Recovering Servicemembers and Veterans:

Sustained Leadership Attention and Systematic Oversight Needed to Resolve Persistent Problems Affecting Care and Benefits

GAO-13-5: Published: Nov 16, 2012. Publicly Released: Nov 16, 2012.

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What GAO Found

Deficiencies exposed at Walter Reed Army Medical Center in 2007 served as a catalyst compelling the Departments of Defense (DOD) and Veterans Affairs (VA) to address a host of problems for wounded, ill, and injured servicemembers and veterans as they navigate through the recovery care continuum. This continuum extends from acute medical treatment and stabilization, through rehabilitation to reintegration, either back to active duty or to the civilian community as a veteran. In spite of 5 years of departmental efforts, recovering servicemembers and veterans are still facing problems with this process and may not be getting the services they need. Key departmental efforts included the creation or modification of various care coordination and case management programs, including the military services' wounded warrior programs. However, these programs are not always accessible to those who need them due to the inconsistent methods, such as referrals, used to identify potentially eligible servicemembers, as well as inconsistent eligibility criteria across the military services' wounded warrior programs. The departments also jointly established an integrated disability evaluation system to expedite the delivery of benefits to servicemembers. However, processing times for disability determinations under the new system have increased since 2007, resulting in lengthy wait times that limit servicemembers' ability to plan for their future. Finally, despite years of incremental efforts, DOD and VA have yet to develop sufficient capabilities for electronically sharing complete health records, which potentially delays servicemembers' receipt of coordinated care and benefits as they transition from DOD's to VA's health care system.

Collectively, a lack of leadership, oversight, resources, and collaboration has contributed to the departments' inability to fully resolve problems facing recovering servicemembers and veterans. Initially, departmental leadership exhibited focus and commitment--through the Senior Oversight Committee--to addressing problems related to case management and care coordination, disability evaluation systems, and data sharing between DOD and VA. However, the committee's oversight waned over time, and in January 2012, it was merged with the VA/DOD Joint Executive Council. Whether this council--which has primarily focused on long-term strategic planning--can effectively address the shorter-term policy focused issues once managed by the Senior Oversight Committee remains to be seen. Furthermore, DOD does not provide central oversight of the military services' wounded warrior programs, preventing it from determining how well these programs are working across the department. However, despite these shortcomings, the departments continue to take steps to resolve identified problems, such as increasing the number of staff involved with the electronic sharing of health records and the integrated disability evaluation process. Additionally, while the departments' previous attempts to collaborate on how to resolve case management and care coordination problems have largely been unsuccessful, a joint task force established in May 2012 is focused on resolving long-standing areas of disagreement between VA, DOD, and the military services. However, without more robust oversight and military service compliance, consistent implementation of policies that result in more effective case management and care coordination programs may be unattainable. GAO recommends that DOD provide central oversight of the military services' wounded warrior programs and that DOD and VA sustain high-level leadership attention and collaboration to fully resolve identified problems. DOD partially concurred with the recommendation for central oversight of the wounded warrior programs, citing issues with common eligibility criteria and systematic monitoring. DOD and VA both concurred with the recommendation for sustained leadership attention.

Why GAO Did This Study

The National Defense Authorization Act for Fiscal Year 2008 required DOD and VA to jointly develop and implement policy on the care, management, and transition of recovering servicemembers. It also required GAO to report on DOD's and VA's progress in addressing these requirements. This report specifically examines (1) the extent to which DOD and VA have resolved persistent problems facing recovering servicemembers and veterans as they navigate the recovery care continuum, and (2) the reasons DOD and VA leadership have not been able to fully resolve any remaining problems. To address these objectives, GAO visited 11 DOD and VA medical facilities selected for population size and range of available resources and met with servicemembers and veterans to identify problems they continue to face. GAO also reviewed documents related to specific DOD and VA programs that assist recovering servicemembers and veterans and interviewed the leadership and staff of these programs to determine why problems have not been fully resolved.

What GAO Recommends

GAO recommends that DOD provide central oversight of the military servicesÂ’ wounded warrior programs and that DOD and VA sustain high-level leadership attention and collaboration to fully resolve identified problems. DOD partially concurred with the recommendation for central oversight of the wounded warrior programs, citing issues with common eligibility criteria and systematic monitoring. DOD and VA both concurred with the recommendation for sustained leadership attention.

For more information, contact Randall B. Williamson at (202) 512-7114 or williamsonr@gao.gov.

Recommendations for Executive Action

  1. Status: Open

    Comments: In attachments to a memo dated April 8, 2014, DOD provided an update on progress made to implement parts (2) and (3) of the DOD-specific recommendation made in GAO-13-5. Regarding part (2), DOD reported that budget constraints had delayed its plan to conduct oversight visits to 63 service sites over a 12-month period to ensure that military wounded warrior programs were operating in compliance with DOD Recovery Coordinator Program policy. DOD stated that the Warrior Care Policy office, in coordination with the military service branches, had intended to begin these oversight visits and interviews in September 2013; that as of March 2014, five sites had been reviewed; and that results of the compliance visits would be available upon completion. Regarding part (3) of the recommendation, DOD?s memo stated that DOD and VA continue work on developing policies on clinical and non-clinical care coordination. It also noted that interagency metrics for monitoring complex care coordination performance were under development by the DOD/VA Interagency Care Coordination Committee. Further, DOD stated that because the Joint Executive Council publishes an annual report, that reporting the progress in developing common terms and definitions used by wounded warrior programs to congressional committees would be of limited value. DOD did not address part (1) of this recommendation?to develop consistent eligibility criteria to ensure that similarly situated recovering servicemembers from different military services have uniform access to wounded warrior programs.

    Recommendation: To ensure that servicemembers have equitable access to the military services' wounded warrior programs, including the RCP, and to establish central accountability for these programs, the Secretary of Defense should establish or designate an office to centrally oversee and monitor the activities of the military services' wounded warrior programs to include the following: (1) Develop consistent eligibility criteria to ensure that similarly situated recovering servicemembers from different military services have uniform access to these programs; (2) Direct the military services' wounded warrior programs to fully comply with the policies governing care coordination and case management programs and any future changes to these policies; (3) Develop a common mechanism to systematically monitor the performance of the wounded warrior programs--to include the establishment of common terms and definitions--and report this information on a biannual basis to the Armed Services Committees of the House of Representatives and the Senate.

    Agency Affected: Department of Defense

  2. Status: Open

    Comments: In its 60-day update on progress made to implement the recommendations in GAO-13-5, VA and DOD jointly stated that to improve care coordination services for recovering servicemembers and veterans, the VA/DOD Joint Executive Council had created the Interagency Care Coordination Council (IC3) to oversee the development and implementation of shared care coordination initiatives. The IC3's overarching objectives include strengthening functional integration between the departments' care coordination programs and also reducing redundancy and overlap between these programs. Specifically, the IC3 would develop guidance for interagency care coordination and implement two initiatives: (1) the Lead Coordinator process and (2) a single, comprehensive care management plan for each recovering servicemember. Both initiatives are intended to strengthen care coordination by improving communication between the departments and eliminating duplicative efforts. While implementation of these two initiatives has been uneven and remains incomplete, DOD and VA have made progress to develop them. For example, in July 2014, VA and DOD signed a memorandum of understanding that described a common operational model for complex care coordination between the departments and also identified responsibilities of the Lead Coordinator. Further, implementation of the Lead Coordinator process was completed in the San Antonio, Texas region in 2014, and a national rollout plan for the process is under development. The VA/DOD memorandum of understanding also noted the requirement that each servicemember or veteran requiring complex care coordination have a personal Interagency Comprehensive Plan that addresses clinical and nonclinical support needed throughout all stages of recovery. According to DOD and VA officials, the departments are now considering a proposal to implement Interagency Comprehensive Plans by linking the existing information systems of individual DOD and VA care coordination programs, instead of developing a single, shared information technology platform as previously envisioned.

    Recommendation: To ensure that persistent challenges with care coordination, disability evaluation, and the electronic sharing of health records are fully resolved, the Secretaries of Defense and Veterans Affairs should ensure that these issues receive sustained leadership attention and collaboration at the highest levels with a singular focus on what is best for the individual servicemember or veteran to ensure continuity of care and a seamless transition from DOD to VA. This should include holding the Joint Executive Council accountable for (1) ensuring that key issues affecting recovering servicemembers and veterans get sufficient consideration, including recommendations made by the Warrior Care and Coordination Task Force and the Recovering Warrior Task Force; (2) developing mechanisms for making joint policy decisions; (3) involving the appropriate decision-makers for timely implementation of policy; and; (4) establishing mechanisms to systematically oversee joint initiatives and ensure that outcomes and goals are identified and achieved.

    Agency Affected: Department of Defense

  3. Status: Open

    Comments: In its 60-day update on progress made to implement the recommendations in GAO-13-5, VA and DOD jointly stated that to improve care coordination services for recovering servicemembers and veterans, the VA/DOD Joint Executive Council had created the Interagency Care Coordination Council (IC3) to oversee the development and implementation of shared care coordination initiatives. The IC3's overarching objectives include strengthening functional integration between the departments' care coordination programs and also reducing redundancy and overlap between these programs. Specifically, the IC3 would develop guidance for interagency care coordination and implement two initiatives: (1) the Lead Coordinator process and (2) a single, comprehensive care management plan for each recovering servicemember. Both initiatives are intended to strengthen care coordination by improving communication between the departments and eliminating duplicative efforts. While implementation of these two initiatives has been uneven and remains incomplete, DOD and VA have made progress to develop them. For example, in July 2014, VA and DOD signed a memorandum of understanding that described a common operational model for complex care coordination between the departments and also identified responsibilities of the Lead Coordinator. Further, implementation of the Lead Coordinator process was completed in the San Antonio, Texas region in 2014, and a national rollout plan for the process is under development. The VA/DOD memorandum of understanding also noted the requirement that each servicemember or veteran requiring complex care coordination have a personal Interagency Comprehensive Plan that addresses clinical and nonclinical support needed throughout all stages of recovery. According to DOD and VA officials, the departments are now considering a proposal to implement Interagency Comprehensive Plans by linking the existing information systems of individual DOD and VA care coordination programs, instead of developing a single, shared information technology platform as previously envisioned.

    Recommendation: To ensure that persistent challenges with care coordination, disability evaluation, and the electronic sharing of health records are fully resolved, the Secretaries of Defense and Veterans Affairs should ensure that these issues receive sustained leadership attention and collaboration at the highest levels with a singular focus on what is best for the individual servicemember or veteran to ensure continuity of care and a seamless transition from DOD to VA. This should include holding the Joint Executive Council accountable for (1) ensuring that key issues affecting recovering servicemembers and veterans get sufficient consideration, including recommendations made by the Warrior Care and Coordination Task Force and the Recovering Warrior Task Force; (2) developing mechanisms for making joint policy decisions; (3) involving the appropriate decision-makers for timely implementation of policy; and; (4) establishing mechanisms to systematically oversee joint initiatives and ensure that outcomes and goals are identified and achieved.

    Agency Affected: Department of Veterans Affairs

 

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