Problems Identifying Potential Enrollees and Reviewing Enrollment Decisions Make It Unclear Whether Those Needing FRCP Services Are Enrolled

It is unclear whether all of the eligible “severely wounded, ill, and injured”  servicemembers and veterans who could benefit from the FRCP are being  enrolled in the program. In  addition, the FRCs must exercise judgment in applying the program’s  criteria for enrollment determinations, and FRCP leadership does not  systematically review these decisions to ensure that these criteria are  applied appropriately so that referred individuals who could benefit from  the program are enrolled, and that individuals who could be served by less  intensive services are referred to other programs. The FRCP’s Potential Enrollee Population Cannot Be Readily Identified from Existing Data Sources, but the FRCP Has Taken a Number of Steps to Identify Potentially Eligible Individuals

FRCP officials have experienced difficulties in identifying the potentially  eligible population of “severely wounded, ill, or injured” servicemembers  and veterans, and as a result, it is unclear whether all of these individuals  who could benefit from care coordination services are enrolled in the  program. As a result, to identify potentially eligible individuals, the FRCP relies on  referrals from others, including program officials and medical facility staff. The FRCP Faces Challenges in Determining Staffing Needs and Has Not Clearly Defined or Documented Its Processes for Managing FRCs’ Caseloads, Making Staffing Decisions, and Placing FRCs

Several challenges confront the FRCP in determining staffing needs for the  program, including how to manage FRCs’ caseloads, deciding when VA  should hire FRCs, and determining where to place them in the field to best  serve current and potential enrollees. According to the FRCP Executive Director, an appropriate caseload is  difficult to determine because care coordination is a new type of function,  and there are no comparable criteria against which to measure and base  caseload size for this program because of its unique activities. The FRCP Executive Director told us that the program is developing a  customized workload assessment tool to help balance FRCs’ caseloads— in other words, to ensure that an FRC’s caseload mix is manageable. The FRCP Executive Director is uncertain how long it  will take to develop a workload assessment tool and has not established  timelines to complete this effort. The FRCP Lacks a Clear and Consistent Rationale for Making FRC Placement Decisions

Deciding where to place FRCs to best serve current and potential  enrollees’ needs is another key staffing issue, despite the fact that FRCs  often coordinate services for enrollees who are located throughout the  country and may not be receiving care at the facility where their assigned  FRC is located. 1.) FRCP officials have also decided to place some new FRCs at two VA  medical centers where servicemembers and veterans with polytrauma  injuries receive care, based on recommendations from DOD and VA  officials. Developing a clear and consistent rationale for placing FRCs, which  includes a systematic analysis of program data, should help ensure that  FRCs are located where they could provide the maximum benefit to  current and potential enrollees. Efforts by the FRCP to improve information sharing are  ongoing. Coordination among the FRCP and DOD and VA Case Management Programs Is Impeded by Limitations on Their Ability to Share Information, and Efforts to Address These Limitations Are Ongoing

Coordination among DOD and VA programs that provide care  coordination and case management is difficult because of the large  number of such programs that exist to address the needs of wounded  servicemembers and veterans and the limitations in the ability of these  programs to share information. At two of the military treatment facilities we visited, for example, a  military program serving wounded servicemembers delays referrals to the  FRCP until a servicemember approaches the point when he or she is  preparing to transition to another facility or VA.

			Information Disclosure Requirements Limited the FRCP’s Information Sharing with DOD’s Wounded Warrior Programs

Prior to January 2011, VA had not completed public disclosure actions  necessary to enable the sharing of information from the Veterans Tracking  Application, the information system used by the FRCP that contains each  enrollee’s personal information and Federal Individual Recovery Plan. Because enrollment decisions are not  well documented or systematically reviewed by FRCP leadership, it is  unclear whether referred servicemembers and veterans who need FRC  services are being enrolled in the program. 2. 3. Agency Comments and Our Evaluation

DOD and VA each provided comments on a draft of this report.
Why GAO Did This Study

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.

What GAO Found

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.

What GAO Recommends

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.