Army Health Care:

Progress Made in Staffing and Monitoring Units that Provide Outpatient Case Management, but Additional Steps Needed

GAO-09-357: Published: Apr 20, 2009. Publicly Released: Apr 20, 2009.

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In February 2007, a series of Washington Post articles disclosed problems at Walter Reed Army Medical Center, particularly with the management of servicemembers receiving outpatient care. In response, the Army established Warrior Transition Units (WTU) for servicemembers requiring complex case management. Each servicemember in a WTU is assigned to a Triad of Care--a primary care manager, a nurse case manager, and a squad leader--who provide case management services to ensure continuity of care. The Army established staff-to-servicemember ratios for each Triad of Care position. This report examines (1) the Army's ongoing efforts to staff WTU Triad of Care positions and (2) how the Army monitors the recovery process of WTU servicemembers. GAO reviewed WTU policies, analyzed Army staffing and monitoring data, interviewed Army officials, and visited five selected WTUs.

The Army has taken several steps to help ensure that WTUs are staffed appropriately. First, the Army developed policies aimed at reducing WTU staffing shortfalls, including a policy requiring the reassignment of other personnel on an installation to fill open WTU positions. Second, in October 2008, the Army revised its WTU staffing model, including the staff-to-servicemember ratios for two of its Triad of Care positions, because an Army study determined that the existing ratios were not adequate to provide an appropriate level of care to servicemembers in WTUs. The Army has made considerable progress in meeting the new ratios, and as of January 2009, the Triad of Care positions at most WTUs were fully staffed. However, staffing ratios for the WTU at Walter Reed Army Medical Center were not revised, even though the Army recognizes that servicemembers treated at this facility have more complex health care needs than servicemembers at other WTUs. Walter Reed might require a different staffing model, for example, one that decreases the number of servicemembers assigned to staff members, but the Army does not plan to conduct an assessment of Walter Reed's staffing model. Third, the Army modified its WTU placement and exit criteria for full-time servicemembers, excluding Army Reserve and National Guard servicemembers who comprise about one-third of the WTU population. These changes are intended to help ensure that only those who need complex case management are in WTUs. Those with less serious health care needs can be reassigned to other units on the installation to continue their recovery. As the Army expected, the WTU population of full-time servicemembers declined by about 1,500 in the 4 months after implementation of the new criteria. To monitor the recovery process of WTU servicemembers, the Army has implemented transition plans for individual servicemembers as well as various upward feedback mechanisms to identify concerns and gauge satisfaction. In January 2008, the Army issued a policy establishing Comprehensive Transition Plans, which can be used to monitor and coordinate servicemembers' care. To help ensure consistent implementation of these plans among its WTUs, the Army is developing a new policy that includes the systematic collection of performance measures across WTUs. However, despite Army officials' repeated assurances to GAO that this policy was forthcoming, it had not been finalized as of February 27, 2009. The Army's feedback mechanisms include its Warrior Transition Unit Program Satisfaction Survey, which collects information from servicemembers in WTUs on a number of issues, including the primary care manager and nurse case manager. However, the survey's response rates for the WTUs have been low (13 to 35 percent) and the Army has not determined whether the results obtained from the respondents are representative of all WTU servicemembers. An Army official told GAO that the Army does not plan to conduct analyses to determine whether the survey results are representative, because it is satisfied with the response rates. In GAO's view, the response rates are too low for the Army to reliably report satisfaction of servicemembers in WTUs.

Status Legend:

More Info
  • Review Pending-GAO has not yet assessed implementation status.
  • Open-Actions to satisfy the intent of the recommendation have not been taken or are being planned, or actions that partially satisfy the intent of the recommendation have been taken.
  • Closed-implemented-Actions that satisfy the intent of the recommendation have been taken.
  • Closed-not implemented-While the intent of the recommendation has not been satisfied, time or circumstances have rendered the recommendation invalid.
    • Review Pending
    • Open
    • Closed - implemented
    • Closed - not implemented

    Recommendations for Executive Action

    Recommendation: To help ensure that the WTU at Walter Reed Army Medical Center is providing an appropriate level of care to servicemembers and help the Army make future staffing decisions for the WTUs that will be caring for this population once Walter Reed closes, the Secretary of Defense should direct the Secretary of the Army to examine Walter Reed's WTU staffing model, including its Triad of Care staff-to-servicemember ratios, in light of the complexity of the health care needs of servicemembers placed in this WTU.

    Agency Affected: Department of Defense

    Status: Closed - Not Implemented

    Comments: DOD stated that a separate, individualized study of the Warrior Transition Units (WTU)staffing levels at Walter Reed Army Medical Center is not warranted because it believes that current, ongoing monitoring efforts are sufficient to identify any staffing issues.

    Recommendation: To help ensure that the Comprehensive Transition Plans are implemented consistently across WTUs and that the Army has performance data for monitoring the implementation of the transition plans, the Secretary of Defense should direct the Secretary of the Army to expedite efforts to finalize and implement its policy for guiding the development of the Comprehensive Transition Plans.

    Agency Affected: Department of Defense

    Status: Closed - Implemented

    Comments: DOD indicated in its agency comments that the policy for guiding the development of Comprehensive Transition Plans was signed on March 10, 2009.

    Recommendation: To determine whether the results of the Warrior Transition Unit Program Satisfaction Survey can be used to assess the effectiveness of the WTUs, the Secretary of Defense should direct the Secretary of the Army to take steps to determine whether the results are representative of all servicemembers in WTUs, such as by conducting nonresponse analyses, and should take additional steps if necessary to obtain results that are representative.

    Agency Affected: Department of Defense

    Status: Closed - Not Implemented

    Comments: The Army did conduct a non-response analysis of its Warrior Transition Unit Survey in 2010. However, due to our concerns about the methodology Army officials used, we are closing this recommendation as "not implemented." First, the Army did not include a date, so we are unsure as to which survey this analysis applies. Secondly,the Army limited its analysis to the demographic characteristics of the non-responders and did not contact them or otherwise attempt to obtain their views on the survey questions, which would have allowed them to determine whether the responses to the survey questions were in fact representative. The Army does not plan to conduct a follow-on analysis.

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