1.) Within each unit, the servicemember is assigned to a team of three key  staff—the Triad of Care—who provide case management services to  ensure continuity of care. 2.) When we last  reported on the Army’s progress in staffing the WTUs in February 2008,  the Army had established a goal of having at least 90 percent of Triad of  Care staff positions filled to meet the staff-to-servicemember ratios that it  had established for its WTUs. The Army Implemented a New WTU Staffing Model in Response to Study Findings, but Walter Reed Was Excluded from This Study

On October 16, 2008, the Army implemented revisions to its WTU staffing  model, including changes to two of its Triad of Care staff-to- servicemember ratios. Nonetheless, the Army had made considerable progress in meeting the  new WTU staff-to-servicemember ratios for the Triad of Care positions. These revised criteria  do not apply to Reserve and National Guard servicemembers, who  comprise about one-third of the WTU population. The Army’s revised WTU entry criteria for active component  servicemembers are intended to help ensure that only those who need  complex case management are placed in the WTU. Along with its policies establishing the revised entry and exit criteria, the  Army required the Warrior Care and Transition Office to assess the  effectiveness of the revised entry and exit criteria in ensuring that only  those servicemembers needing complex case management are in the  WTUs and to monitor the effects of the revised criteria. For example, the  number of servicemembers in WTUs decreased after implementation of  the criteria, as the Army anticipated. The Army Uses Various Mechanisms to Monitor WTU Servicemembers’ Recovery, but Its Feedback Mechanisms May Not Provide Complete Information

To monitor the recovery process of WTU servicemembers, the Army uses  individual transition plans and various upward feedback mechanisms, but  its feedback mechanisms may not provide complete information on the  performance of WTUs. The Army’s feedback mechanisms, which include a  telephone hotline and a satisfaction survey, provide a way for  servicemembers and their families to raise concerns about WTU-related  issues. The Army Is Implementing Plans for Monitoring the Recovery of Individual Servicemembers

To facilitate servicemembers’ recovery, the Army has developed a process  for coordinating and monitoring the care that servicemembers receive  while in a WTU. In January 2008, the Army issued a policy establishing  Comprehensive Transition Plans for WTU servicemembers. This survey is designed to assess  servicemembers’ satisfaction with various aspects of WTUs, including the  primary care manager and nurse case manager. An Army  official told us that the Army does not plan to conduct nonresponse  analyses because it is satisfied with the response rates that it has been  receiving since it began following up with servicemembers by telephone in  February 2008. As of January 2009, almost all of the  Triad of Care positions in the WTUs were fully staffed. However, the Army has not finalized policy that would  allow it to systematically determine whether WTUs are consistently  developing these plans. Recommendations for Executive Action

We recommend that the Secretary of Defense direct the Secretary of the  Army to take the following three actions:    To help ensure that the WTU at Walter Reed Army Medical Center is  providing an appropriate level of care to servicemembers and help the  Army make future staffing decisions for the WTUs that will be caring for  this population once Walter Reed closes, the Army should examine Walter  Reed’s WTU staffing model, including its Triad of Care staff-to- servicemember ratios, in light of the complexity of the health care needs  of servicemembers placed in this WTU. To determine whether the results of the Warrior Transition Unit Program  Satisfaction Survey can be used to assess the effectiveness of the WTUs,  the Army should take steps to determine whether the results are  representative of all servicemembers in WTUs, such as by conducting  nonresponse analyses, and should take additional steps if necessary to  obtain results that are representative. However, DOD did not indicate its most  recent response rates. More specifically, to assess the Army’s ongoing efforts to staff its WTU  Triad of Care positions—primary care managers, nurse case managers,  and squad leaders—we obtained and reviewed the Army Warrior Care &  Transition Program, which established policies for implementing the  WTUs.
Why GAO Did This Study

In February 2007, a series of Washington Post articles disclosed problems at Walter Reed Army Medical Center, particularly with the management of servicemembers receiving outpatient care. In response, the Army established Warrior Transition Units (WTU) for servicemembers requiring complex case management. Each servicemember in a WTU is assigned to a Triad of Care--a primary care manager, a nurse case manager, and a squad leader--who provide case management services to ensure continuity of care. The Army established staff-to-servicemember ratios for each Triad of Care position. This report examines (1) the Army's ongoing efforts to staff WTU Triad of Care positions and (2) how the Army monitors the recovery process of WTU servicemembers. GAO reviewed WTU policies, analyzed Army staffing and monitoring data, interviewed Army officials, and visited five selected WTUs.

What GAO Found

The Army has taken several steps to help ensure that WTUs are staffed appropriately. First, the Army developed policies aimed at reducing WTU staffing shortfalls, including a policy requiring the reassignment of other personnel on an installation to fill open WTU positions. Second, in October 2008, the Army revised its WTU staffing model, including the staff-to-servicemember ratios for two of its Triad of Care positions, because an Army study determined that the existing ratios were not adequate to provide an appropriate level of care to servicemembers in WTUs. The Army has made considerable progress in meeting the new ratios, and as of January 2009, the Triad of Care positions at most WTUs were fully staffed. However, staffing ratios for the WTU at Walter Reed Army Medical Center were not revised, even though the Army recognizes that servicemembers treated at this facility have more complex health care needs than servicemembers at other WTUs. Walter Reed might require a different staffing model, for example, one that decreases the number of servicemembers assigned to staff members, but the Army does not plan to conduct an assessment of Walter Reed's staffing model. Third, the Army modified its WTU placement and exit criteria for full-time servicemembers, excluding Army Reserve and National Guard servicemembers who comprise about one-third of the WTU population. These changes are intended to help ensure that only those who need complex case management are in WTUs. Those with less serious health care needs can be reassigned to other units on the installation to continue their recovery. As the Army expected, the WTU population of full-time servicemembers declined by about 1,500 in the 4 months after implementation of the new criteria. To monitor the recovery process of WTU servicemembers, the Army has implemented transition plans for individual servicemembers as well as various upward feedback mechanisms to identify concerns and gauge satisfaction. In January 2008, the Army issued a policy establishing Comprehensive Transition Plans, which can be used to monitor and coordinate servicemembers' care. To help ensure consistent implementation of these plans among its WTUs, the Army is developing a new policy that includes the systematic collection of performance measures across WTUs. However, despite Army officials' repeated assurances to GAO that this policy was forthcoming, it had not been finalized as of February 27, 2009. The Army's feedback mechanisms include its Warrior Transition Unit Program Satisfaction Survey, which collects information from servicemembers in WTUs on a number of issues, including the primary care manager and nurse case manager. However, the survey's response rates for the WTUs have been low (13 to 35 percent) and the Army has not determined whether the results obtained from the respondents are representative of all WTU servicemembers. An Army official told GAO that the Army does not plan to conduct analyses to determine whether the survey results are representative, because it is satisfied with the response rates. In GAO's view, the response rates are too low for the Army to reliably report satisfaction of servicemembers in WTUs.