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.

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In 2007, following reports of poor case management for outpatients at Walter Reed Army Medical Center, the Departments of Defense (DOD) and Veterans Affairs (VA) jointly developed the Federal Recovery Coordination Program (FRCP) to coordinate the clinical and nonclinical services needed by severely wounded, ill, and injured servicemembers and veterans. The FRCP, which continues to expand, is administered by VA, and the care coordinators, called Federal Recovery Coordinators (FRC), are VA employees. This report examines (1) whether servicemembers and veterans who need FRCP services are being identified and enrolled in the program, (2) staffing challenges confronting the FRCP, and (3) challenges facing the FRCP in its efforts to coordinate care for enrollees. GAO reviewed FRCP policies and procedures and conducted over 170 interviews of FRCP officials, FRCs, headquarters officials and staff of DOD and VA case management programs, and staff at medical facilities where FRCs are located.

It is unclear whether all individuals who could benefit from the FRCP's care coordination services are being identified and enrolled in the program. Because neither DOD nor VA medical and benefits information systems classify servicemembers and veterans as "severely wounded, ill, and injured," FRCs cannot readily identify potential enrollees using existing data sources. Instead, the program must rely on referrals to identify eligible individuals. Once these individuals are identified, FRCs must evaluate them and make their enrollment determinations--a process that involves considerable judgment by FRCs because of broad criteria. However, FRCP leadership does not systematically review FRCs' enrollment decisions, and as a result, program officials cannot ensure that referred individuals who could benefit from the program are enrolled and, conversely, that the individuals who are not enrolled are referred to other programs. The FRCP faces challenges in determining staffing needs, including managing FRCs' caseloads and deciding when VA should hire additional FRCs and where to place them. According to the FRCP Executive Director, appropriately balanced caseloads (size and mix) are difficult to determine because there are no comparable criteria against which to base caseloads for this program because of its unique care coordination activities. The program has taken other steps to manage FRCs' caseloads, including the use of an informal FRC-to-enrollee ratio. Because these methods have some limitations, the FRCP is developing a customized workload assessment tool to help balance the size and mix of FRCs' caseloads but has not determined when this tool will be completed. In addition, the FRCP has not clearly defined or documented the processes for making staffing decisions in FRCP policies or procedures. As a result, it is difficult to determine how staffing decisions are made, or how this process could be sustained during a change in leadership. Finally, the FRCP's basis for placing FRCs at DOD and VA facilities has changed over time, and the program lacks a clear and consistent rationale for making these decisions, which would help ensure that FRCs are located where they could provide maximum benefit to current and potential enrollees. A key challenge facing the FRCP concerns limitations on sharing information needed to coordinate services for enrollees, who may be enrolled in multiple DOD and VA case management programs. These limitations are often blamed for duplication of services and enrollee confusion, prompting two military wounded warrior programs to cease making referrals to the FRCP. One such limitation existed because VA had not completed public disclosure actions necessary to enable the sharing of information from the FRCP's information system. In January 2011, VA completed the process needed to resolve this issue. In addition, incompatibility among information systems used by different case management programs limits data sharing. Although the ultimate solution to information system incompatibility is beyond the capacity of the FRCP to resolve, the program has initiated an effort to improve information exchange. GAO recommends that VA direct the FRCP Executive Director to establish systematic oversight of enrollment decisions, complete development of a workload assessment tool, document staffing decisions, and develop and document a rationale for FRC placement. GAO received comments from DOD and VA; VA concurred with GAO's recommendations.

Status Legend:

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  • 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: The Secretary of Veterans Affairs should direct the Executive Director of the FRCP to clearly define and document the FRCP's decision-making process for determining when and how many FRCs VA should hire to ensure that subsequent FRCP leadership can understand the methods currently used to make staffing decisions.

    Agency Affected: Department of Veterans Affairs

    Status: Open

    Comments: As of July 2011, VA had not provided an update for this recommendation. In responding to our report, however, this process is to be revised when the service measurement intensity tool has been implemented. VA plans to test this tool in the fall 2011, but an implementation date has not been provided.

    Recommendation: The Secretary of Veterans Affairs should direct the Executive Director of the FRCP to complete development of the FRCP's workload assessment tool that will enable the program to assess the complexity of services needed by enrollees and the amount of time required to provide services to improve the management of FRCs' caseloads.

    Agency Affected: Department of Veterans Affairs

    Status: Open

    Comments: In April 2011, the Federal Recovery Coordination Program (FRCP) conducted a two-day offsite with management and 8 Federal Recovery Coordinators (FRCs) to develop and test a trial service intensity measurement tool. Further development and testing is scheduled for the next few months, and the program anticipates field testing the service intensity measurement tool in the fall 2011. Additionally, the FRCP has implemented a workload tracking application within their data management system. The accumulated data will be used to assist with the service intensity measurement tool as well as assist FRCP leadership in balancing FRC workload and resources.

    Recommendation: The Secretary of Veterans Affairs should direct the Executive Director of the FRCP to ensure that referred servicemembers and veterans who need FRC services are enrolled in the program by establishing adequate internal controls regarding the FRCs' enrollment decisions. To accomplish this, the FRCP leadership should (1) require FRCs to record in the Veterans Tracking Application the factors they consider in making an enrollment decision, (2) develop and implement a methodology and protocol for assessing the appropriateness of enrollment decisions, and (3) refine the methodology as needed.

    Agency Affected: Department of Veterans Affairs

    Status: Open

    Comments: In May 2011, VA reported that they have implemented an interim solution of having Federal Recovery Coordinators (FRCs) present each enrollment decision to management for review and approval. The discussions with management and final decisions are documented in the Veterans Tracking Application. With respect to a longer term solution, program officials have designed a preliminary service measurement intensity tool establishing an objective methodology and protocol for enrollment decisions. Further development and testing is scheduled for the next few months, and the program anticipates field testing this tool in the fall 2011.

    Recommendation: The Secretary of Veterans Affairs should direct the Executive Director of the FRCP to develop and document a clear rationale for the placement of FRCs, which should include a systematic analysis of data, such as referral locations, to ensure that future FRC placement decisions are strategic in providing maximum benefit for the program's population.

    Agency Affected: Department of Veterans Affairs

    Status: Open

    Comments: As of July 2011, VA had not provided an update to this recommendation. However, in responding to our report, VA officials stated that a placement strategy would be based on a systematic analysis of data over the next six months (ending fall 2011) and would be documented and updated annually in the FRCP business operation planning document.

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