assistance with veterans' 
benefits, case management, vocational rehabilitation benefits, 
or help finding community resources.
    My experience in this field stems from my clinical and 
administrative experiences as a nurse practitioner and as a 
nurse executive and from the extensive training, Federal 
Recovery Coordination Program training and education on 
veterans' benefits programs, military programs, TRICARE, Social 
Security, U.S. Department of Labor programs, and VA programs.
    My caseload consists of referrals from many sources. 
Referrals come from VA case managers, military personnel, 
caregivers, community and charitable organizations, and clients 
who also refer other wounded warriors to our program.
    I currently work with case managers located in over 35 VAs 
across the country. We collaborate and share resources, 
suggestions, and information that meet the clients' needs. I 
work with VBA personnel who manage the compensation claims, 
vocational rehabilitation, and fiduciary needs of my clients at 
VBA sites across the country.
    Beyond the VA, I work with staff at the Social Security 
Administration, State disability and Medicaid case managers, 
and TRICARE and military nurse case managers on a regular 
basis.
    I stay in close contact with the different Wounded Warrior 
Program representatives and we discuss resources and options 
that might be of benefit to the shared clients.
    We collaborate closely and make sure that the right person 
is doing what is needed and ensure that there is no duplication 
of effort. I work with recovery care coordinators on some cases 
that we share.
    My job is to ensure that all of my clients are moving 
closer to the goals that they established on their Federal 
individual recovery plan.
    I would like to share an example of a client that I have 
worked with that is fairly typical of some of the issues we 
address. I spoke with a case manager at a military treatment 
facility about a new referral. This client had not used the VA 
for health care and had been out of the military for 2 years.
    In addition, the client's veterans' benefits monthly 
special compensation had been decreased, which resulted in the 
veteran having to relocate across the country to live with 
family to be able to afford to live.
    I reviewed the veteran's rating letter and found that the 
rating decrease was possibly due to inadequate documentation 
that had been provided to the rater.
    I began to educate this individual and his family about our 
program and to assist the veteran with collecting the necessary 
documentation to support his appeals claim.
    I called the Marine District Injured Support Cell (DISC) in 
the area and asked him to contact this former Marine as an 
additional support to the family. I connected the veteran with 
a local VA care management team who then contacted the family 
and this client to provide assistance.
    There are many other examples that I could provide that 
describe how closely I work with VA staff, VBA staff, and 
military teams including the different wounded warrior programs 
on a daily basis.
    In conclusion, in the 3 years I have worked as a Federal 
recovery coordinator, I have established rapport with most of 
the stakeholders involved in moving these catastrophically ill 
and injured servicemembers and veterans into a more stable and 
satisfactory life situation.
    I found that what appears to be a simple to resolve 
situation can take multiple phone calls and e-mails to keep the 
process moving forward towards resolution. It takes effective 
communication with a variety of people to address my clients' 
complex needs.
    I provide support as relationships are established with VA 
teams increasing the veteran and family's trust and willingness 
to choose the VA as their health care provider.
    I am proud to serve our country's veterans and 
servicemembers that have sacrificed so much for our country.
    Thank you for having me here today to share with you my 
experiences and I look forward to your questions.
    [The prepared statement of Ms. Gillette appears on p. 47.]
    Ms. Buerkle. Thank you, Ms. Gillette.
    Colonel Mayer.

            STATEMENT OF COLONEL JOHN L. MAYER, USMC

    Colonel Mayer. Good afternoon. Thank you, Chairwoman 
Buerkle, Ranking Member Michaud, and distinguished Members of 
the Subcommittee. It is my privilege to appear before you 
today.
    I also thank you for allowing my family in and I am sure 
they are getting a great education from this afternoon.
    As the Commanding Officer of the Marine Corps Wounded 
Warrior Regiment, I am charged with ensuring the Nation's 
wounded, ill, and injured Marines and their families receive 
the best medical care and support possible.
    These Marines and their families have made selfless 
sacrifices that have resulted in life-changing events. Some are 
even catastrophic. Whether wounded in combat, injured in 
training, or fallen ill, these great Marines and their families 
deserve the very best, the very best top-notch support to 
include resources and tools they need to return to either 
active duty or transition to civilian life.
    This support is provided by the recovery team. The recovery 
team for the Marine Corps consists of Marine section leaders, 
staff sergeants in charge of their leadership and 
accountability and motivation. It consists of recovery care 
coordinators, which are mandated by Congress, to be the experts 
in non-medical needs, and then the case managers provided by 
the hospitals, whether it be Navy or Army, depending on what 
hospital the current Marine is at. Together this team works to 
provide the very best support.
    The recovery care coordinators are an integral part of the 
Marines' recovery equation because they are part of the Wounded 
Warrior Regiment and work hand in hand with all the staff such 
as the Federal recovery coordinators to ensure Marines not only 
heal medically, but also pursue programs to improve their mind, 
body, spirit, and their families.
    The Marine Corps recognizes the value of the Federal 
Recovery Coordination Program and the role that the Federal 
recovery coordinators serve for Marines to transition at the 
transition point or when they transition into becoming 
veterans.
    The Federal recovery coordinators also serve a valuable 
complementary role to recovery care coordinators in providing 
care to our catastrophically injured active-duty Marines.
    Warrior care is a top priority for the Marine Corps and I 
can assure the Subcommittee that we will continue to enhance 
the capabilities of the Wounded Warrior Regiment to provide 
added care and support to our wounded, ill, and injured 
Marines.
    Thank you.
    [The prepared statement of Colonel Mayer appears on p. 49.]
    Ms. Buerkle. Thank you, Colonel Mayer.
    Colonel Gadson, you may proceed. Thank you.

            STATEMENT OF COLONEL GREGORY GADSON, USA

    Colonel Gadson. Good afternoon. Thank you, Chairman 
Buerkle, Ranking Member Michaud, and all the Members of the 
Subcommittee for inviting me here to appear today. I am honored 
to be here.
    As a wounded warrior myself, I wish to thank all the 
Members of this Committee for their interest in the health and 
welfare of our wounded, ill, and injured servicemembers and 
veterans.
    I would like to request my written statement be submitted 
for the record.
    Ms. Buerkle. So ordered.
    Colonel Gadson. The lead proponent of the Army's Warrior 
Care and Transition Program or WCTP is the Warrior Transition 
Command under the command of Brigadier General Darryl A. 
Williams.
    I am the Director of the Army Wounded Warrior Program or 
AW2, an activity of the Warrior Transition Command. AW2 
supports severely-wounded soldiers, veterans, and family 
members through their recovery and transition and even when 
they separate from the Army. We do this through more than 170 
AW2 advocates to provide local personalized support to more 
than 8,300 soldiers, veterans currently enrolled in the 
program.
    The WCTP also encompasses the 29 warrior transition units 
or WTUs located around the country and in Europe where wounded, 
injured, and ill soldiers heal from and prepare for their 
transition.
    I have advocates at each of these WTUs to work with these 
soldiers, families, and WTU personnel to ensure the smoothest 
possible transition for soldiers.
    Each soldier in a WTU is assigned a triad of care 
consisting of a primary care manager, usually a physician, a 
nurse case manager, and a squad leader.
    In addition, the WTUs have a multi-disciplinary approach 
that includes a wide range of clinical and non-clinical 
professionals. AW2 advocates work closely with each of these 
professionals in support of their individual soldier.
    A requirement for every servicemember in the Federal 
Recovery Care Program is to have a comprehensive needs 
assessment or Federal individual recovery plan. This is 
accomplished within the WTUs through a comprehensive training 
plan or CTP wherein soldiers set long and short-term goals in 
each of the six domains of life, family, social, spiritual, 
emotional, career, and physical.
    Families are closely involved with this CTP progress and 
family is one of the six domains of goal setting in this CTP. 
They are all invited to all of the focused transition review 
meetings and to all medical appointments.
    When at AW2 soldier separates from the Army and transitions 
to veteran status, an AW2 advocate continues to support the 
soldier or veteran and their family.
    Another key component of the WCTP is the soldier family 
assistance centers or SFAC on site at the WTUs. They bring 
together many of the programs soldiers and families need to 
provide assistance with everything from child care and lodging 
to arranging for VA care and benefits.
    The Federal Recovery Coordination Program has the potential 
to facilitate positive quality integration across various 
programs throughout the Federal Government and supports the 
severely-wounded, injured, and ill servicemembers.
    The AW2 advocates on my staff report having positive 
relationships with the FRCs and indicate that the FRCs are 
well-trained professionals. The FRCs are well-versed in the 
resources provided by the Department of Veterans Affairs and 
other resources available in their regions.
    I want to discuss the GAO's recommended actions for the 
FRCP. As you have read in the comment section of the GAO 
report, the Honorable John Campbell, Deputy Assistant Secretary 
for Defense Wounded Warrior Care and Transition Policy, 
committed the Department of Defense to continuing to 
collaborate with the VA on these issues.
    A joint DoD/VA Committee has been formed to study how to 
combine and integrate recovery coordination efforts for 
wounded, injured, and ill servicemembers, veterans, and 
families.
    Recommendation one of the GAO report discusses establishing 
adequate internal controls regarding the FRCs' enrollment 
decisions. This is not a problem at AW2. While FRCs are 
afforded broad discretion in determining which servicemembers 
are admitted to the program, AW2 has clear eligibility criteria 
with all eligibility decisions being made at the headquarters 
level.
    The GAO's next recommendation discusses the FRCP's efforts 
to manage the workloads of individual FRCs based on the 
complexity of the services needed. At AW2, we pay very close 
attention to the caseloads of our AW2 advocates. The average 
caseload is 1 to 50, but each soldier requires a different 
level of support depending where he or she is in the recovery 
and transition process.
    For example, AW2 veteran Kortney Clemons, a severely-
wounded veteran, who no longer requires significant level of 
support from AW2, lost his right leg above the knee. Kortney 
has been out of the Army for more than 5 years. He has gone on 
to become an elite level runner and is training for the 
Paralympic games in London next year. He is currently enrolled 
in a master's program at University of Kansas and no longer 
requires the same level of support from an AW2 advocate that he 
did when he was first injured.
    AW2 recognizes that many soldiers and veterans we support 
become more independent as they heal and transition to the next 
phase of their lives. We developed a life cycle case management 
plan or LCMP to help AW2 advocates identify the level of 
support each soldier needs.
    There are four phases. When a soldier requires a 
significant level of support, AW2 calls them at least once a 
month and in some cases and in many cases more. As they 
progress and become more independent, we call them less 
frequently. In the last case, we only call them 180 days.
    I am proud to say that I am one of those that is in the 
lifetime phase of our LCMP.
    Soldiers and veterans can always call their AW2 advocates 
or the AW call center at any time. This initiative allows AW2 
advocates to focus on those with more immediate support.
    The GAO's third recommendation addresses the FRCP's 
decision-making process for making staffing decisions. AW2 
faces the same challenges as the FRCP on this issue. It is 
difficult to predict how many soldiers will qualify for our 
program in the future.
    In 2010, we accepted more than 2,000 soldiers into the 
program. This fact makes it more important that we ensure the 
AW Program runs as efficiently as possible.
    The GAO's final recommendation calls for the FRCP to 
develop a clear rationale for the placement of FRCs. At AW2, we 
evaluate our staffing on a quarterly basis. We assign advocates 
where we have the highest populations of AW2 soldiers and 
veterans essentially by zip codes.
    I would submit that by aligning FRCs in a similar manner 
regionally would better serve both them and the servicemembers 
they serve.
    The GAO report also highlighted the challenges and 
information sharing between DoD and VA. We recognize the 
importance of this challenge. For over a year now, the Warrior 
Transition Command has been developing automated systems that 
are part of an integrated system for tracking and managing the 
care of soldiers and veterans.
    Currently being completed for implementation later this 
year is the central module of this system referred to as the 
Automated Warrior Care and Tracking System which contains the 
history of each soldier and veteran's care.
    The Executive Director of the FRCP and Deputy Under 
Secretary of Defense for Wounded Warrior Care and Transition 
Policy are also co-chairing an information sharing initiative 
or ISI to support the coordination of non-clinical care. The 
ISI will enable sharing of authoritative data electronically 
between DoD, VA, and the Social Security Administration for 
case and care management systems.
    In closing, I thank you again, Madam Chairman and Ranking 
Member Michaud, for inviting me here today and for listening to 
my testimony about the Federal Recovery Coordination Program. I 
appreciate your attention to wounded, injured, and ill 
servicemembers and veterans and their families, and I know that 
we share the same goal of providing the best possible services 
to these individuals who have sacrificed so much.
    Thank you and I look forward to your questions.
    [The prepared statement of Colonel Gadson appears on p. 
51.]
    Ms. Buerkle. Thank you, Colonel Gadson.
    I will now yield myself 5 minutes for questions.
    We have heard from a few of the panelists today about the 
need to provide our servicemen and women with top-notch care. I 
think when we talk about providing quality care, we need to 
provide timely care and access to services.
    So I would like it if each one of you would take a few 
minutes to tell me how can we fix this. What do you see? If you 
could give me one way you think we can improve the coordination 
and whether or not you think it is possible to coordinate the 
Department of Veterans Affairs and DoD and to get the job done 
for our wounded warriors, a recommendation, and whether or not 
you think it is possible.
    I will start with Mr. Lorraine. Thank you.
    Mr. Lorraine. Thank you, Madam Chairwoman.
    My recommendation would be to start where the casualties 
begin and that is to integrate the Federal recovery 
coordinators into the wounded warrior programs so that they can 
be integral at their command level so that they can be part of 
the process more as an advisor.
    What we found was that a bulk of our effort while on active 
duty came through the Department of Defense, but there were 
veterans' issues that came along up until the time they retired 
or separated the servicemembers. At that point, it became very 
heavy in Veterans Affairs. DoD did not have the authority to 
influence it. The FRC did. But their success was because they 
were involved in it beforehand.
    What we also found was while the servicemember had an 
affinity towards Special Operations while they were recovering, 
the more the Federal recovery coordinator assisted them after 
their retirement, the more direct they came to the Federal 
recovery coordinator. It was a very smooth transition.
    So if there is one recommendation, it would be to integrate 
the Federal recovery coordinators at the headquarters levels of 
the service programs, to engage early and to provide strategic 
engagement, solving problems, and directing the local folks as 
needed.
    Ms. Buerkle. Thank you, Mr. Lorraine.
    Dr. Ramos, before you comment, are you included when the 
servicemember is still in acute care and in the hospital 
setting? Are you a part of the discussion at that point?
    Ms. Ramos. Yes, ma'am. We have been alerted usually by the 
case management team when patients are still in their initial 
hospitalization that it is anticipated that they will need the 
services of the FRCP and that a Federal recovery coordinator 
would be advantageous as a participant in the team.
    We have open access to all of the medical conferences, all 
of the discussions, all of the records, and have close 
communication with the care management team as well as the 
providers. We also identify at that point in time who the squad 
leader is and we will have discussions with the squad leader as 
is appropriate.
    I also have very close communication with the medical 
director of our WTU, our warrior transition unit, and with the 
primary care providers who actually do the medical care on an 
outpatient basis.
    So I have open access to everyone and they will ask me 
questions. And I will participate as appropriate in the team, 
although I must admit there are many cases where the 
coordination is going well and what I am doing at that point in 
time is establishing a relationship that is supportive of the 
family so that they know that the things they are anticipating 
happening in the next 2 to 3 years are going to happen with the 
support of a Federal recovery coordinator at their side.
    And so my usual speech includes, you know, right now your 
job is to support your servicemember in recovery, to take care 
of yourself, and to let me know what bumps are in the road so 
that I can smooth them out for you and you can concentrate on 
what is important right now.
    Ms. Buerkle. Thank you, Dr. Ramos.
    Ms. Gillette.
    Ms. Gillette. Thank you.
    I think what I would find the most beneficial, and it 
sounds a little self-serving, is more FRCs around the country. 
You know, we do have a heavy caseload and while I feel like I 
am being very efficient, I could be a lot more efficient 
because there are so many clients out there that are considered 
category two that I assist, but I would really like to carry on 
my caseload.
    Ms. Buerkle. And in your institution in Providence, do you 
have the same situation? Are you included in the acute care 
setting in the discussion in the beginning of the planning?
    Ms. Gillette. The clients that I have that are in an acute 
care setting such as right now I have six at Walter Reed, when 
they have team meetings, I know ahead of time and I can call in 
and participate.
    But when they are in the acute care phase, I spend a lot 
more time supporting the family, preparing the family for 
future planning, letting them know that when we are talking 
about discharge planning, for instance, a client I have right 
now in Tampa who is from Boston, working with the mother of 
thinking about future planning for this young man when he comes 
home to Boston because he will need a type of a TBI-assisted 
living setting.
    Ms. Buerkle. Thank you.
    Colonel Mayer.
    Colonel Mayer. Ma'am, as a commander, especially a 
commander of Marines, I am in charge of everything the Marine 
does and fails to do. Same with his recovery process. And so 
from the beginning, we set goals and the team, the recovery 
team, as I mentioned before, helps the Marine and his family 
achieve those goals.
    And the multi-disciplinary team meetings start right from 
the beginning and they go sometimes daily at the beginning when 
there is a big need and then continuing throughout his 
transition and even beyond.
    And the FRC plays an important part and I ask that they get 
involved with the multi-disciplinary team meetings from the 
beginning, but realize that the Marine, while he is on active 
duty, is going to be under the responsibility of the Marine 
leadership at that particular location. But they play a huge 
part, a complementary part as a member of the team.
    Ms. Buerkle. Thank you, Colonel.
    Colonel Gadson.
    Colonel Gadson. Yes, ma'am. I think what I would do is I 
would kind of echo a little bit of what I said and kind of 
combine with Jim and Ms. Gillette's statement and that is 
establishing a uniform criteria for who will receive the 
services of the FRC.
    And I think that is done at the point of entry and I think 
that will drive, as Ms. Gillette said, more FRCs. If we 
establish a criteria, then we can predict and understand the 
population that we are going to go after and serve and then 
bring up the levels of FRCs that are out there.
    They are powerful members of the team and have again 
tremendous experience and expertise, which everyone has 
demonstrated. It is just a matter of really, I think, having 
them in the kind of numbers that would make a difference across 
the larger force.
    Ms. Buerkle. Thank you, Colonel Gadson.
    Since I appear to have extra time for questions, I will 
indulge myself.
    If you could, would you all mind telling me what is the 
most common issue that you confront with a wounded warrior? We 
will start with Mr. Lorraine.
    Mr. Lorraine. I think the most common issue that I confront 
now are folks who fit in the cracks. They do not qualify for 
the, and I will use the Army, an Army soldier, they may not 
qualify for the Army Wounded Warrior Program because of the 
severity of their injury. They are not severe enough to be an 
FRC. They are already discharged out of the Warrior Transition 
Command.
    So they are a veteran who does not fall within any of the 
programs that exist and they need some guidance. To get through 
the system, it is sort of like handing somebody the New York 
City Yellow Pages and say here you go, you can figure this out. 
And most of our folks just cannot take that step to do it. It 
is difficult to find out who they can trust, who will take 
action. And that is really what the big thing is.
    So how do you find the folks who are in the greatest need? 
There is a lot of folks who slip between the cracks. That is 
why I would advocate for more FRCs, but a broader--they need 
one person to touch, as a veteran, one person to touch who can 
access both the benefits and the health care system, that can 
guide them through and shepherd them not just because of the 
severity of the wound, but the economic or the social position 
that they may have fallen into post service.
    Ms. Buerkle. Thank you, Mr. Lorraine.
    Mr. Lorraine. Yes, ma'am.
    Ms. Buerkle. Dr. Ramos.
    Ms. Ramos. I think the most common thing that I am having 
to cope with is a client and a client's family who are frankly 
totally overwhelmed. This is not a chronic condition. This is 
an acute injury for the most part. This has been a surprise. 
Their whole lives have been derailed.
    They are coming usually to San Antonio from another place 
in the country. They are trying to deal with caring for their 
children, caring for their warrior, caring for themselves, 
trying to coordinate communication, trying to understand what 
is going on with their wounded or injured servicemember, and 
they are totally overwhelmed by the health care issues, the 
social issues, the logistical issues, and trying to carry on 
within every-day life.
    I think it would help if there were a single point of 
contact, but I have to tell you that in my particular setting, 
we kind of negotiate that within the team. Often there is a 
great level of rapport with the special forces person or the 
RCC from the Marines or the case manager who is doing the 
inpatient care. Sometimes it is the Federal recovery 
coordinator.
    But as a team, we kind of decide who is going to be the 
lead for the moment because the situation is so fluid and it 
changes so quickly, we feel it is critical so that the family 
member will have a point of contact.
    We also need for them to have a single point of contact 
because it can be very confusing if we have mom going one 
place, dad going another place, and wife going another place.
    So communication is the key to defusing these situations, 
but I am constantly coping with people who are overwhelmed by 
what is going on and feeling responsible for making sure that 
they feel safe in the situation.
    Ms. Buerkle. And would you say that the services that they 
need to deal with their situation are available?
    Ms. Ramos. Oh, totally.
    Ms. Buerkle. Okay.
    Ms. Ramos. Totally. I love working with my Marines. We have 
the most wonderful services for our individual servicemembers. 
The Navy Safe Harbor people there are wonderful. The AW2s are 
unfailingly helpful. I love the Marines and, you know, the air 
force people are great.
    I carry clients from all four services obviously and Army 
medical center, I carry mostly Army people, but as an FRC who 
takes a lot of the burn patients, I have everybody because we 
are the burn center. And the confusion is the difficulty, just 
people being totally overwhelmed by the situation.
    Ms. Buerkle. So it seems to me if the services are 
available, that is the difficult part. The easy part should be 
the coordination and so that really needs to be the focus 
obviously for the first panel as well in order to get the 
servicemembers what they need.
    Ms. Ramos. I think that at my particular location, we do a 
great job of that because we do talk to each other openly and 
we are always in communication with the different members of 
the care provision team. And we all are totally focused on the 
client and the family. We just work that way. So it is very 
satisfying. It is a difficult job, but it is very satisfying.
    Ms. Buerkle. Thank you.
    Ms. Gillette.
    Ms. Gillette. Being located in the northeast, I will have 
to say that the resources are not available. Many of my clients 
are in very rural areas. For instance, I have 15 clients in 
upstate New York. It is very difficult at times to have a young 
man who had a severe TBI, wants to live at home, which is in a 
rural part of New York, the VA does not provide transport--they 
provide transportation into the VA but nowhere else, and he 
cannot drive. And his family all works.
    So when the veterans, even some of them are still active 
duty but on terminal leave, get into their home setting which 
is a very rural site, the resources are not there. So I spend a 
lot of time working with overwhelmed families, wives, mothers 
who are exhausted, trying to make sure that every VA resource 
and State resource is available to them and then trying to pull 
together charitable organizations, veterans' organizations to 
put all the other pieces together.
    Ms. Buerkle. Thank you.
    Colonel Mayer.
    Colonel Mayer. Yes, ma'am. For the most part, the 
opportunities far exceed the demand for the various 
opportunities. Most of the Marines are 18 to 25 right out of 
high school, when they join the Marine Corps, went through 
training, went over to the war, and then are catastrophically 
injured. And so it is the overwhelming nature of now trying to 
understand the Marine Corps, trying to understand the hospital 
system, and trying to understand the future and setting the 
goals and then sticking with the goals in the new State.
    And I think that, ma'am, the coordination is there and I 
think we do a super job at all the different locations, and you 
heard about Brooke Army Medical Center down there, of working 
at the tactical level to achieve the goals of the Marines.
    Oftentimes it is too many people saying here is what we 
should be doing next. And so I would say most are overwhelmed 
with just trying to understand what is next and the way to go.
    Ms. Buerkle. Thank you, Colonel Mayer.
    Colonel Gadson.
    Colonel Gadson. Yes, ma'am. I am going to echo Colonel 
Mayer. As someone who lost, you know, both my legs, you are 
just overwhelmed with advice, overwhelmed with input. And I 
think that is still a challenge today.
    And then really about the transition, I mean, as well-
intentioned as we all are about helping these folks and their 
families move on, everybody has their own individual timeline 
and it takes some time. And it might be 3 years, it might be 4 
years before someone is ready to come back on a net and move on 
with their life.
    And so there can sometimes be a lot of lost ground and 
those are some of the big challenges I think all the programs 
face.
    Thank you.
    Ms. Buerkle. Thank you, Colonel Gadson.
    Thank you to all of the members of the second panel for 
sharing your expertise with us.
    As I mentioned earlier, I would like to follow-up this 
hearing with another hearing to hear how the program is 
progressing and to make sure we, as a Nation, provide what our 
wounded warriors need from us.
    I ask unanimous consent at this time that all Members have 
5 legislative days to revise and extend their remarks and 
include any extraneous materials. Without objection, so 
ordered.
    Thank you all again. Thank you to the witnesses. Again, my 
sincere apologies for the delay this morning.
    And at this time, the meeting is adjourned. Thank you.
    [Whereupon, at 12:49 p.m., the Subcommittee was adjourned.]



                            A P P E N D I X

                              ----------                              

             Prepared Statement of Hon. Ann Marie Buerkle,
                   Chairwoman, Subcommittee on Health
    Good morning and thank you all for joining us today as we examine 
``The Federal Recovery Coordination Program: From Concept to Reality.''
    The Federal Recovery Coordination Program was the brain child of 
the Commission on Care for America's Returning Wounded Warriors, 
commonly known as the Dole-Shalala Commission.
    The Commission, which was established in 2007, rightly recognized 
that navigating the complex maze of Department of Defense (DoD) and 
Department of Veterans Affairs (VA) care, benefits, and services can be 
a task of almost Herculean effort for wounded warriors and their 
families at a time when all of their energy and focus should be on 
recovery.
    The Commission recommended that we swiftly develop a program to 
establish a single point of contact for wounded warriors and their 
families to make these systems more manageable, eliminate delays and 
gaps in treatment and services, and break through VA and DoD 
jurisdictional boundaries to ensure a truly seamless transition.
    However, almost 4 years since DoD and VA signed a memorandum of 
understanding to establish the Federal Recovery Coordination Program, 
significant challenges persist in areas as fundamental as identifying 
potential enrollees, reviewing enrollment decisions, determining 
staffing needs, defining and managing caseloads, and making placement 
decisions.
    Further, it appears that rather than having the joint program 
envisioned by the Commission to advocate on behalf of wounded warriors 
and ensure comprehensive and seamless rehabilitation, recovery, and 
transition, we have two separate programs--a VA program that utilizes 
Federal Recovery Coordinators and a DoD program that utilizes Recovery 
Care Coordinators.
    The intent was to streamline. The intent was to simplify. The 
intent was to serve the most seriously wounded, ill, and injured. But, 
instead, there is duplication, there is bureaucracy, there is 
confusion.
    This is unacceptable in any program that receives taxpayer funding. 
But it is unforgivable in a program that serves our most severely 
wounded servicemembers, veterans, and their families. I want to hear 
from each of today's witnesses how they are going to solve these 
problems.
    I now recognize our Ranking Member, Mr. Michaud for any remarks he 
may have.

                                 
             Prepared Statement of Hon. Michael H. Michaud,
           Ranking Democratic Member, Subcommittee on Health
    Thank you, Madam Chair.
    I would like to thank you for holding this hearing today. Certainly 
this is an important and appropriate topic for this Subcommittee.
    We are here today to examine the effectiveness of the Federal 
Recovery Coordination Program (FRCP) and to assess if outreach has 
succeeded in bringing coordinated care to veterans who were injured 
prior to the FRCP. When a servicemember returns from combat we must 
make every effort and direct our considerable resources to ensuring 
that they and their families receive compassionate, comprehensive, and 
coordinated care from the beginning. Continued oversight of this 
important program is critical because if it is not done right, 
servicemembers suffer.
    For some time now we have heard stories of servicemembers returning 
home from serving their country, with no guidance and no support. Too 
often we hear of families carrying the burden of a servicemember's 
recovery and reintegration back into civilian life. In addition, we 
know that servicemembers experience confusion, redundancy of services, 
and conflicting advice given by the many coordinators that are part of 
the recovery process. I am sure you will agree that we must do better. 
Challenges remain and there is still much work to be done. Although 
there is a solid foundation for the FRCP, I am looking forward to not 
only hearing testimony from the panelists but also having a frank 
discussion on ways to fix the issues and overcome barriers. I am 
confident that by working together we can do just that.
    The Dole-Shalala Commission, which set out recommendations for the 
care of wounded warriors, said it is not enough ``merely patching the 
system, as has been done in the past. Instead, the experiences of these 
young men and women have highlighted the need for fundamental changes 
in care management and the disability system.'' The Commission 
emphasized that significant improvements require a ``sense of urgency 
and strong leadership.''
    I want to take this opportunity to thank you all for your 
dedication to our Nation's veterans.

                                 
              Prepared Statement of Randall B. Williamson,
      Director, Health Care, U.S. Government Accountability Office
 FEDERAL RECOVERY COORDINATION PROGRAM: Enrollment, Staffing, and Care 
                Coordination Pose Significant Challenges
    Chairwoman Buerkle, Ranking Member Michaud, and Members of the 
Subcommittee:
    I am pleased to be here today as you discuss the challenges facing 
the Federal Recovery Coordination Program (FRCP)--a program that was 
jointly developed by the Departments of Defense (DoD) and Veterans 
Affairs (VA) following critical media reports of deficiencies in the 
provision of outpatient services at Walter Reed Army Medical Center. 
This program was established to assist ``severely wounded, ill, and 
injured'' Operation Enduring Freedom (OEF) and Operation Iraqi Freedom 
(OIF) servicemembers, veterans, and their families with access to care, 
services, and benefits.\1\ Specifically, the program's population was 
to include individuals who had suffered traumatic brain injuries, 
amputations, burns, spinal cord injuries, visual impairment, and post-
traumatic stress disorder. From January 2008--when FRCP enrollment 
began--to May 2011, the FRCP has provided services to a total of 1,665 
servicemembers and veterans; of these, 734 are currently active 
enrollees.
---------------------------------------------------------------------------
    \1\ 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.
---------------------------------------------------------------------------
    As the first care coordination program\2\ developed collaboratively 
by DoD and VA, the FRCP is more comprehensive in scope than clinical or 
nonclinical case management programs. It uses Federal Recovery 
Coordinators (FRC) who are either senior-level registered nurses or 
licensed social workers to monitor and coordinate both the clinical and 
nonclinical services needed by program enrollees by serving as a link 
between case managers of multiple programs. Unlike case managers, FRCs 
have planning, coordination, monitoring, and problem-resolution 
responsibilities that encompass both health services and benefits 
provided through DoD, VA, other Federal agencies, States, and the 
private sector.
---------------------------------------------------------------------------
    \2\ 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.
---------------------------------------------------------------------------
    The FRCs' primary responsibility is to work with each enrollee 
along with his or her family and clinical team to develop a Federal 
Individual Recovery Plan, which sets individualized goals for recovery 
and is intended to guide the enrollee through the continuum of care.\3\ 
As care coordinators, FRCs are generally not expected to directly 
provide the services needed by enrollees. However, FRCs may provide 
services directly to enrollees in certain situations, such as when they 
cannot determine whether a case manager has taken care of an issue for 
an FRCP enrollee, when asked to resolve complex problems, or when 
making complicated arrangements.
---------------------------------------------------------------------------
    \3\ The continuum of care consists of three phases: acute medical 
treatment and stabilization, rehabilitation, and reintegration--either 
a return to active duty or to the civilian community as a veteran.
---------------------------------------------------------------------------
    The FRCP is administered by VA, and FRCs are VA employees. Since 
beginning operation in January 2008, the FRCP has grown considerably 
but experienced turmoil in its early stages, including turnover of 
staff and management. At present, there are 22 FRCs who have been 
located at various military treatment facilities, VA medical centers, 
and the headquarters of two military wounded warrior programs. While 
the FRCs are physically located at certain facilities, their enrollees 
are scattered throughout the country and may not be receiving care at 
the facility where their assigned FRC is located.
    My testimony is based on our March 2011 report,\4\ which examined 
several FRCP implementation issues: (1) whether servicemembers and 
veterans who need FRCP services are being identified and enrolled in 
the program, (2) staffing challenges confronting the FRCP, and (3) 
challenges facing the FRCP in its efforts to coordinate care for 
enrollees.
---------------------------------------------------------------------------
    \4\ GAO, DoD and VA Health Care: Federal Recovery Coordination 
Program Continues to Expand but Faces Significant Challenges, GAO-11-
250 (Washington, DC: Mar. 23, 2011).
---------------------------------------------------------------------------
    To obtain information about these challenges, we conducted more 
than 170 interviews of the following groups: FRCs; FRCP leadership, 
which includes the Executive Director, the Deputy Director for Health, 
and the Deputy Director for Benefits; leadership officials with DoD and 
VA case management programs, including leadership officials from each 
military service's wounded warrior program; and medical facility 
directors and staff at DoD and VA medical facilities. We interviewed 
the FRCs individually to learn about challenges they have encountered, 
using comprehensive interviews of the 15 FRCs who were working in the 
FRCP in or before December 2009 and limited interviews of the 5 FRCs 
who were hired in January 2010. To develop an understanding about how 
clinical and nonclinical officials and staff interact with the FRCs, we 
conducted site visits and telephone interviews with program officials 
at DoD and VA headquarters and medical facility staff at the DoD and VA 
medical facilities where FRCs are located.\5\
---------------------------------------------------------------------------
    \5\ These facilities included Walter Reed Army Medical Center; 
National Naval Medical Center; Brooke Army Medical Center; Naval 
Medical Center-San Diego; Naval Hospital Camp Pendleton; Eisenhower 
Army Medical Center; and the VA medical centers in Houston, Texas; 
Providence, Rhode Island; and Tampa, Florida. In addition, we visited 
three VA medical centers with which FRCs have significant interaction--
the facilities in Richmond, Virginia; Augusta, Georgia; and San Diego, 
California. At the end of calendar year 2010, following the completion 
of our site visits, the FRCP placed two FRCs at the VA medical center 
in Richmond.
---------------------------------------------------------------------------
    We performed content analysis of the qualitative information 
obtained from the FRCs, DoD and VA program officials, and medical 
facility staff by grouping their responses by topic and then 
identifying response patterns. Content analysis of qualitative 
information obtained from DoD and VA program officials and medical 
facility staff was conducted using a software package, which enabled us 
to analyze responses to specific interview topics for a large number of 
interviews. However, the results from our site visits and interviews 
cannot be generalized because while all DoD and VA facilities could 
potentially interact with FRCs, our review focused on facilities where 
FRCs are located as well as some facilities where FRCs have significant 
interaction. In addition, we obtained and reviewed documentation 
related to the FRCP, including VA's October 2009 handbook on care 
management of OEF and OIF veterans; the FRCP Standard Operating 
Procedures; the FRCP fiscal year 2010 operating plan; and draft FRCP 
procedures, such as the VA handbook on the FRCP.\6\
---------------------------------------------------------------------------
    \6\ The FRCP Handbook was finalized on April 1, 2011.
---------------------------------------------------------------------------
    We conducted the performance audit for our report from September 
2009 through March 2011 and updated certain data elements in May 2011 
for this testimony, in accordance with generally accepted government 
auditing standards. These 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.
    In summary, we found that while the FRCP has overcome some early 
setbacks, it currently faces challenges related to the enrollment of 
potentially eligible individuals, determination of FRC staffing needs 
and placement, and the FRCP's ability to coordinate care for enrollees.

      Challenges in identifying potentially eligible 
individuals. It is unclear whether all individuals who could benefit 
from the FRCP's care coordination services are being identified and 
enrolled in the program. Because neither DoD nor VA medical and 
benefits information systems classify servicemembers and veterans as 
``severely wounded, ill, and injured,'' FRCs cannot readily identify 
potential enrollees using existing data sources. Instead, the program 
must rely on referrals to identify eligible individuals. Once these 
individuals are identified, FRCs must evaluate them and make their 
enrollment determinations--a process that involves considerable 
judgment by FRCs because of broad criteria. However, FRCP leadership 
does not systematically review FRCs' enrollment decisions, and as a 
result, program officials cannot ensure that referred individuals who 
could benefit from the program are enrolled and, conversely, that the 
individuals who are not enrolled are referred to other programs.

      Challenges in determining staffing needs and placement 
decisions. The FRCP faces challenges in determining staffing needs, 
including managing FRCs' caseloads and deciding when VA should hire 
additional FRCs and where to place them. According to the FRCP 
Executive Director, appropriately balanced caseloads (size and mix) are 
difficult to determine because there are no comparable criteria against 
which to base caseloads for this program because of its unique care 
coordination activities. The program has taken other steps to manage 
FRCs' caseloads, including the use of an informal FRC-to-enrollee 
ratio. Because these methods have some limitations, the FRCP is 
developing a customized workload assessment tool to help balance the 
size and mix of FRCs' caseloads, but it has not determined when this 
tool will be completed. In addition, the FRCP has not clearly defined 
or documented the processes for making staffing decisions in FRCP 
policies or procedures. As a result, it is difficult to determine how 
staffing decisions are made, or how these processes could be sustained 
during a change in leadership. Finally, the FRCP's basis for placing 
FRCs at DoD and VA facilities has changed over time, and the program 
lacks a clear and consistent rationale for making these decisions, 
which would help ensure that FRCs are located where they could provide 
maximum benefit to current and potential enrollees.

      Challenges in coordinating with other VA and DoD programs 
and supporting FRCs. A key challenge facing the FRCP concerns the 
coordination of services by the large number of DoD and VA programs 
that support wounded servicemembers and veterans. Although these 
programs vary in terms of the severity of the injuries among the 
servicemembers and veterans they serve and the specific types of 
services they coordinate, many programs have similar functions and are 
involved in similar types of activities. Table 1 illustrates the key 
characteristics of major DoD and VA programs and the activities in 
which they are involved.


      Table 1: Characteristics of Major Department of Defense (DoD) and Department of Veterans Affairs (VA)
                     Programs for Seriously and Severely Wounded Servicemembers and Veterans
----------------------------------------------------------------------------------------------------------------
                       Program characteristics                                 Type of services provided
----------------------------------------------------------------------------------------------------------------
                                             Severity   Title of care
                               Program          of       coordinator    Lifetime               Non-     Recovery
      Program name           description    enrollees'     or case     follow-up   Clinical  clinical     plan
                                             injuriesa     manager
----------------------------------------------------------------------------------------------------------------
VA/DoD Federal Recovery   Joint DoD/VA      Severe      Federal                   
 Coordination Program      initiative that               Recovery
 (FRCP)                    coordinates                   Coordinator
                           clinical and                  (FRC)
                           nonclinical
                           services and
                           benefits across
                           Federal, State,
                           and private
                           entities for
                           recovering
                           servicemembers,
                           veterans, and
                           their families.
----------------------------------------------------------------------------------------------------------------
DoD Recovery              DoD program that  Serious     Recovery Care      .........     
 Coordination Program      coordinates                   Coordinator
                           nonclinical
                           services and
                           benefits for
                           recovering
                           servicemembers.
----------------------------------------------------------------------------------------------------------------
Army Warrior Transition   Army unit that    Serious to  Triad of                         
 Units                     provides          severe      nurse case
                           complex                       manager,
                           outpatient case               squad
                           management for                leader, and
                           servicemembers                physician
                           requiring more
                           than 6 months
                           of medical
                           treatment.
----------------------------------------------------------------------------------------------------------------
Military wounded warrior  Programs          Serious to  Case manager       .........     
 programsb                 operated by the   severe      or Advocate
                           military                      (title
                           services that                 varies by
                           help manage                   service)
                           servicemembers'
                           recovery
                           process,
                           including the
                           Army Wounded
                           Warrior
                           Program, Marine
                           Wounded Warrior
                           Regiment, Navy
                           Safe Harbor,
                           Air Force
                           Warrior and
                           Survivor Care
                           Program, and
                           Special
                           Operations
                           Command's Care
                           Coalition.
----------------------------------------------------------------------------------------------------------------
VA OEF/OIF Care           VA program that   Mild to     Case manager,             
 Management Programc       facilitates the   severe      Transition
                           transition of                 Patient
                           care from                     Advocated
                           military to VA
                           medical
                           facilities and
                           the
                           coordination of
                           clinical and
                           nonclinical
                           services for
                           OEF/OIF
                           servicemembers
                           and veterans.
----------------------------------------------------------------------------------------------------------------
VA Spinal Cord Injury     VA system of      Mild to     Nurse, social             
 and Disorders Program     care that         severe      worker
                           provides a
                           coordinated
                           continuum of
                           services for
                           servicemembers
                           and veterans
                           with spinal
                           cord injuries.
----------------------------------------------------------------------------------------------------------------
VA Polytrauma System of   VA system of      Serious to  Social work               
 Care                      specialized       severe      and nurse
                           facilities that               case
                           provides                      managers
                           comprehensive,
                           individually
                           tailored
                           rehabilitation
                           to
                           servicemembers
                           and veterans
                           with multiple
                           injuries.
----------------------------------------------------------------------------------------------------------------
     Source: GAO analysis of DoD and VA program information.
     Note: The characteristics listed in this table are general characteristics of each program; individual
  circumstances may affect the enrollees served and services provided by specific programs.
a  For the purposes of this table, we have categorized the severity of enrollees' injuries according to the
  injury categories established by the DoD and VA Wounded, Ill, and Injured Senior Oversight Committee.
  Servicemembers with mild wounds, illness, or injury are expected to return to duty in less than 180 days;
  those with serious wounds, illness, or injury are unlikely to return to duty in less than 180 days and
  possibly may be medically separated from the military; and those who are severely wounded, ill, or injured are
  highly unlikely to return to duty and also likely to medically separate from the military. These categories
  are not necessarily used by the programs themselves.
b  FRCs placed at the headquarters of Special Operations Command's Care Coalition and Navy Safe Harbor
  coordinate clinical and nonclinical care for enrollees in these two programs and for other FRCP enrollees.
c  OEF/OIF refers to Operation Enduring Freedom and Operation Iraqi Freedom.
d  An OEF/OIF care manager supervises the case managers and transition patient advocates and may also maintain a
  caseload of wounded veterans.


    Many recovering servicemembers and veterans are enrolled in more 
than one program. For example, in September 2010, approximately 84 
percent of FRCP enrollees were also enrolled in a military service 
wounded warrior program. However, limitations on information sharing 
among the programs has resulted in duplication of services and enrollee 
confusion, prompting two military wounded warrior programs to cease 
making referrals to the FRCP. Specifically, the FRCP could not share 
certain enrollee data maintained on its information system with staff 
of non-VA programs because VA had not completed public disclosure 
actions necessary to enable the sharing of this information. In January 
2011, VA completed the process needed to resolve this issue. In 
addition, incompatibility among information systems used by different 
case management programs limits data sharing as information about 
enrollees cannot be easily transferred among these systems. Although 
the ultimate solution to information system incompatibility is beyond 
the capacity of the FRCP to resolve, the program has initiated an 
effort to improve information exchange.
    Finally, FRCs identified several types of logistical problems that 
have affected their ability to carry out their responsibilities. These 
issues center around (1) provision of equipment such as computers, 
printers, landline telephones, and BlackBerrys; (2) technology support 
such as equipment maintenance, software upgrades, and systems security; 
and (3) private workspace at medical facilities.
    Overall, as the first joint care coordination program for DoD and 
VA, the FRCP represents a new patient support paradigm for the 
departments. Because of its unprecedented nature, the program cannot 
refer to preexisting data or policies and procedures to manage the 
program, and as a result, FRCP leadership had to develop management 
processes as the program was being implemented and has largely relied 
on informal processes to oversee and manage key aspects of the program. 
However, now that the program has been operating for several years and 
continues to grow, it has become apparent that the program would 
benefit from more definitive management processes to strengthen program 
oversight and decision-making.
    As a result of our examination of the FRCP, we recommended that the 
Secretary of Veterans Affairs direct the Executive Director of the FRCP 
to take actions to establish adequate internal controls regarding FRCs' 
enrollment decisions, to complete development of the workload 
assessment tool for FRCs' caseloads, and to document procedures to 
strengthen FRC staffing and placement decisions. In their comments on 
our report, DoD stated that it continues to increase its collaboration 
with VA, and VA generally agreed with our conclusions and concurred 
with our recommendations to the Secretary.
    Chairwoman Buerkle, Ranking Member Michaud, and Members of the 
Subcommittee, this completes my prepared statement. I would be pleased 
to respond to any questions you or other Members of the Subcommittee 
may have.
Contacts and Acknowledgments
    For further information about this testimony, please contact 
Randall B. Williamson at (202) 512-7114 or [email protected]. Contact 
points for our Offices of Congressional Relations and Public Affairs 
may be found on the last page of this testimony. Individuals who made 
key contributions to this testimony include Bonnie Anderson, Assistant 
Director; Frederick Caison; Elizabeth Conklin; Deitra Lee; and Lisa 
Motley.

                                 
             Prepared Statement of Karen Guice, M.D., MPP,
    Executive Director, Federal Recovery Coordination Program, U.S. 
                     Department of Veterans Affairs
    Good morning Chairwoman Buerkle, Ranking Member Michaud, and 
Members of the Committee. My name is Karen Guice and I am the Executive 
Director of the Federal Recovery Coordination Program (FRCP), a joint 
DoD/VA program, administered by VA.
    On March 23, 2011, the Government Accountability Office (GAO) 
report released its report on the FRCP, along with four recommendations 
for program improvement. VA concurred with the recommendations and I 
welcome this opportunity to discuss the steps taken since the GAO 
report was issued. I would also like to share with you some of the 
current and planned approaches to the FRCP's challenges with outreach, 
referral, enrollment, communication and staffing in our continuing 
collaboration with DoD to provide comprehensive care coordination to 
severely wounded, ill or injured servicemembers and veterans.
Background
    The Departments of Defense and Veterans Affairs signed two 
memoranda of understanding (MOU, August 31, 2007 and October 30, 2007) 
establishing FRCP as a joint program and providing operational 
parameters. The program was specifically charged with providing 
seamless support from the time a servicemember arrived at the initial 
Military Treatment Facility (MTF) in the United States through care and 
rehabilitation, regardless of whether the goal was to return to 
military duty or transition to veteran status.
    As required by the MOUs, Federal Recovery Coordinators (FRCs) are 
master's prepared nurses and social workers who provide support by 
acting as advocates in all clinical and non-clinical aspects of 
recovery. FRCs work with the relevant military service and VA programs, 
the individual's interdisciplinary clinical team, and all case 
managers. Based on a client's goals, with input from all care 
providers, the FRC creates a Federal Individualized Recovery Plan 
(FIRP). FRCs have delegated authority for oversight and coordination of 
all clinical and non-clinical care identified in the FIRP.
    Specific FRCP eligibility criteria were approved by the DoD/VA 
Senior Oversight Committee (SOC) in October 2007 and included those 
servicemembers or veterans who received acute care at MTFs; those 
diagnosed with specific injuries or conditions; those considered at 
risk for psychosocial complication; and those self or Command-referred 
based on perceived ability to benefit from a recovery plan.
    FRCs are a unique resource for those with severe and complex 
medical and/or social problems. They coordinate benefits and health 
care as servicemembers and veterans heal, aligning information and 
services to deliver support at the right time and in the right order. 
FRCs do not provide direct medical care, issue military orders, or 
transport clients to appointments. Instead, they rely on case managers, 
both clinical and non-clinical, as well as interdisciplinary health 
care team members and servicemembers' units, for those activities. FRCs 
anticipate needs and coordinate among service and benefits providers to 
ensure smooth transitions for their clients, whether the transition is 
between two hospitals or two agencies, in keeping with the intent of 
the MOUs signed by the Departments' Secretaries to create a single 
joint program for care coordination.
    In 2008, the National Defense Authorization Act (NDAA) required the 
creation of a recovery coordination program. This program, the Recovery 
Coordination Program (RCP), was implemented as a DoD-specific program 
for non-clinical case management. Recovery Care Coordinators (RCC) are 
assigned to and employed by the Military Services, with the Office of 
Wounded Warrior Care and Transition Policy providing program policies.
    Although FRCP and RCP provide different services, in an effort to 
align responsibilities and roles with appropriate levels of RCP or FRCP 
support, the SOC approved three categories of service. Category 1 
individuals were those whose recovery was essentially guaranteed and 
for whom only medical case management and relevant health care 
providers were necessary for full recovery. Category 2 individuals were 
those whose recovery had a high probability of requiring at least 180 
days and for whom the addition of a non-clinical case manager or RCC 
appeared appropriate to assist with service delivery. Category 3 
individuals were those with severe and complex medical problems and who 
had a high probability of leaving military service. Individuals 
identified for this latter category were to be assigned to FRCP. These 
service categories and assignment requirements were incorporated into 
the DoD Instruction 1300.24 which governs the DoD RCP. Because these 
categories are more administrative than operational, accurate category 
assignment to FRCP or RCP has been difficult.
GAO Recommendations
 The first of four GAO recommendations stated that the FRCP should 
        establish adequate internal controls to ensure that referred 
        servicemembers and veterans who need FRC services are enrolled 
        in the program. VA concurred with this recommendation.
    Evaluation of potential FRCP clients is based on an assessment of 
the individual's medical and non-medical needs and requirements in 
order to recover, rehabilitate, and reintegrate to the maximum extent 
possible. A key component in the FRCP evaluation process is the 
clinical training and experience of the FRCs and their professional 
judgment of whether an individual would benefit from FRCP care 
coordination. In general, servicemembers and veterans whose recovery is 
likely to require a complex array of specialists, transfers to multiple 
facilities, and long periods of rehabilitation are referred to the 
FRCP.
    Following a referral, FRCs consider a wide range of issues in 
determining whether an individual meets enrollment criteria. The first 
consideration is whether the referred individual meets with the broad 
SOC eligibility criteria. FRCs then conduct a comprehensive record 
review to include all relevant and available health and benefit 
information. They document the medical diagnoses and conditions. They 
conduct a risk assessment; identify anticipated treatment and 
rehabilitation needs; determine the individual's access to care and 
level of support; identify any issues with medications or substance 
abuse; assess the current level of physical and cognitive functioning; 
and review financial, family, military, and legal issues. They also 
discuss the individual with interdisciplinary clinical team members, 
clinical and non-clinical case managers, and others who might provide 
insight into the various issues and challenges the servicemembers or 
veterans and their families face. Finally, and most importantly, the 
FRCs interview the referred individual and family members. Based on all 
input, the FRCs determine whether to enroll the referred individual; 
FRCP enrollment is entirely voluntary. Individuals who are not enrolled 
are directed to alternative resources that are appropriate for their 
level of need.
    Any program's enrollment criteria should reflect its charge and 
mission. For the FRCP, the original eligibility criteria and program's 
defined scope were broad, as specified in the MOUs and approved by the 
SOC. Following the NDAA 2008 requirement for DoD to create the RCP, and 
the SOC's approval of the three service categories, the FRCP's scope 
narrowed to reflect only a Category 3 designation. Since then, the FRCP 
has been capturing information, based on case experience, to help 
refine enrollment criteria. The FRCP will use this information, along 
with a service intensity measurement tool (the development of which is 
discussed later in this testimony) to define an eligibility protocol 
within the program's data management system. In the meantime, the FRCP 
requires all FRCs to discuss each enrollment decision with the FRCP 
management. The FRCP management makes the final eligibility decision to 
ensure enrollment consistency. All enrollment decisions are clearly 
documented in the FRCP data management system. This interim solution 
was implemented immediately following issuance of the GAO report.
    While the FRCP can ensure that all referred severely wounded, ill 
or injured servicemembers and veterans who would benefit from care 
coordination are enrolled, the FRCP does not have visibility of all who 
might be eligible. The FRCP, as currently structured, is a voluntary 
referral program and, as such, relies on the identification and 
referral of those who might benefit from the FRCP services by others 
(case managers, Command, Wounded Warrior Programs, etc.). While the 
original MOUs do not specify a specific category of wounded, ill or 
injured, the FRCP was relegated to care coordination for severely or 
catastrophically wounded, ill or injured once the RCP became 
operational. Absent a defined, automatic referral process aligned with 
the DoDI 1300.24 or the original intent of the MOUs, the FRCP has 
relied on outreach activities and demonstrated outcomes to inform the 
referral
process.
    One way for the FRCP to increase referrals is through a robust 
outreach effort to ensure program awareness. Part of this effort has 
been to provide iterative, informational stakeholder briefings. In 
2008, the FRCP conducted 17 outreach efforts and presentations to a 
variety of audiences, including MTF personnel, DoD and VA program 
personnel, and external stakeholders. In 2009 and 2010, the FRCP 
conducted almost 100 outreach activities each year. In the first 
quarter of calendar year 2011, the FRCP has conducted 34 informational 
briefings, on target to exceed previous outreach effort by 25 percent.
    The FRCP has created a variety of materials to assist with these 
outreach efforts. Program brochures are provided to potential clients 
and families, as well as to participants in the FRCP informational 
briefings. These brochures are also provided to other groups for 
distribution upon request. Along with the brochures, the FRCP developed 
posters and banners for use at conferences or presentations. The FRCP 
has a 1-800 line for program referrals; approximately 30 percent of 
received calls either refer an individual or request more information 
about the program. The FRCP is in the process of creating a specific 
webpage within the VA's Web site which will contain program and contact 
information.
    In addition to these outreach efforts, last year the FRCP conducted 
a ``look back'' project to identify veterans who might still benefit 
from care coordination. This project required access to data for 
servicemembers and veterans who: 1) served in the Armed Services since 
9/11/2001; 2) were severely wounded, ill or injured; and 3) met the 
program's eligibility criteria. No single data source had sufficient 
information to determine this population; instead, the FRCP identified 
7 different data sets from DoD and VA, which were cleaned and merged to 
create a single set of over 40,000 individuals. Within the merged 
dataset, certain data elements were selected as a substitutes or 
``proxies'' to narrow the list to those more likely to meet the FRCP 
program criteria. FRCs then contacted these identified individuals and 
identified only 35 who might still require care coordination.
    Currently, the FRCP's most common source of referral is from a DoD 
or VA clinical case management program or a member of an 
interdisciplinary clinical team. Ten percent of all FRCP clients have 
been referred by a service wounded warrior program and 1 percent of 
referrals have originated from a DoD Recovery Care Coordinator. In 
contrast, 38 percent of all FRCP referrals are from clinical case 
managers or members of an interdisciplinary clinical team.
    The FRCP has been criticized for the inability to provide client 
lists to the various case management and military services wounded 
warrior programs. All Federal agencies, and their programs, must comply 
with the various laws and regulations protecting personally 
identifiable and health information. Until recently, the FRCP was not 
able to provide other agencies' programs with information about clients 
because the FRCP data management system had not gone through a Systems 
of Records Notification (SORN) process. With the SORN now in place, the 
FRCP has clearly prescribed Federal guidelines for the sharing of 
information as well as disclosure rules. The FRCP is currently in the 
process of identifying the information required by other programs so 
that appropriate data transfer agreements can be developed.
    In addition, the FRCP is an active participant in a DoD/VA 
information sharing initiative (ISI). The ISI is currently working on 
an electronic transfer of information between and among case 
management/care coordination programs within the two departments. Six 
specific information items have been identified for exchange. These 
items are: 1) Names, titles and affiliations of all case/care managers/
coordinators assigned to a servicemember or veteran; 2) Ability to 
track benefits applications, benefits processing status and benefits 
awards across the DoD and VA; 3) Visibility of all care, recovery or 
transition plans (medical and non-medical); 4) Ability to view and 
schedule appointments through a shared calendar for servicemembers and 
veterans; 5) Role-based visibility of relevant injury or illness 
information; and 6) Role-based visibility of a shared servicemember and 
veteran problem lists to help identify qualifying benefits. 
Requirements for these data transfers are in varying stages of 
development, with an anticipated exchange of case manager information 
by September 2011.
 GAO recommended that FRCP should complete development of a workload 
        assessment tool. VA concurred with this recommendation.
    Care coordination is essential to the effective management of 
severely wounded, ill or injured servicemembers and veterans, and 
determining the appropriate caseload for each FRC is critical. Since 
care coordination is a relatively new concept, particularly as 
implemented across and within Federal agencies, no guidelines or 
service intensity measurement tools currently exist to accurately 
provide a balanced range of cases. The current FRCP caseload target 
range of 25-35 cases was based on a review of other programs' caseload 
ratios, along with relevant literature, and the awareness that not all 
clients will need the same intensity of coordination.
    A system intensity measurement tool will measure how much time and 
effort a FRC uses to identify ongoing care and required benefit needs 
for a client. By collecting uniform information for these activities, 
the FRCP can improve resource allocation, determine patterns of need, 
target those service areas where the need is critical, and measure 
stabilization over time. The FRCP can also use the system intensity 
measurement scores to define with improved precision those referred 
individuals who would benefit from care coordination, as well as those 
individuals whose needs can be met with alternative resources.
    Developing such a tool is a labor intensive task that requires 
development and testing, along with validity and reliability 
assessments. FRCs are currently participating in a process to validate 
assumptions, complete a scoring algorithm, and measure inter-rater 
reliability prior to full field testing of a new service intensity 
measurement scheme. Completing the development of this tool may require 
a year or more of intense effort.
 GAO recommended that FRCP should better document how hiring decisions 
        are made. VA concurred with this recommendation.
    The FRCP continues to grow in client volume and program referrals. 
In fiscal year (FY) 2008, the program received an average of 25 
referrals per month. In FY 2009, the average number of referrals 
increased to 37 per month, and in FY 2010 the average increased to 50 
per month. Of those referred in 2010, 68 percent were enrolled 
(Active), 18 percent required minimal assistance (Assist), and 14 
percent were redirected to other resources. In FY 2008, the program had 
enrolled and cared for 226 servicemembers and veterans. In FY 2010 
alone, that number had more than doubled to 598. The current number of 
Active clients is 736 with an average FRC caseload between 30-33 
clients.
    To determine the number of FRC positions required, the FRCP 
management considers the number of referrals, the rate of enrollment, 
the number of clients made inactive, and a benchmark range of 25-35 
cases per FRC. The FRCP has established an equation based on these 
elements and incorporated it into the program's operating plan. Upon 
completion of the service intensity measurement tool, the FRCP will 
modify this equation to reflect the average intensity points allowed 
per FRC instead of the current arbitrary 25-35 benchmark case range. 
The FRCP will update staffing processes and plans in the annual 
business operation planning document.
    Currently, 22 FRCs are working at six military treatment 
facilities, four VA medical centers, and two Wounded Warrior Program 
headquarters. FRCs are supported by a VA Central Office staff that 
includes an Executive Director, two Deputies (one for Benefits and one 
for Health), an Executive Assistant, an Administrative Officer, and two 
Staff Assistants. In the past, the FRCP has received personnel support 
at VA Central Office from the U.S. Public Health Service and DoD. While 
the Navy has designated an individual for detail to FRCP, in accordance 
with the MOU, no other military support is currently forthcoming.
 GAO's final recommendation was that the FRCP should develop and 
        document a rationale for Federal Recovery Coordinator (FRC) 
        placement. VA concurred with this recommendation.
    The FRCP will develop a FRC placement strategy based upon a 
systematic analysis of data over the next 6 months. The FRCP's initial 
placement was guided and directed by the MOU, which required that FRCs 
be placed at MTFs where significant numbers of wounded, ill or injured 
servicemembers were located. As the program has grown, and given the 
current requirement for a single FRC to remain assigned to a client for 
optimal care coordination and consistency, the FRCP has considered 
alternative locations. FRC placement is guided by four factors: 
replacement for FRCs who leave the program, supplementation of existing 
FRCs based on documented need, creation of a national ``FRCP network'' 
to optimize coordination, and specific requests for FRCs in order to 
better serve the wounded, ill and injured population of servicemembers 
and veterans. The actual placement of FRCs is based on a case-by-case 
negotiation for space and support.
Conclusion
    Many believe that the FRCP is a redundant program; others suggest 
that because the FRCP is administered by VA and is not in the military 
services' chain of command that the FRCP should only provide support 
for veterans. There are numerous programs that that support 
servicemembers and veterans with recovery. Each of the military 
services has programs that provide lifetime support servicemembers from 
the time of injury or diagnosis through recovery. For example, the 
Marines provide a RCC for every wounded, ill or injured Marine with 
additional support, command, and control provided through the Wounded 
Warrior Regiment. The Army provides the Warrior Care and Transition 
Program for case management and command and control, along with the 
Army Wounded Warrior (AW2) Program for the most seriously wounded ill 
or injured soldiers and veterans. The Air Force Warrior and Survivor 
Care Program and Air Force RCCs care for wounded, ill and injured 
Airmen. The Navy has the Safe Harbor Program and the Special Operations 
Command has the Care Coalition.
    Each MTF provides clinical case managers for both inpatient and 
outpatient case management; TRICARE also provides case managers. The 
Veterans Health Administration (VHA) has the Operation Enduring 
Freedom/Operation Iraqi Freedom/Operation New Dawn (OEF/OIF/OND) 
clinical case managers at each VA medical center, who assist OEF/OIF/
OND servicemembers and veterans navigate the VA's health care system. 
In addition, there are VHA Liaisons at many MTFs, along with Polytrauma 
Nurse Liaisons, who coordinate the transfer of servicemembers to VA's 
health services and programs.
    VA also provides home-based primary care; blind, Traumatic Brain 
Injury (TBI), and spinal cord rehabilitation programs; the homeless 
program, caregiver support personnel, and more. Each of these programs 
provides case management, many of them for the lifetime of the veteran. 
VBA has vocational rehabilitation and the benefits assistance program 
with additional case managers providing support to the servicemember 
and veteran. In addition, there are many other programs, such as the 
Defense Center of Excellence In-Transition Program, the National Guard 
Transition Assistance Advisor, Defense and Veterans Brain Injury 
Center's Recovery Coordinators, who also provide case management 
activities for wounded, ill or injured servicemembers.
    Many wounded, ill and injured servicemembers, veterans and their 
families are confused by the number and types of case managers and 
baffled by benefit eligibility criteria as they move through the DoD's 
and VA's complex systems of care on the road to recovery. The FRCP was 
envisioned to be the single point of contact for these individuals 
through care and recovery; a single point of contact that would help 
them understand the complexities of the medical care provided and the 
array of benefits and services available to assist in recovery. 
Currently, the FRCP is the only joint DoD/VA program that provides 
clinical and non-clinical care coordination for wounded, ill or injured 
servicemembers, veterans and their families with severe and complex 
medical and social problems. The FRCP provides alignment of services, 
coordination of benefits, and resources across DoD, VA and the private 
sector by managing transitions and providing system navigation for 
clients.
    The program works best when FRCs are included early in the 
servicemember's recovery and prior to the first transition, whether 
that transition is from inpatient to outpatient or from one facility to 
another. One FRC will stay with that individual throughout all 
subsequent transitions, coordinating benefits and services as needed. 
This consistency of coordination is important for individuals with 
severe and complex conditions who require multiple DoD, VA and private 
health providers and services. FRCs remain in contact with their 
clients as long as they are needed, whether for a lifetime or a few 
weeks. FRCs involvement is voluntary and, when used as envisioned, 
collaborative. However, FRCP cannot carry out this mission without 
active support from the DoD, including all military services, the VA, 
and Congress.
    In closing, program evaluation, whether by Congress or by an 
investigative body such as GAO, is a vital part of program growth and 
maturation. The FRCP is grateful to the GAO for their comprehensive 
review and to the Subcommittee Members for this opportunity to discuss 
continued challenges.
    Thank you and I look forward to your questions.

                                 
         Prepared Statement of Robert S. Carrington, Director,
    Recovery Care Coordination, Office of Wounded Warrior Care and 
             Transition Policy, U.S. Department to Defense
    Madame Chairwoman and Members of the Subcommittee:
    Thank you for the opportunity to discuss the Department of 
Defense's (DoD) role in the Federal Recovery Coordination Program 
(FRCP). While the FRCP was jointly developed by DoD and Department of 
Veterans Affairs (VA) leaders on the Senior Oversight Committee (SOC), 
the program itself is implemented by VA.
Overview of DoD Recovery Coordination Program
    The DoD Recovery Coordination Program (RCP) was established by 
Section 1611 of the FY 2008 National Defense Authorization Act. This 
mandate called for a comprehensive policy on the care and management of 
covered servicemembers, including the development of comprehensive 
recovery plans, and the assignment of a Recovery Care Coordinator for 
each recovering servicemember. In December 2009, a Department of 
Defense Instruction (DoDI) 1300.24) set policy standardizing non-
medical care provided to wounded, ill and injured servicemembers across 
the military departments. The roles and responsibilities captured in 
the DoDI are as
follows:

      Recovery Care Coordinator: The Recovery Care Coordinator 
(RCC) supports eligible servicemembers by ensuring their non-medical 
needs are met along the road to recovery.
      Comprehensive Recovery Plan: The RCC has primary 
responsibility for making sure the Recovery Plan is complete, including 
establishing actions and points of contact to meet the servicemember's 
and family's goals. The RCC works with the Commander to oversee and 
coordinate services and resources identified in the Comprehensive 
Recovery Plan (CRP).
      Recovery Team: The Recovery Team includes the recovering 
servicemember's Commander, the RCC and, when appropriate, the Federal 
Recovery Coordinator (FRC), for catastrophically wounded, ill or 
injured servicemembers, Medical Care Case Manager and Non-Medical Care 
Manager. The Recovery Team jointly develops the CRP, evaluating its 
effectiveness and adjusting it as transitions occur.
      Reserve/Guard: The policy establishes the guidelines that 
ensure qualified Reserve Component recovering servicemembers receive 
the support of an RCC.

    There are currently 146 RCCs in 67 locations placed within the 
Army, Navy, Marines, Air Force, United States Special Operations 
Command (USSOCOM) and Army Reserves. Care Coordinators are hired and 
jointly trained by DoD and the Services' Wounded Warrior Programs. Once 
placed, they are assigned and supervised by Wounded Warrior Programs 
but have reach back support as needed for resources within the Office 
of Wounded Warrior Care and Transition Policy. DoD RCCs work closely 
with VA FRCs as members of a servicemember's recovery team.
    In the DoDI we have codified that severely injured and ill who are 
highly unlikely to return to duty and will most likely be medically 
separated from the military (Category 3) will also be assigned a FRC. 
The DoDI 1300.24 establishes clear rules of engagement for RCCs and 
FRCs. The RCC's main focus is on servicemembers who will be classified 
as Category II. A Category II servicemember has a serious injury/
illness and is unlikely to return to duty within a time specified by 
his or her Military department and may be medically separated. The 
FRC's main focus is on the servicemembers who are classified as 
Category III. A Category III servicemember has a severe or catastrophic 
injury/illness and is unlikely to return to duty and is likely to be 
medically separated.
    While defined in the DoDI, Category 1 and 2 and 3 are all 
administrative in nature and have been difficult to operationalize. The 
intent of the controlling DoDI is to ensure that wounded, ill, and 
injured servicemembers receive the right level of non-medical care and 
coordination. DoD is working with the FRCP to make sure that 
servicemembers who need the level of clinical and non-clinical care 
coordination provided by a FRC are appropriately referred.
 Government Accountability Office (GAO) Report on Federal Recovery
        Coordination Program
    Although the FRCP is exclusively run and managed by VA, there is a 
presumptive ``hand-off'' from DoD Recovery Care Coordinators, and DoD 
medical case managers to the Federal Recovery Care Coordinators at the 
point that it is clear that the catastrophically wounded, ill, or 
injured servicemember will not return back to duty. This determination 
is highly complex and individualized based on a variety of factors 
including the servicemember's condition, and their desire to stay on 
active duty.
    The majority the findings of the March 2011 GAO Report ``Federal 
Recovery Coordination Program Continues to Expand, but Faces 
Significant Challenges,'' pertain to implementation and oversight of 
the FRCP. There are, however, two areas of the report that directly 
involve DoD:

      Duplication of case management efforts between VA and DoD
      Lack of access to equipment at installations
Duplication of case management efforts between VA and DoD
    The report outlines the confusion and inefficiency that arises as a 
result of a servicemember who may have multiple case managers. The GAO 
report shows a matrix with the various DoD and VA care/case management 
programs in place. As many as 84 percent of servicemembers in the FRCP 
are also enrolled in a Military Service Wounded Warrior Program. While 
the programs vary in the populations they serve and services they 
provide, there is significant overlap in functions.
    The GAO outlined one instance where a recovering servicemember was 
receiving support and guidance from both a DoD Recovery Care 
Coordinator and a VA Federal Recovery Coordinator. The two coordinators 
were effectively providing opposite advice and the servicemember was in 
receipt of conflicting recovery plans. The servicemember had multiple 
amputations and was advised by his FRC to separate from the military in 
order to receive needed Services from the VA, whereas his RCC set a 
goal of remaining on active duty.
    The SOC subsequently directed RCP and FRCP leadership to establish 
a DoD-VA Recovery Care Coordination Executive Committee to identify 
ways to better coordinate the efforts of FRCs and RCCs and resolve 
issues of duplicative or overlapping case management. The Committee 
conducted its first meeting in March and its final 2-day meeting 
earlier this week. The results of the Committee's efforts will be 
briefed to the SOC at its next meeting.
    In March 2011, DoD also conducted an intense 2\1/2\ day Wounded 
Warrior Care Coordination Summit that included focused working groups 
attended by subject matter experts who discussed and recommended 
enhancements to various strategic wounded warrior issues requiring 
attention. One working group focused entirely on collaboration between 
VA and DoD care coordination programs and best practices within 
recovery care coordination and wounded warrior family resiliency. 
Actionable recommendations are currently being reviewed, have been 
presented to the Overarching Integrated Product Team (OIPT) and will 
continue to be worked until the recommendations and policies are 
implemented.
    Lack of access to equipment at installations
    FRCs reported to the GAO that ``logistical problems'' impacted 
their ability to conduct day-to-day work. Specific areas causing this 
include: a) provision of equipment, b) technology support and c) 
private work space. There are existing Memoranda of Agreement between 
the FRCP and the DoD and VA facilities where FRCs work, however 
compliance with these MOAs remains a challenge.
    DoD's Office of Wounded Warrior Care and Transition Policy (WWCTP) 
is currently evaluating the resources required at DoD facilities for 
both Recovery Care Coordinators and Federal Recovery Coordinators. 
WWCTP will work with the Services and the VA to ensure that daily 
duties are not interrupted by equipment, technology or space 
constraints.
                               Conclusion
    DoD is committed to working closely with the VA Federal Recovery 
Coordination Program leadership to ensure a collaborative relationship 
exists between the DoD RCP and the VAFRCP. The Military Department 
Wounded Warrior Programs will also continue to work closely with FRCs 
in support of servicemembers and their families.
    Madam Chairwoman, this concludes my statement. On behalf of the men 
and women in the military today and their families, I thank you and the 
Members of this Subcommittee for your steadfast support.

                                 
      Prepared Statement of James R. Lorraine, Executive Director,
 Central Savannah River Area--Wounded Warrior Care Project, Augusta, GA
    Chairman Ann Marie Buerkle, Representative Michaud, and 
distinguished Members of the Committee: thank you for the opportunity 
to speak with you today about the Federal Recovery Coordination 
Program. First of all, I'd like to thank this Committee for its 
continuing efforts to support servicemembers, veterans, and their 
families as they navigate through the complex web of Department of 
Defense, Department of Veterans Affairs, and civilian programs. I've 
been a member of the military community my entire life; as a Reservist, 
Active Duty Air Force, Military Spouse, Retiree, Government Civilian, 
and Veteran. In my previous position as the founding Director of the 
United States Special Operations Command Care Coalition; an 
organization which advocates for over 4,000 wounded, ill, or injured 
special operations forces and has been recognized as the gold standard 
of non-clinical care management. Recognizing a gap in my Special 
Operations advocacy capabilities, I incorporated a Federal Recovery 
Coordinator as a team member in providing input to the recovery care 
plans for our severely and very severely wounded, ill, or injured 
servicemembers. This one Federal Recovery Coordinator dramatically 
improved how Special Operations provides transitional care coordination 
and made my staff more efficient in support of our special operations 
warriors and families throughout the Nation. I've found that when 
supporting our servicemembers, veterans, and their families there is 
always opportunity for improvement.
    It's essential that our military and veterans have strong 
advocates, both government and non-government, working together at the 
national, regional, and community levels to improve the recovery, 
rehabilitation, and reintegration of our warriors and families. 
However, one program by itself is not enough when it comes to 
supporting our Nation's most valuable resource--the men and women of 
the Armed Forces, our veterans, and their families. I recently left 
government service to assume duties as the Executive Director of the 
Central Savannah River Area--Wounded Warrior Care Project, where my 
current position is to integrate services by developing a strong 
community based organization that maximizes the potential of government 
and non-government programs in Augusta and throughout our region. The 
Federal Recovery Coordination Program is one of those resources.
    From my experience, advocates or care coordinators require three 
attributes in order to be successful. The first attribute is the 
ability to anticipate need. This may sound simple, but staying ahead of 
a problem saves a lot of heartache, money, and time. Much like chess 
master, thinking five to ten moves ahead, this assumes effectiveness 
and competence at various levels of the system. The second attribute is 
the authority to act. A case manager or advocate who anticipates needs 
and develops flawless transition plans, but doesn't have the authority 
to act is powerless to ensure success. In this complex environment of 
wounded warrior recovery, someone who can not act is an obstacle. The 
last attribute is the access to work as a team member. This is 
recognizing that it takes more than one person to reach the goal. Team 
work is probably the most complex of the three attributes, because it 
requires others to be inclusive, sharing of information, trust, and 
requires a great deal of time to coordinate and synchronize efforts. 
Federal Recovery Coordinators are a critical component to the 
successful reintegration of over a thousand wounded, ill, or injured 
and their families, but as I said ``there is always opportunity for 
improvement''.
    By design a Federal Recovery Coordinator has the education and 
credentials to anticipate need. Their level of professionalism, skill, 
and experience enables the coordinator to function at a high level of 
competence in supporting our warriors. They are the most clinically 
qualified of the warrior transition team. However, not everyone has the 
same clinical expertise and access to perform as a Federal Recovery 
Coordinator. We feel the development of a Federal Recovery Coordinator 
certification program is necessary to prepare these Veterans Affairs 
care coordinators to engage a broad spectrum of resources available in 
areas not only of health care, but with a focus on behavior health, 
family support, and benefits availability.
    Innately, the FRC has the authority to act within the Veterans 
Affairs Health Care system and interface with Veterans' Benefits 
Administration representatives. By reporting to the Veterans Affairs 
Central Office the Federal Recovery Coordinator can influence across 
the Nation and regionally. This ability is unique and should be 
capitalized on by the Department of Defense Service Wounded Warrior 
programs and strengthened by the Veterans Benefits Administration. The 
Federal Recovery Coordinator must have the authority to act at the 
strategic level, to ensure case management is being accomplished, 
services are being provided, and that Veterans Affairs resources are 
being maximized, in concert with other government and non-government 
organizations.
    The greatest challenge for the Federal Recovery Coordination 
Program is their access to work as a team member. As I mentioned 
earlier, team work requires inclusiveness. If the Coordinators do not 
have timely access to the warriors and families in need they can't be 
effective. As the saying goes ``You only know what you know.'' 
Involvement in a case must be timely in order to shape an outcome, vice 
manage the consequences of bad decisions. We must work symbiotically to 
synchronize our efforts, operating transparently, and maximizing the 
capabilities of the Departments of Defense, Veterans Affairs, Labor, 
and Health and Human Services, as well as collaboration with non-
government organizations at the national, regional, and local levels. 
Additionally, the Federal Recovery Coordinators must function in a 
coordination role, working by, through, and with Service Wounded 
Warrior Programs while also leveraging local Veterans Affairs case 
managers and benefits counselors. Relationships are critical and the 
Federal Recovery Coordinator must develop trusting interchange with 
those individuals and organizations with the mission to assist the 
servicemember, veteran, and their family.
    Lastly, the scope of the Federal Recovery Coordination Program 
should be expanded to assist those in the greatest need for a 
transitional care coordinator. We should not only support the most 
severely wounded, ill, or injured, but must include those less severe 
whose family dynamics, behavioral health issues, or benefit anomalies 
inhibit their smooth transition to civilian life. The current practice 
of providing ``an assist'', which is short term without fully involved 
care coordination, has been successful. Additionally, those 
transitioning veterans at the greatest risk for homelessness should 
have a Federal Recovery Coordinator shepherd the veteran to success. By 
operating at a strategic level Federal Recovery Coordinators can affect 
the outcome of far more veterans both regionally and locally.
    In conclusion, we have three recommendations to improve the Federal 
Recovery Coordination program.

    1.  Maintain the high credential standards for the Federal Recovery 
Coordinator, but augment with a nationally recognized certification for 
Federal system care coordination in order to strengthen their ability 
to anticipate needs.
    2.  Ensure the Federal Recovery Coordinators have the authority to 
act on needs they've identified, both on a national and local level.
    3.  Make certain the Federal Recovery Coordinator has access to 
work as a team member. Incorporate Federal Recovery Coordinators early 
in the recovery process as strategic partners who can ensure the 
Veterans Affairs resources are maximized to a larger population of 
transitioning servicemembers, veterans, and their families in need of 
someone to shepherd them through this complex system.

    There is currently a very positive feeling in this country towards 
the service and sacrifice of our military, veterans, their families, 
and a desire to support them. One way to help is to utilize existing 
programs, especially at the local level. The Central Savannah River 
Area--Wounded Warrior Care Project stands as the model for many 
communities throughout the Nation who are at the front line of helping 
our veterans come all the way home from combat and fully reintegrate 
into our community. It's also important to educate the military and 
their families about their transition, but it's frequently too late 
after transition has occurred and life's daily pace takes over.
    Thank you for providing us the opportunity to present before the 
Veterans' Affairs Subcommittee on Health.

                                 
              Prepared Statement of Mary Ramos, Ph.D., RN,
Federal Recovery Coordinator, San Antonio, TX, Military Medical Center, 
                  U.S. Department of Veterans Affairs
    Good morning Chairwoman Buerkle, Ranking Member Michaud, and 
Members of the Committee. My name is Mary Ramos, and I work at the San 
Antonio Military Medical Center as a Federal Recovery Coordinator 
(FRC).
    When asked what I do for a living, the simple answer is that I 
coordinate long-and short-term care for the most seriously wounded, 
ill, and injured for the Department of Defense (DoD) and the Department 
of Veterans Affairs (VA). I say that I help clients get everything they 
need from DoD, VA, and the community. People ask if that job is very 
difficult. I have to say that it is certainly a challenge, but also a 
gift. It is an honor working with servicemembers and with veterans and 
their families; every day is a learning experience in how people, 
health care, and systems interface to provide care and benefits to 
those in need.
  I will begin my testimony by providing you with a general picture of 
who a FRC is, our roles and responsibilities.
    My position as a FRC is embedded in a Military Treatment Facility 
(MTF), San Antonio Military Medical Center (SAMMC). We at SAMMC work 
hand-in-hand with military health care providers, VA and civilian 
providers, case managers, care coordinators, and military command as 
well as countless others whose roles touch the wounded, ill, and 
injured clients and their families. Our roles as FRCs are unique within 
the military and VA health care and benefits systems, and each day 
brings discoveries about the respective niches we fill in providing 
care and caring for our clients.
    The FRC role is one of overarching coordination. In operational 
terms, that means that while others have a defined ``lane,'' FRCs 
coordinate across those ``lanes'' for our clients. The FRC communicates 
with key members of the provider team within a clinical setting and, in 
partnership, assesses whether there are interventions or information 
that might assist those providers in optimizing clinical and social 
outcomes. For instance, health providers treat the various medical 
conditions while the clinic staffs facilitate appointments. The FRC 
will identify client or family issues with transportation, motivation, 
adherence, or information. If there are such issues, the FRC will 
validate those impressions with the treatment team and encourage 
additional personnel participation to provide what is needed, 
facilitating clinical and nonclinical care. This function is critical 
when a client is being seen in multiple clinical settings within a 
single facility and even more so when he or she is being seen 
concurrently in multiple facilities.
    On any given day, an active client might be admitted to a hospital, 
transferred between facilities, undergo a procedure, or be seen in one 
of the outpatient clinics. Tracking those events is critical to 
anticipating emerging needs for the clients and families as well as 
indicating to whom we should be communicating that day--for example, 
the client's inpatient case manager, Warrior in Transition Case 
Manager, Recovery Care Coordinator (RCC), VA Liaison for Health care, 
VA Case Manager, or provider may be providing care that the FRC can 
support or facilitate. The client's changing status may introduce 
questions or identify new immediate needs; an unanticipated change may 
introduce some instability in an already precarious client's coping 
strategy. The FRC, then, is constantly reassessing the status of each 
client, balancing past, emerging, and anticipated needs within the 
system of care and formulating flexible care coordination plans within 
the caregiver matrix. That reassessment may also result in a client 
being evaluated for a decrease in acuity within the program.
    The Federal Recovery Coordination Program (FRCP) is most beneficial 
during periods of recovery and rehabilitation when the FRC can provide 
stability and support during transitions. Once a client has settled 
into veteran status, is receiving benefits and has decided to return to 
school or work, the need for FRCP involvement is often reduced. These 
clients may transition to ``inactive'' status with FRCP. Inactive 
status does not mean that FRCP support is withdrawn entirely. Inactive 
clients can continue to call the FRC at any time for any reason, but 
regular contact and the associated Federal Individualized Recovery Plan 
(FIRP) work will be discontinued. Sometimes clients are made inactive 
if the client is unresponsive to the FRC's outreach for at least 3 
months. After that time, the FRC will send a letter to the client 
stating that they may become inactive or if they contact the FRC, they 
will remain active. Under these particular circumstances, the FRC will 
contact any known case manager to ensure the client is receiving 
appropriate services.
    Referrals come to the FRCs at SAMMC in several ways. Most of my 
referrals come directly to me from VA or MTF case managers, RCCs, 
military personnel, health care providers, or from current patients 
referring their friends. I will also get referrals from VA Central 
Office. All referrals are always accepted and reviewed, since one of 
the goals of the FRCP is to provide consultative services to the 
facility and to respond positively to all questions.
    When an FRC receives a referral, the first level of review for 
evaluating possible clients is to collect data from the referral source 
concerning the client's medical condition, injuries, and social and 
family data as well as the referral source's impression of the major 
issues that may be facing the possible client in the next weeks.

      If there is a single issue or a simple question, the 
client may be assessed briefly and entered into the system as an 
``assist.'' If ``assists'' prove to grow in complexity or if the 
client's condition starts to indicate that he or she will benefit from 
the full FRCP, the ``assist'' client can be moved into active status 
after the FRC discusses the client with supervisory staff.
      Comprehensive clinical review is usually accomplished 
with the client placed in ``evaluate'' status.
      If the clinical condition or other factors do not 
indicate that the FRCP would be of benefit to the client or family, or 
if optimal services are being provided, the FRC may, after discussion 
with the team and with supervisory staff, ``redirect'' the client back 
to the team, offering continuing support as needed but without active 
involvement of the FRC.
      If the clinical condition of the client indicates a 
possible long-term need for the FRCP, the referred individual's health 
care records may be reviewed to validate how the FRCP might benefit the 
individual and family. Additionally, the individual and/or family are 
interviewed, the program is explained, and the individual and family 
are given the choice of whether to enroll in the program. If the 
individual does not want the program, the choice is left open for the 
indeterminate future. If they decide to enroll, the individual is 
placed in ``evaluate'' status. Further assessment follows until a 
discussion with supervisors may result in the client being placed in 
``active'' status.

    FRCs at SAMMC introduce clients to the FRCP very early in the 
initial hospitalization. While each client has a full complement of 
caregivers and case managers in this phase of high acuity, there are 
nonclinical details that can be introduced that will facilitate care 
and quality of life later in the recovery process. While the client is 
in the inpatient setting, the FRC provides additional emotional support 
to the client and family and, in partnership, facilitates whatever 
processes the case manager and clinical team suggest. The FRC can 
monitor processes like application for Servicemembers Group Life 
Insurance Traumatic Injury Protection Program (TSGLI) and Social 
Security Disability Insurance (SSDI). The FRC can investigate available 
resources and help arrange after-school child care to enable the spouse 
to be with the injured servicemember.
    In providing such assistance, FRCs establish themselves as willing 
team members who support not only the client, but the entire care team. 
Willingness to serve as a team member is critical to the FRC being 
successful in this unique role. Another function of the FRC is to 
provide information about resources and benefits that are or will be 
available to the client and family. Thus, emotional support, 
instrumental assistance and information are the products of the FRCP in 
the acute treatment phase.
    The most important element the FRC contributes at this early 
treatment phase is the concept of seamless long-term clinical and non-
clinical support. The FRC will be the consistent person in their 
journey from the most acute care through, and perhaps beyond, community 
reintegration. It is true that when the client is in intensive care, he 
or she is not thinking about whether or not they will want to leave the 
service or whether they will seek funding to attend college. But, the 
FRC can assure the client that when they are ready for those decisions, 
the FRC will still be there, carrying information about what the 
immediate past has been for this family and supporting the decisions 
within the close professional relationships that have grown over time.
    Because of early support during the most acute phases of care, plus 
a long record of supporting the family through various crises, the FRC 
builds the closest of professional relationships. Later care is 
mediated through that relationship. The trust relationship with the 
client and family is the foundation for continued support through the 
stresses and decisions that come with the Integrated Disability 
Evaluation System (IDES) process and transitions into community life 
and new health care delivery systems. With constant interaction from 
early in the recovery trajectory through reintegration into the 
community, the FRC learns how each client and family member copes and 
reacts to the stress of injury, treatment, and change. That knowledge 
shapes FRC responses to each client for the provision of individualized 
care.
    Extensive professional education and experience enable each FRC to 
make rapid, continuous assessments and formulate action plans 
efficiently both independently and within multiple teams. Each FRC 
holds at least a Master's Degree in a health care field with basic 
education as either a Nurse or a Social Worker. Many have practiced in 
multiple clinical settings. FRCs bring that clinical experience to the 
FRC cohort and to the practice setting. The variety of events, 
outcomes, roles and personalities in military, VA, and civilian health 
care settings demand an unusual level of professional adaptability in 
FRC practice. Through the course of each client's health care and 
recovery, the FRC role flexes to provide whatever is needed at any 
time. Assessment data are constantly processed and actions formulated 
to ``fill in the blanks.''
    Despite our expertise and experiences, it is expected that FRCs 
will be in a constant learning mode. The spheres of knowledge necessary 
for the position include physical and behavioral health domains, but 
that knowledge is utilized in a context including organizational 
psychology, systems theory and transitions, military command systems, 
military pay systems, military health care, military justice systems, 
military health care finance, evidence-based practice and research, VA 
systems of health care, VA benefits systems, community-based care and 
health care reimbursement, Federal, State and local tax structures, 
civil and criminal legal systems, real estate law, guardianships and 
powers of attorney, and risk communication. Additionally, the FRC must 
understand how to recognize their own personal knowledge deficits and 
to seek resources to apply to emerging situations. Recognizing what one 
does not know as a FRC is as important as knowing and teaching what is 
known.
    FRCs practice with many others who coordinate and provide care for 
patients. The FRC role in coordinating care, however, is unique in 
several aspects. While the FRC may not possess comprehensive knowledge 
concerning any one aspect of a client's life, he or she can see that 
aspect in the context of the client's entire life. The FRC contributes 
by assimilating what is meaningful to the client's care and by 
formulating an overarching care coordination plan. Service-based 
personnel may understand the culture of the service much more deeply 
than the FRC. The FRC will defer to the Service-based representative in 
decisions concerning Service-related issues. However, with broader 
clinical knowledge and the ability to incorporate key elements of 
service-related information, the FRC can build a new care context for 
the client. Some explain this as ``breadth versus depth.''
    The care coordination role sometimes colors the character of the 
relationship between the FRC and the client and family. The FRC 
identifies processes and actions that must take place in the course of 
treatment and care management, and then ensures that those tasks are 
completed. The quasi-oversight function means that the FRC validates 
processes with the team members and clients and observes and assists, 
as needed. The FRC listens attentively to the client's perspective and 
impressions of care, providing encouragement and assurance that 
processes will be completed. Listening and responding can accentuate 
the trust relationship and result in a more therapeutic-type 
relationship than other roles. Maintaining professional boundaries and 
confidentiality is critical to sustaining an appropriate relationship, 
especially in light of clients' and families' tendencies to disclose 
intimate details of their lives.
    Relationships with other professionals within the military 
treatment facility are defined by the documents that set the FRCP in 
place. The FRCs are provided office space and resources to support 
their work, and they are given access to clinical teams, patient 
documents, and information systems. At SAMMC, the FRCs are co-located 
with a large group of Warrior in Transition Unit (WTU) case managers 
and the WTU clinical staff. FRCs participate in clinical activities and 
assist providers in various care processes, establishing their roles as 
team members. The FRCs meet and greet incoming Commanders of WTU, the 
MTF Commander, and other key personnel. Interdisciplinary meetings are 
very productive for the FRCs, including those at the Center for the 
Intrepid (amputee care) and the outpatient Burn Unit meetings. Each 
professional encounter serves as an outreach opportunity and to enhance 
an appreciation of what the FRCP can offer to teams and clients.
    FRCs have open door policies, and while some clients will make 
appointments, some just call or e-mail to ask if they can drop in, or 
they just come to talk. When a client presents, the FRC checks the 
extant FIRP, goes over all open goals, or formulates a new plan if 
necessary. If a client is hospitalized, the FRC will visit several 
times a week and will interact with the inpatient case manager to see 
if the FRC can assist with any functions. FRCs have access to client's 
outpatient appointment schedules and can meet them in the clinics as 
desired by the clients and families. FRCs receive a copy of patients 
scheduled in the Center for the Intrepid for outpatient 
interdisciplinary clinic. It is beneficial to meet with the client's 
care team and listen to their impressions of the client's progress, any 
barriers to ongoing care, and what is planned in the clinic visit. By 
being quietly present, the FRC can be available to answer questions. By 
observing the clinical team caring for the client, the FRC can gain 
insight as to how the client is interfacing with the team and whether 
any FRC coordination would enhance care. Every interaction with the 
clinical and nonclinical staff serves as outreach. Every success 
ensures future referrals to the FRCP.
   I would like to give you some specific examples of what I, as an 
FRC, do in a typical work day.
    I will review my client list early in the work day using our 
program's data management system to review tasks. Much of the early 
activity of the day involves planning and prioritizing, processing 
incoming e-mails and calls. Of course, the day will never follow the 
plan, and priorities evolve during the day, but reviewing issues is 
always beneficial. As an example of our task management, if a new 
veteran contacts me with a concern that his first benefits check is 
lost in the system, as a FRC, I can check on the processing of his 
claim and either resolve an issue or reassure the client that the 
system is working. Task reminders also cue the FRC to review a client's 
record to check and see if benefits have been received.
    I reviewed the Veterans Health Administration (VHA) record for a 
client diagnosed with schizophrenia, who recently moved to another 
city. The client has pending examinations to support the disability 
rating. VHA's records indicated active communication between the case 
manager in the originating city and the receiving case manager. To 
ensure a seamless transition of the client's case, I e-mailed the new 
case manager and Transition Patient Advocate, introducing myself and my 
role and offering support. I also spoke with the client to inquire if 
there were any other issues I could help address.
    I received an e-mail from a Polytrauma Rehabilitation Center (PRC) 
case manager stating that a head injury patient, who was expected to be 
transferred back to his home VA facility, will be remaining at the PRC. 
I e-mailed the Veterans Benefits Administration (VBA) representative 
about the planned home modifications to determine if they would 
continue on schedule or, given the circumstance, would be delayed or 
cancelled. I then spoke to the VBA representative and discussed how 
best to support the family in caring for the client at home following 
discharge from the PRC. The family has decided to check on new 
construction rather than modifying the current home. I exchanged e-
mails with the spouse of this client to check on the family's well-
being.
    I received an e-mail from a client's spouse, who is waiting for 
home modifications. Temperatures are rising with the seasonal change, 
and the client has very little tolerance for heat due to burn injuries. 
I talked to the local VBA representative, who stated that logistics 
were slowing down the process but that he would speak to the client to 
plan for starting the project. I then directed the spouse to check the 
Service-Disabled Veterans Insurance Web site, and followed up as to 
whether the county property tax exemption paperwork had been filed.
    I received a phone call from a client's mother. The client is 
experiencing disturbing medication side effects. She was very upset 
about several other issues as well, including some recent legal issues 
and a critical illness in another family member. I provided supportive 
listening and encouragement. I e-mailed the VHA case manager and asked 
her opinion about whether the primary care provider might consider 
seeing the client for a possible medication change. The VHA case 
manager arranged the appointment.
    I received a phone call from the mother of a veteran who is worried 
that the veteran is not receiving optimal care in a transitional 
traumatic brain injury (TBI) facility. The mother states that she is 
afraid that after 3 years of caring for the veteran, her health is 
suffering, and she has no health insurance or income. She discussed her 
fear that if the veteran is enrolled in an Independent Living Program 
and stays in a transitional TBI treatment facility, that she will have 
to sign over the veteran's VA benefits and she will have no income and 
no place to live. I called the head of the TBI program to discuss 
whether the veteran meets criteria for placement and how the current 
family situation might have an impact on program expectations. I also 
called the Veteran Outreach Specialist at a local Vet Center to see if 
she can assist in finding counseling resources for the mother of the 
veteran.
    I received a phone call from a veteran receiving inpatient 
treatment at a VA Medical Center (VAMC). The veteran called me to 
clarify whether a Power of Attorney was needed now or whether it could 
wait until after being discharged from the VAMC. The veteran's spouse 
is working on financial issues and is worried about money. I e-mailed 
the VBA Regional Office to check on the client's VA claim adjudication 
since the family is in financial distress and needs an income. Regional 
Office personnel confirmed that the client's claim is proceeding. The 
veteran also expressed anxiety about leaving the current treatment 
program. I assured the veteran that I have been planning clinical 
outpatient follow up so that there will be no interruption in 
treatment. The veteran expressed appreciation for all of the help, and 
offered to help other veterans facing similar issues.
    I met with a case manager to discuss two mutual cases. One of the 
cases involved an active duty servicemember with a head injury. 
Rehabilitation progress at this time is slow, and we discussed whether 
there is an alternative placement or if the current placement is the 
best. The spouse and mother of the servicemember are discussing the 
best approach and are anxious about different issues. The mother would 
like the patient in an acute rehabilitation setting. The spouse is 
worried about the children, legal, and financial complications. We 
discussed the best physical location for the servicemember, given the 
demands of multiple compensation and pension examinations in support of 
the Medical Board process. We also discussed the family's applications 
for an auto grant and special adaptive housing, and misinformation that 
had been given to the spouse during the filing process. By the end of 
the meeting, we had developed a single message for all family members 
in order to decrease family anxiety.
    A Navy Safe Harbor (NSH) case manager stopped by my office to 
discuss a case that was troubling her. We discussed her concerns and 
the scope of the issues with the individual. I then reviewed DoD and 
VHA treatment records and discussed the case with the FRC located 
within NSH. My review of the records indicated that the individual has 
significant physical and behavioral health issues, and that the current 
care for these conditions is fragmented. I spoke with the individual 
and discussed FRCP structure and function. The individual expressed an 
interest in the support that the FRCP can provide, and agreed that he 
would work with me to develop a FIRP. I placed the individual in 
evaluation status and again discussed with NSH case manager and with 
the FRC at NSH. Navy personnel support the individual working with me 
as his FRC in partnership with NSH.
    I received an email from a veteran who had been told that he had 
lost his TRICARE coverage. As for many, the interface between Federal 
programs became quite frustrating. An example is this complex 
relationships between Social Security Disability Income (SSDI), 
Medicare, and TRICARE. This wounded servicemember applied for SSDI soon 
after injury and started receiving SSDI within the first 6 months 
following his severe injury. After 2 years of being on SSDI, the 
veteran became Medicare eligible. At that time, Medicare B premiums 
were deducted from his SSDI (Medicare A is without cost). The SSDI 
benefit continued when the (then) veteran returned to work. SSDI 
payment was suspended after 9 months of the veteran's earning more than 
$1000 a month. At that time, the Medicare Program billed the Veteran 
for Medicare premiums. He did not understand the bills and did not pay 
them. Medicare is suspended. Consequently, TRICARE eligibility ceased. 
My role was to explain this complicated situation, encourage him to 
report to the local Social Security office, and assure him that he 
would get any health care he needed during any transition periods.
    I met with another client, who was recently discharged from the 
hospital. The client and spouse are interested in purchasing a home; 
however, they have a poor credit rating and have only saved part of 
their initial TSGLI to use as a down payment. We reviewed all open 
goals in the FIRP with the client, discussed financial counseling 
resources, the financial commitment of owning a home, and I provided 
multiple brochures and contact information. We also discussed the 
advantages of financial planning and strategies to raise their credit 
rating.
Conclusion
    The examples I have provided hopefully demonstrate for you the kind 
of flexibility each FRC must have in providing optimal care for 
veterans, servicemembers, and their families. Each day as a FRC is an 
adventure in providing support that could, in all likelihood, otherwise 
fall through the cracks given the complexity of some of these cases. 
Much of what I provide is not quantifiable, and some of what I provide 
would possibly not be missed by a client who did not expect a sound 
safety net. However, I have come to realize that an intimate 
understanding of a servicemember's or veteran's perspective of everyday 
life within overlapping, impossibly complicated, delivery systems 
equips me to find that (perhaps small) intervention that improves the 
quality of life for those who risked everything for my freedom and my 
grandchildren's quality of life. I never served in battle, but I am 
honored to bring every minute of my personal and professional 
experience to bear in caring for those who bore the battle.
    Thank you again for the opportunity to share my experiences and 
perspective with you, and I look forward to answering your questions.

                                 
          Prepared Statement of Karen Gillette, RN, MSN, GNP,
 Federal Recovery Coordinator, Providence, RI, Department of Veterans 
      Affairs Medical Center, U.S. Department of Veterans Affairs
    Good morning Chairwoman Buerkle, Ranking Member Michaud, and 
Members of the Committee. My name is Karen Gillette, and I am a Federal 
Recovery Coordinator (FRC) from Providence, Rhode Island. Thank you for 
inviting me today to tell you what I do as a FRC to assist recovering 
servicemembers, veterans and their families as they heal and return 
home. My testimony will focus on my roles and responsibilities in the 
service of my clients.
Overview
    I have been a FRC since 2008. My current active caseload includes 
55 clients, all in different stages of recovery and reintegration. Some 
of my clients have been recently injured and are still being treated at 
military treatment facilities, while others are receiving care at 
private rehabilitation facilities. I have clients, now veterans, who 
were injured several years ago and continue to need assistance with 
veterans' benefits, case management issues at their local Department of 
Veterans Affairs (VA) facility, vocational rehabilitation benefits, or 
help finding community resources in their local area. In addition to my 
caseload, I also have clients on my inactive case list that 
occasionally contact me with questions or to just let me know how they 
are doing.
    My experience in this field stems from my clinical and 
administrative experiences as a nurse practitioner and nurse executive, 
and from the extensive Federal Recovery Coordination Program (FRCP) 
training and education on veterans benefits programs, military 
programs, TRICARE, social security, Department of Labor programs and VA 
programs. FRCs attend quarterly training at different sites including 
VA's polytrauma facilities around the country. We have met with the 
staff at Walter Reed Army Medical Center, National Naval Medical 
Center, Quantico, and at Veterans Benefits Administration (VBA) 
Regional Offices. We have had training on mediation, coaching, 
mentoring and motivational interviewing. My experience and training 
have helped me to establish a good working relationship with families, 
and to gain experience in the Veterans Health Administration (VHA) 
system and a working knowledge of VBA policy and resources.
    My caseload consists of referrals from many different sources. 
Referrals come from VA case managers, military personnel, caregivers, 
community and charitable organizations, and clients, who also refer 
other Wounded Warriors to our program. I have Army Wounded Warrior 
(AW2), Air Force Wounded Warrior (AFW2) and Marine District Injured 
Support Cells (DISC) staff who ask me to assist with their clients 
having problems with reintegration into the community. I also make sure 
to ask these sources if there are any other cases they are aware of 
where my services might be beneficial.
    I currently work with case managers located in over 35 VA Medical 
Centers (VAMC). These include Operation Enduring Freedom/Operation 
Iraqi Freedom/Operation New Dawn (OEF/OIF/OND) case managers, 
polytrauma coordinators, spinal cord injury/disability coordinators, 
community nurse coordinators, home-based primary care staff, social 
workers in VA's community living centers, as well as health care 
providers. We collaborate to share resources, suggestions and 
information that meet the client's needs. I work closely with fee basis 
staff and prosthetic department staff, speech therapists and other 
members of the physical medicine and rehabilitation staff at local 
VAMCs and clinics. I work with VBA personnel who manage the 
compensation claims, vocational rehabilitation and fiduciary needs of 
my clients at VBA sites around the country. Beyond VA, I work with 
staff at the Social Security Administration, State disability and 
Medicaid case managers and TRICARE and military nurse case managers on 
a regular basis.
    I stay in close contact with the different wounded warrior program 
representatives, and we discuss resources and options that might be of 
benefit to shared clients. We collaborate closely and make sure the 
right person is doing what is needed. I work with recovery care 
coordinators on some cases that we share. I usually focus on VHA and 
VBA issues and the recovery care coordinators focus on military 
administrative detail. Our collaboration is effective and 
complementary.
    As a FRC, I provide many informational briefings about the program 
at national conferences. I have staffed FRCP booths at a variety of 
meetings and conferences and have used that opportunity to discuss the 
program with attendees. I attend Veterans Integrated Service Network-
level training and conferences in New England and try to stay in 
contact with VA's polytrauma coordinators. I have also attended 
military conferences to discuss the role of the FRC in a client's 
treatment and
recovery.
    I would now like to share with you some examples of the issues I 
handle on a typical workday.
    My workday begins by reviewing my work list, notes, tasks, phone 
calls and e-mail so that I can prioritize the day's issues. My goal, 
however, is to ensure that all of my clients are moving closer to the 
goals established on their Federal Individual Recovery Plan (FIRP).
    In one case, I collaborated with VA staff in getting a client with 
severe traumatic brain injury (TBI) admitted to a VA polytrauma 
rehabilitation facility to be evaluated for admission to an emerging 
consciousness program. The family was relocating, and they were 
interested in having the client receive care at a VAMC close to their 
new home. The mother provides 24/7 in-home care for the client, who is 
minimally conscious but has been showing increased awareness over the 
last 6 months. I conducted a conference call with the closest VA 
polytrauma team to the family's intended place of relocation to review 
the client's case.
    In another case, I spoke to an active duty servicemember's mother 
about the servicemember's progress at a private rehabilitation 
facility, and we discussed future possibilities with her for the next 
phase of his recovery. I then called the servicemember's medical case 
manager at the military treatment facility to discuss future transfer 
plans for this client from the private rehabilitation facility back to 
the military treatment facility, and then on to a VA polytrauma 
facility. The medical case manager agreed to contact the family and 
make travel arrangements for them, and to assist with accommodations at 
a Fisher House.
    I worked with an OEF/OIF/OND VBA case manager to resolve issues 
related to a client's VBA compensation and pension rating process. 
Prior to this, I had worked with VBA to get this client's rating file 
moved to the seriously injured list to expedite the case. The client is 
at a VA spinal cord injury/disability center. The case manager will 
work with the family and the VBA rating official to ensure that the 
client's claim moves forward.
    I received a call from a veteran's family regarding their visit to 
a private neurological residential center that I had located for them 
as a possible site for the veteran's next phase of community re-
integration. This young veteran is a candidate for VA's TBI Assisted 
Living pilot program. The family was very pleased with the site, which 
was in the location of their choice. I provided the TBI-Assisted Living 
pilot program administrator and the local VA with an update on the 
family's visit, and they initiated the required contracting process.
    I spoke to a case manager at a military treatment facility about a 
new referral. The veteran had not used VA for heath care since a 
stroke. In addition, the veteran's VBA Monthly Special Compensation had 
recently been decreased, which resulted in the veteran having to 
relocate across the country. I reviewed the veteran's rating letter and 
found that the rating decrease was possibly due to inadequate 
documentation provided to the rater. I began gathering information to 
help educate the individual and the family about FRCP and to assist the 
veteran with collecting the necessary documentation to support the 
claim.
    I called the Marine District Injured Support Cells in that area and 
asked him to contact this former Marine as an additional support to the 
family. I connected the veteran with the local OEF/OIF/OND care 
management team, who then contacted the family to provide assistance.
    I assisted an OEF/OIF team in finding a private substance abuse 
rehabilitation program for a client who required a more controlled 
environment than VA could provide.
    I contacted a VBA regional OEF/OIF officer and asked for his 
assistance in helping a client whose adapted car recently caught fire 
and was inoperable. This family had been told that they were not 
eligible for another auto grant. The VBA representative contacted the 
family and worked on the issue with them.
    I coordinated with multiple levels of leadership to expedite the 
transfer of one of my clients from one VA community living center to 
another.
    These are just a few examples of what I do every day to assist my 
clients. Most of my time is spent in making multiple phone calls, 
writing and responding to e-mails and following-up to ensure that 
things are progressing as they should. All of my activities are 
documented in the FRCP data management system. I spend a lot of time 
providing medical education to families and clients, as they are 
sometimes reluctant to take up the health provider's time during a 
clinic appointment time just to ask questions. I spend a lot of time on 
the National Resource Directory looking for resources and opportunities 
for my clients and their families.
Conclusion
    In conclusion, in the 3 years I have worked as a Federal Recovery 
Coordinator, I have established rapport with most of the stakeholders 
involved in moving these catastrophically ill and injured 
servicemembers and veterans into more stable and satisfactory life 
situations. I have found that what appears to be a ``simple to 
resolve'' situation can take multiple phone calls and e-mails to keep 
the process moving forward towards resolution. It takes effective 
communication with a variety of people to address my clients' complex 
issues.
    I assist my clients in navigating the intricate VA and military 
health care systems. I have been able to assist many of my families in 
connecting to the right resources at the right time, assist them with 
getting their Social Security and VA claims completed, and connect them 
with private charitable organizations that can meet some of their 
financial needs. I provide support as relationships are established 
with VA teams, increasing the veteran and family's trust and 
willingness to choose VA as their health care provider. I am proud to 
have served our country's veterans and servicemembers that have 
sacrificed so much for our country.
    Thank you for having me here today to share with you my 
experiences, and I look forward to your questions.

                                 
           Prepared Statement of Colonel John L. Mayer, USMC,
 Commanding Officer, Wounded Warrior Regiment, U.S. Marine Corps, U.S. 
                         Department of Defense
    Chairwoman Buerkle, Ranking Member Michaud, and distinguished 
Members of the Health Subcommittee, on behalf of the United States 
Marine Corps, thank you for this opportunity to provide testimony on 
interaction between the Marine Corps' Recovery Coordination Program 
(RCP), which is executed by the Wounded Warrior Regiment (WWR), and the 
Department of Veterans Affairs Federal Recovery Coordination Program 
(FRCP), which is overseen by the DoD/VA Wounded, Ill, and Injured 
Senior Oversight Committee. Many severely wounded, ill, and injured 
(WII) Marines are unable to return to active duty and the Marine Corps 
WWR works to ensure these Marines are postured for success as they 
reintegrate to their communities. We fully recognize that reintegration 
success is largely dependent upon the programs and services offered by 
the Department of Veterans Affairs. As such, the WWR welcomes 
opportunities to increase collaboration between the Department of 
Defense and Department of Veterans Affairs and to integrate efforts 
where appropriate.
The Marine Corps Wounded Warrior Regiment: Background and Assets
    To provide the Subcommittee context on interaction between the 
Marine Corps' RCP and the VA's FRCP, it is important to provide 
background on the mission and scope of the WWR. Established in 2007, 
the WWR was created to provide and facilitate non-medical care to WII 
Marines, and Sailors attached to or in direct support of Marine units, 
and their family members in order to assist them as they return to duty 
or transition to civilian life. Whether wounded in combat, suffering 
from an illness, or injured in the line of duty, the WWR does not make 
distinctions for the purposes of care. The Regimental Headquarters 
element, located in Quantico, VA, commands the operations of two 
Wounded Warrior Battalions located at Camp Pendleton, CA and Camp 
Lejeune, NC, and multiple detachments in locations around the globe, 
including Military Treatment Facilities and at Department of Veterans 
Affairs Polytrauma Rehabilitation Centers.
    In just a few years, the WWR has quickly become a proven unit 
providing WII Marines, their families, and caregivers coordinated non-
medical support. Some of the Regiment's primary care assets include: a 
Resource and Support Center, the Sergeant Merlin German Wounded Warrior 
Call Center, which extends support to Marines and families through 
advocacy, resource identification and referral, information 
distribution, and care coordination; Clinical Services Staff that 
provide immediate assistance and referral for Marines with 
psychological health issues and/or post traumatic stress or traumatic 
brain injury; a Job Transition Cell, manned by Marines and 
representatives of the Departments of Labor and Veterans Affairs; and 
District Injured Support Cells (DISCs) located throughout the country 
to conduct face-to-face visits and telephone outreach to WII Marine and 
their families who are recovering or transitioning to their assigned 
region.
Care Coordination: The Importance of Recovery Teams
    The complexity of WII Marines' care requires a heightened level of 
coordination between various medical and non-medical care providers. 
There is no ``one size fits all'' approach to care and the Regiment 
responds to this requirement by delivering a cross-section of services 
and resources tailored to meet the specific needs of WII Marines and 
their families. We determine the specific requirements to meet these 
needs through the coordinated efforts of medical and non-medical care 
providers who are part of our Marines' Recovery Teams. The Recovery 
Team includes, but is not limited to, Marine Corps leadership; Section 
Leaders who provide daily motivation and accountability; non-medical 
care managers; medical case managers; and Recovery Care Coordinators 
(RCCs). Recovery Team participation may be expanded depending on the 
acuity of the Marine's case or the needs of the Marine and family and 
may include the Primary Care Manager, mental health advisors, and the 
Federal Recovery Coordinator (FRC).
Marine Corps Recovery Care Coordinators
    The Marine Corps' RCCs are highly qualified and dedicated 
individuals who serve as a point of contact for our WII Marines and 
families, and they work hand-in-hand with the WWR's support staff. 
Typically, our RCCs have case management experience, have college 
degrees (some with master's degrees), prior military experience (the 
majority are prior Marines), are combat veterans, and have military 
leadership experience. We have found that this combination of 
credentials provides our WII Marines and their families a high level of 
support. For example, the WWR's 2010 Recovery Care Coordinator Survey 
showed 81 percent of WII Marines and their family members were either 
satisfied or very satisfied with the attributes pertaining to their RCC 
(i.e., timeliness, availability, frequency of communication, advocating 
for needs and goals, coordinating and monitoring medical and non-
medical care, and facilitating reintegration back into the community). 
Moreover, of the respondents that stated they had an RCC, a very high 
percentage (96 percent) reported that their RCC satisfied their 
explained roles and responsibilities. This is particularly important, 
as we know recovering servicemembers and their families can be confused 
by myriad of case managers who may become involved in their recoveries.
    Our Recovery Care Coordinators are located at Military Treatment 
Facilities, VA Polytrauma Centers, and are imbedded within the Regiment 
and Battalions to provide immediate, face-to-face support to our WII 
Marines and their families. Along with their unique ties to the Marine 
Corps, this close proximity to Regimental staff precludes logistical 
challenges, improves information sharing, facilitates care 
coordination, and enhances the quality of care provided. Per WWR 
policy, which comports with Federal statute and regulation, RCCs are 
assigned to certain active duty (typically seriously ill/injured and 
severely ill/injured) WII Marines. RCC caseloads do not exceed the 
prescribed Department of Defense Instruction 40:1 ratio. Assignment 
priority is given to Marines who are joined to the WWR; however, the 
Marine Corps' RCP is available to WII Marines and their families 
whether they are assigned to the WWR or remain with their operational 
units. A key attribute of the Marine Corps recovery care program is 
that it allows WII Marines to remain with their parent commands so long 
as their medical conditions allow and their parent command can support 
their needs. Accordingly, our RCCs allow our WII Marines to ``stay in 
the fight'' by providing assistance to WII Marines who are not joined 
to the WWR.
    Whenever possible, the RCC is one of the first points of contact 
the Marine and family has with the WWR support network. Usually within 
72 hours of assignment, RCCs engage their WII Marine and family and 
immediately begin development of their Comprehensive Transition Plan 
(CTP). RCCs help Marines with immediate needs and set goals for the 
long-term. RCCs perform comprehensive needs assessments with their 
Marines and families, which takes into consideration various recovery 
components such as employment, housing, financing, counseling, family 
support, the disability evaluation process, and more. The information 
derived from the needs assessment becomes the basis for the Marine's 
CTP and is often referred to as a ``life map'' for the recovering 
Marine and family. It reflects their medical and non-medical goals and 
milestones from recovery and rehabilitation to community reintegration. 
The CTP is updated frequently to reflect changes in the Marine's 
health, financial situation, or transition goals. A Marine's outlook or 
goals for their future may be somewhat limited during the recovery 
phase and will improve and become more focused when they start 
rehabilitation, get involved in reconditioning sports, and begin to 
accomplish what may have at one time seemed to be impossible. The RCC, 
in coordination with the Marine Corps leadership and other Recovery 
Team members, will regularly reassess the Marine's mental, physical, 
and emotional state to ensure that their transition plan reflects their 
progress.
    For Marines who move to veteran status and require continued 
transition support, RCCs coordinate the transfer of their case to the 
WWR's DISCs for continued support. Additionally, when a catastrophic 
WII Marine is preparing for transition to veteran status, the RCC may 
coordinate transfer of the Marine's case to an FRC.
RCC-FRC Collaboration
    The Marine Corps fully recognizes the potential of the FRCP and 
where appropriate, we engage FRCs to ensure our severely injured 
Marines who are approaching veteran status receive their support. 
Across the country, we have situations where RCCs are working with FRCs 
on behalf of our severely WII Marines who are approaching veteran 
status. Especially for our Marines who are at VA Polytrauma Centers, 
the FRC provides a valuable support resource to our RCCs.
    As the Marine Corps continues to standardize its RCP, we look for 
opportunities to establish practices with external programs, to include 
the FRCP, to enhance the recoveries of our seriously injured Marines 
and their families. Additionally, we look forward to collaboration and 
leveraging best practices. The Marine Corps actively participated in 
the March 2011 Wounded Warrior Care Coordination Summit, which included 
a working group on Federal Recovery Coordination Program/Recovery 
Coordination Program Collaboration. We also regularly coordinate with 
the other services' wounded warrior programs to identify best practices 
and improve care. We will continue to work with VA, DoD, our sister 
services and all other stakeholders to ensure care provided to our WII 
servicemembers and their families is complementary, not duplicative, 
and fulfills our missions to posture those we serve for recovery and 
transition success, free of unnecessary bureaucracy.
Conclusion
    In his 2010 Planning Guidance, the Commandant of the Marine Corps, 
General James F. Amos, pledged to ``enhance the capabilities of the 
Wounded Warrior Regiment to provide added care and support to our 
wounded, injured and ill.'' This is in keeping with the Marine Corps' 
enduring pledge to take care of their own. We are proud of our ``Once a 
Marine, always a Marine'' ethos and are grateful for the support of 
this Committee and its dedication to the well being of the Marines who 
have so proudly served our great Nation.

                                 
      Prepared Statement of Colonel Gregory Gadson, USA, Director,
     U.S. Army Wounded Warrior Program, U.S. Department of Defense
    Thank you, Chairwoman Buerkle, Ranking Member Michaud, and all 
Members of the Subcommittee for inviting me to appear today. I am 
honored to be here. As a wounded warrior myself, I wish to thank all 
the Members of the Committee for their interest in the health and well-
being of wounded, ill, and injured servicemembers and veterans.
    The lead proponent for the Army's Warrior Care and Transition 
Program (WCTP) is the Warrior Transition Command (WTC), under the 
command of Brigadier General Darryl A. Williams. The WTC supports the 
Army's commitment to the rehabilitation and successful transition of 
wounded, ill, and injured soldiers back to active duty or to veteran 
status and ensures that non-clinical processes and programs that 
support wounded, ill, and injured soldiers are integrated and optimized 
throughout the Army. I am the director of the U.S. Army Wounded Warrior 
Program, or AW2, an activity of WTC. AW2 supports severely wounded 
soldiers, veterans, and families throughout their recovery and 
transition, even when they separate from the Army. We do this through 
more than 170 AW2 advocates who provide local, personalized support to 
the more than 8,300 soldiers and veterans currently enrolled in the 
program.
    The Warrior Care and Transition Program (WCTP) also encompasses the 
29 Warrior Transition Units, or WTUs located around the country and in 
Europe where wounded, ill, and injured soldiers heal and prepare for 
transition. I have AW2 advocates at each of these WTUs, and we identify 
the severely wounded as quickly as possible, so AW2 can begin providing 
support.
    Each soldier in a WTU is assigned to a Triad of Care consisting of 
a primary care manager, usually a physician, a nurse case manager, and 
a squad leader. In addition, the WTUs have a multi-disciplinary 
approach that includes a wide range of clinical and non-clinical 
professionals, such as physical therapists, behavioral health 
professionals, chaplains, social workers, and occupational therapists. 
AW2 advocates work closely with each of these professionals in support 
of the individual soldier.
    A requirement for every servicemember in the Federal Recovery Care 
Program is a comprehensive needs assessment, or Federal Individual 
Recovery Plan. Within the WTUs we conduct this comprehensive needs 
assessment through the development of what is referred to as a 
Comprehensive Transition Plan or CTP. The CTP is not the Army's plan 
for the soldier--it is the soldier's plan for him/herself. Each soldier 
completes a CTP within 30 days of arriving at the WTU, in coordination 
with the multi-disciplinary team. They set long- and short-term goals 
in each of six domains of life: Family, Social, Spiritual, Emotional, 
Career, and Physical. Our goal is to make sure each soldier is well-
prepared for the next phase of their lives, whether they return to the 
force or transition to civilian life. The AW2 advocates are closely 
involved in this process, including the periodic Focused Transition 
Review meetings where the WTU commander gathers the soldier, family 
member or caregiver, and the health care professionals involved in 
caring for the soldier, and they discuss the soldier's progress.
    Families are closely involved with the CTP process, and family is 
one of the six domains of goal-setting in the CTP. Family members and 
caregivers are invited to all of the Focused Transition Review meetings 
and to all medical appointments, therapy treatments, informational 
briefings, etc. AW2 advocates and squad leaders also work closely with 
the families to make sure that their needs are met. When an AW2 soldier 
separates from the Army and transitions to veteran status, an AW2 
advocate continues to support the soldier/veteran and family just as 
they did when the soldier was in the WTU.
    Another key component of WCTP is the Soldier Family Assistance 
Centers, or SFACs. SFACs are operated by the Army's Installation 
Management Command, and they are on-site at WTUs. They bring together 
many of the programs and experts the WTU soldiers and families need to 
provide assistance with everything from childcare and lodging to 
arranging for Department of Veterans Affairs (VA) care and benefits.
    AW2 advocates work closely with Federal Recovery Coordinators (FRC) 
where they are available. As you know, FRCs are currently located in 10 
military and VA medical facilities. There are more than 170 AW2 
advocates on my staff, spread throughout the country, Germany, and five 
U.S. territories. They are present at 60 VA facilities and 29 WTUs, and 
those that are co-located with FRCs do coordinate closely with them. We 
have an open referral process where AW2 advocates and the Triad of Care 
can refer soldiers and veterans to the FRC if we believe they may 
qualify.
    The Federal Recovery Coordination Program (FRCP) has the potential 
to facilitate positive, quality integration across the various programs 
throughout the Federal Government that support severely wounded, ill, 
and injured servicemembers. It has the potential to be a critical 
resource for these servicemembers and their families.
    The AW2 advocates on my staff report having positive relationships 
with the FRCs and indicate that these FRCs are well trained, proficient 
professionals. The FRCs are well-versed in the resources provided by 
the VA and the resources available in their regions. They are also very 
knowledgeable about policies that can support the needs of the wounded, 
ill, and injured population.
    I also want to discuss GAO's recommended actions for the FRCP. As 
you have read in the comments section of the GAO report, the Honorable 
John Campbell, Deputy Assistant Secretary of Defense for Wounded 
Warrior Care and Transition Policy committed the Department of Defense 
to continuing to collaborate with the VA on these issues. A Joint 
Department of Defense (DoD)/VA Committee has been formed to study how 
to combine or integrate recovery coordination efforts for wounded, ill, 
and injured servicemembers, veterans, and families.
    Recommendation 1 of the GAO's report discusses establishing 
adequate internal controls regarding FRC's enrollment decisions. This 
is not a problem at AW2. While FRCs are afforded broad discretion in 
determining which servicemembers are admitted to the program, AW2 has 
very clear eligibility criteria. We accept and support soldiers who 
receive an Army disability rating of at least 30 percent for a single 
injury since September 11, 2001, regardless of whether that injury was 
sustained in combat or not. In 2009, based on AW2's understanding of 
the long-term needs of this population, we expanded that criterion. We 
now also accept Soldiers who receive a combined Army disability rating 
of 50 percent or greater for conditions that are the result of combat 
or are combat-related. All AW2 eligibility decisions are made at the 
headquarters level, by a team of nurses and a Masters-level behavioral 
health professional who closely review all eligibility requests. We 
often accept soldiers before they receive their formal disability 
ratings, if the nature of their injuries makes it very clear that they 
will meet the AW2 eligibility requirements.
    The GAO's next recommendation discusses the FRCP's efforts to 
manage the workloads of individual FRCs based on the complexity of the 
services needed. At AW2, we pay very close attention to the caseloads 
of AW2 advocates. The average caseload is 1 to 50, but each soldier 
requires a different level of support, depending on where he or she is 
in the recovery and transition process, to include veterans.
    For example, AW2 veteran Kortney Clemons is a severely wounded 
veteran who no longer requires a significant level of AW2 support. He 
was a combat medic in Iraq, and he stepped on an IED just 5 days before 
his enlistment was up. He lost his right leg above the knee. Kortney 
has been out of the Army for more than 5 years. He's gone on to become 
the national Paralympic champion in the 100 and 200 meter dash and is 
training for the Paralympic Games in London next year. He is currently 
enrolled in a Masters Degree program through the AW2 Education 
Initiative, a partnership between my program, the U.S. Army Training 
and Doctrine Command, and the University of Kansas. He no longer 
requires the same level of support from an AW2 advocate as he did when 
he was first injured.
    AW2 recognizes that many of the soldiers and veterans we support 
become more independent as they heal and transition to the next phase 
of their lives. We developed the Lifecycle Case Management Plan, or 
LCMP, to help AW2 advocates identify the level of support each soldier 
needs. There are four phases. When the soldier/veteran requires a 
significant level of support, AW2 calls them at least once a month, 
sometimes more, if their personal situation requires it. As they 
progress and become more independent, we call them less frequently, 
every 60 or 90 days in the next two phases. In the last phase, where 
Kortney is, we only call them every 180 days. I am proud to say that I 
personally ``graduated'' to the last phase of the LCMP in March.
    Soldiers and veterans can always call their AW2 advocate or the AW2 
call center if they need support and we will be here for them. This 
initiative allows the AW2 advocates to focus on those with a more 
immediate need for their support, such as the most recently injured, 
those going through the Medical Evaluation Board, or those facing 
significant personal or medical challenges.
    GAO's third recommendation addresses the FRCP's decision-making 
process for determining when and how many FRCs the VA should hire. AW2 
faces some of the same challenges as the FRCP on this issue. It is 
difficult to predict how many additional soldiers will qualify for our 
program in the future. In 2010, we accepted more than 2,000 new 
soldiers into the program. On average, that means we added one 
additional Ssldier to each AW2 advocate's caseload every month. We are 
increasing our staff levels as quickly as possible. This fact makes it 
even more important that we ensure the AW2 program is run as 
efficiently as possible. The LCMP allows us to manage the rate at which 
additional advocates are required.
    One way we have dealt with the need for more advocates is to 
strengthen the communication between AW2 soldiers, veterans and 
families so that they educate and support each other. We have launched 
peer-to-peer tools to enable the AW2 soldiers, veterans, and families 
to communicate with one another. We have established a blog and a 
Facebook account to facilitate a conversation among the 
population online.
    GAO's final recommendation calls for the FRCP to develop and 
document a clear rationale for the placement of FRCs, including a 
systematic analysis of data to support these decisions. At AW2, we 
evaluate our staffing on a quarterly basis. We make advocate 
assignments by zip codes and place them where we have the greatest 
populations of AW2 soldiers and veterans. We have reassigned some of 
the contract positions based on the locations of the population we 
support. As I mentioned before, we have 170 AW2 advocates. Sixty of 
them are at VA facilities and at each of the 29 WTUs, to provide local, 
personalized support to AW2 soldiers, veterans, and families where they 
are. I would submit that aligning FRCs in a similar manner regionally 
would better serve both them and the servicemembers for whom they are 
responsible.
    There are a couple of other items in the GAO report that I want to 
acknowledge. One is access to office space and technology at various VA 
facilities. Many AW2 advocates on my staff have experienced similar 
challenges finding a private space to conduct sensitive conversations 
and getting access to technology. AW2 now has a designated liaison with 
the VA and this has significantly helped the situation. There are still 
individual challenges but by facilitating that relationship and 
proactively talking to regional VA facilities before the new advocate 
arrives we have been able to mitigate this problem.
    The GAO report also highlighted the challenges in information 
sharing between the DoD and VA. We recognize the importance of this 
challenge. For over a year now, the Warrior Transition Command has been 
developing automated systems that are part of an integrated system for 
tracking and managing the care of soldiers and veterans. The CTP 
mentioned previously is a fully automated process which provides 
managers at every level the ability to thoroughly analyze, in real 
time, the performance of staff in the development and updating of these 
plans. Currently being completed for implementation later this year is 
the central module of the system referred to as the Automated Warrior 
Care and Tracking System; the automated CTP will interface with this 
module which contains the history of each soldier and veterans care.
    The Executive Director of the FRCP and the Deputy Under Secretary 
of Defense for Wounded Warrior Care and Transition Policy are co-
chairing an information sharing initiative (ISI) to support 
coordination of non-clinical care for seriously wounded, ill and 
injured Operation Enduring Freedom and Operation Iraqi Freedom (now 
Operation New Dawn) servicemembers, veterans, and families. The Army 
has been an active participant in this joint DoD/VA ISI. The ISI will 
enable sharing of authoritative data electronically between DoD, VA, 
and the Social Security Administration case and care management 
systems. This will eliminate resource-intensive and error-prone work-
arounds. A pilot for this initiative is underway for the bi-lateral 
sharing of benefit and case manager information. Further efforts will 
include such items as select care plan information and appointment and 
calendar functions. These efforts will significantly improve the 
challenges to information sharing between the agencies.
    In closing, I again thank you, Madam Chairman and Ranking Member 
Michaud, for inviting me here today and for listening to my testimony 
about the Federal Recovery Coordination Program. I appreciate your 
attention to wounded, ill, and injured servicemembers, veterans, and 
their families, and I know that we share the same goal of providing the 
best possible services to these individuals who have sacrificed so 
much.

                                 
                      Statement of Adrian Atizado,
  Assistant National Legislative Director, Disabled American Veterans
    Madam Chairwoman and Members of the Subcommittee on Health:
    On behalf of the more than 1.4 million members of the Disabled 
American Veterans (DAV) and our Auxiliary members, thank you for 
inviting our organization to submit testimony to your Subcommittee 
today on the topic of the Federal Recovery Coordination Program (FRCP), 
and in particular your continuing focus on whether the program has 
begun to fulfill its promise to those who have made major sacrifices 
while serving our Nation in hostile combat deployments during the 
worldwide war on terror.
    To examine the FRCP for the purposes of this hearing, it is 
important to view this program in context. As this Subcommittee is 
aware, the Department of Veterans Affairs (VA) has the authority to 
coordinate care with the Department of Defense (DoD) pursuant to 
sections 523(a) and 8111 of title 38, United States Code (U.S.C.). Both 
Departments are also required under Public Law 107-772, which amended 
section 8111 to establish an interagency committee to recommend 
strategic direction for the joint coordination and sharing of health 
care resources and efforts between and within the two Departments.
    VA's current transition, care and case management program can be 
traced back to 2003 with the designation at each VA facility of a 
Combat Veteran Point of Contact and clinically trained Combat Case 
Manager. These individuals were responsible for receiving and 
expediting transfers of servicemembers from the DoD to VA health care 
systems, VA took steps to modify and grow its transition, care and case 
coordination program. Early seamless transition efforts were limited to 
VA and the Army--specifically, with Walter Reed Army Medical Center 
(WRAMC), Brooke, and Eisenhower and Madigan Army Medical Centers--and 
placement of full time Veterans Health Administration (VHA) social 
workers and Veterans Benefits Administration (VBA) representatives.
    The VA Office of Seamless Transition was established in January 
2005, staffed by VHA and VBA staff and DoD's Disabled Soldier Liaison 
Team, where information about servicemembers to be served by the office 
was relayed to VA from DoD in the form of a Physical Evaluation Board 
list of those who were medical separated or retired. Then, as now, data 
flow from DoD to VA and patient tracking were identified 
challenges.\1,\ \2\
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    \1\ http://www.urbanhealthcast.com/NAADPC/
SlidesSeamlessTransition.pdf.
    \2\ U.S. Government Accountability Office. Testimony before the 
House Committee on Veterans' Affairs, GAO-05-1052T, September 28, 2005.
---------------------------------------------------------------------------
    Section 302 of Public Laws 108-422 and 108-447 required VA to 
designate centers for research, education, and clinical activities on 
complex multi-trauma associated with combat injuries. In June 2005, VA 
designated four Polytrauma Rehabilitation Centers (PRCs) to be co-
located with the four existing Traumatic Brain Injury (TBI) Lead 
Centers. In fact, these TBI Lead Centers are not commonly referred to 
as Polytrauma Centers.
    Also in June 2005, VA's policy for the polytrauma system of care 
was issued, which included the infrastructure designation of Level I 
PRCs, Level II Polytrauma Network Sites, Level III Polytrauma Support 
Clinic Teams, and Level IV Polytrauma Points of Contact. Staff at these 
levels include the PRC Clinical Case Managers and PRC Social Work Case 
Managers, OEF/OIF Program Manager, Transition Patient Advocates, OEF/
OIF Program Manager, OEF/OIF Nurse and Social Worker Case Managers for 
clinical and psychological care management respectively, OEF/OIF VBA 
Counselor, VA Liaisons at military treatment facilities, and other case 
and care managers (Women Veterans, Spinal Cord Injured, Visual 
Impairment Service Team, Polytrauma Support Clinic Teams).\3\
---------------------------------------------------------------------------
    \3\ Department of Veterans Affairs, Veterans Health Administration, 
VHA Directive 2005-024, Polytrauma Rehabilitation Centers, June 8, 
2005; Department of Veterans Affairs, Veterans Health Administration, 
VHA Directive 2006-043, Social Work Case Management in VHA Polytrauma 
Centers, July 10 2006. (Rescinded VHA Directive 2005-024, June 8, 2005; 
Department of Veterans Affairs, Veterans Health Administration, VHA 
Directive 2009-028, Polytrauma-Traumatic Brain Injury (TBI) System of 
Care, June 2, 2009;
---------------------------------------------------------------------------
    DoD's current transition, care and case management program, the 
Wounded Warrior Care and Transition Policy program, is based on 
recommendations made by commissions and other review groups\4\ that 
were convened before and after the deficiencies at WRAMC came to light 
in February 2007.
---------------------------------------------------------------------------
    \4\ Inspector General Review of DoD/VA Interagency Care Transition, 
DoD Task Force on Mental Health, the Independent Review Group, the 
Veterans Disability Benefits Commission, the President's Interagency 
Task Force on Returning Global War on Terror Heroes, and Commission on 
Care for America's Returning Wounded Warriors.
---------------------------------------------------------------------------
    Taken from the July 2007 report of President's Commission on Care 
for America's Returning Wounded Warriors, the FRCP was implemented 
through two Memoranda of Understanding dated August 31, 2007, and 
October 15, 2007.\5\ However, it should be noted that developing the 
FRCP occurred simultaneously with legislation subsequently enacted in 
January 2008 as Public Law 110-181, directing VA and DoD to ``jointly 
develop and implement comprehensive policies on the care, management, 
and transition of recovering servicemembers.''
---------------------------------------------------------------------------
    \5\ Accessible at: http://www.tricare.mil/DVPCO/downloads/
Final%20MOU%20VA%20DoD.pdf.
---------------------------------------------------------------------------
    The law's requirements specifically include:

      creating the Recovery Coordination Program (RCP) for 
recovering servicemembers and their families;
      developing uniform program for assignment, training, 
placement, supervision of Recovery Care Coordinators, Medical Care Case 
Managers, and Non-Medical Care Managers;
      developing content and uniform standards for the 
Comprehensive Recovery Plan, including uniform policies, procedures, 
and criteria for referrals; and
      developing uniform guidelines to provide support for 
family members of RSMs.

    Moreover, deployment of the FRCP program occurred during the 
development of what is now the current state of VA and DoD care and 
case management programs.
    DoD's current Wounded Warrior Care and Transition Policy program, 
now includes the FRCP, Recovery Coordination Program, Transition 
Assistance Program, the National Resource Directory, and Wounded 
Warrior Employment initiatives. Within the Recovery Coordination 
Program, front line service is provided by recovery care coordinators, 
medical and non-medical care managers, and an individualized recovery 
or transition plan. Each military service has its own program 
implementing Public Law 110-181 and DoD's four cornerstones and ten 
steps of care, management and transition Coordination policy.\6\ These 
programs include the Army Wounded Warrior Program, Marine Wounded 
Warrior Regiment Recovery Coordination Program, the Navy's Safe Harbor 
program, and the Air Force Wounded Warrior program.\7\ In addition to 
direct support and assistance to servicemembers, each military service 
has programs in place to support the families of wounded, ill or 
injured servicemembers.
---------------------------------------------------------------------------
    \6\ Department of Defense Instruction 6025.20, Medical Management 
Programs in the Direct Care System and Remote Areas, January 5, 2006; 
Department of Defense Instruction 1300.24, Recovery Coordination 
Program (RCP), November 24, 2009; Department of Defense, The 
Foundations of Care, Management and Transition Support for Recovering 
Servicemembers and Their Families, September 15, 2008.
    \7\ Established in 2004, AW2 assigns an AW2 advocate, and the 
Warrior Transition Units (WTUs) where a servicemember is assigned a 
triad of care and development of a Comprehensive Transition Plan. The 
triad includes a primary care manager (normally a physician), nurse 
case manager, and squad leader--who coordinate their care with other 
clinical and non-clinical professionals. WTUs also have platoon 
sergeants to assist where needed. The Marine Wounded Warrior Regiment 
commands the East and West Wounded Warrior Battalions and other 
detachments and uses Recovery Care Coordinators to help define and meet 
a member's recovery plan as well as District Injured Support Cells to 
assist recovering mobilized reserve Marines. Established in 2005 the 
Safe Harbor Program offers two levels of support: Non-medical case 
managers to support and assist member and family needs, and Recovery 
Care Coordinators who oversee and assist with the member's 
Comprehensive Recovery Plan. The Air Force Warrior and Survivor Care 
Program initially depended on family liaison officers and community 
readiness consultants to assist in community reintegration. Air Force 
Recovery Care Coordinators were added whose area of responsibility is 
regionalized and who work closely with family liaison officers, patient 
liaison officers, and medical case managers.
---------------------------------------------------------------------------
    As this Subcommittee is well aware, this coordination program, like 
some of its sister efforts, was born in controversy. In fact we believe 
most of the efforts to create coordinator positions came about on 
discovery of gaps in services or difficulties in conducting a seamless 
transition for the wounded. In particular, when the scandal at WRAMC 
erupted in February 2007, and a number of Federal agencies, task forces 
and commissions reviewed the transition process of injured 
servicemembers, it became obvious that our government was not fully 
supporting the rights and benefits of seriously disabled veterans from 
Iraq and Afghanistan in repatriating to their homes and families in an 
orderly way.
    At WRAMC and elsewhere, hundreds of patients were unnecessarily 
being held in ``medical holds,'' with little prospect of discharge or 
retirement, and with many of their families also held in that same 
limbo. Per diem support and living conditions for family members were 
woefully inadequate. Information was scarce or confusing. Support 
services tailored to individual needs were thin to nonexistent, but 
expectations on these troops were very high that they remain in an 
organized and focused military posture while dealing with their medical 
responsibilities.
    Since the program's inception, servicemembers, veterans and their 
loved ones recognize the assistance they receive from their assigned 
FRC is invaluable, which is a testament to the FRCP. Further, DAV is 
encouraged that the FRCP has been expanded over the years; however, in 
previous testimony our organization has provided to Congress, because 
the FRCP was developed after VA's polytrauma system of care and before 
DoD's Wounded Warrior Care and Transition Policy program, we believe 
this is the source of many of our questions that remain regarding the 
effectiveness of the FRCP in meeting the need of severely injured 
servicemembers.
    With so many coordinators, clinical and non-clinical case managers 
created in the development of VA and DoD's transition programs, we 
sought out basic information to validate these programs are working as 
intended. In April 2008, we testified the data we were receiving at 
that time indicated that for each injured servicemember who is 
currently enrolled in the FRCP, as many as 6 FRCs may be assigned.\8\ A 
number of the families who are beneficiaries of this work have reported 
that the advice they receive is often overlapping, redundant, confusing 
and conflicting. Many of them seek a singularity of advice rather than 
a chorus of competing advisors, to help them steer their paths toward 
recovery.
---------------------------------------------------------------------------
    \8\ Update on VA and DoD Cooperation and Collaboration, Hearing 
before the U.S. Senate Committee on Veterans' Affairs, 110th Congress 
(2008).
---------------------------------------------------------------------------
    For as much emphasis as was placed on the need for a single 
recovery coordinator and the heralding of the FRC as the ``ultimate 
resource,'' DAV remains deeply concerned that the workload and 
expansion of this program has not been accompanied by appropriate 
resources being allocated.
    DAV also raised concerns in testimony about integration of 
Information Technology (IT) access within VA and the Military Training 
Facility (MTF). VA and DoD, at least in the medical arena understand 
the necessity of data systems and information support technologies. 
These can serve an important role in facilitating the timely transfer 
of essential information as patients traverse care systems and 
settings. Moreover, VA and DoD are well aware of the complexity of 
medical and non-medical needs of injured servicemembers, veterans and 
their families, yet the IT support for the FRC remains inadequate.
    Unfortunately, it appears our concerns are well founded as 
portrayed in the March 2011 Government Accountability Office (GAO) 
report titled, ``Federal Recovery Coordination Program Continues to 
Expand but Faces Significant Challenges.''
    If FRCs must, by definition, ensure that systemic barriers to care 
and services are resolved at both the individual and the system level, 
and the FRCP is to provide a system that transcends all boundaries to 
coordinate servicemembers' and veterans' care and benefits through 
recovery, rehabilitation, and reintegration into their home 
communities,\9\ we believe it is only proper that commensurate 
authority and resources to effect change and accomplish such a lofty 
task must be provided.
---------------------------------------------------------------------------
    \9\ Department of Veterans Affairs, VA Handbook 0802, Federal 
Recovery Coordination Program, March 23, 2011.
---------------------------------------------------------------------------
    Madam Chairwoman, in March of this year, the DoD held a Care 
Coordination Summit that focused some of its work on the FRCP. A number 
of recommendations are emerging from that consensus conference, based 
on lessons learned from the past 3 years, that we believe warrant the 
attention of this Subcommittee as you continue your oversight of the 
FRCP. Among the findings and recommendations of the conference's 
workgroups pertinent to this oversight hearing include the following:
FRCP/RCP Collaboration Recommendations:
Objective: Re-defined Care Coordination Program
Recommendations:
    1.  Eliminate category 1, 2, and 3 eligibility criteria. Establish 
appropriate eligibility criteria for care coordination.
    2.  Improve integration within the Care Coordination Program.
    3.  Improve education and develop a strategic communications 
process.
Objective: Improved integration of the Care Coordination Program
Recommendations:
    1.  Improve education and develop a strategic communications 
process.
    2.  Provide interagency access to Information Technology systems.
    3.  Develop and implement a standardized referral and Intake 
Process for the Care Coordination Program.
    4.  Consider geographic alignment of the FRCs.
    5.  Continue to expand and enhance the National Resource Directory.
    A comprehensive report based on the outcome of the Wounded Warrior 
Care Coordination Summit identifying best practices with actionable 
recommendations will be developed with full support from the Wounded 
Warrior Program Directors from each military service, the DoD Recovery 
Coordination Program Director and the Executive Director of the VA 
FRCP.
    This report will be received by the Deputy Assistant Secretary of 
Defense for Wounded Warrior Care and Transition Policy who will in turn 
brief those actionable recommendations to be initiated prior to the end 
of fiscal year 2011, to the Under Secretary of Defense for Personnel 
and Readiness and to the Senior Oversight Committee.
    We urge this Subcommittee to engage the appropriate office in the 
Administration to ensure these recommendations made by front line 
personnel of the VA and DoD care, management, and transition programs 
receive due attention.
    Madam Chairwoman, we hope the Subcommittee will work with its 
counterpart in the Armed Services Committee to instill in both DoD and 
VA a stronger interest in making the FRCP the program that was intended 
by showing a stronger interest in implementing the recommendations of 
its own consensus conference. Moving forcefully on these 
recommendations may also bring VA into compliance with recommendations 
of the Government Accountability Office in its March 2011 report to 
Congress on the VA FRCP.
    Madam Chairwoman, this concludes my testimony on behalf of Disabled 
American Veterans.

                                 
       Statement of the Military Officers Association of America
                           EXECUTIVE SUMMARY
 Response to Recommendations of GAO Report on VA's Federal Recovery 
        Care Program (FRCP)
    The Military Officers Association of America (MOAA) concurs with 
the findings and recommendations in the Government Accountability 
Office's (GAO) report, GAO-11-250, issued March 2011, titled, ``DoD and 
VA Health Care; Federal Recovery Coordination Program Continues to 
Expand but Faces Significant Challenges.'' Specifically, we agree that 
VA should:

      Establish systematic oversight of enrollment decisions;
      Complete development of a workload assessment tool;
      Document staffing decisions; and,
      Develop and document a rationale for Federal Recovery 
Coordinator (FRC) placement.

    While we have seen great progress in VA's development and expansion 
of the FRCP and just how effective these coordinators are based on 
feedback from those wounded warriors and family members receiving these 
services, MOAA believes, as GAO indicates in its report, that more 
needs to be done in the area of program management and accountability.
    Our Association continues to hear from frustrated, and sometimes 
angry wounded warriors and their caregivers who are confused, 
overwhelmed or intimidated by the FRCP. Some have been told they are 
ineligible for an FRC, some were not informed they were eligible, and 
others were constrained in accessing program services when and where 
needed because of improper timing of receipt or coordination of the 
information.
    MOAA believes the absence of a way to systematically identify, 
track FRCP eligibles and administer case management for this population 
presents significant issues that need immediate attention.
Additional Recommendations
    MOAA offers the following additional recommendations to improve the 
FRCP:

      Establish a consistent and uniform system of care 
coordination in both VA and DoD that includes common terminology and 
definitions, and provides a simpler way for wounded warriors and their 
families to access and transition from DoD to VA programs.
      Incorporate and integrate FRCP GAO recommendations and 
future program enhancements into the newly establish VA primary 
caregiver program mandated in the Caregivers and Veterans Omnibus 
Health Services Act of 2010 to ensure consistent and uniform enrollment 
criteria, terminology, and tracking procedures across the system.
      Expand outreach and communication efforts in DoD and VA 
medical and benefit systems to help increase awareness of the FRCP and 
how to enroll eligible members and by conducting periodic needs 
assessment surveys to get feedback from wounded warriors and their 
families to improve the program and identify unmet needs.
                               __________
    MADAM CHAIRMAN BUERKLE, RANKING MEMBER MICHAUD AND DISTINGUISHED 
MEMBERS OF THE SUBCOMMITTEE, thank you for convening this important 
hearing and allowing the Military Officers Association of America 
(MOAA) to provide our observations concerning the GAO findings on the 
FRCP and offer our recommendations.
    MOAA thanks the Subcommittee for its leadership in recent years to 
enhance programs in the VA for our wounded warriors and their families 
and to provide necessary oversight to ensure progress continues to be 
made in the area of health care and benefits so these individuals will 
have the best quality of life possible over their lifetime.
GAO Report Findings
    Many of the broad departmental issues plaguing both VA and DoD 
systems are also impacting and limiting FRCP, and likely a number of 
other wounded warrior programs, preventing them from effectively and 
efficiently meeting the needs of our most vulnerable servicemembers and 
disabled veterans who critically need these support services.
    Specifically, GAO cites limitations in:

      information sharing;
      multiple VA and DoD case management programs for the same 
wounded warriors;
      Federal Recovery Coordinators (FRCs) relying on referrals 
to identify eligible enrollees;
      role confusion on the part of FRCs and DoD-Service 
Recovery Care Coordinators and the numerous other case managers 
overseeing wounded warrior care; and
      issues of compliance, accountability and oversight within 
the FRCP and across VA that inhibit uniformity and consistency of 
operations to achieve a state of seamless transition.

    MOAA is deeply troubled at GAO's finding that ``VA does not know 
the number of severely wounded servicemembers in the Operation Enduring 
Freedom/Operation Iraqi Freedom (OEF/OIF) conflicts because `severely 
wounded' is not a categorical definition used by the DoD or VA medical 
and benefits programs. Further, that estimates of the size of the 
severely wounded population vary depending on definitions and 
methodology.''
    While much has improved in the last 2 years as the FRCP expanded to 
meet workload and improve seamless transition between the two programs, 
MOAA is very concerned that VA and DoD systems still struggle with 
basic terminology, policy, and management and technological system 
differences after more than a decade of war.
    The fact that the FRCP system was the first care coordination 
program jointly developed by the two agencies would lead one to believe 
that the program will be institutionalized and serve as a model for 
other VA-DoD collaboration. But persistent problems with information 
sharing and other long standing issues, to include the proliferation of 
duplicative programs for recovering servicemembers and veterans, points 
to a greater systemic problem well above the control of the Executive 
Director of the FRCP.
    The fact that VA must rely on referrals to identify eligible 
individuals for the program makes the program vulnerable to 
inconsistencies and inefficiencies, and those not identified are also 
more likely to fall through the administrative cracks, resulting in 
unintended medical consequences.
 MOAA concurs with GAO's assessment of the program and urges the 
        Congress to require both VA and DoD to provide a report to this 
        Subcommittee on their progress in addressing these issues and 
        implementing the GAO recommendations.
Additional Recommendations for Consideration
    MOAA believes that fixing the FRCP, in and of itself, will not 
address the challenges facing the program. Multiple case management 
systems and case managers assigned to wounded warriors and the 
proliferation of programs and services in both the VA and DoD medical, 
personnel and benefits systems have greatly confused and overwhelmed 
wounded warriors and their families and have further stressed systems 
already unable to meet the demands and fallout of war.
 Recommend establishing a consistent and uniform system of care 
        coordination in both VA and DoD that includes common 
        terminology, definitions, and provides a simpler way for 
        wounded warriors and their families to access and transition 
        from one system to the other.
    With the lessons learned from establishing and implementing the 
FRCP and remaining issues that need to be addressed, VA has a unique 
opportunity to apply these experiences and knowledge as it rolls out 
the new primary caregiver program mandated in the Caregivers and 
Veterans Omnibus Health Services Act of 2010. VA officials have stated 
on a number of occasions their difficulty in identifying the population 
that is eligible for the new caregiver services and benefits. If the 
two systems are focusing on the same population of severely wounded, 
then the transition process should be more streamlined and seamless.
    We repeatedly hear from servicemembers and veterans who have an FRC 
how great the program is and how the FRCs are an important lifeline. 
Our Association believes it is important for DoD and service programs 
to learn from VA and wounded warriors' experiences.
 MOAA recommends VA incorporate FRCP GAO recommendations and future 
        program enhancements into the newly established VA primary 
        caregiver program to ensure consistent and uniform enrollment 
        criteria, terminology, and tracking procedures across the 
        system.
    A recurring theme we hear from wounded warriors and family members 
is the overwhelming amount of information and program services pushed 
at them when they aren't ready to receive it, or are not in a position 
to understand the information given to them, rather than making it 
accessible when and where they need it. Disturbingly, others have never 
received information or have been given only limited information about 
programs like the FRCP or support services.
    Wounded warriors and families have become increasingly vocal in 
letting government program leaders know that they want to be consulted 
and included in developing and establishing new programs rather than 
having the administrators assume they know what is best for these 
individuals. In other words, they want leaders to make greater efforts 
to ask about and understand their needs before programs are developed 
that don't fit them.
 MOAA recommends expansion of outreach and communication efforts in DoD 
        and VA medical and benefit systems to help increase awareness 
        of the FRCP and how to enroll and by conducting periodic needs 
        assessment surveys to obtain and use feedback from wounded 
        warriors and their families to improve the program and identify 
        unmet needs.

                                 

               Statement of Paralyzed Veterans of America
    Chairwoman Buerkle, Ranking Member Michaud, and Members of the 
Subcommittee, Paralyzed Veterans of America (PVA) would like to thank 
you for the opportunity to submit a statement for the record regarding 
the progress and development of the Federal Recovery Coordination 
Program (FRCP).
    For more than 65 years it has been PVA's mission to help 
catastrophically disabled veterans and their families obtain health 
care and benefits services from the Department of Veterans Affairs 
(VA), and provide support during the rehabilitative process to ensure 
that all disabled veterans have the opportunity to build bright, 
productive futures. It is for this reason that PVA strongly supports 
the FRCP, and appreciates the Subcommittee's continued work on 
improving the transition from active duty to veteran status for 
severely injured, ill, or wounded veterans and servicemembers.
    The FRCP was created as a joint program between VA and the 
Department of Defense (DoD) to provide severely injured, ill, or 
wounded servicemembers and veterans with individualized assistance 
obtaining health care and benefits, and managing rehabilitation and 
reintegration into civilian life. Through the program, veterans and 
servicemembers are assigned a Federal Recovery Coordinator (FRC) and 
create a Federal Individual Recovery Plan that consists of long-term 
goals for the veteran and his or her family members. Such a plan 
motivates veterans to fight through the initial difficulties of 
adjusting to life after a catastrophic injury.
    The purpose of today's hearing is to assess the progress and 
challenges of the FRCP and identify potential ways in which the program 
can be improved in order to fulfill its mission. In the past year, the 
FRCP has made changes to enhance service delivery and expand its 
outreach; however, more work must be done in order to adequately meet 
the needs of veterans. Specifically, PVA believes that VA, DoD, and 
Congress must work together to address challenges in the areas of 
continuity of care, care coordination, and program awareness in order 
to make a difference in the lives of those that have made the ultimate 
sacrifice for our country.
Continuity of Care
    A primary component of the FRCP is continuity of care. As it 
relates to the FRCP, we believe that continuity of care means providing 
veterans and servicemembers with individualized care that is 
facilitated by an assigned primary Federal Recovery Coordinator (FRC) 
who maintains a working relationship with the veteran and his or her 
family to help manage a successful transition into civilian life after 
an illness or injury.
    PVA believes that one way in which continuity of care can be 
improved within the FRCP is to ensure that FRCs remain in contact with 
veterans not only during the initial phases of enrollment and 
administration of the Federal Individual Recovery Plan, but also after 
the veteran has become reintegrated in his or her community setting and 
home. PVA believes it of extreme importance that FRCs keep in touch 
with veterans and their families at this point to ensure that they are 
adjusting to life after a disability, and providing information when 
necessary to make certain that the veteran is aware of VA and DoD 
benefits and services that may be beneficial to him or her as 
utilization of the FRCP lessens.
    In support of continuity of care, VA and DoD must also work to 
create a system that monitors and manages the level of complexity and 
size of FRC caseloads. As it is a goal of the FRCP to meet the 
individualized needs of veterans and servicemembers, each case will be 
unique and require different levels of attention. These factors must be 
taken into consideration if FRCs are expected to provide timely quality 
assistance that is truly helpful to veterans and their families.
    In conjunction with FRC caseloads, the staffing of FRCs is another 
area of concern that must be assessed to determine if current staffing 
levels are adequate to meet veterans' needs. In a recent study 
conducted by the Government Accountability Office (GAO) it was reported 
that ``the FRCP faces challenges in determining staffing needs and has 
not clearly defined or documented its process for managing FRC 
caseloads . . . '' \1\ With a limited number of FRCs, issues involving 
transportation and distance have the potential to hinder access to care 
and resources for many veterans in rural areas, and thus, become 
threats to continuity of care. PVA encourages VA to develop an outreach 
strategy for veterans living in rural areas to make certain that they 
are aware of the FRCP and have access to a FRC if necessary. We also 
strongly recommend that VA develop a system to monitor and measure the 
complexity and size of FRC caseloads. We ask that as the program 
expands, VA, DoD, and Congress consider placing FRCs in locations where 
veterans with disabilities are already seeking services such as VA 
spinal cord injury centers or amputation centers of care.
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    \1\ United States Government Accountability Office, Report to 
Congressional Requestors: ``DoD and VA Health Care: Federal Recovery 
Coordination Program Continues to Expand but Faces Significant 
Challenges.'' March 2011; GAO-11-250.
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Care Coordination
    It is important to remember that veterans participating in the FRCP 
are also utilizing a multiplicity of other services from both VA and 
DoD. Care coordination of all the services and programs that a veteran 
chooses to utilize is extremely important for the success of the FRCP. 
In The Independent Budget for FY 2012--co-authored by PVA, AMVETS, 
Disabled American Veterans, and Veterans of Foreign Wars--it was 
reported that ``. . . veterans transitioning from the DoD to VA who are 
not assisted by the FRCP may be forced to interact with as many as five 
VA representatives . . . '' \2\ Interaction with so many different 
points of contact can be burdensome and overwhelming for veterans and 
their families and lead to disengagement of not only the FRCP, but 
other programs and services as well.
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    \2\ The Independent Budget, ``The Continuing Challenge of Caring 
for War Veterans and Aiding Them in Their Transition to Civilian 
Life,'' pp. 91; 2011.
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    On the contrary, when a veteran participates in the FRCP, the FRC 
is familiar with these various services and programs and can help the 
veteran better manage the multiple areas of care. Therefore, it is 
vital for FRCs to be fully aware of the different programs and services 
available to FRCP participants to avoid a duplication of efforts and 
conflicting information that can lead to ``information overload'' and 
confusion for veterans and servicemembers.
    With regard to VA health care, the Veterans Health Administration 
is currently undergoing a change in the way it delivers health care to 
veterans by utilizing patient aligned care teams (PACT). PACT is 
designed to provide patient-centered care through a team-based approach 
that emphasizes care coordination across disciplines. PVA encourages 
the FRCP leadership to work closely with the VA Office of Patient 
Centered Care and Cultural Transformation since FRCs serve as an 
information resource during the medical recovery process and the PACTs 
will be making FRCP referrals.
    Additionally, in support of care coordination, PVA hopes that FRCs 
will reach out to the service officers and advocates who represent 
various veteran service organizations and work with veterans in a 
similar capacity on a daily basis. PVA has a network of National 
Service Offices within VA that provide services to paralyzed veterans, 
their families, and disabled veterans. These services range from 
bedside visits to guidance in the VA claims process to legal 
representation for appealing denied claims.
    In fact, we recently received multiple reports describing close 
working relationships between PVA's Senior Benefits Advocates and FRCs. 
Our Senior Benefit Advocates and the FRCs work together on a daily 
basis to assist veterans and their families. National Service Officers 
can be a great resource to the FRC for referrals, information on VA 
benefits and programs, and getting the word out about the FRCP within 
the veteran community.
Program Awareness Among Veterans
    Making sure that veterans and servicemembers, as well as their 
families and caregivers, are aware of the FRCP has proven to be a 
continuous challenge. While participation numbers are growing, FRCP 
leadership must work to keep information about the program circulating 
throughout the veteran and military communities. This can best be 
accomplished as a joint effort that incorporates the different offices 
and departments across both the VA and DoD.
    Information posters and pamphlets should be made available to 
veterans and servicemembers when they visit other VA and DoD offices to 
promote the FRCP. Such educational literature would be useful not only 
for the veteran or servicemember, but for their families and caregivers 
as well. As previously mentioned, veterans participate in many VA 
programs, but it is often a loved one or caregiver who is helping 
manage and coordinate the various services of care and who could 
significantly benefit from the help of an FRC.
    Collaboration between FRCP staff and specialized services teams is 
another way to reach the targeted population that can benefit from FRCP 
services. The referral criteria for the FRCP includes veterans and 
servicemembers who have sustained a spinal cord injury, amputation, 
blindness or vision limitations, traumatic brain injury, post-traumatic 
stress disorder, burns, and those considered at risk for psychosocial 
complications--all areas included in VA's system of specialized 
services. Therefore, it is only logical for the FRCP to work with these 
specialty teams to promote the FRCP, and educate veterans entering VA 
specialized systems of care on the FRCP services and benefits.
    In conclusion, PVA urges continued Congressional oversight of this 
extremely important program and recommends that FRCP leadership 
periodically survey veterans and servicemembers, and their families, to 
identify areas for improvement. As the FRCP is a new program, there are 
numerous lessons to be learned and an abundance of opportunities for 
development.
    PVA appreciates the emphasis this Subcommittee has placed on 
reviewing the care being provided to the most severely disabled 
veterans and servicemembers. Navigating through America's two largest 
bureaucracies is a daunting task, but it can be particularly 
overwhelming when doing so after incurring a catastrophic injury such 
as a spinal cord injury, amputation, or as a polytrauma patient. 
Providing veterans with professional guidance and stability during this 
process gives them the resources to make informed decisions involving 
their health care and benefits and focus on their recovery and future 
endeavors.
    PVA would like to once again thank this Subcommittee for the 
opportunity to submit a statement for the record. We look forward to 
working with you to continue to improve the Federal Recovery 
Coordination Program. Thank you.

                                 
                  Statement of Wounded Warrior Project
    Chairwoman Buerkle, Ranking Member Michaud and Members of the 
Subcommittee:
    In presenting our policy agenda in March at a joint hearing before 
the full House and Senate Veterans Affairs Committee, Wounded Warrior 
Project recommended that the Committees review the operation and 
effectiveness of the many programs Congress created to improve 
warriors' transition from military service to civilian status. The 
Federal Recovery Coordination Program may be among the most important 
of those initiatives to our warriors and their families.
    The program has its roots in the President's Commission on the Care 
of America's Returning Wounded Warriors (the Dole-Shalala Commission), 
which found that the system of care, services, and benefits created to 
assist those who had been injured was too complex to navigate alone. 
The Commission recommended the creation of ``recovery coordinators'' 
or, in the words of the father of a severely wounded Marine, ``a case 
manager to manage my case managers.'' Ultimately, the National Defense 
Authorization Act of 2008 (NDAA 2008) directed the Departments of 
Defense (DoD) and Veterans Affairs (VA) to develop and implement a 
comprehensive policy to improve care, management and transition of 
recovering servicemembers and their families, to include the 
development of comprehensive recovery plans, and the assignment of a 
recovery care coordinator for each recovering servicemember.\1\ Working 
jointly, DoD and VA entered into a memorandum of understanding 
establishing a joint VA-DoD Federal Recovery Coordination Program to 
assist those with category 3 injuries--those with a severe or 
catastrophic injury or illness who are highly unlikely to return to 
active duty and will most likely be medically separated. (A separate 
DoD Recovery Coordinator Program was designed for those with category 2 
injuries who might or might not return to duty.)
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    \1\ Public Law 110-181, sec. 1611.
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    In WWP's view, the Federal Recovery Coordination Program is a too-
rare instance of a holistic, integrated effort to help injured veterans 
thrive again. The unique contributions--both medical and non-medical--
that Federal recovery coordinators are making in facilitating wounded 
warriors' care-coordination and reintegration underscores the 
importance of ensuring that this program reaches all who need that 
help, and that it operate as effectively as possible. But while Federal 
Recovery Coordinators provide extraordinary assistance to warriors and 
their families, overarching systemic problems must be addressed to 
ensure that the program fully meets its objectives.
GAO Identifies Systemic Problems
    The General Accountability Office's recent report on the program 
identifies important issues and proposes constructive recommendations 
for VA action. But most importantly, in our view, GAO advises that 
``[s]ome of the daunting challenges facing FRCs and the program are 
beyond the capability of the program's leadership to resolve.'' The 
issues that GAO identifies may appear daunting, but to fail to resolve 
them is to compromise this critical program's effectiveness and to fail 
our warriors. We welcome this hearing as an important step toward that 
needed resolution.
    In essence, GAO highlights critical problems that VA alone cannot 
rectify, including--

      The lack of a DoD data system that readily and 
systematically identifies those servicemembers who are severely 
wounded, ill, or injured, and whose medical conditions are highly 
likely to prevent their return to duty and also likely to result in 
medical separation from the military, namely those who may be 
considered for enrollment into the program;
      Overlap between DoD and VA case-management and care-
coordination programs that compromises effective coordination--the core 
mission of the FRC program--resulting in duplication of effort, waste, 
confusion for enrollees and families, and failures to take needed 
action based on a mistaken belief that another was assisting the 
servicemember;
      DoD and VA data-system incompatibility that impedes 
sharing basic information; and
      Inconsistency in DoD facilities providing FRCs needed 
work space, equipment and technology support, despite memoranda of 
agreement calling for such support.

    We commend GAO for identifying these problems, but are disappointed 
that its report did not go further and offer recommendations for a more 
substantial DoD role in addressing them. GAO did recognize that the FRC 
program was jointly developed by DoD and VA. But since the program is 
staffed by VA, operated by VA, and headquartered in VA, it is too often 
seen as simply a VA program, rather than a joint DoD-VA undertaking. 
This must change for the benefit of those the program is intended to 
serve.
An Inter-Departmental Solution
    The two departments each share a deep obligation to severely 
wounded warriors and their families, but the reality is that they do 
not now share full responsibility for the FRC program. With its 
critical role in ensuring that severely wounded warriors experience a 
seamless transition, the FRC program suffers from such troubling 
interdepartmental gaps that an interdepartmental solution should at 
least be on the table for discussion. We would go further. WWP 
recommends a structural change in the program's governance--
specifically, we propose establishment of an interdepartmental FRC 
program office. We offer this recommendation not because we are 
critical of VA, but in recognition of the inherent limitations of the 
current structure and the overarching obligation owed these warriors 
and their families. The concept of a DoD-VA program office is neither 
novel nor unprecedented.\2\ While different structural solutions could 
be pursued, we foresee continued difficulties for the program, and most 
importantly our warriors, unless fundamental changes are brought about 
that establish truly shared responsibility.
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    \2\ Section 1635 of NDAA 2008 mandated establishment of a DoD/VA 
Interagency Program Office (IPO) to act as a single point of 
accountability for the department's development of electronic record 
systems.
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Referrals for an FRC Assignment: A Broken Process
    One of the many issues that GAO identified particularly underscores 
how important it is that the FRC program become a truly joint 
enterprise. GAO aptly recognizes the importance of identifying all who 
could benefit from having an FRC. But the report confirms that 
individual service departments are not uniformly referring severely and 
catastrophically wounded warriors to the FRC program for assignment, or 
are doing so at much too late a point in the transition process. To 
illustrate, one of the service departments routinely assigns even the 
most severely wounded warriors a Recovery Care Coordinator (RCC), but 
makes no FRC referral. Another service department does not necessarily 
even assign wounded warriors an RCC let alone an FRC, apparently 
deeming that the support provided at warrior transition units meets 
care-coordination needs. It is difficult to reconcile service-
department practices that defer referral of a severely wounded warrior 
until that individual has retired with a longstanding DoD policy or 
with the DoD-VA understanding under which the FRC program was 
established. The DoD policy makes it clear that ``all category 3 
servicemembers shall be enrolled in the FRCP [Federal Recovery 
Coordination Program] and shall be assigned an FRC [Federal Recovery 
Coordinator] and an RT [recovery team].'' \3\ The policy instructs 
further that the Federal Recovery Coordinator is to coordinate with the 
recovery care coordinator and recovery team to ensure the needs of the 
servicemember and his or her family are identified and addressed.
---------------------------------------------------------------------------
    \3\ Department of Defense Instruction (DoDI) Number 1300.24, 
``Recovery Coordination Program (RCP),'' Enclosure 4, sec. 2.d. 
(December 1, 2009).
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    While we are not proponents of blind adherence to policy for its 
own sake, the care-coordination policy developed jointly by VA and DoD 
to implement the care-coordination provisions of the National Defense 
Authorization Act of 2008 is sound. That policy furthers the 
fundamental goal of ensuring that wounded warriors have a seamless 
transition from DoD to VA that best meets their needs, rather than 
furthering the interests of one department or another. Appropriately 
implemented, the policy also helps minimize confusion on the part of 
wounded warriors regarding the roles of those working on their behalf. 
Rather than advancing seamless transition, individual service 
department practices that defer referral for a possible FRC assignment 
until a severely wounded warrior has retired tend to frustrate 
realization of the goals the program was developed to achieve.
    One might ask, what difference does it make whether a wounded 
warrior has a ``Recovery Care Coordinator,'' a ``Federal Care 
Coordinator,'' or some other assistance? In fact, the differences are 
real and substantial.
    The VA-DoD policy recognizes the importance of providing a Federal 
care coordinator for a warrior who has a severe or catastrophic injury 
or illness, is highly unlikely to return to duty, and is most likely to 
be medically separated. Given the complexity of care and transitional 
needs of those with severe or catastrophic wounds, warriors and their 
families may be eligible for and need assistance not only from military 
treatment facilities and the TRICARE program, but from the Veterans 
Health Administration, the Veterans Benefits Administration, the Social 
Security Administration, and Medicare. (As the GAO report recognizes, 
``FRCs are intended to be care coordinators whose planning, 
coordination, monitoring and problem-resolution activities encompass 
both health services and benefits provided through DoD, VA, other 
Federal agencies, States, and the private sector.'') It is critical 
that a Federal coordinator have the depth of experience, training, and 
authority to navigate these multiple care/benefits systems. In contrast 
to those demanding requirements for an FRC, neither warrior transition 
unit staff nor recovery care coordinators (RCCs)--who are to assist 
servicemembers whose injuries are not deemed likely to result in a need 
for medical separation\4\--have the training, let alone the authority, 
to help coordinate care and other needs outside the military system.
---------------------------------------------------------------------------
    \4\ DoDI 1300.24, Enclosure 4, sec. 2.a.
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    Resolving this referral problem is gravely important: failing to 
make a referral for an FRC until severely wounded servicemembers retire 
can mean delay in their recovery, rehabilitation and re-integration. 
These are the very kinds of problems that sparked the call for a 
seamless transition, and it is alarming that they should remain 
unresolved.
    Practices that defer referrals for an FRC until the servicemember 
retires seem to reflect a fundamental lack of understanding of the 
purpose of the FRC program. At a recent DoD-sponsored summit on care 
coordination, Service program personnel repeatedly referred to FRC 
services as ``bringing in the VA.'' Rather than being seen--and 
marginalized--as a ``VA program,'' the FRC program should be operated 
as a joint, integrated effort aimed at coordinating Federal care and 
services. What should be a seamless, coordinated undertaking is too 
often the opposite, as illustrated by the fact that rather than having 
a single recovery plan, warriors may find themselves with multiple 
``comprehensive recovery care plans.''
    Given the very substantial inter-departmental problems GAO 
identified, it is striking that its recommendations were directed only 
to VA. As such, the report tends to reinforce the unfortunate 
impression that the Department of Defense has no responsibility for 
this program. Indeed, DoD's March 4th response to the report (appendix 
II)--coming after nearly a decade of war and years since Congress 
directed the Departments to ensure seamless recovery-care 
coordination--does not seem to reflect any sense of urgency or 
commitment to action. Rather, in a one-sentence comment, the DoD 
response states that ``a Joint DoD/VA Committee has been formed to 
study how to combine or integrate recovery care coordination efforts 
for wounded, ill, and injured servicemembers, veterans, and their 
families.'' (Emphasis added.) We urge the Subcommittee to consider 
GAO's work a starting point, but not necessarily the final word on 
these issues.
    Finally, WWP has also heard concerns from a number of wounded 
warriors and their caregivers regarding lack of communication between 
FRCs and their clients. While some are frustrated at not having heard 
from an FRC, or don't think to initiate a call, FRCs are often working 
on their behalf behind the scenes. WWP recommends that the program 
establish clear expectations regarding the frequency and means of 
communication to ensure that there is common understanding.
    In closing, we urge the Committee to work with the Armed Services 
Committee to ensure that the departments move beyond ``study,'' and 
jointly take on and resolve the problems that impede full realization 
of this program's vital mission. Given the importance of this program 
to severely wounded warriors, it is critical that both departments 
fully support it. We believe shared governance would best achieve that 
objective, and legislation may well be necessary to accomplish that.
    Wounded Warrior Project would be pleased to work further with the 
Subcommittee to realize in full the goals of this important program.

                                 
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