DOD Health Care:
Mental Health and Traumatic Brain Injury Screening Efforts Implemented, but Consistent Pre-Deployment Medical Record Review Policies Needed
GAO-08-615: Published: May 30, 2008. Publicly Released: May 30, 2008.
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The John Warner National Defense Authorization Act for Fiscal Year 2007 included provisions regarding mental health concerns and traumatic brain injury (TBI). GAO addressed these issues as required by the Act. In this report GAO discusses (1) DOD efforts to implement pre-deployment mental health screening; (2) how post-deployment mental health referrals are tracked; and (3) screening requirements for mild TBI. GAO selected the Army, Marine Corps, and Army National Guard for the review. GAO reviewed documents and interviewed DOD officials and conducted site visits to three military installations where the pre-deployment health assessment was being conducted.
DOD has taken positive steps to implement mental health standards for deployment and pre-deployment mental health screening. However, DOD's policies for providers to review medical records are inconsistent. DOD issued minimum mental health standards that servicemembers must meet in order to be deployed to a combat theater and identified the pre-deployment health assessment as a mechanism for ensuring their use in making deployment decisions. DOD's November 2006 policy implementing these deployment standards requires a review of servicemember medical records during the pre-deployment health assessment. However, DOD's August 2006 Instruction on Deployment Health, which implements policy and prescribes procedures for conducting pre-deployment health assessments, is silent on whether such a review is required. Because of this inconsistency, providers determining if Operation Enduring Freedom and Operation Iraqi Freedom servicemembers meet DOD's mental health deployment standards may not have complete medical information. Health care providers at the installations GAO visited where the post-deployment health assessment (PDHA) is conducted manually track whether servicemembers who receive mental health referrals from the PDHA make or complete appointments with mental heath providers. Because health care providers conducting the PDHA and making referrals from the PDHA may not have an ongoing relationship with referred servicemembers, health care providers responsible for tracking referrals at these installations have developed manual systems to track servicemembers to ensure that they made or kept their appointments for evaluations. Tracking is more challenging for Guard and Reserve units because their servicemembers generally receive civilian care. Guard and Reserve units do not know if servicemembers used civilian care to complete their PDHA referrals unless disclosed by the servicemembers, which they may be reluctant to do because of stigma concerns. DOD is addressing the TBI requirement through implementing screening for mild TBI in its PDHA and prior to deployment. DOD has also provided guidance and training for health care providers. DOD in January 2008 added TBI screening to the PDHA, and plans to require screening of all servicemembers for mild TBI prior to deployment beginning in July 2008. The TBI screening questions on the PDHA assess the servicemember's exposure to events that may have increased the risk of a TBI and the servicemember's symptoms. The TBI screening questions to be used prior to deployment are similar to those on the PDHA. Prior to DOD's screening efforts, several installations had been screening servicemembers for mild TBI before or after deployment. An official from the Defense and Veterans Brain Injury Center told GAO that these initiatives would probably be replaced by the DOD-wide screening.
Recommendation for Executive Action
Status: Closed - Not Implemented
Comments: As of April 2012, DoD Instruction 6490.03 is currently under review. According to DoD, when revised in 2013 the Instruction will require a review of medical records as part of the pre-deployment health assessment. However, as this recommendation cannot be fully implemented until the DoD Instruction on Deployment Health is revised, this recommendation is determined to have not been implemented.
Recommendation: In order to address the inconsistency in DOD's policies related to the review of medical record information and to assure that health care providers have reviewed the medical record when screening servicemembers prior to deployment, the Secretary of Defense should direct the Under Secretary of Defense for Personnel and Readiness to revise DOD's Instruction on Deployment Health to require a review of medical records as part of the pre-deployment health assessment.
Agency Affected: Department of Defense