DOD and VA: Preliminary Observations on Efforts to Improve Health
Care and Disability Evaluations for Returning Servicemembers	 
(26-SEP-07, GAO-07-1256T).					 
                                                                 
In February 2007, a series of Washington Post articles disclosed 
troublesome deficiencies in the provision of outpatient services 
at Walter Reed Army Medical Center, raising concerns about the	 
care for returning servicemembers. These deficiencies included a 
confusing disability evaluation system and servicemembers in	 
outpatient status for months and sometimes years without a clear 
understanding about their plan of care. The reported problems at 
Walter Reed prompted broader questions about whether the	 
Department of Defense (DOD) as well as the Department of Veterans
Affairs (VA) are fully prepared to meet the needs of returning	 
servicemembers. In response to the deficiencies reported at	 
Walter Reed, the Army took a number of actions and DOD formed a  
joint DOD-VA Senior Oversight Committee. This statement provides 
information on the near-term actions being taken by the Army and 
the broader efforts of the Senior Oversight Committee to address 
longer-term systemic problems that impact health care and	 
disability evaluations for returning servicemembers. Preliminary 
observations in this testimony are based largely on documents	 
obtained from and interviews with Army officials, and DOD and VA 
representatives of the Senior Oversight Committee, as well as on 
GAO's extensive past work. We discussed the facts contained in	 
this statement with DOD and VA. 				 
-------------------------Indexing Terms------------------------- 
REPORTNUM:   GAO-07-1256T					        
    ACCNO:   A76731						        
  TITLE:     DOD and VA: Preliminary Observations on Efforts to       
Improve Health Care and Disability Evaluations for Returning	 
Servicemembers							 
     DATE:   09/26/2007 
  SUBJECT:   Aid for the disabled				 
	     Disability benefits				 
	     Health care facilities				 
	     Health care programs				 
	     Health care services				 
	     Health centers					 
	     Interagency relations				 
	     Military hospitals 				 
	     Military personnel 				 
	     Oversight committees				 
	     Persons with disabilities				 
	     Post-traumatic stress disorders			 
	     Program evaluation 				 
	     Program management 				 
	     Strategic planning 				 
	     Veterans benefits					 
	     Veterans disability compensation			 

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GAO-07-1256T

   

     * [1]Background
     * [2]While Efforts Are Under Way to Respond to Both Army-Specific

          * [3]Efforts to Improve Case Management for Servicemembers Under
          * [4]Efforts Are Under Way to Improve Disability Evaluation Proce
          * [5]Efforts Under Way to Improve Screening, Diagnosis, and Treat
          * [6]Efforts Under Way to Facilitate Data Sharing between DOD and

     * [7]Concluding Observations
     * [8]Appendix I: Selected Issues Identified by Three Review Group
     * [9]Appendix II: GAO Contacts and Staff Acknowledgments

          * [10]GAO Contacts
          * [11]Acknowledgment

     * [12]Related GAO Products

          * [13]Order by Mail or Phone

     * [14]PDF6-Ordering Information.pdf

          * [15]Order by Mail or Phone

Testimony

Before the Subcommittee on National Security and Foreign Affairs,
Committee on Oversight and Government Reform, House of Representatives

United States Government Accountability Office

GAO

For Release on Delivery
Expected at 10:00 a.m. EDT
Wednesday, September 26, 2007

DOD AND VA

Preliminary Observations on Efforts to Improve Health Care and Disability
Evaluations for Returning Servicemembers

Statement of John H. Pendleton, Acting Director
Health Care

Statement of Daniel Bertoni, Director
Education, Workforce, and Income Security

GAO-07-1256T

Mr. Chairman and Members of the Subcommittee:

We are pleased to be here today as you examine issues related to the
provision of care and services for our returning servicemembers. In
February 2007, a series of Washington Post articles disclosed troublesome
deficiencies in the provision of outpatient services at Walter Reed Army
Medical Center, raising concerns about the care for returning
servicemembers and conditions at Army facilities across the country.
Deficiencies at Walter Reed included poor living conditions, a confusing
disability evaluation system, and servicemembers in outpatient status for
months and sometimes years without a clear understanding about their plan
of care or the future of their military service.

The reported problems at Walter Reed prompted broader questions about
whether the Department of Defense (DOD) as well as the Department of
Veterans Affairs (VA) are fully prepared to meet the needs of the
increasing number of returning servicemembers as well as veterans. Several
review groups were tasked with investigating the reported problems and
identifying recommendations. In February 2007, the Secretary of Defense
established the Independent Review Group, which reported its findings in
April 2007.1 In March 2007, the President established both the Task Force
on Returning Global War on Terror Heroes and the President's Commission on
Care for America's Returning Wounded Warriors, commonly referred to as the
Dole-Shalala Commission. The Task Force reported its findings in April
20072 and the Dole-Shalala Commission reported its findings in July 2007.3
In August 2007, the President announced that he had directed the
Secretaries of DOD and VA to study and implement the recommendations made
by the Dole-Shalala Commission. See appendix I for a summary of selected
findings from each of the review groups.

1Independent Review Group, Rebuilding the Trust: Report on Rehabilitative
Care and Administrative Processes at Walter Reed Army Medical Center and
National Naval Medical Center (Arlington, Va., April 2007).

2Task Force on Returning Global War on Terror Heroes, Report to the
President (April 2007).

3President's Commission on Care for America's Returning Wounded Warriors,
Serve, Support, Simplify (July 2007).

The three review groups identified common areas of concern, including
inadequate case management to ensure continuity of care;4 confusing
disability evaluation systems; the need to better understand and diagnose
traumatic brain injury (TBI) or post-traumatic stress disorder (PTSD),5
sometimes referred to as "invisible injuries;" and insufficient data
sharing between DOD and VA of servicemembers' medical records. Problems in
these areas have been long-standing and the subject of much past work by
GAO.6 For example, we have reported that major disability programs,
including the VA's disability programs, are neither well aligned with the
21st century environment nor positioned to provide meaningful and timely
support.7 Specifically, challenges exist related to ensuring timely
provision of services and benefits as well as interpreting complex
eligibility requirements, among other things. In January 2003, we
designated modernizing federal disability programs as a high-risk area.8

In response to Walter Reed deficiencies reported by the media, the Army
took several actions, most notably initiating the development of the Army
Medical Action Plan in March 2007. The plan, designed to help the Army
become more patient-focused, includes more than 150 tasks for establishing
a continuum of care and services, optimizing the Army Physical Disability
Evaluation System, and maximizing coordination of efforts with VA.
According to the Army, most of the tasks in the Medical Action Plan are to
be completed by January 2008.

In May 2007, DOD established the Wounded, Ill, and Injured Senior
Oversight Committee (Senior Oversight Committee) to bring high-level
attention to addressing the problems associated with the care and services
for returning servicemembers, including the concerns that were being
raised by the various review groups. The committee is co-chaired by the
Deputy Secretaries of Defense and Veterans Affairs, and also includes the
military service Secretaries and other high-ranking officials within DOD
and VA. To conduct its work, the Senior Oversight Committee has
established workgroups that have focused on specific areas including case
management, disability evaluation systems, TBI and psychological health,
including PTSD, and data sharing between DOD and VA.9 Each workgroup
includes representation from DOD, including each of the military services,
and VA. The workgroups report their efforts and recommendations to the
Senior Oversight Committee, which directs the appropriate components of
DOD and VA to act. The Senior Oversight Committee was established for a
12-month time frame, which will end in May 2008.

4Case management is a process for guiding a patient's care from one
provider, agency, organizational program, or service to another.

5TBI is an injury caused by a blow or jolt to the head or a penetrating
head injury that disrupts the normal function of the brain. PTSD is an
anxiety disorder that can develop after exposure to a traumatic ordeal in
which physical harm occurred or was threatened.

6See the end of this statement for a list of related GAO products.

7GAO, Federal Disability Assistance: Wide Array of Programs Needs to be
Examined in Light of 21st Century Challenges, [16]GAO-05-626 (Washington,
D.C.: June 2, 2005).

8GAO, High-Risk Series: An Update, [17]GAO-07-310 (Washington, D.C.:
January 2007).

Today, our remarks are based on preliminary observations drawn from our
ongoing reviews as well as extensive past work. Our statement addresses
the near-term actions being taken by the Army, as well as the broader
efforts of the Senior Oversight Committee to address longer-term systemic
problems that affect care for returning servicemembers, in the following
four areas: case management, disability evaluation systems, TBI and PTSD,
and data sharing between DOD and VA. We focused on efforts of the Army
because it has the majority of servicemembers in Operation Iraqi Freedom
and Operation Enduring Freedom, and, as a result the majority of returning
servicemembers needing care and rehabilitation go to Army facilities. We
also focused on the efforts of the Senior Oversight Committee because it
was specifically established to address concerns about the care and
services provided to returning servicemembers. Our testimony is based
largely on documents obtained from and interviews with Army officials,
including the Army's Office of the Surgeon General, and DOD and VA
representatives of the Senior Oversight Committee. Specifically, we
reviewed Army's staffing data related to the initiatives established in
the Army Medical Action Plan. We did not verify the accuracy of these
data; however, we interviewed agency officials knowledgeable about the
data, and we determined that they were sufficiently reliable for the
purposes of this statement. We visited Walter Reed Army Medical Center in
August 2007 to talk with officials about how they are implementing the
Army's Medical Action Plan and to obtain views from servicemembers about
how the efforts are affecting their care. Our findings are preliminary and
it was beyond the scope of our work for this statement to review the
efforts under way in other military services or throughout DOD and VA. We
discussed the facts contained in this statement with DOD and VA, and we
incorporated their comments where appropriate. We are conducting the work
we began in June in accordance with generally accepted government auditing
standards.

9Additional workgroups are examining the condition of DOD and VA
facilities as well as issues about personnel, pay, and financial support
systems, among others.

In summary, the Army took near-term actions to respond to reported
deficiencies about the care and services provided to its returning
servicemembers, and the Senior Oversight Committee is undertaking efforts
to address more systemic problems. However, challenges remain to overcome
long-standing problems and ensure sustainable progress in the four areas
we reviewed: (1) case management, (2) disability evaluation systems, (3)
TBI and PTSD, and (4) data sharing between DOD and VA.

           o Case management: The Army has developed a new organizational
           structure--Warrior Transition Units--for providing an integrated
           continuum of care for its returning servicemembers. Within each
           unit, a servicemember is assigned to a team of three critical
           staff--physician, nurse case manager, and squad leader--who manage
           the servicemember's care. As of mid-September, 17 of the 32 units
           had less than 50 percent of staff in place in one or more of these
           critical positions. To facilitate continuity of care across
           departments, the Senior Oversight Committee is developing a plan
           to establish recovery coordinators to oversee the care of severely
           injured servicemembers across federal agencies, including DOD and
           VA. This action is being taken to address a recommendation by the
           Dole-Shalala Commission. Although initial implementation is slated
           for mid-October 2007, as of mid-September, the committee had not
           determined how many federal recovery coordinators will be needed.
           This is partly because it is still unclear exactly what portion of
           returning servicemembers these recovery coordinators will serve.

           o Disability evaluation systems: The Army is pursuing several
           initiatives to help streamline the disability evaluation process
           for its servicemembers--for example, by reducing the caseloads of
           staff who help servicemembers navigate the system--and has taken
           steps to help mitigate servicemembers' confusion, such as
           providing additional briefings about the process and an online
           tool. To address more systemic concerns about the timeliness and
           consistency of DOD's and VA's disability evaluation systems, the
           Senior Oversight Committee is planning to pilot a joint DOD/VA
           disability evaluation system that may include variations of three
           elements: (1) a single, comprehensive medical examination; (2) a
           single disability rating performed by VA; and (3) a DOD-level
           retention board for adjudicating servicemembers' fitness for duty.
           The departments initially slated the pilot to begin on August 1,
           2007, but the date has slipped as DOD and VA continue to review
           pilot options and take steps to address key questions including
           those related to emerging legislative proposals and long-standing
           challenges.

           o TBI and PTSD: To improve the care provided to servicemembers
           with TBI and PTSD, both the Army and the Senior Oversight
           Committee have efforts under way to improve screening, diagnosis,
           and treatment of these conditions. As part of the Army Medical
           Action Plan, the Army has established policies to provide training
           on mild TBI and PTSD to all its nurse case managers and
           psychiatric nurses, among others. As of September 13, 2007, 6 of
           the Army's 32 Warrior Transition Units had completed training for
           all of these staff. The Senior Oversight Committee has developed a
           policy for DOD and VA to establish a national Center of Excellence
           for TBI and PTSD that will coordinate the efforts of the two
           departments related to promoting research, awareness, and best
           practices on these conditions.

           o Data sharing: DOD and VA have been working for almost 10 years
           to facilitate the exchange of medical information. The Army has
           service-specific efforts under way to improve the sharing of data
           between its military treatment facilities and VA. Also, the Senior
           Oversight Committee has developed a workgroup to accelerate
           data-sharing efforts between the two departments and to help
           provide for the data-sharing needs of other efforts being overseen
           by the Senior Oversight Committee. The need for DOD and VA to
           share patient data continues to be critical. For example, data
           sharing is important to the proposed recovery coordinators who
           will require timely and reliable patient information to ensure
           continuity of care across the many organizational seams in DOD and
           VA.

           Given the importance of all these issues for providing appropriate
           and high-quality care to our returning servicemembers, it is
           critical for top leaders at DOD and VA to continue to implement as
           well as to oversee these efforts to ensure the goals of the
           efforts are achieved in a timely manner, particularly since there
           is an increasing need to provide care to servicemembers.
			  
			  Background

           DOD and VA offer health care benefits to active duty
           servicemembers and veterans, among others. Under DOD's health care
           system, eligible beneficiaries may receive care from military
           treatment facilities or from civilian providers. Military
           treatment facilities are individually managed by each of the
           military services--the Army, the Navy,10 and the Air Force. Under
           VA, eligible beneficiaries may obtain care through VA's integrated
           health care system of hospitals, ambulatory clinics, nursing
           homes, residential rehabilitation treatment programs, and
           readjustment counseling centers. VA has organized its health care
           facilities into a polytrauma system of care11 that helps address
           the medical needs of returning servicemembers and veterans, in
           particular those who have an injury to more than one part of the
           body or organ system that results in functional disability and
           physical, cognitive, psychosocial, or psychological impairment.
           Persons with polytraumatic injuries may have injuries or
           conditions such as TBI, amputations, fractures, and burns.

           Over the past 6 years, DOD has designated over 29,000
           servicemembers involved in Operation Iraqi Freedom and Operation
           Enduring Freedom as wounded in action, and almost 70 percent of
           these servicemembers are from the Army active, reserve, and
           national guard components. Servicemembers injured in these
           conflicts are surviving injuries that would have been fatal in
           past conflicts, due, in part, to advanced protective equipment and
           medical treatment. The severity of their injuries can result in a
           lengthy transition from patient back to duty, or to veterans'
           status. Initially, most seriously injured servicemembers from
           these conflicts, including activated National Guard and Reserve
           members, are evacuated to Landstuhl Regional Medical Center in
           Germany for treatment. From there, they are usually transported to
           military treatment facilities in the United States, with most of
           the seriously injured admitted to Walter Reed Army Medical Center
           or the National Naval Medical Center. According to DOD officials,
           once they are stabilized and discharged from the hospital,
           servicemembers may relocate closer to their homes or military
           bases and are treated as outpatients by the closest military or VA
           facility.

           Returning injured servicemembers must potentially navigate two
           different disability evaluation systems that generally rely on the
           same criteria but for different purposes. DOD's system serves a
           personnel management purpose by identifying servicemembers who are
           no longer medically fit for duty. The military's process starts
           with identification of a medical condition that could render the
           servicemember unfit for duty, a process that could take months to
           complete. The servicemember goes through a medical evaluation
           board proceeding, where medical evidence is evaluated, and
           potentially unfit conditions are identified. The member then goes
           through a physical evaluation board process, where a determination
           of fitness or unfitness for duty is made and, if found unfit for
           duty, a combined percentage rating is assigned for all unfit
           conditions and the servicemember is discharged from duty. The
           injured servicemember then receives monthly disability retirement
           payments if he or she meets the minimum rating and years of duty
           thresholds or, if not, a lump-sum severance payment.

10The Navy is responsible for the medical care of servicemembers in the
Marine Corps.

11The system is composed of categories of medical facilities that offer
varying levels of services.

           VA provides veterans compensation for lost earning capacity due to
           service-connected disabilities. Although a servicemember may file
           a VA claim while still in the military, he or she can only obtain
           disability compensation from VA as a veteran. VA will evaluate all
           claimed conditions, whether they were evaluated by the military
           service or not. If the veteran is found to have one or more
           service-connected disabilities with a combined rating of at least
           10 percent,12 VA will pay monthly compensation. The veteran can
           claim additional benefits, for example, if a service-connected
           disability worsens.
			  
			  While Efforts Are Under Way to Respond to Both Army-Specific and
			  Systemic Problems, Challenges Are Emerging

           While the Army took near-term actions to respond to reported
           deficiencies in care for its returning servicemembers, and the
           Senior Oversight Committee is undertaking efforts to address more
           systemic problems, challenges remain to overcome long-standing
           problems and ensure sustainable progress. In particular, efforts
           were made to respond to problems in four key areas: (1) case
           management, (2) disability evaluation systems, (3) TBI and PTSD,
           and (4) data sharing between DOD and VA. The three review groups
           identified several problems in these four areas including: a need
           to develop more comprehensive and coordinated care and services; a
           need to make the disability systems more efficient; more
           collaboration of research and establishment of practice guidelines
           for TBI and PTSD; and more data sharing between DOD and VA. While
           efforts have been made in all four areas, challenges have emerged
           including staffing for the case management initiatives and
           transforming the disability evaluation system.
			  
12VA determines the degree to which veterans are disabled in 10 percent
increments on a scale of 0 to 100 percent.

           Efforts to Improve Case Management for Servicemembers Under Way,
			  but Human Capital and Other Challenges Are Surfacing

           The three review groups reporting earlier this year identified
           numerous problems with DOD's and VA's case management of
           servicemembers, including a lack of comprehensive and
           well-coordinated care, treatment, and services. Case management--a
           process intended to assist returning servicemembers with
           management of their clinical and nonclinical care throughout
           recovery, rehabilitation, and community reintegration--is
           important because servicemembers often receive services from
           numerous therapists, providers, and specialists, resulting in
           differing treatment plans as well as receiving prescriptions for
           multiple medications. One of the review groups reported that the
           complexity of injuries in some patients requires a coordinated
           method of case management to keep the care of the returning
           servicemember focused and goal directed, and that this type of
           care was not evident at Walter Reed.13 The Dole-Shalala Commission
           recommended that recovery coordinators be appointed to craft and
           manage individualized recovery plans that would be used to guide
           the servicemembers' care. The Dole-Shalala Commission further
           recommended that these recovery coordinators come from outside DOD
           or VA, possibly from the Public Health Service, and be highly
           skilled and have considerable authority to be able to access
           resources necessary to implement the recovery plans. The Army and
           the Senior Oversight Committee's workgroup on case management have
           initiated efforts to develop case management approaches that are
           intended to improve the management of servicemembers' recovery
           process. See table 1 for selected efforts by the Army and Senior
           Oversight Committee to improve case management services.
			  
13Independent Review Group, Rebuilding the Trust: Report on Rehabilitative
Care and Administrative Processes at Walter Reed Army Medical Center and
National Naval Medical Center (Arlington, Va.: April 2007).

           Table 1: Selected Army and Senior Oversight Committee Efforts to
           Improve Case Management

U.S. Army                                                                  
      o Established a new organizational structure for providing care to      
      returning servicemembers that combines active duty and reserve          
      servicemembers who are in outpatient status.                            
      o Established a case management approach that includes a primary care   
      physician, nurse case manager, and military squad leader who will       
      coordinate the management of a servicemember's recovery process.        
Senior Oversight Committee                                                 
      o Developed policy requiring DOD and VA to establish a joint Recovery   
      Coordinator Program no later than October 15, 2007, to integrate care   
      and service delivery for returning servicemembers and their families.   
      The recovery coordinators are to be provided by VA.                     
      o Mapped the case management process across the military services and   
      developed common roles and responsibilities for case managers for an    
      integrated DOD and VA approach and joint standards of practice and      
      training.                                                               
      o Planning to develop DOD/VA oversight metrics to ensure accountability 
      and continuous process improvement.                                     

           Sources: Army and Senior Oversight Committee.

           The Army's approach includes developing a new organizational
           structure for providing care to returning active duty and reserve
           servicemembers who are unable to perform their duties and are in
           need of health care--this structure is referred to as a Warrior
           Transition Unit. Within each unit, the servicemember is assigned
           to a team of three key staff and this team is responsible for
           overseeing the continuum of care for the servicemember.14 The Army
           refers to this team as a "triad," and it consists of a (1) primary
           care manager--usually a physician who provides primary oversight
           and continuity of health care and ensures the quality of the
           servicemember's care; (2) nurse case manager--usually a registered
           nurse who plans, implements, coordinates, monitors, and evaluates
           options and services to meet the servicemember's needs; and (3)
           squad leader--a noncommissioned officer who links the
           servicemember to the chain of command, builds a relationship with
           the servicemember, and works along side the other parts of the
           triad to ensure the needs of the servicemember and his or her
           family are met. As part of the Army's Medical Action Plan, the
           Army established 32 Warrior Transition Units, to provide a unit in
           every medical treatment facility that has 35 or more eligible
           servicemembers.15 The Army's goal is to fill the triad positions
           according to the following ratios: 1:200 for primary care
           managers; 1:18 for nurse case managers; and 1:12 for squad
           leaders. This approach is a marked departure for the Army. Prior
           to the creation of the Warrior Transition Units, the Army
           separated active and reserve component soldiers into different
           units.16 One review group reported that this approach contributed
           to discontent about which group received better treatment.17
           Moreover, the Army did not have formalized staffing structures nor
           did it routinely track patient-care ratios, which the Independent
           Review Group reported contributed to the Army's inability to
           adequately oversee its program or identify gaps.
			  
14The Warrior Transition Unit also includes other staff, such as human
resources and financial management specialists.			  

           As the Army has sought to fill its Warrior Transition Units,
           challenges to staffing key positions are emerging. For example,
           many locations have significant shortfalls in registered nurse
           case managers and non-commissioned officer squad leaders. As shown
           in figure 1, about half of the total required staffing needs of
           the Warrior Transition Units had been met across the Army by
           mid-September 2007. However, the Army had filled many of these
           slots thus far by temporarily borrowing staff from other
           positions.
			  
15The Army also established three Warrior Transition Units in Germany.

16Active-duty servicemembers were typically placed in Medical Hold units,
while Reserve and National Guard servicemembers were placed into separate
Medical Holdover units.

17Independent Review Group, Rebuilding the Trust: Report on Rehabilitative
Care and Administrative Processes at Walter Reed Army Medical Center and
National Naval Medical Center.

           Figure 1: Status of Warrior Transition Unit Staffing, as of
           September 13, 2007

           Note: Percentages do not add to 100 percent due to rounding.

           The Warrior Transition Unit staffing shortages are significant at
           many locations. As of mid-September, 17 of the 32 units had less
           than 50 percent of staff in place in one or more critical
           positions. (See table 2.) Consequently, 46 percent of the Army's
           returning servicemembers who were eligible to be assigned to a
           unit had not been assigned, due in part to these staffing
           shortages. As a result, these servicemembers' care was not being
           coordinated through the triad. Army officials reported that their
           goal is to have all Warrior Transition Units in place and fully
           staffed by January 2008.

           Table 2: Locations Where Warrior Transition Units Had Less Than 50
           Percent of Staff in Place in One or More Critical Positions, as of
           September 13, 2007
			  
                                                     Critical positions
                                Total number of                               
                              servicemembers at            Nurse case  Squad  
Location                           locationa Physicians  managers  leaders 
Fort Hood, Texas                         743                x         x    
Fort Lewis,                              617     x          x              
Washington                                                                 
Fort Bragg, North                        586                x              
Carolina                                                                   
Fort Gordon,                             546     x                    x    
Georgia                                                                    
Fort Knox,                               430                          x    
Kentucky                                                                   
Fort Carson,                             394     x          x         x    
Colorado                                                                   
Fort Campbell,                           328                          x    
Kentucky                                                                   
Tripler, Hawaii                          237                          x    
Fort Stewart,                            223                x              
Georgia                                                                    
Fort Riley,                              209                x         x    
Kansas                                                                     
Fort Eustis,                             128                          x    
Virginia                                                                   
Fort Sill,                               127                          x    
Oklahoma                                                                   
West Point, New                           99                          x    
York                                                                       
Fort Leonard                              78                          x    
Wood, Missouri                                                             
Fort Wainwright,                          51                x              
Alaska                                                                     
Fort Jackson,                             45                x         x    
South Carolina                                                             
Redstone Arsenal,                          4    N/Ab       N/Ab       x    
Alabama                                                                    

           Source: GAO analysis of Army data.

           Note: Warrior Transition Units also include other positions, such
           as social workers, occupational therapists, and administrative
           staff.

           aTotal number of servicemembers includes those in outpatient
           care--assigned to a Warrior Transition Unit as well as in the
           Medical Evaluation Board process and who have not been assigned to
           a Warrior Transition Unit.

           bNo staff were authorized for this position.

           The Senior Oversight Committee's approach for providing a
           continuum of care includes establishment of recovery coordinators
           and recovery plans, as recommended by the Dole-Shalala Commission.
           This approach is intended to complement the military services'
           existing case management approaches and place the recovery
           coordinators at a level above case managers, with emphasis on
           ensuring a seamless transition between DOD and VA. The recovery
           coordinator is expected to be the patient's and family's single
           point of contact for making sure each servicemember receives the
           care outlined in the servicemember's recovery plan--a plan to
           guide and support the servicemember through the phases of medical
           care, rehabilitation, and disability evaluation to community
           reintegration.

           The Senior Oversight Committee has indicated that DOD and VA will
           establish a joint Recovery Coordinator Program no later than
           October 15, 2007. At the time of our review, the committee was
           determining the details of the program. For example, the
           Dole-Shalala Commission recommended this approach for every
           seriously injured servicemember, and the Senior Oversight
           Committee workgroup on case management was developing criteria for
           determining who is "seriously injured." The workgroup was also
           determining the role of the recovery coordinators--how they will
           be assigned to servicemembers and how many are needed, which will
           ultimately determine what the workload for each will be. The
           Senior Oversight Committee has, however, indicated that the
           positions will be filled with VA staff. A representative of the
           Senior Oversight Committee told us that the recovery coordinators
           would not be staffed from the U.S. Public Health Service
           Commissioned Corps, as recommended by the Dole-Shalala Commission.
           The official told us that it is appropriate for VA to staff these
           positions because VA ultimately provides the most care for
           servicemembers over their lifetime. Moreover, Senior Oversight
           Committee officials told us that depending on how many recovery
           coordinators are ultimately needed, VA may face significant human
           capital challenges in identifying and training individuals for
           these positions, which are anticipated to be complex and
           demanding.
			  
			  Efforts Are Under Way to Improve Disability Evaluation Processes,
			  but Challenges Remain in Transforming the Overall System

           As we have previously reported, providing timely and consistent
           disability decisions is a challenge for both DOD and VA. In a
           March 2006 report about the military disability evaluation system,
           we found that the services were not meeting DOD timeliness goals
           for processing disability cases; used different policy, guidance
           and processes for aspects of the system; and that neither DOD nor
           the services systematically evaluated the consistency of
           disability decisions.18 On multiple occasions, we have also
           identified long-standing challenges for VA in reducing its backlog
           of claims and improving the accuracy and consistency of its
           decisions.19
			  
18GAO, Military Disability System: Improved Oversight Needed to Ensure
Timely and Consistent Outcomes for Reserve and Active Duty Service
Members, [20]GAO-06-362 (Washington, D.C.: Mar. 31, 2006).

19For additional information on VA disability claims processing, see GAO,
Veterans' Disability Benefits: Long-Standing Claims Processing Challenges
Persist, [21]GAO-07-512T (Washington, D.C.: Mar. 7, 2007); and GAO,
Veterans' Disability Benefits: Processing of Claims Continues to Present
Challenges, [22]GAO-07-562T (Washington, D.C.: Mar. 13, 2007).

           The controversy over conditions at Walter Reed and the release of
           subsequent reports raised the visibility of problems in the
           military services' disability evaluation system. In a March 2007
           report, the Army Inspector General identified numerous issues with
           the Army Physical Disability Evaluation System.20 These findings
           included a failure to meet timeliness standards for
           determinations, inadequate training of staff involved in the
           process, and servicemember confusion about the disability rating
           system. Similarly, in recently-issued reports, the Task Force on
           Returning Global War on Terror Heroes, the Independent Review
           Group, and the Dole-Shalala Commission found that DOD's disability
           evaluation system often generates long delays in disability
           determinations and creates confusion among servicemembers and
           their families. Also, they noted significant disparities in the
           implementation of the disability evaluation system among the
           services, and in the purpose and outcome of disability evaluations
           between DOD and VA. Two reports also noted the adversarial nature
           of DOD's disability evaluation system, as servicemembers endeavor
           to reach a rating threshold that entitles them to lifetime
           benefits. In addition to these findings about current processes,
           the Dole-Shalala Commission questioned DOD's basic role in making
           disability payments to veterans and recommended that VA assume
           sole responsibility for disability compensation for veterans.

           In response to the Army Inspector General's findings, the Army
           made near-term operational improvements. For example, the Army
           developed several initiatives to streamline its disability
           evaluation system and address bottlenecks. These initiatives
           include reducing the caseloads of evaluation board liaisons who
           help servicemembers navigate the disability evaluation system. In
           addition, the Army developed and conducted the first certification
           training for evaluation board liaisons. Furthermore, the Army
           increased outreach to servicemembers to address confusion about
           the process. For example, it initiated briefings conducted by
           evaluation board liaisons and soldiers' counsels to educate
           servicemembers about the process and their rights. The Army also
           initiated an online tool that enables servicemembers to check the
           status of their case during the evaluation process. We were not
           able to fully assess the implementation and effectiveness of these
           initiatives because some changes are still in process and complete
           data are not available.

20 Office of the Inspector General, Department of the Army, Report on the
Army Physical Disability Evaluation System, (Washington, D.C.: Mar. 6,
2007).
           To address more systemic concerns about the timeliness and
           consistency of DOD's and VA's disability evaluation systems, DOD
           and VA are planning to pilot a joint disability evaluation system.
           DOD and VA are reviewing multiple options that incorporate
           variations of the following three elements: (1) a single,
           comprehensive medical examination to be used by both DOD and VA in
           their disability evaluations; (2) a single disability rating
           performed by VA; and (3) incorporating a DOD-level evaluation
           board for adjudicating servicemembers' fitness for duty. For
           example, in one option, the DOD-level evaluation board makes
           fitness for duty determinations for all of the military services;
           whereas in another option, the services make fitness for duty
           determinations, and the DOD-level board adjudicates appeals of
           these determinations. Another open question is whether DOD or VA
           would conduct the comprehensive medical examination.21 Table 3
           summarizes four pilot options under consideration by DOD and VA.

21On August 31, 2007, the Senior Oversight Committee directed DOD and VA
to create by October 1, 2007 a single, standardized examination to be used
by DOD to determine fitness for all seriously injured servicemembers and
by VA to determine disability ratings, but it did not specify which agency
will be responsible for conducting the examinations.

           Table 3: Summary of Pilot Options under Consideration by DOD and
           VA

            Comprehensive       Single disability                             
            medical examination rating done by VA DOD-level evaluation board  
Option 1 Done by VA          Yes               Makes fitness               
                                                  determinations.             
Option 2 Done by DOD         Yes               None. Services make fitness 
                                                  determinations.             
Option 3 Done by VA          Yes               Adjudicates appeals of      
                                                  services' fitness           
                                                  determinations.             
Option 4 Done by VA          Yes               Conducts quality assurance  
                                                  reviews of services'        
                                                  fitness determinations.     

           Source: GAO analysis of information provided by DOD.

           Note: DOD and VA explored these options at pilot planning
           exercises conducted in August 2007, but are also considering
           variations of these options including combining portions of them.
           For example, one option may be to have DOD conduct comprehensive
           medical examinations and to have a DOD-level evaluation board make
           fitness determinations.

           As recent pilot planning exercises verified, in addition to
           agreeing on which pilot option to implement, DOD and VA must
           address several key design issues before the pilot can begin. For
           example, it has not been decided how DOD will use VA's disability
           rating to determine military disability benefits for
           servicemembers in the pilot. In addition, DOD and VA have not
           finalized a set of performance metrics to assess the effect of the
           piloted changes. DOD and VA officials had hoped to begin the pilot
           on August 1, 2007, but the intended start date slipped as agency
           officials took steps to further consider alternatives and address
           other important questions related to recent and expected events
           that may add further complexity to the pilot development process.
           For example, the Senior Oversight Committee may either choose or
           be directed by the Congress to pilot the Dole-Shalala
           recommendation that only VA and not DOD provide disability
           payments to veterans. Implementing this recommendation would
           require a change to current law, and could affect whether or how
           the agencies implement key pilot elements under consideration. In
           addition, the Veterans' Disability Benefits Commission, which is
           scheduled to report in October 2007, may recommend changes that
           could also influence the pilot's structure. Further, the Congress
           is considering legislation that may require DOD and VA to conduct
           multiple, alternative disability evaluation pilots.22

           DOD and VA face other critical challenges in creating a new
           disability evaluation system. For example, DOD is challenged to
           overcome servicemembers' distrust of a disability evaluation
           process perceived to be adversarial. Implementing a pilot without
           adequately considering alternatives or addressing critical policy
           and procedural details may feed that distrust because DOD and VA
           plan to pilot the new system with actual servicemembers. The
           agencies also face staffing and training challenges to conduct
           timely and consistent medical examinations and disability
           evaluations. Both the Independent Review Group and the
           Dole-Shalala Commission recommended that only VA establish
           disability ratings. However, as we noted above, VA is dealing with
           its own long-standing challenges in providing veterans with timely
           and consistent decisions.23 Similarly, if VA becomes responsible
           for servicemembers' comprehensive physical examinations, it would
           face additional staffing and training challenges, at a time when
           it is already addressing concerns about the timeliness and quality
           of its examinations. Further, while having a single disability
           evaluation could ensure more consistent disability ratings, VA's
           Schedule for Rating Disabilities is outdated because it does not
           adequately reflect changes in factors such as labor market
           conditions and assistive technologies on disabled veterans'
           ability to work. As we have reported, the nature of work has
           changed in recent decades as the national economy has moved away
           from manufacturing-based jobs to service- and knowledge-based
           employment.24 Yet VA's disability program remains mired in
           concepts from the past, particularly the concept that impairment
           equates to an inability to work.

22H.R. 1538, as passed by the Senate on July 25, 2007, Sec. 154.

23To help address processing challenges, VA hired about 1,000 new
disability claims processing employees since January 2007.

24GAO, High-Risk Series: An Update, [23]GAO-03-119 (Washington, D.C.: Jan.
1, 2003) and SSA and VA Disability Programs: Re-Examination of Disability
Criteria Needed to Help Ensure Program Integrity, [24]GAO-02-597
(Washington, D.C.: Aug. 9, 2002).

           Efforts Under Way to Improve Screening, Diagnosis, and Treatment
			  for TBI and PTSD

           The three independent review groups examining the deficiencies
           found at Walter Reed identified a range of complex problems
           associated with DOD and VA's screening, diagnosis, and treatment
           of TBI and PTSD, signature injuries of recent conflicts. Both
           conditions are sometimes referred to as "invisible injuries"
           because outwardly the individual's appearance is just as it was
           before the injury or onset of symptoms. In terms of mild TBI,
           there may be no observable head injury and symptoms may overlap
           with those associated with PTSD. With respect to PTSD, there is no
           objective diagnostic test and its symptoms can sometimes be
           associated with other psychological conditions (e.g., depression).
           Recommendations from the review groups examining these areas
           included better coordination of DOD and VA research and practice
           guidelines and hiring and retaining qualified health
           professionals. However, according to Army officials and the
           Independent Review Group report, obtaining qualified health
           professionals, such as clinical psychologists, is a challenge,
           which is due to competition with private sector salaries and
           difficulty recruiting for certain geographical locations. The
           Dole-Shalala Commission noted that while VA is considered a leader
           in PTSD research and treatment, knowledge generated through
           research and clinical experience is not systematically
           disseminated to all DOD and VA providers of care. Both the Army
           and the Senior Oversight Committee are working to address this
           broad range of issues. (See table 4.)

           Table 4: Selected Army and Senior Oversight Committee Efforts to
           Improve Screening, Diagnosis, and Treatment of TBI and PTSD

U.S. Army                                                                  
      o Providing mild-TBI and PTSD training for social workers, nurse case   
      managers, psychiatric nurses, and psychiatric nurse practitioners.      
      o Exploring ways to track incidents on the battlefield (e.g., blasts)   
      that may result in TBI or PTSD.                                         
      o Examining procedures for screening servicemembers for mild TBI and    
      PTSD prior to an involuntary release from the Army to ensure that       
      servicemembers are not inappropriately separated for behavioral         
      problems.                                                               
Senior Oversight Committee                                                 
      o Developed policy requiring DOD and VA to establish a national Center  
      of Excellence for TBI and PTSD no later than November 30, 2007.         
      o Establishing common educational and training materials and screening  
      processes for mild TBI and PTSD, as well as consistent definitions for  
      mild-TBI diagnosis.                                                     

           Sources: Army and Senior Oversight Committee.

           The Army, through its Medical Action Plan, has policies in place
           requiring all servicemembers sent overseas to a war zone to
           receive training on recognizing the symptoms of mild TBI and PTSD.
           The Army is also exploring ways to track events on the
           battlefield, such as blasts, that may result in TBI or PTSD. In
           addition, the Army recently developed policies to provide mild TBI
           and PTSD training to all social workers, nurse case managers,
           psychiatric nurses, and psychiatric nurse practitioners to better
           identify these conditions. As of September 13, 2007, 6 of the
           Army's 32 Warrior Transition Units had completed training for all
           of these staff.

           A Senior Oversight Committee workgroup on TBI and PTSD is working
           to ensure health care providers have education and training on
           screening, diagnosing, and treating both mild TBI and PTSD, mainly
           by developing a national Center of Excellence as recommended by
           the three review groups.25 This Center of Excellence is expected
           to combine experts and resources from all military services and VA
           to promote research, awareness, and best practices on mild TBI as
           well as PTSD and other psychological health issues. A
           representative of the Senior Oversight Committee workgroup on TBI
           and psychological health told us that the Center of Excellence
           would include the existing Defense and Veterans Brain Injury
           Center--a collaboration among DOD, VA, and two civilian partners
           that focuses on TBI treatment, research, and education.26
			  
			  Efforts Under Way to Facilitate Data Sharing between DOD and VA

           DOD and VA have been working for almost 10 years to facilitate the
           exchange of medical information. However, the three independent
           review groups identified the need for DOD and VA to further
           improve and accelerate efforts to share data across the
           departments. Specifically, the Dole-Shalala Commission indicated
           that DOD and VA must move quickly to get clinical and benefit data
           to users, including making patient data immediately viewable by
           any provider, allied health professional, or program administrator
           who needs the data. Furthermore, in July 2007, we reported that
           although DOD and VA have made progress in both their long-term and
           short-term initiatives to share health information, much work
           remains to achieve the goal of a seamless transition between the
           two departments.27 While pursuing their long-term initiative to
           develop a common health information system that would allow the
           two-way exchange of computable health data,28 the two departments
           have also been working to share data in their existing systems.
           See table 5 for selected efforts under way by the Army and Senior
           Oversight Committee to improve data sharing between DOD and VA.

25VA has a national Center on PTSD that was required to be established by
the Veterans' Health Care Act of 1984. This center advances the clinical
care and social welfare of veterans though research, education, and
training of clinicians in the causes, diagnosis, and treatment of PTSD.

26In April 2007, VA established policy requiring all Operation Iraqi
Freedom and Operation Enduring Freedom veterans receiving care within the
VA system to be screened for TBI. Additionally, if the screen determines
that the veteran might have TBI, then the veteran must be offered further
evaluation and treatment by providers with expertise in this area.

           Table 5: Selected Army and Senior Oversight Committee Efforts to
           Improve DOD and VA Data Sharing
			  
U.S. Army                                                                  
      o Army Medical Department is developing a memorandum of understanding   
      regarding sharing of medical data between Army military treatment       
      facilities and VA.                                                      
Senior Oversight Committee                                                 
      o Developed policy requiring DOD and VA to develop a plan to execute a  
      single Web portal to support the care and needs of servicemembers and   
      veterans by December 31, 2007.                                          
      o Developed data sharing policies requiring DOD and VA to (1) develop a 
      plan for interagency sharing of essential health images, such as        
      radiology studies, by March 31, 2008; (2) ensure that all essential     
      health and administrative data are made available and viewable to both  
      departments, and requiring that progress be reported by a scorecard no  
      later than October 31, 2008.                                            

           Sources: Army and Senior Oversight Committee.

           As part of the Army Medical Action Plan, the Army has taken steps
           to facilitate the exchange of data between its military treatment
           facilities and VA. For example, the Army Medical Department is
           developing a memorandum of understanding between the Army and VA
           that would allow VA access to data on severely injured
           servicemembers who are being transferred to a VA polytrauma
           center. The memorandum of understanding would also allow VA's
           Veterans Health Administration and Veterans Benefits
           Administration access to data in a servicemember's medical record
           that are related to a disability claim the servicemember has filed
           with VA. Army officials told us that the Army's medical records
           are part paper (hard copy) and part electronic, and this effort
           would provide the VA access to the paper data until the capability
           to share the data electronically is available at all sites.29

27GAO, Information Technology: VA and DOD Are Making Progress in Sharing
Medical Information, but Remain Far from Having Comprehensive Electronic
Medical Records, [25]GAO-07-1108T (Washington, D.C.: July 18, 2007).

28Computable data are data in a format that a computer application can act
on--for example, to provide alerts to clinicians of drug allergies.

           Given that DOD and VA already have a number of efforts under way
           to improve data sharing between the two departments, the Senior
           Oversight Committee, through its data sharing workgroup, has been
           looking for opportunities to accelerate the departments' sharing
           initiatives that are already planned or in process and to identify
           additional data sharing requirements that have not been clearly
           articulated. For example, the Senior Oversight Committee has
           approved several policy changes in response to the Dole-Shalala
           Commission, one of which requires DOD and VA to ensure that all
           essential health and administrative data are made available and
           viewable to both agencies, and that progress is reported by a
           scorecard, by October 31, 2008. A representative of the data
           sharing workgroup told us that the departments are achieving
           incremental increases to data sharing capabilities and plan to
           have all essential health data--such as outpatient pharmacy,
           allergy, laboratory results, radiology reports, and provider
           notes--viewable by all DOD and VA facilities by the end of
           December 2007.30 Although the agencies have recently experienced
           delays in efforts to exchange data, the representative said that
           the departments are on track to meet all the timelines established
           by the Senior Oversight Committee.

           A Senior Oversight Committee workgroup on data sharing has also
           been coordinating with other committee workgroups on their
           information technology needs. Although workgroup officials told us
           that they have met numerous times with the case management and
           disability evaluation systems workgroups to discuss their data
           sharing needs, they have not begun implementing necessary systems
           because they are dependent on the other workgroups to finalize
           their information technology needs. For example, the Senior
           Oversight Committee has required DOD and VA to establish a plan
           for information technology support of the recovery plan to be used
           by recovery coordinators, which integrates essential clinical
           (e.g., medical care) and nonclinical aspects (e.g., education,
           employment, disability benefits) of recovery, no later than
           November 1, 2007. However, this cannot be done until the case
           management workgroup has identified the components and information
           technology needs of these clinical and nonclinical aspects, and as
           of early September this had not been done. Data sharing workgroup
           representatives indicated that the departments' data sharing
           initiatives will be ongoing because medications, diagnoses,
           procedures, standards, business practices, and technology are
           constantly changing, but the departments expect to meet most of
           the data sharing needs of patients and providers by end of fiscal
           year 2008.

29Officials from Walter Reed Army Medical Center told us that Walter Reed
already has the capability to share this data electronically.

30DOD facilities in combat zones may not have this capability because they
operate in a different environment with different informational technology
capabilities.

           Concluding Observations

           Our preliminary observations are that fixing the long-standing and
           complex problems spotlighted in the wake of Walter Reed media
           accounts as expeditiously as possible is critical to ensuring
           high-quality care for our returning servicemembers, and success
           will ultimately depend on sustained attention, systematic
           oversight by DOD and VA, and sufficient resources. Efforts thus
           far have been on separate but related tracks, with the Army
           seeking to address service-specific issues while DOD and VA are
           working together to address systemic problems. Many challenges
           remain, and critical questions remain unanswered. Among the
           challenges is how the efforts of the Army--which has the bulk of
           the returning servicemembers needing medical care--will be
           coordinated with the broader efforts being undertaken by DOD and
           VA.

           The centerpiece of the Army's effort is its Medical Action Plan,
           and the success of the plan hinges on staffing the newly-created
           Warrior Transition Units. Permanently filling these slots may
           prove difficult, and borrowing personnel from other units has been
           a temporary fix but it is not a long-term solution. The Army can
           look to the private sector for some skills, but it must compete
           for personnel in a civilian market that is vying for medical
           professionals with similar skills and training.

           Perhaps one of the most complex efforts under way is that of
           redesigning DOD's disability evaluation system. Delayed decisions,
           confusing policies, and the perception that DOD and VA disability
           ratings result in inequitable outcomes have eroded the credibility
           of the system. Thus, it is imperative that DOD and VA take prompt
           steps to address fundamental system weaknesses. However, as we
           have noted, key program design and operational policy questions
           must be addressed to ensure that any proposed system redesign has
           the best chance for success and that servicemembers and veterans
           receive timely, accurate, and consistent decisions. This will
           require careful study of potential options, a comprehensive
           assessment of outcome data associated with the pilot, proper
           metrics to gauge success, and an evaluation mechanism to ensure
           needed adjustments are made to the process along the way. Failure
           to properly consider alternatives or address critical policy and
           procedural details could exacerbate delays and confusion for
           servicemembers, and potentially jeopardize the system's successful
           transformation.

           Mr. Chairman, this completes my prepared remarks. We would be
           happy to respond to any questions you or other members of the
           subcommittee may have at this time.

           For further information about this testimony, please contact John
           H. Pendleton at (202) 512-7114 or [18][email protected] or Daniel
           Bertoni at (202) 512-7215 or [19][email protected] . Contact points
           for our Offices of Congressional Relations and Public Affairs may
           be found on the last page of this statement. GAO staff who made
           major contributions to this report are listed in appendix II.
			  
			  Appendix I: Selected Issues Identified by Three Review Groups
			  following the Reporting of Deficiencies at Walter Reed

           In the aftermath of deficiencies identified at Walter Reed Medical
           Center, three separate review groups--the President's Commission
           on Care for America's Returning Wounded Warriors, commonly
           referred to as the Dole-Shalala Commission; the Independent Review
           Group, established by the Secretary of Defense; and the
           President's Task Force on Returning Global War on Terror
           Heroes--investigated the factors that may have led to these
           problems. Selected findings of each report are summarized in table
           6.

Table 6: Selected Findings of Review Groups Reporting on Walter Reed Army
Medical Center Deficiencies

Review groups                Findings                                      
President's Commission on       o A patient-centered recovery plan is      
Care for America's Returning    needed for all seriously injured           
Wounded Warriors                servicemembers.                            
(Dole-Shalala Commission)       o Department of Defense's (DOD) disability 
                                   and compensation systems need to be        
(July 2007)                     "completely restructured."                 
                                   o DOD and the Department of Veterans       
                                   Affairs (VA) must work to aggressively     
                                   prevent and treat post-traumatic stress    
                                   disorder (PTSD) and traumatic brain injury 
                                   (TBI) and reduce perceived stigma of both  
                                   conditions.                                
                                   o Support for servicemembers' families     
                                   must be strengthened, including expanding  
                                   DOD respite care and extending the Family  
                                   and Medical Leave Act for up to six months 
                                   for spouses and parents of the seriously   
                                   injured.                                   
                                   o DOD and VA should work together to       
                                   quickly share clinical and administrative  
                                   data with each other. A "My eBenefits"     
                                   page for servicemembers should be          
                                   established.                               
                                   o DOD and VA must assure that Walter Reed  
                                   Army Medical Center has the clinical and   
                                   administrative staff it needs, until its   
                                   closure in 2011.                           
Secretary of Defense's          o Comprehensive care, treatment, and       
Independent Review Group on     administrative services not provided to    
Rehabilitative Care and         the outpatient in a collaborative manner   
Administrative Processes at     at Walter Reed Army Medical Center.        
Walter Reed Army Medical        o Lack of clear, consistent standards for  
Center and National Naval       qualifications and training of outpatient  
Medical Center                  case managers across the Army, Navy, and   
                                   Air Force.                                 
(April 2007)                    o Lack of early identification techniques  
                                   and comprehensive clinical practice        
                                   guidelines for TBI and its overlap with    
                                   PTSD, within the military health system,   
                                   results in inconsistent diagnosis and      
                                   treatment.                                 
                                   o Serious difficulties administering the   
                                   Physical Disability Evaluation System due  
                                   to significant variance in policy and      
                                   guidelines among the military services.    
                                   The current process is cumbersome,         
                                   inconsistent, and confusing to providers,  
                                   patients, and families.                    
                                   o No common automated interface exists     
                                   between the clinical and administrative    
                                   systems within DOD and among the services, 
                                   or between DOD and VA.                     
President's Task Force on       o DOD's and VA's disability evaluation     
Returning Global War on         systems are confusing, time consuming, and 
Terror Heroes                   sometimes inconsistent among the services  
                                   and between DOD and VA.                    
(April 2007)                    o No formal agreements for how active duty 
                                   servicemembers should be managed when they 
                                   receive services from both DOD and VA.     
                                   o No agreements on definition of case      
                                   management, functions of case managers, or 
                                   how DOD and VA case managers should        
                                   transfer patients to one another to assure 
                                   continuity of care.                        
                                   o Servicemembers with mild to moderateTBI  
                                   can be particularly difficult to diagnose  
                                   given the lack of easily visible symptoms. 
                                   o While VA provides a comprehensive        
                                   medical benefits package for enrolled      
                                   veterans, the current paper and online     
                                   versions of the required paperwork for     
                                   certain benefits packages do not allow for 
                                   identification of Operation Enduring       
                                   Freedom / Operation Iraqi Freedom          
                                   veterans. Further, the online application  
                                   does not provide e-authentication or       
                                   e-signature capabilities thereby requiring 
                                   veterans to submit signed applications and 
                                   complete the entire form, including some   
                                   data they have already supplied VA.        

Sources: President's Commission on Care for America's Returning Wounded
Warriors, the Independent Review Group, and the President's Task Force on
Returning Global War on Terror Heroes.

Appendix II: GAO Contacts and Staff Acknowledgments

GAO Contacts

John H. Pendleton at (202) 512-7114 or [26][email protected] or Daniel
Bertoni at (202) 512-7215 or [27][email protected]

Acknowledgment

In addition to the contact named above, Bonnie Anderson, Assistant
Director; Michele Grgich, Assistant Director; Jennie Apter; Janina Austin;
Joel Green; Christopher Langford; Chan My Sondhelm; Barbara Steel-Lowney;
and Greg Whitney, made key contributions to this statement.

Related GAO Products Related GAO Products

DOD Civilian Personnel: Medical Policies for Deployed DOD Federal
Civilians and Associated Compensation for Those Deployed. [28]GAO-07-1235T
. Washington, D.C.: September 18, 2007.

Global War on Terrorism: Reported Obligations for the Department of
Defense. [29]GAO-07-1056R . Washington, D.C.: July 26, 2007.

Information Technology: VA and DOD Are Making Progress in Sharing Medical
Information, but Remain Far from Having Comprehensive Electronic Medical
Records. [30]GAO-07-1108T . Washington, D.C.: July 18, 2007.

Defense Health Care: Comprehensive Oversight Framework Needed to Help
Ensure Effective Implementation of a Deployment Health Quality Assurance
Program. [31]GAO-07-831 . Washington, D.C.: June 22, 2007.

DOD's 21st Century Health Care Spending Challenges, Presentation for the
Task Force on the Future of Military Health Care. Statement delivered by
David M. Walker, Comptroller General of the United States. [32]GAO-07-766
-CG. Washington, D.C.: April 18, 2007.

Veterans' Disability Benefits: Long-Standing Claims Processing Challenges
Persist. [33]GAO-07-512T . Washington, D.C.: March 7, 2007.

DOD and VA Health Care: Challenges Encountered by Injured Servicemembers
during Their Recovery Process. [34]GAO-07-589T . Washington, D.C.: March
5, 2007.

VA Health Care: Spending for Mental Health Strategic Plan Initiatives Was
Substantially Less Than Planned. [35]GAO-07-66 . Washington, D.C.:
November 21, 2006.

VA and DOD Health Care: Efforts to Provide Seamless Transition of Care for
OEF and OIF Servicemembers and Veterans. [36]GAO-06-794R . Washington,
D.C.: June 30, 2006.

Post-Traumatic Stress Disorder: DOD Needs to Identify the Factors Its
Providers Use to Make Mental Health Evaluation Referrals for
Servicemembers. [37]GAO-06-397 . Washington, D.C.: May 11, 2006.

Military Disability System: Improved Oversight Needed to Ensure Consistent
and Timely Outcomes for Reserve and Active Duty Service Members.
[38]GAO-06-362 . Washington, D.C.: March 31, 2006.

VA and DOD Health Care: Opportunities to Maximize Resource Sharing Remain.
[39]GAO-06-315 . Washington, D.C.: March 20, 2006.

VA and DOD Health Care: VA Has Policies and Outreach Efforts to Smooth
Transition from DOD Health Care, but Sharing of Health Information Remains
Limited. [40]GAO-05-1052T . Washington, D.C.: September 28, 2005.

Federal Disability Assistance: Wide Array of Programs Needs to be Examined
in Light of 21st Century Challenges. [41]GAO-05-626 . Washington, D.C.:
June 2, 2005.

Veterans' Disability Benefits: Claims Processing Problems Persist and
Major Performance Improvements May Be Difficult. [42]GAO-05-749T .
Washington, D.C.: May 26, 2005.

DOD and VA: Systematic Data Sharing Would Help Expedite Servicemembers'
Transition to VA Services. [43]GAO-05-722T . Washington, D.C.: May 19,
2005.

VA Health Care: VA Should Expedite the Implementation of Recommendations
Needed to Improve Post-Traumatic Stress Disorder Services. [44]GAO-05-287
. Washington, D.C.: February 14, 2005.

VA and Defense Health Care: More Information Needed to Determine If VA Can
Meet an Increase in Demand for Post-Traumatic Stress Disorder Services.
[45]GAO-04-1069 . Washington, D.C.: September 20, 2004.

(290658)

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To view the full product, including the scope

and methodology, click on [46]GAO-07-1256T .

For more information, contact John H. Pendleton at (202) 512-7114 or
[email protected]; or Daniel Bertoni, at (202) 512-7215 or
[email protected].

Highlights of [47]GAO-07-1256T , a testimony before the Subcommittee on
National Security and Foreign Affairs, Committee on Oversight and
Government Reform, House of Representatives

September 26, 2007

DOD AND VA

Preliminary Observations on Efforts to Improve Health Care and Disability
Evaluations for Returning Servicemembers

In February 2007, a series of Washington Post articles disclosed
troublesome deficiencies in the provision of outpatient services at Walter
Reed Army Medical Center, raising concerns about the care for returning
servicemembers. These deficiencies included a confusing disability
evaluation system and servicemembers in outpatient status for months and
sometimes years without a clear understanding about their plan of care.
The reported problems at Walter Reed prompted broader questions about
whether the Department of Defense (DOD) as well as the Department of
Veterans Affairs (VA) are fully prepared to meet the needs of returning
servicemembers. In response to the deficiencies reported at Walter Reed,
the Army took a number of actions and DOD formed a joint DOD-VA Senior
Oversight Committee.

This statement provides information on the near-term actions being taken
by the Army and the broader efforts of the Senior Oversight Committee to
address longer-term systemic problems that impact health care and
disability evaluations for returning servicemembers. Preliminary
observations in this testimony are based largely on documents obtained
from and interviews with Army officials, and DOD and VA representatives of
the Senior Oversight Committee, as well as on GAO's extensive past work.
We discussed the facts contained in this statement with DOD and VA.

While efforts are under way to respond to both Army-specific and systemic
problems, challenges are emerging such as staffing new initiatives. The
Army and the Senior Oversight Committee have efforts under way to improve
case management--a process intended to assist returning servicemembers
with management of their care from initial injury through recovery. Case
management is especially important for returning servicemembers who must
often visit numerous therapists, providers, and specialists, resulting in
differing treatment plans. The Army's approach for improving case
management for its servicemembers includes developing a new organizational
structure--a Warrior Transition Unit, in which each servicemember would be
assigned to a team of three key staff--a physician care manager, a nurse
case manager, and a squad leader. As the Army has sought to staff its
Warrior Transition Units, challenges to staffing critical positions are
emerging. For example, as of mid-September 2007, over half the U.S.
Warrior Transition Units had significant shortfalls in one or more of
these critical positions. The Senior Oversight Committee's plan to provide
a continuum of care focuses on establishing recovery coordinators, which
would be the main contact for a returning servicemember and his or her
family. This approach is intended to complement the military services'
existing case management approaches and place the recovery coordinators at
a level above case managers, with emphasis on ensuring a seamless
transition between DOD and VA. At the time of GAO's review, the committee
was still determining how many recovery coordinators would be necessary
and the population of seriously injured servicemembers they would serve.

As GAO and others have previously reported, providing timely and
consistent disability decisions is a challenge for both DOD and VA. To
address identified concerns, the Army has taken steps to streamline its
disability evaluation process and reduce bottlenecks. The Army has also
developed and conducted the first certification training for evaluation
board liaisons who help servicemembers navigate the system. To address
more systemic concerns, the Senior Oversight Committee is planning to
pilot a joint disability evaluation system. Pilot options may incorporate
variations of three key elements: (1) a single, comprehensive medical
examination; (2) a single disability rating done by VA; and (3) a
DOD-level evaluation board for adjudicating servicemembers' fitness for
duty. DOD and VA officials hoped to begin the pilot in August 2007, but
postponed implementation in order to further review options and address
open questions, including those related to proposed legislation.

Fixing these long-standing and complex problems as expeditiously as
possible is critical to ensuring high-quality care for returning
servicemembers, and success will ultimately depend on sustained attention,
systematic oversight by DOD and VA, and sufficient resources.

GAO's Mission

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References

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  53. mailto:[email protected]
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