GAO-12-342SP: Health: 15. Military and Veterans Health Care

Health > 15. Military and Veterans Health Care

The Departments of Defense and Veterans Affairs need to improve integration across care coordination and case management programs to reduce duplication and better assist servicemembers, veterans, and their families.

Why This Area Is Important

In 2007, in reaction to media reports criticizing the deficiencies in the provision of outpatient services at Walter Reed Army Medical Center, various review groups investigated the challenges that the Departments of Defense (DOD) and Veterans Affairs (VA) faced in providing care to wounded, ill, and injured servicemembers. The review groups cited common areas of concern, including case management, which helps ensure continuity of care by coordinating services from multiple providers and guiding servicemembers’ transitions between care providers, from active duty status to veteran status, or back to the civilian community. One of these review groups, the President’s Commission on Care for America’s Returning Wounded Warriors—commonly referred to as the Dole-Shalala Commission—issued a report noting that while the military services did provide case management, some servicemembers were being assigned multiple case managers, having no single person to monitor and coordinate their activities, which often resulted in confusion, redundancy, and delay in addressing servicemembers’ health care issues.[1]

To elevate the response needed to address the problems associated with the provision of care and services for returning servicemembers, DOD and VA established the Wounded, Ill, and Injured Senior Oversight Committee (Senior Oversight Committee) in May 2007. Co-chaired by the Deputy Secretaries of Defense and Veterans Affairs, the Senior Oversight Committee was designed to be the main decision-making body for the oversight, strategy, and integration of DOD’s and VA’s efforts to improve seamlessness across the recovery care continuum.[2] The committee included the most senior decision makers from both departments, who met on a routine basis to ensure timely decisions and actions, including ensuring that the recommendations of various review groups were properly evaluated, coordinated, implemented, and resourced.

Under the purview of the Senior Oversight Committee, DOD and VA jointly developed the Federal Recovery Coordination Program (FRCP) in response to the Dole-Shalala Commission’s recommendation for an integrated approach to care management. Specifically, the FRCP was designed to assist Operation Enduring Freedom and Operation Iraqi Freedom servicemembers,[3] veterans, and their families with access to care, services, and benefits provided through DOD, VA, other federal agencies, states, and the private sector. The FRCP was envisioned to serve “severely” wounded, ill, and injured servicemembers who are most likely to be medically separated from the military, including those who have suffered traumatic brain injuries, amputations, burns, spinal cord injuries, visual impairment, and post-traumatic stress disorder.[4] The program uses coordinators to monitor and coordinate both the clinical and nonclinical services[5] needed by program enrollees, by serving as the single point of contact among all of the case managers of DOD, VA, and other governmental and private care coordination[6] and case management[7] programs that provide services directly to servicemembers and veterans.

Separately, the Recovery Coordination Program (RCP) was established in response to the National Defense Authorization Act for Fiscal Year 2008 to improve the care, management, and transition of recovering servicemembers. It is a DOD-specific program that was designed to use coordinators to provide nonclinical care coordination to “seriously” wounded, ill, and injured servicemembers, who may return to active duty unlike those categorized as “severely” wounded, ill, or injured. The RCP is centrally coordinated by DOD’s Office of Wounded Warrior Care and Transition Policy, but is implemented separately by each of the military services. Most of the military services have implemented the RCP within their existing wounded warrior programs, including the Navy Safe Harbor Program, the Air Force Warrior and Survivor Care Program,[8] and the Marine Wounded Warrior Regiment. The Army Wounded Warrior Program and the U.S. Special Operations Command’s Care Coalition also provide care coordination services using coordinators referred to as “advocates” that meet the requirements of the RCP, although they did not specifically implement the RCP program. Depending on how a military service’s wounded warrior program is structured, a servicemember may receive either case management or care coordination services or both. For example, the Navy Safe Harbor Program only provides care coordination services and does not have a case management component, whereas the Marine Wounded Warrior Regiment provides all servicemembers with both case management and care coordination services.[9]



[1]President’s Commission on Care for America’s Returning Wounded Warriors, Serve, Support, Simplify (July 2007).

[2]The 2007 Dole-Shalala Commission report outlined a vision for a recovery care continuum that provides continuous and integrated care management across both DOD and VA to create seamless transitions between the many providers and facilities recovering servicemembers and veterans must navigate.

[3]Operation Enduring Freedom, which began in October 2001, supports combat operations in Afghanistan and other locations, and Operation Iraqi Freedom, which began in March 2003, supported combat operations in Iraq and other locations. Beginning September 1, 2010, Operation Iraqi Freedom was referred to as Operation New Dawn.

[4]The Department of Defense established three injury categories—mild, serious, and severe. Servicemembers with “mild” wounds, illnesses, or injuries are expected to return to duty in less than 180 days; those with “serious” wounds, illnesses, or injuries are unlikely to return to duty in less than 180 days and possibly may be medically separated from the military; and those who are “severely” wounded, ill, or injured are highly unlikely to return to duty and also likely to medically separate from the military.

[5]For the purposes of this report, clinical services include services such as scheduling medical appointments and providing outreach education about medical conditions such as post-traumatic stress disorder. Nonclinical services include services such as assisting servicemembers with financial benefits and accessing accommodations for families.

[6]According to the National Coalition on Care Coordination, care coordination is a client-centered, assessment-based interdisciplinary approach to integrating health care and social support services in which an individual’s needs and preferences are assessed, a comprehensive care plan is developed, and services are managed and monitored by an identified care coordinator.

[7]According to the Case Management Society of America, case management is defined as a collaborative process of assessment, planning, facilitation, and advocacy for options and services to meet an individual’s health needs through communication and available resources to promote quality, cost-effective outcomes.

[8]The Air Force Warrior Survivor Care Program is an overarching wounded warrior program, which includes a care coordination component called the Air Force Recovery Care Program and a case management component called the Air Force Wounded Warrior Program.

[9]The Marine Wounded Warrior Regiment provides nonclinical case management services to its enrollees. Although it does not provide clinical case management services, the program does facilitate access to medical programs and care needs that have been identified for its servicemembers.

What GAO Found

Many recovering servicemembers and veterans are enrolled in more than one care coordination or case management program, and as a result, they may have multiple care coordinators and case managers, potentially duplicating agencies’ efforts and reducing the effectiveness and efficiency of the assistance they provide. (See table below.) For example, although the FRCP and RCP were intended to serve different populations, a DOD official told GAO that shortly after the military services implemented the RCP, they began to provide assistance to servicemembers who were “severely” wounded, ill, and injured—individuals who may also be enrolled in the FRCP—because DOD officials believed these servicemembers would also benefit from having RCP coordinators.[1] As a result, servicemembers may have care coordinators from both programs. In addition, recovering servicemembers and veterans who have a care coordinator also may be enrolled in one or more of the multiple DOD or VA programs that provide case management services to “seriously” and “severely” wounded, ill, and injured servicemembers, veterans, and their families. These programs include the military services’ wounded warrior programs and VA’s Operation Enduring Freedom/Operation Iraqi Freedom Care Management Program, among others. For one wounded warrior program—the U.S. Special Operations Command’s Care Coalition—enrollees may be dually enrolled in another wounded warrior program because servicemembers that are part of the Special Operations Forces belong to a separate military service branch.[2] Servicemembers who have specialty needs also may have case managers affiliated with specialty programs or services, such as for polytrauma or spinal cord injury, during their recovery process, outside of, but in coordination with, wounded warrior programs.

Characteristics of Selected Department of Defense and Department of Veterans Affairs Care Coordination and Case Management Programs for “Seriously” and “Severely” Wounded, Ill, and Injured Servicemembers, Veterans, and Their Families

Type of services provided

Program

Severity of enrollees’ injuriesa

Number of active enrollees
(Sept. 2011)

Clinical

Nonclinical

Recovery plan

DOD and VA Care Coordination Program

Federal Recovery Coordination Program

Severeb

777

DOD Recovery Coordination Programs by Military Servicec

Navy Safe Harbor Program

Mild to severe

728

Air Force Recovery Care Program

Mild to severe

946d

Marine Wounded Warrior Regiment’s Recovery Coordination Program

Serious to severe

1,020e

Other DOD Care Coordination Programs by Military Service

Army Warrior Care and Transition Program: Army Wounded Warrior Programf

Severe

9,144g

U.S. Special Operations Command’s Care Coalition Recovery Programh

Serious to severe

115i

DOD Case Management Programs by Military Service

Army Warrior Care and Transition Program: Warrior Transition Units and Community Based Warrior Transition Unitsf

Serious to severe

9,778g

Air Force Wounded Warrior Program

Serious to severe

1270d

Marine Wounded Warrior Regimentj

Serious to severe

1,020e

U.S. Special Operations Command’s Care Coalition

Mild to severe

3,615i

VA Case Management Program

VA Operation Enduring Freedom/Operation Iraqi Freedom Care Management Program

Mild to severe

50,256

Source: GAO analysis of DOD and VA program information.

Notes: The characteristics listed in this table are general characteristics of each program; individual circumstances may affect the enrollees served and services provided by specific programs. For the purposes of this report, clinical services include services such as scheduling medical appointments and providing outreach education about medical conditions such as post-traumatic stress disorder. Nonclinical services include services such as assisting servicemembers with financial benefits and accessing accommodations for families.

Because servicemembers and veterans may be enrolled in multiple programs, it is difficult to determine the overall number of unique individuals served by these programs. Furthermore, the number of “seriously” and “severely” wounded, ill, and injured servicemembers in the Operation Enduring Freedom/Operation Iraqi Freedom conflicts is not known with certainty because the terms “seriously” and “severely” are not categorical designations used by DOD or VA medical or benefits programs, and determinations of the size of this population vary, depending on definitions and methodology.

aFor the purposes of this table, GAO has categorized the severity of enrollees’ injuries according to the injury categories established by DOD. Servicemembers with mild wounds, illness, or injury are expected to return to duty in less than 180 days; those with serious wounds, illness, or injury are unlikely to return to duty in less than 180 days and possibly may be medically separated from the military; and those who are severely wounded, ill, or injured are highly unlikely to return to duty and also likely to medically separate from the military. These categories are not necessarily used by the programs themselves.

bAlthough the Federal Recovery Coordination Program (FRCP) enrollment criteria state that the program is for severely wounded, ill, and injured servicemembers and veterans, FRCP officials told GAO that the program enrolls or assists seriously wounded, ill, and injured servicemembers and veterans who need the program’s care coordination services.

cMost of the military services have implemented DOD’s Recovery Coordination Program (RCP) within their existing wounded warrior programs, including the Navy Safe Harbor Program, the Air Force Warrior and Survivor Care Program, and the Marine Wounded Warrior Regiment.

dAbout one-third (286) of the Air Force Recovery Care Program enrollees were also either tracked or actively assisted by the Air Force Wounded Warrior Program.

eAll servicemembers that are enrolled in the Marine Wounded Warrior Regiment receive care coordination and case management services.

fThe Army Warrior Care and Transition Program includes the Army Wounded Warrior Program as well as the Warrior Transition Units and Community Based Warrior Transition Units. The Army did not implement DOD’s RCP. However, according to officials, the Army Wounded Warrior Program provides care coordination services that meet the requirements of the RCP.

gOver 1,100 Army Wounded Warrior Program enrollees were also enrolled in a Warrior Transition Unit. Most Army Wounded Warrior Program enrollees are veterans because the program supports enrollees throughout their recovery and transition, even into veteran status.

hThe U.S. Special Operations Command did not implement DOD’s RCP. However, according to officials, the U.S. Special Operations Command’s Care Coalition Recovery Program provides care coordination services that meet the requirements of the RCP.

iEnrollees of the U.S. Special Operations Command’s Care Coalition Recovery Program also receive case management services. They may also be enrolled in a military service’s wounded warrior program based on their branch of service, but the U.S. Special Operations Command’s Care Coalition Recovery Program takes the lead for providing nonclinical case management.

jThe Marine Wounded Warrior Regiment provides nonclinical case management services to its enrollees. Although it does not provide clinical case management services, the program does facilitate access to medical programs and care needs that have been identified for its servicemembers.

GAO found that inadequate information exchange and poor coordination between these programs have resulted in not only duplication of effort but confusion and frustration for enrollees, particularly when case managers and care coordinators duplicate or contradict one another’s efforts.[3] For example, an FRCP coordinator told GAO that in one instance there were five case managers working on the same life insurance issue for an individual. In another example, an FRCP coordinator and an RCP coordinator were not aware the other was involved in coordinating care for the same servicemember and had unknowingly established conflicting recovery goals for this individual. In this case, a servicemember with multiple amputations was advised by his FRCP coordinator to separate from the military in order to receive needed services from VA, whereas his RCP coordinator set a goal of remaining on active duty. These conflicting goals caused considerable confusion for this servicemember and his family.

DOD and VA have been unsuccessful in jointly developing options for improved collaboration and potential integration of the two care coordination programs—the FRCP and RCP—although they have made a number of attempts to do so. Despite the identification of various options, no final decisions to revamp, merge, or eliminate programs have been agreed upon. As outlined in the following examples, the departments’ lack of progress illustrates their continued difficulty in collaborating to resolve program duplication.

  • Beginning in December 2010, the Senior Oversight Committee directed its care management work group[4] to conduct an inventory of DOD and VA case managers and perform a feasibility study of recommendations on the governance, roles, and mission of DOD and VA care coordination. According to DOD and VA officials, this information was requested for the purpose of formulating options for improving DOD and VA care coordination. However, DOD officials stated that following compilation of this information, no action was taken by the committee, and other issues, such as responding to budget reductions, were given higher priority.
  • In May 2011, the Senior Oversight Committee was asked by the House Committee on Veterans Affairs Subcommittee on Health to develop options for integrating the FRCP and RCP in order to reduce duplication and to provide a response to the subcommittee by June 20, 2011. On September 12, 2011—almost 3 months after the subcommittee requested a response—the co-chairs of the Senior Oversight Committee issued a joint letter following notification by the subcommittee that it would hold a hearing on the FRCP and RCP care coordination issue. The letter stated that the departments are considering several options to maximize care coordination resources, but these options had not been finalized and were not specifically identified or outlined in the letter.

Nonetheless, as GAO has previously reported, the need for better collaboration and integration extends beyond the FRCP and RCP to also encompass other DOD and VA case management programs, such as DOD’s wounded warrior programs that also serve seriously and severely wounded, ill, and injured servicemembers and veterans. Without interdepartmental coordination and action to better align and integrate these programs, problems with duplication and overlap will persist, and perhaps worsen as the number of enrollees served by these programs continues to grow. Moreover, the confusion this creates for recovering servicemembers, veterans, and their families may hamper their recovery. Consequently, the intended purpose of these programs—to better manage and facilitate care and services—may actually have the opposite effect.



[1]According to the Army, they have been providing care to severely wounded, ill, and injured servicemembers since 2004.

[2]According to a U.S. Special Operations Command’s Care Coalition Recovery Program official, when an enrollee is dually enrolled in another wounded warrior program, the U.S. Special Operations Command’s Care Coalition Recovery Program takes the lead for providing nonclinical case management.

[3]While FRCP coordinators are generally not expected to provide services directly to enrollees, they may do so in certain situations, such as when they cannot determine whether a case manager has taken care of an issue for an individual or when asked to make complicated arrangements, such as assisting enrollees with adaptive housing grants or obtaining medical equipment or prosthetics.

[4]The Senior Oversight Committee is supported by several internal work groups devoted to specific issues, such as DOD and VA care coordination and case management. Participants in the committee’s care management work group include officials from the FRCP and the RCP.

Actions Needed

To improve the effectiveness, efficiency, and efficacy of services for recovering servicemembers, veterans, and their families by reducing duplication and overlap, GAO recommended in October 2011 that the Secretaries of Defense and Veterans Affairs should direct the co-chairs of the Senior Oversight Committee to

  • expeditiously develop and implement a plan to strengthen functional integration across all DOD and VA care coordination and case management programs that serve this population, including—but not limited to—the FRCP and RCP.

How GAO Conducted Its Work

The information contained in this analysis is based on findings from the products listed in the related GAO products section as well as additional work GAO conducted to be published as a separate product in 2012. GAO interviewed officials from each of DOD’s wounded warrior programs and the VA Operation Enduring Freedom/Operation Iraqi Freedom Care Management Program to obtain information about the services that they provide and their enrollees.

Agency Comments & GAO Contact

GAO provided a draft of its October 2011 report as well as a draft of this report section to DOD and VA for review and comment. Although DOD and VA did not specifically comment on the recommendation, they provided technical comments, which were incorporated as appropriate. As part of its routine audit work, GAO will track the extent to which progress has been made to address the identified actions and report to Congress.

For additional information about this area, please contact Debra Draper at (202) 512-7114 or draperd@gao.gov or Randall B. Williamson at (202) 512-7114 or williamsonr@gao.gov.

Related Products

DOD and VA Health Care:

Action Needed to Strengthen Integration across Care Coordination and Case Management Programs
GAO-12-129T:
Published: Oct 6, 2011. Publicly Released: Oct 6, 2011.

Federal Recovery Coordination Program:

Enrollment, Staffing, and Care Coordination Pose Significant Challenges
GAO-11-572T:
Published: May 13, 2011. Publicly Released: May 13, 2011.

DOD and VA Health Care:

Federal Recovery Coordination Program Continues to Expand but Faces Significant Challenges
GAO-11-250:
Published: Mar 23, 2011. Publicly Released: Mar 23, 2011.