VA Health Care: VA Should Expedite the Implementation of	 
Recommendations Needed to Improve Post-Traumatic Stress Disorder 
Services (14-FEB-05, GAO-05-287).				 
                                                                 
Post-traumatic stress disorder (PTSD), which is caused by an	 
extremely stressful event, can develop after military combat and 
exposure to the threat of death or serious injury. Mental health 
experts estimate that the intensity of warfare in Iraq and	 
Afghanistan could cause more than 15 percent of servicemembers	 
returning from these conflicts to develop PTSD. Symptoms of PTSD 
can be debilitating and include insomnia; intense anxiety; and	 
difficulty coping with work, social, and family relationships.	 
Left untreated, PTSD can lead to substance abuse, severe	 
depression, and suicide. Symptoms may appear within months of the
traumatic event or be delayed for years. While there is no cure  
for PTSD, experts believe early identification and treatment of  
PTSD symptoms may lessen their severity and improve the overall  
quality of life for individuals with this disorder. The 	 
Department of Veterans Affairs (VA) is a world leader in PTSD	 
treatment and offers PTSD services to eligible veterans. To	 
inform new veterans about the health care services it offers, VA 
has increased outreach efforts to servicemembers returning from  
the Iraq and Afghanistan conflicts. Outreach efforts, coupled	 
with expanded access to VA health care for these new veterans,	 
are likely to result in greater numbers of veterans with PTSD	 
seeking VA services. Congress highlighted the importance of VA	 
PTSD services more than 20 years ago when it required the	 
establishment of the Special Committee on Post-Traumatic Stress  
Disorder (Special Committee) within VA, primarily to aid	 
Vietnam-era veterans diagnosed with PTSD. A key charge of the	 
Special Committee is to make recommendations for improving VA's  
PTSD services. The Special Committee issued its first report on  
ways to improve VA's PTSD services in 1985 and its latest report,
which includes 37 recommendations for VA, in 2004. The Special	 
Committee reports also include evaluations of whether VA has met 
or not met the recommendations made by the Special Committee in  
prior reports. The Department of Veterans Affairs (VA) is a world
leader in PTSD treatment and offers PTSD services to eligible	 
veterans. To inform new veterans about the health care services  
it offers, VA has increased outreach efforts to servicemembers	 
returning from the Iraq and Afghanistan conflicts. Outreach	 
efforts, coupled with expanded access to VA health care for these
new veterans, are likely to result in greater numbers of veterans
with PTSD seeking VA services. Congress asked us to determine	 
whether VA has addressed the Special Committee's recommendations 
to improve VA's PTSD services. We focused our review on 24	 
recommendations related to clinical care and education made by	 
VA's Special Committee on PTSD in its 2004 report to determine	 
(1) the extent to which VA has met each recommendation related to
clinical care and education and (2) VA's time frame for 	 
implementing each of these recommendations.			 
-------------------------Indexing Terms------------------------- 
REPORTNUM:   GAO-05-287 					        
    ACCNO:   A17697						        
  TITLE:     VA Health Care: VA Should Expedite the Implementation of 
Recommendations Needed to Improve Post-Traumatic Stress Disorder 
Services							 
     DATE:   02/14/2005 
  SUBJECT:   Health care services				 
	     Mental health care services			 
	     Veterans						 
	     Veterans benefits					 
	     Mental illnesses					 
	     Warfare						 
	     DOD Operation Iraqi Freedom			 
	     Operation Enduring Freedom 			 
	     Post-Traumatic Stress Disorder			 
	     Iraq						 
	     Afghanistan					 

******************************************************************
** This file contains an ASCII representation of the text of a  **
** GAO Product.                                                 **
**                                                              **
** No attempt has been made to display graphic images, although **
** figure captions are reproduced.  Tables are included, but    **
** may not resemble those in the printed version.               **
**                                                              **
** Please see the PDF (Portable Document Format) file, when     **
** available, for a complete electronic file of the printed     **
** document's contents.                                         **
**                                                              **
******************************************************************
GAO-05-287

                 United States Government Accountability Office

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

                                 February 2005

VA HEALTH CARE

VA Should Expedite the Implementation of Recommendations Needed to Improve
                    Post-Traumatic Stress Disorder Services

GAO-05-287

Contents

         Letter                                                             1 
                                         Summary                            3 
                           Recommendation for Executive Action              4 
                            Agency Comments and Our Evaluation              4 
       Appendix I                    Briefing Slides                

Appendix II	The 24 Special Committee Recommendations in Our Review

Appendix III Scope and Methodology

Appendix IV	GAO's Analysis of the Implementation Status of 24 Special
Committee Recommendations

         Appendix V Comments from the Department of Veterans Affairs 53

  Appendix VI GAO Contact and Staff Acknowledgments 58

GAO Contact 58 Acknowledgments 58

  Tables

Table 1: The Special Committee's Clinical Care and Education
Recommendations in Our Review 41 Table 2: Fourteen Recommendations that
GAO Determined Were Partially Met by VA 46 Table 3: Ten Recommendations
that GAO Determined Were Not Met by VA 51

Abbreviations

DOD Department of Defense
OEF Operation Enduring Freedom
OIF Operation Iraqi Freedom
PTSD post-traumatic stress disorder
VA Department of Veterans Affairs

This is a work of the U.S. government and is not subject to copyright
protection in the United States. It may be reproduced and distributed in
its entirety without further permission from GAO. However, because this
work may contain copyrighted images or other material, permission from the
copyright holder may be necessary if you wish to reproduce this material
separately.

United States Government Accountability Office Washington, DC 20548

February 14, 2005

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

Dear Mr. Evans:

Post-traumatic stress disorder (PTSD), which is caused by an extremely
stressful event, can develop after military combat and exposure to the
threat of death or serious injury. Mental health experts estimate that the
intensity of warfare in Iraq and Afghanistan could cause more than 15
percent of servicemembers returning from these conflicts to develop
PTSD.1, 2 Symptoms of PTSD can be debilitating and include insomnia;
intense anxiety; and difficulty coping with work, social, and family
relationships. Left untreated, PTSD can lead to substance abuse, severe
depression, and suicide. Symptoms may appear within months of the
traumatic event or be delayed for years. While there is no cure for PTSD,
experts believe early identification and treatment of PTSD symptoms may
lessen their severity and improve the overall quality of life for
individuals with this disorder.

The Department of Veterans Affairs (VA) is a world leader in PTSD
treatment and offers PTSD services to eligible veterans. To inform new
veterans about the health care services it offers, VA has increased
outreach efforts to servicemembers returning from the Iraq and Afghanistan
conflicts. Outreach efforts, coupled with expanded access to VA health
care for these new veterans, are likely to result in greater numbers of
veterans with PTSD seeking VA services.

1Servicemembers include active duty members of the Army, Marines, Air
Force, and Navy and members of the Reserves and National Guard.

2Based on data under the broad definition of PTSD provided in Charles W.
Hoge, MD et. al., "Combat Duty in Iraq and Afghanistan, Mental Health
Problems, and Barriers to Care," The New England Journal of Medicine, 351
(2004):13-22.

Congress highlighted the importance of VA PTSD services more than 20 years
ago when it required the establishment of the Special Committee on
Post-Traumatic Stress Disorder (Special Committee) within VA, primarily to
aid Vietnam-era veterans diagnosed with PTSD.3 A key charge of the Special
Committee is to make recommendations for improving VA's PTSD services. The
Special Committee issued its first report on ways to improve VA's PTSD
services in 1985 and its latest report, which includes 37 recommendations
for VA, in 2004.4 The Special Committee reports also include evaluations
of whether VA has met or not met the recommendations made by the Special
Committee in prior reports. We did not conduct an analysis to determine
the merits of each recommendation since VA generally concurred in concept
with the recommendations made by the Special Committee. In some cases, VA
provided further information that it believed would meet the intent of the
Special Committee's recommendations.

You asked us to determine whether VA has addressed the Special Committee's
recommendations to improve VA's PTSD services. We focused our review on 24
recommendations related to clinical care and education5 made by VA's
Special Committee on PTSD in its 2004 report to determine (1) the extent
to which VA has met each recommendation related to clinical care and
education and (2) VA's time frame for implementing each of these
recommendations.

To determine the extent to which VA has met each recommendation related to
clinical care and education, we (1) reviewed and analyzed the criteria
used by the Special Committee to determine whether a recommendation was
met and obtained information from members of the Special Committee on the
information and process the Special Committee used to designate a
recommendation as met, (2) interviewed VA officials

3VA was the Veterans' Administration in 1984.

4Department of Veterans Affairs Under Secretary for Health's Special
Committee on Posttraumatic Stress Disorder, Fourth Annual Report of the
Department of Veterans Affairs: Under Secretary for Health's Special
Committee on Post-traumatic Stress Disorder: 2004.

5We focused on the recommendations related to clinical care and education
because implementation of these recommendations most directly affects the
provision of PTSD services. We excluded 2 clinical care and education
recommendations because one relates to VA's role during a national
emergency and the Special Committee stated that the other requires a
legislative change in order for VA to fully implement the recommendation.
See app. II for a table summarizing each of the 24 Special Committee
recommendations included in our review.

responsible for implementing the Special Committee's recommendations to
determine the status of each recommendation, and (3) analyzed VA's written
responses to each of the recommendations in the Special Committee's 2004
report. We made our determination of the extent to which VA has met each
recommendation based on documented evidence that VA has implemented all
(fully met) or some (partially met) components of a recommendation, or has
not implemented any (not met) components of a recommendation. To determine
VA's time frames for implementing each Special Committee recommendation,
we (1) determined when the Special Committee initially made the
recommendation by reviewing Special Committee reports from 1985 to 2004
and (2) reviewed VA's planning documents, including VA's draft mental
health strategic plan. We conducted our review from September 2004 through
February 2005 in accordance with generally accepted government auditing
standards. On February 1, 2005, we briefed your staff on the results of
our work. This letter formally conveys our findings, conclusions, and
recommendation provided during the briefing. Appendix I contains the
briefing slides, appendix II lists the Special Committee recommendations
included in our review, and appendix III contains a more detailed
discussion of our scope and methodology.

In summary, we determined that VA has not fully met any of 24 Special
Committee recommendations in our review related to clinical care and
education. Specifically, we determined that VA has not met 10
recommendations and has partially met 14 of these 24 recommendations. For
example, the Special Committee recommended that VA develop, disseminate,
and implement a best practice treatment guideline for PTSD. The Special
Committee designated the recommendation as met because VA had developed
and disseminated the guideline. However, because we found that VA does not
have documentation to show that the treatment part of the guideline is
being implemented at its medical facilities and community-based clinics,
we designated the recommendation as partially met. We also determined that
VA does not plan to fully implement 23 of 24 recommendations until fiscal
year 2007 or later. Ten of these are longstanding recommendations that
were first made in the Special Committee report issued in 1985.

VA's delay in fully implementing the recommendations raises questions
about VA's capacity to identify and treat veterans returning from military
combat who may be at risk for developing PTSD, while maintaining PTSD
services for veterans currently receiving them. This is particularly
important because we reported in September 2004 that officials at six of

  Summary

Recommendation for Executive Action

  Agency Comments and Our Evaluation

seven VA medical facilities stated that they may not be able to meet an
increase in demand for PTSD services. In addition, the Special Committee
reported in its 2004 report that VA does not have sufficient capacity to
meet the needs of new combat veterans while still providing for veterans
of past wars. If servicemembers returning from military combat do not have
access to PTSD services, many mental health experts believe that the
chance may be missed, through early identification and treatment of PTSD,
to lessen the severity of the symptoms and improve the overall quality of
life for these combat veterans with PTSD. Moreover, VA has identified
geographic areas of the country where large numbers of servicemembers are
returning from the current conflicts in Iraq and Afghanistan. VA could
consider focusing first on ensuring service availability at facilities in
areas that are likely to experience the most demand for PTSD services.

To help ensure that VA has the capacity to diagnose and treat veterans
returning from the Iraq and Afghanistan conflicts, as well as to maintain
these services for other veterans, we recommend that the Secretary of
Veterans Affairs direct the Under Secretary for Health to prioritize those
recommendations needed to improve PTSD services and to expedite VA's time
frames for fully implementing those recommendations.

In commenting on a draft of this report, VA disagreed with our assessment
of its progress in implementing the recommendations made by its Special
Committee and disagreed with our recommendation. VA stated that our report
does not accurately portray the actual provision of PTSD services to
veterans by VA over the past 20 years or VA's ability to provide future
PTSD services to veterans. VA's comments are reprinted in appendix V. VA
also provided technical comments, which we incorporated as appropriate.

VA stated that this report will leave the average reader with the
impression that VA's services to veterans with PTSD are woefully
inadequate. The adequacy of services was not within the scope of our
review. Instead, our analysis addresses the status of VA's implementation
of the Special Committee's 24 recommendations and VA's planned time frames
for fully implementing them.

VA also said that our report misrepresents VA's ability to provide care to
returning Operation Enduring Freedom (OEF) and Operation Iraqi Freedom
(OIF) veterans. VA cited as evidence its provision of PTSD services to
6,400 OEF and OIF veterans to date, and added that VA has

sufficient capacity because this is a small percentage of the more than
244,000 veterans treated for PTSD in its health care system. We disagree
with VA's conclusion. First, we do not know if the 6,400 veterans treated
by VA represent all OEF and OIF veterans seeking VA PTSD services. In
fact, there could be unmet need because VA's data for the fourth quarter
of fiscal year 2004 show that less than half of veterans accessing VA
health care are screened for PTSD. Second, although 6,400 veterans is a
relatively small percentage of 244,000, VA has not presented evidence of
its capacity to absorb increasing numbers of veterans needing treatment
for PTSD in the future. Given that we reported in September 2004 that
officials at six of seven medical centers told us that they may not be
able to meet an increase in demand for PTSD services and that the VA
Inspector General found that VA's PTSD capacity data are error-prone and
inadequately supported, we believe our report appropriately raises
questions about VA's capacity to meet veterans' needs for PTSD services.
Moreover, the Special Committee in its 2004 report concluded that "VA must
meet the needs of new combat veterans while still providing for veterans
of past wars. Unfortunately, VA does not have sufficient capacity to do
this. VA PTSD services had been steadily losing capacity even before
OEF/OIF began."6

VA commented that the co-chairs of the Special Committee reviewed VA's
draft mental health strategic plan and concurred that the Special
Committee's recommendations are fully addressed in the plan and that the
implementation time frames are appropriate. We did not assess whether the
Special Committee's recommendations are fully addressed in VA's draft
mental health strategic plan. Instead, we relied on VA's comparison of the
Special Committee's recommendations and its draft mental health strategic
plan to determine the time frames VA targeted for implementation of a
recommendation. Moreover, we did not determine whether the time frames
targeted in the draft mental health strategic plan for full implementation
of the recommendations are appropriate. We found, however, that none of
the 24 recommendations included in the Special Committee's 2004 report is
fully met-14 recommendations are partially met and 10 recommendations are
not met-even though they range from 4 to 20 years old. This continues to
concern us in light of the potential increase in demand for PTSD services
predicted by mental health experts.

6Fourth Annual Report of the Department of Veterans Affairs: Under
Secretary for Health's Special Committee on Post-traumatic Stress
Disorder: 2004, pg. 5.

VA also stated that our report significantly discounts the progress made
on each of the Special Committee recommendations and ignores relevant
information provided by VA experts. During our exit briefing with VA
officials and mental health experts, a co-chair of the Special Committee
stated that our findings were a fair representation of the status of the
24 recommendations. Subsequently, VA submitted two letters signed by the
Special Committee co-chairs who wrote that our report fails to address the
many efforts undertaken by VA and the members of the Special Committee to
improve the care delivered to veterans with PTSD. However, some of the
efforts cited in the Special Committee co-chairs' letters are included in
our analysis of those recommendations that are partially implemented.
Other efforts cited by VA and the Special Committee co-chairs address
recommendations not within the scope of our review. The two letters signed
by the Special Committee co-chairs are reproduced in appendix V.

VA requested that we include, as part of its comments, the Secretary's
2004 Special Committee report transmittal letter to the Ranking Democratic
Member, House Committee on Veterans' Affairs, the executive summary, and
excerpts from the Special Committee's 2004 report, including the Special
Committee's table designating the status of all 37 of its recommendations
and the Under Secretary for Health's responses to 7 priority actions. One
action is a recommendation included in our review, which the Special
Committee highlighted in its 2004 report. However, VA did not include as
part of the excerpts its responses to the recommendations we reviewed that
the Special Committee designated as not met. We did not reprint this
material from VA because we believe our report better captures the status
of VA's implementation of the Special Committee's recommendations. To
obtain a copy of the Special Committee's 2004 report, contact VA's Office
of Public Affairs at (202) 273-6000.

As agreed with your office, unless you publicly announce its contents
earlier, we plan no further distribution of this report until 15 days
after its date. We will then send copies of this report to the Secretary
of Veterans Affairs and other interested parties. We will also make copies
available to others upon request. In addition, this report will be
available at no charge on the GAO Web site at http://www.gao.gov.

If you or your staff have any questions about this report, please call me
at (202) 512-7101. Another contact and key contributors are listed in
appendix VI.

Sincerely yours,

Cynthia A. Bascetta Director, Health Care-Veterans' Health and Benefits
Issues

                          Appendix I: Briefing Slides

                          Appendix I: Briefing Slides

                          Appendix I: Briefing Slides

                          Appendix I: Briefing Slides

                          Appendix I: Briefing Slides

                          Appendix I: Briefing Slides

                          Appendix I: Briefing Slides

                          Appendix I: Briefing Slides

                          Appendix I: Briefing Slides

                          Appendix I: Briefing Slides

                          Appendix I: Briefing Slides

  Appendix I: Briefing Slides Appendix I: Briefing Slides Appendix I: Briefing
Slides Appendix I: Briefing Slides Appendix I: Briefing Slides Appendix I:
Briefing Slides Appendix I: Briefing Slides Appendix I: Briefing Slides Appendix
I: Briefing Slides Appendix I: Briefing Slides Appendix I: Briefing Slides
  Appendix I: Briefing Slides Appendix I: Briefing Slides Appendix I: Briefing
Slides Appendix I: Briefing Slides Appendix I: Briefing Slides Appendix I:
Briefing Slides Appendix I: Briefing Slides Appendix I: Briefing Slides Appendix
                               I: Briefing Slides

         Recommendation         GAO analysis of VA's actions not completed    
                              We determined these recommendations were        
Develop, disseminate, and  partially met because although VA developed and 
implement a best practice  disseminated a clinical practice guideline for  
treatment guideline for    PTSD, it does not have documentation to show    
PTSD                       that the clinical practice guideline,           
                              specifically the treatment part of the          
                              guideline, is being implemented at VA medical   
                              facilities and community-based clinics.         
Establish a PTSD screening Additionally, VA does not have documentation to 
and referral mechanism in  show that its communitybased clinics have       
    every VA community-based  developed referral mechanisms for veterans who  
             clinic           need PTSD services when those services are not  
                              available. However, VA has started collecting   
                              data to monitor use of one of the assessment    
                              tools for PTSD in the clinical practice         
    Develop and implement a   guideline-a fourquestion screening tool. VA's   
national standardized set  fourth quarter data for fiscal year 2004        
of tools for assessment of indicate that 47 percent of veterans were       
              PTSD            screened for PTSD using this tool. However,     
                              this calculation includes those already         
                              diagnosed with PTSD.                            

Appendix II: The 24 Special Committee Recommendations in Our Review

The Special Committee's 2004 report contains 37 recommendations related to
PTSD clinical care, education, research, and benefits. We focused our
review on 24 of the 26 recommendations that the Special Committee
designated as clinical care and education issues. We excluded 2 of the 26
recommendations because one relates to VA's role during a national
emergency and the Special Committee stated that the other requires a
legislative change in order for VA to fully implement the recommendation.
Table 1 lists the 24 recommendations in our review.

Table 1: The Special Committee's Clinical Care and Education
Recommendations in Our Review

Recommendation short title Special Committee recommendation

Recognize specialized PTSD programs as VA should recognize specialized
PTSD programs as a critically important component of

an important component of care	VA expertise and service. In addition to
meeting a core need of VA (provision of mental health services for
veterans suffering from PTSD, which is the single most prevalent mental
disorder arising from combat), these programs maintain America's readiness
to deal with survivors of future wars, disasters, and acts of terrorism
and mass destruction.

Develop and implement procedures to prevent closure of PTSD programs
without authorization from VA headquarters

Reinvest resources from closed PTSD programs into other PTSD programs

Implement a VA network director performance measure on PTSD capacity

Develop and implement a national standardized set of tools for assessment
of PTSD

Establish a PTSD screening and referral mechanism in every VA
community-based clinic

Establish electronic clinical records that follow veterans across VA's
system of care VA headquarters needs to develop, announce, and apply clear
and prompt consequences when VA network leaders close PTSD programs
without VA headquarters authorization.

VA should establish systemwide administrative mechanisms to ensure that
when PTSD programs are closed, the resources freed up by the closure are
reinvested in other PTSD programs. This will ensure that VA does not
reduce its capacity to treat PTSD.

The Committee will work with VA headquarters officials to develop a
network director's performance measure aimed at maintaining capacity to
treat PTSD within each network and ensuring that PTSD resources, when
reassigned, remain within the PTSD continuum of care.

VA should develop and implement a national standardized set of tools for
assessment of PTSD.

Every VA community-based clinic should have a PTSD screening mechanism in
place and should define how veterans who screen positive for PTSD will
gain access to PTSD services.

The clinical database derived from the standardized assessment tools and
the medical record of the veteran with PTSD must follow the veteran across
the VA system. The Committee should work with VA medical record
specialists and computer experts to develop a system for sharing pertinent
clinical data across the entire PTSD continuum of care, including Vet
Centers.

Improve the continuum of care for PTSD	The present continuum of care
established to treat PTSD in VA needs better coordination and further
refinement, which should include early identification and intervention;
assessment, triage, and referral; acute stabilization and intervention
(including option for hospitalization in a general psychiatric unit or a
specialty PTSD unit as clinically appropriate); treatment and
rehabilitation, involving short- or longer-term care on an outpatient or
residential basis; and other outpatient care, encompassing continuing
care, monitoring, and relapse prevention for those who also have substance
use disorders.

Appendix II: The 24 Special Committee Recommendations in Our Review

Recommendation short title Special Committee recommendation

Provide sustained treatment settings for Because PTSD is a chronic
condition with frequent coexisting psychiatric and medical PTSD and
coexisting psychiatric and conditions, sustained treatment settings of
varying intensities are required. medical conditions

Utilize Vet Center appointments to satisfy Vet Center appointments should
              satisfy VA performance standards for follow-up care.

VA performance standards for PTSD followup care

                   Improve VA medical facility and Vet Center

collaboration VA medical facilities and Vet Centers need to work together
to ensure full collaboration in the service of veterans with PTSD. The
Committee recognizes the unique contributions of VA medical facilities and
Vet Centers and the critical importance of maintaining their distinct
identities. At the same time, we advocate innovations, including (but not
limited to) a common PTSD database for each veteran with PTSD, joint
access to clinical notes relevant to PTSD treatment across the two
systems, and joint assessment of local and national needs within each
system that could be addressed by sharing clinical resources through such
programs as collocation and telemedicine. Develop, disseminate, and
implement best VA should disseminate and implement "best practice" PTSD
treatment guidelines. practice treatment guidelines for PTSD

Develop PTSD guidelines for aging veterans, various cultural groups, and
other special populations

Develop more effective treatment approaches for veterans with PTSD and
coexisting substance abuse

Develop and implement a rehabilitation approach to PTSD and coexisting
conditions VA should develop special guidelines for work with aging
veterans; for ethnic and cultural groups shown to have different risks and
needs with respect to PTSD; for veterans of peacekeeping missions; for
female and male survivors of sexual and other noncombat trauma in the
military; and for other populations for whom specific needs are
identified.

More effective treatment approaches are needed for veterans with PTSD and
coexisting substance abuse. These include improved methods of identifying
PTSD among substance abusers.

In addition to aiming at decreasing PTSD severity, treatment efforts
should be directed toward decreasing the effects of coexisting conditions,
improving function, and improving social support systems. This
"rehabilitation" perspective (recovery model) is more appropriate in
dealing with a chronic and complex disorder.

Develop and implement an integrated clinical approach for assisting aging
veterans with PTSD The medical problems of our aging population of
veterans with PTSD require an integrated approach of primary care,
geriatric, and PTSD experts.

                     Coordinate PTSD care with VA community

based clinics VA needs to improve coordination of care between specialized
PTSD programs and VA clinics, including community-based clinics. The goal
is to improve health habits and to identify and manage coexisting medical
disorders. This will improve health-related quality of life and lower
unnecessary health care costs.

Provide increased access to PTSD services 	VA needs to increase access to
PTSD services. This can be facilitated through the continued expansion of
Vet Centers, community-based clinics (with specialized PTSD services), and
telemedicine services into underserved geographic areas.

Extend efforts to monitor productivity and VA should extend its efforts to
monitor the productivity and quality of specialized PTSD quality of
specialized services across the services across the PTSD continuum of
care, including measures of functionality, quality PTSD continuum of care
of life, and social support.

Expand PTSD treatment to include family VA must expand the focus of PTSD
treatment to include family assessment and

assessment and treatment services 	intervention, in order to help veterans
and their families deal with the symptoms of PTSD.

Develop a national PTSD education plan for VA

VA should create a national PTSD education plan for VA staff with
consistent access across the system.

                     Develop credentialing standards for VA

clinicians specializing in PTSD

VA should develop multidisciplinary credentialing standards for VA
clinicians specializing in PTSD.

      Appendix II: The 24 Special Committee Recommendations in Our Review

          Recommendation short title Special Committee recommendation

Improve VA collaboration with DOD on PTSD education

     VA should improve educational collaboration with DOD. Designate a PTSD
                             coordinator in each VA

network VA should designate a PTSD coordinator in each VA network to
ensure implementation of the PTSD continuum of care in each network.

                     Source: VA Special Committee on PTSD.

                      Appendix III: Scope and Methodology

VA's Special Committee on PTSD has submitted 15 reports to Congress since
1985 with recommendations on how VA could improve the provision of PTSD
services to veterans. In its 2004 report, the Special Committee made 37
recommendations to VA related to PTSD clinical care, education, research,
and benefits. Twenty-six of these recommendations relate to PTSD clinical
care and education. We focused our review on 24 of these 26
recommendations and excluded 2 recommendations because one relates to VA's
role during a national emergency and the Special Committee stated that the
other requires a legislative change in order for VA to fully implement the
recommendation. Our objectives were to determine (1) the extent to which
VA has met each recommendation related to clinical care and education and
(2) VA's time frame for implementing each of these recommendations.

To determine the extent to which VA has met each recommendation related to
clinical care and education, we reviewed the Special Committee's 2004
report to determine whether the Special Committee had designated a
recommendation as having been met or not met, and interviewed members of
the Special Committee to determine the information and process they used
to make a designation. We also reviewed VA policy documents, memorandums,
and reports related to VA's provision of PTSD services, including reports
by the VA Inspector General. Furthermore, we analyzed VA's written
responses to recommendations contained in the Special Committee's 2004
report and interviewed VA officials responsible for implementing the
recommendations and DOD officials responsible for working on joint VA/DOD
efforts recommended by the Special Committee.

Based on our review of VA documents and our discussions with VA officials,
we determined that the information we obtained was sufficient to analyze
the extent to which VA met each recommendation. We did not conduct an
analysis to determine the merits of each recommendation since VA generally
concurred in concept with the recommendations made by the Special
Committee. In some cases, VA provided further information that it believed
would meet the intent of the Special Committee's recommendations. Unlike
the Special Committee, which used two categories-met or not met-to
designate the implementation status of each recommendation, we made our
determinations based on the following three categories:

o 	Fully met. We determined that a recommendation was fully met if VA has
documented evidence that it has fully implemented all components of a
recommendation.

Appendix III: Scope and Methodology

o 	Partially met. We determined that a recommendation was partially met if
VA has documented evidence that it has implemented some but not all
components of a recommendation.

o 	Not met. We determined that a recommendation was not met if VA has not
implemented any components of a recommendation.

We decided the implementation status of each recommendation by determining
whether any of the components of the recommendation had been fully
implemented. For example, the components for one recommendation-to improve
VA medical facility and Vet Center collaboration-include a common database
for veterans with PTSD, joint access to clinical notes across the two
systems, and a joint medical center and Vet Center assessment of local and
national needs within each system that could be addressed by sharing
resources through collocation and telemedicine. All three components of
this recommendation had to be fully implemented for us to make a
determination that the recommendation was fully met; one of the three
components had to be fully implemented for a determination of partially
met; and if none of the components were fully implemented, we determined
that the recommendation was not met.

To determine VA's time frames for implementing each of 24 Special
Committee recommendations in our review, we analyzed 15 Special Committee
reports from 1985 to 2004 to determine when a recommendation was first
made.1 We also reviewed VA planning documents, including its draft mental
health strategic plan, which contains VA's planned activities and
associated targeted time frames to improve mental health services,
including those for PTSD.2 We obtained VA's comparison of the
recommendations in the Special Committee's 2004 report with the planned
activities and their associated time frames in VA's draft mental health
strategic plan. We used this comparison to determine the time frames that
VA had targeted to implement each recommendation. We calculated the total
number of years it may take VA to implement a recommendation as the
difference between the date the recommendation was first made and the date
targeted for full implementation in VA's draft mental health strategic
plan.

Our work was conducted from September 2004 through February 2005 in
accordance with generally accepted government auditing standards.

1The Special Committee did not issue a report in every year. 2We reviewed
a draft of VA's mental health strategic plan dated July 2004.

Appendix IV: GAO's Analysis of the Implementation Status of 24 Special Committee
Recommendations

This appendix summarizes our analysis of the extent to which VA has met
each of 24 clinical care and education recommendations included in our
review. Table 2 provides information on the 14 recommendations that we
determined were partially met by VA because VA has implemented some
component of each recommendation. Table 3 provides information on the 10
recommendations we determined that VA has not met because VA has not fully
implemented any component of the recommendation.

 Table 2: Fourteen Recommendations that GAO Determined Were Partially Met by VA

                                    VA's targeted time   
                                    frame                
                        Year         (fiscal year) for   
                   recommendation   implementing planned 
                  initially made by actions associated   
                                    with                 
                                                         GAO analysis of VA's 
Recommendation                      recommendation             actions not 
                  Special Committee                                 completed 

Develop and implement procedures to prevent closure of PTSD programs
without authorization from VA headquarters

                                 2001 2006-2007

We determined these recommendations were partially met because VA
headquarters has not received any closure requests, yet VA data shows that
in at least two instances VA facilities did not follow procedures and
closed PTSD programs without authorization in fiscal year 2003. Moreover,
VA does not know whether these facilities have reinvested resources from
the closed PTSD programs into other PTSD programs. The Special Committee
designated these recommendations as met because VA issues an annual report
on its capacity to provide specialized PTSD programs for seriously
mentally ill veterans, a subset of the veterans receiving VA PTSD
services.

Reinvest resources from closed PTSD programs into other PTSD programs

2001 2006-2007 Develop and implement 2001 2008 or later We determined this
                          recommendation was partially

an integrated clinical approach for assisting aging veterans with PTSD met
because VA's study conducted to determine the access that aging veterans
have to primary care, including veterans with PTSD, was the first step
toward developing an integrated approach for assisting aging veterans with
PTSD. However, VA has not implemented this integrated approach. The
Special Committee designated this recommendation as met because the study
was completed.

Appendix IV: GAO's Analysis of the Implementation Status of 24 Special
Committee Recommendations

                                    VA's targeted time   
                                    frame                
                        Year         (fiscal year) for   
                   recommendation   implementing planned 
                  initially made by actions associated   
                                    with                 
                                                         GAO analysis of VA's 
Recommendation                      recommendation             actions not 
                  Special Committee                                 completed 

Implement a VA network director performance measure on PTSD capacity

2001 2006-2007 	We determined this recommendation was partially met
because VA cites its annual report on capacity to provide PTSD services as
support for meeting this recommendation. However, the annual report on
capacity does not address the care delivered to all veterans treated by VA
for PTSD. In addition, the VA Inspector General found that data supporting
the number of VA specialized PTSD programs are incorrect. The Special
Committee designated this recommendation as met because VA issues an
annual report on its capacity to provide specialized PTSD programs for
seriously mentally ill veterans, a subset of the veterans receiving VA
PTSD services.

Coordinate PTSD care with VA community-based clinics

2001 2008 or later 	We determined this recommendation was partially met
because a VA official acknowledged that they need to develop referral
mechanisms to provide PTSD services when these services are not available
at VA community-based clinics. In addition, although VA developed and
disseminated a clinical practice guideline for PTSD, VA does not have
documentation to show the extent of treatment provided in accordance with
the guideline at VA medical facilities and community-based clinics. The
Special Committee designated this recommendation as met because VA
developed and disseminated the clinical practice guideline for PTSD.

Appendix IV: GAO's Analysis of the Implementation Status of 24 Special
Committee Recommendations

                                    VA's targeted time   
                                    frame                
                        Year         (fiscal year) for   
                   recommendation   implementing planned 
                  initially made by actions associated   
                                    with                 
                                                         GAO analysis of VA's 
Recommendation                      recommendation             actions not 
                  Special Committee                                 completed 

Develop, disseminate, and 2001 2006-2007 We determined these
recommendations were implement best practice partially met because
although VA has developed treatment guidelines for and disseminated a
clinical practice guideline for PTSD PTSD, it does not have documentation
to show that Establish a PTSD 1985 2008 or later the clinical practice
guideline, specifically the screening and referral treatment part of the
clinical practice guideline, is mechanism in every VA being implemented at
VA medical facilities and community-based clinic community-based clinics.
Additionally, VA does not

have documentation to show that its community-Develop and implement a 1985
2008 or later based clinics have developed referral mechanisms national
standardized set for veterans who need PTSD services when those of tools
for assessment of services are not available. However, VA has PTSD started
collecting data to monitor use of one of the assessment tools for PTSD in
the clinical practice guideline-a four-question screening tool. VA's
fourth quarter data for fiscal year 2004 indicate that 47 percent of
veterans were screened for PTSD using this tool. However, this calculation
includes those already diagnosed with PTSD. The Special Committee
designated these recommendations as met because the clinical practice
guideline on PTSD that includes standardized assessment tools for PTSD was
developed and disseminated at VA medical facilities and community-based
clinics.

Appendix IV: GAO's Analysis of the Implementation Status of 24 Special
Committee Recommendations

                                    VA's targeted time   
                                    frame                
                        Year         (fiscal year) for   
                   recommendation   implementing planned 
                  initially made by actions associated   
                                    with                 
                                                         GAO analysis of VA's 
Recommendation                      recommendation             actions not 
                  Special Committee                                 completed 

Recognize specialized PTSD programs as an important component of care

2001 2006-2007 	We determined this recommendation was partially met
because VA is collecting data on the results of its efforts to annually
screen all veterans to identify those at risk for PTSD. However, VA's
Office of Quality and Performance told us that VA uses the data on PTSD
screening as a supporting indicator, an interim step in the development of
a performance measure. Research shows that quality is highest in areas
where VA has established performance measures and actively monitors
performance. VA cites its annual report on capacity to provide PTSD
services as support for meeting this recommendation. However, the annual
report on capacity does not address the care delivered to all veterans
treated by VA for PTSD. VA has recently demonstrated the importance of
PTSD programs through, for example, adding 50 positions at Vet Centers to
be filled by veterans from the current conflicts to perform outreach and
requiring community-based clinics treating more than 1,500 veterans to
provide mental health services. The Special Committee designated this
recommendation as met because VA issues an annual report on its capacity
to provide PTSD services to seriously mentally ill veterans, a subset of
veterans receiving VA PTSD services.

Improve collaboration  1985 2008 or later               We determined this 
            with                                 recommendation was partially 
DOD on PTSD education                      met because although VA and DOD 
                                                              collaborated to 
                                               develop educational materials, 
                                                             such as the PTSD 
                                              clinical practice guideline, VA 
                                                            and DOD are still 
                                               formalizing their future plans 
                                                          for PTSD education. 
                                             The Special Committee designated 
                                                           this               
                                                    recommendation as not met 
                                                           because VA has not 
                                             provided a list of all the joint 
                                             VA/DOD ongoing                   
                                             educational efforts and has not  
                                                         provided             
                                               information on its plans for   
                                                      improving its           
                                             collaboration on PTSD with DOD.  

    Develop more effective   1985 2008 or We determined these recommendations 
                                   later  were                                
treatment approaches for                partially met because the existing 
                                                            clinical practice 
    veterans with PTSD and                   guideline addresses two of these 
                                                                  issues-PTSD 
     coexisting substance                 and coexisting substance abuse and  
                                                          the                 
             abuse                          rehabilitation approach (recovery 
                                                               model)-to some 
    Develop and implement a       2008 or    extent. Treatment approaches are 
    rehabilitation approach  2001  later    now being developed and evaluated 
              to                                       for veterans with PTSD 

PTSD and coexisting         and coexisting substance abuse and VA needs to 
       conditions              continue its efforts to implement the recovery 

Appendix IV: GAO's Analysis of the Implementation Status of 24 Special
Committee Recommendations

                                    VA's targeted time   
                                    frame                
                        Year         (fiscal year) for   
                   recommendation   implementing planned 
                  initially made by actions associated   
                                    with                 
                                                         GAO analysis of VA's 
Recommendation                      recommendation             actions not 
                  Special Committee                                 completed 

                           2001 2008 or later model through training of staff 
Develop PTSD guidelines                                on this approach to 
     for aging veterans,                         PTSD treatment. The clinical 
           various                                         practice guideline 
    cultural groups, and                      mentions a few special needs of 
            other                                           the aging veteran 
                                                      and veterans in various 
     special populations                          cultural groups and special 
                                               populations, such as women and 
                                                             the homeless. In 
                                                  addition, other educational 
                                                      materials are available 
                                                for clinicians on a VA Web    
                                                     site. The Special        
                                                   Committee designated these 
                                                           recommendations as 
                                                 met because VA developed and 
                                                             disseminated the 
                                                  PTSD clinical practice      
                                                        guideline.            

Provide increased 1985 2008 or later We determined this recommendation was 
        access                                                      partially 
to PTSD services                     met because although VA has increased 
                                        the                                   
                                             number of veterans it treats for 
                                                             PTSD, it has not 
                                         developed referral mechanisms in all 
                                                                   community- 
                                           based clinics that do not offer    
                                                    mental health             
                                              services. The Special Committee 
                                                              designated this 
                                          recommendation as not met because   
                                                        PTSD                  
                                        services are not widely available in  
                                                        VA's                  
                                              community-based clinics.        

                             Source: GAO analysis.

Appendix IV: GAO's Analysis of the Implementation Status of 24 Special
Committee Recommendations

      Table 3: Ten Recommendations that GAO Determined Were Not Met by VA

                                               VA's targeted time             
                        Year                 frame (fiscal year) for          
                    recommendagtion           implementing planned            
                  initially made by          actions associated with          
Recommendation                   recommendation GAO's analysis actions not 
                  Special Committee                                 completed 

Provide sustained treatment settings for PTSD and coexisting psychiatric
and medical conditions

2001 2004-2005 	We agree with the Special Committee that this
recommendation is not met because VA has not established a mechanism to
ensure the continuity of treatment across various treatment settings for
veterans with PTSD. Further, not all communitybased clinics have mental
health services available or referral mechanisms in place to ensure that
veterans who need specialized PTSD treatment services are transferred to
these settings. We also reported in September 2004 that not all veterans
may have access to PTSD services because officials at six of seven VA
medical facilities we visited stated that they may not be able to meet an
increase in demand for PTSD services.

Extend efforts to monitor productivity and quality of specialized services
across the PTSD continuum of care

1985 2008 or later 	We agree with the Special Committee that this
recommendation is not met because according to VA's response to the
Special Committee's 2004 report, VA has developed a functional measure,
which is expected to include a scale for quality of life and social
support, but has not completed the testing of this new measure. Although
VA collects information on employment status and incidents of violent
behavior for veterans treated for PTSD, it does not collect data on other
measures of functionality and productivity, such as the amount of social
support a veteran receives from community sources.

Expand PTSD treatment  2001 2008 or later We agree with the Special        
             to                              Committee that this              
       include family                        recommendation is not met        
         assessment                          because VA has not               
and treatment services                    developed or implemented a plan  
                                                        to provide            
                                                  services to the families of 
                                                     veterans with PTSD at VA 
                                                   medical facilities.        

Improve VA medical 1985 2008 or later We agree with the Special Committee  
        facility                         that this                            
     and Vet Center                      recommendation is not met because VA 
     collaboration                       medical                              
                                         facilities and Vet Centers do not    
                                         have a common                        
                                          database for veterans with PTSD, do 
                                                               not have joint 
                                          access to clinical notes across the 
                                                             two systems, and 
                                                   have not completed a joint 
                                                      assessment of local and 
                                         national needs within each system    
                                         that could be                        
                                            addressed by sharing resources by 
                                                              collocation and 
                                                    telemedicine.             

Appendix IV: GAO's Analysis of the Implementation Status of 24 Special
Committee Recommendations

                                               VA's targeted time             
                        Year                 frame (fiscal year) for          
                    recommendagtion           implementing planned            
                  initially made by          actions associated with          
Recommendation                   recommendation GAO's analysis actions not 
                  Special Committee                                 completed 

Establish electronic  1985 2008 or later We agree with the Special         
         clinical                           Committee that this               
    records that follow                     recommendation is not met because 
         veterans                                                  VA medical 
across VA's system of                           facilities and Vet Centers 
           care                                    maintain separate clinical 
                                              records. Medical facility staff 
                                                        cannot electronically 
                                               access Vet Center clinical     
                                                        records.              

      Designate a PTSD     2001 2008 or later       We agree with the Special 
                                                          Committee that this 
coordinator in each VA                           recommendation is not met 
                                                           because VA has not 
           network                            assigned PTSD coordinators in   
                                              its networks.                   
    Improve the continuum  1985   2006-2007         We agree with the Special 
             of                                           Committee that this 
        care for PTSD                               recommendation is not met 
                                                           because VA has not 
                                              developed or implemented a plan 
                                                                 of action to 
                                               improve the continuum of care  
                                                         for PTSD.            

    Develop a national   1985 2008 or later We agree with the Special         
           PTSD                             Committee that this               
education plan for VA                    recommendation is not met because 
                                            VA has not                        
                                                    developed a comprehensive 
                                                      national education plan 
                                               for VA staff. Furthermore, our 
                                                          analysis shows that 
                                            while VA has undertaken various   
                                            educational                       
                                                initiatives, these do not     
                                                  constitute a national       
                                             approach as recommended by the   
                                                         Special              
                                                       Committee.             

    Develop credentialing  2001 2008 or later We agree with the Special       
                                              Committee that this             
      standards for VA                              recommendation is not met 
         clinicians                                        because VA has not 
                                                      developed credentialing 
    specializing in PTSD                         standards for its clinicians 
                                                   specializing in PTSD.      
     Utilize Vet Center    2001 2008 or later We agree with the Special       
                                              Committee that this             
appointments to satisfy                          recommendation is not met 
             VA                                            because VA has not 
    performance standards                     modified its performance        
             for                              standard to allow Vet           
     PTSD follow-up care                       Center appointments to satisfy 
                                                           the VA requirement 
                                                    for follow-up care.       

                             Source: GAO analysis.

Page 53 GAO-05-287 Recommendations to Improve VA PTSD Services

         Page 54 GAO-05-287 Recommendations to Improve VA PTSD Services

         Page 55 GAO-05-287 Recommendations to Improve VA PTSD Services

         Page 56 GAO-05-287 Recommendations to Improve VA PTSD Services

         Page 57 GAO-05-287 Recommendations to Improve VA PTSD Services

Appendix VI: GAO Contact and Staff Acknowledgments

GAO Contact Marcia A. Mann (202) 512-9526

Acknowledgments 	In addition to the contact named above, key contributors
to this report were Mary Ann Curran, Linda Diggs, Martha Fisher, Lori
Fritz, Alice L. London, Janet Overton, and Marion Slachta.

  GAO's Mission

Obtaining Copies of GAO Reports and Testimony

The Government Accountability Office, the audit, evaluation and
investigative arm of Congress, exists to support Congress in meeting its
constitutional responsibilities and to help improve the performance and
accountability of the federal government for the American people. GAO
examines the use of public funds; evaluates federal programs and policies;
and provides analyses, recommendations, and other assistance to help
Congress make informed oversight, policy, and funding decisions. GAO's
commitment to good government is reflected in its core values of
accountability, integrity, and reliability.

The fastest and easiest way to obtain copies of GAO documents at no cost
is through GAO's Web site (www.gao.gov). Each weekday, GAO posts newly
released reports, testimony, and correspondence on its Web site. To have
GAO e-mail you a list of newly posted products every afternoon, go to
www.gao.gov and select "Subscribe to Updates."

Order by Mail or Phone 	The first copy of each printed report is free.
Additional copies are $2 each. A check or money order should be made out
to the Superintendent of Documents. GAO also accepts VISA and Mastercard.
Orders for 100 or more copies mailed to a single address are discounted 25
percent. Orders should be sent to:

U.S. Government Accountability Office 441 G Street NW, Room LM Washington,
D.C. 20548

To order by Phone: 	Voice: (202) 512-6000 TDD: (202) 512-2537 Fax: (202)
512-6061

  To Report Fraud, Contact:

Waste, and Abuse in Web site: www.gao.gov/fraudnet/fraudnet.htm

E-mail: [email protected] Programs Automated answering system: (800)
424-5454 or (202) 512-7470

Gloria Jarmon, Managing Director, [email protected] (202)
512-4400Congressional U.S. Government Accountability Office, 441 G Street
NW, Room 7125 Relations Washington, D.C. 20548

Public Affairs 	Paul Anderson, Managing Director, [email protected] (202)
512-4800 U.S. Government Accountability Office, 441 G Street NW, Room 7149
Washington, D.C. 20548

                           PRINTED ON RECYCLED PAPER
*** End of document. ***