Vocational Rehabilitation: More VA and DOD Collaboration Needed  
to Expedite Services for Seriously Injured Servicemembers	 
(14-JAN-05, GAO-05-167).					 
                                                                 
More than 10,000 U.S. military servicemembers, including National
Guard and Reserve members, have been injured in the conflicts in 
Afghanistan and Iraq. Those with serious injuries are likely to  
be discharged from the military and return to civilian life with 
disabilities. The Department of Veterans Affairs (VA) offers	 
vocational rehabilitation and employment (VR&E) services to help 
these injured servicemembers in their transition to civilian	 
employment. GAO has noted that early intervention--the provision 
of rehabilitation services as soon as possible after the onset of
a disability--is a practice that significantly facilitates the	 
return to work. GAO examined how VA expedites VR&E services to	 
seriously injured servicemembers and the challenges VA faces in  
its efforts to do so.						 
-------------------------Indexing Terms------------------------- 
REPORTNUM:   GAO-05-167 					        
    ACCNO:   A15696						        
  TITLE:     Vocational Rehabilitation: More VA and DOD Collaboration 
Needed to Expedite Services for Seriously Injured Servicemembers 
     DATE:   01/14/2005 
  SUBJECT:   Employment of the disabled 			 
	     Interagency relations				 
	     Military personnel 				 
	     Veterans						 
	     Veterans employment programs			 
	     Vocational rehabilitation				 
	     Data collection					 
	     Data integrity					 
	     Policy evaluation					 
	     Job placement					 
	     Policies and procedures				 
	     VA Vocational Rehabilitation and			 
	     Employment Program 				 
                                                                 
	     Afghanistan					 
	     Iraq						 

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GAO-05-167

                 United States Government Accountability Office

  GAO Report to the Ranking Democratic Member, Committee on Veterans' Affairs,
                            House of Representatives

January 2005

VOCATIONAL REHABILITATION

More VA and DOD Collaboration Needed to Expedite Services for Seriously Injured
                                 Servicemembers

GAO-05-167

January 2005

VOCATIONAL REHABILITATION

More VA and DOD Collaboration Needed to Expedite Services for Seriously Injured
Servicemembers

  What GAO Found

VA has taken steps to expedite vocational rehabilitation and employment
services for servicemembers returning from Afghanistan and Iraq with
serious injuries. The agency has instructed its regional offices to make
seriously injured servicemembers a high priority for all VA assistance,
including VR&E services, and has asked DOD to provide data that would help
VA identify and monitor this population. It has also deployed additional
staff to five major Army military treatment facilities where the majority
of the seriously injured are treated. Pending an agreement with DOD for
sharing data, VA has relied on its regional offices to learn who the
seriously injured are and where they are located. We found that the
regional offices we reviewed had developed information that varied in
completeness and reliability. We also found that VA does not have a policy
for maintaining contact with those with serious injuries who may later be
ready for VR&E services but did not initially apply for VR&E.
Nevertheless, some regional offices did attempt to maintain contact while
other regional offices did not.

Seriously Injured Army Servicemembers Receive Treatment at Five Major Army
Medical Facilities and Relocate to One of 57 VA Regions after Medical
Stabilization

VA faces significant challenges in expediting VR&E services to seriously
injured servicemembers. These include: the inherent challenge that
individual differences and uncertainties in the recovery process make it
difficult to determine when a servicemember will be ready to consider VR&E
services; DOD's concerns that VA's outreach, including early intervention
with VR&E, could work at cross purposes to military retention goals for
servicemembers whose discharge from military service is not yet certain;
and the lack of access to data from DOD that would allow VA to readily
know which servicemembers are seriously injured and where they are
located.

VA and DOD generally concurred with our findings and recommendations.

United States Government Accountability Office

Contents

  Letter

Results in Brief
Background
VA Has Taken Steps to Expedite Vocational Rehabilitation and

Employment Services for Seriously Injured Servicemembers VA Faces
Significant Challenges in Expediting Services to

Seriously Injured Servicemembers Conclusions Recommendations Agency
Comments

                                       1

                                      2 4

                                       8

12 16 17 18

         Appendix I Comments from the Department of Veterans Affairs 20

Appendix II Comments from the Department of Defense

Related GAO Products

  Figures

Figure 1: Seriously Injured Army Servicemembers Receive Treatment at Five
Major Army Medical Facilities and Relocate to One of 57 VA Regions after
Medical Stabilization 6

Figure 2:VA's Early Intervention Could Work at Cross Purposes to DOD's
Retention Evaluation Process 15

Abbreviations

DOD Department of Defense
MTF Military Treatment Facility
VR&E Vocational Rehabilitation and Employment
VA Department of Veterans Affairs

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protection in the United States. It may be reproduced and distributed in
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separately.

United States Government Accountability Office Washington, DC 20548

January 14, 2005

The Honorable Lane Evans Ranking Democratic Member Committee on Veterans'
Affairs House of Representatives

Dear Mr. Evans:

Since the onset of U.S. operations in Afghanistan in October 2001 and Iraq
in March 2003, the Department of Defense (DOD) has reported that more than
10,000 service men and women have been injured in combat. While many
return to active duty after they are treated, others who are more
seriously injured are likely to be discharged from their military
obligations and return to civilian life with disabilities. In addition to
cash compensation, the Department of Veterans Affairs (VA) offers
vocational rehabilitation and employment (VR&E) services to help veterans
with disabilities restore their lives and participate in the civilian
workforce. We have reported that intervening early after a disabling
injury increases the likelihood that an individual will successfully
return to work.1 Moreover, there is growing awareness that people with
disabilities can and want to work and that changes in the nature of work
and advances in assistive technologies help them to do so. Further, as the
U.S. workforce is projected to shrink, the U.S. economy will need all who
are able to participate in the paid labor force. Because federal
disability programs, including VA's, lack emphasis on the potential for
vocational rehabilitation to return people to work and also rely on
outmoded assumptions about the relationship between impairment and work,
we have designated these as "high-risk" programs.2

In view of the importance of early intervention in returning people who
have been disabled to work, you asked that we review how quickly VA is
able to provide VR&E services to seriously injured servicemembers from
Afghanistan and Iraq who are likely to become veterans with disabilities.
We assessed (1) how VA expedites VR&E services to these seriously

1GAO, SSA Disability: Return-to-Work Strategies From Other Systems May
Improve Federal Programs, GAO-96-133 (Washington, D.C.: July 11, 1996).

2GAO, High-Risk Series: An Update, GAO-03-119 (Washington, D.C.: Jan.
2003).

injured servicemembers and (2) the challenges VA faces in its efforts to
do so.

To address these objectives, we reviewed VA's formal and informal
procedures for expediting VR&E services to seriously injured
servicemembers returning from Afghanistan and Iraq. We reviewed applicable
laws and regulations. We interviewed officials at VA's central office and
at 12 of VA's 57 regional offices. Five of these offices are located near
the five major Army medical treatment facilities treating the majority of
the seriously injured Army servicemembers: Brooke Army Medical Center at
Fort Sam Houston, Texas; Darnall Army Community Hospital at Fort Hood,
Texas; Eisenhower Army Medical Center at Fort Gordon, Georgia; Madigan
Army Medical Center at Fort Lewis, Washington; and Walter Reed Army
Medical Center in Washington, D.C. The corresponding VA regional offices
are Houston and Waco, Texas; Atlanta, Georgia; Seattle, Washington; and
Washington, D.C. We selected the other seven regional offices based on
Army data indicating that servicemembers injured in Afghanistan and Iraq
are being treated at military treatment facilities in their regions. They
are Buffalo, New York; Denver, Colorado; Muskogee, Oklahoma; Nashville,
Tennessee; New Orleans, Louisiana; Wichita, Kansas; and Winston-Salem,
North Carolina. Our findings for these regional offices cannot be
generalized to all of VA's regional offices. We focused on Army
servicemembers, including activated National Guard and Reserve, because
they constituted the majority of servicemembers wounded in Afghanistan and
Iraq. In addition, we visited Walter Reed Army Medical Center in
Washington, D.C., where most seriously injured Army servicemembers are
initially treated. We also interviewed DOD officials about their efforts
to work with VA on the transition of injured servicemembers being
discharged from active duty. We conducted our work between April 2004 and
November 2004 in accordance with generally accepted government auditing
standards.

We found that VA has taken steps to expedite VR&E services for seriously
injured servicemembers returning from Iraq and Afghanistan. VA has
instructed its regional offices to make seriously injured servicemembers a
high priority for all VA assistance and asked DOD to share data that would
help VA identify and monitor them. Because most seriously injured
servicemembers are initially treated at major military treatment
facilities, VA deployed staff to these sites to provide information on VA
benefits programs, including VR&E services, to servicemembers injured in
the conflicts in Afghanistan and Iraq. To ensure the identification and
monitoring of all seriously injured servicemembers, VA initiated a

  Results in Brief

memorandum of agreement proposing that DOD systematically provide
information on them, including their names, location, and medical
condition. Pending an agreement with DOD, VA instructed its regional
offices to establish local liaison with military medical treatment
facilities in their areas to learn who the seriously injured are, where
they are located, and the severity of their injuries. Reliance on local
relationships, however, has resulted in varying completeness and
reliability of information developed by the 12 regional offices in our
review. We also found that VA has no policy for VR&E staff to maintain
contact with seriously injured servicemembers who do not apply for VR&E
services. Nevertheless, some offices reported efforts to maintain contact
with these servicemembers, noting that some who are not initially ready to
consider employment when contacted about VR&E services may be receptive at
a future time.

We found significant challenges to VA's efforts to expedite VR&E services.
An inherent challenge is that individual differences and uncertainties in
the recovery process make it difficult to determine when a seriously
injured service member will be ready to consider VR&E services.
Additionally, given that VA is conducting outreach to servicemembers whose
discharge from military service is not yet certain, VA is challenged by
DOD's concerns that VA's outreach about benefits, including early
intervention with VR&E services, could work at cross purposes to the
military's retention goals. Finally, VA is currently challenged by a lack
of access to DOD data that would, at a minimum, allow the agency to
readily identify and locate all seriously injured servicemembers. VA
officials we interviewed both in the regional offices and at the central
office reported that this information would provide them with a more
reliable way to identify and monitor the progress of those servicemembers
with serious injuries. However, DOD officials reported that they have
privacy concerns about the type of information that VA had requested and
the time that VA wants it to be provided.

To improve VA's efforts to expedite VR&E services, we recommend that VA
and DOD collaborate to reach agreement about information that VA needs to
promote the recovery and return to work of seriously injured
servicemembers and that VA develop a policy and procedures for maintaining
contact with those who do not initially apply for VR&E services. VA and
DOD provided written comments on a draft of this report. Both VA and DOD
generally concurred with our findings and recommendations.

Background

VA's VR&E program is designed to ensure that veterans with disabilities
find meaningful work and achieve maximum independence in daily living. In
2004, VA estimates that it spent more than $670 million on its VR&E
program to serve about 73,000 participants. This represents about 2
percent of VA's $37 billion budget for nonmedical benefits, most of which
involves cash compensation for veterans with disabilities.

VR&E services include vocational counseling, evaluation, and training that
can include payment for tuition and other expenses for education, as well
as job placement assistance. Interested veterans generally apply for VR&E
services after they have applied and qualified for disability compensation
based on a rating of their service-connected disability. This disability
rating-ranging from 0 to 100 percent in 10 percent increments-entitles
veterans to monthly cash payments based on their average loss in earning
capacity resulting from a service-connected injury or combination of
injuries. To be entitled to VR&E services, veterans with disabilities
generally must have at least a 20 percent disability rating and an
employment handicap as determined by a vocational rehabilitation
counselor. Although cash compensation is not available to servicemembers
until after they separate from the military, they can receive VR&E
services prior to separation under certain circumstances.3 To make these
services available prior to discharge, VA expedites the determination of
eligibility for VR&E by granting a preliminary rating, known as a
memorandum rating.

VA's outreach to servicemembers who plan to apply for veterans' disability
compensation has been part of its transition assistance program, which was
established in 1990.4 Either in group sessions or in one-on-one
encounters, VA provides servicemembers with information about disability
benefits and services, which includes the VR&E program, and offers
assistance in applying for them. In addition, VA administers a
pre-discharge program that expedites the disability compensation claims
processing for servicemembers who are pending discharge. This program also
helps VR&E staff identify those who could benefit from vocational

3Hospitalized military personnel pending discharge may receive all
vocational rehabilitation and employment benefits-such as counseling,
evaluation, and training-except for the monthly subsistence allowance. 38
U.S.C. S:S: 3102, 3104, and 3113.

4GAO, Military and Veterans' Benefits: Observations on the Transition
Assistance Program, GAO-02-914T (Washington, D.C.: July 18, 2002).

rehabilitation and employment services. VA has recently included activated
National Guard and Reserve members in its outreach efforts.

Servicemembers injured in Iraq and Afghanistan are surviving injuries that
would have been fatal in past conflicts, due, in part, to advanced
protective equipment and medical treatment. However, the severity of their
injuries can result in a lengthy transition from injured servicemember to
veteran. Initially, most seriously injured servicemembers, including
activated National Guard and Reserve members, are brought to Landstuhl
Regional Medical Center in Germany for treatment. From there, they are
transported to the appropriate U.S. medical facilities, which are usually
major military treatment facilities (MTFs) but may also be VA medical
centers. According to DOD officials, once stabilized and discharged from
the hospital, servicemembers usually relocate to be closer to their homes
or military bases and are treated as outpatients by the closest VA or
military hospital. (See fig. 1.) At this point, the military generally
begins to assess whether the servicemember will be able to remain in the
military, a process that could take months to complete. The process can
take even longer if the servicemember appeals the military's initial
disability decision.

Figure 1: Seriously Injured Army Servicemembers Receive Treatment at Five
Major Army Medical Facilities and Relocate to One of 57 VA Regions after
Medical Stabilization

In response to recommendations made by the VA Vocational Rehabilitation
and Employment Task Force, VA is beginning to change its approach to VR&E
to better reflect contemporary views of disability. The Secretary of
Veterans Affairs established this external task force in 2003 to conduct a
comprehensive review of VA's VR&E program.5 In addition,

5VA Vocational Rehabilitation and Employment Task Force. Report to the
Secretary of Veterans Affairs: The Vocational Rehabilitation and
Employment Program for the 21st Century Veteran (Washington, D.C.: March
2004).

faced with the immediate need to provide benefits and services to a new
generation of veterans with disabilities, VA in August 2003 formed an
internal task force to develop and implement policies to improve the
transition of injured servicemembers back to civilian life. Known as the
Seamless Transition Task Force, it included ad hoc participation from
DOD.6 Although this task force's initial priority was to ensure the

continuity of medical care for injured servicemembers as they transition
from military to VA health care, it has also coordinated efforts to ensure
access to all other VA benefits, including VR&E services.

We have previously reported on the importance of early intervention to
maximize the work potential of individuals with disabilities. We have also
reported, however, that current federal disability programs offer little
opportunity for early intervention with individuals who apply for
compensation. These programs require lengthy assessments in which
applicants must focus on demonstrating their work limitations rather than
their abilities and potential to work.7 Consequently, vocational
rehabilitation is typically introduced late in the process. Furthermore,
we have designated federal disability programs, including VA's, as
high-risk programs because they lack emphasis on the potential for
vocational rehabilitation to return people to work and also rely on
outmoded assumptions about the relationship between impairment and work.

6DOD has supported transition assistance in various ways. For example, the
VA/DOD Joint Executive Committee was established in February 2002 to
further promote collaboration between the two agencies, including
resolving obstacles to information sharing. The committee is chaired by
the Deputy Secretary of Veterans Affairs and the Under Secretary of
Defense for Personnel and Readiness. In addition, the Army-in cooperation
with VA- established the Disabled Soldier Support System (DS3) in April
2004 as an advocacy group and information clearinghouse to clarify the
services available to disabled soldiers as they transition to civilian
life.

7GAO, SSA Disability: Program Redesign Necessary to Encourage Return to
Work, GAO/HEHS-96-62 (Washington, D.C.: Apr. 24, 1996).

  VA Has Taken Steps to Expedite Vocational Rehabilitation and Employment
  Services for Seriously Injured Servicemembers

VA has instructed its regional offices to make seriously injured
servicemembers a high priority for all VA assistance and asked DOD to
provide data that would ensure VA's ability to identify and monitor this
population. Because many seriously injured servicemembers are initially
treated at major military treatment facilities, VA has deployed staff to
these sites to provide information on all veterans' benefits, including
VR&E services. To ensure the identification and monitoring of all
seriously injured servicemembers, VA initiated a memorandum of agreement
proposing that DOD share a range of information, including the names of
those with serious injuries, their medical condition, and their military
status. As of December 2004, a formal agreement with DOD had not been
reached. In the meantime, VA has instructed its regional offices to
develop local liaison with DOD in order to identify and assist seriously
injured servicemembers. The 12 regional offices we reviewed have developed
information of varying completeness and reliability. However, once
regional offices have identified and contacted seriously injured
servicemembers, VA has no policy for VR&E staff to maintain contact with
those individuals who do not apply for VR&E services while in the hospital
or after they return home. Nevertheless, some regional offices reported
maintaining contact with these servicemembers while others did not.

    VA Has Instructed Its Regional Offices to Make Seriously Injured
    Servicemembers a High Priority and Asked DOD for Data to Help Identify Them

In a September 2003 letter, VA instructed its regional offices to provide
priority consideration and assistance to seriously injured servicemembers
returning from Afghanistan and Iraq. VA specifically instructed regional
offices to focus on servicemembers whose disabilities are definitely or
likely to result in military separation. Minimally, this includes
servicemembers with injuries DOD has classified as "very serious,"
"serious," or in a "special category."8 In this letter, VA instructed its
regional offices to assign a case manager to each seriously injured
servicemember who applies for disability compensation. In addition, VA
noted the particular importance of early intervention for those who are
seriously injured and emphasized that seriously injured servicemembers
applying for VR&E should receive the fastest possible service. Moreover,
VA reminded VR&E staff that they can initiate evaluation and counseling

8Army regulations classify illness and injuries as "very serious" when
life is imminently endangered; as "serious" when there is a cause for
immediate concern but there is no imminent danger to life; and as "special
category" when the patient has a particular condition, such as loss of
limb or sight, a psychiatric condition, paralysis, or a permanent
disfigurement.

and, in some cases, authorize training before a servicemember is
discharged.

Since most seriously injured servicemembers are initially treated at major
MTFs, VA has detailed staff to these facilities.9 These staff have
included VA social workers and disability compensation benefits
counselors. In addition to these staff, at Walter Reed, where the largest
number of seriously injured servicemembers has been treated, VA's
Washington D.C. regional office has since 2001 provided a vocational
rehabilitation counselor to work with hospitalized patients.

To identify and monitor those whose injuries may result in a need for VA
services, including vocational rehabilitation, VA has asked DOD to share
data about injured servicemembers. VA has been working to develop a formal
agreement with DOD on what specific information to share. In the spring of
2004, VA submitted a draft memorandum of agreement to DOD's Office of the
Assistant Secretary of Defense for Health Affairs proposing that DOD
provide lists of all injured servicemembers admitted to MTFs. In addition,
VA requested personal identifying information, medical information, and
DOD's injury classification for each listed servicemember. VA also
requested monthly lists of servicemembers being evaluated for medical
separation from military service. Several VA officials and regional office
staff we interviewed said that systematic information from DOD would
provide them with a way to more reliably identify and monitor seriously
injured servicemembers. As of December 2004, a formal agreement with DOD
was still pending.

    VA Regional Offices Have Relied on Local Liaisons with MTFs In Order to
    Identify Seriously Injured Servicemembers Who May Need Assistance

In the absence of a formal arrangement to ensure that DOD provides data on
seriously injured servicemembers, VA has relied on its regional offices to
obtain information about them. In its September 2003 letter, the agency
asked the regional offices to coordinate with staff at MTFs and VA medical
centers in their areas to ascertain the identities, medical conditions,
and military status of the seriously injured. While VA officials reported
to us that they had provided veterans' benefits information to injured

9These six facilities are Brooke Army Medical Center in Texas; Walter Reed
Army Medical Center in Washington, D.C.; Madigan Army Medical Center in
Washington; Darnall Army Community Hospital in Texas; Eisenhower Army
Medical Center in Georgia; and the Bethesda Naval Medical Center in
Maryland. We focused on the five Army medical treatment facilities.

servicemembers, they did not have complete and reliable data as to how
many of these were seriously injured.

In response to guidance by VA's central office, every regional office has
designated a coordinator to serve as a point of contact with MTFs and VA
medical centers, as well as other VA regional offices, in order to monitor
injured servicemembers as they relocate across the country. When
servicemembers are discharged from an MTF, VA officials told us that the
affiliated VA regional office coordinator notifies the coordinator in the
region to which the person relocates. The new coordinator contacts the
seriously injured servicemember to discuss any claims that have been filed
and to provide those who have not already done so an opportunity to apply
for other benefits, including VR&E services. Regional officials we
interviewed reported that they have followed VA's instructions to keep
updated logs of all contacts they have with seriously injured
servicemembers. Regional offices are required to send these logs to VA's
central office, which uses them to monitor outreach.

In our review of 12 regional offices, we found that they have developed
different information sources resulting in varying levels of information
on seriously injured servicemembers. The nature of the local relationships
between VA staff and military staff at MTFs was a key factor in the
completeness and reliability of the information that the military
provided. For example, the military MTF staff at one regional office
provided VA staff with only the names of new patients with no indication
of the severity of their condition or the theater from which they were
returning. Another regional office reported receiving lists of
servicemembers for whom the Army has initiated a medical separation in
addition to lists of patients with information on the severity of their
injuries. Some regional offices were able to capitalize on longstanding
informal relationships. For example, the VA coordinator responsible for
identifying and monitoring the seriously injured at one regional office
had served as an Army nurse at the local MTF and was provided all
pertinent information. In contrast, staff at another regional office
reported that local military staff did not until recently provide them
with information on seriously injured servicemembers admitted to the MTF.

Once they have identified the seriously injured servicemembers, regional
office staff reported that they are largely following outreach,
coordination, and case management procedures outlined in VA's September
2003 guidance. Under these procedures, disability compensation benefit
counselors usually conduct VA's initial outreach by contacting
hospitalized servicemembers to provide information on all veterans'

benefits, including VR&E. Traditionally responsible for taking
applications and processing disability compensation claims, these staff
members are neither vocational rehabilitation experts nor are they
generally trained to work with persons who have serious injuries.
Accordingly, VA reported that it has begun requiring all staff members who
provide in-person or telephone outreach to receive training on how to
interact with seriously injured servicemembers. VR&E staff reported that
they generally rely on the benefits counselors to notify them of injured
servicemembers at MTFs who are interested in or who apply for VR&E. Only
then would a vocational rehabilitation counselor or counseling
psychologist usually contact the hospitalized servicemember to begin
counseling and evaluation. In one regional office, VR&E staff said that
they do not contact injured servicemembers until they apply for services
and obtain a memorandum rating establishing their eligibility.

The Washington, D.C. regional office has assigned a vocational
rehabilitation counselor to be available on site at Walter Reed Army
Medical Center, where a large number of seriously injured servicemembers
are treated. Although VA also deployed benefits counselors to Walter Reed
who are responsible for outreach activities and the provision of
information on all VA benefits, the VR&E counselor works with hospitalized
patients specifically to offer and provide vocational counseling and
evaluation. She reported attempting to contact all patients within 48
hours of their arrival and visiting them routinely thereafter to establish
rapport. Her primary mission is to work with servicemembers who will need
to prepare for civilian employment, although she told us that her early
intervention efforts could also help servicemembers who are able to remain
in the military.

According to VA staff, many seriously injured servicemembers are not ready
or able to consider VR&E services when they are first contacted. Yet, we
found that VA has no policy for maintaining contact with those
servicemembers who do not apply for VR&E services when they were in the
hospital or when they returned to a home base or to their residence.
Several regional offices reported that they do not stay in contact with
these individuals while others attempt to do so in various ways. One
office said it is considering contacting them after one year. Another
regional VR&E officer reported that staff ask the servicemembers to
specify when they would like to be contacted for further information or to
begin program participation. Staff at this regional office noted that they
are strong advocates of early intervention. They said that they try to
contact servicemembers as soon as possible to establish rapport and
provide VR&E program information even before the servicemembers are

physically ready to begin developing a vocational rehabilitation plan. At
the same time, they noted that readiness to participate in VR&E varies by
individual and that professional judgment is required to balance effective
outreach with an approach that could be viewed as intrusive.

VR&E program officials noted the potential value of maintaining contact
with seriously injured servicemembers who may not initially be ready to
participate when initially contacted by VA, but they also recognized the
need to focus resources on those who do participate. Nevertheless,
officials from a veterans service organization told us that it is critical
to maintain contact with seriously injured veterans who do not initially
apply for VR&E because they may need months or even years before they are
ready. In our prior work, we have also noted that maintaining contact with
individuals who have disabilities may help encourage their return to

10

work.

While experts and advocates for individuals with disabilities attest to
the value of early intervention for returning people to work, VA is
challenged to reach injured servicemembers early for several reasons.
First, determining the best time to approach recently injured
servicemembers and gauge their personal receptivity to consider employment
in the civilian sector is inherently difficult. The nature of the recovery
process is highly individualized and requires professional judgment to
determine the appropriate time to begin vocational rehabilitation.
Further, because VA is trying to prepare servicemembers who are still on
active duty for a transition to civilian life, DOD is concerned that VA's
efforts may be working at cross purposes to the military's retention
goals. Finally, because VA lacks systematic information from DOD on
seriously injured servicemembers, VA cannot ensure that all servicemembers
and veterans who could benefit from the VR&E program have the opportunity
to receive services at the appropriate time.

  VA Faces Significant Challenges in Expediting Services to Seriously Injured
  Servicemembers

10GAO, SSA Disability: Return-to-Work Strategies From Other Systems May
Improve Federal Programs, GAO/HEHS-96-133 (Washington, D.C: July 11,
1996).

    Individual Differences in the Recovery Process Complicate the Timing of
    Early Intervention

Individual differences and uncertainties in the recovery process make it
inherently difficult to determine when a seriously injured servicemember
will be ready to consider vocational rehabilitation. Since the appropriate
time to intervene depends to a large extent on the individual's medical
condition and personal readiness, the time to broach the subject of a
return to work, whether in the military or the civilian labor force, will
vary. Regional office staff reported that many servicemembers are eager to
return to military duty and do not intend to consider a career outside
military service. They also reported that many injured servicemembers need
time to recover and adjust to the likelihood that they may have to leave
the military and prepare for civilian employment.

Because of the individual differences in receptivity to VR&E, VA staff
reported needing to monitor the condition of seriously injured
servicemembers and to engage them more than once during their recovery to
be able to gauge their readiness for VR&E. One regional VR&E official told
us that VA could benefit from more collaboration with DOD medical staff in
order to make decisions on the appropriate timing of VR&E intervention.
The vocational rehabilitation counselor at Walter Reed reported visiting
servicemembers routinely, including evenings and weekends, so that she
would be available when they were ready to discuss their need for
vocational rehabilitation. For one patient, she reported visiting him 12
times before he expressed interest in VR&E. In some locations, VA staff
reported participating in pre-discharge planning meetings with military
and medical staff, which they said helped them stay informed about the
servicemember's condition and likely discharge and provided an opportunity
to include VR&E in their discharge planning.

    VA Is Challenged by DOD's Concern that Early Intervention Could Work at
    Cross Purposes to Military Retention

VA is also challenged by DOD's concern that outreach about VA benefits,
including disability compensation and VR&E services, could work at cross
purposes to military retention goals. In particular, DOD expressed concern
about the timing of VA's outreach to servicemembers whose discharge from
military service is not yet certain. To expedite VR&E services, VA's
outreach process may overlap with the military's process for evaluating
servicemembers for a possible return to duty. According to DOD officials,
it may be premature for VA to begin working with injured servicemembers
who may eventually return to active duty. (See fig. 2.) With advances in
medicine and prosthetic devices, many serious injuries no longer result in
work-related impairments. Army officials who track injured

servicemembers told us that many seriously injured servicemembers overcome
their injuries and return to active duty. Recognizing this potential, both
Congress11 and the President have recently expressed interest in seeing
the military provide the retraining needed to support the return of
injured servicemembers to their military occupations or other occupations
within the military if possible. In an attempt to enable more amputees to
return to active duty, Walter Reed Army Medical Center plans to open a new
rehabilitation center in 2005.

Both VA and DOD officials suggested that the earliest appropriate time for
VA to intervene for regular active duty servicemembers would be when it is
clear that the servicemember will not be retained by the military.
Currently, VA can only provide VR&E services to active duty servicemembers
who are pending discharge due to a disability. VR&E services could begin
earlier for injured members of the National Guard and Reserve since these
individuals usually expect to return to their previous civilian
employment. They may need VR&E services to return to their prior
employment or to prepare for a different occupation in the civilian
economy.

11Congress expressed its sense that the Secretary of Defense should
develop protocols that include options for injured servicemembers who are
highly motivated to return to active duty service and for them to be
retrained to perform military missions for which they are fully capable.
Ronald W. Reagan National Defense Authorization Act for Fiscal Year 2005,
Pub. L. No. 108-375, S: 588, Oct. 28, 2004, the "Sense of Congress
Regarding Return of Members to Active Duty Service upon Rehabilitation
from Service-Related Injuries."

Figure 2:VA's Early Intervention Could Work at Cross Purposes to DOD's Retention
                               Evaluation Process

    VA Is Also Challenged by the Lack of Access to Systematic Data Regarding
    Seriously Injured Servicemembers

Conclusions

In the absence of a formal information sharing agreement with DOD, VA does
not have systematic access to DOD data about the population who may need
its services. Specifically, VA cannot reliably identify all seriously
injured servicemembers or know with certainty when they are medically
stabilized, when they are undergoing evaluation for a medical discharge,
or when they are actually medically discharged from the military. VA has
instead had to rely on ad hoc regional office arrangements at the local
level to identify and obtain specific data about seriously injured
servicemembers. While regional office staff generally expressed confidence
that the information sources they developed enabled them to identify most
seriously injured servicemembers, they have no official data source from
DOD with which to confirm the completeness and reliability of their data
nor can they provide reasonable assurance that some seriously injured
servicemembers have not been overlooked. In addition, informal data
sharing relationships could break down with changes in personnel at either
the MTF or the regional office.

DOD officials expressed their concerns about the type of information to be
shared and when the information would be shared. DOD noted that it needed
to comply with legal privacy rules on sharing individual patient
information.12 DOD officials told us that information could be made
available to VA "upon separation" from military service, that is, when a
servicemember enters the separation process. At this time, servicemembers
would undergo assessment by a physical evaluation board, which DOD
officials said typically takes between 30 to 90 days and usually results
in a medical discharge from the military. However, prior to separation,
information can only be provided under certain circumstances, such as when
a patient's authorization is obtained.13

VA has taken steps to help the nation's newest generation of veterans move
forward with their lives, particularly those who return from combat with
disabling injuries. VA has made seriously injured servicemembers a
priority and, among other measures, deployed staff to major MTFs to
conduct outreach to them prior to separation. However, VA benefits
counselors are usually the first VA representatives to contact injured
servicemembers. While they may provide an overview of all VA benefits,

12Health Insurance Portability and Accountability Act (HIPAA) Privacy
Rule, 45 C.F.R. Parts 160 and 164.

1345 C.F.R. S: 164.508(a).

they may not emphasize vocational rehabilitation and employment services.

The importance of early intervention for returning individuals with
disabilities to the workforce is well documented in the vocational
rehabilitation literature. However, the lack of an agreement with DOD for
systematic data sharing impedes VA's attempt to identify all seriously
injured servicemembers who might benefit from such intervention. It also
poses the risk that some who are discharged with disabilities may be
overlooked and not afforded the opportunity for VR&E. As VA recognizes,
the current ad hoc approach of their regional offices for obtaining
information is not the most efficient way to proceed. Furthermore, because
individuals with disabilities vary in their readiness and need for VR&E
services, maintaining contact with them would better ensure that VR&E
staff know when the person is ready to participate. Because VA has no
policy for maintaining contact with those who do not apply for VR&E,
opportunities to rehabilitate veterans who have sustained serious injuries
in Afghanistan and Iraq may be lost.

At a time when the U.S. labor force is projected to shrink, it is
imperative that those who can work, whether in military or civilian jobs,
are well supported in their efforts to do so. VA's early VR&E efforts,
rather than working at cross purposes to DOD goals, could facilitate
servicemembers' return to the same or different military occupation, or to
a civilian occupation, if they were not able to remain in the military. In
this regard, the prospect for early intervention with VR&E services
presents both a challenge and an opportunity for VA and DOD to collaborate
to provide better outcomes for this new generation of seriously injured
servicemembers.

To improve VA's efforts to expedite VR&E services to seriously injured
servicemembers, we recommend that VA and DOD collaborate to reach an
agreement for VA to have access to information that both agencies agree is
needed to promote servicemembers' recovery and return to work.

We also recommend that the Secretary of Veterans Affairs direct the Under
Secretary for Benefits to develop a policy and procedures for regional
offices to maintain contact with seriously injured servicemembers who do
not initially apply for VR&E services, in order to ensure that they have
the opportunity to participate in the program when they are ready.

  Recommendations

  Agency Comments

In commenting on a draft of this report, VA concurred with our findings
and recommendations. VA emphasized that access to DOD information is
crucial to promoting servicemembers' recovery and return to work and, to
that end, is currently negotiating an agreement to allow VA to obtain
protected medical information on servicemembers prior to their discharge
for VA benefits purposes. In addition, VA noted that its follow-up
policies and procedures include sending veterans information on VR&E
benefits upon notification of a disability compensation award and 60 days
later. However, we believe a more individualized approach, such as
maintaining personal contact, could better ensure the opportunity for
veterans to participate in the program when they are ready. VA noted that
it is currently reviewing its outreach and follow-up procedures for
injured servicemembers and will make any appropriate revisions. VA's
written comments are reprinted in appendix I.

DOD also concurred with our findings and recommendations. DOD stated its
commitment to retaining seriously injured servicemembers who are able and
willing to return to duty. DOD also noted that a draft memorandum of
agreement for information sharing between VA and DOD is under
consideration by the two departments and the military services. DOD's
written comments are reprinted in appendix II.

As agreed with your office, unless you publicly announce the contents of
this report earlier, we plan no further distribution of this report until
30 days after the date of this letter. We will then send copies of this
report to the Secretary of Veterans Affairs, the Secretary of Defense,
appropriate congressional committees, and other interested parties. The
report will also be available on GAO's Web site at http://www.gao.gov.

If you or your staff have any questions regarding this report, please call
me at (202) 512-7215 or Irene Chu, Assistant Director, at (202) 512-7102.

Susan Bernstein, Connie Peebles Barrow, Margaret Boeckmann, William R.
Chatlos, Clarette Kim, Joseph J. Natalicchio, and Roger Thomas also made
key contributions to this report.

Sincerely yours,

Cynthia A. Bascetta Director, Education, Workforce, and Income Security
Issues

                  Page 20 GAO-05-167 Vocational Rehabilitation

                  Page 21 GAO-05-167 Vocational Rehabilitation

                  Page 22 GAO-05-167 Vocational Rehabilitation

Appendix II: Comments from the Department of Defense

Appendix II: Comments from the Department of Defense

Appendix II: Comments from the Department of Defense

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