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




 
                   THE FEDERAL RECOVERY COORDINATION
             PROGRAM: ASSESSING PROGRESS TOWARD IMPROVEMENT

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

                                HEARING

                               before the

                         SUBCOMMITTEE ON HEALTH

                                 of the

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

                      ONE HUNDRED TWELFTH CONGRESS

                             FIRST SESSION

                               __________

                            OCTOBER 6, 2011

                               __________

                           Serial No. 112-29

                               __________

       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
MARK E. AMODEI, Nevada
ROBERT L. TURNER, New York

            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 
official version. Because electronic submissions are used to prepare 
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

                               __________

                            October 6, 2011

                                                                   Page
The Federal Recovery Coordination Program: Assessing Progress 
  Toward Improvement.............................................     1

                           OPENING STATEMENTS

Chairwoman Ann Marie Buerkle.....................................     1
    Prepared statement of Chairwoman Buerkle.....................    33
Hon. Michael H. Michaud, Ranking Democratic Member...............     2
    Prepared statement of Congressman Michaud....................    34

                               WITNESSES

U.S. Government Accountability Office, Debra A. Draper, Director, 
  Health Care....................................................     3
    Prepared statement of Ms. Draper.............................    34
U.S. Department of Defense, Philip A. Burdette, Principal 
  Director, Wounded Warrior Care and Transition Policy, Office of 
  the Under Secretary of Defense for Personnel and Readiness.....    10
    Prepared statement of Mr. Burdette...........................    41
U.S. Department of Veterans Affairs, John Medve, Executive 
  Director, Office of the U.S. Department of Veterans Affairs-
  U.S. Department of Defense Collaboration, Office of Policy and 
  Planning.......................................................    12
    Prepared statement of Mr. Medve..............................    43

                                 ______

Military Officers Association of America, Commander Rene A. 
  Campos, USN (Ret.), Deputy Director, Government Relations......    27
    Prepared statement of Commander Campos.......................    50
Paralyzed Veterans of America, Alethea Predeoux, Associate 
  Director of Health Legislation.................................    25
    Prepared statement of Ms. Predeoux...........................    48
Wounded Warrior Project, Abbie Holland Schmit, Manager, Alumni...    24
    Prepared statement of Ms. Schmit.............................    45

                       SUBMISSION FOR THE RECORD

Carnahan, Hon. Russ, a Representative in Congress from the State 
  of Missouri....................................................    55

                   MATERIAL SUBMITTED FOR THE RECORD

Gail H. McGinn, Deputy Under Secretary of Defense (Plans) 
  Performing the Duties of the Under Secretary of Defense for 
  Personnel and Readiness, transmitting U.S. Department of 
  Defense Instruction Number 1300.24, regarding ``Recovery 
  Coordination Program,'' dated December 2, 2009.................    56


                     THE FEDERAL RECOVERY PROGRAM:
                 ASSESSING PROGRESS TOWARD IMPROVEMENT

                              ----------                              


                       THURSDAY, OCTOBER 6, 2011

             U.S. House of Representatives,
                    Committee on Veterans' Affairs,
                                    Subcommittee on Health,
                                                    Washington, DC.

    The Subcommittee met, pursuant to call, at 8:30 a.m., in 
Room 334, Cannon House Office Building, Hon. Ann Marie Buerkle 
[Chairwoman of the Subcommittee] presiding.
    Present: Representatives Buerkle, Bilirakis, Roe, Michaud, 
and Donnelly.

            OPENING STATEMENT OF CHAIRWOMAN BUERKLE

    Ms. Buerkle. Good morning. I want to thank all of you for 
joining us this morning as we continue our oversight of the 
Federal Recovery Coordination Program (FRCP).
    Last May, our Subcommittee held a hearing to examine the 
significant challenges that the FRCP faces in areas as 
fundamental as identifying potential enrollees, reviewing 
enrollment decisions, determining staffing needs, defining and 
managing caseloads, and making placement decisions.
    At that hearing, unfortunately, it became patently clear 
that rather than having a single joint program to advocate on 
behalf of our wounded warriors and to ensure a comprehensive 
and seamless rehabilitation, recovery, and transition, we have 
two separate overlapping programs, the Recovery Coordination 
Program (RCP) operated within the U.S. Department of Defense 
(DoD) and the FRCP operated within the U.S. Department of 
Veterans Affairs (VA).
    Needless to say, this has created unnecessary and 
unacceptable confusion about the roles and the responsibilities 
of each program and has added yet another burdensome 
bureaucratic maze for our wounded warriors and their families 
to navigate through at a time when recovery and reintegration 
should really be their only focus.
    I was so concerned about the pervasive issues with the 
operation of these two programs that immediately following that 
hearing, I sent a letter jointly with Ranking Member Michaud to 
the co-chairs of the VA-DoD Wounded, Ill, and Injured Senior 
Oversight Committee (SOC) with oversight over the FRCP.
    In that letter, we requested a detailed plan and a timeline 
for how the VA and DoD jointly would implement the 
recommendations contained in the recent U.S. Government 
Accountability Office (GAO) report, which identified 
significant shortcomings of the FRCP.
    Further, we asked for an analysis on how the FRCP and RCP 
could be integrated under a single umbrella to reduce 
redundancy and ensure the seamless transition of our wounded 
warriors.
    A response was requested by June the 20th. More than 2 
months passed since this deadline and, following the notice of 
this additional hearing, we finally received a response to our 
letter. Unfortunately, it did not include the detail nor the 
timeline we requested and expected.
    With regard to an analysis of and potential actions for 
integrating the FRCP and the RCP, we were told that SOC, quote, 
is currently considering several options to maximize resources 
in care coordination and preparing for final recommendations, 
end quote. These programs are not new and the time for 
considering and recommending has long since passed.
    As Chairwoman, it has been my privilege this year to spend 
time with our honored heroes who have returned from battle 
bearing the wounds of war and the families who stand by their 
side through it all.
    I have traveled to Brooke Army Medical Center, the Center 
for the Intrepid, and VA medical facilities across our great 
country. It is clear to me that FRCP is failing.
    It is also clear to me that these families cannot wait any 
longer. They can no longer be party to the bureaucratic in 
fighting and turf battles. They can no longer be told that they 
have several points of contact.
    When answers are needed, we cannot take 3 months to respond 
to a letter. When answers are needed, we cannot continue to 
consider our options. Today we are looking for answers.
    I now recognize the Ranking Member, Mr. Michaud, for any 
remarks he might have.
    [The prepared statement of Chairwoman Buerkle appears on p. 
33.]

          OPENING STATEMENT OF HON. MICHAEL H. MICHAUD

    Mr. Michaud. Thank you very much, Madam Chair. I would like 
to thank you for holding this hearing today on this extremely 
important program.
    As you heard, in May, this Subcommittee held a hearing on 
the very same issue and I am pleased that we are the critical 
oversight of this very critical program. If it is not done 
right, our servicemembers will suffer.
    Following that Subcommittee hearing, I joined the 
Chairwoman in sending a letter on May 26 to the Senior 
Oversight Committee requesting a detailed response to how the 
VA and the DoD can work together on implementing the Government 
Accountability Office recommendations and requesting an 
analysis of integrating the FRCP and the Recovery Coordination 
Program.
    On August 19th, we then sent a follow-up letter because of 
the lack of response from the Senior Oversight Committee. The 
letter that we did finally receive dated September 12th was 
hardly what we were expecting.
    The GAO reports that the agencies reached an impasse on the 
content of the final letter responding to our concerns as a 
Committee. This lack of response only serves to magnify in my 
mind the continued problems between the VA and the DoD in 
working collaboratively and highlights the lack of progress 
that we have heard and read about in recent submissions and 
testimony.
    I can only imagine what this means with other critical 
decisions that directly impact veterans and their families. I 
do not feel confident that the Department of Veterans Affairs 
and the Department of Defense can overcome existing barriers 
and the tangling of bureaucracy seems to surround the 
implementation of this program.
    Let us all keep in mind that this is not about individuals 
sitting in this room. This is about the brave men and women who 
wear the uniform, who have been injured while serving this 
country, and our absolute commitment to their recovery and 
reintegration back into the communities where they live. 
Whatever it takes, we owe that much to them.
    Today I would like to hear about solid progress that has 
been made and what is being done to move this forward in an 
effective and efficient manner. I would also like to hear from 
each of the panels what this Subcommittee might be able to do 
to help.
    It is unconscionable that we have a bureaucracy that is 
supposed to be helping our soldiers and our veterans but 
because of the entanglement within the bureaucracy, these brave 
men and women are not being served like they should.
    I would encourage each and every one of you who are 
responsible for this program to step up to the plate, think of 
what these men and women have gone through and are going 
through each and every day. And I look forward to your 
testimony.
    Madam Chair, I want to thank you for holding this hearing 
on this very important topic. So thank you very much.
    [The prepared statement of Congressman Michaud appears on 
p. 34.]
    Ms. Buerkle. Thank you, Mr. Michaud.
    At this time, I would like to welcome our first panel to 
the table. With us this morning is Dr. Debra Draper, Director 
of the Health Care team at the United States Government 
Accountability Office.
    Thank you very much for joining us this morning and I look 
forward to hearing your testimony. We will start with you now. 
Thank you.

   STATEMENT OF DEBRA A. DRAPER, DIRECTOR, HEALTH CARE, U.S. 
                GOVERNMENT ACCOUNTABILITY OFFICE

    Ms. Draper. Chairwoman Buerkle, Ranking Member Michaud, and 
Members of the Subcommittee, I am pleased to be here today as 
you discuss efforts by DoD and VA to address issues of concern 
that were raised during your May 13th hearing on the Federal 
Recovery Coordination Program, a program jointly developed by 
DoD and VA to provide care coordination for our most severely 
wounded, ill, and injured servicemembers and veterans, 
individuals who because of the severity of their injuries and 
illnesses could benefit greatly from care coordination 
services.
    At the May 13th hearing, we highlighted various concerns 
identified in our March 2011 report about the program. We also 
emphasized the importance of this program's coordination with 
other DoD and VA programs that are similarly intended to 
improve care coordination and case management including DoD's 
Recovery Coordination Program.
    In my statement today, I will discuss the status of actions 
taken by DoD and VA to implement the recommendations from our 
March report. I will also discuss efforts by DoD and VA to 
identify and analyze potential options to better integrate 
their care coordination programs.
    Regarding our March recommendations, we are pleased that VA 
has made progress in improving program management of enrollment 
decisions as well as care coordinator staffing needs, 
caseloads, and placement decisions.
    While our recommendations were directed to the Secretary of 
VA because VA administers the program, DoD and VA were both 
asked to provide a response to the Subcommittee about how the 
Departments could jointly implement them.
    We found that DoD's assistance to VA has been limited to a 
June 30th e-mail to the commanders of the military services' 
Wounded Warrior programs about referrals to the program. 
According to VA officials, however, they have seen no change in 
referrals since the e-mail was sent.
    More troubling, however, is the status of DoD and VA's 
efforts to jointly identify and analyze potential solutions to 
better integrate their care coordination programs. The 
Departments have made little progress reaching agreement on 
integration options despite a number of attempts to do so.
    Most recently, DoD and VA failed to provide a timely 
response to the Subcommittee's May 26 request to jointly 
develop potential solutions for integrating their care 
coordination programs.
    On September 12, several months after the request, a joint 
letter was issued stating that the Departments were considering 
a number of options to maximize their care coordination 
resources. However, this letter did not specifically identify 
or outline any of these options. Other efforts have also failed 
to advance a jointly devised solution.
    This lack of progress to better integrate the Departments' 
care coordination programs illustrates the continued difficulty 
by DoD and VA to reach a collaborative solution to address 
program duplication and overlap.
    We currently have work underway to further study this issue 
and identify key impediments affecting recovering 
servicemembers and veterans during the course of their care.
    Also, as we have previously reported, there are numerous 
DoD and VA programs that provide similar services to 
individuals who are often enrolled in more than one program and 
as a result may have multiple care coordinators and case 
managers.
    One Federal Recovery Coordinator (FRC) told us that in one 
instance, five case managers were working on the same life 
insurance for the same individual.
    In another instance, DoD and VA care coordinators 
unknowingly established conflicting recovery goals for a 
servicemember about whether to separate from the military. This 
created considerable confusion for the individual and his 
family.
    The bottom line is that there has been little progress made 
by DoD and VA to more effectively align and integrate their 
care coordination and case management programs across the 
Departments.
    This is particularly disconcerting as the number of 
individuals served by these programs continues to grow. Without 
better interdepartmental coordination, problems with 
duplication and overlap will persist and perhaps worsen.
    Furthermore, the confusion this creates for recovering 
servicemembers, veterans, and their families may hamper their 
recovery. Unfortunately, the intended purpose of these programs 
to better manage and facilitate care and services may actually 
have the opposite effect.
    Based on our continuing concerns, we are recommending that 
the secretaries of DoD and VA direct the Senior Oversight 
Committee to expeditiously develop and implement a plan to 
strengthen integration across all DoD and VA care coordination 
and case management programs including the Federal Recovery 
Coordination and Recovery Coordination programs to improve 
their effectiveness, efficiency, and efficacy.
    Madam Chairwoman, this concludes my opening remarks. I am 
happy to answer any questions.
    [The prepared statement of Ms. Draper appears on p. 34.]
    Ms. Buerkle. Thank you, Dr. Draper.
    I will now yield myself 5 minutes for questions.
    I just want to pick up on a couple of things and follow-up 
with some of your testimony here this morning.
    The first thing that concerns me is that you are saying 
that the failure of VA and DoD to reach some sort of an 
agreement and the duplication and the conflicting goals of 
these two programs may hamper their recovery.
    So it is your testimony this morning that this program is 
right now in its current form hurting our veterans rather than 
helping them?
    Ms. Draper. Well, we have concerns because there appears to 
be little, if any, cooperation or collaboration. And since our 
May testimony, the situation actually seems to be worsening 
based on our updated work for this particular hearing.
    For our work related to the testimony, we received 
differing versions as to why further progress has not been 
made, and it was very difficult to get a clear understanding of 
what the difficulties are between the two Departments.
    We are aware of some activity, but we do not know the 
details of those activities, and the activities seem to be done 
in silos at VA and at DoD but nothing collaboratively.
    Our concern is that the lack of cooperation and 
collaboration not only fails to address existing program 
duplication and overlap but fails to fully consider the impact 
on our most severely wounded servicemembers and veterans.
    As you know, these are particularly vulnerable individuals 
that can benefit greatly from care coordination services. 
Somehow this interdepartmental tug of war seems to have lost 
sight of why the programs exist in the first place, which is to 
care for our wounded servicemembers and veterans.
    Ms. Buerkle. Thank you.
    You mentioned that your recommendation is to expeditiously 
develop and implement a plan.
    So if you would give us some insights. What do you consider 
expeditious and what should our expectation be? What is 
realistic from what you have observed from DoD and VA?
    Ms. Draper. We have a couple of things that we would think 
are important to consider in moving towards a solution. First 
of all, I would just say that the progress made has been too 
slow. Ensuring that the Departments address our recommendation 
is important.
    Reevaluating the role of the Senior Oversight Committee, 
that is probably something that needs to be done. Is there more 
that they can be doing? Should they be doing something 
differently?
    The Departments should determine whether the original 
intent of the program continues to be important, and if so, 
they should ensure that the proposed solutions really preserve 
that original intent.
    And if the desire is for this to be a truly joint DoD and 
VA program, it seems reasonable that DoD and VA should have 
joint administrative, budgetary, and other responsibilities, 
and joint incentives should be designed to ensure that the 
desired outcomes are achieved. As, you know, currently DoD does 
not have administrative or a budgetary role in this program.
    And, you know, to be quite frank, it would be helpful to 
hold the Department's feet to the fire and require them to 
periodically report on their plans and progress.
    Ms. Buerkle. In your opinion, where should we go from here 
as a Subcommittee?
    We want to see this program moved along. As the Ranking 
Member mentioned as well as myself, this is not about the 
people in this room. This is about our wounded warriors. So if 
you could just give us some insight as to where you think we 
should go from here.
    Ms. Draper. Well, we strongly encourage DoD and VA to 
examine the strength of their coordination for these programs.
    But I do want to reiterate that our concerns go beyond the 
Federal Recovery Coordination or Recovery Coordination 
programs. As I mentioned in my testimony, there are numerous 
care coordination and case management programs across the 
Departments, and we believe that it is now time to take a 
comprehensive look at all these similar programs to identify 
duplication and overlap and to develop and implement a plan to 
improve their overall effectiveness, efficiency, and efficacy.
    Ms. Buerkle. Thank you, Dr. Draper.
    I now yield 5 minutes to the Ranking Member.
    Mr. Michaud. Thank you very much, Madam Chair.
    While you were conducting the interview and performing your 
audits, were you confused by the way that these programs were 
set up to function or could you understand the functionality of 
the programs?
    Ms. Draper. I would say we were confused more by the 
responses we were getting from DoD and VA. They did not seem to 
be very aligned, and we got differing views from each of the 
Departments. So, it was very hard to piece the story together.
    Mr. Michaud. First of all, it is disheartening to me that 
the DoD and VA have made little progress towards integrating 
the care and coordination and case management across the 
Departments.
    What can we do to help facilitate the coordination and 
communication between the agencies? I mean, to me, it seems it 
is very simple, but evidently--well, it is not working. So what 
do you think that we should do to help facilitate that?
    Ms. Draper. Well, again, I think holding their feet to the 
fire, creating joint incentives for the programs that force 
that alignment of the Departments' goals, and giving joint 
responsibilities and accountability to both Departments.
    I do want to say, though, that there is some inherent 
tensions between the way the Federal Recovery Coordination 
Program is set up between DoD and VA that involves when and how 
best to involve the Federal Recovery Coordinators.
    DoD's stance is that they are concerned about involving VA 
too soon because it sends the wrong message to a recovering 
servicemember, mainly that their military career may be over. 
Also, I think there is a cultural stance within the military 
services to take care of their own.
    On the other hand, you have VA who has authority to realy 
work with recovering servicemembers veterans, and their 
families, and they want to get involved early so that they can 
make the transition for that recovering servicemember to 
civilian life much easier.
    Mr. Michaud. Would you agree then by the fact that the DoD 
is reluctant to let the VA step in early because they are 
afraid that there might be the perception of kicking them out?
    The bottom line that concerns me is the fact that if a 
servicemember or veteran is not getting the service that they 
need, that is going to cause a lot more stress on the 
individual member of the service as well as the family and 
ultimately could potentially lead to suicide. And that is the 
huge concern that I have with the lack of coordination and the 
lack of the case management as I have heard about since we 
implemented the program.
    And have you heard any concerns about that or in your 
investigation about the suicide?
    Ms. Draper. We did not hear about that.
    Mr. Michaud. Thank you, Madam Chair.
    Ms. Buerkle. I yield 5 minutes to the gentleman from 
Tennessee, Mr. Roe.
    Mr. Roe. Thank you, Dr. Draper, for being here.
    And let me just start out by saying that this should be 
something we are really good at. You know, we provide the best 
health care on the battlefield that there is in the world or 
ever has been. And people are surviving injuries now that they 
did not survive when I was in service in the 1970s and during 
Vietnam. So this is something we should be really good at.
    I looked at these numbers last night and there are 21 of 
the Federal Recovery coordinators and there are 1,827 
servicemen that have been treated so far. And this is over a 
period of 3\1/2\ years.
    Ms. Draper. Uh-huh.
    Mr. Roe. Eighteen hundred and twenty-seven people got care. 
I saw between 3,000 to 4,000 patients a year myself plus 
assisted or did several hundred operations during 1 year, one 
person did.
    And I did the math on this and these people average taking 
care of one person every other week. This should not be 
overwhelming anybody. And I do not know what in the world, why 
this has been so hard. And you pointed out something that we 
see.
    Sometimes you have several people involved in a discussion 
when maybe a veteran does not get the answer or a soldier does 
not get the answer they want. It is a tremendous waste of 
resources when you have five people working on the same issue. 
That is ridiculous.
    And you had stated here the GAO references one FRC that 
estimates that his enrollees have on average eight different 
case managers affiliated with eight different programs. This 
overlap can lead to significant redundancy, conflict, and 
frustration for the servicemember or veteran and their family 
throughout the recovery and reintegration process.
    I could not agree more. I mean, you do not have anybody 
leading the ship and that is what I thought the FRC was. Am I 
right or wrong about that?
    Ms. Draper. Well, the original intent was to have one 
person being the umbrella to coordinate both the clinical and 
non-clinical services. I mean, that is our concern with the 
duplication and overlap. Having so many people involved runs 
counter to the intent of the program.
    Mr. Roe. Yeah. But, I mean, I guess what I am looking at, 
if I had this many resources to take care of 1,827 people, I 
believe I could do that pretty well, pretty easily, and without 
all this confusion. And that is what I am baffled by.
    Where is the problem? I mean, when you do the math on this 
in 3\1/2\ years, the average coordinator is taking care of 25 
persons per year. That is one every other week. Am I wrong?
    Ms. Draper. That is correct.
    Mr. Roe. Do you have an explanation for that?
    Ms. Draper. I do not.
    Mr. Roe. I think maybe later in the testimony, we will get 
an explanation for that, but I agree. And I see this in our 
office and I know all of us that have offices that work with 
veterans. Sometimes they are in the senator's office. Sometimes 
they are in our office. I know it gets conflicted sometimes 
when a case gets in two different places.
    But this is a situation where that should not happen 
because we have control of these folks. They are either in DoD 
under their umbrella, or in VA under their umbrella.
    Ms. Draper. And I want to emphasize that these are very 
important services, particularly for this population that is 
very vulnerable. And as you know, we just need to find a way to 
make the programs work and work well.
    Mr. Roe. And they are critical services. I want to hear 
actually later in the testimony, and thank you for the work you 
have done, Dr. Draper, to point out why this is not working 
after going on now 4 years.
    I yield back.
    Ms. Buerkle. Thank you, Dr. Roe.
    Mr. Donnelly.
    Mr. Donnelly. Just a follow-up to Dr. Roe's question. Where 
would we look for the explanation as to the numbers that he was 
talking about as to the productivity and how many people were 
being taken care of?
    Ms. Draper. Yes. I would direct that to the program 
officials.
    Mr. Donnelly. Okay. The next question is about cooperation. 
You have DoD. You have VA. What have you found in terms of 
cooperation and working with them?
    Ms. Draper. We have found that it is not working very well 
at all.
    Mr. Donnelly. And what are the major causes of that? I know 
in your testimony, you pointed at some of the quote. How do we 
get these people to work seamlessly together?
    Ms. Draper. As I mentioned earlier, there are some inherent 
tensions based on differences between the two Departments, and 
I think these differences are key to improving collaboration.
    One difference is looking at when and how to get a Federal 
Recovery Coordinator involved in care. There seems to be a lot 
of disagreement about that when that happens.
    I think also that the Departments should be held 
accountable, and they should be required to periodically report 
on their plans and progress.
    And I also would strongly recommend that they implement the 
recommendation that we are making in our testimony today and 
that is to expeditiously develop and implement a plan to look 
at integration across care coordination and case management 
programs.
    And I want to reiterate that our concerns are much beyond 
the Federal Recovery Coordination and Recovery Coordination 
programs and extend to the numerous care coordination and case 
management programs. I think this is a time to take a 
comprehensive look across those programs to identify and 
eliminate duplication and overlap.
    Mr. Donnelly. I was going to ask you, the other programs, 
it is the same difficulty or there are the same difficulties?
    Ms. Draper. We are currently doing work looking at some of 
those programs, so I cannot say that for sure. But I think that 
when you see evidence, when a Federal Recovery Coordinator 
tells you that five case managers are working on the same life 
insurance issues and that is problematic. And to me that 
indicates there is the potential for deeper problems.
    Mr. Donnelly. Madam Chair, the only other thing I would 
like to say is that in terms of focus, the focus should not be 
on what makes DoD happy and what makes VA happy, but what helps 
our wounded warriors and using our taxpayer dollars to the best 
effect.
    As Mr. Roe was talking about, he saw 3,000 plus patients a 
year by himself and I know he is a good doctor, but that is not 
unusual, I do not think. You know, I think the focus has to be 
on the people who deserve it.
    Ms. Buerkle. Thank you.
    Dr. Draper, thank you very much for being here this 
morning----
    Ms. Draper. Thank you.
    Ms. Buerkle [continuing]. For your work on this very 
important issue. You are now free to go.
    Ms. Draper. Thank you very much.
    Ms. Buerkle. I would like to invite our second panel to the 
witness table. Joining us from the Department of Defense is Mr. 
Philip Burdette, Principal Director of Wounded Warrior Care and 
Transition Policy for the Office of the Under Secretary of 
Defense for Personnel and Readiness.
    Also on our second panel is John Medve, the Executive 
Director for the Office of VA-DoD Collaboration for the Office 
of Policy and Planning for the Department of Veterans Affairs.
    Thank you both for joining us this morning.
    Mr. Burdette, you may proceed.

 STATEMENTS OF PHILIP A. BURDETTE, PRINCIPAL DIRECTOR, WOUNDED 
    WARRIOR CARE AND TRANSITION POLICY, OFFICE OF THE UNDER 
    SECRETARY OF DEFENSE FOR PERSONNEL AND READINESS, U.S. 
  DEPARTMENT OF DEFENSE; AND JOHN MEDVE, EXECUTIVE DIRECTOR, 
    OFFICE OF THE U.S. DEPARTMENT OF VETERANS AFFAIRS-U.S. 
   DEPARTMENT OF DEFENSE COLLABORATION, OFFICE OF POLICY AND 
         PLANNING, U.S. DEPARTMENT OF VETERANS AFFAIRS

                  STATEMENT OF PHILIP BURDETTE

    Mr. Burdette. Good morning, Chairwoman Buerkle and Ranking 
Member Michaud, Members of the Subcommittee.
    I am pleased to be here this morning with my colleague and 
friend, Mr. John Medve, from the Department of Veterans 
Affairs. It is not an uncommon occurrence for me to appear with 
Mr. Medve who heads the VA-DoD Collaboration Office as we meet 
weekly and often more often than that to discuss our 
Departments' interaction.
    Discerning and discussing the redundancies and the overlap 
between the Federal Recovery Coordination Program and DoD's 
Recovery Coordination Program is from my perspective a 
wonderful problem. This dialogue simply would not have taken 
place in 2008 when the problem was not too many resources but 
too few.
    On March 13th, 2008, Sergeant Edward Wade's wife, Sarah 
testified before this Committee. Sergeant Wade suffered 
multiple injuries in Iraq in 2004. Mrs. Wade testified that 
they had difficulty accessing necessary services for her 
husband where and when he needed them.
    She recommended patient specific case management and the 
development of individualized treatment plans. Today we have 
delivered just what she asked for. Today, Sergeant Wade would 
receive the clinical expertise of a Federal Recovery 
Coordinator and the non-clinical assistance of a Recovery Care 
Coordinator as part of his care team.
    The use of FRCs and RCCs demonstrates just how far we have 
come in those 4 years. Rather than a scarcity of care and a 
lack of available resources, today we are discussing how to 
best utilize a multitude of resources available 24/7 for 
recovering servicemembers and their families.
    The perception that we have put too many overlapping 
resources in place really highlights an intentional safety net 
of concurrent resources. We firmly believe that the programs 
are not duplicative but complementary, with a redundancy that 
is important for our recovering servicemembers to truly have 
seamless coordination in their recovery period.
    This is no less than our servicemembers expect and no less 
than what they deserve. We simply cannot over-invest in the 
care management of our wounded warriors.
    I do not mean to infer that the Departments are not taking 
serious and thoughtful steps towards efficiency and wise 
stewardship of these complementary programs. We are.
    After the release of the GAO report on the Federal Recovery 
Coordination Program, the Deputy Secretary of Defense and the 
Deputy Secretary of Veterans Affairs challenged us to actively 
and aggressively address the GAO findings. We have.
    As a result, the Departments have been focused on improving 
our care coordination and continually working to bring the 
counterpart programs closer together.
    The Wounded Warrior Care Coordination Summit, held this 
past March and the DoD-VA Executive Committee agreed upon 
expectations for how this can be best accomplished.
    This summer, the Senior Oversight Committee focused on 
those expectations and the four areas raised by the GAO. We 
have also used the findings of the Recovering Warrior Task 
Force, which was established by this Congress as an independent 
and objective guide in our efforts.
    From my seat, the biggest problem surrounding the programs 
is probably the programs' names themselves which are simply too 
similar despite intentionally different roles. This not only 
confuses us at the policy level, but most importantly, it 
confuses recovering servicemembers and their families at our 
military treatment facilities (MTFs).
    While we have obvious work to do in eliminating that 
confusion at the headquarters level, I can report that these 
programs are delivering critical resources to our recovering 
servicemembers nationwide.
    Just this past Monday, I visited the new Walter Reed 
National Military Medical Center in Bethesda, as I do every 
month. While there, I met with a recovering Marine corporal and 
his wife along with their Federal Recovery Coordinator and 
their Recovery Care Coordinator.
    I can report to you, and this is not anecdotal, that these 
programs work in our hospitals every day where trauma teams 
triage new patients and collectively make decisions about which 
servicemembers need an FRC most.
    These educated decisions are made where they should be 
made, at the hospitals and by the trauma teams and care 
coordinators. This is where the referral is made, FRC caseloads 
are managed, and appropriate resources are assigned to the care 
team.
    I can tell you that although better integration is always 
the goal, quality services can and do coexist during this 
critical time for our recovering servicemembers and their 
families.
    As servicemembers, we pay close attention not only to what 
is said but also to what is written. We pay close attention to 
details.
    One such detail speaks more to unity than any testimony you 
will hear today and that is simply the business card that that 
FRC gave me on Monday and that every FRC provides to their 
servicemembers. On this card, side by side is not the seal of 
the VA but those of both the DoD and the VA symbolizing both 
agencies striving to deliver the collaborative services to our 
servicemembers who need them most.
    Madam Chairwoman, this concludes my statement. I look 
forward to your questions.
    [The prepared statement of Mr. Burdette appears on p. 41.]
    Ms. Buerkle. Thank you, Mr. Burdette.
    Mr. Medve, you may proceed.

                    STATEMENT OF JOHN MEDVE

    Mr. Medve. Good morning, Chairman Buerkle and Ranking 
Member Michaud and Members of the Subcommittee.
    I am John Medve, Executive Director, Office of VA-DoD 
Collaboration within the VA's Office of Policy and Planning. I 
am pleased to be here with my partner, Phil Burdette, today to 
discuss the Federal Recovery Coordination Program and the 
progress that has been made in addressing improvements 
recommended by the GAO.
    The FRCP is designed to complement existing military 
service and VA-provided case management support and transition 
coordinators. FRCP is specifically charged with providing 
seamless support for its referred clients from the 
servicemember's arrival at the initial military treatment 
facility in the United States through the duration of their 
recovery, rehabilitation, and reintegration.
    The FRCP is an integral part of VA and DoD efforts to 
address issues raised about the coordination and care and 
transitions between the two Departments for recovering 
servicemembers.
    On behalf of the clients, FRCs work closely with clinical 
and non-clinical care and case managers from the military 
services, the VA, and the private sector as part of their 
recovery team.
    The March GAO report contained four recommendations. VA 
concurred with the recommendations and is taking action to 
implement each of them.
    GAO's first recommendation was that the FRCP establish 
adequate and internal controls regarding FRCs' enrollment 
decisions. As a result, more stringent internal controls were 
implemented to include management review of all enrollment 
decisions.
    The challenge still remains in getting the referrals from 
the military services for those needing FRCP services. The 
program's visibility on these potential clients is based solely 
upon those who are referred.
    For those who are referred to the FRCP, they are evaluated 
to determine the individual's medical and nonmedical needs and 
requirements in order for them to recover, rehabilitate, and 
reintegrate.
    A key component in the FRCP evaluation process is whether 
an individual would benefit from the FRC level of care 
coordination.
    The bottom line is that while FRC clients represent a small 
portion of the recovering servicemember population, those who 
are referred and who meet the established criteria are offered 
enrollment in FRC.
    GAO's second recommendation was to complete development of 
a workload assessment tool. FRCs have embarked on the 
development of a service intensity tool that would fulfill the 
workload assessment requirements of the GAO recommendation and 
further tie the assessment to enrollment decisions. This 
process will likely be completed by the summer of 2012.
    GAO's third recommendation to the VA was to clearly define 
and document the FRCP's decision-making process for determining 
when and how many FRCs VA should hire. FRC positions are based 
on an analysis of an anticipated number of referrals, the rate 
of enrollment, and the number of clients made inactive and a 
targeted caseload.
    Upon completion of the service intensity tool evaluation, 
FRC will modify this equation.
    GAO's fourth and final recommendation was to develop and 
document a clear rationale for placement of FRCs. Original 
placements were based upon putting FRCs at MTFs where 
significant numbers of wounded, ill, or injured servicemembers 
were located.
    As the program has grown, the assignment of FRCs has spread 
to additional locations.
    Servicemembers, veterans, and their family are often 
confused by the number and types of case management and baffled 
by benefit eligibility criteria as they move through the DoD 
and VA's complex system of care. FRCP clients say the program 
works best when FRCs are included early in the servicemember's 
recovery and prior to the first transition.
    Once assigned, an FRC will continue to support a client 
regardless of where the client is located. This consistency of 
coordination is important for individuals whose conditions 
require multiple DoD, VA, and private health providers and 
services transitions.
    FRCs will remain in contact with their clients as long as 
they are needed whether for a few months or a lifetime.
    This concludes my statement. I am happy to answer any 
questions you may have.
    [The prepared statement of Mr. Medve appears on p. 43.]
    Ms. Buerkle. Thank you very much.
    I will now yield myself 5 minutes for questions.
    Mr. Burdette, with all due respect, I feel like I am in a 
parallel universe with what I just heard from the GAO and with 
what you are saying here this morning.
    A card that says VA and DoD on it does not mean anything. 
Saying that that indicates that there is a good partnership 
concerns me.
    I am more interested in what the GAO is reporting and that 
is that you are not good partners. You are not working 
together.
    When you applaud this duplication as a safety net, that is 
inefficiency. That is a lack of coordination of care and 
effort. And I think you have to be really careful.
    As Dr. Roe pointed out, 1,800 enrollees so far. You have 26 
care coordinators. There is a lot of resources as you stated, 
but I am not sure and I feel pretty confident they are not 
being used effectively and efficiently.
    So I am really concerned. Let's worry less about cards and 
symbolism and more about what is actually happening here for 
our wounded warriors.
    You mentioned that you are a full partner with the VA and 
that you assist with the implementing of the GAO's 
recommendations, yet the GAO in Dr. Draper's testimony said 
that DoD has provided limited assistance to the VA with the 
implementation of the GAO recommendations.
    I was extremely disappointed to read that DoD's response to 
serious deficiencies was an email, you outlined an email 
telling the Wounded Warrior Programs that they should refer all 
severely wounded, ill, and injured to the FRC Program.
    VA states they have not noticed any difference in the 
number of referral numbers or patterns since that time. So this 
flies in the face of that card that has got DoD and the VA as a 
partnership. So I would like to just give you an opportunity to 
explain that.
    Mr. Burdette. Thank you, Madam Chairwoman.
    I think the card is and symbolism are enormous. One of the 
big perceptions of the program as was alluded to by Dr. Draper 
is the real fear of a servicemember when she meets the VA 
representative and then it dawns on her she is not going back 
to her unit.
    The fact that that DoD seal is still on the card I think is 
enormously heartening to that servicemember that says this is a 
concerted effort. This person is there as a resource for me. I 
might be able to stay in military service.
    So I absolutely accept your viewpoint on that, but I think 
that that is the importance of the fact that the two seals are 
on the card.
    Ms. Buerkle. If I could interrupt just for a second. It is 
not my concern with the symbolism to the servicemember. It is 
my concern that you see you have a viable and a working 
partnership with the VA. That card does not mean anything if 
the veterans and the wounded warriors are not getting the care 
they need.
    So my concern is the symbolism with regards to your 
partnership because what I am seeing and hearing from the GAO 
is that you do not have a good partnership, that you are not 
working together, and the coordination of care is not 
effective.
    Mr. Burdette. Yes, Madam Chairman. I began my response with 
the servicemember focus because that is where we are all 
focused. First and foremost is how we deliver that service to 
that servicemember at the military treatment facilities. So 
that has to be the be all and end all.
    I think the Ranking Member said it absolutely correctly. If 
we do not get this right, servicemembers will suffer.
    So to take that then to your other point about the DoD-VA 
collaboration at a more strategic level, the synergy is 
tremendous.
    The fact that both Secretaries now meet on a quarterly 
basis and then help drive SOC agenda items, the fact that this 
issue has been on the SOC agenda every time the SOC has met 
this year, the absolutely groundbreaking work that the VA has 
taken on through an internal task force, top to bottom care 
coordination that Dr. Draper talked about, and some of the 
impacts of the many programs through the leadership of Mr. 
Gingrich at the VA, they have absolutely gone top to bottom and 
said how do we impact and touch every one of our servicemembers 
and new veterans, how can that be most efficient, what is the 
VA doing to complement that, what can we do away with, and what 
can we then amplify to make sure that that quality service is 
given to the servicemember.
    In the area of referral, ma'am, we have work to do. I 
accept that. I hold up this fax form that we have asked the 
field to use. So when Dr. Draper referenced my guidance to the 
services to do a better job on referring, in 2011, if I am 
telling the services to go to a fax machine, I am behind. But 
that is the tool we have today. We are going to get better and 
get away from a fax machine referral form and make that a 
better process.
    My commitment to you is we will get there. That is one of 
just many steps that she highlighted that we have taken over 
the summer as a result of our care coordination summit which 
was a 3-day off-site with the VA and the FRCs, many of whom are 
in the back of the room today and have traveled to this hearing 
because they care so deeply about their patients and about the 
programs that they are involved in.
    But that is just one step. Throughout the summer, a whole 
tally of efforts has been undertaken by both Departments to 
make sure that we study the problem, that we get the answer 
right, and as the Ranking Member has asked us to deliver is to 
deliver the right solution.
    Ms. Buerkle. Thank you, Mr. Burdette.
    I just have one last question and then I will yield to the 
Ranking Member.
    You mentioned in your testimony that the program titles 
create confusion for those transitioning or possibly 
transitioning out of active duty into the veterans' world. But 
it also creates policy confusions.
    That concerns me with a program that is 4 years old that we 
have not gotten the policies down and what we are trying to 
accomplish and how we are going to accomplish it. So if you 
could just comment on that.
    Mr. Burdette. Yes, Madam Chairwoman.
    This program grew out of the horrors of Walter Reed 
revelations in 2007. And the SOC, to its great credit, enacted 
quick solutions and fielded resources to help the wounded 
warriors and their families.
    As that matured over the last 4 years, a lot of programs 
have been put in place. If we had thought, I think, when we 
fielded the Recovery Coordination Program to clearly delineate 
titles and responsibilities at that time, we would be better 
off than we are today. We owe that to you. I think that that 
work is really in earnest.
    We spoke earlier about the lateness of the letter. I think 
that the lateness of the letter really reflects our intense 
desire to get it right but also to be timely, but to err on the 
side of getting it right.
    So I think that that work will be completed soon and we 
look forward to reporting it to you.
    Ms. Buerkle. Thank you.
    I yield now to the Ranking Member.
    Mr. Michaud. Thank you very much, Madam Chair.
    Is the Defense Center of Excellence out at Bethesda 
supposed to coordinate with the VA as well?
    Mr. Burdette. Mr. Ranking Member, when a servicemember is 
evacuated from the battlefield in Afghanistan, most frequently 
they will go to Landstuhl. Then they will be air lifted back to 
Andrews Air Force Base. And on September 2 with the closing of 
Walter Reed as we knew it, they will now be air ambulanced or 
motorcade ambulanced to Bethesda.
    At that point, the trauma team meets with that patient and 
the families and that's when the care team comes together and 
makes triage decisions on what resources we are going to give 
immediately to that family and then downstream through the 
recovery period.
    Mr. Michaud. So at that point in time, they are supposed to 
coordinate with the VA----
    Mr. Burdette. Absolutely.
    Mr. Michaud [continuing]. At the Center of Excellence?
    Mr. Burdette. At Bethesda, at those trauma and triage 
teams, and the FRCs in the back of the room are a part of those 
trauma teams, meet when the servicemembers arrive and the 
doctors and the nurse case managers and that trauma team 
assembles and says what resources are we going to apply.
    Mr. Michaud. Well, that is interesting because I just came 
from Bethesda on Monday. I went to visit a wounded soldier from 
Maine, and the doctor at the Center of Excellence told me that 
there was zero coordination with the VA.
    The other part of the trip was to see what a soldier would 
have to go through in that process, but not once was I 
introduced to a Recovery Coordinator.
    So from what you are saying and what is actually being 
implemented are two separate things. And it is consistent with 
what we heard from the GAO about a lack of coordination between 
DoD and the VA, which is a huge concern because my bottom line 
is to take care of the wounded soldier.
    The Military Officers Association made a recommendation 
that we mandate a single joint VA-DoD program so we do not have 
to worry about two. It would be one program if I understand 
their recommendations.
    I would like you both to comment on that.
    Mr. Burdette. Mr. Ranking Member, I think the easiest thing 
to do and the quickest thing to do would be go back to the SOC, 
where I serve as the Executive Director, and we issue a memo 
that says we now have a joint program. I think that does little 
on the ground to effect and fix the coordination.
    We have intentionally written policy with flexible language 
to allow the military treatment facilities and the doctors and 
the case managers on the ground to decide what resources need 
to be applied to patients. That is a patient-centric focus that 
we have not wavered from.
    So I think that is the right approach to get that is to get 
it right rather than the names and what we put on the 
letterhead. If we declare a joint program, we have not fixed 
anything. If we fix the mechanics and the roles and 
responsibility is clearly delineated, I do not think it matters 
who they pay, who pays them, or who they work for as long as 
that family feels supported and has the resources they need.
    Mr. Michaud. So it sounds to me like we have a problem with 
those who are implementing these programs, and that is a big 
concern. We can change the titles. You are right. I think the 
law is very clear on the coordination and there does not appear 
to be any coordination.
    So if that is not happening, then that leads me to believe 
that those that are responsible for these programs are not 
doing their jobs and, therefore, probably should be fired and 
get someone in there who can do the job in taking care of these 
soldiers.
    Like I said, when I went out to the Center of Excellence, 
when I heard the doctor say there is no coordination with the 
VA system, that is concerning. When I read the GAO report, that 
is concerning.
    And I hear both of you here saying there is coordination. 
There probably could be some improvements. But the bottom line 
is they are not being taken care of.
    I will ask the VA to comment.
    Mr. Medve. Sir, I think what I identified is we do have 
challenges with accession into the program and contact. But I 
will also say that a number of our referrals are coming from 
the medical teams in the hospitals.
    What the DoD instruction has in it is referral of Category 
3 and they are supposed to be severely and catastrophic. As I 
am not a clinician, but when I have asked our VHA, Veterans 
Health Administration, people what that means to them, it does 
not mean a lot.
    So I have been instructed by our Under Secretary of Health 
to translate what that means into more clinical terms so that 
the teams on the ground then have something as they are looking 
at somebody in a clinical setting to say, all right, this meets 
the criteria, we need to call the FRC in to meet on this 
particular case.
    Mr. Michaud. Thank you.
    I see my time has run out. Thank you, Madam Chair.
    Ms. Buerkle. I now yield to the gentleman from Tennessee, 
Dr. Roe.
    Mr. Roe. Thank you, Madam Chairman.
    Back to just it is not a lack of resources, it seems like 
we have plenty of help.
    When I look at the FRCs and it says in here the program has 
777 current active enrollees, that is 37 people per FRC. That 
is not a very heavy caseload and at least looking at it from my 
standpoint from what I have done for 30 plus years.
    It looks to me like that it is a coordination problem. How 
do you answer the question? And I realize that the bureaucracy 
is big.
    Having served in the military and being a young officer 
back from overseas duty, we had 2,000 women that needed PAP 
smears at Fort Eustis, Virginia, in 1973 and I was absolutely 
convinced I was going to fix that problem.
    When I left almost a year later, there were 2,000 people on 
there. So I do share some of your frustration of getting it 
done. I just ran into a brick wall.
    But as Mr. Michaud said, that we should not accept that. We 
are having people that are surviving injuries now that they 
would never have survived before and they need help and their 
families need help. We have the resources to do it and we are 
good at this. This is not something we are bad at. Health care 
is something we are really good at.
    I do not know why it took months to answer a letter. Could 
you square me away on that.
    Mr. Medve. Sir, I will just say that I take responsibility 
for not ensuring that on the VA side that the letter was 
delivered in a reasonable time frame. We worked it through the 
system and----
    Mr. Roe. Well, let's don't worry about letters. We are here 
now and the important thing is to get these soldiers taken care 
of.
    And I know if I am a soldier, I am thinking to myself what 
Mr. Michaud just described at Bethesda. If you are there, you 
are looking for help. If you are a family member, you do not 
know all these things that your wife or husband are going to 
need. And we need to take care of all that problem so they do 
not have to worry about that. They know right where to go for 
these resources.
    And how would you answer when you have five people working 
on the same thing or eight in some cases?
    And as you well know, we are up here fighting back and 
forth about the resources now and not having enough resources 
and having budget cuts. We have the resources. Matter of fact, 
we have over-resourced. We are not using them very well, it 
does not sound like.
    Mr. Burdette. Sir, I think I might answer that question by 
quoting a young spouse that I met when I traveled to Brooke 
Army Medical Center earlier this spring.
    And I said tell me about the perception. Did we inundate 
you on arrival, rip you out of Fort Hood, Texas, tell you you 
have to meet your loved one here at Brooke Army Medical Center 
and your husband is in a bad medical condition?
    And then we immediately overwhelm you and we leave you with 
25 business cards and you feel overwhelmed and a little 
confused and perhaps not well taken care of.
    And she looked me right in the eye and said I would be 
upset if I did not have 25 business cards. She said if I do not 
get an answer from the first person, I will call the second and 
third.
    Mr. Roe. My point is, though--wait a minute, whoa, whoa 
right there--she should be able to get the answer from the 
first person. That is what their job is. That is what they do.
    And that is the problem that I ran into is that somebody 
needs to be in charge of the ship. Otherwise, it just goes in 
50 different directions like an amoeba.
    Mr. Burdette. Sir, completely agree. On a Sunday night at 
7:00 p.m. when the servicemember needs help, that first 
business card might not always get--that phone might not always 
get answered. So I think what we are speaking there to is the 
redundancy of available resources.
    I am certain and I have watched the briefs be given that we 
brief on the----
    Mr. Roe. Back up again. When somebody is getting ready to 
have a baby in my practice and the phone rings, somebody 
answered it.
    Mr. Burdette. I apologize, sir, for not making a 
distinction. The clinical teams are always available. The 
doctor who is in charge of the care for that patient is always 
available and the Recovery care team is always available.
    When we are talking about somebody to talk about life 
insurance benefits or transition benefits to the VA, that 
person may not be available.
    Mr. Roe. They could make a call to the Recovery coordinator 
or, look, you said that a name change, call it the health team 
of the hero team or whatever you want to call it. If you want 
to do that, change the name if that is confusing to somebody.
    But I ought to be able to as a family member make a phone 
call and that person says I am going to help you. I will get 
that information for you and I will be back to you in a timely 
fashion.
    Mr. Burdette. Sir, I am confident that the Recovery Teams 
offer that availability to that servicemember. And then I am 
also confident that if that person is not available for 
whatever reason, in surgery, unavailable for a holiday or 
vacation or something, that there is another person right 
behind them to step up and help that family member.
    Mr. Roe. So in some length of time, can you all tell, are 
you going to implement the four GAO recommendations and if we 
ask this question 6 months from now, what is the answer going 
to be?
    Mr. Burdette. Sir, the four GAO recommendations that came 
in March, the VA-centric ones, VA has already undertaken much 
progress to get those done. Those detailed plans were included 
in our September 13th letter. So that was a part of it.
    The second part of the Chairwoman's letter and Ranking 
Member's letter to us was what is the future of this program. 
The Recovering Warrior Task Force that this body chartered 
reported to us on September 2nd with some additional 
recommendations for the program.
    I think that combined with the VA's top to bottom review 
now gives us the body of evidence, objective and otherwise, to 
chart the road ahead.
    I am confident that in our next meeting that we will have 
that answer. I think we will publish it to you in a letter in 
advance of the next hearing on just what the future was in 
essence an answer, ma'am, to your second question from that 
letter.
    Mr. Roe. I yield back.
    Ms. Buerkle. Thank you, Dr. Roe.
    I now yield to Mr. Bilirakis.
    Mr. Bilirakis. Thank you, Madam Chair. Appreciate it very 
much.
    Again, the same issue. I like the concept of having a 
single point of contact so that injured servicemembers and 
veterans have a one-stop shop in which to go for assistance. 
And I hear about this all the time in my district but also up 
here at the hospitals.
    Do you think that there is any circumstance where it is 
necessary or appropriate for an individual to have multiple of 
these caseworkers or coordinators? Is there a circumstance?
    And it seems to me that if coordinators all have a similar 
and uniform level of training, they would provide similar 
advice. So the question is, what is the standard of training 
for caseworkers and care coordinators?
    Mr. Burdette. Sir, I can speak to the Recovery Care 
Coordinators. The Recovery Care Coordinators on the DoD side, 
we have approximately 167 at over 67 sites nationwide. At the 
DoD level, they are all uniformly trained in what they deliver 
in the non-clinical case management.
    By that, I mean life plans for the family members, life 
plans for the servicemembers, and things that open them to 
opportunities such as vocational rehab through the Veterans 
Affairs and other educational opportunities.
    I think Mr. Medve can speak to what the FRCs are trained 
and deliver.
    Mr. Medve. Yes, sir. Congressman, we currently have 23 
FRCs. They are all either Master's trained nurses or social 
workers. They have a series of quarterly training events back 
here in DC to level them.
    As a matter of fact, this afternoon, I am going to be 
addressing a series of FRCs to update them on changes to the 
Integrated Disability Evaluation System so they understand the 
process for that as they advise their clients.
    So we set a fairly high bar in terms of the certification 
of FRCs.
    Mr. Bilirakis. Thank you very much.
    I yield back, Madam Chair. Thank you.
    Ms. Buerkle. Thank you, Mr. Bilirakis.
    I am going to just start a second round of question in case 
any of the other Members have questions.
    Mr. Medve, I would like to ask you. We have heard about 
disagreements between DoD and the VA. Can you elaborate on 
that. What is your understanding? Where are the points of 
disagreement and how will we overcome those?
    Mr. Medve. Madam Chairwoman, I would be less than honest if 
I did not tell you we clearly have an issue with accession into 
the FRC Program of ensuring that we identify who needs to come 
into the program. That is one of the issues that Mr. Burdette 
and I are currently working on.
    Part of what we are grappling with, and I shared with him 
just the other day a draft set of clinical definitions to help 
guide the teams and the MTFs to help make those referrals more 
timely so we bring in the FRCs earlier. And that to me is the 
largest challenge we face at this time.
    Ms. Buerkle. Mr. Burdette, how are you going to address 
that issue and do you see that as a problem as well?
    Mr. Burdette. Madam Chairwoman, at the DoD, we have taken 
several steps to make sure that the referral process is a solid 
one from our standpoint.
    The Deputy Secretary of the VA uses the analogy all the 
time if you do not throw me the football, I cannot catch it. 
That is my responsibility to make sure that we are referring 
the servicemembers to the VA.
    The email that Dr. Draper referenced and the letter that I 
sent to the services clearly did not do it enough. I need to 
give them a better tool than the fax sheet as well.
    And also in the area of language, I think that Mr. Medve 
alludes to a perfect example. We have used the very broad 
language of whoever most needs an FRC intentionally because if 
we get down to a clinician's viewpoint point system of who gets 
one, then we find that year over year, we will exclude people 
who really need an FRC.
    For example, the complex injuries we are seeing today from 
the battlefields are staggering. And it is not just a single 
amputee anymore. It is multiple internal injuries. It is 
multiple non-visible injuries with traumatic brain injury (TBI) 
and with post-traumatic stress disorder (PTSD) and other things 
that just make it so complex that the FRCs and the clinicians 
and the practitioners said if we had written criteria that were 
very specific, a point system, for example, in 2007 and 2008, 
it would be outdated now and we again would be in that round of 
now who gets one. And we would have had a totally different 
clientele that we would have excluded had we been too 
prescriptive.
    That is our challenge. Our balance is to get that right. 
And we need to get it right.
    Ms. Buerkle. Do you have a policy in place for referrals?
    Mr. Burdette. We do. We do. But the prob----
    Ms. Buerkle. Can you provide that to the Committee?
    Mr. Burdette. Absolutely. Absolutely.
    [The DoD subsequently provided the following information:]

    The Department of Defense Instruction (DoDI) 1300.24, which appears 
on p. 56, is the policy document governing the Department's Recovery 
Coordination Program, including servicemembers who are referred to the 
Department of Veterans Affairs Federal Recovery Program. For severely 
and catastrophically injured and ill servicemembers who will most 
likely transition from nilitary service, a Federal Recovery Coordinator 
will become part of the Recovery Team in addition to the Recovery Care 
Coordinator and assist the servicemember as they transition to Veterans 
status.

    Ms. Buerkle. It seems to me now 4 years after this program 
started that you would have policy and then you would work 
through that policy. And when VA says we are not getting 
referrals quickly enough, you would alter that policy and this 
would be a moving, developing policy.
    But, it seems like we do not have that. It is not about 
something that is out there. It is about wounded warriors. It 
is about people who served this Nation. It is about people who 
are in need.
    This is 4 years old. If we are not meeting their needs, we 
have a problem here. And the fact that they come home and they 
need services and DoD is not making a timely referral or one 
person is working on the same issue, five people are working on 
the same issue, that is a problem.
    This is not something where we have the luxury of time and 
it is some policy thing. It is people and it is people's lives. 
And that is why we are having this hearing and we will continue 
to monitor this, to stay on top of this, and to make sure that 
our veterans get what they need.
    I am going to ask if any of the other Members would like a 
second round of question.
    Mr. Michaud. Yes. Mr. Burdette, you mentioned that you are 
coming forward with some options regarding the current policies 
and how we might be able to maximize the resources of care and 
coordination.
    Can you tell us what some of those options that you are 
coming up with?
    Mr. Burdette. Again, Mr. Ranking Member, the options are 
all pre-decisional. There has always been, I think, a sincere 
desire to take the GAO recommendations and the Recovering 
Warrior Task Force recommendations and perhaps just say an 
overarching umbrella over both sides of this house may make it 
a little more of the direct line and not a dotted line of lines 
of responsibility.
    There are smart people at the field level who think that is 
not the way to go either. That is why we brought them all in in 
March and said let's sit around the table and talk. Some dozens 
of recommendations come out that we are not discussing today 
how we improved both programs.
    But that core issue is the definition of who gets referred 
and that is when we have to get it right to your first opening 
comment, sir, and that is what we are committed to doing.
    Mr. Michaud. And are you working with the wounded warriors 
themselves to find out what would be helpful to them versus 
what might be easier for VA or DoD? Have you requested their 
assistance as well?
    Mr. Burdette. We could not do it without that, Mr. Ranking 
Member. I saw you on Monday also when you were on the campus of 
Bethesda. As well, we do not go there for optics. We go there 
for information and to ask them directly what do you need and 
are the systems we have fielded serving you well. Without their 
input, we do not have a solution.
    Mr. Michaud. Thank you.
    I yield back the balance of my time. Thank you.
    Ms. Buerkle. Thank you.
    Dr. Roe.
    Mr. Roe. Just one question that I did not get answered a 
minute ago on the coordination.
    When GAO references one FRC who estimates his enrollees 
have on average eight different case managers affiliated with 
eight different programs, is that going to continue or is there 
a one-stop shop that somebody can go to to get headed in--if 
they are maybe injured, have sight impairment or an orthopedic 
problem or a prosthesis problem?
    I am going to get you to where you need to be and take care 
of you. You do not have to worry about it. You call me. I am 
going to get you down the right road. I am your GPS in this 
maze.
    Mr. Medve. Congressman, I could not agree more that at 
least from my perspective, the FRCs are designed to be that 
overarching lynchpin. That is why they handle both the clinical 
and non-clinical piece.
    Now, sometimes they think we, and I know again not being a 
clinician, as somebody who is assigned to an MTF and they are 
having specific procedures, we have designated liaison 
specialists to handle that component of it, but the FRC should 
be the one that is helping to arrange all that and ensure that 
is all happening in a synchronized manner.
    Mr. Roe. Because I know that Recovery coordinators have 
some frustrations. And I would like to hear what they have to 
say.
    I mean, my door is always open in the office to hear what 
their frustrations are because I think if you call the people 
actually doing the work and they can tell you where the bumps 
in the road are.
    I mean, the 21 people that are doing that, I think they 
have a lot of information to share with us. We have not heard 
them today and maybe in some written testimony or either just 
make an appointment in my office and come back and let me know.
    I yield back.
    Ms. Buerkle. Thank you, Dr. Roe.
    Mr. Bilirakis.
    Mr. Bilirakis. One, Madam Chair.
    When do you realistically, and I may have missed this 
because I came in late, when do you realistically estimate you 
will have a concrete plan to maximize this care coordination 
between DoD and the VA?
    Mr. Burdette. Sir, if I could, we get a new Deputy 
Secretary of Defense today. And when Dr. Carter takes his post 
today, he will become the co-chair of the Senior Oversight 
Committee.
    If I could take that answer for the record, I need to get 
his guidance on time tables as the new co-chair of the SOC and 
then he will meet with the Deputy Secretary of the Veterans 
Affairs.
    But I am confident we have all the data we need at this 
point. We need to forward a decision memo for those two co-
chairs and then have them make the decision. They are anxious 
for that decision and I know Dr. Carter awaits my brief on that 
options matrix.
    Mr. Bilirakis. Can you get back to us?
    Mr. Burdette. I will, sir.
    Mr. Bilirakis. Maybe other Members of the Committee would 
like to know as well.
    Mr. Burdette. I will, sir.
    [The DoD subsequently provided the following information:]

    Currently, DoD and VA are working on the decision memorandum 
regarding the future of the Federal Recovery Coordination Program and 
Recovery Coordination Program. In December, I am scheduled to deliver 
the memorandum to the Senior Oversight Committee for consideration and 
decision.

    Mr. Bilirakis. Thank you.
    Thank you very much. I yield back, Madam Chair.
    Ms. Buerkle. Thank you.
    At this time, we are finished with our questioning for our 
second panel.
    Mr. Burdette, you will provide to the Committee the 
policies and procedures with regards to the referrals from DoD?
    Mr. Burdette. I will, ma'am.
    [The DoD subsequently provided the following information:]

    The Department of Defense Instruction 1300.24, which appears on p. 
56, is the policy document governing the Department's Recovery 
Coordination Program, including who is referred to the Department of 
Veterans Affairs Federal Recovery Program. For severely and 
catastrophically injured and ill servicemembers who will most likely 
transition from military service, a Federal Recovery Coordinator will 
become part of the Recovery Team in addition to the Recovery Care 
Coordinator and assist the servicemember as they transition to veterans 
status.

    Ms. Buerkle. Thank you.
    Thank you both very much for being here this morning.
    Mr. Medve. Thank you, Madam Chair.
    Ms. Buerkle. Would our third panel please join us at the 
table.
    Joining us on our final panel this morning are 
representatives from our veterans service organizations (VSOs). 
First, we have Ms. Abbie Holland Schmit, Manager and Alumnus 
from the Wounded Warrior Project (WWP); Althea Predeoux, 
Associate Director of Health Legislation from the Paralyzed 
Veterans of America (PVA); and Commander Rene A. Campos of the 
United States Navy, retired, the Deputy Director of Government 
Relations from the Military Officers Association of America 
(MOAA).
    Thank you all very much for joining us this morning.
    Ms. Schmit if you would like to start.

 STATEMENTS OF ABBIE HOLLAND SCHMIT, MANAGER, ALUMNI, WOUNDED 
WARRIOR PROJECT; ALETHEA PREDEOUX, ASSOCIATE DIRECTOR OF HEALTH 
LEGISLATION, PARALYZED VETERANS OF AMERICA; AND COMMANDER RENE 
 A. CAMPOS, USN (RET.), DEPUTY DIRECTOR, GOVERNMENT RELATIONS, 
            MILITARY OFFICERS ASSOCIATION OF AMERICA

               STATEMENT OF ABBIE HOLLAND SCHMIT

    Ms. Schmit. Chairwoman Buerkle, Ranking Member Michaud, and 
Members of the Subcommittee, thank you for inviting the Wounded 
Warrior Project to testify on this important subject. We 
appreciate the Committee's oversight of Federal Recovery 
Coordination Program.
    My background in working with wounded warriors has given me 
an on-the-ground perspective on the importance of this program 
to warriors and their families.
    As all of my managers with the WWP in Chicago, I work with 
warriors and their families on a daily basis. Before joining 
WWP in June, I served for more than 2 years as an advocate with 
the Army's AW2 Program (Army's Wounded Warrior Program).
    As someone who served in the Army National Guard, I had a 
hard journey home due to PTSD and traumatic brain injury. The 
issues before you are deeply personal to me.
    The FRCP was designated to assist those warriors who need 
help in navigating an often complex transition process. FRCs 
are making a real difference in helping severely injured 
warriors and their families thrive again.
    But as you heard in your hearing in May, individual service 
Departments are not routinely referring those servicemembers 
who need the help to the program.
    The service Departments seem to view the FRCP as a VA 
program and tend to make referrals to the program only when the 
warrior is about to separate or retire.
    The FRCP should be operated as a joint integrated effort to 
coordinate Federal care and services. But current practices 
risk delaying warriors' recovery, rehabilitation, and 
reintegration. These are not just hypothetical concerns. Let me 
share the case of Army specialist Steven Bohn, who testified 
before the Senate VA Committee in May and had been badly 
injured in 2008 when a suicide bomber in Afghanistan detonated 
explosives that buried him under collapsed debris and resulted 
in his suffering severe internal and spinal injuries.
    Breakdowns in coordination led initially to his being sent 
to the wrong military treatment facility. Later, poor 
communication led his Army command to threaten him with an AWOL 
(absent without leave) while he was still recovering from 
surgery.
    Eventually he underwent a DoD Medical Evaluation Board that 
rated him at 40-percent disabled for spinal and neck injuries. 
But it did not take into his account his internal injuries.
    While his transition from DoD to VA seemed to begin 
smoothly, backlogs in scheduling his VA compensation exams 
bogged down the process. Seven months after retiring from 
service, VA had still not adjudicated his claim and he was 
struggling financially. Unable to work because of his injuries, 
he was living on a military retired pay of $700 a month.
    Steve also fell through the cracks in getting his VA 
medical care. It took more than 6 months before anyone 
approached him to discuss any VA treatment. Steve testified 
that no one ever discussed with him or his family the 
possibility of having an FRC assigned to his case. It seems 
clear it would have made a big difference.
    Steve's experience is not unique, but it shows how easily a 
severely wounded warrior can fall through the cracks. This 
frequent failure to refer severely wounded warriors or an FRC 
is a problem that can and must be remedied. But the joint VA-
DoD response to the Subcommittee's questions fails to provide 
that remedy.
    In their cover letter, the two Department secretaries state 
that all Category 3 servicemembers who would be most eligible 
from the Federal Recovery Coordination, FRC, would be referred. 
But in quotes, their letter states just the opposite saying the 
program cannot ensure that all potentially eligible individuals 
are referred to FRCP.
    It is difficult to understand why the senior leadership of 
the two Departments have failed to resolve this problem. VA and 
DoD share a deep obligation to severely wounded warriors and 
their families. But the reality is that they do not share full 
responsibility of the FRCP.
    Warriors and families need this help early in their 
transition process. In our view, our warriors would be better 
served if they were truly shared VA and DoD responsibilities 
for the program.
    In that regard, WWP welcomes the introduction of H.R. 3016, 
a bill that would require VA and DoD to jointly operate this 
important program. We strongly support this legislation, which 
we believe would go a long way towards resolving critical 
issues affecting the program and toward ensuring its goals are 
fully realized.
    Thank you again for this opportunity to testify. I would be 
pleased to respond to any questions you may have.
    [The prepared statement of Ms. Schmit appears on p. 45.]
    Ms. Buerkle. Thank you very much.
    Ms. Predeoux, you may proceed.

                  STATEMENT OF ALTHEA PREDEOUX

    Ms. Predeoux. Chairwoman Buerkle, Ranking Member Michaud, 
and Members of the Subcommittee, Paralyzed Veterans of America 
would like to thank you for the opportunity to present our 
views on the Federal Recovery Coordination Program, the 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 from the Department of Veterans 
Affairs and provide support during the rehabilitative process 
to ensure that all disabled veterans have the opportunity to 
build bright and 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, and wounded veterans and servicemembers.
    When PVA provided the Subcommittee with a statement for the 
record for the hearing held on May 13th which examined the 
progress and challenges of the FRCP, we identified three areas 
in need of improvement, continuity of care, care coordination, 
and program awareness.
    Today, we still believe that these areas are critical to 
the success of the FRCP and are in direct alignment with the 
issues and recommendations outlined by the Government 
Accountability Office, GAO, in a March 2011 report entitled, 
``The Federal Recovery Coordination Program Continues to Expand 
but Faces Significant Challenges.''
    The first recommendation from this report was to ensure 
that referred servicemembers and veterans who need Federal 
Recovery coordinator, FRC, services, that they establish 
adequate internal controls regarding the FRC's enrollment 
decisions.
    In particular, this recommendation identified the need to 
require FRCs to record the factors they consider in making FRCP 
enrollment decisions as well as the need to create an 
assessment tool to evaluate these decisions.
    PVA believes that the use of recording methods and 
assessment tools will help streamline the enrollment process 
and ensure that veterans and their families are receiving help 
when it is requested.
    Servicemember enrollment is one of the most critical 
elements of the FRCP. Ensuring 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 different 
offices and Departments across both VA and DoD.
    The second recommendation from the GAO report encouraged 
complete development of an FRCP workload assessment tool that 
will enable the program to assess the complexity of services 
needed by enrollees.
    PVA believes that monitoring and managing the level of 
complexity and size of FRC caseloads is extremely important to 
adequately addressing the needs and concerns of veterans and 
servicemembers.
    No matter how well prepared and trained an FRC may be, he 
or she will not be able to effectively help veterans and 
servicemembers to the best of their ability if they are spread 
too thin and overwhelmed with an unreasonable caseload.
    The third recommendation to clearly define and document the 
FRCP's decision-making process for determining when and how 
many FRCs VA should hire is an area of serious concern for PVA. 
Adequate staffing of the FRCP is essential for providing 
veterans and servicemembers with timely and helpful assistance.
    With a limited number of FRCs, issues involving 
transportation and distance have the potential to hinder access 
to FRCP services for many veterans in rural areas and, thus, 
becomes a threat to continuity of care for newly injured and 
severely ill veterans and servicemembers.
    The GAO final recommendation calls for the FRCP to develop 
and document a clear rationale for the placement of FRCs. We 
understand that as a newer program, time is needed to create, 
implement, and assess the inner workings of such a 
comprehensive initiative.
    However, we ask that as the program expands, VA and DoD 
consider placing FRCs in locations where veterans with 
disabilities are already seeking services, such as spinal cord 
injury centers and amputation centers of care.
    In conclusion, PVA recommends that FRCP leadership 
periodically survey veterans, servicemembers, and their 
families to identify areas for improvement. There are numerous 
lessons to be learned and an abundance of opportunities for 
development.
    Thank you for this opportunity to testify today and I would 
be happy to answer any further questions that you and the 
Committee may have.
    [The prepared statement of Ms. Predeoux appears on p. 48.]
    Ms. Buerkle. Thank you very much.
    Commander Campos.

       STATEMENT OF COMMANDER RENE A. CAMPOS, USN (RET.)

    Commander Campos. Madam Chair and distinguished Members of 
the Subcommittee, on behalf of the 370,000 members of the 
Military Officers Association of America, I am grateful for 
this opportunity to present our observations on the FRCP.
    MOAA commends the Subcommittee for its leadership and sense 
of urgency on the critical topic of care coordination of 
wounded, ill, and injured.
    We also thank the VA and DoD for expending a great deal of 
effort and resources on our Nation's heroes these last 10 
years. However, we are extremely troubled by the business as 
usual message conveyed by VA and DoD officials at the May 13th 
hearing and in a recent letter to the Subcommittee indicating 
that the Departments have significant command and control 
issues and lack a roadmap for addressing system failures.
    It is not possible to talk about the FRCP without talking 
about the DoD Recovery Coordination Program, RCP, since the two 
programs are seen as fulfilling the same roles in their 
respective agencies.
    To better understand the programs, it is helpful to look 
back at the timelines for establishing them. August and October 
of 2007, the secretaries of VA and DoD signed Memorandums of 
Understanding (MOUs) establishing and implementing the FRCP 
designating FRCs as the ultimate resource for assisting wounded 
warriors.
    January 28, 2008, the fiscal year 2008 National Defense 
Authorization Act directed the agencies to establish joint 
policy for care, management, and transition of recovering 
servicemembers to include policy on recovery care coordination 
not later than July 1st, 2008.
    DoD did not establish that policy until almost a year and a 
half later on December 1st, 2009 and then delegated 
responsibility to the service wounded warrior programs.
    Three months later, VA published a handbook establishing 
the FRCP procedures for both agencies. In that handbook, the 
RCCs are assigned to servicemembers whose period of recovery is 
anticipated to exceed 180 days but who are likely to return to 
active duty, assisting them through the DoD system of benefits 
and care.
    Because the FRCP was the first coordination program and was 
to be the ultimate resource, many believed the program would 
serve as a model for other VA and DoD collaboration. Instead, 
VA and DoD continue to struggle today to implement a joint 
program that they committed to over 4 years ago and is 
highlighted in a September DoD Recovering Warrior Task Force 
report.
    The report cites a number of Wound Warrior Program 
discrepancies and specifically recommends standardizing and 
clearly defining the roles, responsibilities, and criteria for 
assigning FRCs, RCCs, and other case managers.
    Additionally, beneficiaries in the programs continue to 
talk about their experiences are all over the map. Some say too 
many coordinators doing opposite of each other. Others love 
their FRC or their FRC and still others who say they have no 
assistance or assistance comes too late in the process.
    Clearly the two Departments have been unable to fix the 
issues of care coordination for this relatively small 
population of catastrophically wounded and disabled members and 
are unlikely to do so in the immediate future without outside 
intervention to address policy and program compliance, 
accountability, communications, and oversight issues across all 
wounded warrior programs.
    MOAA recommends Congress, one, revise and expand Section 
1611 of Public Law 110-181 to mandate a single joint VA-DoD 
program, establishing an office for care coordination, and 
requiring DoD to adopt VA's FRCP policies and procedures.
    Two, to conduct joint Veterans' Affairs and Armed Services 
Committee hearings on wounded warrior issues to ensure common 
understanding and guidance in addressing the problems.
    Three, to commission an outside entity to evaluate the FRCP 
and RCP within the context of the broader wounded warrior 
programs.
    Four, to require VA and DoD medical and benefit systems to 
expand outreach and communication efforts, and, finally, to 
conduct periodic needs assessment surveys among beneficiaries 
to improve programs and identify unmet needs.
    MOAA is grateful to the Subcommittee for your commitment to 
our Nation's wounded, ill, and injured and their families, and 
we appreciate this opportunity to provide our views.
    Thank you.
    [The prepared statement of Commander Campos appears on p. 
50.]
    Ms. Buerkle. Thank you all very much.
    I will now yield myself 5 minutes for questions.
    My first question is to all three of you. Have any of your 
organizations been asked to participate with representatives 
from either DoD or VA about ways in which to revamp or merge or 
eliminate and to make these programs more efficient?
    Ms. Schmit. Not that I am aware of.
    Ms. Predeoux. Not that I am aware of.
    Commander Campos. No.
    Ms. Buerkle. Thank you.
    It would seem to me that we should reach out to the 
veterans, to those who are in need and learn from their 
experiences.
    The three of you, how would each of you respond to the 
GAO's comment with regards to the confusion and the lack of 
coordination actually hampering recovery for our veterans 
rather than helping them, if you would comment on that?
    Ms. Predeoux. I will take a stab at that. With regard to 
coordination and multiple care coordinators and confusion, that 
is obvious how that can happen. But at the same token, I think 
it is important not to lose sight that the Federal Recovery 
coordinators serve a very unique purpose. They are the only 
coordinators that straddle both systems and they are able to 
provide all of the services both social supports as well as 
clinical.
    So regardless of redundancy or multiple care coordination, 
we must keep in mind that FRC coordinators are supposed to be 
the main coordinators.
    Ms. Schmit. And just to dovetail, the FRCs are the people 
that are coordinating the coordinators. And so if I was a 
warrior that was critically injured, ill, or wounded, that 
would be my first and primary point of contact.
    And I think that is important any time that you are going 
through the transition. My transition was not as bad as someone 
that would need an FRC, but knowing who to call. And once you 
have a person like that, I think it really does help.
    Commander Campos. I think I would refer back to what GAO 
said. And these are really the issues with the FRCP and the RCP 
programs are really systemic of broader issues throughout the 
two systems.
    And we see it in a lot of other wounded warrior programs 
that are within DoD and VA. And so we just believe that the FRC 
and RCP programs are just kind of victims of bigger problems 
within the systems.
    Ms. Buerkle. Thank you.
    And then if I could just ask the three of you for your 
insights as to where you think we should go from here to get 
this program up and running and get it to the point where it 
should be.
    Ms. Predeoux. Perhaps continued oversight from the 
Subcommittee would be recommended. And, additionally, perhaps 
also establishing, I guess, enforced and understanding of where 
to start. Establish a point where regardless of what department 
identifies, whether it be DoD or VA, that an FRC is needed, but 
that each side knows that it starts with the Federal Recovery 
Coordination Program.
    Commander Campos. I believe that the oversight issue is a 
big issue. We saw many of the wounded warrior programs develop 
over time because of Congress' active engagement after Walter 
Reed. And over time, we have seen with the change in 
administration and leadership in the agencies a lowering of the 
SOC in the organizations. There just has not been the level of 
oversight and transparency.
    So we believe, one, that, as I said in our testimony, that 
we need to combine these two programs, but there really needs 
to be, and as GAO recommended, there needs to be a broader 
review of all the wounded warrior programs because there is a 
tremendous amount of, you know, confusion across all the 
programs.
    And we believe that there needs to be again accountability 
and I think only through Congress having frequent and periodic 
hearings will focus that level of urgency on the two systems.
    Ms. Schmit. I will just kind of dovetail what both of these 
women have said. I would say that it needs to go beyond a 
memorandum of understanding, that we need to actually see both 
the VA and the DoD work together, and that, you know, hopefully 
you cannot tell where one ends and the other begins and we will 
have that seamless transition.
    Ms. Buerkle. Thank you all very much.
    I now yield 5 minutes to the Ranking Member.
    Mr. Michaud. Thank you, Madam Chair.
    I just want to follow-up on the Chairwoman's question. I do 
know that there was a summit, the Wounded Warrior Care 
Coordination Summit in March of 2011. I understand that you did 
not participate in that summit?
    Ms. Predeoux. No, sir.
    Ms. Schmit. No, sir.
    Mr. Michaud. Well, I wish the Committee staff will follow-
up on who did if the VSOs and the different organizations here 
did not participate in that summit. I would like to have a 
follow-up question on that.
    How do each of you feel? You talk about the handoff and 
clearly the program is not working. How do you feel about the 
smooth transition? If any one thing that this Committee or the 
VA or DoD could do to make that transition smooth, what would 
you recommend?
    Ms. Schmit. And this is from my own personal experience as 
an AW2 advocate. I would say that the sharing systems, the non-
sharing systems, and the fact that each component has their own 
way to take notes and keep logs and not all of those notes are 
always passed along. The recovery care plan needs to go from 
the Warrior Transition Units (WTU) to the VA so they can 
continuously follow-up on that plan and make it go in motion. 
So better communication.
    Ms. Predeoux. I would have to agree with Ms. Schmit. The 
GAO report, I believe, discussed the information sharing 
initiative. And just to get that in place and actually have it 
work would be extreme progress in addition to again identifying 
a specific point of contact earlier within the FRCP, be it on 
the VA or the DoD side.
    Commander Campos. The two systems still view themselves, I 
think, as separate systems. And in doing so, I think it is 
clear that they want to identify the point where one point of 
care is done and the next system takes over. And I do not think 
the systems really have embraced that these wounded warriors 
and family members will be moving back and forth between the 
systems. So in that seamless transition, it is not a one way, 
one direction care. So these folks will be moving back and 
forth in between the systems.
    So I think that there has to be a better understanding of 
even again what the role is of the RCCs and the FRCs. I think 
DoD has delegated too much to the services and each of the 
services have a different way of identifying or have different 
terminology for RCCs. The Army has the AW2 Program. So, again, 
other terminology problems.
    So, again, I think DoD probably needs to do a little more 
oversight over the services to make sure that they are 
implementing the policies that have been put in place.
    Ms. Schmit. And to back into what I just said is that each 
one of those different branches all have their own network, 
their own computer way of tracking their servicemembers and 
none of those notes are shared with anyone else, not with the 
DoD, not with the VA. And if you are at a VA site, you cannot 
put your own notes into the VA. So there is a communication 
kind of mishap there.
    Mr. Michaud. So from what you are saying then, there is 
more than just a problem with the DoD coordinating with the VA? 
It is the DoD coordinating within itself?
    Commander Campos. Absolutely.
    Mr. Michaud. My last question is, when you talk to some of 
the RCCs or FRCs, what are some of the frustrations? Have they 
explained some of their frustrations within the system that 
they might not be able to explain to their hierarchy? Have they 
told any of you some of their problems?
    Commander Campos. In the field, the FRCs that we talk to in 
the field have sort of like the FRCs and RCCs kind of look at 
each other, not sure what each other is doing or again they are 
duplicating efforts.
    So there is a sense of frustration there, too, in not being 
able to work with DoD in again trying to identify who they are, 
why they are there. Again, the communication in these two 
programs between the systems here, you know, at the 
headquarters level but all the way down to the field is just 
not clear.
    Mr. Michaud. Thank you very much.
    Madam Chairwoman, I hope that both the VA and the DoD, 
especially the DoD, hears the bigger problem within DoD 
coordinating among the services let alone coordinating with the 
VA.
    Hopefully that they will go back and do everything that 
they can to make sure that this is seamless not only within 
DoD, but between the two Departments because I just want to 
restate the bottom line for me is to make sure we provide that 
service to the soldier. And that is the bottom line. And I 
think we have to do everything that we can.
    And there is no reason why that coordination of caregiver 
services cannot happen if we put aside the different silos that 
the different Departments have to work in and focus on the 
wounded warrior.
    So with that, I yield back the balance of my time.
    Ms. Buerkle. Thank you very much.
    Let me begin by thanking our panel, our third panel for 
being here today. Thank you for your service to our Nation. We 
deeply appreciate that. Thank you for being here.
    I also would like to take this opportunity on behalf of the 
Ranking Member and myself to thank all of you in this room who 
are serving or who have served our Nation. We owe a debt of 
gratitude to our military, to the men and women who serve this 
Nation and keep us safe. And that is what this Committee, the 
Subcommittee is committed to do, to make sure our veterans get 
what they need and really deserve.
    I ask unanimous consent that all Members have 5 legislative 
days to revise and extend their remarks and include extraneous 
material. Without objection, so ordered.
    Thank you again today to all of our witnesses and our 
audience for joining us and joining in this very important 
conversation.
    As has been recommended, you can be assured that this 
Subcommittee will continue to be vigilant and will be providing 
oversight to make sure that this program gets implemented and 
that our wounded warriors get what they need as they transition 
out of active duty into the veteran world.
    Thank you all very much for being here.
    This hearing is adjourned.
    [Whereupon, at 10:05 a.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. I want to thank you all for joining us today as we 
continue our oversight of the Federal Recovery Coordination Program 
(FRCP).
    Last May, the Subcommittee held a hearing to examine the 
significant challenges the FRCP program faces in areas as fundamental 
as identifying potential enrollees, reviewing enrollment decisions, 
determining staffing needs, defining and managing caseloads, and making 
placement decisions.
    At that hearing it became patently clear that rather than having a 
single, joint program to advocate on behalf of wounded warriors and 
ensure a comprehensive and seamless rehabilitation, recovery, and 
transition, we have two separate, overlapping programs--the Recovery 
Coordination Program (RCP) operated within the Department of Defense 
(DoD) and the FRCP operated within the Department of Veterans Affairs 
(VA).
    Needless to say, this has created unnecessary and unacceptable 
confusion about the roles and responsibilities of each program and has 
added yet another burdensome bureaucratic maze for our wounded warriors 
and their families to navigate at a time when recovery and 
reintegration should be their only focus.
    So concerned was I about the pervasive issues with the operation of 
these two programs, that immediately following the hearing, I sent a 
letter jointly with Ranking Member Michaud to the co-chairs of the VA/
DoD Wounded, Ill, and Injured Senior Oversight Committee (SOC), with 
oversight authority over the FRCP.
    In that letter, we requested a detailed plan and a timeline for how 
VA and DoD jointly would implement the recommendations contained in the 
recent Government Accountability Office (GAO) report which identified 
significant shortcomings of the FRCP. Further, we asked for an analysis 
on how the FRCP and RCP could be integrated under a single umbrella to 
reduce redundancy and ensure the seamless transition of our wounded 
warriors.
    A response was requested by June 20. More than 2 months past the 
deadline and following the notice of this additional hearing, we 
finally received a response to our letter.
    Unfortunately, it did not include the detail or timeline we 
requested and expected.
    With regard to an analysis of and potential options for integrating 
the FRCP and the RCP, we were told that the SOC is ``. . . currently 
considering several options . . . to maximize resources in care 
coordination . . . and preparing for final recommendations . . .''
    These programs are not new and the time for considering and 
recommending has long past.
    As Chairwoman, it has been my privilege this year to spend time 
with our honored heroes who have returned from battle bearing the 
wounds of war and the families who stand by their side through it all. 
I have traveled to Brooke Army Medical Center, the Center for the 
Intrepid in Bethesda, and VA medical facilities across our great 
country.
    It is clear to me that the FRCP is failing to meet its mission.
    It also clear to me that these families cannot wait any longer. 
They can no longer be party to bureaucratic in-fighting and turf 
battles. They can no longer be told that they have several ``single 
points of contact.''
    When answers are needed, we cannot take 3 months to respond to a 
letter. When answers are needed, we cannot keep considering our 
options.
    Today, I want answers.
    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 today's hearing on the 
progress of the Federal Recovery Coordination Program (FRCP). In May, 
this Subcommittee held a hearing on the very same issue, and I am 
pleased with the continued oversight of this critical program. If it is 
not done right, servicemembers suffer.
    Following the Subcommittee hearing, I joined Ms. Buerkle in sending 
a letter on May 26th to the Senior Oversight Committee requesting a 
detailed response as to how the VA and DoD can work together on 
implementing the Government Accountability Office's recommendations and 
requesting an analysis of integrating the FRCP and the Recovery 
Coordination Program.
    On August 19th, we then had to send a follow-up letter because of 
the lack of a response from the Senior Oversight Committee. The letter 
we finally did receive, dated September 12, 2011, was hardly detailed. 
The GAO reports that the agencies reached an ``impasse'' on the content 
of the final letter responding to our concerns.
    This lack of response only serves to magnify, in my mind, the 
continuing problems between the VA and DoD in working collaboratively 
and highlights the lack of progress that we have heard and read about 
recently in submitted testimony. I can only imagine what this means for 
other critical decisions that directly impact veterans and their 
families. I do not feel confident that the Department of Veterans' 
Affairs and the Department of Defense can overcome existing barriers 
and the tangle of bureaucracy that seems to surround the implementation 
of this program.
    Let us all keep in mind that this isn't about the individuals 
sitting in this room today. This is about the brave men and women who 
have been injured while serving this country and our absolute 
commitment to their recovery and reintegration back into the 
communities where they live--whatever that takes. We owe them that.
    Today, I would like to hear about solid progress that has been made 
and what is being done to move this forward in an efficient and 
effective manner. I also would like to hear from each of the panels 
what this Subcommittee might be able to do to help.
    Madam Chair, thank you again for holding this hearing, the second 
in a series of hearings to assist in our oversight of the Federal 
Recovery Coordination Program. As we continue to monitor this issue, we 
will work to actively engage the VA and DoD as we move forward.
    I yield back.

                                 
            Prepared Statement of Debra A. Draper, Director,
           Health Care, U.S. Government Accountability Office
DoD and VA Health Care: Action Needed to Strengthen Integration across 
             Care Coordination and Case Management Programs

    Chairwoman Buerkle, Ranking Member Michaud, and Members of the 
Subcommittee:
    I am pleased to be here today as you discuss the actions taken by 
the Departments of Defense (DoD) and Veterans Affairs (VA) to address 
issues of concern that were raised during your May 13, 2011, hearing on 
the Federal Recovery Coordination Program (FRCP). Our statement for 
that hearing,\1\ based on our March 2011 report,\2\ outlined several 
implementation issues for the FRCP, which was jointly implemented by 
DoD and VA to assist some of the most severely wounded, ill, and 
injured servicemembers, veterans, and their families with access to 
care, services, and benefits. Specifically, we reported on challenges 
faced by FRCP leadership when identifying potentially eligible 
individuals for program enrollment and determining staffing needs and 
placement locations. We also cited challenges faced by the FRCP when 
coordinating with other VA and DoD care coordination \3\ and case 
management \4\ programs that support wounded servicemembers, veterans, 
and their families, including DoD's Recovery Coordination Program 
(RCP). Specifically, we reported that poor coordination among these 
programs can result in duplication of effort and enrollee confusion 
because these programs often provide similar services and individuals 
may be enrolled in more than one program.
---------------------------------------------------------------------------
    \1\ GAO, Federal Recovery Coordination Program: Enrollment, 
Staffing, and Care Coordination Pose Significant Challenges, GAO-11-
572T(Washington, D.C.: May 13, 2011).
    \2\ GAO, DoD and VA Health Care: Federal Recovery Coordination 
Program Continues to Expand but Faces Significant Challenges, GAO-11-
250 (Washington, D.C.: Mar. 23, 2011).
    \3\ 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.
    \4\ According to the Case Management Society of America, case 
management is defined as a collaborative process of assessment, 
planning, facilitation, and advocacy for options and services to meet 
an individual's health needs through communication and available 
resources to promote quality, cost-effective outcomes.
---------------------------------------------------------------------------
    Based on the concerns raised during the May 2011 hearing, your 
Subcommittee requested that DoD and VA provide a detailed response on 
how they plan to jointly implement the recommendations to improve FRCP 
management that were outlined in our report. You also requested that 
the two Departments analyze potential options for integrating the FRCP 
and RCP under a single administrative umbrella to reduce redundancy and 
to better fulfill the goal of establishing a seamless transition for 
wounded servicemembers and their families. Although a response was 
requested by June 20, 2011, the Departments had not responded by 
September 2, 2011, when this Subcommittee announced that it intended to 
hold an oversight hearing on continuing concerns about the care 
coordination issues of the FRCP and RCP.
    Our review of DoD's and VA's care coordination and case management 
programs, including the FRCP and RCP, is part of a body of ongoing work 
that is focused on the continuity of care for recovering servicemembers 
and veterans. My testimony today addresses the status of DoD and VA's 
efforts to (1) implement the recommendations to improve FRCP management 
from our March 2011 report and (2) identify and analyze potential 
options to integrate the FRCP and the RCP as requested by this 
Subcommittee.
    We conducted the original performance audit for our 2011 report 
from September 2009 through March 2011 and obtained updated data and 
additional information in September 2011 for this testimony. 
Specifically, to obtain information on the status of the 
recommendations contained in our March 2011 report, we reviewed 
documentation provided by VA and interviewed the Acting Executive 
Director for the FRCP. Although our recommendations were directed to 
VA, which administers the program, we also obtained information from 
DoD officials that described to what extent they have worked with VA to 
implement them based on your request for the Departments to work 
together. To obtain information regarding the status of DoD and VA's 
efforts aimed at identifying and analyzing options for integrating or 
otherwise revamping the FRCP and RCP, we conducted interviews with DoD 
and VA officials and reviewed documents provided by both Departments. 
We also obtained updated information about DoD's and VA's care 
coordination and case management programs by reviewing program 
documentation and by interviewing DoD and VA program officials.
    We conducted our work for this testimony in accordance with 
generally accepted government auditing standards. Those standards 
require that we plan and perform the audit to obtain sufficient, 
appropriate evidence to provide a reasonable basis for our findings and 
conclusions based on our audit objectives. We believe that the evidence 
obtained provides a reasonable basis for our findings and conclusions 
based on our audit objectives.

Background

    The FRCP was jointly developed by DoD and VA following critical 
media reports of deficiencies in the provision and coordination of 
outpatient services at Walter Reed Army Medical Center. It was 
established to assist severely wounded, ill, and injured Operation 
Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) 
servicemembers,\5\ veterans, and their families with access to care, 
services, and benefits provided through DoD, VA, other Federal 
agencies, States, and the private sector. The FRCP is intended to serve 
individuals who are highly unlikely to return to active duty and most 
likely will be separated from the military, including those who have 
suffered traumatic brain injuries, amputations, burns, spinal cord 
injuries, visual impairment, and post-traumatic stress disorder. From 
January 2008--when FRCP enrollment began--to September 12, 2011, the 
FRCP has provided services to a total of 1,827 servicemembers and 
veterans; \6\ of these, 777 are currently active enrollees.\7\
---------------------------------------------------------------------------
    \5\ 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.
    \6\ In addition to active enrollees in the FRCP, the 1,827 
servicemembers and veterans served includes individuals who were 
evaluated for the program but were not enrolled (in which case the FRCs 
provided temporary assistance to the individual, redirected the 
individual to another program, or both) and enrollees who were 
deactivated from the program because they could not be contacted, no 
longer required FRCP services, or had died.
    \7\ FRCP enrollment has continued to grow. In September 2010, for 
example, the FRCP had 607 active enrollees and had provided services to 
a total of 1,268 servicemembers and veterans.
---------------------------------------------------------------------------
    As the first care coordination program developed collaboratively by 
DoD and VA, the FRCP uses Federal Recovery Coordinators (FRC) to 
monitor and coordinate both the clinical and nonclinical services 
needed by program enrollees; FRCs are intended to accomplish this by 
serving as the single point of contact among case managers of DoD, VA, 
and other governmental and private care coordination and case 
management programs. As of September 12, 2011, there were 21 FRCs 
located at various military treatment facilities and VA medical 
centers. Although the program was jointly created by DoD and VA, it is 
administered by VA, and FRCs are VA employees.
    Separately, the RCP was established in response to the National 
Defense Authorization Act for Fiscal Year 2008 to improve the care, 
management, and transition of recovering servicemembers. It is a DoD-
specific program that uses Recovery Care Coordinators (RCC) to provide 
nonclinical care coordination to both seriously and severely wounded, 
ill, and injured servicemembers. Servicemembers who are severely 
wounded, ill, and injured and who will most likely be medically 
separated from the military, also are to be assigned an FRC. While the 
program is centrally coordinated by DoD's Office of Wounded Warrior 
Care and Transition Policy, it has been implemented separately by each 
of the military services, which have integrated RCCs \8\ within their 
existing wounded warrior programs.\9\ According to DoD's Office of 
Wounded Warrior Care and Transition Policy, in September 2011, there 
were 162 RCCs and over 170 Army Advocates \10\ who worked in more than 
100 locations, including military treatment facilities and VA medical 
centers. As of September 2011, these RCCs have assisted approximately 
14,000 recovering servicemembers and their families and sometimes 
continue this assistance for those servicemembers who separate from 
active duty.\11\
---------------------------------------------------------------------------
    \8\ RCCs are assigned to and supervised by each of the military 
services' wounded warrior programs.
    \9\ The military wounded warrior programs are the Army Wounded 
Warrior Program, Marine Wounded Warrior Regiment, Navy Safe Harbor, Air 
Force Warrior and Survivor Care Program, Army Reserve Wounded Warrior 
Component, and Special Operations Command's Care Coalition.
    \10\ The Army's Wounded Warrior Program refers to its nonclinical 
care coordinators as ``Advocates.''
    \11\ According to a DoD official, the number of servicemembers in 
the RCP program has steadily increased over time as conflicts continue 
and people take longer to transition out of the military.
---------------------------------------------------------------------------
    The FRCP and RCP are two of at least a dozen DoD and VA programs 
that provide care coordination and case management services to 
recovering servicemembers, veterans, and their families, as we have 
previously reported.\12\ Although these programs may vary in terms of 
the severity of injuries or illnesses among the population they serve, 
or in the types of services they provide, many, including the FRCP and 
RCP, provide similar services. (See table 1.)
---------------------------------------------------------------------------
    \12\ GAO-11-250.

Table 1: Characteristics of Selected Department of Defense (DoD) and 
        Department of Veterans Affairs (VA) Care Coordination and Case 
        Management Programs for Seriously and Severely Wounded, Ill, 
---------------------------------------------------------------------------
        and Injured Servicemembers, Veterans, and Their Families


----------------------------------------------------------------------------------------------------------------
                                                                              Type of services  provided
                                     Severity of     Title of care  --------------------------------------------
             Program                  enrollees'     coordinator or                                   Recovery
                                      injuries a      case manager     Clinical      Nonclinical        plan
----------------------------------------------------------------------------------------------------------------
VA/DoD Federal Recovery            Severe           Federal
 Coordination Program (FRCP).                        Recovery
                                                     Coordinator
                                                     (FRC)
----------------------------------------------------------------------------------------------------------------
DoD Recovery Coordination Program  Serious          Recovery Care
 (RCP).                                              Coordinator
----------------------------------------------------------------------------------------------------------------
Army Warrior Transition Units....  Serious to       Nurse case
                                    severe           manager, squad
                                                     leader,
                                                     physician (one
                                                     of each is
                                                     assigned)
----------------------------------------------------------------------------------------------------------------
Military wounded warrior programs  Serious to       Case manager or
 b,c.                               severe           Advocate
                                                     (title varies
                                                     by service)
----------------------------------------------------------------------------------------------------------------
VA OEF/OIF Care Management         Mild to severe   Case manager,
 Program d.                                          Transition
                                                     Patient
                                                     Advocate e
----------------------------------------------------------------------------------------------------------------
VA Spinal Cord Injury and          Mild to severe   Nurse, social
 Disorders Program.                                  worker
----------------------------------------------------------------------------------------------------------------
VA Polytrauma System of Care.....  Serious to       Social work and
                                    severe           nurse case
                                                     managers

----------------------------------------------------------------------------------------------------------------
Source: GAO analysis of DoD and VA program information.
Notes: 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 are also likely to medically separate from the military. These
  categories are not necessarily used by the programs themselves.
b The military wounded warrior programs are the Army Wounded Warrior Program, Marine Wounded Warrior Regiment,
  Navy Safe Harbor, Air Force Warrior and Survivor Care Program, Army Reserve Wounded Warrior Component, and
  Special Operations Command's Care Coalition.
c An FRC placed at the Special Operations Command's Care Coalition headquarters coordinates clinical and
  nonclinical care for Care Coalition and other FRCP enrollees.
d OEF/OIF refers to Operation Enduring Freedom and Operation Iraqi Freedom, respectively. Since September 1,
  2010, OIF is referred to as Operation New Dawn.
e An OEF/OIF care manager supervises the case managers and transition patient advocates and may also maintain a
  caseload of wounded veterans.


VA Has Made Progress in Addressing Our Recommendations to Improve FRCP 
        Management Processes, and DoD Has Provided Limited Assistance

    VA has recently made progress addressing the recommendations from 
our March 2011 report, and although our recommendations were directed 
to VA, DoD has provided limited assistance for one of the 
recommendations. We previously reported that the FRCP would benefit 
from more definitive management processes to strengthen program 
oversight and decision-making, and that program leadership could no 
longer rely on the informal management processes it had developed to 
oversee and manage key aspects of the program. Because VA maintains 
administrative control of the program, we recommended that the 
Secretary of VA direct the FRCP to take actions to address management 
issues related to FRC enrollment decisions, FRCs' caseloads, and 
program staffing needs and placement decisions. VA concurred with all 
of our recommendations and its progress in addressing them is outlined 
below:

      FRC enrollment decisions. To ensure that referred 
servicemembers and veterans who need FRC services are enrolled in the 
program, we recommended that the FRCP establish adequate internal 
controls regarding enrollment decisions by requiring FRCs to record the 
factors they consider in making enrollment decisions, to develop and 
implement a methodology and protocols for assessing the appropriateness 
of enrollment decisions, and to refine the methodology as needed.

       In May 2011, VA reported that the FRCP had fully implemented an 
interim solution, which requires that FRCs present each enrollment 
decision to FRCP management for review and approval. The discussion 
between the FRC and management and the final decisions are documented 
in the program's data management system. As of September 2011, VA 
reported that the FRCP continues to review and refine the enrollment 
process and establish document protocols.

      FRC caseloads. In an effort to improve the management of 
FRCs' caseloads, we recommended that the FRCP complete the development 
of a workload assessment tool, which would enable the program to assess 
the complexity of services needed by enrollees and the amount of time 
required to provide services.

       As of September 2011, the FRCP has implemented a workload 
intensity tool within the program's data management system, and FRCs 
began using it for all new referrals in September 2011. According to 
the Acting Executive Director for the FRCP, the FRCP will be monitoring 
the effectiveness of the workload intensity tool and will be making 
modifications to it as needed.

      Staffing needs and placement decisions. We recommended 
that the FRCP clearly define and document the decision-making process 
for determining when VA should hire FRCs, how many it should hire, and 
that the FRCP develop and document a clear rationale for FRC placement.

       In September 2011, VA reported that the FRCP has documented the 
formula that the program currently uses to determine the number of FRC 
positions required. In addition, the FRCP is developing a systematic 
analysis to better inform decisions about the future placement of FRCs. 
This analysis considers referrals received by the program, client 
location upon reintegration into the community, and requests from 
programs or facilities for placing FRCs at particular locations. 
According to the Acting Executive Director for the FRCP, the FRCP will 
report updated information about staffing and placement processes 
annually in its business operation planning document.

    Although our recommendations to improve the management of the FRCP 
were directed to the Secretary of VA, both DoD and VA were asked to 
provide a response to this Subcommittee about how the Departments could 
jointly implement the recommendations. DoD has provided limited 
assistance to VA with the implementation of our recommendation 
regarding enrollment. Specifically, according to DoD and VA officials, 
an e-mail communication was sent on June 30, 2011, to the commanders of 
the military services' wounded warrior programs stating that they 
should refer all severely wounded, ill, and injured servicemembers who 
could benefit from the services of an FRC to the program for 
evaluation. Despite this effort, VA officials stated that they have not 
noticed any change in referral numbers or patterns from DoD since the 
e-mail was sent.
DoD and VA Have Made Little Progress Reaching Agreement on Options to 
        Better Integrate Care Coordination Programs
    DoD and VA have made little progress reaching agreement on options 
to better integrate the FRCP and RCP, although they have made a number 
of attempts to address this issue. Most recently, DoD and VA 
experienced difficulty jointly providing potential options for 
integrating these programs in response to this Subcommittee's May 26, 
2011, request to the deputy secretaries, who co-chair the DoD and VA 
Wounded, Ill, and Injured Senior Oversight Committee (Senior Oversight 
Committee).\13\ The Subcommittee requested that the co-chairs provide a 
written response to the Subcommittee by June 20, 2011. In the absence 
of such a response, on August 19, 2011, the Subcommittee contacted the 
Secretaries of DoD and VA and requested that they facilitate moving 
this matter forward.
---------------------------------------------------------------------------
    \13\ In May 2007, DoD and VA established the Senior Oversight 
Committee to address problems identified with the care of recovering 
servicemembers. The Committee is co-chaired by the deputy secretaries 
of DoD and VA and includes military service secretaries and other high-
ranking officials within both Departments.
---------------------------------------------------------------------------
    On September 12, 2011, the co-chairs of the Senior Oversight 
Committee issued a joint letter that stated that the Departments are 
considering several options to maximize care coordination resources. 
However, these options have not been finalized and were not 
specifically identified or outlined in the letter. According to DoD and 
VA officials, the development of this response involved a back-and-
forth between the Departments because of disagreement over its 
contents. Although officials of both Departments collaborated on the 
development of the letter, changes were made during the review process 
that resulted in the delay of its release to the Subcommittee. 
According to DoD and VA officials, after VA had signed the letter and 
sent it to DoD for review and signature, DoD officials unilaterally 
modified the wording, to which VA officials objected. Officials from 
both Departments told us that the resulting impasse caused considerable 
delay in finalizing the letter and was resolved only after DoD agreed 
to withdraw its changes. Issuance of the letter followed notification 
by the Subcommittee that it would hold a hearing on the FRCP and RCP 
care coordination issue in September 2011.
    The two Departments have made prior attempts to jointly develop 
options for improved collaboration and potential integration of the 
FRCP and RCP. Despite these efforts, no final decisions to revamp, 
merge, or eliminate programs have been agreed upon. For example:

      Beginning in December 2010, the Senior Oversight 
Committee directed its care management work group \14\ to conduct an 
inventory of DoD and VA case managers and perform a feasibility study 
of recommendations on the governance, roles, and mission of DoD and VA 
care coordination. According to DoD and VA officials, this information 
was requested for the purpose of formulating options for improving DoD 
and VA care coordination. DoD officials stated that following 
compilation of this information, no action was taken by the Committee, 
and care coordination was subsequently removed from the Senior 
Oversight Committee's agenda as other issues, such as budget 
reductions, were given higher priority. Recently, care coordination has 
again been placed on the Committee's agenda for a meeting scheduled in 
October 2011.
---------------------------------------------------------------------------
    \14\ The Senior Oversight Committee is supported by several 
internal work groups devoted to specific issues, such as DoD and VA 
care coordination and case management. Participants in the Committee's 
care management work group include officials from the FRCP and the RCP.

      In March 2011, the DoD Office of Wounded Warrior Care and 
Transition Policy sponsored a summit that included a review of DoD and 
VA care coordination issues. This effort resulted in the development of 
five recommendations to improve collaboration between the FRCP and RCP, 
including a more standardized methodology for making referrals to the 
FRCP, and two recommendations to redefine the FRCP and the RCP. 
However, there was no joint response to these recommendations and no 
agreement appears to have been reached to jointly implement them. 
Although DoD officials contend that they have taken action on many of 
these recommendations within DoD's care coordination program, VA 
maintains that no substantive action has been taken to jointly 
implement them. The degree of disagreement that exists between DoD and 
VA on implementing these recommendations may be illustrated by the 
continued disagreement between the Departments about when the FRC 
should engage with a seriously wounded, ill, and injured servicemember. 
In discussing one of the outcomes of this coordination summit, DoD 
officials asserted that the FRCP should become engaged with the 
servicemember during rehabilitation after medical treatment has been 
finished. In contrast, VA maintains that the point of engagement should 
be in the early stage of medical treatment to build rapport and trust 
with their clients and their clients' families throughout their course 
---------------------------------------------------------------------------
of care.

    In July 2011, a task force consisting of staff representing 
different VA programs, including the FRCP, began meeting independently 
of DoD to examine more broadly the range of services VA provides to the 
wounded, ill, and injured veterans it serves. VA officials said that 
this task force was formed to provide a critical examination of how 
VA's care coordination and case management programs are meeting the 
needs of this population. However, a VA official stated that this is an 
ongoing effort, and that the task force has not yet identified any 
options or recommendations related to its review. While the task force 
has not yet shared information about its efforts with DoD, a VA 
official told us that it is planning to make a presentation of its 
efforts to the Senior Oversight Committee at a meeting scheduled in 
October 2011.
    The lack of progress to date in reaching agreement on options to 
better integrate the FRCP and the RCP illustrates DoD's and VA's 
continued difficulty in collaborating to resolve care coordination 
program duplication and overlap. We currently have work underway to 
further study this issue and identify the key impediments that continue 
to affect recovering servicemembers and veterans during the course of 
their care. Additionally, as we have previously reported, there are 
numerous programs in addition to the FRCP and RCP that provide similar 
services to recovering servicemembers and veterans--many of whom are 
enrolled in more than one program and therefore have multiple care 
coordinators and case managers. For example, as of September 12, 2011, 
75 percent of active FRCP enrollees also were enrolled in DoD's wounded 
warrior programs. According to one FRC, his enrollees have, on average, 
eight case managers who are affiliated with different programs. We 
found that inadequate information exchange and poor coordination 
between these programs has resulted in not only redundancy, but 
confusion and frustration for enrollees, particularly when care 
coordinators and case managers duplicate or contradict one another's 
efforts. For example, an FRC told us that in one instance there were 
five case managers working on the same life insurance issue for an 
individual. In another example, an FRC and RCC were not aware the other 
was involved in coordinating care for the same servicemember and had 
unknowingly established conflicting recovery goals for this individual. 
In this case, a servicemember with multiple amputations was advised by 
his FRC to separate from the military in order to receive needed 
services from VA, whereas his RCC set a goal of remaining on active 
duty. These conflicting goals caused considerable confusion for this 
servicemember and his family.

Conclusions

    Numerous programs, including the FRCP and RCP, have been 
established or modified to improve care coordination and case 
management for recovering servicemembers, veterans, and their 
families--individuals who because of the severity of their injuries and 
illnesses could particularly benefit from these services. While well 
intended, the proliferation of these programs, which often provide 
similar services, has resulted not only in inefficiencies, but also 
confusion for those being served. Consequently, the intended purpose of 
these programs--to better manage and facilitate care and services--may 
actually have the opposite effect. Particularly disconcerting is the 
continued lack of progress by DoD and VA to more effectively align and 
integrate their care coordination and case management programs across 
the Departments. This concern is heightened further as the number of 
enrollees served by these programs continues to grow. Without 
interdepartmental coordination and action to better coordinate these 
programs, problems with duplication and overlap will persist, and 
perhaps worsen. Moreover, the confusion this creates for recovering 
servicemembers, veterans, and their families may hamper their recovery.

Recommendation for Executive Action

    To improve the effectiveness, efficiency, and efficacy of services 
for recovering servicemembers, veterans, and their families, we 
recommend that the Secretaries of DoD and VA direct the Senior 
Oversight Committee to expeditiously develop and implement a plan to 
strengthen functional integration across all DoD and VA care 
coordination and case management programs that serve this population, 
including the FRCP and RCP, to reduce redundancy and overlap.

Agency Comments

    We obtained oral comments on the content of this statement from 
both DoD and VA officials. These officials provided additional 
information and technical comments, which we incorporated as 
appropriate.
    Chairwoman Buerkle, Ranking Member Michaud, and Members of the 
Subcommittee, this completes my prepared statement. I would be pleased 
to respond to any questions that you may have at this time.

GAO Contact and Staff Acknowledgments

    If you or your staff have any questions about this testimony, 
please contact me 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 statement. Individuals who made key 
contributions to this testimony include Bonnie Anderson, Assistant 
Director; Jennie Apter; Frederick Caison; Deitra Lee; Mariel Lifshitz; 
and Elise Pressma.

                                 
   Prepared Statement of Philip Burdette, Principal Director, Wounded
  Warrior Care and Transition Policy, Office of the Under Secretary of
    Defense for Personnel and Readiness, U.S. Department of Defense

    Madam 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) 
in August 2007, the program is administered by VA.

Overview of DoD Recovery Coordination Program

    The DoD Recovery Coordination Program (RCP) was established later 
by Section 1611 of the FY 2008 National Defense Authorization Act. This 
mandate called for a comprehensive policy on the non-medical care and 
management of recovering servicemembers, including the development of a 
comprehensive recovery plan, and the assignment of a Recovery Care 
Coordinator for each recovering servicemember. In January 2009, a 
Directive-Type Memorandum followed in December 2009 with 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. A summary of the roles and responsibilities 
captured in the DoDI are as follows:

      Recovery Care Coordinator (RCC): The RCC supports 
eligible servicemembers by ensuring their non-medical needs are met 
along the road to recovery.
      Comprehensive Recovery Plan (CRP): The RCC has primary 
responsibility for making sure the CRP 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 CRP.
      Recovery Team: The Recovery Team (RT) includes the 
recovering servicemember's Commander, the RCC, Medical Care Case 
Manager, Non-Medical Care Manager, and, when appropriate, the Federal 
Recovery Coordinator (FRC) for catastrophically wounded, ill or injured 
servicemembers. The RT jointly develops the CRP, evaluating its 
effectiveness and adjusting it as transitions occur.

    There are currently 162 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.
    The DoDI 1300.24 establishes the standardized processes for 
referral for care coordination of seriously, severely and catastrophic 
injured and ill servicemembers for RCCs and FRCs. The RCC's focus is on 
servicemembers who will be classified as Category 2 and 3. A Category 2 
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. A Category 3 servicemember has a severe or 
catastrophic injury/illness and is unlikely to return to duty and is 
likely to be medically separated. The FRC's focus is on those 
servicemembers referred by Service Wounded Warrior programs.
    While defined in the DoDI, Categories 1, 2 and 3 are all 
administrative in nature and have proven difficult to operationalize. 
The intent of the DoDI is to ensure that wounded, ill, and injured 
Servicemembers receive the right level of non-medical care and 
coordination. DoD is continuing to work with the FRCP to ensure that 
servicemembers who need the level of medical and nonmedical care 
coordination provided by a FRC are appropriately referred.

Government Accountability Office (GAO) Report on Federal Recovery 
        Coordination Program

    The Departments recognize that the FRCP and RCP are complementary, 
not redundant programs. There is a ``hand-off'' from DoD RCCs to the VA 
FRCs. This occurs when it is clear that the catastrophically wounded, 
ill, or injured servicemember will not return back to duty, which is a 
highly individualized determination based on multiple factors, 
including the servicemembers' condition, and their desire to stay on 
active duty. While we concur in principle that the establishment of a 
single recovery coordination program may be the preferred course of 
action to provide fully integrated care coordination services, the two 
Departments are still in the process of working out the details.
    As a full partner with the VA, the Department of Defense will 
assist with implementing the GAO recommendations. Specifically, in 
accordance with DoD Policy, all Category 3 (severe or catastrophic 
injury or illness) and other recovering servicemembers who would most 
benefit from the services of a Federal Recovery Coordinator (FRC) will 
be referred. In order to ensure the capabilities are in place to 
address these recommendations, we are in the process of evaluating the 
care coordination resources and capabilities of VA and DoD so that the 
necessary personnel are available with the appropriate skill levels to 
support the wounded, ill, and injured population.
    Following are DoD's responses to the GAO report.

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 a necessary overlap in functions.
    The GAO outlined one instance where a recovering servicemember was 
receiving support and guidance from both a DoD RCC and a VA FRC. 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 VA, 
whereas with his RCC he set a goal of remaining on active duty. We 
recognize that better coordination in the future will avoid these 
situations.
    The SOC directed RCP and FRCP leadership to establish a joint 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 two-day meeting in May. The 
results of the Committee's efforts were briefed to the SOC and DoD 
supports the recommendations to better integrate the FRCP into the RCP 
while considering options to improve transitions for Recovering 
servicemembers In March 2011, DoD also conducted an intense two and a 
half 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. 
One chartered working group focused entirely on collaboration between 
VA and DoD care coordination programs. Actionable recommendations were 
reviewed, presented to the Overarching Integrated Product Team and will 
continue to be worked until the recommendations and policies are 
implemented. The joint DoD-VA Committee also considered the work 
produced by the working group at this summit in coming up with its 
recommendations on how to best collaborate, coordinate, or integrate 
these two programs.

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 (MOA) 
between DoD and VA at facilities where FRCs work, however immediate 
compliance with these MOAs in an environment of reduced or limited 
resources is always a challenge.
    DoD's Office of Wounded Warrior Care and Transition Policy (WWCTP) 
stands ready to assist in securing the resources required at DoD 
facilities for FRCs and will work with the services and VA to ensure 
that daily duties are not interrupted by equipment, technology or space 
constraints.

Conclusion

    The Committee requested an analysis of, and potential options for, 
integrating the FRCP and RCP under a single umbrella, to reduce 
redundancy and better fulfill the goal of establishing a seamless 
transition for wounded warriors and their families. The Departments 
recognize that the FRCP and RCP are complementary, not redundant 
programs. While we concur in principle that the establishment of a 
single recovery coordination program may be the preferred course of 
action to provide fully integrated care coordination services for the 
wounded, ill, or injured servicemembers, Veterans, and their families, 
the two Departments are still in the process of working out the details 
for the SOC.
    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 VA FRCP. The Military Department 
Wounded Warrior Programs will also continue to work closely with FRCs 
in support of recovering 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 John Medve, Executive Director, Office of the
 U.S. Department of Veterans Affairs-U.S. Department of Defense Office
    Collaboration Office of Policy and Planning, U.S. Department of 
                            Veterans Affairs

    Good afternoon Chairwoman Buerkle, Ranking Member Michaud, and 
Members of the Subcommittee. I am John Medve, Executive Director, 
Office of VA-DoD Collaboration within the Office of Policy and 
Planning. I am pleased to be here today to discuss the Federal Recovery 
Coordination Program (FRCP) and the progress that has been made in 
addressing improvements recommended by the Government Accountability 
Office (GAO).
    The FRCP is a designed to complement existing military service-and 
VA-provided case management, support, and transition coordinators. FRCP 
is specifically charged with providing seamless support from the 
servicemember's arrival at the initial Medical Treatment Facility (MTF) 
in the United States through the duration of their recovery, 
rehabilitation, and reintegration. The FRCP staff at the policy level 
coordinates with its DoD counterparts under the umbrella of the Senior 
Oversight Committee. The FRCP is an integral part of VA and DoD efforts 
to address issues raised about the coordination of care and transitions 
between the two Departments for recovering servicemembers. On behalf of 
its clients, Federal Recovery Coordinators (FRCs) work closely with 
clinical and non-clinical care and case managers from the military 
services, the VA, and the private sector as part of their Recovery 
Team. FRCs are master's degree-prepared nurses and clinical social 
workers who support severely wounded and ill Servicemembers, Veterans 
and their families by advocating in all clinical and non-clinical 
aspects of recovery. FRCs work with 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 and coordinators, the FRC creates a Federal Individual 
Recovery Plan (FIRP). FRCs oversee and coordinate all clinical and non-
clinical care identified in the FIRP. To show greater transparency with 
Servicemembers and Veterans, the FIRP is available through the 
eBenefits portal 24 hours-a-day, 7 days-a-week.
    GAO issued a report in March 2011 containing four VA 
recommendations. VA concurred with the recommendations and has taken 
action to implement each of them. GAO's first recommendation was that 
VA establish adequate internal controls regarding FRCs' enrollment 
decisions to ensure that referred Servicemembers and Veterans who need 
FRC services are enrolled in the program. GAO also recommended that 
FRCP leadership require FRCs to record in the Veterans Tracking 
Application (VTA) the factors considered in making the enrollment 
decision, develop and implement a methodology and protocol for 
assessing the appropriateness of enrollment decisions, and refine the 
methodology as needed. VA concurred with this recommendation and 
immediately implemented more stringent internal controls to include 
management review of all enrollment decisions and documentation of 
decision determinations in VTA to ensure that referred Servicemembers 
and Veterans who need FRC services are offered enrollment in FRCP.
    Potential clients referred to FRCP are evaluated to determine 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 offered enrollment in 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 the broad Senior 
Oversight Committee (SOC) eligibility criteria. The SOC criteria covers 
Servicemembers or Veterans who are: in an acute care setting within a 
military treatment facility; diagnosed or referred with spinal cord 
injury, burns, amputation, visual impairment, traumatic brain injury 
and/or Post-Traumatic Stress Disorder; considered at risk for 
psychosocial complication; or self or Command referred based on 
perceived ability to benefit from a recovery plan. 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 recommend 
enrollment of the referred individual into the FRCP. The FRCs then 
present the case for their recommendation to a member of the FRCP 
leadership team for final approval. The results of the final decision 
are documented in the FRCP data management system. FRCP enrollment is 
entirely voluntary. Individuals who are not enrolled are directed to 
alternative resources that are appropriate for their level of need. 
FRCP continues to review and refine the enrollment process and 
establish and document protocols as recommended by GAO. FRCP has 
completed the first phase of an intensity tool designed to add further 
consistency to the enrollment decision process. Testing was completed 
in late summer and we began using the tool on all new referrals earlier 
this month.
    GAO's second recommendation was to complete development of a 
workload assessment tool that will enable the program to assess the 
complexity of services needed by enrollees and the amount of time 
required to provide services to improve management of FRCs' caseloads. 
FRCP embarked on the development of a service intensity tool that would 
fulfill the workload assessment requirements of the GAO recommendation 
and further tie the assessment to enrollment decisions. FRCP dedicated 
substantial time and research into the development and testing of its 
service intensity tool. Several comprehensive sessions with FRCs, 
analysts, and FRCP management were held to develop the tool, validate 
assumptions, conduct reliability testing and refine the scoring 
mechanisms. As noted in VA's original response to GAO, this process 
will likely be completed by summer 2012. The first phase of the tool 
was launched program-wide. FRCP will further analyze the results as we 
continue development of the second phase which will be used to assess 
the amount of time required to provide services. In the interim, FRCP 
is testing other caseload management strategies. Currently, FRCP is 
evaluating the feasibility of establishing intensity levels within the 
active client population to meet the needs of clients and improve 
management of FRC caseloads.
    GAO's third recommendation to VA was to clearly define and document 
the FRCP's decision-making process for determining when and how many 
FRCs VA should hire to ensure that subsequent FRCP leadership can 
understand the methods currently used to make staffing decisions. VA 
concurred with the recommendation and documented the formula used to 
determine the number of FRC positions required. These positions are 
based on an analysis of the anticipated number of referrals, the rate 
of enrollment, the number of clients made inactive, and a target 
caseload range of between 25-35 per FRC. Upon completion of the service 
intensity tool, FRCP will modify this equation to reflect the average 
intensity points allowed per FRC instead of the current caseload range.
    GAO's fourth and final recommendation was to develop and document a 
clear rationale for placement of FRCs, which should include a 
systematic analysis of data, such as referral locations, to ensure that 
FRC placement decisions are strategic in providing maximum benefit for 
the program's population. VA concurred with this recommendation and is 
developing a systematic analysis to inform future placements. The 
original placement of FRCs was guided and directed by an October 2007 
Memorandum of Understanding, signed by the Secretary of Defense and the 
Acting Secretary of Veterans Affairs, which required that FRCs be 
placed at MTFs where significant numbers of wounded, ill, or injured 
Servicemembers were located. As the program grew, the FRCs spread to 
additional 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 to better serve 
the wounded, ill, and injured population of Servicemembers and 
Veterans.
    Thanks to the flexibility of the program, VA has made significant 
progress in implementing the GAO's recommendations during these past 6 
months. FRCP is continuously improving and provides a unique service to 
severely wounded, ill, and injured Servicemembers, Veterans, and their 
families. FRCP is not redundant with existing support programs in VA 
and DoD, but rather complementary as stated in its establishing 
Memorandum of Understanding (MOU).
    FRCP was established specifically to provide care coordination 
across VA and DoD for the most complex cases. FRCs assist clients by 
coordinating health care and benefits from DoD, VA, and other Federal 
agencies as well as State, local and private entities. Most 
coordination and case management support is facility-based. This is not 
true for FRCs. Once assigned, a FRC will continue to support a client 
regardless of where the client is located. This philosophy provides an 
invaluable level of consistency for a client at time when care needs 
and transitions can be overwhelming. Feedback suggests FRCP clients are 
extremely satisfied with the services provided by FRCs. FRCs assist 
clients in overcoming systems barriers, ensure smooth transitions, 
educate clients concerning complex benefits and services, and help them 
navigate across the many systems, programs, and agencies to obtain 
necessary services and benefits. These needs continue to exist for the 
FRCP client population. FRCs clinical backgrounds combined with an 
intensive and comprehensive education on programs and services 
available to Servicemembers and Veterans make them uniquely qualified 
to provide the care coordination services necessary for successful 
recovery and reintegration.
    Beginning next month, FRCP will pilot a new data management system. 
Efforts are already underway to ensure that the data collected and 
stored in the new Internet-based platform is capable of being shared 
throughout VA and DoD. Additionally, VA is engaged in an Information 
Sharing Initiative (ISI) with DoD. ISI is designed to further support 
smooth transitions between DoD and VA. ISI will provide care 
coordinators and case managers the ability to track benefits 
applications, benefits processing status, and benefits awards. It will 
also provide visibility of all clinical and non-clinical care plans and 
provide the ability to view a shared calendar for Servicemember and 
Veterans appointment scheduling.
    In an effort to ensure VA is providing the greatest level of 
coordinated support to the wounded, ill, and injured population, VA 
recently established an internal Wounded, Ill, and Injured Task Force 
to examine current VA programs and ensure appropriate resources, 
programs, and services are available to our wounded, ill, and injured 
populations. A goal of the Task Force is to ensure effective access to 
and delivery of health care and benefits.
    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 DoD's and 
VA's complex systems of care on the road to recovery, rehabilitation, 
and reintegration. The FRCP was envisioned to be the consistent 
resource available to these individuals through care and recovery -a 
consistent resource 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 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.
    Our clients tell us 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. Once assigned, a FRC will continue to 
support a client regardless of where the client is located. 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 few months or a lifetime.
    This concludes my statement, and I am happy to answer any questions 
you may have.

                                 
              Prepared Statement of Abbie Holland Schmit,
                Manager, Alumni, Wounded Warrior Project

    Chairwoman Buerkle, Ranking Member Michaud and Members of the 
Subcommittee:
    Wounded Warrior Project (WWP) applauds the Subcommittee for your 
important oversight into the Federal Recovery Coordination Program 
(FRCP). The Subcommittee's hearing in May raised important issues 
regarding the program's management and governance, and we appreciate 
your follow-up questions to the Co-Chairs of the Senior Oversight 
Committee and your scheduling this second hearing today.
    In testifying today for WWP, I hope to share an ``on the ground'' 
perspective on the FRCP based on my experience in working with wounded 
warriors. As a WWP Alumni Manager in Chicago, I work with wounded 
warriors and their families on a daily basis. Prior to joining WWP in 
June, I served for more than 2 years as an advocate with the Army's 
Wounded Warrior Program--referred to as the AW2 program. The AW2 
program assists and advocates for severely wounded, ill, and injured 
soldiers, veterans, and their families during their recovery and 
transition. Those who qualify are to be assigned to the program as soon 
as possible after arriving at a Warrior Transition Unit. As one who 
served for 6 years in the Army National Guard and had a hard journey 
home due to PTSD and traumatic brain injury after deploying to Iraq 
from 2003 to 2004, the issues before you are not only important, but 
deeply personal for me.
    The FRCP was designed to help those warriors, who--given 
overwhelming injuries--would not only be unable to return to active 
duty, but would likely encounter difficulty in navigating a transition 
process that might involve three or more Federal Departments of 
government and issues ranging from income support, to continuing health 
care and rehabilitation, specially adapted housing, vocational 
rehabilitation and education, caregiver support, and more. In assigning 
knowledgeable, savvy ``special navigators'' in the form of Federal 
Recovery Coordinators (FRC), to assist those warriors and their 
families with this complex process, the program has proven highly 
successful--and unique--in providing holistic, integrated support. FRCs 
are making a real difference in helping severely injured warriors and 
their families to thrive again.
    As your May hearing underscored, individual service Departments are 
not routinely referring severely and catastrophically wounded 
servicemembers to the FRCP, or are doing so at much too late a point in 
the transition process. The Service Departments appear to view the FRCP 
as a VA program; and tend to only refer warriors and their families to 
the program when the warrior is about to separate or retire from 
service. Rather than being marginalized as a VA-only program, the FRCP 
should be operated as initially intended, a joint, integrated effort 
aimed at coordinating Federal care and services. But current 
practices--seemingly reinforced by a shortsighted insistence on 
service-specific care--risk delaying recovery, rehabilitation and 
reintegration rather than fostering a seamless transition. What should 
be a seamless, coordinated undertaking is too often the opposite, as 
illustrated by the experience of warriors who--rather than having a 
single ``comprehensive recovery plan''--find themselves with multiple 
recovery plans.
    These are not abstract or hypothetical concerns. Consider the case 
of Army Specialist Steve Bohn who described his difficult transition at 
a Senate Veterans Affairs Committee hearing in May. Steve was badly 
injured in November 2008, when a suicide bomber in Afghanistan 
detonated 2000 pounds of explosives that buried him under collapsed 
debris and resulted in his suffering severe internal injuries and 
spinal injuries. He experienced multiple breakdowns in the coordination 
of his care and benefits. Steve was initially flown from Germany to 
Fort Campbell, Kentucky--apparently in error--given that he needed 
surgery. After finally undergoing spinal surgery at Walter Reed, Fort 
Campbell threatened to put him on AWOL if he didn't return. As a 
result, he was flown back to Fort Campbell, later returning to Walter 
Reed to undergo bladder surgery. Ultimately he underwent a DoD Medical 
Evaluation Board that eventually assigned him a 40 percent Permanent 
disability rating, 30 percent for spinal injuries and 10 percent for 
neck injuries. But that rating did not take account of his internal 
injuries. He was finally medically retired from the Army in October 
2010.
    While his transition from DoD to VA seemed to begin appropriately 
with his paperwork being sent to VA 180 days before the estimated 
separation date to permit timely claims-adjudication, backlogs in 
scheduling VA compensation examinations bogged down the process. At the 
time Steve testified--7 months after retiring from service--VA had not 
adjudicated his case and he was struggling financially. Unable to work 
because of his injuries, he was living on his military retired pay of 
less than $700/month.
    Steve also seemed to have fallen through the cracks in terms of 
getting VA medical care. While he had had multiple VA compensation 
examinations, it took more than 6 months before anyone at VA approached 
him to discuss any treatment. And many months after becoming a veteran, 
he had yet to be assigned a VA primary care doctor. Steve testified 
that no one ever discussed with him or his family the possibility of 
having an FRC assigned to his case. It seems clear it would have made a 
big difference.
    Steve's experience is hardly unique. But it underscores how easily 
a severely wounded servicemember can fall through the cracks--despite 
very serious injuries, and despite how much emphasis has been placed on 
``seamless transition.''
    Following the direction of the National Defense Authorization Act 
of 2008 (NDAA 08), VA and DoD entered into a memorandum of 
understanding establishing the joint VA-DoD FRCP to assist 
servicemembers with Category 3 injuries, defined as 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 to assist those with injuries 
falling below this defined category who's return to duty may in some 
way be possible. Inconsistency within the individual service 
Departments in operationalizing the term ``Category 3 injuries'' has 
arguably created ambiguity as to who is to be referred for an FRC.
    This referral issue is a problem that can and must be remedied. But 
the recent response from the Co-Chairs of the Senior Oversight 
Committee to the Subcommittee's questions fails to provide that remedy. 
In their cover letter, Deputy Secretaries Gould and Lynn state 
categorically that ``in accordance with DoD Policy, all Category 3 
(severe or catastrophic injury or illness and other recovering 
servicemembers who would most benefit from the services of a Federal 
Recovery Coordinator (FRC) will be referred.'' Yet in the enclosure to 
their letter, which the Co-Chairs describe as setting out ``detailed 
implementation plans,'' they state just the opposite: ``[T]he program 
cannot ensure that all potentially eligible individuals are referred to 
FRCP.'' According to the enclosure, the reason is that ``FRCP, as 
currently structured, is a voluntary referral program and, as such, 
relies on the identification and referral of those who might benefit 
from FRCP services by others.'' \1\ Yet DoD's strongly worded policy 
requires that ``All Category 3 recovering servicemembers shall be 
enrolled in the FRCP and shall be assigned an FRC and Recovery Team.'' 
Given that policy, it would follow that--if something about the 
program's ``current structure'' or voluntary referral process impedes a 
reliable, effective referral process, that could and should be changed. 
Rather than advising the Committee that this problem has been resolved 
or reporting on a specific plan to remedy it, the Deputy Secretary of 
Defense has simply advised this Committee that the terms used to 
describe the population who should be referred to the FRCP are ``left 
to interpretation,'' and ``currently mechanisms are not in place to 
measure compliance with this policy.'' It is difficult to understand 
why the senior leadership of the two Departments have failed to resolve 
this problem.
---------------------------------------------------------------------------
    \1\ DoD/VA Wounded, Ill, and Injured Senior Oversight Committee. 
Response to the Subcommittee on Health, Committee on Veterans' Affairs, 
House of Representatives regarding the Federal Recovery Care 
Coordination Program and GAO recommendations. (September 12, 2011).
---------------------------------------------------------------------------
    VA and DoD 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 FRCP. As we advised the Subcommittee in our 
statement for the record for your hearing in May, the FRCP has become 
much less a joint program, and seen as more a VA program--to the 
detriment of the warriors it was designed to serve. Warriors and 
families continue to need this kind of help early in the transition 
process. With the program's critical role in ensuring that severely 
wounded warriors experience a seamless transition, those warriors and 
their families would be better served if there were truly shared 
responsibility for the program, such as through establishment of an 
interdepartmental FRCP office. Such a proposal should not be deemed to 
reflect a lack of confidence in VA, but rather recognition of the 
inherent limitations of program governance residing in any single 
department. The concept of a DoD-VA program office is neither novel nor 
unprecedented.\2\ While different structural solutions could be 
pursued, WWP foresees continued difficulties for the program, and most 
importantly our warriors, unless fundamental changes are instituted to 
ensure truly shared responsibility. To that end, we urge the 
Subcommittee to consider taking up legislation to ensure that 
objective.
---------------------------------------------------------------------------
    \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.
---------------------------------------------------------------------------
    Thank you again for the opportunity to testify. I would be pleased 
to respond to any questions you may have.

                                 
           Prepared Statement of Alethea Predeoux, Associate
     Director of Health Legislation, 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 present our views on 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 from the Department of Veterans Affairs (VA), and to 
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 again assess challenges of the 
FRCP and identify ways in which we can continue to improve this program 
to best meet the needs of veterans and servicemembers. 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.
    When PVA provided the Subcommittee with a statement for the record 
for the hearing held on May 13, 2011, which examined the progress and 
challenges of the FRCP, we identified three areas in need of 
improvement: continuity of care, care coordination, and program 
awareness. Today, we still believe that these areas are critical to the 
success of the FRCP and are in direct alignment with the issues and 
recommendations outlined by the Government Accountability Office (GAO) 
in a March 2011 report entitled, ``DoD and VA Health Care: Federal 
Recovery Coordination Program Continues to Expand but Faces Significant 
Challenges (GAO-11-250).'' In this report, GAO identified three primary 
challenges with implementation of the FRCP: servicemember enrollment, 
hiring Federal Recovery Coordinators (FRCs), and care coordination. GAO 
concluded the report with four main recommendations to help VA 
leadership address issues stemming from the main challenges facing the 
program. Today, PVA will provide our position in support of the GAO 
recommendations, and our views on the current progress of the 
implementation of the FRCP.

FRCP Enrollment

    The first recommendation from the GAO report was to ``ensure that 
referred servicemembers and veterans who need FRC services are enrolled 
in the program by establishing adequate internal controls regarding the 
FRCs' enrollment decisions.'' In particular, this recommendation 
identifies the need to require FRCs to record the factors they consider 
in making FRCP enrollment decisions, as well as the need to create an 
assessment tool to evaluate such decisions. PVA believes that the use 
of such recording methods and assessment tools will help streamline the 
enrollment process, and ensure that veterans and their families are 
receiving help when it is requested. Additionally, as it relates to 
veterans seeking assistance and looking to enroll in the FRCP, tracking 
enrollment decisions will provide FRCs with the opportunity to identify 
how a servicemember has learned about the FRCP. Identifying referral 
sources will enable both VA and DoD to establish partnerships with 
other Departments in and outside of their agencies to promote the FRCP 
and possibly reduce duplication of care-coordination efforts across VA 
and DoD programs.
    PVA believes that servicemember enrollment is one of the most 
critical elements of the FRCP. Servicemembers must be informed of the 
FRCP and the variety of services available to them through the program. 
However, 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 different offices and 
Departments across both the VA and DoD.
    To promote the FRCP, information posters and pamphlets should be 
made available to veterans and servicemembers when they visit different 
offices within VA and DoD. The FRCP services should also be announced 
through social media tools such as Facebook and Twitter to inform 
veterans and servicemembers of this program. Such educational 
literature would be useful not only for veterans and servicemembers, 
but for their families and caregivers as well. Veterans and 
servicemembers 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 they can 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 program, and educate veterans entering 
VA specialized systems of care on the FRCP services and benefits.
    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 
can make referrals when a veteran or servicemember appears to be in 
need of FRCP services.
    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, and 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.

FRC Caseloads

    The second recommendation from the GAO report encouraged ``complete 
development of the FRCP's workload assessment tool that will enable the 
program to assess the complexity of services needed by enrollees and 
the amount of time required to provide services to improve the 
management of FRCs' caseloads.'' PVA believes that monitoring and 
managing the level of complexity and size of FRC caseloads is extremely 
important to adequately addressing the needs and concerns of veterans 
and servicesmembers enrolled in the FRCP.
    No matter how well prepared and trained an FRC may be, he or she 
will not be able to effectively help veterans and servicemembers to 
their best ability if they are spread too thin and overwhelmed with an 
unreasonable caseload. Conversely, an FRC managing a smaller caseload 
of enrollees with polytraumatic and severe injuries will need fewer 
cases to provide adequate attention and assistance to those veterans 
and servicemembers. That said, a work load assessment tool is 
absolutely necessary to ensuring that FRCs are available to hear the 
concerns and needs of veterans and servicemembers and provide 
appropriate assistance during the recovery and rehabilitation 
processes.
    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 servicemembers and their families.

Hiring FRCs

    The third recommendation, to ``clearly define and document the 
FRCP's decision-making process for determining when and how many FRCs 
VA should hire to ensure that subsequent FRCP leadership can understand 
the methods currently used to make staffing decisions, '' is an area of 
serious concern for PVA. Adequate staffing of the FRCP is essential for 
providing servicemembers with timely, quality care.
    PVA believes that in conjunction with the aforementioned 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' and servicemembers' needs. With such a limited number of 
FRCs, issues involving transportation and distance have the potential 
to hinder access to FRCP services for many veterans in rural areas, and 
thus, become threats to continuity of care. Further, developing a 
decision-making tool to determine when and how many FRCs should be 
hired has the potential to increase the program retention.
    If FRC caseloads are manageable, and the FRCs believe that they can 
actually help veterans and servicemembers, it is likely that employee 
job-satisfaction will be high, and FRCs will continue performing their 
duties. This will lead to adequate staffing of the program, which will 
allow for FRCs and enrollees to develop effective long-term 
relationships. It is these relationships that can help veterans and 
servicemembers adjust to life after a severe or catastrophic injury.

Placement of FRCs

    The final GAO recommendation calls for the FRCP to ``develop and 
document a clear rationale for the placement of FRCs, which should 
include a systematic analysis of data, such as referral locations, to 
ensure that future FRC placement decisions are strategic in providing 
maximum benefit for the program's population.'' PVA believes that all 
veterans and servicemembers who are injured, ill, or wounded have 
earned access to the FRCP. We understand that as a new program, time is 
needed to create, implement, and assess the inner-workings of such a 
comprehensive initiative.
    As recommendations for improvement are provided to VA leadership, 
we strongly encourage both VA and DoD to utilize existing care-delivery 
models such as telehealth and teleconferencing, or electronic enrollee 
accessible programs like My HealtheVet to meet with and communicate 
with veterans and servicemembers in areas that do not have reasonable 
access to an FRC.
    Particularly, 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 an FRC if necessary. Specifically, 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. Developing a clear rationale for the placement of FRCs will help 
ensure that those who have paid a significant price in service to our 
country are not only aware of the resourceful programs available to 
them, but also have the opportunity to participate in them.
    In conclusion, PVA would like to thank the Committee for their 
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. 
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 two of America's 
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 testify today, and we look forward to working with you 
to continue to improve the Federal Recovery Coordination Program. Thank 
you.

                                 
            Prepared Statement of Commander Rene A. Campos,
           USN (Ret.), Deputy Director, Government Relations,
                Military Officers Association of America

EXECUTIVE SUMMARY
    The Military Officers Association of America (MOAA) was extremely 
troubled by the findings 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,'' and even more disappointed by the 
testimony presented to this Subcommittee at the May 13, 2011 hearing on 
the Federal Recovery Coordination Program (FRCP).
    Further, MOAA found the September 12, 2011 letter signed by the 
Deputy Secretary of VA and DoD to the Subcommittee's May 26 letter 
requesting their plan for implementing GAO's recommendations and 
analysis of how the FRCP and DoD's Recovery Coordination Program (RCP) 
could be integrated indicates to us more of a `business as usual' 
approach rather than a roadmap of specifics that show the Departments' 
sense of urgency in addressing these issues in the immediate future.
    MOAA's assessment of the current state of the FRCP supports GAO's 
findings and centers around three key areas.
    Many of the issues identified in the GAO report are similar to 
those in the Defense Department's RCP. We believe strongly the FRCP and 
RCP are victims of much larger systemic problems in wounded warrior 
care across the Departments of Defense (DoD) and Veterans Affairs (VA). 
These systemic issues inhibit uniformity and consistency of operations 
to achieve a state of seamless transition, and include:

      Lack of systematic compliance, accountability, and 
oversight;
      Limitations on information sharing, accuracy of 
information, and communications; and,
      Multiple segregated policies, programs, and services that 
are duplicative, inefficient, ineffective, and add to the already 
confusing bureaucratic morass.

Recommendations:

    MOAA fully concurs with the four recommendations outlined in the 
GAO's report.
    Additionally, we offer the following recommendations to improve the 
FRCP and address the larger systemic issues that exist in delivering 
care coordination between and within the DoD and VA:

      Revise and expand Sec. 1611 of Public Law 110-181 to 
mandate a single, joint VA-DoD program, establishing an office for 
managing, coordinating and assisting severely wounded, ill, and injured 
servicemembers, veterans and their families through recovery, 
rehabilitation, and reintegration. Direct DoD to adopt and fully 
integrate VA's FRCP policy and procedures outlined in VA Handbook 0802, 
March 23, 2011.
      Future hearings related to wounded warrior care 
coordination should be joint hearings before both the Veterans Affairs 
and Armed Services Committees.
      An outside entity should be commissioned to evaluate the 
FRCP and RCP, assess how the programs function and operate within the 
context of the 10 major VA and DoD wounded warrior programs, and 
collect feedback from recovering warriors and family members on how to 
provide simpler ways for wounded warriors and their families to access 
care and services during transition.
      Require VA and DoD medical and benefit systems to expand 
outreach and communication efforts to help increase awareness of all 
wounded warrior programs.
      Conduct periodic needs assessment surveys to gather 
information from wounded warriors and their families on ways to improve 
programs and identify unmet needs.

    MADAM CHAIRMAN AND DISTINGUISHED MEMBERS OF THE SUBCOMMITTEE, on 
behalf of the 370,000 members of the Military Officers Association of 
America (MOAA), I am grateful for the opportunity to present testimony 
on MOAA's observations concerning the Federal Recovery Coordinator 
Program (FRCP).
    MOAA does not receive any grants or contracts from the Federal 
Government.
    MOAA thanks the Subcommittee for its commitment to enhancing the 
Department of Veterans Affairs (VA) care and support to our Nation's 
wounded, ill and injured and their families so they experience no loss 
of continuity in care, and their transition is as seamless as possible.
    Our Association also commends the Subcommittee for its leadership, 
persistent oversight and sense of urgency on the critical topic of care 
coordination for the heroes and the families these programs are 
intended to support.

FRCP and RCP Issues

    While the focus of this hearing is on the FRCP, it is not possible 
to have a discussion on the program without including the DoD Recovery 
Coordination Program (RCP) since the two programs are interrelated and 
are seen as fulfilling the same roles and responsibilities in their 
respective agencies.
    To better understand the two programs, it is helpful to look back 
at the timelines and purposes for establishing them.

      The Senior Oversight Committee (SOC) implemented the FRCP 
through two Memorandums of Understanding (MOU) between the VA and DoD.

          The first MOU was signed by the Secretary of Veterans 
        Affairs and the Secretary of Defense on August 31, 2007, 
        requiring the establishment of the FRCP.
          On October 31, 2007, the VA released a statement 
        announcing the agency and DoD had signed an agreement (October 
        30), establishing the FRCP to help ``ensure medical services 
        and other benefits are provided to seriously wounded, injured 
        and ill active duty servicemembers and veterans.''

    The program supported one of the recommendations of the President's 
Commission on Care for America's Returning Wounded Warriors, better 
known as the Dole-Shalala Commission.

    The MOU further ``defined the FRCP, designated the Federal Recovery 
Coordinators (FRCs) as the `ultimate resource' for monitoring the 
implementation of services for wounded, ill and injured servicemembers 
and veterans enrolled in the FRCP. VA would provide the coordinators in 
collaboration with DoD, to coordinate services at military treatment 
facilities, services between the two Departments, private-sector 
facilities.''

      On January 28, 2008, the President signed into law the 
National Defense Authorization Act for Fiscal Year 2008 (P.L. 110-181), 
directing VA and DoD to jointly develop and implement a comprehensive 
policy on improvements to care, management, and transition of 
recovering servicemembers not later than July 1, 2008.

      As part of this joint policy, recovery care coordinators were to 
be assigned to recovering servicemembers. Their duties were to include 
``overseeing and assisting the servicemember's course through the 
entire spectrum of care, management, transition, and rehabilitation 
services available from the Federal Government, including assistance 
and services provided by the DoD, VA, Department of Labor, and the 
Social Security Administration.''

      On December 1, 2009, DoD Instruction 1300.24 established 
the RCP. The instruction assigns Commanders of Military Departments' 
Wounded Warrior Programs overall responsibility for the management of 
their individual RCPs. Further, the instruction requires recovering 
servicemembers to be referred to the appropriate RCP, either the DoD 
RCP or the FRC.
      On March 23, 2010, VA Handbook 0802 established 
procedures for the FRCP--a combined initiative of VA and DoD to assist 
severely wounded, ill and injured post-9/11 servicemembers, veterans 
and their families through recovery, rehabilitation, and reintegration 
into their home community.

    In the handbook, VA defines the RCC as ``an individual assigned by 
the military services to recovering servicemembers whose period of 
recovery is anticipated to exceed 180 days, but who are likely to 
return to active duty. RCCs' duties include assisting servicemembers as 
they process through the DoD system of benefits and care.''
    The fact that the FRCP was the first care coordination program 
jointly created and implemented by the two agencies and was to be the 
`ultimate resource for wounded warriors and their families with 
questions or concerns about VA, DoD or other Federal benefits' would 
lead one to believe that the program would be institutionalized and 
should serve as a model for other VA-DoD collaboration.
    While both VA and DoD care coordination programs boast of being 
joint, the reality is both are managed and operated in the opposite 
manner, separate and distinct from each other as was clearly stated by 
VA and DoD FRC and RCP officials at the May 13 hearing. During the 
hearing:

      The VA official concurred with the GAO recommendations, 
mentioning that many in DoD/Service wounded warrior programs refer to 
the FRCP as a VA program and think the FRCP should only care for 
wounded warriors when they become or are about to become veterans.
      The DoD official talked about the RCP being directed by 
Congress and that FRCs and RCCs serve similar purposes, but cover 
different categories of wounded warriors--RCCs are assigned, day one. 
The official pointed to the RCP instruction that indentifies when the 
FRCs come into the DoD process to provide more comprehensive care. 
While DoD told the Subcommittee they were willing to bring the FRCs 
earlier into the process, the Department was quite clear that they 
``wanted control over their people,'' and so did the military services.

    The latter statement sums up the problem quite succinctly. Rather 
than fulfill the objective of jointness and seamlessness, the various 
bureaucracies too often end up putting their organizational interests 
ahead of those of wounded members and families.
    A recent letter signed by the Deputy of Secretary of VA and DoD on 
September 12, corroborates our view that the two agencies continue to 
operate as separate programs, struggling to implement the joint program 
they committed to over 4 years ago when the agency's leadership signed 
the first MOU establishing the FRCP program in October of 2007. 
Comments such as:

      ``In order to ensure the capabilities are in place to 
address these (GAO) recommendations, we are in the process of 
evaluating the care coordination resources and capabilities of VA and 
DoD so that the necessary personnel are available with the appropriate 
skill levels to support the wounded, ill and injured population.
      The Departments recognize that the FRCP and RCP are 
complementary, not redundant programs.
      While we concur in principle that the establishment of a 
single recovery coordination program may be the preferred course of 
action to provide fully integrated care and coordination services for 
the wounded, ill and injured servicemembers, veterans and their 
families, we are still in the process of working out the details for 
the Senior Oversight Committee.''

    Clearly, the two Departments have not been able to fix these policy 
and programmatic gaps on their own these last 4 years--and, unlikely to 
do so in the immediate future without some sort of immediate outside 
intervention and oversight. Wounded warriors and their families are 
struggling and need help now--the last thing they want to hear 
policymakers say is that `we are working on the problem and we will 
have a plan in place soon.'
    So today, wounded, ill and injured servicemembers, disabled 
veterans and their families are once again faced with trying to 
understand the complexities, nuances, and navigate two more separate 
programs in the VA and DoD systems, including unique and fragmented 
service care coordination programs in each of the Military Departments. 
Simply put, the programs that were built to be joint and help them 
navigate the complicated processes have themselves become parochial and 
part of the navigation problem.
    The current FRCP and RCP policies are opaque, confusing and 
incongruent with the intent of Congress. The VA and DoD were supposed 
to jointly develop and implement a comprehensive policy on improvements 
to care, management, and transition of recovering servicemembers, but 
have in fact developed separate and independent programs.
    While the FRCP was operational January 2008, program procedures 
weren't published until this year, March 2011. Additionally, DoD did 
not publish its RCP policy until December 2008, well past the July 1, 
2008 congressional deadline.
    The Department of Defense Recovering Warrior Task Force, 2010-2011 
Annual Report, published September 2, 2011, highlights a significant 
number of program deficiencies, recommending the need to ``standardize 
and clearly define the roles and responsibilities of the RCC, FRC, non-
medical care manager, VA Liaison for Health care, and VA Polytrauma 
Case Managers serving a recovering warrior and his or her family. 
Standardize the criteria for who is eligible to be assigned to a RCC 
(or Army Wounded Warrior (AW2) Advocate) and FRC.''
    While both the FRCP and RCP programs have deficiencies, MOAA hears 
far less complaints and far more compliments for the FRCP. VA's policy 
and procedures also tend to be more comprehensive and easier to 
understand than DoD's RCP regulations.
 MOAA urges the Subcommittee to revise and expand Sec. 1611 of Public 
Law 110-181 to mandate a single, joint VA-DoD program and establish an 
office for managing, coordinating and assisting severely wounded, ill, 
    and injured servicemembers, veterans and their families through 
recovery, rehabilitation, and reintegration. DoD should be directed to 
 adopt and fully integrate VA's FRCP policy and procedures outlined in 
                   VA Handbook 0802, March 23, 2011.

Systemic Issues

    Many of the broad departmental issues plaguing both VA and DoD 
systems are also impacting and limiting the FRCP, the RCP and likely 
the 10 other major wounded warrior programs cited by GAO at the May 
hearing. The persistent problems with information sharing, and the 
long-standing issues of inadequate collaboration between the agencies 
are well documented and alive and well today. These issues continue to 
impede progress and prevent VA and DoD from effectively and efficiently 
serving our most vulnerable servicemembers and disabled veterans who 
critically need these support services.
    MOAA believes strongly that the key systemic issues which inhibit 
uniformity and consistency of operations to achieve a state of seamless 
transition include:

      Lack of systematic compliance, accountability, and 
oversight;
      Limitations on information sharing, accuracy of 
information, and communications; and,
      Multiple segregated policies, programs, and services that 
are duplicative, inefficient, ineffective, and add to the already 
confusing bureaucratic morass.

    The DoD Recovering Warrior Task Force highlighted similar themes in 
its report (Department of Defense Recovering Warrior Task Force, 2010-
2011 Annual Report):

     ``Disparities exist across recovering warrior (RWs) programs and 
policies in the Headquarters or Department vision and in the way in 
which those programs and policies are implemented in the field and 
experienced by RWs and their families. Clear, consistent, and accurate 
information does not reliably reach RWs about the programs and policies 
intended to support them. Also, parity of care across the services has 
not been achieved. From language used to services offered, eligibility 
criteria, and staffing requirements, the services implement policies 
and programs differently. There also are significant differences in the 
experiences of Active Component (AC) RWs, Reserve Component (RC) RWs 
healing at Active Duty installations, and RC RWs receiving community-
based care.''

    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, management, and technological system 
differences after more than a decade of war.
    The impact of these system failures can have a profound impact on 
the medical outcomes and the quality of life our wounded warriors and 
their families will experience. The impact and experiences of these 
individuals today continue to be all over the map, regardless of the 
time frame of the injuries.

      One caregiver whose loved one was injured early in 2010 
told the Senate Veterans Affairs Committee of the difficulties in 
transitioning out of the military at a hearing this past July, ``. . . 
Coordination of care for her wounded warrior has also been a problem. 
There seem to be so many coordinators that they are actually not all on 
the same page and sometimes doing things opposite of each other. Though 
she was trying to help, I rarely got to see our FRC, who seemed to have 
too many people she was responsible for. The lack of communication also 
extended to benefits and programs . . . ,'' she said.
      To another caregiver, the mother of her severely disabled 
son, ``Our FRC is affectionately called our `Wonderful FRC!' It is as 
simple as that, yet, what she has done, and continues to do for our 
family is nothing short of miraculous and a Godsend. She has taken care 
of every aspect of my son's care back to 2008 when he was critically 
injured. Not only has the FRC provided excellent care and has been my 
son's number one advocate, she has been supportive and an inspiration 
to me as my son's primary caregiver--and I know she must be the same to 
the dozen or more wounded warriors families she also cares for each and 
every day.''
      Another wounded warrior couple whose servicemember was 
injured in 2009 and was first introduced to their RCC at the time of 
their medical board, was provided no information about the FRCP. This 
spouse told us, ``We completely trust our RCC, though things were a 
little rocky at first--now he has our full trust! Financially, the 
transition has been difficult. Her wounded warrior is on the Temporary 
Duty Retirement List (TDRL) . . . The military has taken months to 
reevaluate her husband's condition, and the family no longer has the 
financial resources while on active duty. The TDRL process and 
navigating the medical and benefits systems has been a battle from the 
beginning of his injury--no one has been there to explain the 
process.''

    Wounded, ill and injured servicemembers, disabled veterans and 
families deserve the very best care and support from systems that are 
simple, transparent and accessible. They don't want more policies or 
programs to further bog down the progress--they just want the systems 
to do their job--and to fulfill the obligations, promises and 
commitments made to them.
    MOAA urges Congress to provide the necessary leadership in:

      Ensuring that future hearings related to wounded warrior 
care coordination are joint hearings that include both the Veterans 
Affairs and Armed Services Committees.
      Commissioning an outside entity to evaluate the FRCP and 
RCP, to include how the programs operate within the context of the 10 
major VA and DoD wounded warrior programs and collection of feedback 
from recovering warriors and family members on how to develop simpler 
ways for wounded warriors and their families to access services and 
support during transition.
      Requiring VA and DoD medical and benefit systems to 
expand outreach and communication efforts to help increase awareness of 
all wounded warrior programs.
      Conducting periodic needs assessment surveys to gather 
information from wounded warriors and their families to improve 
programs and identify unmet needs.

Conclusion

    MOAA is grateful to the Subcommittee for your leadership in 
supporting our wounded, ill and injured servicemembers, disabled 
veterans and their families who have ``borne the battle'' in defense of 
the Nation.

                                 
              Prepared Statement of Hon. Russ Carnahan, a
         Representative in Congress from the State of Missouri

    Chairwoman Buerkle, Ranking Member Michaud, and Members of the 
Subcommittee, thank you for hosting this hearing to discuss expansion 
and revision of the Federal Recovery Coordination Program (FRCP). 
Providing support to those who were injured or became ill in service to 
our country is of paramount importance. Today's hearing facilitates a 
conversation between Congress and those with knowledge of what needs to 
be done to ensure our Nation's heroes receive the most expedient and 
effective assistance in their time of need.

    In 2007, following reports of poor outpatient care from Walter Reed 
Medical Center, the Department of Defense (DoD) and the Veteran's 
Administration (VA) jointly created FRCP to coordinate clinical and 
nonclinical services for recovery, rehabilitation and reintegration of 
wounded, ill or severely injured servicemembers and Veterans. While the 
program continues to expand, practices must be reviewed to ensure that 
our servicemembers and Veterans across the country uniformly receive 
the best care possible.
    A recent Government Accountability Office (GAO) report found 
concern with the client referral system employed by FRCP. Eligible 
patients are not being identified in existing DoD and VA databases 
because records are currently not coded to classify veterans and 
servicemembers as ``severely wounded, ill, and injured.'' The program 
relies solely on referrals to identify qualified individuals. Also, 
FRCP is understaffed and there is no current system to place new hires 
and delegate caseload. Additionally, FRCP has been confronted with 
problems in communicating patient information from DoD and VA 
facilities to supporting organizations.
    I look forward to hearing from our witnesses on ways we can 
overcome challenges facing the Federal Recovery Coordination Program 
and expand services to ensure comprehensive care for our Nation's 
heroes.
                                 
                   MATERIAL SUBMITTED FOR THE RECORD
                       U.S. Department of Defense
                              INSTRUCTION
                                                     NUMBER 1300.24
                                                   December 1, 2009
                                                           USD(P&R)
    SUBJECT: Recovery Coordination Program (RCP)

    References: See Enclosure 1

    1.  PURPOSE. In accordance with the authority in DoD Directive 
(DoDD) 5124.02 (Reference (a)) and the guidance in sections 1611, 1614, 
and 1648 of Public Law 110-181 (Reference (b)), this Instruction:

        a.  Establishes policy, assigns responsibilities, and 
        prescribes uniform guidelines, procedures, and standards for 
        improvements to the care, management, and transition of 
        recovering servicemembers (RSMs) across the Military 
        Departments.
        b.  Establishes the RCP evaluation process to provide for a 
        coordinated review of the policies, procedures, and issues of 
        the program.
        c.  Incorporates and cancels Under Secretary of Defense for 
        Personnel and Readiness (USD(P&R)) Directive-type Memorandum 
        08-049 (Reference (c)).

    2.  APPLICABILITY. This Instruction applies to:

        a.  OSD, the Military Departments (including the Coast Guard at 
        all times, including when it is a Service in the Department of 
        Homeland Security by agreement with that Department), the 
        Office of the Chairman of the Joint Chiefs of Staff and the 
        Joint Staff, the Combatant Commands, the Office of the 
        Inspector General of the Department of Defense, the Defense 
        Agencies, the DoD Field Activities, and all other 
        organizational entities within the Department of Defense.
        b.  The Joint Task Force National Capital Region Medical 
        (JTFCapMed).
        c.  RSMs as defined in the Glossary, regardless of component or 
        duty status.
        d.  Eligible family members of RSMs as defined in the Glossary.

    3.  DEFINITIONS. See Glossary.
    4.  POLICY. It is DoD policy that:

        a.  The RCP shall be established to provide program and policy 
        oversight of DoD resources necessary to ensure uniform care and 
        support for RSMs and their families when the RSM has been 
        wounded or injured or has an illness that prevents him or her 
        from providing that support. Implementation of uniform 
        guidelines, procedures, and standards for the care, management, 
        and transition of RSMs shall ensure consistent, high quality 
        medical and non-medical care for RSMs and their families.
        b.  DoD programs established for the benefit of RSMs and their 
        families shall comply with DoD RCP policies and support the 
        needs of the RSM.
        c.  All RSMs shall be eligible to receive uniform standard 
        support, resources, and access to programs, whether members of 
        the Army, Navy, Air Force, Marine Corps, or Coast Guard.

    5.  RESPONSIBILITIES. See Enclosure 2.
    6.  PROCEDURES. Enclosures 3 through 7 provide overarching 
procedures and requirements for the administration, implementation, and 
management of the RCP.
    7.  INFORMATION REQUIREMENTS

        a.  The collection, use, and dissemination of personally 
        identifiable formation (PII) shall be administered in 
        compliance with DoDD 5400.11 (Reference (d)) and DoDD 5411.11-R 
        Reference (e)).
        b.  Collection of PII from immediate family members and non-
        dependent family members must be preceded by provision of an 
        appropriate privacy act statement as required by Reference (e).

    8.  RELEASABILITY. UNLIMITED. This Instruction is approved for 
public release and is available on the Internet from the DoD Issuances 
Web Site at http://www.dtic.mil/whs/directives.
    9.  EFFECTIVE DATE. This Instruction is effective immediately.

                                                     Gail H. McGinn
                          Deputy Under Secretary of Defense (Plans)
                    Performing the Duties of the Under Secretary of
                                Defense for Personnel and Readiness
    Enclosures

    1.  1. References
    2.  2. Responsibilities
    3.  3. Program Management
    4.  4. Recovery Coordination Process
    5.  5. Transition Procedures
    6.  6. Workload and Supervision Procedures
    7.  7. RCP Evaluation Procedures

    Glossary

                               __________

                           TABLE OF CONTENTS
REFERENCES

RESPONSIBILITIES

        USD(P&R)
        ASD(HA)
        SECRETARIES OF MILITARY DEPARTMENTS

PROGRAM MANAGEMENT

        SURGEONS GENERAL OF THE MILITARY DEPARTMENTS
        COMMANDER, JTFCAPMED
        COMMANDERS, WOUNDED WARRIOR PROGRAMS
        RTs

        Composition
        Overarching Roles and Responsibilities
        RCC Responsibilities
        MCCM Responsibilities
        NMCM Responsibilities

RECOVERY COORDINATION PROCESS

    SERVICEMEMBER SCREENING
    CATEGORY ASSIGNMENT
    DESIGNATED CAREGIVERS
    CRP
    FAMILY SUPPORT

        Response to Family Needs
        Medical Support for Non-Dependent Family Members
        Advice and Training Services
        Financial Assistance and Job Placement Services

TRANSITION PROCEDURES

    TRANSITION FROM DoD CARE AND TREATMENT TO VA CARE, TREATMENT, AND 
REHABILITATION
    TRANSITION FROM DoD CARE AND TREATMENT TO CIVILIAN CARE, TREATMENT, 
AND REHABILITATION
    RETURN TO DUTY
    MEDICAL SEPARATION OR RETIREMENT
    TRANSITION SUPPORT

        Transition From DoD Care
        Separation or Retirement

7WORKLOAD AND SUPERVISION PROCEDURES

    WORKLOAD

        RCCs and NMCMs
        MCCMs

    SUPERVISION

RCP EVALUATION PROCEDURES

    STAFF ASSISTANCE VISITS
    EVALUATION PROGRAM

GLOSSARY

    ABBREVIATIONS AND ACRONYMS
    DEFINITIONS

TABLE

    Servicemember Care Coordination Categories

                               __________
                              ENCLOSURE 1

                               REFERENCES

    a.  DoD Directive 5124.02, ``Under Secretary of Defense for 
Personnel and Readiness (USD(P&R)),'' June 23, 2008
    b.  Sections 1611, 1614, and 1648 of Public Law 110-181, ``The 
National Defense Authorization Act for Fiscal Year 2008,'' January 28, 
2008
    c.  Directive-Type Memorandum (DTM) 08-049, ``Recovery Coordination 
Program: Improvements to the Care, Management, and Transition of 
Recovering Servicemembers (RSMs),'' January 19, 2009 (hereby canceled)
    d.  DoD Directive 5400.11, ``DoD Privacy Program,'' May 8, 2007
    e.  DoD Regulation 5400.11-R, ``DoD Privacy Program,'' May 14, 2007
    f.  DoD Centers of Excellence for Psychological Health and 
Traumatic Brain Injury, ``Suicide Assessment Five Step Evaluation and 
Triage (SAFE-T),'' 2007
    g.  Assistant Secretary of Defense for Health Affairs Memorandum, 
``TRICARE Policy for Access to Care and Prime Service Area Standards,'' 
February 21, 2006
    h.  Parts A and B of Volume I of the Joint Federal Travel 
Regulations, current edition
    i.  Secretary of Defense Memorandum, ``DoD Housing Inspection 
Standards for Medical Hold and Holdover Personnel,'' September 18, 2007
    j.  TRICARE Management Activity, ``Medical Management Guide,'' 
January 2006
    k.  Public Law 104-191, ``Health Insurance Portability and 
Accountability Act of 1996,'' August 21, 1996
    l.  Chapter 61 and section 1145 of title 10, United States Code
    m.  DoD Directive 1332.18, ``Separation or Retirement for Physical 
Disability,'' November 4, 1996
    n.  DoD Directive 1332.35, ``Transition Assistance for Military 
Personnel,'' December 9, 1993
    o.  DoD Instruction 1100.13, ``Surveys of DoD Personnel,'' November 
21, 1996
    p.  Chapter 77 of title 38, United States Code

                               __________
                              ENCLOSURE 2

                            RESPONSIBILITIES

    1.  USD(P&R). The USD(P&R) shall be responsible for RCP policy and 
program oversight and shall:

        a.  Execute RCP policy and program oversight through the 
        USD(P&R) Office of Wounded Warrior Care and Transition Policy 
        (WWCTP). The WWCTP shall:

          1.  Administer the RCP and provide oversight of its 
        implementation and guidance for continuous process improvement 
        pursuant to Reference (a).
          2.  Coordinate with the Assistant Secretary of Defense for 
        Health Affairs (ASD(HA)) regarding programs that support RSMs 
        and their families when preparing RCP policy.

        b.  Oversee all RSM support programs throughout the Department 
        of Defense and adjust RCP policy and procedures as necessary.
        c.  Oversee the development of core training conducted by the 
        WWCTP for the Military Department recovery care coordinators 
        (RCC).
        d.  Oversee Military Department development ofpolicies and 
        procedures that are uniform and standardized across the 
        Military Departments to provide services and resources for RSMs 
        and their families.
        e.  Coordinate with the VA to develop and implement 
        administrative processes, procedures, and standards for 
        transitioning RSMs from DoD care and treatment to VA care, 
        treatment, and rehabilitation that are consistent with 
        Enclosure 5 of this Instruction.

    2.  ASD(HA). The ASD(HA), under the authority, direction, and 
control of the USD(P&R), shall:
        a.  Provide RSMs with timely access to inpatient and outpatient 
        medical and behavioral health services through DoD facilities, 
        purchased care, or in coordination with the VA.
        b.  Ensure that policies and procedures for RSM medical care 
        case managers (MCCMs) are developed, implemented, and 
        consistent across the Military Departments.
        c.  Establish uniform professional qualifications, including 
        education and training, for MCCMs identified to become members 
        of the RSM recovery team (RT).
        d.  Ensure that MCCM workload is delineated based on the 
        medical constraints and requirements of the RSMs served.
        e.  Develop medically appropriate training for RCCs, MCCMs, and 
        non-medical care managers (NMCMs) that addresses detection, 
        notification, and tracking of early warning signs of post-
        traumatic stress disorder, suicidal or homicidal thoughts or 
        behaviors, and other behavioral heath concerns among RSMs. 
        Ensure such training includes procedures for the appropriate 
        specialty consultation and referral following detection of such 
        signs in accordance with DoD Centers of Excellence for 
        Psychological Health and Traumatic Brain Injury publication 
        (Reference (f)) for initiating behavioral health early warning 
        sign notification and tracking procedures.
        f.  Coordinate with the VA to develop and implement medically 
        related processes, procedures, and standards for transitioning 
        RSMs from DoD care and treatment to VA care, treatment, and 
        rehabilitation that address:

          1.  RSM transition without gaps in medical care or the 
        quality of medical care, benefits, and services to the maximum 
        extent feasible.
          2.  RSM enrollment in the VA health care system.
          3.  Assignment of DoD and VA case management personnel in 
        military treatment facilities (MTFs) VA medical centers, and 
        other medical facilities caring for RSMs.
          4.  Integration of DoD and VA medical care and management of 
        RSMs during transition, to include the accommodation of VA 
        medical personnel in DoD facilities as required to participate 
        in the needs assessments of RSMs.
          5.  VA access to the health records of RSMs receiving or 
        anticipating receipt of care and treatment in VA facilities.
          6.  Utilization of a joint separation and evaluation physical 
        examination that meets the DoD and VA requirements for 
        disability evaluation of RSMs.
          7.  Measurement of RSM and family satisfaction with the 
        quality of health care for RSMs provided by the Department of 
        Defense to facilitate appropriate oversight of such care and 
        services by leadership. (This measurement is separate from that 
        conducted by the WWCTP in the annual RCP evaluation described 
        in Enclosure 7 of this Instruction.) Measured results shall be 
        reported to the WWCTP.

    3.  SECRETARIES OF THE MILITARY DEPARTMENTS. The Secretaries of the 
Military Departments shall:

        a.  Ensure RSM care, management, and transition policies are 
        uniform and standardized.
        b.  Establish uniform procedures for tracking RSMs that 
        facilitate:

          1.  Locating RSMs.
          2.  Tracking RSM attendance at medical care, physical exam, 
        and evaluation appointments and scheduling additional 
        appointments as needed.
          3.  Tracking RSM progress through medical and physical 
        evaluation boards (PEBs).

        c.  Ensure their RCPs are extended to include RSMs in their 
        Reserve Components (RC) and inc2rporate all program services, 
        to include identifying RSMs, assigning RSMs to RCCs, and 
        preparing recovery plans.
        d.  Establish and appropriately resource their Military 
        Department RCP elements, wounded warrior programs, and family 
        support programs.
        e.  Ensure that wounded warrior and family support programs 
        execute the policies of this Instruction.
        f.  Exercise the authority to:

          1.  Grant waivers to the maximum number of RSM cases assigned 
        to RCCs and NMCMs as described in subparagraph 1.a.(2) of 
        Enclosure 6.
          2.  Grant RSM requests to continue on duty after being found 
        unfit for duty as described in paragraph 3.b. of Enclosure 5.

        g.  Ensure the Surgeons General comply with the requirements of 
        section 1 of Enclosure 3.
        h.  Authorize access to basic outpatient and inpatient medical 
        and behavioral health services through DoD facilities for 
        members of families who are providing support to RSMs and who 
        are not otherwise eligible for care as dependents (e.g., 
        parents, siblings) and are providing support to RSMs.

                               __________
                              ENCLOSURE 3

                           PROGRAM MANAGEMENT

    1.  SURGEONS GENERAL OF THE MILITARY DEPARTMENTS. The Surgeons 
General of the Military Departments shall:

        a.  Establish policies and procedures to ensure compliance with 
        this Instruction within their respective components and MTFs.
        b.  Provide appropriately trained medical personnel in 
        accordance with Reference (a) to support RSM care management 
        throughout the continuum of care.
        c.  Ensure that installation medical directors provide 
        oversight of the medical care delivered to RSMs.
        d.  Ensure that MTF commanders facilitate access to family 
        support services within MTFs, and between MTFs and local family 
        service entities (e.g., childcare).
        e.  Ensure that RSMs have the highest priority for appointments 
        to non-urgent and other health care services in DoD MTFs and 
        for any purchased care medical services. Ensure RSMs receive 
        referrals to other DoD, VA, or purchased care providers if 
        appointments are not available within the MTF that meet TRICARE 
        access standards in accordance with ASD(HA) Memorandum 
        (Reference (g)).

    2.  COMMANDER, JTFCAPMED. The Commander, JTFCapMed, shall ensure 
compliance with this Instruction within the JTFCapMed area of 
responsibility.
    3.  COMMANDERS, WOUNDED WARRIOR PROGRAMS. Commanders shall:

        a.  Have overall responsibility for the management of their 
        Military Department RCP, and shall maintain operational, 
        tactical, and administrative control of their RCP and non-
        medical personnel to ensure they execute the roles and 
        responsibilities in this Instruction.
        b.  Ensure that RSMs are referred to the appropriate RCP, 
        either the DoD RCP or the Federal Recovery Coordination Program 
        (FRCP), established by the Department of Defense and/or the VA.
        c.  Provide appropriately trained RCCs, NMCMs, and other non-
        medical members of the RT, in accordance with Reference (b), to 
        support RSM care management throughout the continuum of care.
        d.  Conduct Military Department-specific training for their 
        RCCs, MCCMs, and NMCMs, provide a certificate of completion to 
        those who have attended the training, and forward a roster of 
        attendees' names to the WWCTP training office.
        e.  Establish work and duty assignments for RSMs, with the 
        recommendation of appropriate medical and non-medical 
        authorities, that support recovery, rehabilitation, and 
        reintegration, and that may include training and education 
        tailored to the abilities of RSMs.
        f.  Assist RSMs in obtaining needed medical care and services 
        by providing transportation and subsistence in accordance with 
        parts A and B of Volume 1 of the Joint Federal Travel 
        Regulations (Reference (h)).
        g.  Ensure RSMs have access to educational and vocational 
        training and rehabilitation opportunities at the earliest 
        possible point in their recovery.

    4.  RTs

        a.  Composition. All RTs shall include the RSM's Commander, 
        RSM; an RCC or a Federal recovery coordinator (FRC); an MCCM; 
        and an NMCM. They may also include medical professionals such 
        as primary care managers, mental health providers, physical and 
        occupational therapists, and others such as PEB liaison 
        officers, VA military services coordinators, chaplains, and 
        family support program representatives.
        b.  Overarching Roles and Responsibilities. RT members shall:

    1.  Complete Military Department-specific training prior to 
independently assuming the duties of their positions, and comply with 
continuing education requirements.
    2.  Collaborate with the RCC and other RT members to develop the 
comprehensive recovery plan (CRP), evaluate its effectiveness in 
meeting the RSM's goals, and readjust it as necessary to accommodate 
the RSM's changing objectives, abilities, and recovery status.
    3.  Determine the RSM's location of care based primarily on the 
RSM's medical care needs, with consideration given to the desires of 
the RSM and family and/or designated caregiver. Provide the RSM and 
family or designated caregiver options for care locations during 
development of the CRP that address:

          a.  The RSM's medical care and non-medical support needs.
          b.  Capabilities required for the RSM's care.
          c.  The availability of DoD, VA, or civilian facilities with 
        appropriate capabilities and accreditation or licensure.

    4.  Determine the appropriate course of action for the RSM when he 
or she is located at an MTF, specialty medical care facility, military 
quarters, or leased housing that is found to be deficient in accordance 
with Secretary of Defense Memorandum (Reference (i)); this course of 
action may be temporary or permanent based on the deficiency and the 
RSM's needs.
    5.  Reevaluate the needs of the RSM in accordance with the options 
for care locations if relocation is required.
    6.  Facilitate the most expeditious appointment available for the 
RSM for non-urgent care to include appointments for follow-up and/or 
specialty care, diagnostic referral and studies, and surgery.
    7.  Allow the RSM to waive the TRICARE standards for access to care 
detailed in the TRICARE Management Activity guide (Reference (j)) when 
either of these circumstances occur:

          a.  No appointment is available that meets access standards 
        within DoD MTFs or the TRICARE program.
          b.  Travel is required beyond the TRICARE catchment area, and 
        the health care provider has determined that travel will not 
        adversely affect the health of the RSM.

    8.  Document in writing, and maintain in the RSM's records, any 
situation in which the RSM waives a standard for access to care.

    c.  RCC Responsibilities. The RCC shall:

        1.  Complete uniform core training conducted by WWCTP, and 
        Military Department-specific training conducted by the 
        cognizant wounded warrior program prior to assuming the duties 
        of their positions.
        2.  Have primary responsibility for development of the CRP, in 
        conjunction with the RT, and assist the commander in overseeing 
        and coordinating the services and resources identified in the 
        CRP.
        3.  Ensure, in coordination with the Secretary of the Military 
        Department concerned, that the RSM and family and/or designated 
        caregiver have access to all medical and non-medical services 
        throughout the continuum of care.
        4.  Minimize delays and gaps in treatment and services.
        5.  Provide a hard copy of the CRP to the RSM and family and/or 
        designated caregiver upon completion and whenever changes are 
        made to the document. Review and update the CRP in person (when 
        possible) with the RSM and family or designated caregiver as 
        frequently as necessary based on the RSM's needs and during 
        transition phases in the RSM's care (change in location or 
        familial, marital, financial, job, medical, or retirement 
        status).
        6.  Facilitate and monitor the execution of services for the 
        RSM across the continuum of care as documented in the recovery 
        plan, to include services available from the Department of 
        Defense, the VA, the Department of Labor, and the Social 
        Security Administration.
        7.  Coordinate the transfer of an updated CRP to, and directly 
        communicate with, appropriate medical and non-medical personnel 
        should the RSM be moved to a different location for care.
        8.  Close out the CRP when the RSM has met all goals or 
        declines further support and retain all documents according to 
        applicable Military Department policies.

    d.  MCCM Responsibilities. MCCMs shall:

        1.  Ensure the RSM understands his or her medical conditions 
        and treatments and receives appropriate coordinated health 
        care.
        2.  Assist the RSM and family or designated caregiver in 
        understanding the RSM's medical status during care, recovery, 
        and transition.
        3.  Assist the RSM in receiving well-coordinated prescribed 
        medical care during all phases of the continuum of care.
        4.  Conduct periodic reviews of the RSM's medical status. When 
        possible, reviews shall be conducted in person with the RSM and 
        family or designated caregiver.

    e.  NMCM Responsibilities. The NMCM shall:

        1.  Work within established service program procedures to 
        ensure the RSM and family or designated caregiver gets needed 
        non-medical support such as assistance with resolving 
        financial, administrative, personnel, and logistical problems.
        2.  Provide feedback on the effectiveness of the CRP in meeting 
        the RSM's personal goals.
        3.  Communicate with the RSM and family or designated caregiver 
        regarding non-medical matters that arise during care, 
        management, and transition; assist the RSM in resolving non-
        medical issues.
        4.  Assist the RSM with finding the resources to maintain or 
        improve his or her welfare and quality of life.

                               __________
                              ENCLOSURE 4

                     RECOVERY COORDINATION PROCESS

    1.  SERVICEMEMBER SCREENING

        a.  In accordance with standard medical practice, 
        servicemembers shall be screened for medical and psychosocial 
        needs upon initial presentation to a medical care provider. For 
        servicemembers who are unlikely to return to duty within a 
        specific period of time determined by their Military 
        Departments wounded warrior program, care and support needs 
        will be assessed by their wounded warrior programs using 
        standardized tools for RCP category assignment and enrollment.
        b.  Servicemembers may self-refer to the RCP or be referred by 
        their command, medical care provider, Military Department 
        wounded warrior program, or the Wounded Warrior Resource 
        Center.

    2.  CATEGORY ASSIGNMENT

        a.  The Military Departments shall use the care coordination 
        categories shown in the table or a similar process standardized 
        within their wounded warrior program to determine an initial 
        care coordination category.


                                 Table.
               Servicemember Care Coordination Categories
------------------------------------------------------------------------

------------------------------------------------------------------------
Category 1 (CAT 1)                           Has a mild injury
                                             or illness
                                             Is expected to
                                             return to duty within a
                                             time specified by his or
                                             her Military Department
                                             Receives short-term
                                             inpatient medical treatment
                                             or outpatient medical
                                             treatment and/or
                                             rehabilitation
------------------------------------------------------------------------
Category 2 (CAT 2)                           Has a serious
                                             injury or illness
                                             I unlikely to
                                             return to duty within a
                                             time specified by his or
                                             her Military Department
                                             May be medically
                                             separated from the military
------------------------------------------------------------------------
Category 3 (CAT 3)                           Has a severe or
                                             catastrophic injury or
                                             illness
                                             Is highly unlikely
                                             to return to duty
                                             Will most likely be
                                             medically separated from
                                             the military
------------------------------------------------------------------------


        b.  Servicemembers who are determined to be CAT 2 and CAT 3 or 
        who fall within their equivalent Military Department's wounded 
        warrior program's standardized care coordination categories are 
        RSMs.
        c.  A CAT 2 RSM who is enrolled in the RCP shall be assigned an 
        RCC and an RT. The Military Department wounded warrior program 
        shall assign the RCC to provide assistance for the RSM's 
        recovery, rehabilitation, and transition activities.
        d.  All CAT 3 RSMs shall be enrolled in the FRCP and shall be 
        assigned an FRC and an RT. The FRC will coordinate with the RCC 
        and RT to ensure the needs of the RSM and his or her family are 
        identified and addressed.
        e.  An RSM assigned to CAT 2, who later meets the criteria for 
        CAT 3, shall be placed in CAT 3 and an FRC shall be assigned.
        f.  An RSM assigned to CAT 3, who later meets the criteria for 
        CAT 2, shall be placed in CAT 2. The FRC shall remain with the 
        RSM until such time as the FRC and RSM and family agree that 
        the services of the FRC are no longer needed.
        g.  An RSM assigned to CAT 1, who later meets the criteria for 
        CAT 2 or 3, shall be placed in the appropriate category and 
        assigned an RCC, FRC, and an RT as required by the category.

    3.  DESIGNATED CAREGIVERS. RSMs who do not have or want immediate 
families (spouse or children) to support them with their recovery shall 
be permitted to designate another individual as a caregiver. The 
caregiver may be a friend, fiancee or fiance, co-worker, member of the 
family who is not a military dependent, etc. RSMs may also decide that 
he or she does not want to designate a caregiver.
    4.  CRP

        a.  All RSMs enrolled in a Military Department RCP shall 
        receive a CRP. (RSMs assigned an FRC shall also receive a 
        Federal individual recovery care.) The RSM, family or 
        designated caregiver, and RT members will create action steps 
        for accomplishing plan goals that must be specific, measurable, 
        and achievable within an agreed upon time frame. In addition to 
        the action to be taken, action steps shall contain these data 
        elements:

          1.  An identified point of contact for each step.
          2.  A list of the support and resources available to the RSM 
        and family or designated caregiver for each action, including 
        the location of the support and resources.

        a.  The RSM and family or designated caregiver, and the RCC 
        shall review the CRP and sign the document, demonstrating their 
        understanding of the plan and commitment to its implementation.
        b.  The Military Departments may customize the CRP based on 
        internal requirements, provided the criteria in paragraphs 4.a. 
        and 4.b. of this enclosure are met.

    5.  FAMILY SUPPORT

        a.  Response to Family Needs. The NMCM shall:

          1.  Identify any immediate family needs upon first 
        interaction with the family. Needs may include lodging, 
        transportation, medical care, finances, or childcare.
          2.  Contact the appropriate family support programs to obtain 
        services and resources that respond to the identified family 
        needs. This initial interface with family support services and 
        resources is key to ensuring the RSM's family is appropriately 
        supported.
          3.  nsure key family needs are addressed in relevant goals in 
        the recovery plan.

        2.  Medical Support for Non-Dependent Family Members. The RCC 
        or FRC, MCCM, and NMCM, in coordination with the Secretary of 
        the Military Department concerned or designee, shall facilitate 
        non-dependent family member access to medical care at DoD MTFs. 
        The RCC or FRC, MCCM, and NMCM shall facilitate non-dependent 
        family member access to non-Federal care providers as needed 
        (not at Government expense). In general, medical care and 
        counseling may be provided at a DoD MTF on a space-available 
        basis when:

          1.  The family member is on invitational travel orders to 
        care for the RSM.
          2.  The family member is issued non-medical attendant orders 
        to care for the RSM.
          3.  The family member is receiving per diem payments from the 
        Department of Defense while caring for the RSM.

        c.  Advice and Training Services. Advice and training services 
        include, but are not limited to, financial counseling, spouse 
        employment assistance, respite care information, and childcare 
        assistance. When the family has arrived at the treatment 
        facility, the NMCM, RCC, or FRC should provide information on 
        services and resources available through the National Resource 
        Directory (https://www.nationalresourcedirectory.org), the 
        Wounded Warrior Resource Center Call Center (1-800-342-9647) 
        and Web Site (http://www.woundedwarriorresourcecenter.com), and 
        the Wounded, Ill, and Injured Compensation and Benefits 
        Handbook (http://tricare.mil/mybenefit/Download/Forms/
        Compensation-Benefits-Handbook.pdf).
        d.  Financial Assistance and Job Placement Services. The RT 
        shall:

          1.  Identify any loss of income and financial challenges 
        facing the RSM's family.
          2.  Ensure the recovery plan identifies benefits, 
        compensation, services (such as job placement services), and 
        resources from Federal, State, and local agencies and non-
        profit organizations for which the RSM's family is eligible.

                               __________
                              ENCLOSURE 5

                         TRANSITION PROCEDURES

    1.  TRANSITION FROM DoD CARE AND TREATMENT TO VA CARE, TREATMENT, 
AND REHABILITATION

        a.  Prior to transition of the RSM to the VA, the RCC (assisted 
        by the RT) shall ensure that all appropriate care coordination 
        activities, both medical and non-medical, have been completed, 
        including:

          1.  Notification to the appropriate VA point of contact (such 
        as a Transition Patient Advocate) when the RSM begins physical 
        disability evaluation process, as applicable.
          2.  Scheduling initial appointments with the Veterans Health 
        Administration system.
          3.  Transmittal of the RSM's military service record and 
        health record to the VA. The transmittal shall include:

            a.  The RSM's authorization (or that of an individual 
        legally recognized to make medical decisions on behalf of the 
        RSM) for the transmittal in accordance with Public Law 104-191 
        (Reference (k)). The RSM may have authorized release of his or 
        her medical records if he or she applied for benefits prior to 
        this point in the transition. If so, a copy of that 
        authorization shall be included with the records.
            b.  The RSM's address and contact information.
            c.  The RSM's DD Form 214, ``Certificate of Release or 
        Discharge from Active Duty,'' which shall be transmitted 
        electronically when possible, and in compliance with Reference 
        (d).
            d.  The results of any PEB.
            e.  A determination of the RSM's entitlement to 
        transitional health care, a conversion health policy, or other 
        health benefits through the Department of Defense, as explained 
        in section 1145 of title 10, United States Code (U.S.C.) 
        (Reference (l)).
            f.  A copy of requests for assistance from the VA, or of 
        applications made by the RSM for health care, compensation and 
        vocational rehabilitation, disability, education benefits, or 
        other benefits for which he or she may be eligible pursuant to 
        laws administered by the Secretary of Veterans Affairs.

          4.  Transmittal of the RSM's address and contact information 
        to the department or agency for veterans affairs of the State 
        in which the RSM intends to reside after retirement or 
        separation.
          5.  Update the CRP for the RSM's transition that shall 
        include standardized elements of care, treatment requirements, 
        and accountability for the plan. The CRP shall also include:

            a.  Detailed instructions for the transition from the DoD 
        disability evaluation system to the VA disability system.
            b.  The recommended schedule and milestones for the RSM's 
        transition from military service.
            c.  Information and guidance designed to assist the RSM in 
        understanding and meeting the schedule and milestones.

    b.  The RCC and RT shall:

        1.  Consider the desires of the RSM and the family or 
        designated caregiver when determining the location of the RSM's 
        care, treatment, and rehabilitation.
        2.  Coordinate the transfer to the VA by direct communication 
        between appropriate medical and non-medical staff of the losing 
        and gaining facilities (e.g., MCCM to accepting physician).

    2.  TRANSITION FROM DoD CARE AND TREATMENT TO CIVILIAN CARE, 
TREATMENT, AND REHABILITATION

        a.  Prior to transition of the RSM to a civilian medical care 
        facility, the RCC (assisted by the RT) shall ensure that all 
        care coordination activities, both mdical and non-medical, have 
        been completed, including:

          1.  Appointment scheduling with civilian medical care 
        facility providers.
          2.  Transmittal of the RSM's health record to the civilian 
        medical care facility. The transmittal shall include:

            a.  The RSM's authorization (or that of an individual 
        legally recognized to make medical decisions on behalf of the 
        RSM) for the transmittal in accordance with Reference (i).
            b.  A determination of the RSM's entitlement to 
        transitional health care, a conversion health policy, or other 
        health benefits through the Department of Defense, as explained 
        in section 1145 of Reference (l).

        b.  Transmittal of the RSM's address and contact information.
        c.  Preparation of detailed plans for the RSM's transition, to 
        include standardized elements of care, treatment requirements, 
        and accountability of the CRP.
        d.  The RCC and RT shall:

          1.  Consider the desires of the RSM and the family or 
        designated caregiver when determining the location of the RSM's 
        care, treatment, and rehabilitation.
          2.  Coordinate the transfer by direct communication between 
        appropriate medical and non-medical staff of the losing and 
        gaining facilities (e.g., RCC to FRC, MCCM to accepting 
        physician).

    3.  RETURN TO DUTY

        a.  An RSM who is found fit for duty by a PEB shall be returned 
        to duty in accordance with the policies and procedures of the 
        Military Department concerned.
        b.  In accordance with DoDD 1332.18 (Reference (m)), an RSM may 
        request to continue on permanent limited duty status or active 
        duty in the Ready Reserve after being found unfit for duty. The 
        Secretary of the Military Department concerned may grant such 
        requests based on a determination that the needs of the Service 
        and the RSM's service obligation, special skills, experience, 
        or reclassification justifies the continuation. Transfer of the 
        RSM to another Service may also be considered.
        c.  Members of the RC who are not designated as RSMs, who are 
        released from active duty and are returned to their units, and 
        who are entitled to non-urgent medical care for injuries or 
        illnesses incurred while on active duty are required to 
        coordinate authorization for medical care and schedule 
        appointments through their units and the Military Medical 
        Support Office.

    4.  MEDICAL SEPARATION OR RETIREMENT

        a.  Upon medical retirement, the RSM will receive the same 
        benefits as other retired members of the Military Departments. 
        This includes eligibility for participation in TRICARE and to 
        apply for care through the VA.
        b.  An RSM who is enrolled in the RCP and subsequently placed 
        on the temporary disability retired list shall continue to 
        receive the support of an RCC, including implementation of the 
        recovery plan, until such time as the wounded warrior program 
        determines that the services and resources necessary to meet 
        identified needs are in place through non-DoD programs.

    5.  TRANSITION SUPPORT

        a.  Transition From DoD Care. The RT shall provide transition 
        support to the RSM and family or designated caregiver before, 
        during, and after relocation from one treatment or 
        rehabilitation facility to another or from one care provider to 
        another. Transition preparation will occur with sufficient 
        advance notice and information that the upcoming change in 
        location or caregiver is anticipated by the RSM and family or 
        designated caregiver, and will be documented in the CRP.
        b.  Separation or Retirement. Once the PEB determines that the 
        RSM will not return to duty:

          1.  The RT shall:

            a.  Work with the RSM and family or designated caregiver to 
        prepare for the transition to retirement and veteran status.
            b.  Ensure transition plans are written prior to the time 
        of separation for RSMs being retired or separated pursuant to 
        chapter 61 of Reference (l).

          2.  The RCC or FRC shall:

        a.  Discuss with the RSM his or her short- and long-term 
        personal and professional goals such as employment, education, 
        and vocational training, and the rehabilitation needed to meet 
        those goals; identify the options and transition activities in 
        the CRP.
        b.  Ensure the RSM, as appropriate, has received the mandatory 
        pre-separation counseling and has the opportunity to attend the 
        VA benefits briefing and to participate in the Disabled 
        Transition Assistance Program (TAP) and the Department of Labor 
        TAP Employment Workshop. Encourage the RSM to establish a TAP 
        account through the Internet at http://www.TurboTAP.org, as 
        outlined in DoDD 1332.35 (Reference (n)).
        c.  Ensure RCRSMs have the opportunity to participate in the 
        Benefits Delivery at Discharge Program as appropriate.

                               __________
                              ENCLOSURE 6

                  WORKLOAD AND SUPERVISION PROCEDURES

    1.  WORKLOAD

        a.  RCCs and NMCMs

          1.  The wounded warrior program shall assign RCCs and NMCMs a 
        maximum of 40 RSMs to serve. The actual number assigned will 
        depend on the acuity of the RSMs' medical conditions and 
        complexity of their non-medical needs.
          2.  A waiver will be required by the Secretary of the 
        cognizant Military Department or such individual as delegated 
        the authority by the Secretary if the maximum number of RSM 
        cases assigned to an RCC or NMCM is exceeded. Waivers shall not 
        exceed 120 days.

        b.  MCCMs. Guidance on MCCM workload shall be established by 
        the ASD(HA), in accordance with section 2 of Enclosure 2.

    2.  SUPERVISION

        a.  The Military Departments will provide supervision for the 
        RCCs and NMCMs employed by their wounded warrior programs.

          1.  Supervisors of RCCs and NMCMs shall be military officers 
        in the grade of O-5 or O-6, or civilian employees of equivalent 
        grade.
          2.  The occupational specialty of persons appointed to 
        supervise RCCs and NMCMs is at the discretion of the Military 
        Departments.

        b.  Supervisors of MCCMs shall be Military Department medical 
        officers in the grade of O-5 or O-6, or civilian employees of 
        equivalent rank or grade within the MCCM's chain of command.

          1.  The Surgeons General will oversee the MCCMs employed in 
        the Military Health care System.
          2.  The medical occupational specialty of supervisors of 
        MCCMs is at the discretion of the Military Department Surgeons 
        General.

                               __________
                              ENCLOSURE 7

                       RCP EVALUATION PROCEDURES

    1.  STAFF ASSISTANCE VISITS

        a.  The WWCTP shall conduct only staff assistance visits from 
        the effective date of this Instruction to 1 year after its 
        effective date to allow the Military Departments to implement 
        the RCP and fully staff the wounded warrior programs.
        b.  The WWCTP shall provide a planned visit schedule, subject 
        to change, to the Military Departments within 30 days from the 
        effective date of this Instruction.

    2.  EVALUATION PROGRAM

    a.  The WWCTP shall:

          1.  Develop and conduct an annual, formal RCP evaluation 
        across the Military Departments using existing DoD assessment 
        tools and information found in DoD Instruction 1100.13 
        (Reference (o)), to measure compliance with Reference (b) 
        requirements.
          2.  Conduct a baseline evaluation beginning 1 year from the 
        effective date of this Instruction, and from 6 months of the 
        date of the baseline evaluation shall initiate a recurring 
        program evaluation schedule.
          3.  Encourage the Military Departments to conduct internal 
        evaluations as well.

        b.  The RCP evaluation shall focus on the care, management, and 
        transition process of the RSM. The evaluation will include, at 
        a minimum:

          1.  A review of RCC roles and responsibilities.
          2.  A review of the maximum number of RSMs that RCCs and 
        NMCMs are allowed to serve.
          3.  An assessment of RSM, veteran, and family experiences 
        with the RCP.

        c.  The WCCTP shall use the results of the evaluation to 
        implement improvements to the RCP and ensure quality in the 
        delivery of health care services to the RSM and family. The 
        resulting modifications to RCP care, management, and transition 
        processes or procedures will be reflected in a change to or 
        revision to this Instruction.

                               __________
                                GLOSSARY

                   PART I. ABBREVIATIONS AND ACRONYMS

    ASD(HA)-Assistant Secretary of Defense for Health Affairs
    CAT-category
    CRP-comprehensive recovery plan
    DoDD-DoD Directive
    FR-Federal recovery coordinator
    FRCP-Federal Recovery Coordination Program
    JTF-CapMed Joint Task Force Capital Region Medical
    MCCM-medical care case manager
    MTF-military treatment facility
    NMCM-non-medical care manager
    PEB-physical evaluation board
    RC-Reserve Component
    RCC-recovery care coordinator
    RCP-recovery coordination program
    RSM-recovering servicemember
    RT--recovery team
    TAP-Transition Assistance Program
    U.S.C.-United States Code
    USD(P&R)-Under Secretary of Defense for Personnel and Readiness
    VA-Department of Veterans Affairs
    WWCTP-Office of Wounded Warrior Care and Transition Policy

                          PART II. DEFINITIONS

    These terms and their definitions are for the purpose of this 
Instruction.
    acuity. The level of severity or urgency of an RSM's medical 
condition as related to the need for certain care or treatment.
    eligible family member. An RSM's spouse, child (including 
stepchildren, adopted children, and illegitimate children), parent or 
person in loco parentis, or sibling on invitational travel orders or 
serving as a non-medical attendee while caring for the RSM for more 
than 45 days during a 1-year period.
    FRC. An individual assigned by the VA to serve as the ultimate 
point of contact for an RSM and family or designated caregiver to 
ensure the RSM medical and non-medical needs are met.
    FRCP. The program established by the Department of Defense and the 
VA to provide management and oversight of the resources needed to 
coordinate care and support to RSMs through recovery, rehabilitation, 
and reintegration.
    invitational travel orders. Military travel orders that allow an 
RSM's family to travel and stay with the RSM during treatment and 
recovery after suffering a wound, illness, or injury.
    recovery plan. A patient-centered plan prepared by an RT, RSM, and 
family or designated caregiver with medical and non-medical goals for 
recovery, rehabilitation, and transition, as well as personal and 
professional goals, and the identified services and resources needed to 
achieve the goals.
    RSM. A member of the military services who is undergoing medical 
treatment, recuperation, or therapy and is in an inpatient or 
outpatient status, who incurred or aggravated a serious illness or 
injury in the line of duty, and who may be assigned to a temporary 
disability retired or permanent disability retired list due to the 
Military Department's disability evaluation system proceedings.
    TAP. A program designed to ease the transition of servicemembers 
from military service to the civilian workforce and community.
    temporary disability retired list. A disposition finding by a PEB 
for an RSM who has one or more Service unfitting conditions that were 
incurred in the line of duty and that have a combined rating of 30 
percent or higher, and who is considered not stable as a result.
    transition. A process that may include:

         Leaving military service by way of discharge, separation, or 
        retirement.
         Release from active duty (REFRAD) for RC members.
         Transfer from the military health care system to the VA health 
        care system.

    VA. The Federal agency responsible for providing a wide range of 
programs and services to servicemembers and veterans as required by 
chapter 77 of title 38, U.S.C. (Reference (p)). The VA includes, among 
other components, the Veterans Health Administration and the Veterans 
Benefits Administration.
    wounded warrior program. A system of support and advocacy to guide 
and assist the RSM and family or designated caregiver through 
treatment, rehabilitation, return to duty, or military retirement and 
transition into the civilian community. Each Military Department has a 
unique wounded warrior program that addresses its servicemembers' 
needs.