Federal Recovery Coordination Program:

Enrollment, Staffing, and Care Coordination Pose Significant Challenges

GAO-11-572T: Published: May 13, 2011. Publicly Released: May 13, 2011.

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Randall B. Williamson
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This testimony discusses the challenges facing the Federal Recovery Coordination Program (FRCP)--a program that was jointly developed by the Departments of Defense (DOD) and Veterans Affairs (VA) following critical media reports of deficiencies in the provision of outpatient services at Walter Reed Army Medical Center. This program was established to assist "severely wounded, ill, and injured" Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) servicemembers, veterans, and their families with access to care, services, and benefits. Specifically, the program's population was to include individuals who had suffered traumatic brain injuries, amputations, burns, spinal cord injuries, visual impairment, and post-traumatic stress disorder. From January 2008--when FRCP enrollment began--to May 2011, the FRCP has provided services to a total of 1,665 servicemembers and veterans; of these, 734 are currently active enrollees. As the first care coordination program developed collaboratively by DOD and VA, the FRCP is more comprehensive in scope than clinical or nonclinical case management programs. It uses Federal Recovery Coordinators (FRC) who are either senior-level registered nurses or licensed social workers to monitor and coordinate both the clinical and nonclinical services needed by program enrollees by serving as a link between case managers of multiple programs. Unlike case managers, FRCs have planning, coordination, monitoring, and problem-resolution responsibilities that encompass both health services and benefits provided through DOD, VA, other federal agencies, states, and the private sector. The FRCs' primary responsibility is to work with each enrollee along with his or her family and clinical team to develop a Federal Individual Recovery Plan, which sets individualized goals for recovery and is intended to guide the enrollee through the continuum of care. As care coordinators, FRCs are generally not expected to directly provide the services needed by enrollees. However, FRCs may provide services directly to enrollees in certain situations, such as when they cannot determine whether a case manager has taken care of an issue for an FRCP enrollee, when asked to resolve complex problems, or when making complicated arrangements. The FRCP is administered by VA, and FRCs are VA employees. Since beginning operation in January 2008, the FRCP has grown considerably but experienced turmoil in its early stages, including turnover of staff and management. At present, there are 22 FRCs who have been located at various military treatment facilities, VA medical centers, and the headquarters of two military wounded warrior programs. While the FRCs are physically located at certain facilities, their enrollees are scattered throughout the country and may not be receiving care at the facility where their assigned FRC is located. This testimony is based on our March 2011 report, which examined several FRCP implementation issues: (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.

In summary, we found that while the FRCP has overcome some early setbacks, it currently faces challenges related to the enrollment of potentially eligible individuals, determination of FRC staffing needs and placement, and the FRCP's ability to coordinate care for enrollees. (1) Challenges in identifying potentially eligible individuals. 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. (2) Challenges in determining staffing needs and placement decisions. 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 it 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 these processes 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. (3) Challenges in coordinating with other VA and DOD programs and supporting FRCs. A key challenge facing the FRCP concerns the coordination of services by the large number of DOD and VA programs that support wounded servicemembers and veterans. Although these programs vary in terms of the severity of the injuries among the servicemembers and veterans they serve and the specific types of services they coordinate, many programs have similar functions and are involved in similar types of activities.