Readjustment Counseling Service: Vet Centers Address Multiple Client
Problems, but Improvement Is Needed (Letter Report, 07/17/96,
GAO/HEHS-96-113).

Pursuant to a congressional request, GAO reviewed the Department of
Veterans Affairs' (VA) Vet Center program, focusing on: (1) the
individuals served and the services provided; and (2) VA methodology for
determining whether Vet Center services are appropriate and effective.

GAO found that: (1) vet centers help certain veterans make a successful
transition from military to civilian life; (2) vet center services range
from assistance with basic needs and benefits to drug and alcohol abuse
and post-traumatic stress disorder (PTSD) counseling; (3) veterans who
have more serious psychological problems, such as PTSD, visit vet
centers more often than veterans with employment or benefit concerns;
(4) about 283,000 new clients used vet centers during fiscal years 1993
through 1995; (5) many veterans have social concerns that can be
addressed by other VA and non-VA programs, thus limiting the number of
center visits needed; (6) client visits are generally recorded
accurately in the workload reporting system, but program managers and
supervisors lack the information needed to oversee the program and
monitor staff activities and resources; and (7) VA has established
standards for determining whether treatment plans are appropriate, but
it has not developed a systematic approach for demonstrating that vet
center services are effective in meeting veterans' psychological needs.

--------------------------- Indexing Terms -----------------------------

 REPORTNUM:  HEHS-96-113
     TITLE:  Readjustment Counseling Service: Vet Centers Address 
             Multiple Client Problems, but Improvement Is Needed
      DATE:  07/17/96
   SUBJECT:  Veterans benefits
             Rehabilitation counseling
             Drug treatment
             Alcohol or drug abuse problems
             Rehabilitation programs
             Mental health care services
             Community health services
             Employment or training programs
             Health resources utilization
             Medical records
IDENTIFIER:  VA Readjustment Counseling Program
             VA Veterans Integrated Service Network
             VA Disabled Veteran Outreach Program
             VA Transitional Assistance Program
             VA Activity Reporting System
             
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Cover
================================================================ COVER


Report to the Chairman, Committee on Veterans' Affairs, U.S.  Senate

July 1996

READJUSTMENT COUNSELING SERVICE -
VET CENTERS ADDRESS MULTIPLE
CLIENT PROBLEMS, BUT IMPROVEMENT
IS NEEDED

GAO/HEHS-96-113

Vet Center Program

(101474)


Abbreviations
=============================================================== ABBREV

  M&M - mortality and morbidity
  PTSD - post-traumatic stress disorder
  RCS - Readjustment Counseling Service
  SARS - Service Activity Reporting System
  TAP - Transition Assistance Program
  VA - Department of Veterans Affairs
  VHA - Veterans Health Administration
  VISN - Veterans Integrated Service Network

Letter
=============================================================== LETTER


B-266316

July 17, 1996

The Honorable Alan K.  Simpson
Chairman, Committee on Veterans' Affairs
United States Senate

Dear Senator Simpson: 

The Department of Veterans Affairs (VA), through its Readjustment
Counseling Service (RCS), operates 205 community-based facilities
known as Vet Centers to help certain veterans make a successful
transition from military to civilian life.  This readjustment
counseling program, initially established by the Congress in 1979 to
assist Vietnam era veterans, has been expanded to cover veterans who
served in all areas of military conflict since Vietnam, including
Lebanon, Grenada, Panama, the Persian Gulf, and Somalia.  Vet Centers
also serve family members and significant others to the extent
necessary to help veterans.  Services provided by Vet Centers range
from assistance with basic needs and benefits to therapeutic
counseling for drug and alcohol abuse, sexual trauma, and
post-traumatic stress disorder (PTSD).\1

RCS is part of VA's Veterans Health Administration (VHA) and is
subject to its budget and administrative review.  However, within
VHA, which also manages VA medical centers, RCS has its own
organizational structure, manages its own resources, and evaluates
its own program. 

This report responds to your request for information about RCS' Vet
Center program to assist in the Committee's evaluation of the
appropriateness of the organizational structure of RCS and the
effectiveness of its programs.  It addresses the following areas: 

  -- Who are the individuals that Vet Centers serve and what services
     are provided? 

  -- How accurate is RCS' workload reporting system, and does it
     ensure that services reported are actually delivered? 

  -- How adequate is VA's methodology to determine whether Vet Center
     services are appropriate and effective? 

  -- Should RCS maintain an organizational structure within VHA that
     is separate from medical centers? 

In 1987, we reported on various aspects of VA's readjustment
counseling program and made recommendations for improvement in some
program areas.\2 Our report included observations on the accuracy of
RCS' database, the need for RCS to better monitor Vet Center
activities by making regional office site visits as required, and the
need to better evaluate the quality of Vet Center care.  This report
recognizes RCS' efforts in these areas and identifies the need for
further improvements. 

In performing this review, we visited RCS' central office in
Washington, D.C., four of RCS' seven regional offices,\3

and five Vet Centers.\4 At these locations we reviewed documentation,
discussed program activities with officials, and at three of the Vet
Centers we met with veterans to obtain their views on the program. 
We also obtained workload activity data for fiscal years 1993 through
1995 from 39 randomly selected Vet Centers that helped to describe
clients and services provided.  We also met with officials of several
veteran service organizations to obtain their views on the program. 
We performed our work between June 1995 and April 1996 in accordance
with generally accepted government auditing standards.  (See app.  I
for a detailed description of our scope and methodology.)


--------------------
\1 PTSD is a condition caused by severely stressful or traumatic
events such as military combat and may be chronic.  Its symptoms
include intense reliving of events, anxiety, sleep disturbance,
depression, and social isolation. 

\2 Vietnam Veterans:  A Profile of VA's Readjustment Counseling
Program (GAO/HRD-87-63, Aug.  26, 1987). 

\3 The RCS regional offices we visited are in Bay Pines, Florida;
Hines, Illinois; Denver, Colorado; and Providence, Rhode Island. 

\4 The Vet Centers we visited are in Cheyenne, Wyoming; Chicago,
Illinois; Norwich, Connecticut; Tampa, Florida; and White River
Junction, Vermont. 


   RESULTS IN BRIEF
------------------------------------------------------------ Letter :1

Vet Center counselors reported visiting with approximately 138,000
veterans during fiscal year 1995, 84,000 of whom were new to Vet
Centers.  Most veterans do not establish long-term relationships with
Vet Center counselors; however, those who do represent a core group
who use services over extended periods for serious psychological
problems such as PTSD.  Other veterans usually visit Vet Center
counselors only once or twice for social concerns such as employment
or benefit needs. 

Although Vet Centers track their number of visits with clients, RCS'
workload measurement system overcounts some activities and
undercounts others.  Also, the system does not track staff resources
used during client visits and cannot distinguish between client
visits requiring minimal staff time and visits that require extended
periods of staff effort. 

RCS has taken steps to help ensure that the services provided by Vet
Center staff are appropriate.  These steps include recurring
consultation and records reviews by supervisory and clinical
professionals within and external to Vet Centers, annual clinical
reviews by RCS regional officials, and increased RCS emphasis on the
credentials of its staff.  However, problems exist with documenting
client records, and RCS has not developed a systematic approach for
measuring the effectiveness of Vet Center services in meeting
clients' psychological needs. 

VA is currently implementing a new health care services management
structure known as the Veterans Integrated Service Networks (VISN) to
coordinate and integrate health care resources within 22 local
service networks.  The VISN structure recognizes Vet Centers as a
resource within each local network but continues RCS' organizational
independence within VHA.  Our work suggests that, at this time, RCS'
independence is consistent with its mission of providing both social
and psychological readjustment counseling services to veterans and
the developing nature of the VISN structure.  However, as VA
completes implementation of the VISN structure for its health care
services, reconsideration of RCS' organizational structure may be
warranted. 


   BACKGROUND
------------------------------------------------------------ Letter :2

Under the Veterans' Health Care Amendments of 1979 (P.L.  96-22), the
Congress authorized a temporary program of readjustment counseling
services for Vietnam era veterans who served from August 5, 1964, to
May 7, 1975, to assist them in the transition to postwar civilian
life.  At that time it was recognized that a veteran suffering from a
"readjustment problem" might exhibit "a low-grade motivational or
behavioral impairment" that interfered with interpersonal
relationships, job or educational performance, or overall ability to
cope with daily life.  This condition, in combination with other
symptoms, was later termed post-traumatic stress disorder (PTSD).  At
that time VA medical centers did not have special programs in place
to treat these problems.  Veterans who did go to VA medical centers
for treatment were usually admitted to the general psychiatric
service where these problems were not well understood. 

PTSD is caused by severely stressful or traumatic events such as
military combat, seeing people die, or incarceration as a prisoner of
war.  PTSD symptoms include intense reliving of the event in memory
or dreams, anxiety, sleep disturbance, depression, social isolation,
and an incapacity for intimate relations with others.  PTSD may not
be curable and can be a chronic condition with symptoms that are
stress-induced and effects that may increase with a person's age. 

The readjustment counseling program was authorized as a
community-based program separate from VA medical centers at least
partially on the premise that many Vietnam era veterans were so
distrustful and suspicious of government institutions that they would
not come to VA's inpatient hospitals to seek care.  It was also
believed that providing mental health services in outpatient
facilities would help to remove the stigma often associated with
so-called "mental illness." The guiding principle was that
readjustment services should be provided on an outpatient basis,
regardless of the veteran's income, and that unnecessary barriers to
care should be removed.  In addition, requests for counseling should
be speedily honored with a minimum of red tape.\5 In passing the
authorizing legislation, the Congress recognized that Vet Centers
would provide services to address not only psychological problems,
but also other aspects of readjustment.  Over the intervening 17
years, the Congress has expanded the program to include veterans who
participated in all post-Vietnam military conflicts.  The Congress
also made the Vet Center program permanent and specifically
authorized VA, supported by Vet Centers, to provide counseling to
veterans who experienced sexual trauma while on active duty. 

As currently configured, the Director of RCS reports to the Under
Secretary for Health and is responsible for overall program oversight
and direction.  The Director is assisted in many management
responsibilities by staff in seven regional offices.\6 Each regional
office is headed by a regional manager who is responsible for
monitoring Vet Center services, hiring and training Vet Center staff,
enhancing relations with other VA facilities, and assessing program
performance. 

Two clinical field managers are responsible for monitoring the
quality of clinical services provided by Vet Centers.  One, based in
Bay Pines, Florida, is responsible for all Vet Centers in the East
and the other, in Denver, is responsible for western Vet Centers. 

To meet clients' needs, Vet Centers provide easy, "hassle free"
access to a variety of services, including individual, group, and
family counseling; referrals to other VA and community resources; and
outreach activities to identify veterans needing assistance.  Vet
Centers are also authorized to provide services to family members and
significant others to the extent necessary to help veterans who are
being treated by program staff.  In assisting clients, counselors
draw from an array of psychosocial services. 

Social services address problems such as basic needs, unemployment,
and veterans benefits.  Social services include coordinating with
community providers for basic services, state representatives of
Disabled Veteran Outreach Programs who work to match veterans with
employment opportunities, and VA benefit offices who attempt to
assist veterans with the benefits to which they are entitled. 
Psychological services address issues such as PTSD, drug and alcohol
abuse, and sexual trauma.  Vet Center staff may either directly
provide the psychological care needed or refer the veterans to other
sources of treatment.  For example, veterans who need medications or
inpatient care for PTSD are generally referred to VA medical centers. 

During the first 16 years of the program, approximately 1.2 million
veterans had about 7.3 million visits with Vet Center counselors. 
RCS currently operates 205 Vet Centers at an estimated fiscal year
1996 cost of about $64 million.\7 Vet Centers are generally located
in community storefront facilities and staffed with counselors who
are often veterans themselves.  In general, each Vet Center has three
to six staff members, including a team leader,\8

counselor(s), and an office manager.  Ten of the 205 Vet Centers are
also known as Veterans Resource Centers and may be staffed with as
many as six counselors.  Some Vet Centers contract with private
mental health professionals in locations that are distant from the
Vet Center or other VA providers.  These contractors provide
therapeutic services to veterans with psychological problems, such as
PTSD. 

Although located apart from established VA facilities, each Vet
Center is administratively assigned to a VA support facility (usually
a VA medical center) that provides services such as purchasing
supplies, paying bills, and maintaining the payroll. 

Currently many medical centers have their own inpatient and
outpatient programs specifically to address PTSD-related problems. 
In some cases, veterans need inpatient care to address debilitating
symptoms while others may need medications to treat symptoms but only
on an outpatient basis.  Today there are 61 inpatient and 93
outpatient specialized medical center programs for veterans who are
diagnosed as having PTSD. 

Over the life of the Vet Center program, questions have been raised
about the continued need for readjustment counseling services,
whether, organizationally, RCS should be more closely connected with
VA medical centers, and what program management improvements could be
made.  A number of studies have addressed these questions, including
our 1987 report on the readjustment counseling program.  These
studies have consistently recommended the continuation of
readjustment counseling services and RCS' organizational independence
within VHA.  (See the bibliography for a list of major studies and
reports related to RCS' Vet Center program and the diagnosis and
treatment of PTSD.)


--------------------
\5 Veterans' Health Care Amendments of 1979, Report of the Committee
on Veterans' Affairs, United States Senate, Report No.  96-100, pp. 
27-31. 

\6 RCS regional offices are in Baltimore, Maryland; Bay Pines,
Florida; Benicia, California; Dallas, Texas; Denver, Colorado; Hines,
Illinois; and Providence, Rhode Island. 

\7 See app.  II for a list of all Vet Center locations. 

\8 The team leader directly supervises and oversees the performance
of Vet Center staff in the provision of outreach, counseling, and
referral services.  Duties include selecting and evaluating staff,
administering the budget, collaborating with staff in the supporting
VA medical facility, and providing direct clinical services. 


   MANY VETERANS ARE SERVED, BUT
   FEW REQUIRE EXTENDED VET CENTER
   SERVICES
------------------------------------------------------------ Letter :3

Approximately 138,000 veterans visited with Vet Center staff during
fiscal year 1995,\9 of which about 84,000 were new veterans to the
program.\10 (See app.  III for RCS' fiscal year 1995 Service Activity
Reporting System (SARS) data.) Most veterans do not remain in contact
with counselors over extended periods.  Nevertheless, veterans who
have more serious psychological problems, such as PTSD, represent a
core group who visit with Vet Center staff, on average, more often
than veterans with social concerns such as the need for employment or
veterans' benefits. 

While RCS reports that a large number of veterans are seen each year,
most do not establish long-term relationships with Vet Center
counselors.  RCS reported that nearly 283,000 new veteran clients
visited Vet Centers during fiscal years 1993 through 1995.  Of these
veterans, we estimate based on our sample\11 that 59 percent had only
one visit with Vet Center staff, 80 percent had three or fewer
visits, and 90 percent had seven or fewer staff visits during the
3-year period.  The remaining 10 percent of Vet Center clients
visited eight or more times.\12 The 17 counselors and team leaders we
met with at five Vet Centers each had an average clinical caseload of
about 26 clients. 

New veterans with psychological problems such as PTSD and sub-PTSD\13
were seen more often by Vet Center counselors.  For example, veterans
with PTSD averaged 5 visits and those with sub-PTSD averaged 4.3 Vet
Center staff visits during fiscal year 1995.  Over a 3-year period,
veterans with these problems averaged 9.4 and 6.4 Vet Center staff
visits, respectively.  Conversely, veterans who had social concerns,
such as employment and VA benefit needs, averaged 1.9 and 1.5 visits
during fiscal years 1993 through 1995.\14

A relatively small percentage or core group of veterans are long-term
users of the Vet Center program.  For example, of the veterans who
first visited with a Vet Center counselor before fiscal year 1993, 20
percent were seen 13 or more times through fiscal year 1995; 10
percent had 32 or more visits in that period.  In addition, during
our visits with 50 clients (veterans and family members) at three Vet
Centers, some of the veterans and spouses commented that the Vet
Center staff were responsible for saving these veterans' lives and
they very much needed the Vet Center program.  These veterans also
stated that they preferred to obtain services at Vet Centers rather
than VA medical centers.  As a result, many of these veterans now,
and in the foreseeable future, are likely to continue to use the
counseling services provided by this community-based program. 

Family members and significant others constitute about 8 percent of
the total number of visits.  We found that these clients, on average,
have fewer visits with Vet Center counselors than veterans in all
areas, except for marriage and family problems, where significant
other and family member visits with Vet Center staff exceeded those
of veterans over our 3-year period of review.  Table 1 shows the
average and median number of visits by new veterans and family and
significant others by problem areas addressed for fiscal year 1995. 
Table 2 shows data for the 3-year study period, fiscal years 1993
through 1995. 



                          Table 1
          
             FY 1995 Visits by New Veterans and
             Family and Significant Others, by
                     Problem Addressed


Problem          Average      Median   Average      Median
addressed         visits      visits    visits      visits
--------------  --------  ----------  --------  ----------
Sexual trauma        6.7         3.0       2.8         2.0
PTSD                 5.0         2.0       2.7         1.0
Sub-PTSD             4.3         2.0       2.7         1.0
Marital/             3.1         1.0       2.8         1.0
 family
Psych/other          3.0         1.0       1.9         1.0
Legal                2.4         1.0       1.3         1.0
Drug/alcohol         2.4         1.0       1.3         1.0
Homeless             1.8         1.0       1.0         1.0
Employment           1.6         1.0       1.1         1.0
Basic needs          1.6         1.0       1.1         1.0
Other                1.5         1.0       1.1         1.0
Medical              1.4         1.0       1.2         1.0
Benefits             1.3         1.0       1.2         1.0
----------------------------------------------------------
Source:  GAO analysis of SARS data. 



                          Table 2
          
           FY 1993-95 Visits by New Veterans and
             Family and Significant Others, by
                     Problem Addressed


Problem          Average      Median   Average      Median
addressed         visits      visits    visits      visits
--------------  --------  ----------  --------  ----------
Sexual trauma       11.2         4.0       4.8         2.0
PTSD                 9.4         3.0       4.1         1.0
Sub-PTSD             6.4         2.0       3.6         1.0
Marital/             4.5         2.0       4.8         2.0
 family
Psych/other          3.8         1.0       2.8         1.0
Drug/alcohol         3.0         1.0       1.5         1.0
Homeless             2.5         1.0       1.1         1.0
Legal                2.2         1.0       1.4         1.0
Other                2.1         1.0       1.2         1.0
Employment           1.9         1.0       1.2         1.0
Basic needs          1.7         1.0       1.2         1.0
Medical              1.6         1.0       1.4         1.0
Benefits             1.5         1.0       1.3         1.0
----------------------------------------------------------
Source:  GAO analysis of SARS data. 

We found two reasons that partially explain why most veterans do not
continue to use Vet Centers after a few visits.  First, many veterans
have social concerns that can be addressed in three or fewer visits
with staff.  These visits might include helping clients with basic
needs, legal problems, employment matters, and homelessness issues. 
Vet Center staff may draw on their own resources to assist with these
problems or may refer clients to other VA and non-VA programs, thus
limiting the number of visits needed. 

Second, RCS restricts veterans from World War II, the Korean War, and
noncombat veterans from conflicts other than Vietnam to three visits
with Vet Center counselors.  In fiscal year 1995, RCS reported that
almost one-fourth of the new veteran clients were from these eras. 


--------------------
\9 For the purpose of our analysis, Vet Center visits include
face-to-face and substantive telephone contacts between Vet Center
counselors and clients. 

\10 A veteran who has never had an open/active record at a particular
Vet Center is defined by RCS as a "new veteran."

\11 With RCS assistance, we obtained workload measurement data from a
sample of 39 Vet Centers for fiscal years 1993 through 1995.  The
data from these centers provide a national estimate based on the
sample. 

\12 In our sample, the highest number of visits was 236. 

\13 Sub-PTSD is a clinical diagnosis for someone found to have been
exposed to a traumatic event but who fails to meet all of the
criteria to support a diagnosis of PTSD. 

\14 Vet Center staff are responsible for reporting the problems
addressed during each client's visits, and counselors can report up
to three problems per visit.  For each subsequent client visit, Vet
Center staff record problems in the same manner except that the
problems addressed may be different, with the exception of PTSD. 
Once a veteran is identified with PTSD, it is automatically counted
as one of the problems addressed in all future contacts. 


   VET CENTER WORKLOAD REPORTING
   SYSTEM NEEDS IMPROVEMENT
------------------------------------------------------------ Letter :4

SARS is RCS' primary means for collecting productivity data from its
Vet Centers.  In our review of 40 records in four Vet Centers, we
found that data on client visits were, for the most part, accurately
entered in the SARS database.  However, refinements are needed to
make the information more useful.  SARS, as currently designed,
produces data that emphasize the quantitative rather than the
qualitative aspects of the Vet Center program.  For example, it does
not accurately describe Vet Center operations or distinguish between
client visits requiring minimal staff time and visits that require
extended periods of staff effort.  As a result, the core group of
veterans who use the largest portion of Vet Centers' staff resources
are not readily identifiable, and managers and supervisors may lack
information needed to oversee the program and monitor staff
activities. 


      CLIENT VISITS ARE GENERALLY
      RECORDED ACCURATELY IN RCS'
      WORKLOAD REPORTING SYSTEM
---------------------------------------------------------- Letter :4.1

Client visits were accurately recorded at three of the four Vet
Centers where we compared our sample of client records with
information in the SARS database.  All Vet Center staff are required
to maintain handwritten daily activity log sheets that record each of
their client contacts throughout the day.  These daily activity logs
are the original documents from which SARS data are entered.  To test
the accuracy of the SARS database, we compared the SARS data, daily
activity logs, and 40 client records to determine whether information
about client visits was consistent among the three sources.  We found
the information was correctly recorded at three of the four Vet
Centers we visited and, in total, was accurate in 95 percent (38 of
40) of the cases.  At one Vet Center, the client visits were shown in
the progress notes in two of the client records we reviewed but not
in the daily logs or SARS. 


      WORKLOAD SYSTEM DOES NOT
      ADEQUATELY REPORT STAFF
      ACTIVITIES
---------------------------------------------------------- Letter :4.2

The workload reporting system does not provide adequate information
about the activities conducted by Vet Center staff.  For example,
when reporting activities in SARS, staff in some Vet Centers count
meetings they conduct with active duty personnel in the Transitional
Assistance Program (TAP).\15 These meetings may include 10 to 100
people, each of whom may be counted in SARS as an individual client
visit. 

Our analysis of the data from 39 Vet Centers showed that visits with
active duty personnel accounted for more than 21 percent of the
outreach visits performed in 5 of the 39 Vet Centers during fiscal
year 1995.  Moreover, in three of the five Vet Centers, active duty
personnel accounted for over two-thirds of the total number of
outreach visits. 

While contacting military personnel who are about to be separated
from active duty is a legitimate Vet Center outreach activity,
recording group meetings as individual client visits makes them
appear to be the same as visits that involve extended counseling. 
This method of counting and recording Vet Center visits inflates
productivity data. 

Vet Center staff also told us that several services and activities
they provide or participate in are not recorded in the workload
reporting system.  We were told, for example, that staff help clients
through crisis situations, such as suicidal periods, provide
assistance with support groups for family members of active duty
personnel who have been deployed for an overseas mission, and
participate in community events during holidays such as Veterans Day. 
These and similar types of actions are not recorded in the workload
reporting system, which contributes to understating the activities
performed by Vet Center staff. 

Furthermore, the workload reporting system does not collect
information to determine how Vet Center staff resources are used. 
Through fiscal year 1992, time spent with clients was recorded by Vet
Center staff; however, this information is no longer included in
SARS.  The time spent by counselors to help clients can vary
dramatically.  In some instances, counselors may spend 15 minutes and
make only one or two phone calls to provide the assistance their
clients need.  In other situations, counselors may spend all day
helping clients cope with serious situations and more complex issues. 
Without information on how time is spent, supervisors cannot (1)
readily identify the core group of clients who use the largest
portion of staff resources, (2) measure how staff allocate their time
over a given period, or (3) determine whether the time spent with
certain clients is appropriate. 


--------------------
\15 TAP was established to provide active duty personnel nearing
separation from military service with employment and training
information.  Vet Center counselors meet with them to describe the
services eligible veterans can get from the centers. 


   PROCESSES AND STAFFING IN
   PLACE, BUT DOCUMENTATION OF
   RECORDS AND PROGRAM
   EFFECTIVENESS NEED TO BE
   ADDRESSED
------------------------------------------------------------ Letter :5

RCS has taken steps to ensure that Vet Center services are
appropriate, but problems exist with documenting client records and
demonstrating, on a systematic basis, that these services are
effective.  Activities to ensure that the services provided by Vet
Center staff are appropriate include recurring consultation and
records reviews by supervisory and clinical professionals within and
external to Vet Centers, annual clinical reviews by RCS regional
officials, and increased RCS emphasis on the credentials of its
staff.  However, some clients' records are not well documented, and
RCS has not developed a systematic approach for demonstrating that
the Vet Center program is effective, on a continuing basis, in
meeting the psychological needs of its clients. 


      PROCESSES IN PLACE TO REVIEW
      THE APPROPRIATENESS OF VET
      CENTER SERVICES
---------------------------------------------------------- Letter :5.1

Since our 1987 report, RCS has instituted processes to ensure that
services provided to its clients are appropriate.  RCS has
established standards for Vet Center clinical records and case
reviews by supervisory and clinical staff.  During the required
evaluations, Vet Center team leaders, regional office staff, and
clinical coordinators review current client cases to determine
whether (1) records are adequately documented, (2) treatment plans
are being followed and progress made toward the treatment goals, and
(3) treatment services are appropriate.  Table 3 summarizes these
activities. 



                          Table 3
          
            Summary of Activities to Ensure the
           Appropriateness of Vet Center Services

Activity        Performed by    Description
--------------  --------------  --------------------------
Clinical        Vet Center      Monthly reviews of client
reviews of      staff           records are performed by
client records                  team leaders with clinical
                                backgrounds and/or the
                                clinical coordinator on
                                staff at each Vet Center
                                to evaluate case
                                documentation,
                                appropriateness of care,
                                and progress toward
                                treatment goals.

Site reviews    Regional        Annual clinical reviews
                office staff    are conducted at all Vet
                                Centers. A sample of
                                client records is reviewed
                                for documentation and
                                appropriateness of care.

External        VA medical      All Vet Centers are
clinical        center or       required to undergo at
reviews         contract staff  least 4 hours of monthly
                                external clinical
                                consultation. The sessions
                                review the assessment and
                                treatment planning for all
                                active cases.

Crisis          Vet Center      Vet Centers have plans
intervention    staff           that describe the
                                appropriate method for
                                addressing crisis
                                situations such as suicide
                                threats. The plans aim to
                                reduce the (1) likelihood
                                of a crisis at a Vet
                                Center and (2) severity of
                                a crisis when it occurs.
                                Staff seek to identify
                                clients at risk of
                                dangerous behaviors to
                                provide them with the
                                means of handling their
                                situations.

Mortality and   Regional        M&M reviews are conducted
morbidity       office and Vet  on all suicide cases and
(M&M) reviews   Center staff    serious suicide attempts
                                to, among other things,
                                determine (1) if care was
                                appropriate and adequate,
                                (2) if other steps and
                                interventions might have
                                altered the outcome, and
                                (3) whether Vet Center
                                practices are adequate.
----------------------------------------------------------

      INCREASED EMPHASIS GIVEN TO
      VET CENTER STAFF CREDENTIALS
---------------------------------------------------------- Letter :5.2

Over time, RCS has enhanced the credentials of the Vet Center staff
in order to meet the psychological counseling needs of veterans
suffering with clinically diagnosed PTSD and sub-PTSD.  Originally,
Vet Centers were to serve as outreach, entry, and treatment points
for Vietnam veterans, many of whom were unwilling to use mainstream
VA programs.  However, the Vet Centers soon became the preferred
location for some Vietnam era veterans to obtain psychological
treatment services. 

To meet the clinical needs of clients suffering with psychological
readjustment problems, RCS strengthened the educational backgrounds
of key staff.  For example, as of January 1996, RCS reported that 87
percent (179 of 205) of its Vet Center team leaders had master's or
doctorate degrees.  In 17 of 18 Vet Centers with team leaders holding
bachelor's degrees or less, other staff members had master's or
doctorate degrees.  In seven of eight Vet Centers without team
leaders, other staff members also had master's or doctorate degrees. 
The other two Vet Centers were staffed with personnel who held less
than a bachelor's degree.  At these two Vet Centers, we were told
that the clinical coordinator from another Vet Center and the PTSD
clinical team at a nearby VA medical center provide clinical
consultation.  See table 4 for a summary of the educational levels of
Vet Center team leaders. 



                          Table 4
          
             Summary of Vet Center Team Leader
                  Educational Backgrounds

                    (As of January 1996)

Vet Center team leader
educational backgrounds              Number   Percentage\a
----------------------------  -------------  -------------
Doctorate degree                         26           12.7
Master's degree                         153           74.6
Bachelor's degree                        13            6.3
Less than bachelor's degree               5            2.4
Vacant position                           8            3.9
----------------------------------------------------------
\a Because of rounding, column does not equal 100 percent. 

Source:  RCS Staffing List for January 28, 1996. 

Vet Center staff receive in-service training to further their
professional development and, in 1995, RCS conducted its first
national team leader training conference. 


      DOCUMENTATION OF CLIENTS'
      RECORDS CONTINUES TO BE A
      PROBLEM
---------------------------------------------------------- Letter :5.3

In 1987, we reported that about one-third of the client files we
reviewed inadequately documented the reasons for the clients' visits
and the assistance given them.  Although RCS has increased its
monitoring of Vet Centers, the documentation of clients' records
continues to be a problem.  As previously mentioned, RCS' regional
office staff conduct annual clinical reviews of Vet Centers within
their regions.  To monitor RCS' self-assessment of the quality of
services and the results of treatment Vet Centers provided to
veterans, we reviewed the fiscal year 1995 results from clinical site
visits in the four regions we visited.\16

Regional officials reported various Vet Center deficiencies in record
keeping and other required activities.  Record keeping problems
included inadequate documentation of treatment plans, military
histories, and progress notes.  Forms that would have provided client
information were sometimes missing from files, incomplete, or needed
updating.  For example, one region found 35 percent of its Vet
Centers had deficiencies with the military history forms.  In the
four regions, RCS regional officials reported deficiencies in client
treatment plans at 38 percent of the Vet Centers. 

Other problems regional staff cited during Vet Center visits were
associated with activities such as team leader record reviews and
counselor follow-up of clients.  For example, 26 percent of the team
leaders in the four regions were not providing appropriate clinical
reviews or supervision as RCS policy requires.  Moreover, 19 percent
of the Vet Centers were not documenting follow-up contacts with
clients.  See table 5 for a summary of the deficiencies reported by
RCS regional officials in the four regions we visited during their
fiscal year 1995 reviews. 



                          Table 5
          
             Summary of Vet Center Deficiencies
                  Reported by Four Regions

                     (Fiscal year 1995)

                              Number of Vet     Percentage
                               Centers with           with
Deficiency cited                 deficiency   deficiencies
----------------------------  -------------  -------------
Treatment plans                          45             38
Military history                         30             26
Team leader file reviews or              30             26
 supervision
Progress notes                           27             23
Follow-up contact                        22             19
Psychosocial assessment                  19             16
Health history                           17             15
Closing summaries                        16             14
----------------------------------------------------------
Source:  RCS regional office clinical site visit reports. 

Our own review of client records revealed findings similar to those
of the regional staffs.  In a sample of 90 client records, we found
that in 26 (29 percent), forms such as problem lists and military
histories were missing or incomplete. 

While RCS has procedures in place for determining whether clients
received appropriate care, records are often not well documented and
clinical record reviews are not always performed.  Missing or
incomplete clinical file information prevents an adequate assessment
of the nature and quality of services rendered to veterans.  The RCS
director acknowledged that documentation within client records is a
problem, and he has initiated actions to improve record keeping
practices, such as standardizing client treatment files. 


--------------------
\16 The four regions have a total of 119 Vet Centers under their
jurisdiction, of which 117 had clinical site visits during fiscal
year 1995.  The 117 Vet Centers included in our analysis of four
regions represent 57 percent of the program's centers. 


      SYSTEMATIC APPROACH NEEDED
      TO EVALUATE PSYCHOLOGICAL
      SERVICES
---------------------------------------------------------- Letter :5.4

RCS does not have a systematic approach to demonstrate whether the
Vet Center program is effective, on a continuing basis, in meeting
the psychological needs of its clients.  Although PTSD may not be
curable, improved record keeping would allow program officials to
examine the progress made as a result of treatment services.  In
1987, we concluded that RCS had little assurance that its centers
were providing quality care because clinical record keeping practices
and file review procedures were inadequate.  Also, in May 1991, VA's
Deputy Assistant Secretary for Program Coordination and Evaluation
recommended, among other things, that RCS and the Mental Health and
Behavioral Sciences Service establish a joint program evaluation and
research component to include mechanisms for developing ongoing
outcome data to measure the effectiveness of all PTSD programs.\17

RCS officials acknowledge that outcome measures have not been
developed for the Vet Center program but said they have relied on
other ways of determining how well centers are serving their clients. 
For example, clinicians review records to determine whether clients
are receiving appropriate care and making progress toward their
treatment goals.  Other methods, such as surveys of client
satisfaction with Vet Center services, stability in clients' work
lives, and improved family relationships are used by RCS officials as
outcome measures in evaluating the effectiveness of the program. 

RCS has been associated with two efforts that addressed the
effectiveness of Vet Centers.  In 1991, it undertook a study with the
National Center for PTSD of 1,006 Persian Gulf war zone veterans to
evaluate the prevalence of PTSD over time.  They found that veterans
who obtained psychological treatment at Vet Centers upon their return
from the Persian Gulf showed lower levels of PTSD after approximately
6 months than those who were not immediately treated.\18 PTSD
prevalence among veterans who sought psychological treatment from Vet
Centers decreased from 26.9 to 19.4 percent.  On the other hand, the
prevalence of PTSD symptoms among veterans who used Vet Centers but
did not seek psychological counseling increased from 7.8 to 9.8
percent.  RCS officials concluded, among other things, that the Vet
Center treatment model of providing outreach, social and economic
services, and psychological counseling for PTSD is appropriate for
the needs of returning war veterans. 

In May 1995, RCS reported the results of a nationwide customer
satisfaction survey it conducted of a random sample of 1,112 veterans
who used the Vet Centers during fiscal years 1988 and 1991.  On the
basis of a 30-percent response rate, RCS found that 90 percent of
these clients indicated they would recommend the Vet Center program
to other veterans.  RCS officials also reported that clients who
visited Vet Centers more often were more likely to benefit from the
services provided.  For example, of those surveyed, the clients who
made between 25 to 49 visits reported that they derived the most
benefit from Vet Center services. 

RCS' actions and evaluation efforts do not, however, clearly
demonstrate the overall effectiveness of Vet Centers in meeting the
psychological needs of their clients.  While assessments of the
quality of the care clients receive are made during internal and
external clinical reviews, these reviews are limited to a sample of
current clients and do not measure progress on a program basis.  A
systematic approach is needed for measuring outcomes and evaluating
the extent to which Vet Centers are effective, on a continuing basis,
in treating their clients, but RCS has not developed one.  Without a
systematic evaluation approach, RCS lacks the information necessary
to demonstrate that its psychological services are effective. 


--------------------
\17 Department of Veterans Affairs, A Program Evaluation of the
Department of Veterans Affairs Post Traumatic Stress Disorder (PTSD)
Programs, report no.  1990-04 (Washington, D.C.:  Office of the
Deputy Assistant Secretary for Program Coordination and Evaluation,
May 1991). 

\18 These results relate to the PTSD levels in the 226 veterans who
were tracked over a 6-month period. 


   CURRENT RCS ORGANIZATIONAL
   INDEPENDENCE WITHIN VHA DOES
   NOT CONFLICT WITH ASSIGNED
   RESPONSIBILITIES
------------------------------------------------------------ Letter :6

In meeting their readjustment counseling responsibilities as defined
by authorizing legislation, Vet Centers provide both social and
psychological services to veterans.  Although the psychiatric
treatment in Vet Centers is similar to the outpatient PTSD care
provided by some medical centers, the two types of facilities
generally focus on different clients and missions. 

The health care management structure VA is currently implementing
maintains RCS' organizational independence within VHA.  Our work
suggests that RCS independence, at this time, is consistent with its
mission of providing both social and psychological readjustment
counseling services to veterans and the developing nature of VHA's
VISN structure.  Once the VISN structure has been fully implemented,
reconsideration of RCS' organizational structure may be warranted. 


      ATTITUDES HAVE CHANGED SINCE
      VET CENTER PROGRAM WAS
      ESTABLISHED
---------------------------------------------------------- Letter :6.1

The alienation and hostility Vietnam era veterans felt toward the VA
system at the end of the war have diminished for many to the point
that they are now more likely to seek clinical care at VA medical
centers.  While many veterans would rather obtain the therapeutic
services they need from Vet Center staff, reluctance to use the VA
system is often related to the bureaucracy veterans encounter or
expect to encounter when visiting a VA medical center. 

Some Vet Center counselors with whom we met estimated that the
segment of all Vietnam era veterans who are still unwilling to seek
help from medical centers ranges from 10 to 35 percent.  More
favorable veteran attitudes toward VA medical center care relate to,
in part, the time that has passed since the war ended and
improvements in medical center staff understanding and treatment of
PTSD. 

During our discussions with veterans at three of the five Vet Centers
we visited, many told us that they prefer to receive their care in
the Vet Center rather than the medical center.  However, a number of
them indicated that they were using or had used medical center
services as well.  These veterans, many of whom were long-term
clients of the Vet Centers, were not averse to using medical center
services when needed. 

RCS staff told us that over the past several years, referrals of
veterans to medical centers for PTSD care have increased.  Some staff
stated that they have been instrumental in easing veterans'
resistance to seeking medical center care.  In some cases, clients
are referred for inpatient care or for medication that the Vet Center
staff do not prescribe.  We were told that Vet Center staff not only
refer veterans to medical centers but may, if necessary, take the
veterans there. 


      VET CENTERS AND MEDICAL
      CENTERS GENERALLY SERVE
      DIFFERENT CLIENTS AND
      MISSIONS
---------------------------------------------------------- Letter :6.2

Many medical centers support their own inpatient and outpatient
programs to specifically address PTSD-related problems.  In some
cases, veterans need inpatient care to address debilitating symptoms,
while others may need medications to treat symptoms but only on an
outpatient basis.  Today, there are 61 inpatient and 93 outpatient
specialized medical center programs designed to meet the needs of
veterans diagnosed as having PTSD.  In contrast, Vet Centers do not
provide inpatient care or medical prescriptions but do provide
services that medical centers cannot or do not provide. 

When compared with medical centers, Vet Centers serve different
roles, purposes, and benefits by

  -- being located in small, community-based storefront facilities;

  -- providing care to all veterans who served during the authorized
     eras of conflict without regard to their income (generally, to
     receive free medical center services for non-service-connected
     illness, veterans must have incomes below a specified amount);

  -- providing counseling to veterans' family members and significant
     others to assist with the veterans' readjustment (medical
     centers seldom include others in veterans' treatment);

  -- providing counseling for social and economic needs such as
     employment and VA benefits, which is generally not provided by
     medical centers;

  -- performing outreach activities to identify veterans who could
     benefit from Vet Center or other VA services (medical centers
     perform little or no outreach);

  -- establishing close ties with local service providers and linking
     veterans with the services they need;

  -- hiring a staff of team leaders and counselors of whom about 60
     percent are veterans of Vietnam and later conflicts; and

  -- if needed, working with veterans for longer periods than medical
     centers generally do. 

Some medical centers do provide services that Vet Centers cannot by

  -- providing psychological services for veterans from World War II
     and the Korean War, which Vet Centers are not authorized to
     serve on an extended basis;

  -- dealing with veterans severely affected by psychological
     problems who are more appropriately cared for in medical
     centers; and

  -- developing specialized outpatient programs that provide
     medication for veterans with PTSD, if needed. 

Vet Center and medical center services also differ in their treatment
settings, staff expertise, and emphasis.  Medical centers focus
primarily on psychological issues while Vet Centers address social as
well as psychological issues.  As a result, some veterans are more
likely to contact and be successfully treated in Vet Centers, while
others are more likely to contact and be treated in medical centers. 


      HOW DOES RCS FIT INTO VA'S
      VISION FOR RESTRUCTURING ITS
      HEALTH CARE SYSTEM? 
---------------------------------------------------------- Letter :6.3

VHA is implementing a new plan for managing its health care
resources.  Recognizing that major changes are occurring in the
health care environment, VHA intends to increase ambulatory care
access points, emphasize primary care, decentralize decision-making,
and integrate VA's delivery assets to provide an interdependent,
interlocking system of care.  Vet Centers will be an indirect part of
that interlocking system. 

In 1995, VA operated 159 medical centers, 375 ambulatory clinics, 133
nursing homes, 39 domiciliaries, and 205 Vet Centers.  VHA's plan
calls for these providers to be reorganized into a community-based
system founded on the concept of coordinating and integrating all
health delivery assets into 22 Veterans Integrated Service Networks
(VISN).  Under VHA's plan, the geographic area each VISN serves is
defined by patient referral patterns; the number of beneficiaries in
each area; facilities needed to support and provide primary,
secondary, and tertiary care; and, to a lesser extent, political
jurisdictional boundaries such as state borders.  While hospitals
will remain an important, albeit less central, component of each
network, the integration of ambulatory, acute, and extended care
services will be emphasized to provide a coordinated continuum of
care. 

Under VHA's VISN plan, RCS will remain independent within VHA, and
RCS Vet Center coordinators will act as the link with, but will not
report to, VISN directors.  VHA's Deputy Under Secretary for Health
told us that RCS will retain its independence under the plan
primarily for three reasons.  First, VHA's top officials believed RCS
had done a good job of serving its clients in the past, and they did
not want to draw it into the difficulties of implementing a major
medical program reorganization.  Second, Vet Centers offer a unique
approach to client care in that they are community-based, they act as
access points for many veterans seeking VA services, and they perform
outreach to the veteran population.  Finally, these officials
believed that in a number of locations, good interaction and
coordination occurs between Vet Center and medical center staff and
they did not want to interrupt it.  The Deputy Under Secretary stated
that as the VISN structure is implemented and as network services
become more integrated, VHA may need to reassess RCS' organizational
relationship within that structure. 

Once the VISN structure is in place, VA can reassess the role and
relationship Vet Centers have with other VA health care providers and
how Vet Centers can best be integrated into VA's continuum of care to
serve the greatest number of veterans with the health care resources
currently available.  For example, in some communities, the Vet
Center represents the only nearby access point veterans have to VA
personnel and the care and services available through the VA system. 
Forty-one Vet Centers are more than 30 miles from a VA medical center
or VA outpatient clinic and 27 of these are more than 50 miles from
such facilities.  For veterans in those communities, the Vet Centers
not only provide psychosocial services but also act as access and
referral points for needed medical center services.  In other
communities, Vet Centers are close to VA medical centers; 133 are
within 10 miles of a VA medical center or an outpatient clinic. 
Future consideration of Vet Center locations and their relationship
with other VA providers might best take place within the context of
each VISN's geographic area. 

RCS' continued independence is consistent with recommendations made
by past studies.  In its January 1986 report, the Vet Center Planning
Committee concluded that of the five options considered for RCS'
future organizational structure, the one that would maintain RCS'
organizational independence was the most appropriate.  Two more
recent studies--the May 1991 VA program evaluation of PTSD programs
and the April 1995 biannual report of the Advisory Committee on the
Readjustment of Vietnam and Other War Veterans--also concluded that
RCS' current independent organizational structure should be
maintained.\19


--------------------
\19 For complete citations, please see the bibliography. 


   CONCLUSIONS
------------------------------------------------------------ Letter :7

Vet Centers continue to provide a range of services to a large number
of veterans and their significant others.  We found three program
areas, however, that need improvement.  First, the workload reporting
system, SARS, focuses only on quantitative, not qualitative, aspects
of the Vet Center program.  Hence, although SARS reports productivity
data, it provides insufficient information about actual Vet Center
activities and the resources used to perform them.  Second, the
documentation in client case files is not always sufficient to ensure
that veterans are receiving the care they need and that an adequate
assessment of the appropriateness and quality of services rendered
can be made.  And third, RCS lacks a method of demonstrating that its
treatment services are effective in meeting the psychological needs
of Vet Center clients. 

VA's current restructuring of medical services under the VISN concept
maintains RCS' independence within VHA.  We believe that continuing
RCS' organizational independence is consistent with its mission of
providing both social and psychological services to veterans and the
developing nature of VHA's VISN structure.  Once the VISN structure
has been implemented, however, reconsideration of RCS' organizational
position may be warranted. 


   RECOMMENDATIONS
------------------------------------------------------------ Letter :8

We recommend that the Secretary of the Department of Veterans Affairs
direct RCS to

  -- make changes to the Service Activity Reporting System so that it
     will more accurately reflect Vet Center activity and staff
     resources used;

  -- require Vet Center counselors to properly document the care
     provided to veterans and that when documentation problems are
     identified, take corrective action; and

  -- develop a method for demonstrating, on a continuing basis, the
     effectiveness of the Vet Center program. 


   AGENCY COMMENTS AND OUR
   EVALUATION
------------------------------------------------------------ Letter :9

In a letter dated May 28, 1996, VA's Under Secretary for Health
expressed satisfaction with our generally positive conclusions about
RCS' operations and concurred with our three recommendations, with
qualifications.  VHA agreed that limitations of the existing workload
reporting system, SARS, are responsible for significant
underreporting of actual RCS activities but did not agree that
overreporting of activities is an issue since it assumed that our
conclusions were based on evidence from only one Vet Center.  It
indicated that reporting group contacts made under the Transition
Assistance Program as though they were individual visits is not a
serious problem and stated that the generalization of our findings in
this area to other centers was misleading. 

Our discussion of Vet Centers' overreporting as a result of the way
TAP contacts are recorded was based on data obtained from a number of
Vet Centers.  We added information to the report to clarify the basis
for our conclusions.  We are encouraged by RCS' stated efforts to
upgrade the SARS information collection capability to more fairly and
accurately report Vet Center staff activity and believe that this may
address the overreporting problem that we identified during our
review. 

VHA stated that established processes are already in place to meet
the intent of our recommendation that counselors be required to
properly document the care provided to veterans and that when
problems are identified, corrective action be taken.  VHA cited the
standards established by RCS for clinical record keeping and the
processes in place for quality and chart reviews.  Our report does
not take issue with the standards and processes in place.  Our
concern rests with the high level of noncompliance identified during
RCS regional office clinical site visits, the level of noncompliance
identified in the sample of cases we reviewed, and similar file
documentation problems we noted in our 1987 report on RCS. 

We believe that continued documentation problems of the magnitude we
identified point to the need for stronger action than proposed in
VHA's comments.  VHA's statements that "monitoring of compliance with
these policies and processes will continue to be an ongoing activity"
and "The RCS program office will .  .  .  continue to stress the
importance of complete documentation" do not indicate a recognition
of the need for compliance that we believe is called for in this
area.  We believe that RCS must initiate a concerted effort to
educate counselors on the importance of full case documentation and
to ensure that when documentation problems are identified, effective
action is taken to correct deficiencies.  Not doing so leaves in
question the quality of care Vet Center clients are receiving. 

VHA also offered several technical comments on our draft report that
we incorporated into the final report, as appropriate.  The text of
VHA's comments is in appendix IV. 

Copies of this report are being sent to the Secretary of Veterans
Affairs, other congressional committees, and interested parties. 
Copies will be made available to others upon request. 

Please call me at (202) 512-7101 if you have any questions or need
additional assistance.  Other GAO contacts and contributors to this
report are listed in appendix V. 

Sincerely yours,

David P.  Baine
Director, Federal Health Care
 Delivery and Quality Issues


SCOPE AND METHODOLOGY
=========================================================== Appendix I

In performing our review of the Readjustment Counseling Service's
(RCS) Vet Center program, we (1) interviewed officials from VHA's and
RCS' central office in Washington, D.C., and RCS' regional offices in
Bay Pines, Florida; Hines, Illinois; Denver, Colorado; and
Providence, Rhode Island; (2) reviewed studies, reports, and program
information from RCS' central office and the RCS regional offices we
visited as well as documents from several advisory councils and
committees; (3) visited Vet Centers in Cheyenne, Wyoming; Chicago,
Illinois; Norwich, Connecticut; Tampa, Florida; and White River
Junction, Vermont; (4) analyzed workload reporting system data for a
sample of 39 Vet Centers for fiscal years 1993 through 1995; and (5)
talked with officials of VA's National Center for Post-Traumatic
Stress Disorder (PTSD) in White River Junction, Vermont, and four
veteran service organizations. 

At the four RCS regional offices, we discussed the Vet Center program
and reviewed documentation on regional efforts to evaluate the care
provided by the centers.  In Providence, we also met with RCS'
National Data Coordinator to discuss the Service Activity Reporting
System (SARS) and to collect program data from it.  In Bay Pines and
Denver we met with RCS' clinical field managers to discuss their role
in monitoring and improving the quality of clinical services Vet
Centers provide in their areas of responsibility. 

The five Vet Centers we visited were selected because they are
geographically and operationally diverse.  For example, the White
River Junction Vet Center is in a rural area close to a medical
center.  The Vet Center in Norwich is about 50 miles from the closest
VA medical center and has a military base in its catchment area.  The
Tampa and Chicago Vet Centers are in large urban areas and both are
close to VA medical centers.  Chicago is unique within the five in
that it is a Veterans Resource Center--a Vet Center with expanded
employment and alcohol/drug abuse services and staffing.  The
Cheyenne Vet Center is close to a VA medical center and did not, at
the time of our visit, have a full-time team leader.  While the White
River Junction and Norwich Vet Centers are geographically similar,
the others serve distinctly different geographic areas.  At each Vet
Center we met with the team leader and counselors to get their views
about the program.  We reviewed activities, observed Vet Center
operations, and in three Vet Centers we met with veterans and
significant others to obtain their views.  We also obtained workload
data from each center and, in four centers, reviewed a sample of case
files to evaluate case documentation and the accuracy of SARS data
compared with data in case files. 

We met with officials of VA's National Center for Post-Traumatic
Stress Disorder in White River Junction to discuss the treatment of
PTSD in VA medical centers and Vet Centers and the current methods of
evaluating treatment outcomes.  We also met with officials of four
veteran service organizations--The American Legion, Vietnam Veterans
of America, Inc., Veterans of Foreign Wars, and Disabled American
Veterans--to obtain their views on the program. 

We reviewed a number of studies and reports on readjustment
counseling services and the diagnosis and treatment of PTSD in VA
programs, prepared by several organizations, advisory councils, and
committees, including our 1987 report on the readjustment counseling
program.\20

As part of our review of RCS' workload reporting system--SARS--we
requested activity data for 40 randomly selected Vet Centers for
fiscal years 1993 through 1995.  The 40 were selected from the
universe of 205 Vet Centers, minus three\21 that were new in 1995 and
did not have many cases in their data system and five\22 that are not
located in the continental United States and, according to an RCS
official, are not typical of other Vet Centers.  This resulted in a
sample universe of 197 Vet Centers.  We obtained data from 39 of the
40 Vet Centers.  One center was unable to provide information as a
result of a computer problem.  The data include information on all
clients who visited the 39 Vet Centers during fiscal years 1993,
1994, and 1995.  We analyzed the data from the 39 Vet Centers to
describe the clients served, the number of visits clients made, and
the type of problems addressed. 

The statistics we cite are estimates relating to all 197 Vet Centers
contained in our sampling universe.  Our sampling errors for the
estimates were calculated at the 95-percent confidence level.  This
means that in 95 out of 100 instances, the sampling procedure we used
would produce a confidence interval\23 containing the population
value we are estimating. 

The sampling errors for estimates of the average number of visits
used in this report are given in tables I.1 and I.2 and in subsequent
paragraphs. 



                         Table I.1
          
            Sampling Errors for Average FY 1995
           Visits by New Veterans and Family and
          Significant Others, by Problem Addressed


                                 95%                   95%
Problem          Average    sampling   Average    sampling
addressed         visits   error (ï¿½)    visits   error (ï¿½)
--------------  --------  ----------  --------  ----------
Sexual trauma        6.7         1.7       2.8         0.6
PTSD                 5.0         0.7       2.7         0.6
Sub-PTSD             4.3         0.8       2.7         1.0
Marital/             3.1         0.4       2.8         0.6
 family
Psych/other          3.0         0.5       1.9         0.3
Legal                2.4         1.0       1.3         0.4
Drug/alcohol         2.4         0.4       1.3         0.1
Homeless             1.8         0.5       1.0         0.0
Employment           1.6         0.2       1.1         0.1
Basic needs          1.6         0.3       1.1         0.2
Other                1.5         0.3       1.1         0.1
Medical              1.4         0.1       1.2         0.2
Benefits             1.3         0.1       1.2         0.1
----------------------------------------------------------


                         Table I.2
          
           Sampling Errors for Average FY 1993-95
           Visits by New Veterans and Family and
          Significant Others, by Problem Addressed


                                 95%                   95%
Problem          Average    sampling   Average    sampling
addressed         visits   error (ï¿½)    visits   error (ï¿½)
--------------  --------  ----------  --------  ----------
Sexual trauma       11.2         2.1       4.8         1.2
PTSD                 9.4         1.3       4.1         0.8
Sub-PTSD             6.4         1.1       3.6         1.0
Marital/             4.5         0.5       4.8         0.8
 family
Psych/other          3.8         0.6       2.8         0.6
Drug/alcohol         3.0         0.4       1.5         0.1
Homeless             2.5         1.2       1.1         0.1
Legal                2.2         0.4       1.4         0.3
Other                2.1         0.5       1.2         0.1
Employment           1.9         0.3       1.2         0.2
Basic needs          1.7         0.2       1.2         0.2
Medical              1.6         0.2       1.4         0.2
Benefits             1.5         0.1       1.3         0.1
----------------------------------------------------------
Our estimates and corresponding sampling errors for the number of
visits made by new veterans during fiscal years 1993 through 1995 are
as follows:  59 percent had only one visit with Vet Center staff ï¿½ 4
percent, 80 percent had three or fewer visits ï¿½ 2 percent, and 90
percent had seven or fewer visits during the 3-year period ï¿½ 1
percent.  The remaining 10 percent of Vet Center clients visited
eight or more times ï¿½ 1 percent. 

For the core group of veterans who are long-term users of the Vet
Center program, our sampling errors were as follows:  20 percent ï¿½ 3
percent of the veterans who first visited a Vet Center prior to
fiscal year 1993 had 13 or more visits and of these 10 percent ï¿½ 2
percent had 32 or more visits through fiscal year 1995. 


--------------------
\20 Vietnam Veterans:  A Profile of VA's Readjustment Counseling
Program (GAO/HRD-87-63, Aug.  26, 1987). 

\21 The three new Vet Centers that opened in 1995 were Raleigh, North
Carolina; Bellingham, Washington; and Yakima Valley, Washington. 

\22 These five Vet Centers are in Agana, Guam; Arecibo, Puerto Rico;
Ponce, Puerto Rico; St.  Croix, Virgin Islands; and St.  Thomas,
Virgin Islands. 

\23 "Confidence interval" is another term for the range defined by
our estimate, plus or minus the sampling error. 


RCS' 205 VET CENTERS BY LOCATION
========================================================== Appendix II

   Figure II.1:  Vet Center
   Locations

   (See figure in printed
   edition.)


READJUSTMENT COUNSELING SERVICE
FISCAL YEAR 1995 SARS DATA
========================================================= Appendix III

------------------------------------------------  --------
Veterans seen first time this fiscal year          138,393

New veteran clients
----------------------------------------------------------
Vietnam theater                                     28,363
Vietnam non-theater                                 21,809
Persian Gulf                                        10,692
Lebanon                                                534
Grenada                                                309
Panama                                                 418
Somalia                                              1,047
Korean theater                                       1,634
World War II theater                                 1,469
Other                                               17,978
Total                                               84,253

Non-time defined visits
----------------------------------------------------------
Veteran                                            587,116
Significant others                                  53,729
Total                                              640,845
Visits by location
In center                                          488,293
Out of center                                      123,728
Phone                                               37,351
Client sessions by type
Individual                                         383,674
Group                                              209,842
Family                                              22,001
Hours of outreach/education                        114,432
Hours of consultation/supervision                  128,511

Problem areas treated
----------------------------------------------------------
PTSD                                               279,323
Sub-PTSD                                            63,955
Drug/alcohol                                        84,020
Marital/family                                      85,633
Psychological, other                               111,404
Employment                                          66,500
Benefits                                            81,769
Basic needs                                         20,564
Medical                                             19,150
Legal                                                7,908
Homeless                                            14,425
Other                                               25,163
Women veteran-sexual trauma                         29,004
Total                                              888,818
----------------------------------------------------------
Source:  Service Activity Report for Period Ending September 30,
1995, Readjustment Counseling Service, VA. 




(See figure in printed edition.)Appendix IV
COMMENTS FROM THE DEPARTMENT OF
VETERANS' AFFAIRS
========================================================= Appendix III



(See figure in printed edition.)



(See figure in printed edition.)



(See figure in printed edition.)



(See figure in printed edition.)



(See figure in printed edition.)



(See figure in printed edition.)


GAO CONTACTS AND STAFF
ACKNOWLEDGMENTS
=========================================================== Appendix V

GAO CONTACTS

George Poindexter, Assistant Director, (202) 512-7213
Stuart Fleishman, Senior Evaluator, (202) 512-7173
Timothy Hall, Senior Evaluator, (202) 512-7192

ACKNOWLEDGMENTS

James A.  Carlan, Assistant Director
Rich LaMore, Senior Evaluator
Art Merriam, Evaluator
Leonard Hamilton, Evaluator
Joan Vogel, Data Specialist


BIBLIOGRAPHY
=========================================================== Appendix 0

READJUSTMENT COUNSELING SERVICE

Advisory Committee on the Readjustment of Vietnam and Other War
Veterans.  Biannual Report of the Advisory Committee on the
Readjustment of Vietnam and Other War Veterans, 1993-94.  Washington,
D.C.:  VA, Apr.  20, 1995. 

Department of Veterans Affairs.  Client Satisfaction Follow-up
Project, Final Report.  Washington, D.C.:  VA, Readjustment
Counseling Service, Client Satisfaction Questionnaire Committee, May
1995. 

_____.  Advisory Committee on the Readjustment of Vietnam and Other
War Veterans, Summary Report 1992.  Washington, D.C.:  VA, Office of
Readjustment Counseling Service, Feb.  1993. 

_____.  Report of the Vet Center Planning Committee.  Washington,
D.C.:  VA, Vet Center Planning Committee, Jan.  8, 1986. 

U.S.  General Accounting Office.  Vietnam Veterans:  A Profile of
VA's Readjustment Counseling Program.  GAO/HRD-87-63, Aug.  26, 1987. 

POST-TRAUMATIC STRESS DISORDER

Department of Veterans Affairs.  Treatment of Posttraumatic Stress
Disorder in the Department of Veterans Affairs:  Fiscal Year 1995
Service Delivery and Performance.  West Haven, Conn.:  Northeast
Program Evaluation Center, Feb.  6, 1996. 

_____.  The Long Journey Home IV:  The Fourth Progress Report on the
Specialized PTSD Programs.  West Haven, Conn.:  Northeast Program
Evaluation Center, July 1, 1995. 

_____.  The National Center for Post-Traumatic Stress Disorder, 5th
Annual Report, Fiscal Year 1994.  White River Junction, Vt.:  VA,
National Center for Post-Traumatic Stress Disorder, no date. 

_____.  9th Report of the Special Committee on Post-traumatic Stress
Disorder.  Washington, D.C.:  VA, Special Committee on Post-traumatic
Stress Disorder, Dec.  31, 1993. 

_____.  Interim Report of the Special Committee on Post-traumatic
Stress Disorder.  Washington, D.C.:  VA, Special Committee on
Post-traumatic Stress Disorder, July 1, 1993. 

_____.  The Long Journey Home III:  The Third Progress Report on the
Specialized PTSD Programs.  West Haven, Conn.:  Northeast Program
Evaluation Center, May 1, 1993. 

_____.  A Program Evaluation of the Department of Veterans Affairs
Post Traumatic Stress Disorder (PTSD) Programs.  Report No.  1990-04. 
Washington, D.C.:  VA, Deputy Assistant Secretary for Program
Coordination and Evaluation, May 1991. 

Friedman, Matthew J., Lawrence C.  Kolb, Arthur Arnold, and others. 
Third Annual Report of the Chief Medical Director's Special Committee
on Post-Traumatic Stress Disorder.  Washington, D.C.:  VA, Feb.  1,
1987. 

Kulka, Richard A., William E.  Schlenger, John A.  Fairbank, and
others.  National Vietnam Veterans Readjustment Study.  Research
Triangle Park, N.C.:  Research Triangle Institute, Nov.  7, 1988. 


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