While Efforts Are Under Way to Respond to Both Army-Specific and Systemic Problems, Challenges Are Emerging

While the Army took near-term actions to respond to reported deficiencies  in care for its returning servicemembers, and the Senior Oversight  Committee is undertaking efforts to address more systemic problems,  challenges remain to overcome long-standing problems and ensure  sustainable progress. Case management—a process intended to assist returning  servicemembers with management of their clinical and nonclinical care  throughout recovery, rehabilitation, and community reintegration—is  important because servicemembers often receive services from numerous  therapists, providers, and specialists, resulting in differing treatment plans  as well as receiving prescriptions for multiple medications. Within each unit, the  servicemember is assigned to a team of three key staff and this team is  responsible for overseeing the continuum of care for the servicemember. The Army refers to this team as a “triad,” and it consists of a (1) primary  care manager—usually a physician who provides primary oversight and  continuity of health care and ensures the quality of the servicemember’s  care; (2) nurse case manager—usually a registered nurse who plans,  implements, coordinates, monitors, and evaluates options and services to  meet the servicemember’s needs; and (3) squad leader—a  noncommissioned officer who links the servicemember to the chain of  command, builds a relationship with the servicemember, and works along  side the other parts of the triad to ensure the needs of the servicemember  and his or her family are met. As the Army has sought to fill its Warrior Transition Units, challenges to  staffing key positions are emerging. For example, many locations have  significant shortfalls in registered nurse case managers and non- commissioned officer squad leaders. As of mid-September, 17 of the 32 units had less than 50 percent  of staff in place in one or more critical positions. The Senior Oversight Committee’s approach for providing a continuum of  care includes establishment of recovery coordinators and recovery plans,  as recommended by the Dole-Shalala Commission. This approach is  intended to complement the military services’ existing case management  approaches and place the recovery coordinators at a level above case  managers, with emphasis on ensuring a seamless transition between DOD  and VA. At the time of our review, the committee was determining the details  of the program. Efforts Are Under Way to Improve Disability Evaluation Processes, but Challenges Remain in Transforming the Overall System

As we have previously reported, providing timely and consistent disability  decisions is a challenge for both DOD and VA. These initiatives include reducing the caseloads of evaluation  board liaisons who help servicemembers navigate the disability evaluation  system. In addition, the Army developed and conducted the first  certification training for evaluation board liaisons. To address more systemic concerns about the timeliness and consistency  of DOD’s and VA’s disability evaluation systems, DOD and VA are planning  to pilot a joint disability evaluation system. DOD and VA are reviewing  multiple options that incorporate variations of the following three  elements: (1) a single, comprehensive medical examination to be used by  both DOD and VA in their disability evaluations; (2) a single disability  rating performed by VA; and (3) incorporating a DOD-level evaluation  board for adjudicating servicemembers’ fitness for duty. See table 5 for selected  efforts under way by the Army and Senior Oversight Committee to  improve data sharing between DOD and VA.
As part of the Army Medical Action Plan, the Army has taken steps to  facilitate the exchange of data between its military treatment facilities and  VA. For example, the Army Medical Department is developing a  memorandum of understanding between the Army and VA that would  allow VA access to data on severely injured servicemembers who are  being transferred to a VA polytrauma center. A Senior Oversight Committee workgroup on data sharing has also been  coordinating with other committee workgroups on their information  technology needs. Concluding Observations

Our preliminary observations are that fixing the long-standing and  complex problems spotlighted in the wake of Walter Reed media accounts  as expeditiously as possible is critical to ensuring high-quality care for our  returning servicemembers, and success will ultimately depend on  sustained attention, systematic oversight by DOD and VA, and sufficient  resources. Global War on Terrorism: Reported Obligations for the Department of  Defense.
Why GAO Did This Study

In February 2007, a series of Washington Post articles disclosed troublesome deficiencies in the provision of outpatient services at Walter Reed Army Medical Center, raising concerns about the care for returning servicemembers. These deficiencies included a confusing disability evaluation system and servicemembers in outpatient status for months and sometimes years without a clear understanding about their plan of care. The reported problems at Walter Reed prompted broader questions about whether the Department of Defense (DOD) as well as the Department of Veterans Affairs (VA) are fully prepared to meet the needs of returning servicemembers. In response to the deficiencies reported at Walter Reed, the Army took a number of actions and DOD formed a joint DOD-VA Senior Oversight Committee. This statement provides information on the near-term actions being taken by the Army and the broader efforts of the Senior Oversight Committee to address longer-term systemic problems that impact health care and disability evaluations for returning servicemembers. Preliminary observations in this testimony are based largely on documents obtained from and interviews with Army officials, and DOD and VA representatives of the Senior Oversight Committee, as well as on GAO's extensive past work. We discussed the facts contained in this statement with DOD and VA.

What GAO Found

While efforts are under way to respond to both Army-specific and systemic problems, challenges are emerging such as staffing new initiatives. The Army and the Senior Oversight Committee have efforts under way to improve case management--a process intended to assist returning servicemembers with management of their care from initial injury through recovery. Case management is especially important for returning servicemembers who must often visit numerous therapists, providers, and specialists, resulting in differing treatment plans. The Army's approach for improving case management for its servicemembers includes developing a new organizational structure--a Warrior Transition Unit, in which each servicemember would be assigned to a team of three key staff--a physician care manager, a nurse case manager, and a squad leader. As the Army has sought to staff its Warrior Transition Units, challenges to staffing critical positions are emerging. For example, as of mid-September 2007, over half the U.S. Warrior Transition Units had significant shortfalls in one or more of these critical positions. The Senior Oversight Committee's plan to provide a continuum of care focuses on establishing recovery coordinators, which would be the main contact for a returning servicemember and his or her family. This approach is intended to complement the military services' existing case management approaches and place the recovery coordinators at a level above case managers, with emphasis on ensuring a seamless transition between DOD and VA. At the time of GAO's review, the committee was still determining how many recovery coordinators would be necessary and the population of seriously injured servicemembers they would serve. As GAO and others have previously reported, providing timely and consistent disability decisions is a challenge for both DOD and VA. To address identified concerns, the Army has taken steps to streamline its disability evaluation process and reduce bottlenecks. The Army has also developed and conducted the first certification training for evaluation board liaisons who help servicemembers navigate the system. To address more systemic concerns, the Senior Oversight Committee is planning to pilot a joint disability evaluation system. Pilot options may incorporate variations of three key elements: (1) a single, comprehensive medical examination; (2) a single disability rating done by VA; and (3) a DOD-level evaluation board for adjudicating servicemembers' fitness for duty. DOD and VA officials hoped to begin the pilot in August 2007, but postponed implementation in order to further review options and address open questions, including those related to proposed legislation. Fixing these long-standing and complex problems as expeditiously as possible is critical to ensuring high-quality care for returning servicemembers, and success will ultimately depend on sustained attention, systematic oversight by DOD and VA, and sufficient resources.