In response to congressional interest and media coverage regarding  inadequate and substandard care for Army soldiers recovering from  serious medical conditions at the former Walter Reed Army Medical  Center, the Army in 2007 developed its Army Medical Action Plan. The Army Has Not Assessed the Effectiveness of the Triad of Care Model despite the Change in the Composition of Diagnoses among WTU Soldiers

The Army has not assessed the effectiveness of the Triad of Care model,  the core structure of the WTU program and consisting of a team of three  key staff that provide medical case management. Despite this change, the Army has  not assessed its approach for managing soldiers’ medical care. The five  WTUs we visited reported having taken ad-hoc measures to help meet  the increase in behavioral health needs in the absence of such an  assessment. Composition of Diagnoses among WTU Soldiers Has Changed Significantly

The Army established the Triad of Care model at a time when WTU  soldiers’ diagnoses were primarily for physical conditions. Specifically, in  2008, the first full year of the WTU program, about 36 percent of the  12,228 WTU soldiers had a behavioral health diagnosis, while in 2015,  over half of the 2,628 soldiers, about 52 percent, had such a diagnosis. The Warrior Transition Command Has Not Assessed Whether Army- wide Changes to the Triad of Care Model Are Needed to Respond to the Change in the Composition of Diagnoses

While the Army conducts reviews and inspections of the WTU program  and WTUs, it has not assessed the effectiveness of the Triad of Care  model, in light of the change in the composition of diagnoses. Assessing the  Triad of Care model in light of changes in, for example, the prevalence of  behavioral health conditions would position the Army to better determine  how to meet WTU soldiers’ medical needs. The Army Faces Challenges in Overseeing the Selection of Certain WTU Staff, in Evaluating Their Training, and in Adjusting Staff Levels if Needed

The Army has established selection processes and updated its selection  criteria to require additional information about potential squad leaders and  platoon sergeants for its WTUs, but the Army is not monitoring full  adherence to policy, specifically the requirement to interview candidates  for these positions. In  addition, the Army has not developed a plan that explains how to meet  any potential increases in demand for staff, if needed, at the WTUs. Candidates for these positions are  drawn from a mix of Army occupations, such as infantry or transportation  corps, and the selection process, including interviews, is intended to  ensure the suitability of the staff selected for the position. The Army Has Made Efforts to Improve Training, but Does Not Incorporate a Key Post- Training Assessment

The Army Medical Department Center and School has made efforts to  make improve WTU training for squad leaders and platoon sergeants, but  the program does not incorporate a post-training assessment of the  application of training to the work environment. Without information that could be obtained from conducting post-training  assessments, the Army Medical Department Center and School may miss  a valuable opportunity to improve its programs by incorporating useful  information concerning the practical application of training. A key planning consideration in  the decision to inactivate 11 WTUs by August 2016 was the Army’s ability  to reverse these changes in the event that the demand for the Army’s  WTU program was to increase. However, they stated that they have not yet taken  steps to address this issue. The Army Does Not Track Instances in Which Commanders Have Made Exceptions to WTU Admittance Criteria and Has Not Analyzed Proposed Changes to Criteria for the Reserve Component

The Army has implemented a structured process for reviewing the  eligibility of soldiers to be admitted to WTUs, but it does not track  instances in which Commanders have made exceptions to these criteria  for active-duty soldiers. However, by not tracking this information, the  Army does not know how frequently such exceptions are made and  cannot ensure the best use of resources. The Army Has Not Yet Examined the Costs and Benefits of Expanding a WTU-Alternative Program for Army Reserve Soldiers

The Army is planning to expand an alternative WTU program to the Army  Reserve, but it has not yet examined the costs and benefits of this  expansion. Exercise oversight responsibility to track full adherence to selection  processes for squad leaders and platoon sergeants, including the  requirement to conduct interviews for these positions. Develop plans to adjust staff levels, if needed, to accommodate a  potential future surge in demand. To help ensure the best use of resources for managing the medical care  of soldiers recovering from serious medical conditions, we recommend  that the Secretary of the Army direct the Chief of the Army Reserve, in  conjunction with the Army Surgeon General, to take the following action:
Develop an analysis that compares the costs and benefits of  maintaining the current system of Community Care Units with the  costs and benefits of expanding the Reserve Component Managed  Care program. We also discussed the Army’s  ability to adjust WTU staff levels with officials from the Warrior Transition  Command. 5).
Why GAO Did This Study

The Army established its WTU program in 2007 after congressional interest and media coverage about substandard care for soldiers at the former Walter Reed Army Medical Center. The program is to coordinate care for soldiers recovering from serious physical and behavioral health conditions. As the WTU soldier population has declined, the Army has reduced its WTUs--from 45 in 2008 to a planned total of 14 by August 2016.
The House Report accompanying a bill for the National Defense Authorization Act for Fiscal Year 2016 included a provision for GAO to review the WTU program. GAO evaluated, among other things, the extent to which the Army has (1) assessed the effectiveness of the Triad of Care model; (2) established processes to oversee the selection of WTU personnel, assess their training, and adjust staff levels; and (3) assessed adherence to WTU admittance criteria and the impact of any changes to them. GAO conducted site visits to 5 WTUs, based on a mix of active and reserve component soldiers and other variables.

What GAO Found

The Army has not assessed the effectiveness of the Triad of Care model, the core structure of the Warrior Transition Unit (WTU) program, consisting of a team of three key staff that provide medical case management. The Army established the Triad of Care model at a time when WTU soldiers' diagnoses were primarily for physical conditions. Since then, the composition of diagnoses has changed significantly. Specifically, in 2008, about 36 percent of the 12,228 soldiers who entered the WTUs had a behavioral health diagnosis. In 2015, however, over half of the 2,628 soldiers who entered the WTUs, about 52 percent, had such a diagnosis. Despite the change in the composition of diagnoses, the Army has not assessed its approach for managing soldiers' care. Officials from the five WTUs that GAO visited stated that they have added social workers to the Triad as an ad-hoc measure to provide better case management and certain types of behavioral health services. These local adaptations represent efforts to meet an immediate medical need and support the need for analysis of whether the Triad model should change. Assessing the Triad in light of the changes in WTU soldiers' diagnoses would position the Army to better determine how to meet WTU soldiers' medical needs.
The Army faces challenges in its oversight of the selection of squad leaders and platoon sergeants to staff WTUs, in the evaluation of staff training, and in the ability to adjust future staff levels if needed. Specifically, the Army has established selection processes and updated its selection criteria for these WTU personnel, but it is not exercising oversight responsibility to track full adherence to these policies, specifically the Army's requirement to interview candidates for these positions. Candidates for these positions are drawn from a mix of Army occupations, and the selection process, including interviews, is intended to ensure the suitability of the staff selected for these sensitive positions. While the Army has taken steps to improve its training program for squad leaders and platoon sergeants, the program does not incorporate a post-training assessment of the application of training to the work environment. Without information that could be obtained from such assessments, the Army may miss an opportunity to incorporate information concerning the practical application of training. In addition, the Army has not developed plans for how it would increase WTU staff levels, if needed, to support any potential future increase in demand. The ability to reverse the decision to inactivate 11 WTUs by August 2016 was a key planning consideration for the Army. However, without a plan to address staff level changes, the Army lacks assurance that it can select, train, and assign staff to its WTUs in a timely manner.
While the Army has implemented a process for reviewing the eligibility of soldiers to be admitted to WTUs, it does not track instances in which Commanders have made exceptions to these criteria. By not tracking this information, the Army does not know how frequently such exceptions are made and cannot ensure the best use of resources. In addition, the Army is planning to expand a WTU-alternative program to the Army Reserve, but has not examined the costs and benefits of such an expansion. Without comparing the costs and benefits of program expansion with the current system, the Army could incur significant costs without clearly articulated benefits.

What GAO Recommends

GAO's recommendations include that the Army assess the Triad of Care model's effectiveness; track adherence to selection processes for WTU staff; assess the application of their training; develop plans to ensure the ability to adjust staff levels, if needed; track exceptions to WTU admittance criteria; and compare the costs and benefits of expanding a WTU-alternative program for Army Reserve soldiers. DOD concurred with each of GAO's recommendations.