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.

Recommendations for Executive Action

  1. Status: Closed - Implemented

    Comments: In October 2012, VA reported that the Federal Recovery Coordination Program (FRCP) established a formalized process where a Federal Recovery Coordinator presents the evaluation results and enrollment recommendation to FRCP management for review and approval. The results for the enrollment review are captured in the FRCP data management system. VA also reported that the FRCP developed a service intensity tool to track the objective methodology and protocol for enrollment decisions. The FRCP instituted the use of the intensity tool in September 2011.

    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

  2. Status: Closed - Not Implemented

    Comments: As of October 2014, VA reported that the Federal Recovery Coordination Program (FRCP) had developed a workload tracking application to assess the intensity of services needed by enrollees. However, the results were found not to be useful and the tracking became cumbersome. The FRCP abandoned this procedure and now relies on individual FRCs reporting high-intensity cases to FRCP management.

    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

  3. Status: Closed - Implemented

    Comments: In October 2012, VA reported that the Federal Recovery Coordination Program (FRCP) documents its process for making staffing decisions, citing that the process considers the anticipated referrals, enrollment projections, expected attrition, and target caseloadd in determining the need for additional Federal Recovery Coordinators. VA stated that staffing processes and plans for the FRCP will be reviewed annually and updated as needed.

    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

  4. Status: Closed - Not Implemented

    Comments: In October 2014, VA reported that the Federal Recovery Coordinators were placed at DOD and VA facilities throughout the country. However, VA did not document a rationale for determining how these and future placements would meet the program's strategic objectives or address the care coordination needs of seriously injured servicemembers and veterans.

    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

 

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