[House Hearing, 112 Congress]
[From the U.S. Government Publishing Office]
THE FEDERAL RECOVERY COORDINATION
PROGRAM: ASSESSING PROGRESS TOWARD IMPROVEMENT
=======================================================================
HEARING
before the
SUBCOMMITTEE ON HEALTH
of the
COMMITTEE ON VETERANS' AFFAIRS
U.S. HOUSE OF REPRESENTATIVES
ONE HUNDRED TWELFTH CONGRESS
FIRST SESSION
__________
OCTOBER 6, 2011
__________
Serial No. 112-29
__________
Printed for the use of the Committee on Veterans' Affairs
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COMMITTEE ON VETERANS' AFFAIRS
JEFF MILLER, Florida, Chairman
CLIFF STEARNS, Florida BOB FILNER, California, Ranking
DOUG LAMBORN, Colorado CORRINE BROWN, Florida
GUS M. BILIRAKIS, Florida SILVESTRE REYES, Texas
DAVID P. ROE, Tennessee MICHAEL H. MICHAUD, Maine
MARLIN A. STUTZMAN, Indiana LINDA T. SANCHEZ, California
BILL FLORES, Texas BRUCE L. BRALEY, Iowa
BILL JOHNSON, Ohio JERRY McNERNEY, California
JEFF DENHAM, California JOE DONNELLY, Indiana
JON RUNYAN, New Jersey TIMOTHY J. WALZ, Minnesota
DAN BENISHEK, Michigan JOHN BARROW, Georgia
ANN MARIE BUERKLE, New York RUSS CARNAHAN, Missouri
TIM HUELSKAMP, Kansas
MARK E. AMODEI, Nevada
ROBERT L. TURNER, New York
Helen W. Tolar, Staff Director and Chief Counsel
SUBCOMMITTEE ON HEALTH
ANN MARIE BUERKLE, New York, Chairwoman
CLIFF STEARNS, Florida MICHAEL H. MICHAUD, Maine, Ranking
GUS M. BILIRAKIS, Florida CORRINE BROWN, Florida
DAVID P. ROE, Tennessee SILVESTRE REYES, Texas
DAN BENISHEK, Michigan RUSS CARNAHAN, Missouri
JEFF DENHAM, California JOE DONNELLY, Indiana
JON RUNYAN, New Jersey
Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public
hearing records of the Committee on Veterans' Affairs are also
published in electronic form. The printed hearing record remains the
official version. Because electronic submissions are used to prepare
both printed and electronic versions of the hearing record, the process
of converting between various electronic formats may introduce
unintentional errors or omissions. Such occurrences are inherent in the
current publication process and should diminish as the process is
further refined.
C O N T E N T S
__________
October 6, 2011
Page
The Federal Recovery Coordination Program: Assessing Progress
Toward Improvement............................................. 1
OPENING STATEMENTS
Chairwoman Ann Marie Buerkle..................................... 1
Prepared statement of Chairwoman Buerkle..................... 33
Hon. Michael H. Michaud, Ranking Democratic Member............... 2
Prepared statement of Congressman Michaud.................... 34
WITNESSES
U.S. Government Accountability Office, Debra A. Draper, Director,
Health Care.................................................... 3
Prepared statement of Ms. Draper............................. 34
U.S. Department of Defense, Philip A. Burdette, Principal
Director, Wounded Warrior Care and Transition Policy, Office of
the Under Secretary of Defense for Personnel and Readiness..... 10
Prepared statement of Mr. Burdette........................... 41
U.S. Department of Veterans Affairs, John Medve, Executive
Director, Office of the U.S. Department of Veterans Affairs-
U.S. Department of Defense Collaboration, Office of Policy and
Planning....................................................... 12
Prepared statement of Mr. Medve.............................. 43
______
Military Officers Association of America, Commander Rene A.
Campos, USN (Ret.), Deputy Director, Government Relations...... 27
Prepared statement of Commander Campos....................... 50
Paralyzed Veterans of America, Alethea Predeoux, Associate
Director of Health Legislation................................. 25
Prepared statement of Ms. Predeoux........................... 48
Wounded Warrior Project, Abbie Holland Schmit, Manager, Alumni... 24
Prepared statement of Ms. Schmit............................. 45
SUBMISSION FOR THE RECORD
Carnahan, Hon. Russ, a Representative in Congress from the State
of Missouri.................................................... 55
MATERIAL SUBMITTED FOR THE RECORD
Gail H. McGinn, Deputy Under Secretary of Defense (Plans)
Performing the Duties of the Under Secretary of Defense for
Personnel and Readiness, transmitting U.S. Department of
Defense Instruction Number 1300.24, regarding ``Recovery
Coordination Program,'' dated December 2, 2009................. 56
THE FEDERAL RECOVERY PROGRAM:
ASSESSING PROGRESS TOWARD IMPROVEMENT
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THURSDAY, OCTOBER 6, 2011
U.S. House of Representatives,
Committee on Veterans' Affairs,
Subcommittee on Health,
Washington, DC.
The Subcommittee met, pursuant to call, at 8:30 a.m., in
Room 334, Cannon House Office Building, Hon. Ann Marie Buerkle
[Chairwoman of the Subcommittee] presiding.
Present: Representatives Buerkle, Bilirakis, Roe, Michaud,
and Donnelly.
OPENING STATEMENT OF CHAIRWOMAN BUERKLE
Ms. Buerkle. Good morning. I want to thank all of you for
joining us this morning as we continue our oversight of the
Federal Recovery Coordination Program (FRCP).
Last May, our Subcommittee held a hearing to examine the
significant challenges that the FRCP faces in areas as
fundamental as identifying potential enrollees, reviewing
enrollment decisions, determining staffing needs, defining and
managing caseloads, and making placement decisions.
At that hearing, unfortunately, it became patently clear
that rather than having a single joint program to advocate on
behalf of our wounded warriors and to ensure a comprehensive
and seamless rehabilitation, recovery, and transition, we have
two separate overlapping programs, the Recovery Coordination
Program (RCP) operated within the U.S. Department of Defense
(DoD) and the FRCP operated within the U.S. Department of
Veterans Affairs (VA).
Needless to say, this has created unnecessary and
unacceptable confusion about the roles and the responsibilities
of each program and has added yet another burdensome
bureaucratic maze for our wounded warriors and their families
to navigate through at a time when recovery and reintegration
should really be their only focus.
I was so concerned about the pervasive issues with the
operation of these two programs that immediately following that
hearing, I sent a letter jointly with Ranking Member Michaud to
the co-chairs of the VA-DoD Wounded, Ill, and Injured Senior
Oversight Committee (SOC) with oversight over the FRCP.
In that letter, we requested a detailed plan and a timeline
for how the VA and DoD jointly would implement the
recommendations contained in the recent U.S. Government
Accountability Office (GAO) report, which identified
significant shortcomings of the FRCP.
Further, we asked for an analysis on how the FRCP and RCP
could be integrated under a single umbrella to reduce
redundancy and ensure the seamless transition of our wounded
warriors.
A response was requested by June the 20th. More than 2
months passed since this deadline and, following the notice of
this additional hearing, we finally received a response to our
letter. Unfortunately, it did not include the detail nor the
timeline we requested and expected.
With regard to an analysis of and potential actions for
integrating the FRCP and the RCP, we were told that SOC, quote,
is currently considering several options to maximize resources
in care coordination and preparing for final recommendations,
end quote. These programs are not new and the time for
considering and recommending has long since passed.
As Chairwoman, it has been my privilege this year to spend
time with our honored heroes who have returned from battle
bearing the wounds of war and the families who stand by their
side through it all.
I have traveled to Brooke Army Medical Center, the Center
for the Intrepid, and VA medical facilities across our great
country. It is clear to me that FRCP is failing.
It is also clear to me that these families cannot wait any
longer. They can no longer be party to the bureaucratic in
fighting and turf battles. They can no longer be told that they
have several points of contact.
When answers are needed, we cannot take 3 months to respond
to a letter. When answers are needed, we cannot continue to
consider our options. Today we are looking for answers.
I now recognize the Ranking Member, Mr. Michaud, for any
remarks he might have.
[The prepared statement of Chairwoman Buerkle appears on p.
33.]
OPENING STATEMENT OF HON. MICHAEL H. MICHAUD
Mr. Michaud. Thank you very much, Madam Chair. I would like
to thank you for holding this hearing today on this extremely
important program.
As you heard, in May, this Subcommittee held a hearing on
the very same issue and I am pleased that we are the critical
oversight of this very critical program. If it is not done
right, our servicemembers will suffer.
Following that Subcommittee hearing, I joined the
Chairwoman in sending a letter on May 26 to the Senior
Oversight Committee requesting a detailed response to how the
VA and the DoD can work together on implementing the Government
Accountability Office recommendations and requesting an
analysis of integrating the FRCP and the Recovery Coordination
Program.
On August 19th, we then sent a follow-up letter because of
the lack of response from the Senior Oversight Committee. The
letter that we did finally receive dated September 12th was
hardly what we were expecting.
The GAO reports that the agencies reached an impasse on the
content of the final letter responding to our concerns as a
Committee. This lack of response only serves to magnify in my
mind the continued problems between the VA and the DoD in
working collaboratively and highlights the lack of progress
that we have heard and read about in recent submissions and
testimony.
I can only imagine what this means with other critical
decisions that directly impact veterans and their families. I
do not feel confident that the Department of Veterans Affairs
and the Department of Defense can overcome existing barriers
and the tangling of bureaucracy seems to surround the
implementation of this program.
Let us all keep in mind that this is not about individuals
sitting in this room. This is about the brave men and women who
wear the uniform, who have been injured while serving this
country, and our absolute commitment to their recovery and
reintegration back into the communities where they live.
Whatever it takes, we owe that much to them.
Today I would like to hear about solid progress that has
been made and what is being done to move this forward in an
effective and efficient manner. I would also like to hear from
each of the panels what this Subcommittee might be able to do
to help.
It is unconscionable that we have a bureaucracy that is
supposed to be helping our soldiers and our veterans but
because of the entanglement within the bureaucracy, these brave
men and women are not being served like they should.
I would encourage each and every one of you who are
responsible for this program to step up to the plate, think of
what these men and women have gone through and are going
through each and every day. And I look forward to your
testimony.
Madam Chair, I want to thank you for holding this hearing
on this very important topic. So thank you very much.
[The prepared statement of Congressman Michaud appears on
p. 34.]
Ms. Buerkle. Thank you, Mr. Michaud.
At this time, I would like to welcome our first panel to
the table. With us this morning is Dr. Debra Draper, Director
of the Health Care team at the United States Government
Accountability Office.
Thank you very much for joining us this morning and I look
forward to hearing your testimony. We will start with you now.
Thank you.
STATEMENT OF DEBRA A. DRAPER, DIRECTOR, HEALTH CARE, U.S.
GOVERNMENT ACCOUNTABILITY OFFICE
Ms. Draper. Chairwoman Buerkle, Ranking Member Michaud, and
Members of the Subcommittee, I am pleased to be here today as
you discuss efforts by DoD and VA to address issues of concern
that were raised during your May 13th hearing on the Federal
Recovery Coordination Program, a program jointly developed by
DoD and VA to provide care coordination for our most severely
wounded, ill, and injured servicemembers and veterans,
individuals who because of the severity of their injuries and
illnesses could benefit greatly from care coordination
services.
At the May 13th hearing, we highlighted various concerns
identified in our March 2011 report about the program. We also
emphasized the importance of this program's coordination with
other DoD and VA programs that are similarly intended to
improve care coordination and case management including DoD's
Recovery Coordination Program.
In my statement today, I will discuss the status of actions
taken by DoD and VA to implement the recommendations from our
March report. I will also discuss efforts by DoD and VA to
identify and analyze potential options to better integrate
their care coordination programs.
Regarding our March recommendations, we are pleased that VA
has made progress in improving program management of enrollment
decisions as well as care coordinator staffing needs,
caseloads, and placement decisions.
While our recommendations were directed to the Secretary of
VA because VA administers the program, DoD and VA were both
asked to provide a response to the Subcommittee about how the
Departments could jointly implement them.
We found that DoD's assistance to VA has been limited to a
June 30th e-mail to the commanders of the military services'
Wounded Warrior programs about referrals to the program.
According to VA officials, however, they have seen no change in
referrals since the e-mail was sent.
More troubling, however, is the status of DoD and VA's
efforts to jointly identify and analyze potential solutions to
better integrate their care coordination programs. The
Departments have made little progress reaching agreement on
integration options despite a number of attempts to do so.
Most recently, DoD and VA failed to provide a timely
response to the Subcommittee's May 26 request to jointly
develop potential solutions for integrating their care
coordination programs.
On September 12, several months after the request, a joint
letter was issued stating that the Departments were considering
a number of options to maximize their care coordination
resources. However, this letter did not specifically identify
or outline any of these options. Other efforts have also failed
to advance a jointly devised solution.
This lack of progress to better integrate the Departments'
care coordination programs illustrates the continued difficulty
by DoD and VA to reach a collaborative solution to address
program duplication and overlap.
We currently have work underway to further study this issue
and identify key impediments affecting recovering
servicemembers and veterans during the course of their care.
Also, as we have previously reported, there are numerous
DoD and VA programs that provide similar services to
individuals who are often enrolled in more than one program and
as a result may have multiple care coordinators and case
managers.
One Federal Recovery Coordinator (FRC) told us that in one
instance, five case managers were working on the same life
insurance for the same individual.
In another instance, DoD and VA care coordinators
unknowingly established conflicting recovery goals for a
servicemember about whether to separate from the military. This
created considerable confusion for the individual and his
family.
The bottom line is that there has been little progress made
by DoD and VA to more effectively align and integrate their
care coordination and case management programs across the
Departments.
This is particularly disconcerting as the number of
individuals served by these programs continues to grow. Without
better interdepartmental coordination, problems with
duplication and overlap will persist and perhaps worsen.
Furthermore, the confusion this creates for recovering
servicemembers, veterans, and their families may hamper their
recovery. Unfortunately, the intended purpose of these programs
to better manage and facilitate care and services may actually
have the opposite effect.
Based on our continuing concerns, we are recommending that
the secretaries of DoD and VA direct the Senior Oversight
Committee to expeditiously develop and implement a plan to
strengthen integration across all DoD and VA care coordination
and case management programs including the Federal Recovery
Coordination and Recovery Coordination programs to improve
their effectiveness, efficiency, and efficacy.
Madam Chairwoman, this concludes my opening remarks. I am
happy to answer any questions.
[The prepared statement of Ms. Draper appears on p. 34.]
Ms. Buerkle. Thank you, Dr. Draper.
I will now yield myself 5 minutes for questions.
I just want to pick up on a couple of things and follow-up
with some of your testimony here this morning.
The first thing that concerns me is that you are saying
that the failure of VA and DoD to reach some sort of an
agreement and the duplication and the conflicting goals of
these two programs may hamper their recovery.
So it is your testimony this morning that this program is
right now in its current form hurting our veterans rather than
helping them?
Ms. Draper. Well, we have concerns because there appears to
be little, if any, cooperation or collaboration. And since our
May testimony, the situation actually seems to be worsening
based on our updated work for this particular hearing.
For our work related to the testimony, we received
differing versions as to why further progress has not been
made, and it was very difficult to get a clear understanding of
what the difficulties are between the two Departments.
We are aware of some activity, but we do not know the
details of those activities, and the activities seem to be done
in silos at VA and at DoD but nothing collaboratively.
Our concern is that the lack of cooperation and
collaboration not only fails to address existing program
duplication and overlap but fails to fully consider the impact
on our most severely wounded servicemembers and veterans.
As you know, these are particularly vulnerable individuals
that can benefit greatly from care coordination services.
Somehow this interdepartmental tug of war seems to have lost
sight of why the programs exist in the first place, which is to
care for our wounded servicemembers and veterans.
Ms. Buerkle. Thank you.
You mentioned that your recommendation is to expeditiously
develop and implement a plan.
So if you would give us some insights. What do you consider
expeditious and what should our expectation be? What is
realistic from what you have observed from DoD and VA?
Ms. Draper. We have a couple of things that we would think
are important to consider in moving towards a solution. First
of all, I would just say that the progress made has been too
slow. Ensuring that the Departments address our recommendation
is important.
Reevaluating the role of the Senior Oversight Committee,
that is probably something that needs to be done. Is there more
that they can be doing? Should they be doing something
differently?
The Departments should determine whether the original
intent of the program continues to be important, and if so,
they should ensure that the proposed solutions really preserve
that original intent.
And if the desire is for this to be a truly joint DoD and
VA program, it seems reasonable that DoD and VA should have
joint administrative, budgetary, and other responsibilities,
and joint incentives should be designed to ensure that the
desired outcomes are achieved. As, you know, currently DoD does
not have administrative or a budgetary role in this program.
And, you know, to be quite frank, it would be helpful to
hold the Department's feet to the fire and require them to
periodically report on their plans and progress.
Ms. Buerkle. In your opinion, where should we go from here
as a Subcommittee?
We want to see this program moved along. As the Ranking
Member mentioned as well as myself, this is not about the
people in this room. This is about our wounded warriors. So if
you could just give us some insight as to where you think we
should go from here.
Ms. Draper. Well, we strongly encourage DoD and VA to
examine the strength of their coordination for these programs.
But I do want to reiterate that our concerns go beyond the
Federal Recovery Coordination or Recovery Coordination
programs. As I mentioned in my testimony, there are numerous
care coordination and case management programs across the
Departments, and we believe that it is now time to take a
comprehensive look at all these similar programs to identify
duplication and overlap and to develop and implement a plan to
improve their overall effectiveness, efficiency, and efficacy.
Ms. Buerkle. Thank you, Dr. Draper.
I now yield 5 minutes to the Ranking Member.
Mr. Michaud. Thank you very much, Madam Chair.
While you were conducting the interview and performing your
audits, were you confused by the way that these programs were
set up to function or could you understand the functionality of
the programs?
Ms. Draper. I would say we were confused more by the
responses we were getting from DoD and VA. They did not seem to
be very aligned, and we got differing views from each of the
Departments. So, it was very hard to piece the story together.
Mr. Michaud. First of all, it is disheartening to me that
the DoD and VA have made little progress towards integrating
the care and coordination and case management across the
Departments.
What can we do to help facilitate the coordination and
communication between the agencies? I mean, to me, it seems it
is very simple, but evidently--well, it is not working. So what
do you think that we should do to help facilitate that?
Ms. Draper. Well, again, I think holding their feet to the
fire, creating joint incentives for the programs that force
that alignment of the Departments' goals, and giving joint
responsibilities and accountability to both Departments.
I do want to say, though, that there is some inherent
tensions between the way the Federal Recovery Coordination
Program is set up between DoD and VA that involves when and how
best to involve the Federal Recovery Coordinators.
DoD's stance is that they are concerned about involving VA
too soon because it sends the wrong message to a recovering
servicemember, mainly that their military career may be over.
Also, I think there is a cultural stance within the military
services to take care of their own.
On the other hand, you have VA who has authority to realy
work with recovering servicemembers veterans, and their
families, and they want to get involved early so that they can
make the transition for that recovering servicemember to
civilian life much easier.
Mr. Michaud. Would you agree then by the fact that the DoD
is reluctant to let the VA step in early because they are
afraid that there might be the perception of kicking them out?
The bottom line that concerns me is the fact that if a
servicemember or veteran is not getting the service that they
need, that is going to cause a lot more stress on the
individual member of the service as well as the family and
ultimately could potentially lead to suicide. And that is the
huge concern that I have with the lack of coordination and the
lack of the case management as I have heard about since we
implemented the program.
And have you heard any concerns about that or in your
investigation about the suicide?
Ms. Draper. We did not hear about that.
Mr. Michaud. Thank you, Madam Chair.
Ms. Buerkle. I yield 5 minutes to the gentleman from
Tennessee, Mr. Roe.
Mr. Roe. Thank you, Dr. Draper, for being here.
And let me just start out by saying that this should be
something we are really good at. You know, we provide the best
health care on the battlefield that there is in the world or
ever has been. And people are surviving injuries now that they
did not survive when I was in service in the 1970s and during
Vietnam. So this is something we should be really good at.
I looked at these numbers last night and there are 21 of
the Federal Recovery coordinators and there are 1,827
servicemen that have been treated so far. And this is over a
period of 3\1/2\ years.
Ms. Draper. Uh-huh.
Mr. Roe. Eighteen hundred and twenty-seven people got care.
I saw between 3,000 to 4,000 patients a year myself plus
assisted or did several hundred operations during 1 year, one
person did.
And I did the math on this and these people average taking
care of one person every other week. This should not be
overwhelming anybody. And I do not know what in the world, why
this has been so hard. And you pointed out something that we
see.
Sometimes you have several people involved in a discussion
when maybe a veteran does not get the answer or a soldier does
not get the answer they want. It is a tremendous waste of
resources when you have five people working on the same issue.
That is ridiculous.
And you had stated here the GAO references one FRC that
estimates that his enrollees have on average eight different
case managers affiliated with eight different programs. This
overlap can lead to significant redundancy, conflict, and
frustration for the servicemember or veteran and their family
throughout the recovery and reintegration process.
I could not agree more. I mean, you do not have anybody
leading the ship and that is what I thought the FRC was. Am I
right or wrong about that?
Ms. Draper. Well, the original intent was to have one
person being the umbrella to coordinate both the clinical and
non-clinical services. I mean, that is our concern with the
duplication and overlap. Having so many people involved runs
counter to the intent of the program.
Mr. Roe. Yeah. But, I mean, I guess what I am looking at,
if I had this many resources to take care of 1,827 people, I
believe I could do that pretty well, pretty easily, and without
all this confusion. And that is what I am baffled by.
Where is the problem? I mean, when you do the math on this
in 3\1/2\ years, the average coordinator is taking care of 25
persons per year. That is one every other week. Am I wrong?
Ms. Draper. That is correct.
Mr. Roe. Do you have an explanation for that?
Ms. Draper. I do not.
Mr. Roe. I think maybe later in the testimony, we will get
an explanation for that, but I agree. And I see this in our
office and I know all of us that have offices that work with
veterans. Sometimes they are in the senator's office. Sometimes
they are in our office. I know it gets conflicted sometimes
when a case gets in two different places.
But this is a situation where that should not happen
because we have control of these folks. They are either in DoD
under their umbrella, or in VA under their umbrella.
Ms. Draper. And I want to emphasize that these are very
important services, particularly for this population that is
very vulnerable. And as you know, we just need to find a way to
make the programs work and work well.
Mr. Roe. And they are critical services. I want to hear
actually later in the testimony, and thank you for the work you
have done, Dr. Draper, to point out why this is not working
after going on now 4 years.
I yield back.
Ms. Buerkle. Thank you, Dr. Roe.
Mr. Donnelly.
Mr. Donnelly. Just a follow-up to Dr. Roe's question. Where
would we look for the explanation as to the numbers that he was
talking about as to the productivity and how many people were
being taken care of?
Ms. Draper. Yes. I would direct that to the program
officials.
Mr. Donnelly. Okay. The next question is about cooperation.
You have DoD. You have VA. What have you found in terms of
cooperation and working with them?
Ms. Draper. We have found that it is not working very well
at all.
Mr. Donnelly. And what are the major causes of that? I know
in your testimony, you pointed at some of the quote. How do we
get these people to work seamlessly together?
Ms. Draper. As I mentioned earlier, there are some inherent
tensions based on differences between the two Departments, and
I think these differences are key to improving collaboration.
One difference is looking at when and how to get a Federal
Recovery Coordinator involved in care. There seems to be a lot
of disagreement about that when that happens.
I think also that the Departments should be held
accountable, and they should be required to periodically report
on their plans and progress.
And I also would strongly recommend that they implement the
recommendation that we are making in our testimony today and
that is to expeditiously develop and implement a plan to look
at integration across care coordination and case management
programs.
And I want to reiterate that our concerns are much beyond
the Federal Recovery Coordination and Recovery Coordination
programs and extend to the numerous care coordination and case
management programs. I think this is a time to take a
comprehensive look across those programs to identify and
eliminate duplication and overlap.
Mr. Donnelly. I was going to ask you, the other programs,
it is the same difficulty or there are the same difficulties?
Ms. Draper. We are currently doing work looking at some of
those programs, so I cannot say that for sure. But I think that
when you see evidence, when a Federal Recovery Coordinator
tells you that five case managers are working on the same life
insurance issues and that is problematic. And to me that
indicates there is the potential for deeper problems.
Mr. Donnelly. Madam Chair, the only other thing I would
like to say is that in terms of focus, the focus should not be
on what makes DoD happy and what makes VA happy, but what helps
our wounded warriors and using our taxpayer dollars to the best
effect.
As Mr. Roe was talking about, he saw 3,000 plus patients a
year by himself and I know he is a good doctor, but that is not
unusual, I do not think. You know, I think the focus has to be
on the people who deserve it.
Ms. Buerkle. Thank you.
Dr. Draper, thank you very much for being here this
morning----
Ms. Draper. Thank you.
Ms. Buerkle [continuing]. For your work on this very
important issue. You are now free to go.
Ms. Draper. Thank you very much.
Ms. Buerkle. I would like to invite our second panel to the
witness table. Joining us from the Department of Defense is Mr.
Philip Burdette, Principal Director of Wounded Warrior Care and
Transition Policy for the Office of the Under Secretary of
Defense for Personnel and Readiness.
Also on our second panel is John Medve, the Executive
Director for the Office of VA-DoD Collaboration for the Office
of Policy and Planning for the Department of Veterans Affairs.
Thank you both for joining us this morning.
Mr. Burdette, you may proceed.
STATEMENTS OF PHILIP A. BURDETTE, PRINCIPAL DIRECTOR, WOUNDED
WARRIOR CARE AND TRANSITION POLICY, OFFICE OF THE UNDER
SECRETARY OF DEFENSE FOR PERSONNEL AND READINESS, U.S.
DEPARTMENT OF DEFENSE; AND JOHN MEDVE, EXECUTIVE DIRECTOR,
OFFICE OF THE U.S. DEPARTMENT OF VETERANS AFFAIRS-U.S.
DEPARTMENT OF DEFENSE COLLABORATION, OFFICE OF POLICY AND
PLANNING, U.S. DEPARTMENT OF VETERANS AFFAIRS
STATEMENT OF PHILIP BURDETTE
Mr. Burdette. Good morning, Chairwoman Buerkle and Ranking
Member Michaud, Members of the Subcommittee.
I am pleased to be here this morning with my colleague and
friend, Mr. John Medve, from the Department of Veterans
Affairs. It is not an uncommon occurrence for me to appear with
Mr. Medve who heads the VA-DoD Collaboration Office as we meet
weekly and often more often than that to discuss our
Departments' interaction.
Discerning and discussing the redundancies and the overlap
between the Federal Recovery Coordination Program and DoD's
Recovery Coordination Program is from my perspective a
wonderful problem. This dialogue simply would not have taken
place in 2008 when the problem was not too many resources but
too few.
On March 13th, 2008, Sergeant Edward Wade's wife, Sarah
testified before this Committee. Sergeant Wade suffered
multiple injuries in Iraq in 2004. Mrs. Wade testified that
they had difficulty accessing necessary services for her
husband where and when he needed them.
She recommended patient specific case management and the
development of individualized treatment plans. Today we have
delivered just what she asked for. Today, Sergeant Wade would
receive the clinical expertise of a Federal Recovery
Coordinator and the non-clinical assistance of a Recovery Care
Coordinator as part of his care team.
The use of FRCs and RCCs demonstrates just how far we have
come in those 4 years. Rather than a scarcity of care and a
lack of available resources, today we are discussing how to
best utilize a multitude of resources available 24/7 for
recovering servicemembers and their families.
The perception that we have put too many overlapping
resources in place really highlights an intentional safety net
of concurrent resources. We firmly believe that the programs
are not duplicative but complementary, with a redundancy that
is important for our recovering servicemembers to truly have
seamless coordination in their recovery period.
This is no less than our servicemembers expect and no less
than what they deserve. We simply cannot over-invest in the
care management of our wounded warriors.
I do not mean to infer that the Departments are not taking
serious and thoughtful steps towards efficiency and wise
stewardship of these complementary programs. We are.
After the release of the GAO report on the Federal Recovery
Coordination Program, the Deputy Secretary of Defense and the
Deputy Secretary of Veterans Affairs challenged us to actively
and aggressively address the GAO findings. We have.
As a result, the Departments have been focused on improving
our care coordination and continually working to bring the
counterpart programs closer together.
The Wounded Warrior Care Coordination Summit, held this
past March and the DoD-VA Executive Committee agreed upon
expectations for how this can be best accomplished.
This summer, the Senior Oversight Committee focused on
those expectations and the four areas raised by the GAO. We
have also used the findings of the Recovering Warrior Task
Force, which was established by this Congress as an independent
and objective guide in our efforts.
From my seat, the biggest problem surrounding the programs
is probably the programs' names themselves which are simply too
similar despite intentionally different roles. This not only
confuses us at the policy level, but most importantly, it
confuses recovering servicemembers and their families at our
military treatment facilities (MTFs).
While we have obvious work to do in eliminating that
confusion at the headquarters level, I can report that these
programs are delivering critical resources to our recovering
servicemembers nationwide.
Just this past Monday, I visited the new Walter Reed
National Military Medical Center in Bethesda, as I do every
month. While there, I met with a recovering Marine corporal and
his wife along with their Federal Recovery Coordinator and
their Recovery Care Coordinator.
I can report to you, and this is not anecdotal, that these
programs work in our hospitals every day where trauma teams
triage new patients and collectively make decisions about which
servicemembers need an FRC most.
These educated decisions are made where they should be
made, at the hospitals and by the trauma teams and care
coordinators. This is where the referral is made, FRC caseloads
are managed, and appropriate resources are assigned to the care
team.
I can tell you that although better integration is always
the goal, quality services can and do coexist during this
critical time for our recovering servicemembers and their
families.
As servicemembers, we pay close attention not only to what
is said but also to what is written. We pay close attention to
details.
One such detail speaks more to unity than any testimony you
will hear today and that is simply the business card that that
FRC gave me on Monday and that every FRC provides to their
servicemembers. On this card, side by side is not the seal of
the VA but those of both the DoD and the VA symbolizing both
agencies striving to deliver the collaborative services to our
servicemembers who need them most.
Madam Chairwoman, this concludes my statement. I look
forward to your questions.
[The prepared statement of Mr. Burdette appears on p. 41.]
Ms. Buerkle. Thank you, Mr. Burdette.
Mr. Medve, you may proceed.
STATEMENT OF JOHN MEDVE
Mr. Medve. Good morning, Chairman Buerkle and Ranking
Member Michaud and Members of the Subcommittee.
I am John Medve, Executive Director, Office of VA-DoD
Collaboration within the VA's Office of Policy and Planning. I
am pleased to be here with my partner, Phil Burdette, today to
discuss the Federal Recovery Coordination Program and the
progress that has been made in addressing improvements
recommended by the GAO.
The FRCP is designed to complement existing military
service and VA-provided case management support and transition
coordinators. FRCP is specifically charged with providing
seamless support for its referred clients from the
servicemember's arrival at the initial military treatment
facility in the United States through the duration of their
recovery, rehabilitation, and reintegration.
The FRCP is an integral part of VA and DoD efforts to
address issues raised about the coordination and care and
transitions between the two Departments for recovering
servicemembers.
On behalf of the clients, FRCs work closely with clinical
and non-clinical care and case managers from the military
services, the VA, and the private sector as part of their
recovery team.
The March GAO report contained four recommendations. VA
concurred with the recommendations and is taking action to
implement each of them.
GAO's first recommendation was that the FRCP establish
adequate and internal controls regarding FRCs' enrollment
decisions. As a result, more stringent internal controls were
implemented to include management review of all enrollment
decisions.
The challenge still remains in getting the referrals from
the military services for those needing FRCP services. The
program's visibility on these potential clients is based solely
upon those who are referred.
For those who are referred to the FRCP, they are evaluated
to determine the individual's medical and nonmedical needs and
requirements in order for them to recover, rehabilitate, and
reintegrate.
A key component in the FRCP evaluation process is whether
an individual would benefit from the FRC level of care
coordination.
The bottom line is that while FRC clients represent a small
portion of the recovering servicemember population, those who
are referred and who meet the established criteria are offered
enrollment in FRC.
GAO's second recommendation was to complete development of
a workload assessment tool. FRCs have embarked on the
development of a service intensity tool that would fulfill the
workload assessment requirements of the GAO recommendation and
further tie the assessment to enrollment decisions. This
process will likely be completed by the summer of 2012.
GAO's third recommendation to the VA was to clearly define
and document the FRCP's decision-making process for determining
when and how many FRCs VA should hire. FRC positions are based
on an analysis of an anticipated number of referrals, the rate
of enrollment, and the number of clients made inactive and a
targeted caseload.
Upon completion of the service intensity tool evaluation,
FRC will modify this equation.
GAO's fourth and final recommendation was to develop and
document a clear rationale for placement of FRCs. Original
placements were based upon putting FRCs at MTFs where
significant numbers of wounded, ill, or injured servicemembers
were located.
As the program has grown, the assignment of FRCs has spread
to additional locations.
Servicemembers, veterans, and their family are often
confused by the number and types of case management and baffled
by benefit eligibility criteria as they move through the DoD
and VA's complex system of care. FRCP clients say the program
works best when FRCs are included early in the servicemember's
recovery and prior to the first transition.
Once assigned, an FRC will continue to support a client
regardless of where the client is located. This consistency of
coordination is important for individuals whose conditions
require multiple DoD, VA, and private health providers and
services transitions.
FRCs will remain in contact with their clients as long as
they are needed whether for a few months or a lifetime.
This concludes my statement. I am happy to answer any
questions you may have.
[The prepared statement of Mr. Medve appears on p. 43.]
Ms. Buerkle. Thank you very much.
I will now yield myself 5 minutes for questions.
Mr. Burdette, with all due respect, I feel like I am in a
parallel universe with what I just heard from the GAO and with
what you are saying here this morning.
A card that says VA and DoD on it does not mean anything.
Saying that that indicates that there is a good partnership
concerns me.
I am more interested in what the GAO is reporting and that
is that you are not good partners. You are not working
together.
When you applaud this duplication as a safety net, that is
inefficiency. That is a lack of coordination of care and
effort. And I think you have to be really careful.
As Dr. Roe pointed out, 1,800 enrollees so far. You have 26
care coordinators. There is a lot of resources as you stated,
but I am not sure and I feel pretty confident they are not
being used effectively and efficiently.
So I am really concerned. Let's worry less about cards and
symbolism and more about what is actually happening here for
our wounded warriors.
You mentioned that you are a full partner with the VA and
that you assist with the implementing of the GAO's
recommendations, yet the GAO in Dr. Draper's testimony said
that DoD has provided limited assistance to the VA with the
implementation of the GAO recommendations.
I was extremely disappointed to read that DoD's response to
serious deficiencies was an email, you outlined an email
telling the Wounded Warrior Programs that they should refer all
severely wounded, ill, and injured to the FRC Program.
VA states they have not noticed any difference in the
number of referral numbers or patterns since that time. So this
flies in the face of that card that has got DoD and the VA as a
partnership. So I would like to just give you an opportunity to
explain that.
Mr. Burdette. Thank you, Madam Chairwoman.
I think the card is and symbolism are enormous. One of the
big perceptions of the program as was alluded to by Dr. Draper
is the real fear of a servicemember when she meets the VA
representative and then it dawns on her she is not going back
to her unit.
The fact that that DoD seal is still on the card I think is
enormously heartening to that servicemember that says this is a
concerted effort. This person is there as a resource for me. I
might be able to stay in military service.
So I absolutely accept your viewpoint on that, but I think
that that is the importance of the fact that the two seals are
on the card.
Ms. Buerkle. If I could interrupt just for a second. It is
not my concern with the symbolism to the servicemember. It is
my concern that you see you have a viable and a working
partnership with the VA. That card does not mean anything if
the veterans and the wounded warriors are not getting the care
they need.
So my concern is the symbolism with regards to your
partnership because what I am seeing and hearing from the GAO
is that you do not have a good partnership, that you are not
working together, and the coordination of care is not
effective.
Mr. Burdette. Yes, Madam Chairman. I began my response with
the servicemember focus because that is where we are all
focused. First and foremost is how we deliver that service to
that servicemember at the military treatment facilities. So
that has to be the be all and end all.
I think the Ranking Member said it absolutely correctly. If
we do not get this right, servicemembers will suffer.
So to take that then to your other point about the DoD-VA
collaboration at a more strategic level, the synergy is
tremendous.
The fact that both Secretaries now meet on a quarterly
basis and then help drive SOC agenda items, the fact that this
issue has been on the SOC agenda every time the SOC has met
this year, the absolutely groundbreaking work that the VA has
taken on through an internal task force, top to bottom care
coordination that Dr. Draper talked about, and some of the
impacts of the many programs through the leadership of Mr.
Gingrich at the VA, they have absolutely gone top to bottom and
said how do we impact and touch every one of our servicemembers
and new veterans, how can that be most efficient, what is the
VA doing to complement that, what can we do away with, and what
can we then amplify to make sure that that quality service is
given to the servicemember.
In the area of referral, ma'am, we have work to do. I
accept that. I hold up this fax form that we have asked the
field to use. So when Dr. Draper referenced my guidance to the
services to do a better job on referring, in 2011, if I am
telling the services to go to a fax machine, I am behind. But
that is the tool we have today. We are going to get better and
get away from a fax machine referral form and make that a
better process.
My commitment to you is we will get there. That is one of
just many steps that she highlighted that we have taken over
the summer as a result of our care coordination summit which
was a 3-day off-site with the VA and the FRCs, many of whom are
in the back of the room today and have traveled to this hearing
because they care so deeply about their patients and about the
programs that they are involved in.
But that is just one step. Throughout the summer, a whole
tally of efforts has been undertaken by both Departments to
make sure that we study the problem, that we get the answer
right, and as the Ranking Member has asked us to deliver is to
deliver the right solution.
Ms. Buerkle. Thank you, Mr. Burdette.
I just have one last question and then I will yield to the
Ranking Member.
You mentioned in your testimony that the program titles
create confusion for those transitioning or possibly
transitioning out of active duty into the veterans' world. But
it also creates policy confusions.
That concerns me with a program that is 4 years old that we
have not gotten the policies down and what we are trying to
accomplish and how we are going to accomplish it. So if you
could just comment on that.
Mr. Burdette. Yes, Madam Chairwoman.
This program grew out of the horrors of Walter Reed
revelations in 2007. And the SOC, to its great credit, enacted
quick solutions and fielded resources to help the wounded
warriors and their families.
As that matured over the last 4 years, a lot of programs
have been put in place. If we had thought, I think, when we
fielded the Recovery Coordination Program to clearly delineate
titles and responsibilities at that time, we would be better
off than we are today. We owe that to you. I think that that
work is really in earnest.
We spoke earlier about the lateness of the letter. I think
that the lateness of the letter really reflects our intense
desire to get it right but also to be timely, but to err on the
side of getting it right.
So I think that that work will be completed soon and we
look forward to reporting it to you.
Ms. Buerkle. Thank you.
I yield now to the Ranking Member.
Mr. Michaud. Thank you very much, Madam Chair.
Is the Defense Center of Excellence out at Bethesda
supposed to coordinate with the VA as well?
Mr. Burdette. Mr. Ranking Member, when a servicemember is
evacuated from the battlefield in Afghanistan, most frequently
they will go to Landstuhl. Then they will be air lifted back to
Andrews Air Force Base. And on September 2 with the closing of
Walter Reed as we knew it, they will now be air ambulanced or
motorcade ambulanced to Bethesda.
At that point, the trauma team meets with that patient and
the families and that's when the care team comes together and
makes triage decisions on what resources we are going to give
immediately to that family and then downstream through the
recovery period.
Mr. Michaud. So at that point in time, they are supposed to
coordinate with the VA----
Mr. Burdette. Absolutely.
Mr. Michaud [continuing]. At the Center of Excellence?
Mr. Burdette. At Bethesda, at those trauma and triage
teams, and the FRCs in the back of the room are a part of those
trauma teams, meet when the servicemembers arrive and the
doctors and the nurse case managers and that trauma team
assembles and says what resources are we going to apply.
Mr. Michaud. Well, that is interesting because I just came
from Bethesda on Monday. I went to visit a wounded soldier from
Maine, and the doctor at the Center of Excellence told me that
there was zero coordination with the VA.
The other part of the trip was to see what a soldier would
have to go through in that process, but not once was I
introduced to a Recovery Coordinator.
So from what you are saying and what is actually being
implemented are two separate things. And it is consistent with
what we heard from the GAO about a lack of coordination between
DoD and the VA, which is a huge concern because my bottom line
is to take care of the wounded soldier.
The Military Officers Association made a recommendation
that we mandate a single joint VA-DoD program so we do not have
to worry about two. It would be one program if I understand
their recommendations.
I would like you both to comment on that.
Mr. Burdette. Mr. Ranking Member, I think the easiest thing
to do and the quickest thing to do would be go back to the SOC,
where I serve as the Executive Director, and we issue a memo
that says we now have a joint program. I think that does little
on the ground to effect and fix the coordination.
We have intentionally written policy with flexible language
to allow the military treatment facilities and the doctors and
the case managers on the ground to decide what resources need
to be applied to patients. That is a patient-centric focus that
we have not wavered from.
So I think that is the right approach to get that is to get
it right rather than the names and what we put on the
letterhead. If we declare a joint program, we have not fixed
anything. If we fix the mechanics and the roles and
responsibility is clearly delineated, I do not think it matters
who they pay, who pays them, or who they work for as long as
that family feels supported and has the resources they need.
Mr. Michaud. So it sounds to me like we have a problem with
those who are implementing these programs, and that is a big
concern. We can change the titles. You are right. I think the
law is very clear on the coordination and there does not appear
to be any coordination.
So if that is not happening, then that leads me to believe
that those that are responsible for these programs are not
doing their jobs and, therefore, probably should be fired and
get someone in there who can do the job in taking care of these
soldiers.
Like I said, when I went out to the Center of Excellence,
when I heard the doctor say there is no coordination with the
VA system, that is concerning. When I read the GAO report, that
is concerning.
And I hear both of you here saying there is coordination.
There probably could be some improvements. But the bottom line
is they are not being taken care of.
I will ask the VA to comment.
Mr. Medve. Sir, I think what I identified is we do have
challenges with accession into the program and contact. But I
will also say that a number of our referrals are coming from
the medical teams in the hospitals.
What the DoD instruction has in it is referral of Category
3 and they are supposed to be severely and catastrophic. As I
am not a clinician, but when I have asked our VHA, Veterans
Health Administration, people what that means to them, it does
not mean a lot.
So I have been instructed by our Under Secretary of Health
to translate what that means into more clinical terms so that
the teams on the ground then have something as they are looking
at somebody in a clinical setting to say, all right, this meets
the criteria, we need to call the FRC in to meet on this
particular case.
Mr. Michaud. Thank you.
I see my time has run out. Thank you, Madam Chair.
Ms. Buerkle. I now yield to the gentleman from Tennessee,
Dr. Roe.
Mr. Roe. Thank you, Madam Chairman.
Back to just it is not a lack of resources, it seems like
we have plenty of help.
When I look at the FRCs and it says in here the program has
777 current active enrollees, that is 37 people per FRC. That
is not a very heavy caseload and at least looking at it from my
standpoint from what I have done for 30 plus years.
It looks to me like that it is a coordination problem. How
do you answer the question? And I realize that the bureaucracy
is big.
Having served in the military and being a young officer
back from overseas duty, we had 2,000 women that needed PAP
smears at Fort Eustis, Virginia, in 1973 and I was absolutely
convinced I was going to fix that problem.
When I left almost a year later, there were 2,000 people on
there. So I do share some of your frustration of getting it
done. I just ran into a brick wall.
But as Mr. Michaud said, that we should not accept that. We
are having people that are surviving injuries now that they
would never have survived before and they need help and their
families need help. We have the resources to do it and we are
good at this. This is not something we are bad at. Health care
is something we are really good at.
I do not know why it took months to answer a letter. Could
you square me away on that.
Mr. Medve. Sir, I will just say that I take responsibility
for not ensuring that on the VA side that the letter was
delivered in a reasonable time frame. We worked it through the
system and----
Mr. Roe. Well, let's don't worry about letters. We are here
now and the important thing is to get these soldiers taken care
of.
And I know if I am a soldier, I am thinking to myself what
Mr. Michaud just described at Bethesda. If you are there, you
are looking for help. If you are a family member, you do not
know all these things that your wife or husband are going to
need. And we need to take care of all that problem so they do
not have to worry about that. They know right where to go for
these resources.
And how would you answer when you have five people working
on the same thing or eight in some cases?
And as you well know, we are up here fighting back and
forth about the resources now and not having enough resources
and having budget cuts. We have the resources. Matter of fact,
we have over-resourced. We are not using them very well, it
does not sound like.
Mr. Burdette. Sir, I think I might answer that question by
quoting a young spouse that I met when I traveled to Brooke
Army Medical Center earlier this spring.
And I said tell me about the perception. Did we inundate
you on arrival, rip you out of Fort Hood, Texas, tell you you
have to meet your loved one here at Brooke Army Medical Center
and your husband is in a bad medical condition?
And then we immediately overwhelm you and we leave you with
25 business cards and you feel overwhelmed and a little
confused and perhaps not well taken care of.
And she looked me right in the eye and said I would be
upset if I did not have 25 business cards. She said if I do not
get an answer from the first person, I will call the second and
third.
Mr. Roe. My point is, though--wait a minute, whoa, whoa
right there--she should be able to get the answer from the
first person. That is what their job is. That is what they do.
And that is the problem that I ran into is that somebody
needs to be in charge of the ship. Otherwise, it just goes in
50 different directions like an amoeba.
Mr. Burdette. Sir, completely agree. On a Sunday night at
7:00 p.m. when the servicemember needs help, that first
business card might not always get--that phone might not always
get answered. So I think what we are speaking there to is the
redundancy of available resources.
I am certain and I have watched the briefs be given that we
brief on the----
Mr. Roe. Back up again. When somebody is getting ready to
have a baby in my practice and the phone rings, somebody
answered it.
Mr. Burdette. I apologize, sir, for not making a
distinction. The clinical teams are always available. The
doctor who is in charge of the care for that patient is always
available and the Recovery care team is always available.
When we are talking about somebody to talk about life
insurance benefits or transition benefits to the VA, that
person may not be available.
Mr. Roe. They could make a call to the Recovery coordinator
or, look, you said that a name change, call it the health team
of the hero team or whatever you want to call it. If you want
to do that, change the name if that is confusing to somebody.
But I ought to be able to as a family member make a phone
call and that person says I am going to help you. I will get
that information for you and I will be back to you in a timely
fashion.
Mr. Burdette. Sir, I am confident that the Recovery Teams
offer that availability to that servicemember. And then I am
also confident that if that person is not available for
whatever reason, in surgery, unavailable for a holiday or
vacation or something, that there is another person right
behind them to step up and help that family member.
Mr. Roe. So in some length of time, can you all tell, are
you going to implement the four GAO recommendations and if we
ask this question 6 months from now, what is the answer going
to be?
Mr. Burdette. Sir, the four GAO recommendations that came
in March, the VA-centric ones, VA has already undertaken much
progress to get those done. Those detailed plans were included
in our September 13th letter. So that was a part of it.
The second part of the Chairwoman's letter and Ranking
Member's letter to us was what is the future of this program.
The Recovering Warrior Task Force that this body chartered
reported to us on September 2nd with some additional
recommendations for the program.
I think that combined with the VA's top to bottom review
now gives us the body of evidence, objective and otherwise, to
chart the road ahead.
I am confident that in our next meeting that we will have
that answer. I think we will publish it to you in a letter in
advance of the next hearing on just what the future was in
essence an answer, ma'am, to your second question from that
letter.
Mr. Roe. I yield back.
Ms. Buerkle. Thank you, Dr. Roe.
I now yield to Mr. Bilirakis.
Mr. Bilirakis. Thank you, Madam Chair. Appreciate it very
much.
Again, the same issue. I like the concept of having a
single point of contact so that injured servicemembers and
veterans have a one-stop shop in which to go for assistance.
And I hear about this all the time in my district but also up
here at the hospitals.
Do you think that there is any circumstance where it is
necessary or appropriate for an individual to have multiple of
these caseworkers or coordinators? Is there a circumstance?
And it seems to me that if coordinators all have a similar
and uniform level of training, they would provide similar
advice. So the question is, what is the standard of training
for caseworkers and care coordinators?
Mr. Burdette. Sir, I can speak to the Recovery Care
Coordinators. The Recovery Care Coordinators on the DoD side,
we have approximately 167 at over 67 sites nationwide. At the
DoD level, they are all uniformly trained in what they deliver
in the non-clinical case management.
By that, I mean life plans for the family members, life
plans for the servicemembers, and things that open them to
opportunities such as vocational rehab through the Veterans
Affairs and other educational opportunities.
I think Mr. Medve can speak to what the FRCs are trained
and deliver.
Mr. Medve. Yes, sir. Congressman, we currently have 23
FRCs. They are all either Master's trained nurses or social
workers. They have a series of quarterly training events back
here in DC to level them.
As a matter of fact, this afternoon, I am going to be
addressing a series of FRCs to update them on changes to the
Integrated Disability Evaluation System so they understand the
process for that as they advise their clients.
So we set a fairly high bar in terms of the certification
of FRCs.
Mr. Bilirakis. Thank you very much.
I yield back, Madam Chair. Thank you.
Ms. Buerkle. Thank you, Mr. Bilirakis.
I am going to just start a second round of question in case
any of the other Members have questions.
Mr. Medve, I would like to ask you. We have heard about
disagreements between DoD and the VA. Can you elaborate on
that. What is your understanding? Where are the points of
disagreement and how will we overcome those?
Mr. Medve. Madam Chairwoman, I would be less than honest if
I did not tell you we clearly have an issue with accession into
the FRC Program of ensuring that we identify who needs to come
into the program. That is one of the issues that Mr. Burdette
and I are currently working on.
Part of what we are grappling with, and I shared with him
just the other day a draft set of clinical definitions to help
guide the teams and the MTFs to help make those referrals more
timely so we bring in the FRCs earlier. And that to me is the
largest challenge we face at this time.
Ms. Buerkle. Mr. Burdette, how are you going to address
that issue and do you see that as a problem as well?
Mr. Burdette. Madam Chairwoman, at the DoD, we have taken
several steps to make sure that the referral process is a solid
one from our standpoint.
The Deputy Secretary of the VA uses the analogy all the
time if you do not throw me the football, I cannot catch it.
That is my responsibility to make sure that we are referring
the servicemembers to the VA.
The email that Dr. Draper referenced and the letter that I
sent to the services clearly did not do it enough. I need to
give them a better tool than the fax sheet as well.
And also in the area of language, I think that Mr. Medve
alludes to a perfect example. We have used the very broad
language of whoever most needs an FRC intentionally because if
we get down to a clinician's viewpoint point system of who gets
one, then we find that year over year, we will exclude people
who really need an FRC.
For example, the complex injuries we are seeing today from
the battlefields are staggering. And it is not just a single
amputee anymore. It is multiple internal injuries. It is
multiple non-visible injuries with traumatic brain injury (TBI)
and with post-traumatic stress disorder (PTSD) and other things
that just make it so complex that the FRCs and the clinicians
and the practitioners said if we had written criteria that were
very specific, a point system, for example, in 2007 and 2008,
it would be outdated now and we again would be in that round of
now who gets one. And we would have had a totally different
clientele that we would have excluded had we been too
prescriptive.
That is our challenge. Our balance is to get that right.
And we need to get it right.
Ms. Buerkle. Do you have a policy in place for referrals?
Mr. Burdette. We do. We do. But the prob----
Ms. Buerkle. Can you provide that to the Committee?
Mr. Burdette. Absolutely. Absolutely.
[The DoD subsequently provided the following information:]
The Department of Defense Instruction (DoDI) 1300.24, which appears
on p. 56, is the policy document governing the Department's Recovery
Coordination Program, including servicemembers who are referred to the
Department of Veterans Affairs Federal Recovery Program. For severely
and catastrophically injured and ill servicemembers who will most
likely transition from nilitary service, a Federal Recovery Coordinator
will become part of the Recovery Team in addition to the Recovery Care
Coordinator and assist the servicemember as they transition to Veterans
status.
Ms. Buerkle. It seems to me now 4 years after this program
started that you would have policy and then you would work
through that policy. And when VA says we are not getting
referrals quickly enough, you would alter that policy and this
would be a moving, developing policy.
But, it seems like we do not have that. It is not about
something that is out there. It is about wounded warriors. It
is about people who served this Nation. It is about people who
are in need.
This is 4 years old. If we are not meeting their needs, we
have a problem here. And the fact that they come home and they
need services and DoD is not making a timely referral or one
person is working on the same issue, five people are working on
the same issue, that is a problem.
This is not something where we have the luxury of time and
it is some policy thing. It is people and it is people's lives.
And that is why we are having this hearing and we will continue
to monitor this, to stay on top of this, and to make sure that
our veterans get what they need.
I am going to ask if any of the other Members would like a
second round of question.
Mr. Michaud. Yes. Mr. Burdette, you mentioned that you are
coming forward with some options regarding the current policies
and how we might be able to maximize the resources of care and
coordination.
Can you tell us what some of those options that you are
coming up with?
Mr. Burdette. Again, Mr. Ranking Member, the options are
all pre-decisional. There has always been, I think, a sincere
desire to take the GAO recommendations and the Recovering
Warrior Task Force recommendations and perhaps just say an
overarching umbrella over both sides of this house may make it
a little more of the direct line and not a dotted line of lines
of responsibility.
There are smart people at the field level who think that is
not the way to go either. That is why we brought them all in in
March and said let's sit around the table and talk. Some dozens
of recommendations come out that we are not discussing today
how we improved both programs.
But that core issue is the definition of who gets referred
and that is when we have to get it right to your first opening
comment, sir, and that is what we are committed to doing.
Mr. Michaud. And are you working with the wounded warriors
themselves to find out what would be helpful to them versus
what might be easier for VA or DoD? Have you requested their
assistance as well?
Mr. Burdette. We could not do it without that, Mr. Ranking
Member. I saw you on Monday also when you were on the campus of
Bethesda. As well, we do not go there for optics. We go there
for information and to ask them directly what do you need and
are the systems we have fielded serving you well. Without their
input, we do not have a solution.
Mr. Michaud. Thank you.
I yield back the balance of my time. Thank you.
Ms. Buerkle. Thank you.
Dr. Roe.
Mr. Roe. Just one question that I did not get answered a
minute ago on the coordination.
When GAO references one FRC who estimates his enrollees
have on average eight different case managers affiliated with
eight different programs, is that going to continue or is there
a one-stop shop that somebody can go to to get headed in--if
they are maybe injured, have sight impairment or an orthopedic
problem or a prosthesis problem?
I am going to get you to where you need to be and take care
of you. You do not have to worry about it. You call me. I am
going to get you down the right road. I am your GPS in this
maze.
Mr. Medve. Congressman, I could not agree more that at
least from my perspective, the FRCs are designed to be that
overarching lynchpin. That is why they handle both the clinical
and non-clinical piece.
Now, sometimes they think we, and I know again not being a
clinician, as somebody who is assigned to an MTF and they are
having specific procedures, we have designated liaison
specialists to handle that component of it, but the FRC should
be the one that is helping to arrange all that and ensure that
is all happening in a synchronized manner.
Mr. Roe. Because I know that Recovery coordinators have
some frustrations. And I would like to hear what they have to
say.
I mean, my door is always open in the office to hear what
their frustrations are because I think if you call the people
actually doing the work and they can tell you where the bumps
in the road are.
I mean, the 21 people that are doing that, I think they
have a lot of information to share with us. We have not heard
them today and maybe in some written testimony or either just
make an appointment in my office and come back and let me know.
I yield back.
Ms. Buerkle. Thank you, Dr. Roe.
Mr. Bilirakis.
Mr. Bilirakis. One, Madam Chair.
When do you realistically, and I may have missed this
because I came in late, when do you realistically estimate you
will have a concrete plan to maximize this care coordination
between DoD and the VA?
Mr. Burdette. Sir, if I could, we get a new Deputy
Secretary of Defense today. And when Dr. Carter takes his post
today, he will become the co-chair of the Senior Oversight
Committee.
If I could take that answer for the record, I need to get
his guidance on time tables as the new co-chair of the SOC and
then he will meet with the Deputy Secretary of the Veterans
Affairs.
But I am confident we have all the data we need at this
point. We need to forward a decision memo for those two co-
chairs and then have them make the decision. They are anxious
for that decision and I know Dr. Carter awaits my brief on that
options matrix.
Mr. Bilirakis. Can you get back to us?
Mr. Burdette. I will, sir.
Mr. Bilirakis. Maybe other Members of the Committee would
like to know as well.
Mr. Burdette. I will, sir.
[The DoD subsequently provided the following information:]
Currently, DoD and VA are working on the decision memorandum
regarding the future of the Federal Recovery Coordination Program and
Recovery Coordination Program. In December, I am scheduled to deliver
the memorandum to the Senior Oversight Committee for consideration and
decision.
Mr. Bilirakis. Thank you.
Thank you very much. I yield back, Madam Chair.
Ms. Buerkle. Thank you.
At this time, we are finished with our questioning for our
second panel.
Mr. Burdette, you will provide to the Committee the
policies and procedures with regards to the referrals from DoD?
Mr. Burdette. I will, ma'am.
[The DoD subsequently provided the following information:]
The Department of Defense Instruction 1300.24, which appears on p.
56, is the policy document governing the Department's Recovery
Coordination Program, including who is referred to the Department of
Veterans Affairs Federal Recovery Program. For severely and
catastrophically injured and ill servicemembers who will most likely
transition from military service, a Federal Recovery Coordinator will
become part of the Recovery Team in addition to the Recovery Care
Coordinator and assist the servicemember as they transition to veterans
status.
Ms. Buerkle. Thank you.
Thank you both very much for being here this morning.
Mr. Medve. Thank you, Madam Chair.
Ms. Buerkle. Would our third panel please join us at the
table.
Joining us on our final panel this morning are
representatives from our veterans service organizations (VSOs).
First, we have Ms. Abbie Holland Schmit, Manager and Alumnus
from the Wounded Warrior Project (WWP); Althea Predeoux,
Associate Director of Health Legislation from the Paralyzed
Veterans of America (PVA); and Commander Rene A. Campos of the
United States Navy, retired, the Deputy Director of Government
Relations from the Military Officers Association of America
(MOAA).
Thank you all very much for joining us this morning.
Ms. Schmit if you would like to start.
STATEMENTS OF ABBIE HOLLAND SCHMIT, MANAGER, ALUMNI, WOUNDED
WARRIOR PROJECT; ALETHEA PREDEOUX, ASSOCIATE DIRECTOR OF HEALTH
LEGISLATION, PARALYZED VETERANS OF AMERICA; AND COMMANDER RENE
A. CAMPOS, USN (RET.), DEPUTY DIRECTOR, GOVERNMENT RELATIONS,
MILITARY OFFICERS ASSOCIATION OF AMERICA
STATEMENT OF ABBIE HOLLAND SCHMIT
Ms. Schmit. Chairwoman Buerkle, Ranking Member Michaud, and
Members of the Subcommittee, thank you for inviting the Wounded
Warrior Project to testify on this important subject. We
appreciate the Committee's oversight of Federal Recovery
Coordination Program.
My background in working with wounded warriors has given me
an on-the-ground perspective on the importance of this program
to warriors and their families.
As all of my managers with the WWP in Chicago, I work with
warriors and their families on a daily basis. Before joining
WWP in June, I served for more than 2 years as an advocate with
the Army's AW2 Program (Army's Wounded Warrior Program).
As someone who served in the Army National Guard, I had a
hard journey home due to PTSD and traumatic brain injury. The
issues before you are deeply personal to me.
The FRCP was designated to assist those warriors who need
help in navigating an often complex transition process. FRCs
are making a real difference in helping severely injured
warriors and their families thrive again.
But as you heard in your hearing in May, individual service
Departments are not routinely referring those servicemembers
who need the help to the program.
The service Departments seem to view the FRCP as a VA
program and tend to make referrals to the program only when the
warrior is about to separate or retire.
The FRCP should be operated as a joint integrated effort to
coordinate Federal care and services. But current practices
risk delaying warriors' recovery, rehabilitation, and
reintegration. These are not just hypothetical concerns. Let me
share the case of Army specialist Steven Bohn, who testified
before the Senate VA Committee in May and had been badly
injured in 2008 when a suicide bomber in Afghanistan detonated
explosives that buried him under collapsed debris and resulted
in his suffering severe internal and spinal injuries.
Breakdowns in coordination led initially to his being sent
to the wrong military treatment facility. Later, poor
communication led his Army command to threaten him with an AWOL
(absent without leave) while he was still recovering from
surgery.
Eventually he underwent a DoD Medical Evaluation Board that
rated him at 40-percent disabled for spinal and neck injuries.
But it did not take into his account his internal injuries.
While his transition from DoD to VA seemed to begin
smoothly, backlogs in scheduling his VA compensation exams
bogged down the process. Seven months after retiring from
service, VA had still not adjudicated his claim and he was
struggling financially. Unable to work because of his injuries,
he was living on a military retired pay of $700 a month.
Steve also fell through the cracks in getting his VA
medical care. It took more than 6 months before anyone
approached him to discuss any VA treatment. Steve testified
that no one ever discussed with him or his family the
possibility of having an FRC assigned to his case. It seems
clear it would have made a big difference.
Steve's experience is not unique, but it shows how easily a
severely wounded warrior can fall through the cracks. This
frequent failure to refer severely wounded warriors or an FRC
is a problem that can and must be remedied. But the joint VA-
DoD response to the Subcommittee's questions fails to provide
that remedy.
In their cover letter, the two Department secretaries state
that all Category 3 servicemembers who would be most eligible
from the Federal Recovery Coordination, FRC, would be referred.
But in quotes, their letter states just the opposite saying the
program cannot ensure that all potentially eligible individuals
are referred to FRCP.
It is difficult to understand why the senior leadership of
the two Departments have failed to resolve this problem. VA and
DoD share a deep obligation to severely wounded warriors and
their families. But the reality is that they do not share full
responsibility of the FRCP.
Warriors and families need this help early in their
transition process. In our view, our warriors would be better
served if they were truly shared VA and DoD responsibilities
for the program.
In that regard, WWP welcomes the introduction of H.R. 3016,
a bill that would require VA and DoD to jointly operate this
important program. We strongly support this legislation, which
we believe would go a long way towards resolving critical
issues affecting the program and toward ensuring its goals are
fully realized.
Thank you again for this opportunity to testify. I would be
pleased to respond to any questions you may have.
[The prepared statement of Ms. Schmit appears on p. 45.]
Ms. Buerkle. Thank you very much.
Ms. Predeoux, you may proceed.
STATEMENT OF ALTHEA PREDEOUX
Ms. Predeoux. Chairwoman Buerkle, Ranking Member Michaud,
and Members of the Subcommittee, Paralyzed Veterans of America
would like to thank you for the opportunity to present our
views on the Federal Recovery Coordination Program, the FRCP.
For more than 65 years, it has been PVA's mission to help
catastrophically disabled veterans and their families obtain
health care and benefits from the Department of Veterans
Affairs and provide support during the rehabilitative process
to ensure that all disabled veterans have the opportunity to
build bright and productive futures.
It is for this reason that PVA strongly supports the FRCP
and appreciates the Subcommittee's continued work on improving
the transition from active duty to veteran status for severely
injured, ill, and wounded veterans and servicemembers.
When PVA provided the Subcommittee with a statement for the
record for the hearing held on May 13th which examined the
progress and challenges of the FRCP, we identified three areas
in need of improvement, continuity of care, care coordination,
and program awareness.
Today, we still believe that these areas are critical to
the success of the FRCP and are in direct alignment with the
issues and recommendations outlined by the Government
Accountability Office, GAO, in a March 2011 report entitled,
``The Federal Recovery Coordination Program Continues to Expand
but Faces Significant Challenges.''
The first recommendation from this report was to ensure
that referred servicemembers and veterans who need Federal
Recovery coordinator, FRC, services, that they establish
adequate internal controls regarding the FRC's enrollment
decisions.
In particular, this recommendation identified the need to
require FRCs to record the factors they consider in making FRCP
enrollment decisions as well as the need to create an
assessment tool to evaluate these decisions.
PVA believes that the use of recording methods and
assessment tools will help streamline the enrollment process
and ensure that veterans and their families are receiving help
when it is requested.
Servicemember enrollment is one of the most critical
elements of the FRCP. Ensuring that veterans and servicemembers
as well as their families and caregivers are aware of the FRCP
has proven to be a continuous challenge.
While participation numbers are growing, FRCP leadership
must work to keep information about the program circulating
throughout the veteran and military communities. This can best
be accomplished as a joint effort that incorporates different
offices and Departments across both VA and DoD.
The second recommendation from the GAO report encouraged
complete development of an FRCP workload assessment tool that
will enable the program to assess the complexity of services
needed by enrollees.
PVA believes that monitoring and managing the level of
complexity and size of FRC caseloads is extremely important to
adequately addressing the needs and concerns of veterans and
servicemembers.
No matter how well prepared and trained an FRC may be, he
or she will not be able to effectively help veterans and
servicemembers to the best of their ability if they are spread
too thin and overwhelmed with an unreasonable caseload.
The third recommendation to clearly define and document the
FRCP's decision-making process for determining when and how
many FRCs VA should hire is an area of serious concern for PVA.
Adequate staffing of the FRCP is essential for providing
veterans and servicemembers with timely and helpful assistance.
With a limited number of FRCs, issues involving
transportation and distance have the potential to hinder access
to FRCP services for many veterans in rural areas and, thus,
becomes a threat to continuity of care for newly injured and
severely ill veterans and servicemembers.
The GAO final recommendation calls for the FRCP to develop
and document a clear rationale for the placement of FRCs. We
understand that as a newer program, time is needed to create,
implement, and assess the inner workings of such a
comprehensive initiative.
However, we ask that as the program expands, VA and DoD
consider placing FRCs in locations where veterans with
disabilities are already seeking services, such as spinal cord
injury centers and amputation centers of care.
In conclusion, PVA recommends that FRCP leadership
periodically survey veterans, servicemembers, and their
families to identify areas for improvement. There are numerous
lessons to be learned and an abundance of opportunities for
development.
Thank you for this opportunity to testify today and I would
be happy to answer any further questions that you and the
Committee may have.
[The prepared statement of Ms. Predeoux appears on p. 48.]
Ms. Buerkle. Thank you very much.
Commander Campos.
STATEMENT OF COMMANDER RENE A. CAMPOS, USN (RET.)
Commander Campos. Madam Chair and distinguished Members of
the Subcommittee, on behalf of the 370,000 members of the
Military Officers Association of America, I am grateful for
this opportunity to present our observations on the FRCP.
MOAA commends the Subcommittee for its leadership and sense
of urgency on the critical topic of care coordination of
wounded, ill, and injured.
We also thank the VA and DoD for expending a great deal of
effort and resources on our Nation's heroes these last 10
years. However, we are extremely troubled by the business as
usual message conveyed by VA and DoD officials at the May 13th
hearing and in a recent letter to the Subcommittee indicating
that the Departments have significant command and control
issues and lack a roadmap for addressing system failures.
It is not possible to talk about the FRCP without talking
about the DoD Recovery Coordination Program, RCP, since the two
programs are seen as fulfilling the same roles in their
respective agencies.
To better understand the programs, it is helpful to look
back at the timelines for establishing them. August and October
of 2007, the secretaries of VA and DoD signed Memorandums of
Understanding (MOUs) establishing and implementing the FRCP
designating FRCs as the ultimate resource for assisting wounded
warriors.
January 28, 2008, the fiscal year 2008 National Defense
Authorization Act directed the agencies to establish joint
policy for care, management, and transition of recovering
servicemembers to include policy on recovery care coordination
not later than July 1st, 2008.
DoD did not establish that policy until almost a year and a
half later on December 1st, 2009 and then delegated
responsibility to the service wounded warrior programs.
Three months later, VA published a handbook establishing
the FRCP procedures for both agencies. In that handbook, the
RCCs are assigned to servicemembers whose period of recovery is
anticipated to exceed 180 days but who are likely to return to
active duty, assisting them through the DoD system of benefits
and care.
Because the FRCP was the first coordination program and was
to be the ultimate resource, many believed the program would
serve as a model for other VA and DoD collaboration. Instead,
VA and DoD continue to struggle today to implement a joint
program that they committed to over 4 years ago and is
highlighted in a September DoD Recovering Warrior Task Force
report.
The report cites a number of Wound Warrior Program
discrepancies and specifically recommends standardizing and
clearly defining the roles, responsibilities, and criteria for
assigning FRCs, RCCs, and other case managers.
Additionally, beneficiaries in the programs continue to
talk about their experiences are all over the map. Some say too
many coordinators doing opposite of each other. Others love
their FRC or their FRC and still others who say they have no
assistance or assistance comes too late in the process.
Clearly the two Departments have been unable to fix the
issues of care coordination for this relatively small
population of catastrophically wounded and disabled members and
are unlikely to do so in the immediate future without outside
intervention to address policy and program compliance,
accountability, communications, and oversight issues across all
wounded warrior programs.
MOAA recommends Congress, one, revise and expand Section
1611 of Public Law 110-181 to mandate a single joint VA-DoD
program, establishing an office for care coordination, and
requiring DoD to adopt VA's FRCP policies and procedures.
Two, to conduct joint Veterans' Affairs and Armed Services
Committee hearings on wounded warrior issues to ensure common
understanding and guidance in addressing the problems.
Three, to commission an outside entity to evaluate the FRCP
and RCP within the context of the broader wounded warrior
programs.
Four, to require VA and DoD medical and benefit systems to
expand outreach and communication efforts, and, finally, to
conduct periodic needs assessment surveys among beneficiaries
to improve programs and identify unmet needs.
MOAA is grateful to the Subcommittee for your commitment to
our Nation's wounded, ill, and injured and their families, and
we appreciate this opportunity to provide our views.
Thank you.
[The prepared statement of Commander Campos appears on p.
50.]
Ms. Buerkle. Thank you all very much.
I will now yield myself 5 minutes for questions.
My first question is to all three of you. Have any of your
organizations been asked to participate with representatives
from either DoD or VA about ways in which to revamp or merge or
eliminate and to make these programs more efficient?
Ms. Schmit. Not that I am aware of.
Ms. Predeoux. Not that I am aware of.
Commander Campos. No.
Ms. Buerkle. Thank you.
It would seem to me that we should reach out to the
veterans, to those who are in need and learn from their
experiences.
The three of you, how would each of you respond to the
GAO's comment with regards to the confusion and the lack of
coordination actually hampering recovery for our veterans
rather than helping them, if you would comment on that?
Ms. Predeoux. I will take a stab at that. With regard to
coordination and multiple care coordinators and confusion, that
is obvious how that can happen. But at the same token, I think
it is important not to lose sight that the Federal Recovery
coordinators serve a very unique purpose. They are the only
coordinators that straddle both systems and they are able to
provide all of the services both social supports as well as
clinical.
So regardless of redundancy or multiple care coordination,
we must keep in mind that FRC coordinators are supposed to be
the main coordinators.
Ms. Schmit. And just to dovetail, the FRCs are the people
that are coordinating the coordinators. And so if I was a
warrior that was critically injured, ill, or wounded, that
would be my first and primary point of contact.
And I think that is important any time that you are going
through the transition. My transition was not as bad as someone
that would need an FRC, but knowing who to call. And once you
have a person like that, I think it really does help.
Commander Campos. I think I would refer back to what GAO
said. And these are really the issues with the FRCP and the RCP
programs are really systemic of broader issues throughout the
two systems.
And we see it in a lot of other wounded warrior programs
that are within DoD and VA. And so we just believe that the FRC
and RCP programs are just kind of victims of bigger problems
within the systems.
Ms. Buerkle. Thank you.
And then if I could just ask the three of you for your
insights as to where you think we should go from here to get
this program up and running and get it to the point where it
should be.
Ms. Predeoux. Perhaps continued oversight from the
Subcommittee would be recommended. And, additionally, perhaps
also establishing, I guess, enforced and understanding of where
to start. Establish a point where regardless of what department
identifies, whether it be DoD or VA, that an FRC is needed, but
that each side knows that it starts with the Federal Recovery
Coordination Program.
Commander Campos. I believe that the oversight issue is a
big issue. We saw many of the wounded warrior programs develop
over time because of Congress' active engagement after Walter
Reed. And over time, we have seen with the change in
administration and leadership in the agencies a lowering of the
SOC in the organizations. There just has not been the level of
oversight and transparency.
So we believe, one, that, as I said in our testimony, that
we need to combine these two programs, but there really needs
to be, and as GAO recommended, there needs to be a broader
review of all the wounded warrior programs because there is a
tremendous amount of, you know, confusion across all the
programs.
And we believe that there needs to be again accountability
and I think only through Congress having frequent and periodic
hearings will focus that level of urgency on the two systems.
Ms. Schmit. I will just kind of dovetail what both of these
women have said. I would say that it needs to go beyond a
memorandum of understanding, that we need to actually see both
the VA and the DoD work together, and that, you know, hopefully
you cannot tell where one ends and the other begins and we will
have that seamless transition.
Ms. Buerkle. Thank you all very much.
I now yield 5 minutes to the Ranking Member.
Mr. Michaud. Thank you, Madam Chair.
I just want to follow-up on the Chairwoman's question. I do
know that there was a summit, the Wounded Warrior Care
Coordination Summit in March of 2011. I understand that you did
not participate in that summit?
Ms. Predeoux. No, sir.
Ms. Schmit. No, sir.
Mr. Michaud. Well, I wish the Committee staff will follow-
up on who did if the VSOs and the different organizations here
did not participate in that summit. I would like to have a
follow-up question on that.
How do each of you feel? You talk about the handoff and
clearly the program is not working. How do you feel about the
smooth transition? If any one thing that this Committee or the
VA or DoD could do to make that transition smooth, what would
you recommend?
Ms. Schmit. And this is from my own personal experience as
an AW2 advocate. I would say that the sharing systems, the non-
sharing systems, and the fact that each component has their own
way to take notes and keep logs and not all of those notes are
always passed along. The recovery care plan needs to go from
the Warrior Transition Units (WTU) to the VA so they can
continuously follow-up on that plan and make it go in motion.
So better communication.
Ms. Predeoux. I would have to agree with Ms. Schmit. The
GAO report, I believe, discussed the information sharing
initiative. And just to get that in place and actually have it
work would be extreme progress in addition to again identifying
a specific point of contact earlier within the FRCP, be it on
the VA or the DoD side.
Commander Campos. The two systems still view themselves, I
think, as separate systems. And in doing so, I think it is
clear that they want to identify the point where one point of
care is done and the next system takes over. And I do not think
the systems really have embraced that these wounded warriors
and family members will be moving back and forth between the
systems. So in that seamless transition, it is not a one way,
one direction care. So these folks will be moving back and
forth in between the systems.
So I think that there has to be a better understanding of
even again what the role is of the RCCs and the FRCs. I think
DoD has delegated too much to the services and each of the
services have a different way of identifying or have different
terminology for RCCs. The Army has the AW2 Program. So, again,
other terminology problems.
So, again, I think DoD probably needs to do a little more
oversight over the services to make sure that they are
implementing the policies that have been put in place.
Ms. Schmit. And to back into what I just said is that each
one of those different branches all have their own network,
their own computer way of tracking their servicemembers and
none of those notes are shared with anyone else, not with the
DoD, not with the VA. And if you are at a VA site, you cannot
put your own notes into the VA. So there is a communication
kind of mishap there.
Mr. Michaud. So from what you are saying then, there is
more than just a problem with the DoD coordinating with the VA?
It is the DoD coordinating within itself?
Commander Campos. Absolutely.
Mr. Michaud. My last question is, when you talk to some of
the RCCs or FRCs, what are some of the frustrations? Have they
explained some of their frustrations within the system that
they might not be able to explain to their hierarchy? Have they
told any of you some of their problems?
Commander Campos. In the field, the FRCs that we talk to in
the field have sort of like the FRCs and RCCs kind of look at
each other, not sure what each other is doing or again they are
duplicating efforts.
So there is a sense of frustration there, too, in not being
able to work with DoD in again trying to identify who they are,
why they are there. Again, the communication in these two
programs between the systems here, you know, at the
headquarters level but all the way down to the field is just
not clear.
Mr. Michaud. Thank you very much.
Madam Chairwoman, I hope that both the VA and the DoD,
especially the DoD, hears the bigger problem within DoD
coordinating among the services let alone coordinating with the
VA.
Hopefully that they will go back and do everything that
they can to make sure that this is seamless not only within
DoD, but between the two Departments because I just want to
restate the bottom line for me is to make sure we provide that
service to the soldier. And that is the bottom line. And I
think we have to do everything that we can.
And there is no reason why that coordination of caregiver
services cannot happen if we put aside the different silos that
the different Departments have to work in and focus on the
wounded warrior.
So with that, I yield back the balance of my time.
Ms. Buerkle. Thank you very much.
Let me begin by thanking our panel, our third panel for
being here today. Thank you for your service to our Nation. We
deeply appreciate that. Thank you for being here.
I also would like to take this opportunity on behalf of the
Ranking Member and myself to thank all of you in this room who
are serving or who have served our Nation. We owe a debt of
gratitude to our military, to the men and women who serve this
Nation and keep us safe. And that is what this Committee, the
Subcommittee is committed to do, to make sure our veterans get
what they need and really deserve.
I ask unanimous consent that all Members have 5 legislative
days to revise and extend their remarks and include extraneous
material. Without objection, so ordered.
Thank you again today to all of our witnesses and our
audience for joining us and joining in this very important
conversation.
As has been recommended, you can be assured that this
Subcommittee will continue to be vigilant and will be providing
oversight to make sure that this program gets implemented and
that our wounded warriors get what they need as they transition
out of active duty into the veteran world.
Thank you all very much for being here.
This hearing is adjourned.
[Whereupon, at 10:05 a.m., the Subcommittee was adjourned.]
A P P E N D I X
----------
Prepared Statement of Hon. Ann Marie Buerkle,
Chairwoman, Subcommittee on Health
Good morning. I want to thank you all for joining us today as we
continue our oversight of the Federal Recovery Coordination Program
(FRCP).
Last May, the Subcommittee held a hearing to examine the
significant challenges the FRCP program faces in areas as fundamental
as identifying potential enrollees, reviewing enrollment decisions,
determining staffing needs, defining and managing caseloads, and making
placement decisions.
At that hearing it became patently clear that rather than having a
single, joint program to advocate on behalf of wounded warriors and
ensure a comprehensive and seamless rehabilitation, recovery, and
transition, we have two separate, overlapping programs--the Recovery
Coordination Program (RCP) operated within the Department of Defense
(DoD) and the FRCP operated within the Department of Veterans Affairs
(VA).
Needless to say, this has created unnecessary and unacceptable
confusion about the roles and responsibilities of each program and has
added yet another burdensome bureaucratic maze for our wounded warriors
and their families to navigate at a time when recovery and
reintegration should be their only focus.
So concerned was I about the pervasive issues with the operation of
these two programs, that immediately following the hearing, I sent a
letter jointly with Ranking Member Michaud to the co-chairs of the VA/
DoD Wounded, Ill, and Injured Senior Oversight Committee (SOC), with
oversight authority over the FRCP.
In that letter, we requested a detailed plan and a timeline for how
VA and DoD jointly would implement the recommendations contained in the
recent Government Accountability Office (GAO) report which identified
significant shortcomings of the FRCP. Further, we asked for an analysis
on how the FRCP and RCP could be integrated under a single umbrella to
reduce redundancy and ensure the seamless transition of our wounded
warriors.
A response was requested by June 20. More than 2 months past the
deadline and following the notice of this additional hearing, we
finally received a response to our letter.
Unfortunately, it did not include the detail or timeline we
requested and expected.
With regard to an analysis of and potential options for integrating
the FRCP and the RCP, we were told that the SOC is ``. . . currently
considering several options . . . to maximize resources in care
coordination . . . and preparing for final recommendations . . .''
These programs are not new and the time for considering and
recommending has long past.
As Chairwoman, it has been my privilege this year to spend time
with our honored heroes who have returned from battle bearing the
wounds of war and the families who stand by their side through it all.
I have traveled to Brooke Army Medical Center, the Center for the
Intrepid in Bethesda, and VA medical facilities across our great
country.
It is clear to me that the FRCP is failing to meet its mission.
It also clear to me that these families cannot wait any longer.
They can no longer be party to bureaucratic in-fighting and turf
battles. They can no longer be told that they have several ``single
points of contact.''
When answers are needed, we cannot take 3 months to respond to a
letter. When answers are needed, we cannot keep considering our
options.
Today, I want answers.
I now recognize our Ranking Member, Mr. Michaud for any remarks he
may have.
Prepared Statement of Hon. Michael H. Michaud,
Ranking Democratic Member, Subcommittee on Health
Thank you, Madam Chair.
I would like to thank you for holding today's hearing on the
progress of the Federal Recovery Coordination Program (FRCP). In May,
this Subcommittee held a hearing on the very same issue, and I am
pleased with the continued oversight of this critical program. If it is
not done right, servicemembers suffer.
Following the Subcommittee hearing, I joined Ms. Buerkle in sending
a letter on May 26th to the Senior Oversight Committee requesting a
detailed response as to how the VA and DoD can work together on
implementing the Government Accountability Office's recommendations and
requesting an analysis of integrating the FRCP and the Recovery
Coordination Program.
On August 19th, we then had to send a follow-up letter because of
the lack of a response from the Senior Oversight Committee. The letter
we finally did receive, dated September 12, 2011, was hardly detailed.
The GAO reports that the agencies reached an ``impasse'' on the content
of the final letter responding to our concerns.
This lack of response only serves to magnify, in my mind, the
continuing problems between the VA and DoD in working collaboratively
and highlights the lack of progress that we have heard and read about
recently in submitted testimony. I can only imagine what this means for
other critical decisions that directly impact veterans and their
families. I do not feel confident that the Department of Veterans'
Affairs and the Department of Defense can overcome existing barriers
and the tangle of bureaucracy that seems to surround the implementation
of this program.
Let us all keep in mind that this isn't about the individuals
sitting in this room today. This is about the brave men and women who
have been injured while serving this country and our absolute
commitment to their recovery and reintegration back into the
communities where they live--whatever that takes. We owe them that.
Today, I would like to hear about solid progress that has been made
and what is being done to move this forward in an efficient and
effective manner. I also would like to hear from each of the panels
what this Subcommittee might be able to do to help.
Madam Chair, thank you again for holding this hearing, the second
in a series of hearings to assist in our oversight of the Federal
Recovery Coordination Program. As we continue to monitor this issue, we
will work to actively engage the VA and DoD as we move forward.
I yield back.
Prepared Statement of Debra A. Draper, Director,
Health Care, U.S. Government Accountability Office
DoD and VA Health Care: Action Needed to Strengthen Integration across
Care Coordination and Case Management Programs
Chairwoman Buerkle, Ranking Member Michaud, and Members of the
Subcommittee:
I am pleased to be here today as you discuss the actions taken by
the Departments of Defense (DoD) and Veterans Affairs (VA) to address
issues of concern that were raised during your May 13, 2011, hearing on
the Federal Recovery Coordination Program (FRCP). Our statement for
that hearing,\1\ based on our March 2011 report,\2\ outlined several
implementation issues for the FRCP, which was jointly implemented by
DoD and VA to assist some of the most severely wounded, ill, and
injured servicemembers, veterans, and their families with access to
care, services, and benefits. Specifically, we reported on challenges
faced by FRCP leadership when identifying potentially eligible
individuals for program enrollment and determining staffing needs and
placement locations. We also cited challenges faced by the FRCP when
coordinating with other VA and DoD care coordination \3\ and case
management \4\ programs that support wounded servicemembers, veterans,
and their families, including DoD's Recovery Coordination Program
(RCP). Specifically, we reported that poor coordination among these
programs can result in duplication of effort and enrollee confusion
because these programs often provide similar services and individuals
may be enrolled in more than one program.
---------------------------------------------------------------------------
\1\ GAO, Federal Recovery Coordination Program: Enrollment,
Staffing, and Care Coordination Pose Significant Challenges, GAO-11-
572T(Washington, D.C.: May 13, 2011).
\2\ GAO, DoD and VA Health Care: Federal Recovery Coordination
Program Continues to Expand but Faces Significant Challenges, GAO-11-
250 (Washington, D.C.: Mar. 23, 2011).
\3\ According to the National Coalition on Care Coordination, care
coordination is a client-centered, assessment-based interdisciplinary
approach to integrating health care and social support services in
which an individual's needs and preferences are assessed, a
comprehensive care plan is developed, and services are managed and
monitored by an identified care coordinator.
\4\ According to the Case Management Society of America, case
management is defined as a collaborative process of assessment,
planning, facilitation, and advocacy for options and services to meet
an individual's health needs through communication and available
resources to promote quality, cost-effective outcomes.
---------------------------------------------------------------------------
Based on the concerns raised during the May 2011 hearing, your
Subcommittee requested that DoD and VA provide a detailed response on
how they plan to jointly implement the recommendations to improve FRCP
management that were outlined in our report. You also requested that
the two Departments analyze potential options for integrating the FRCP
and RCP under a single administrative umbrella to reduce redundancy and
to better fulfill the goal of establishing a seamless transition for
wounded servicemembers and their families. Although a response was
requested by June 20, 2011, the Departments had not responded by
September 2, 2011, when this Subcommittee announced that it intended to
hold an oversight hearing on continuing concerns about the care
coordination issues of the FRCP and RCP.
Our review of DoD's and VA's care coordination and case management
programs, including the FRCP and RCP, is part of a body of ongoing work
that is focused on the continuity of care for recovering servicemembers
and veterans. My testimony today addresses the status of DoD and VA's
efforts to (1) implement the recommendations to improve FRCP management
from our March 2011 report and (2) identify and analyze potential
options to integrate the FRCP and the RCP as requested by this
Subcommittee.
We conducted the original performance audit for our 2011 report
from September 2009 through March 2011 and obtained updated data and
additional information in September 2011 for this testimony.
Specifically, to obtain information on the status of the
recommendations contained in our March 2011 report, we reviewed
documentation provided by VA and interviewed the Acting Executive
Director for the FRCP. Although our recommendations were directed to
VA, which administers the program, we also obtained information from
DoD officials that described to what extent they have worked with VA to
implement them based on your request for the Departments to work
together. To obtain information regarding the status of DoD and VA's
efforts aimed at identifying and analyzing options for integrating or
otherwise revamping the FRCP and RCP, we conducted interviews with DoD
and VA officials and reviewed documents provided by both Departments.
We also obtained updated information about DoD's and VA's care
coordination and case management programs by reviewing program
documentation and by interviewing DoD and VA program officials.
We conducted our work for this testimony in accordance with
generally accepted government auditing standards. Those standards
require that we plan and perform the audit to obtain sufficient,
appropriate evidence to provide a reasonable basis for our findings and
conclusions based on our audit objectives. We believe that the evidence
obtained provides a reasonable basis for our findings and conclusions
based on our audit objectives.
Background
The FRCP was jointly developed by DoD and VA following critical
media reports of deficiencies in the provision and coordination of
outpatient services at Walter Reed Army Medical Center. It was
established to assist severely wounded, ill, and injured Operation
Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF)
servicemembers,\5\ veterans, and their families with access to care,
services, and benefits provided through DoD, VA, other Federal
agencies, States, and the private sector. The FRCP is intended to serve
individuals who are highly unlikely to return to active duty and most
likely will be separated from the military, including those who have
suffered traumatic brain injuries, amputations, burns, spinal cord
injuries, visual impairment, and post-traumatic stress disorder. From
January 2008--when FRCP enrollment began--to September 12, 2011, the
FRCP has provided services to a total of 1,827 servicemembers and
veterans; \6\ of these, 777 are currently active enrollees.\7\
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\5\ OEF, which began in October 2001, supports combat operations in
Afghanistan and other locations, and OIF, which began in March 2003,
supports combat operations in Iraq and other locations. Since September
1, 2010, OIF is referred to as Operation New Dawn.
\6\ In addition to active enrollees in the FRCP, the 1,827
servicemembers and veterans served includes individuals who were
evaluated for the program but were not enrolled (in which case the FRCs
provided temporary assistance to the individual, redirected the
individual to another program, or both) and enrollees who were
deactivated from the program because they could not be contacted, no
longer required FRCP services, or had died.
\7\ FRCP enrollment has continued to grow. In September 2010, for
example, the FRCP had 607 active enrollees and had provided services to
a total of 1,268 servicemembers and veterans.
---------------------------------------------------------------------------
As the first care coordination program developed collaboratively by
DoD and VA, the FRCP uses Federal Recovery Coordinators (FRC) to
monitor and coordinate both the clinical and nonclinical services
needed by program enrollees; FRCs are intended to accomplish this by
serving as the single point of contact among case managers of DoD, VA,
and other governmental and private care coordination and case
management programs. As of September 12, 2011, there were 21 FRCs
located at various military treatment facilities and VA medical
centers. Although the program was jointly created by DoD and VA, it is
administered by VA, and FRCs are VA employees.
Separately, the RCP was established in response to the National
Defense Authorization Act for Fiscal Year 2008 to improve the care,
management, and transition of recovering servicemembers. It is a DoD-
specific program that uses Recovery Care Coordinators (RCC) to provide
nonclinical care coordination to both seriously and severely wounded,
ill, and injured servicemembers. Servicemembers who are severely
wounded, ill, and injured and who will most likely be medically
separated from the military, also are to be assigned an FRC. While the
program is centrally coordinated by DoD's Office of Wounded Warrior
Care and Transition Policy, it has been implemented separately by each
of the military services, which have integrated RCCs \8\ within their
existing wounded warrior programs.\9\ According to DoD's Office of
Wounded Warrior Care and Transition Policy, in September 2011, there
were 162 RCCs and over 170 Army Advocates \10\ who worked in more than
100 locations, including military treatment facilities and VA medical
centers. As of September 2011, these RCCs have assisted approximately
14,000 recovering servicemembers and their families and sometimes
continue this assistance for those servicemembers who separate from
active duty.\11\
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\8\ RCCs are assigned to and supervised by each of the military
services' wounded warrior programs.
\9\ The military wounded warrior programs are the Army Wounded
Warrior Program, Marine Wounded Warrior Regiment, Navy Safe Harbor, Air
Force Warrior and Survivor Care Program, Army Reserve Wounded Warrior
Component, and Special Operations Command's Care Coalition.
\10\ The Army's Wounded Warrior Program refers to its nonclinical
care coordinators as ``Advocates.''
\11\ According to a DoD official, the number of servicemembers in
the RCP program has steadily increased over time as conflicts continue
and people take longer to transition out of the military.
---------------------------------------------------------------------------
The FRCP and RCP are two of at least a dozen DoD and VA programs
that provide care coordination and case management services to
recovering servicemembers, veterans, and their families, as we have
previously reported.\12\ Although these programs may vary in terms of
the severity of injuries or illnesses among the population they serve,
or in the types of services they provide, many, including the FRCP and
RCP, provide similar services. (See table 1.)
---------------------------------------------------------------------------
\12\ GAO-11-250.
Table 1: Characteristics of Selected Department of Defense (DoD) and
Department of Veterans Affairs (VA) Care Coordination and Case
Management Programs for Seriously and Severely Wounded, Ill,
---------------------------------------------------------------------------
and Injured Servicemembers, Veterans, and Their Families
----------------------------------------------------------------------------------------------------------------
Type of services provided
Severity of Title of care --------------------------------------------
Program enrollees' coordinator or Recovery
injuries a case manager Clinical Nonclinical plan
----------------------------------------------------------------------------------------------------------------
VA/DoD Federal Recovery Severe Federal
Coordination Program (FRCP). Recovery
Coordinator
(FRC)
----------------------------------------------------------------------------------------------------------------
DoD Recovery Coordination Program Serious Recovery Care
(RCP). Coordinator
----------------------------------------------------------------------------------------------------------------
Army Warrior Transition Units.... Serious to Nurse case
severe manager, squad
leader,
physician (one
of each is
assigned)
----------------------------------------------------------------------------------------------------------------
Military wounded warrior programs Serious to Case manager or
b,c. severe Advocate
(title varies
by service)
----------------------------------------------------------------------------------------------------------------
VA OEF/OIF Care Management Mild to severe Case manager,
Program d. Transition
Patient
Advocate e
----------------------------------------------------------------------------------------------------------------
VA Spinal Cord Injury and Mild to severe Nurse, social
Disorders Program. worker
----------------------------------------------------------------------------------------------------------------
VA Polytrauma System of Care..... Serious to Social work and
severe nurse case
managers
----------------------------------------------------------------------------------------------------------------
Source: GAO analysis of DoD and VA program information.
Notes: The characteristics listed in this table are general characteristics of each program; individual
circumstances may affect the enrollees served and services provided by specific programs.
a For the purposes of this table, we have categorized the severity of enrollees' injuries according to the
injury categories established by the DoD and VA Wounded, Ill, and Injured Senior Oversight Committee.
Servicemembers with mild wounds, illness, or injury are expected to return to duty in less than 180 days;
those with serious wounds, illness, or injury are unlikely to return to duty in less than 180 days and
possibly may be medically separated from the military; and those who are severely wounded, ill, or injured are
highly unlikely to return to duty and are also likely to medically separate from the military. These
categories are not necessarily used by the programs themselves.
b The military wounded warrior programs are the Army Wounded Warrior Program, Marine Wounded Warrior Regiment,
Navy Safe Harbor, Air Force Warrior and Survivor Care Program, Army Reserve Wounded Warrior Component, and
Special Operations Command's Care Coalition.
c An FRC placed at the Special Operations Command's Care Coalition headquarters coordinates clinical and
nonclinical care for Care Coalition and other FRCP enrollees.
d OEF/OIF refers to Operation Enduring Freedom and Operation Iraqi Freedom, respectively. Since September 1,
2010, OIF is referred to as Operation New Dawn.
e An OEF/OIF care manager supervises the case managers and transition patient advocates and may also maintain a
caseload of wounded veterans.
VA Has Made Progress in Addressing Our Recommendations to Improve FRCP
Management Processes, and DoD Has Provided Limited Assistance
VA has recently made progress addressing the recommendations from
our March 2011 report, and although our recommendations were directed
to VA, DoD has provided limited assistance for one of the
recommendations. We previously reported that the FRCP would benefit
from more definitive management processes to strengthen program
oversight and decision-making, and that program leadership could no
longer rely on the informal management processes it had developed to
oversee and manage key aspects of the program. Because VA maintains
administrative control of the program, we recommended that the
Secretary of VA direct the FRCP to take actions to address management
issues related to FRC enrollment decisions, FRCs' caseloads, and
program staffing needs and placement decisions. VA concurred with all
of our recommendations and its progress in addressing them is outlined
below:
FRC enrollment decisions. To ensure that referred
servicemembers and veterans who need FRC services are enrolled in the
program, we recommended that the FRCP establish adequate internal
controls regarding enrollment decisions by requiring FRCs to record the
factors they consider in making enrollment decisions, to develop and
implement a methodology and protocols for assessing the appropriateness
of enrollment decisions, and to refine the methodology as needed.
In May 2011, VA reported that the FRCP had fully implemented an
interim solution, which requires that FRCs present each enrollment
decision to FRCP management for review and approval. The discussion
between the FRC and management and the final decisions are documented
in the program's data management system. As of September 2011, VA
reported that the FRCP continues to review and refine the enrollment
process and establish document protocols.
FRC caseloads. In an effort to improve the management of
FRCs' caseloads, we recommended that the FRCP complete the development
of a workload assessment tool, which would enable the program to assess
the complexity of services needed by enrollees and the amount of time
required to provide services.
As of September 2011, the FRCP has implemented a workload
intensity tool within the program's data management system, and FRCs
began using it for all new referrals in September 2011. According to
the Acting Executive Director for the FRCP, the FRCP will be monitoring
the effectiveness of the workload intensity tool and will be making
modifications to it as needed.
Staffing needs and placement decisions. We recommended
that the FRCP clearly define and document the decision-making process
for determining when VA should hire FRCs, how many it should hire, and
that the FRCP develop and document a clear rationale for FRC placement.
In September 2011, VA reported that the FRCP has documented the
formula that the program currently uses to determine the number of FRC
positions required. In addition, the FRCP is developing a systematic
analysis to better inform decisions about the future placement of FRCs.
This analysis considers referrals received by the program, client
location upon reintegration into the community, and requests from
programs or facilities for placing FRCs at particular locations.
According to the Acting Executive Director for the FRCP, the FRCP will
report updated information about staffing and placement processes
annually in its business operation planning document.
Although our recommendations to improve the management of the FRCP
were directed to the Secretary of VA, both DoD and VA were asked to
provide a response to this Subcommittee about how the Departments could
jointly implement the recommendations. DoD has provided limited
assistance to VA with the implementation of our recommendation
regarding enrollment. Specifically, according to DoD and VA officials,
an e-mail communication was sent on June 30, 2011, to the commanders of
the military services' wounded warrior programs stating that they
should refer all severely wounded, ill, and injured servicemembers who
could benefit from the services of an FRC to the program for
evaluation. Despite this effort, VA officials stated that they have not
noticed any change in referral numbers or patterns from DoD since the
e-mail was sent.
DoD and VA Have Made Little Progress Reaching Agreement on Options to
Better Integrate Care Coordination Programs
DoD and VA have made little progress reaching agreement on options
to better integrate the FRCP and RCP, although they have made a number
of attempts to address this issue. Most recently, DoD and VA
experienced difficulty jointly providing potential options for
integrating these programs in response to this Subcommittee's May 26,
2011, request to the deputy secretaries, who co-chair the DoD and VA
Wounded, Ill, and Injured Senior Oversight Committee (Senior Oversight
Committee).\13\ The Subcommittee requested that the co-chairs provide a
written response to the Subcommittee by June 20, 2011. In the absence
of such a response, on August 19, 2011, the Subcommittee contacted the
Secretaries of DoD and VA and requested that they facilitate moving
this matter forward.
---------------------------------------------------------------------------
\13\ In May 2007, DoD and VA established the Senior Oversight
Committee to address problems identified with the care of recovering
servicemembers. The Committee is co-chaired by the deputy secretaries
of DoD and VA and includes military service secretaries and other high-
ranking officials within both Departments.
---------------------------------------------------------------------------
On September 12, 2011, the co-chairs of the Senior Oversight
Committee issued a joint letter that stated that the Departments are
considering several options to maximize care coordination resources.
However, these options have not been finalized and were not
specifically identified or outlined in the letter. According to DoD and
VA officials, the development of this response involved a back-and-
forth between the Departments because of disagreement over its
contents. Although officials of both Departments collaborated on the
development of the letter, changes were made during the review process
that resulted in the delay of its release to the Subcommittee.
According to DoD and VA officials, after VA had signed the letter and
sent it to DoD for review and signature, DoD officials unilaterally
modified the wording, to which VA officials objected. Officials from
both Departments told us that the resulting impasse caused considerable
delay in finalizing the letter and was resolved only after DoD agreed
to withdraw its changes. Issuance of the letter followed notification
by the Subcommittee that it would hold a hearing on the FRCP and RCP
care coordination issue in September 2011.
The two Departments have made prior attempts to jointly develop
options for improved collaboration and potential integration of the
FRCP and RCP. Despite these efforts, no final decisions to revamp,
merge, or eliminate programs have been agreed upon. For example:
Beginning in December 2010, the Senior Oversight
Committee directed its care management work group \14\ to conduct an
inventory of DoD and VA case managers and perform a feasibility study
of recommendations on the governance, roles, and mission of DoD and VA
care coordination. According to DoD and VA officials, this information
was requested for the purpose of formulating options for improving DoD
and VA care coordination. DoD officials stated that following
compilation of this information, no action was taken by the Committee,
and care coordination was subsequently removed from the Senior
Oversight Committee's agenda as other issues, such as budget
reductions, were given higher priority. Recently, care coordination has
again been placed on the Committee's agenda for a meeting scheduled in
October 2011.
---------------------------------------------------------------------------
\14\ The Senior Oversight Committee is supported by several
internal work groups devoted to specific issues, such as DoD and VA
care coordination and case management. Participants in the Committee's
care management work group include officials from the FRCP and the RCP.
In March 2011, the DoD Office of Wounded Warrior Care and
Transition Policy sponsored a summit that included a review of DoD and
VA care coordination issues. This effort resulted in the development of
five recommendations to improve collaboration between the FRCP and RCP,
including a more standardized methodology for making referrals to the
FRCP, and two recommendations to redefine the FRCP and the RCP.
However, there was no joint response to these recommendations and no
agreement appears to have been reached to jointly implement them.
Although DoD officials contend that they have taken action on many of
these recommendations within DoD's care coordination program, VA
maintains that no substantive action has been taken to jointly
implement them. The degree of disagreement that exists between DoD and
VA on implementing these recommendations may be illustrated by the
continued disagreement between the Departments about when the FRC
should engage with a seriously wounded, ill, and injured servicemember.
In discussing one of the outcomes of this coordination summit, DoD
officials asserted that the FRCP should become engaged with the
servicemember during rehabilitation after medical treatment has been
finished. In contrast, VA maintains that the point of engagement should
be in the early stage of medical treatment to build rapport and trust
with their clients and their clients' families throughout their course
---------------------------------------------------------------------------
of care.
In July 2011, a task force consisting of staff representing
different VA programs, including the FRCP, began meeting independently
of DoD to examine more broadly the range of services VA provides to the
wounded, ill, and injured veterans it serves. VA officials said that
this task force was formed to provide a critical examination of how
VA's care coordination and case management programs are meeting the
needs of this population. However, a VA official stated that this is an
ongoing effort, and that the task force has not yet identified any
options or recommendations related to its review. While the task force
has not yet shared information about its efforts with DoD, a VA
official told us that it is planning to make a presentation of its
efforts to the Senior Oversight Committee at a meeting scheduled in
October 2011.
The lack of progress to date in reaching agreement on options to
better integrate the FRCP and the RCP illustrates DoD's and VA's
continued difficulty in collaborating to resolve care coordination
program duplication and overlap. We currently have work underway to
further study this issue and identify the key impediments that continue
to affect recovering servicemembers and veterans during the course of
their care. Additionally, as we have previously reported, there are
numerous programs in addition to the FRCP and RCP that provide similar
services to recovering servicemembers and veterans--many of whom are
enrolled in more than one program and therefore have multiple care
coordinators and case managers. For example, as of September 12, 2011,
75 percent of active FRCP enrollees also were enrolled in DoD's wounded
warrior programs. According to one FRC, his enrollees have, on average,
eight case managers who are affiliated with different programs. We
found that inadequate information exchange and poor coordination
between these programs has resulted in not only redundancy, but
confusion and frustration for enrollees, particularly when care
coordinators and case managers duplicate or contradict one another's
efforts. For example, an FRC told us that in one instance there were
five case managers working on the same life insurance issue for an
individual. In another example, an FRC and RCC were not aware the other
was involved in coordinating care for the same servicemember and had
unknowingly established conflicting recovery goals for this individual.
In this case, a servicemember with multiple amputations was advised by
his FRC to separate from the military in order to receive needed
services from VA, whereas his RCC set a goal of remaining on active
duty. These conflicting goals caused considerable confusion for this
servicemember and his family.
Conclusions
Numerous programs, including the FRCP and RCP, have been
established or modified to improve care coordination and case
management for recovering servicemembers, veterans, and their
families--individuals who because of the severity of their injuries and
illnesses could particularly benefit from these services. While well
intended, the proliferation of these programs, which often provide
similar services, has resulted not only in inefficiencies, but also
confusion for those being served. Consequently, the intended purpose of
these programs--to better manage and facilitate care and services--may
actually have the opposite effect. Particularly disconcerting is the
continued lack of progress by DoD and VA to more effectively align and
integrate their care coordination and case management programs across
the Departments. This concern is heightened further as the number of
enrollees served by these programs continues to grow. Without
interdepartmental coordination and action to better coordinate these
programs, problems with duplication and overlap will persist, and
perhaps worsen. Moreover, the confusion this creates for recovering
servicemembers, veterans, and their families may hamper their recovery.
Recommendation for Executive Action
To improve the effectiveness, efficiency, and efficacy of services
for recovering servicemembers, veterans, and their families, we
recommend that the Secretaries of DoD and VA direct the Senior
Oversight Committee to expeditiously develop and implement a plan to
strengthen functional integration across all DoD and VA care
coordination and case management programs that serve this population,
including the FRCP and RCP, to reduce redundancy and overlap.
Agency Comments
We obtained oral comments on the content of this statement from
both DoD and VA officials. These officials provided additional
information and technical comments, which we incorporated as
appropriate.
Chairwoman Buerkle, Ranking Member Michaud, and Members of the
Subcommittee, this completes my prepared statement. I would be pleased
to respond to any questions that you may have at this time.
GAO Contact and Staff Acknowledgments
If you or your staff have any questions about this testimony,
please contact me at (202) 512-7114 or [email protected]. Contact points
for our Offices of Congressional Relations and Public Affairs may be
found on the last page of this statement. Individuals who made key
contributions to this testimony include Bonnie Anderson, Assistant
Director; Jennie Apter; Frederick Caison; Deitra Lee; Mariel Lifshitz;
and Elise Pressma.
Prepared Statement of Philip Burdette, Principal Director, Wounded
Warrior Care and Transition Policy, Office of the Under Secretary of
Defense for Personnel and Readiness, U.S. Department of Defense
Madam Chairwoman and Members of the Subcommittee:
Thank you for the opportunity to discuss the Department of
Defense's (DoD) role in the Federal Recovery Coordination Program
(FRCP). While the FRCP was jointly developed by DoD and Department of
Veterans Affairs (VA) leaders on the Senior Oversight Committee (SOC)
in August 2007, the program is administered by VA.
Overview of DoD Recovery Coordination Program
The DoD Recovery Coordination Program (RCP) was established later
by Section 1611 of the FY 2008 National Defense Authorization Act. This
mandate called for a comprehensive policy on the non-medical care and
management of recovering servicemembers, including the development of a
comprehensive recovery plan, and the assignment of a Recovery Care
Coordinator for each recovering servicemember. In January 2009, a
Directive-Type Memorandum followed in December 2009 with a Department
of Defense Instruction (DoDI 1300.24), set policy standardizing non-
medical care provided to wounded, ill and injured servicemembers across
the military departments. A summary of the roles and responsibilities
captured in the DoDI are as follows:
Recovery Care Coordinator (RCC): The RCC supports
eligible servicemembers by ensuring their non-medical needs are met
along the road to recovery.
Comprehensive Recovery Plan (CRP): The RCC has primary
responsibility for making sure the CRP is complete, including
establishing actions and points of contact to meet the servicemember's
and family's goals. The RCC works with the Commander to oversee and
coordinate services and resources identified in the CRP.
Recovery Team: The Recovery Team (RT) includes the
recovering servicemember's Commander, the RCC, Medical Care Case
Manager, Non-Medical Care Manager, and, when appropriate, the Federal
Recovery Coordinator (FRC) for catastrophically wounded, ill or injured
servicemembers. The RT jointly develops the CRP, evaluating its
effectiveness and adjusting it as transitions occur.
There are currently 162 RCCs in 67 locations placed within the
Army, Navy, Marines, Air Force, United States Special Operations
Command (USSOCOM) and Army Reserves. Care Coordinators are hired and
jointly trained by DoD and the Services' Wounded Warrior Programs. Once
placed, they are assigned and supervised by Wounded Warrior Programs
but have reach back support as needed for resources within the Office
of Wounded Warrior Care and Transition Policy. DoD RCCs work closely
with VA FRCs as members of a servicemember's recovery team.
The DoDI 1300.24 establishes the standardized processes for
referral for care coordination of seriously, severely and catastrophic
injured and ill servicemembers for RCCs and FRCs. The RCC's focus is on
servicemembers who will be classified as Category 2 and 3. A Category 2
servicemember has a serious injury/illness and is unlikely to return to
duty within a time specified by his or her Military department and may
be medically separated. A Category 3 servicemember has a severe or
catastrophic injury/illness and is unlikely to return to duty and is
likely to be medically separated. The FRC's focus is on those
servicemembers referred by Service Wounded Warrior programs.
While defined in the DoDI, Categories 1, 2 and 3 are all
administrative in nature and have proven difficult to operationalize.
The intent of the DoDI is to ensure that wounded, ill, and injured
Servicemembers receive the right level of non-medical care and
coordination. DoD is continuing to work with the FRCP to ensure that
servicemembers who need the level of medical and nonmedical care
coordination provided by a FRC are appropriately referred.
Government Accountability Office (GAO) Report on Federal Recovery
Coordination Program
The Departments recognize that the FRCP and RCP are complementary,
not redundant programs. There is a ``hand-off'' from DoD RCCs to the VA
FRCs. This occurs when it is clear that the catastrophically wounded,
ill, or injured servicemember will not return back to duty, which is a
highly individualized determination based on multiple factors,
including the servicemembers' condition, and their desire to stay on
active duty. While we concur in principle that the establishment of a
single recovery coordination program may be the preferred course of
action to provide fully integrated care coordination services, the two
Departments are still in the process of working out the details.
As a full partner with the VA, the Department of Defense will
assist with implementing the GAO recommendations. Specifically, in
accordance with DoD Policy, all Category 3 (severe or catastrophic
injury or illness) and other recovering servicemembers who would most
benefit from the services of a Federal Recovery Coordinator (FRC) will
be referred. In order to ensure the capabilities are in place to
address these recommendations, we are in the process of evaluating the
care coordination resources and capabilities of VA and DoD so that the
necessary personnel are available with the appropriate skill levels to
support the wounded, ill, and injured population.
Following are DoD's responses to the GAO report.
Duplication of case management efforts between VA and DoD
The report outlines the confusion and inefficiency that arises as a
result of a servicemember who may have multiple case managers. The GAO
report shows a matrix with the various DoD and VA care/case management
programs in place. As many as 84 percent of servicemembers in the FRCP
are also enrolled in a Military Service Wounded Warrior Program. While
the programs vary in the populations they serve and services they
provide, there is a necessary overlap in functions.
The GAO outlined one instance where a recovering servicemember was
receiving support and guidance from both a DoD RCC and a VA FRC. The
two coordinators were effectively providing opposite advice and the
servicemember was in receipt of conflicting recovery plans. The
servicemember had multiple amputations and was advised by his FRC to
separate from the military in order to receive needed services from VA,
whereas with his RCC he set a goal of remaining on active duty. We
recognize that better coordination in the future will avoid these
situations.
The SOC directed RCP and FRCP leadership to establish a joint DoD-
VA Recovery Care Coordination Executive Committee to identify ways to
better coordinate the efforts of FRCs and RCCs and resolve issues of
duplicative or overlapping case management. The Committee conducted its
first meeting in March and its final two-day meeting in May. The
results of the Committee's efforts were briefed to the SOC and DoD
supports the recommendations to better integrate the FRCP into the RCP
while considering options to improve transitions for Recovering
servicemembers In March 2011, DoD also conducted an intense two and a
half day Wounded Warrior Care Coordination Summit that included focused
working groups attended by subject matter experts who discussed and
recommended enhancements to various strategic wounded warrior issues.
One chartered working group focused entirely on collaboration between
VA and DoD care coordination programs. Actionable recommendations were
reviewed, presented to the Overarching Integrated Product Team and will
continue to be worked until the recommendations and policies are
implemented. The joint DoD-VA Committee also considered the work
produced by the working group at this summit in coming up with its
recommendations on how to best collaborate, coordinate, or integrate
these two programs.
Lack of access to equipment at installations
FRCs reported to the GAO that ``logistical problems'' impacted
their ability to conduct day-to-day work. Specific areas causing this
include: a) provision of equipment, b) technology support and c)
private work space. There are existing Memoranda of Agreement (MOA)
between DoD and VA at facilities where FRCs work, however immediate
compliance with these MOAs in an environment of reduced or limited
resources is always a challenge.
DoD's Office of Wounded Warrior Care and Transition Policy (WWCTP)
stands ready to assist in securing the resources required at DoD
facilities for FRCs and will work with the services and VA to ensure
that daily duties are not interrupted by equipment, technology or space
constraints.
Conclusion
The Committee requested an analysis of, and potential options for,
integrating the FRCP and RCP under a single umbrella, to reduce
redundancy and better fulfill the goal of establishing a seamless
transition for wounded warriors and their families. The Departments
recognize that the FRCP and RCP are complementary, not redundant
programs. While we concur in principle that the establishment of a
single recovery coordination program may be the preferred course of
action to provide fully integrated care coordination services for the
wounded, ill, or injured servicemembers, Veterans, and their families,
the two Departments are still in the process of working out the details
for the SOC.
DoD is committed to working closely with the VA Federal Recovery
Coordination Program leadership to ensure a collaborative relationship
exists between the DoD RCP and the VA FRCP. The Military Department
Wounded Warrior Programs will also continue to work closely with FRCs
in support of recovering servicemembers and their families.
Madam Chairwoman, this concludes my statement. On behalf of the men
and women in the military today and their families, I thank you and the
members of this Subcommittee for your steadfast support.
Prepared Statement of John Medve, Executive Director, Office of the
U.S. Department of Veterans Affairs-U.S. Department of Defense Office
Collaboration Office of Policy and Planning, U.S. Department of
Veterans Affairs
Good afternoon Chairwoman Buerkle, Ranking Member Michaud, and
Members of the Subcommittee. I am John Medve, Executive Director,
Office of VA-DoD Collaboration within the Office of Policy and
Planning. I am pleased to be here today to discuss the Federal Recovery
Coordination Program (FRCP) and the progress that has been made in
addressing improvements recommended by the Government Accountability
Office (GAO).
The FRCP is a designed to complement existing military service-and
VA-provided case management, support, and transition coordinators. FRCP
is specifically charged with providing seamless support from the
servicemember's arrival at the initial Medical Treatment Facility (MTF)
in the United States through the duration of their recovery,
rehabilitation, and reintegration. The FRCP staff at the policy level
coordinates with its DoD counterparts under the umbrella of the Senior
Oversight Committee. The FRCP is an integral part of VA and DoD efforts
to address issues raised about the coordination of care and transitions
between the two Departments for recovering servicemembers. On behalf of
its clients, Federal Recovery Coordinators (FRCs) work closely with
clinical and non-clinical care and case managers from the military
services, the VA, and the private sector as part of their Recovery
Team. FRCs are master's degree-prepared nurses and clinical social
workers who support severely wounded and ill Servicemembers, Veterans
and their families by advocating in all clinical and non-clinical
aspects of recovery. FRCs work with relevant military service and VA
programs, the individual's interdisciplinary clinical team, and all
case managers. Based on a client's goals, with input from all care
providers and coordinators, the FRC creates a Federal Individual
Recovery Plan (FIRP). FRCs oversee and coordinate all clinical and non-
clinical care identified in the FIRP. To show greater transparency with
Servicemembers and Veterans, the FIRP is available through the
eBenefits portal 24 hours-a-day, 7 days-a-week.
GAO issued a report in March 2011 containing four VA
recommendations. VA concurred with the recommendations and has taken
action to implement each of them. GAO's first recommendation was that
VA establish adequate internal controls regarding FRCs' enrollment
decisions to ensure that referred Servicemembers and Veterans who need
FRC services are enrolled in the program. GAO also recommended that
FRCP leadership require FRCs to record in the Veterans Tracking
Application (VTA) the factors considered in making the enrollment
decision, develop and implement a methodology and protocol for
assessing the appropriateness of enrollment decisions, and refine the
methodology as needed. VA concurred with this recommendation and
immediately implemented more stringent internal controls to include
management review of all enrollment decisions and documentation of
decision determinations in VTA to ensure that referred Servicemembers
and Veterans who need FRC services are offered enrollment in FRCP.
Potential clients referred to FRCP are evaluated to determine the
individual's medical and non-medical needs and requirements in order to
recover, rehabilitate, and reintegrate to the maximum extent possible.
A key component in the FRCP evaluation process is the clinical training
and experience of the FRCs and their professional judgment of whether
an individual would benefit from FRCP care coordination. In general,
Servicemembers and Veterans whose recovery is likely to require a
complex array of specialists, transfers to multiple facilities, and
long periods of rehabilitation are offered enrollment in FRCP.
Following a referral, FRCs consider a wide range of issues in
determining whether an individual meets enrollment criteria. The first
consideration is whether the referred individual meets the broad Senior
Oversight Committee (SOC) eligibility criteria. The SOC criteria covers
Servicemembers or Veterans who are: in an acute care setting within a
military treatment facility; diagnosed or referred with spinal cord
injury, burns, amputation, visual impairment, traumatic brain injury
and/or Post-Traumatic Stress Disorder; considered at risk for
psychosocial complication; or self or Command referred based on
perceived ability to benefit from a recovery plan. FRCs then conduct a
comprehensive record review to include all relevant and available
health and benefit information. They document the medical diagnoses and
conditions. They conduct a risk assessment; identify anticipated
treatment and rehabilitation needs; determine the individual's access
to care and level of support; identify any issues with medications or
substance abuse; assess the current level of physical and cognitive
functioning; and review financial, family, military, and legal issues.
They also discuss the individual with interdisciplinary clinical team
members, clinical and non-clinical case managers, and others who might
provide insight into the various issues and challenges the
Servicemembers or Veterans and their families face. Finally, and most
importantly, the FRCs interview the referred individual and family
members. Based on all input, the FRCs determine whether to recommend
enrollment of the referred individual into the FRCP. The FRCs then
present the case for their recommendation to a member of the FRCP
leadership team for final approval. The results of the final decision
are documented in the FRCP data management system. FRCP enrollment is
entirely voluntary. Individuals who are not enrolled are directed to
alternative resources that are appropriate for their level of need.
FRCP continues to review and refine the enrollment process and
establish and document protocols as recommended by GAO. FRCP has
completed the first phase of an intensity tool designed to add further
consistency to the enrollment decision process. Testing was completed
in late summer and we began using the tool on all new referrals earlier
this month.
GAO's second recommendation was to complete development of a
workload assessment tool that will enable the program to assess the
complexity of services needed by enrollees and the amount of time
required to provide services to improve management of FRCs' caseloads.
FRCP embarked on the development of a service intensity tool that would
fulfill the workload assessment requirements of the GAO recommendation
and further tie the assessment to enrollment decisions. FRCP dedicated
substantial time and research into the development and testing of its
service intensity tool. Several comprehensive sessions with FRCs,
analysts, and FRCP management were held to develop the tool, validate
assumptions, conduct reliability testing and refine the scoring
mechanisms. As noted in VA's original response to GAO, this process
will likely be completed by summer 2012. The first phase of the tool
was launched program-wide. FRCP will further analyze the results as we
continue development of the second phase which will be used to assess
the amount of time required to provide services. In the interim, FRCP
is testing other caseload management strategies. Currently, FRCP is
evaluating the feasibility of establishing intensity levels within the
active client population to meet the needs of clients and improve
management of FRC caseloads.
GAO's third recommendation to VA was to clearly define and document
the FRCP's decision-making process for determining when and how many
FRCs VA should hire to ensure that subsequent FRCP leadership can
understand the methods currently used to make staffing decisions. VA
concurred with the recommendation and documented the formula used to
determine the number of FRC positions required. These positions are
based on an analysis of the anticipated number of referrals, the rate
of enrollment, the number of clients made inactive, and a target
caseload range of between 25-35 per FRC. Upon completion of the service
intensity tool, FRCP will modify this equation to reflect the average
intensity points allowed per FRC instead of the current caseload range.
GAO's fourth and final recommendation was to develop and document a
clear rationale for placement of FRCs, which should include a
systematic analysis of data, such as referral locations, to ensure that
FRC placement decisions are strategic in providing maximum benefit for
the program's population. VA concurred with this recommendation and is
developing a systematic analysis to inform future placements. The
original placement of FRCs was guided and directed by an October 2007
Memorandum of Understanding, signed by the Secretary of Defense and the
Acting Secretary of Veterans Affairs, which required that FRCs be
placed at MTFs where significant numbers of wounded, ill, or injured
Servicemembers were located. As the program grew, the FRCs spread to
additional locations. FRC placement is guided by four factors:
replacement for FRCs who leave the program, supplementation of existing
FRCs based on documented need, creation of a national FRCP network to
optimize coordination, and specific requests for FRCs to better serve
the wounded, ill, and injured population of Servicemembers and
Veterans.
Thanks to the flexibility of the program, VA has made significant
progress in implementing the GAO's recommendations during these past 6
months. FRCP is continuously improving and provides a unique service to
severely wounded, ill, and injured Servicemembers, Veterans, and their
families. FRCP is not redundant with existing support programs in VA
and DoD, but rather complementary as stated in its establishing
Memorandum of Understanding (MOU).
FRCP was established specifically to provide care coordination
across VA and DoD for the most complex cases. FRCs assist clients by
coordinating health care and benefits from DoD, VA, and other Federal
agencies as well as State, local and private entities. Most
coordination and case management support is facility-based. This is not
true for FRCs. Once assigned, a FRC will continue to support a client
regardless of where the client is located. This philosophy provides an
invaluable level of consistency for a client at time when care needs
and transitions can be overwhelming. Feedback suggests FRCP clients are
extremely satisfied with the services provided by FRCs. FRCs assist
clients in overcoming systems barriers, ensure smooth transitions,
educate clients concerning complex benefits and services, and help them
navigate across the many systems, programs, and agencies to obtain
necessary services and benefits. These needs continue to exist for the
FRCP client population. FRCs clinical backgrounds combined with an
intensive and comprehensive education on programs and services
available to Servicemembers and Veterans make them uniquely qualified
to provide the care coordination services necessary for successful
recovery and reintegration.
Beginning next month, FRCP will pilot a new data management system.
Efforts are already underway to ensure that the data collected and
stored in the new Internet-based platform is capable of being shared
throughout VA and DoD. Additionally, VA is engaged in an Information
Sharing Initiative (ISI) with DoD. ISI is designed to further support
smooth transitions between DoD and VA. ISI will provide care
coordinators and case managers the ability to track benefits
applications, benefits processing status, and benefits awards. It will
also provide visibility of all clinical and non-clinical care plans and
provide the ability to view a shared calendar for Servicemember and
Veterans appointment scheduling.
In an effort to ensure VA is providing the greatest level of
coordinated support to the wounded, ill, and injured population, VA
recently established an internal Wounded, Ill, and Injured Task Force
to examine current VA programs and ensure appropriate resources,
programs, and services are available to our wounded, ill, and injured
populations. A goal of the Task Force is to ensure effective access to
and delivery of health care and benefits.
Many wounded, ill and injured Servicemembers, Veterans and their
families are confused by the number and types of case managers and
baffled by benefit eligibility criteria as they move through DoD's and
VA's complex systems of care on the road to recovery, rehabilitation,
and reintegration. The FRCP was envisioned to be the consistent
resource available to these individuals through care and recovery -a
consistent resource that would help them understand the complexities of
the medical care provided and the array of benefits and services
available to assist in recovery. Currently, the FRCP provides clinical
and non-clinical care coordination for wounded, ill or injured
Servicemembers, Veterans and their families with severe and complex
medical and social problems. The FRCP provides alignment of services,
coordination of benefits, and resources across DoD, VA and the private
sector by managing transitions and providing system navigation for
clients.
Our clients tell us the program works best when FRCs are included
early in the Servicemember's recovery and prior to the first
transition, whether that transition is from inpatient to outpatient or
from one facility to another. Once assigned, a FRC will continue to
support a client regardless of where the client is located. This
consistency of coordination is important for individuals with severe
and complex conditions who require multiple DoD, VA and private health
providers and services. FRCs remain in contact with their clients as
long as they are needed, whether for a few months or a lifetime.
This concludes my statement, and I am happy to answer any questions
you may have.
Prepared Statement of Abbie Holland Schmit,
Manager, Alumni, Wounded Warrior Project
Chairwoman Buerkle, Ranking Member Michaud and Members of the
Subcommittee:
Wounded Warrior Project (WWP) applauds the Subcommittee for your
important oversight into the Federal Recovery Coordination Program
(FRCP). The Subcommittee's hearing in May raised important issues
regarding the program's management and governance, and we appreciate
your follow-up questions to the Co-Chairs of the Senior Oversight
Committee and your scheduling this second hearing today.
In testifying today for WWP, I hope to share an ``on the ground''
perspective on the FRCP based on my experience in working with wounded
warriors. As a WWP Alumni Manager in Chicago, I work with wounded
warriors and their families on a daily basis. Prior to joining WWP in
June, I served for more than 2 years as an advocate with the Army's
Wounded Warrior Program--referred to as the AW2 program. The AW2
program assists and advocates for severely wounded, ill, and injured
soldiers, veterans, and their families during their recovery and
transition. Those who qualify are to be assigned to the program as soon
as possible after arriving at a Warrior Transition Unit. As one who
served for 6 years in the Army National Guard and had a hard journey
home due to PTSD and traumatic brain injury after deploying to Iraq
from 2003 to 2004, the issues before you are not only important, but
deeply personal for me.
The FRCP was designed to help those warriors, who--given
overwhelming injuries--would not only be unable to return to active
duty, but would likely encounter difficulty in navigating a transition
process that might involve three or more Federal Departments of
government and issues ranging from income support, to continuing health
care and rehabilitation, specially adapted housing, vocational
rehabilitation and education, caregiver support, and more. In assigning
knowledgeable, savvy ``special navigators'' in the form of Federal
Recovery Coordinators (FRC), to assist those warriors and their
families with this complex process, the program has proven highly
successful--and unique--in providing holistic, integrated support. FRCs
are making a real difference in helping severely injured warriors and
their families to thrive again.
As your May hearing underscored, individual service Departments are
not routinely referring severely and catastrophically wounded
servicemembers to the FRCP, or are doing so at much too late a point in
the transition process. The Service Departments appear to view the FRCP
as a VA program; and tend to only refer warriors and their families to
the program when the warrior is about to separate or retire from
service. Rather than being marginalized as a VA-only program, the FRCP
should be operated as initially intended, a joint, integrated effort
aimed at coordinating Federal care and services. But current
practices--seemingly reinforced by a shortsighted insistence on
service-specific care--risk delaying recovery, rehabilitation and
reintegration rather than fostering a seamless transition. What should
be a seamless, coordinated undertaking is too often the opposite, as
illustrated by the experience of warriors who--rather than having a
single ``comprehensive recovery plan''--find themselves with multiple
recovery plans.
These are not abstract or hypothetical concerns. Consider the case
of Army Specialist Steve Bohn who described his difficult transition at
a Senate Veterans Affairs Committee hearing in May. Steve was badly
injured in November 2008, when a suicide bomber in Afghanistan
detonated 2000 pounds of explosives that buried him under collapsed
debris and resulted in his suffering severe internal injuries and
spinal injuries. He experienced multiple breakdowns in the coordination
of his care and benefits. Steve was initially flown from Germany to
Fort Campbell, Kentucky--apparently in error--given that he needed
surgery. After finally undergoing spinal surgery at Walter Reed, Fort
Campbell threatened to put him on AWOL if he didn't return. As a
result, he was flown back to Fort Campbell, later returning to Walter
Reed to undergo bladder surgery. Ultimately he underwent a DoD Medical
Evaluation Board that eventually assigned him a 40 percent Permanent
disability rating, 30 percent for spinal injuries and 10 percent for
neck injuries. But that rating did not take account of his internal
injuries. He was finally medically retired from the Army in October
2010.
While his transition from DoD to VA seemed to begin appropriately
with his paperwork being sent to VA 180 days before the estimated
separation date to permit timely claims-adjudication, backlogs in
scheduling VA compensation examinations bogged down the process. At the
time Steve testified--7 months after retiring from service--VA had not
adjudicated his case and he was struggling financially. Unable to work
because of his injuries, he was living on his military retired pay of
less than $700/month.
Steve also seemed to have fallen through the cracks in terms of
getting VA medical care. While he had had multiple VA compensation
examinations, it took more than 6 months before anyone at VA approached
him to discuss any treatment. And many months after becoming a veteran,
he had yet to be assigned a VA primary care doctor. Steve testified
that no one ever discussed with him or his family the possibility of
having an FRC assigned to his case. It seems clear it would have made a
big difference.
Steve's experience is hardly unique. But it underscores how easily
a severely wounded servicemember can fall through the cracks--despite
very serious injuries, and despite how much emphasis has been placed on
``seamless transition.''
Following the direction of the National Defense Authorization Act
of 2008 (NDAA 08), VA and DoD entered into a memorandum of
understanding establishing the joint VA-DoD FRCP to assist
servicemembers with Category 3 injuries, defined as those with a severe
or catastrophic injury or illness who are highly unlikely to return to
active duty and will most likely be medically separated. A separate DoD
recovery coordinator program was designed to assist those with injuries
falling below this defined category who's return to duty may in some
way be possible. Inconsistency within the individual service
Departments in operationalizing the term ``Category 3 injuries'' has
arguably created ambiguity as to who is to be referred for an FRC.
This referral issue is a problem that can and must be remedied. But
the recent response from the Co-Chairs of the Senior Oversight
Committee to the Subcommittee's questions fails to provide that remedy.
In their cover letter, Deputy Secretaries Gould and Lynn state
categorically that ``in accordance with DoD Policy, all Category 3
(severe or catastrophic injury or illness and other recovering
servicemembers who would most benefit from the services of a Federal
Recovery Coordinator (FRC) will be referred.'' Yet in the enclosure to
their letter, which the Co-Chairs describe as setting out ``detailed
implementation plans,'' they state just the opposite: ``[T]he program
cannot ensure that all potentially eligible individuals are referred to
FRCP.'' According to the enclosure, the reason is that ``FRCP, as
currently structured, is a voluntary referral program and, as such,
relies on the identification and referral of those who might benefit
from FRCP services by others.'' \1\ Yet DoD's strongly worded policy
requires that ``All Category 3 recovering servicemembers shall be
enrolled in the FRCP and shall be assigned an FRC and Recovery Team.''
Given that policy, it would follow that--if something about the
program's ``current structure'' or voluntary referral process impedes a
reliable, effective referral process, that could and should be changed.
Rather than advising the Committee that this problem has been resolved
or reporting on a specific plan to remedy it, the Deputy Secretary of
Defense has simply advised this Committee that the terms used to
describe the population who should be referred to the FRCP are ``left
to interpretation,'' and ``currently mechanisms are not in place to
measure compliance with this policy.'' It is difficult to understand
why the senior leadership of the two Departments have failed to resolve
this problem.
---------------------------------------------------------------------------
\1\ DoD/VA Wounded, Ill, and Injured Senior Oversight Committee.
Response to the Subcommittee on Health, Committee on Veterans' Affairs,
House of Representatives regarding the Federal Recovery Care
Coordination Program and GAO recommendations. (September 12, 2011).
---------------------------------------------------------------------------
VA and DoD share a deep obligation to severely wounded warriors and
their families, but the reality is that they do not now share full
responsibility for the FRCP. As we advised the Subcommittee in our
statement for the record for your hearing in May, the FRCP has become
much less a joint program, and seen as more a VA program--to the
detriment of the warriors it was designed to serve. Warriors and
families continue to need this kind of help early in the transition
process. With the program's critical role in ensuring that severely
wounded warriors experience a seamless transition, those warriors and
their families would be better served if there were truly shared
responsibility for the program, such as through establishment of an
interdepartmental FRCP office. Such a proposal should not be deemed to
reflect a lack of confidence in VA, but rather recognition of the
inherent limitations of program governance residing in any single
department. The concept of a DoD-VA program office is neither novel nor
unprecedented.\2\ While different structural solutions could be
pursued, WWP foresees continued difficulties for the program, and most
importantly our warriors, unless fundamental changes are instituted to
ensure truly shared responsibility. To that end, we urge the
Subcommittee to consider taking up legislation to ensure that
objective.
---------------------------------------------------------------------------
\2\ Section 1635 of NDAA 2008 mandated establishment of a DoD/VA
Interagency Program Office (IPO) to act as a single point of
accountability for the department's development of electronic record
systems.
---------------------------------------------------------------------------
Thank you again for the opportunity to testify. I would be pleased
to respond to any questions you may have.
Prepared Statement of Alethea Predeoux, Associate
Director of Health Legislation, Paralyzed Veterans of America
Chairwoman Buerkle, Ranking Member Michaud, and Members of the
Subcommittee, Paralyzed Veterans of America (PVA) would like to thank
you for the opportunity to present our views on the Federal Recovery
Coordination Program (FRCP).
For more than 65 years it has been PVA's mission to help
catastrophically disabled veterans and their families obtain health
care and benefits from the Department of Veterans Affairs (VA), and to
provide support during the rehabilitative process to ensure that all
disabled veterans have the opportunity to build bright, productive
futures. It is for this reason that PVA strongly supports the FRCP, and
appreciates the Subcommittee's continued work on improving the
transition from active duty to veteran status for severely injured,
ill, or wounded veterans and servicemembers.
The FRCP was created as a joint program between VA and the
Department of Defense (DoD) to provide severely injured, ill, or
wounded servicemembers and veterans with individualized assistance
obtaining health care and benefits, and managing rehabilitation and
reintegration into civilian life. Through the program, veterans and
servicemembers are assigned a Federal Recovery Coordinator (FRC) and
create a Federal Individual Recovery Plan that consists of long-term
goals for the veteran and his or her family members. Such a plan
motivates veterans to fight through the initial difficulties of
adjusting to life after a catastrophic injury.
The purpose of today's hearing is to again assess challenges of the
FRCP and identify ways in which we can continue to improve this program
to best meet the needs of veterans and servicemembers. In the past
year, the FRCP has made changes to enhance service delivery and expand
its outreach; however, more work must be done in order to adequately
meet the needs of veterans.
When PVA provided the Subcommittee with a statement for the record
for the hearing held on May 13, 2011, which examined the progress and
challenges of the FRCP, we identified three areas in need of
improvement: continuity of care, care coordination, and program
awareness. Today, we still believe that these areas are critical to the
success of the FRCP and are in direct alignment with the issues and
recommendations outlined by the Government Accountability Office (GAO)
in a March 2011 report entitled, ``DoD and VA Health Care: Federal
Recovery Coordination Program Continues to Expand but Faces Significant
Challenges (GAO-11-250).'' In this report, GAO identified three primary
challenges with implementation of the FRCP: servicemember enrollment,
hiring Federal Recovery Coordinators (FRCs), and care coordination. GAO
concluded the report with four main recommendations to help VA
leadership address issues stemming from the main challenges facing the
program. Today, PVA will provide our position in support of the GAO
recommendations, and our views on the current progress of the
implementation of the FRCP.
FRCP Enrollment
The first recommendation from the GAO report was to ``ensure that
referred servicemembers and veterans who need FRC services are enrolled
in the program by establishing adequate internal controls regarding the
FRCs' enrollment decisions.'' In particular, this recommendation
identifies the need to require FRCs to record the factors they consider
in making FRCP enrollment decisions, as well as the need to create an
assessment tool to evaluate such decisions. PVA believes that the use
of such recording methods and assessment tools will help streamline the
enrollment process, and ensure that veterans and their families are
receiving help when it is requested. Additionally, as it relates to
veterans seeking assistance and looking to enroll in the FRCP, tracking
enrollment decisions will provide FRCs with the opportunity to identify
how a servicemember has learned about the FRCP. Identifying referral
sources will enable both VA and DoD to establish partnerships with
other Departments in and outside of their agencies to promote the FRCP
and possibly reduce duplication of care-coordination efforts across VA
and DoD programs.
PVA believes that servicemember enrollment is one of the most
critical elements of the FRCP. Servicemembers must be informed of the
FRCP and the variety of services available to them through the program.
However, making sure that veterans and servicemembers, as well as their
families and caregivers, are aware of the FRCP has proven to be a
continuous challenge. While participation numbers are growing, FRCP
leadership must work to keep information about the program circulating
throughout the veteran and military communities. This can best be
accomplished as a joint effort that incorporates different offices and
Departments across both the VA and DoD.
To promote the FRCP, information posters and pamphlets should be
made available to veterans and servicemembers when they visit different
offices within VA and DoD. The FRCP services should also be announced
through social media tools such as Facebook and Twitter to inform
veterans and servicemembers of this program. Such educational
literature would be useful not only for veterans and servicemembers,
but for their families and caregivers as well. Veterans and
servicemembers participate in many VA programs, but it is often a loved
one or caregiver who is helping manage and coordinate the various
services of care and they can significantly benefit from the help of an
FRC.
Collaboration between FRCP staff and specialized services teams is
another way to reach the targeted population that can benefit from FRCP
services. The referral criteria for the FRCP includes veterans and
servicemembers who have sustained a spinal cord injury, amputation,
blindness or vision limitations, traumatic brain injury, post-traumatic
stress disorder, burns, and those considered at risk for psychosocial
complications--all areas included in VA's system of specialized
services. Therefore, it is only logical for the FRCP to work with these
specialty teams to promote the program, and educate veterans entering
VA specialized systems of care on the FRCP services and benefits.
With regard to VA health care, the Veterans Health Administration
is currently undergoing a change in the way it delivers health care to
veterans by utilizing patient aligned care teams (PACT). PACT is
designed to provide patient-centered care through a team-based approach
that emphasizes care coordination across disciplines. PVA encourages
the FRCP leadership to work closely with the VA Office of Patient
Centered Care and Cultural Transformation since FRCs serve as an
information resource during the medical recovery process and the PACTs
can make referrals when a veteran or servicemember appears to be in
need of FRCP services.
Additionally, in support of care coordination, PVA hopes that FRCs
will reach out to the service officers and advocates who represent
various veteran service organizations and work with veterans in a
similar capacity on a daily basis. PVA has a network of National
Service Offices within VA that provide services to paralyzed veterans,
their families, and disabled veterans. These services range from
bedside visits, to guidance in the VA claims process, and legal
representation for appealing denied claims.
In fact, we recently received multiple reports describing close
working relationships between PVA's Senior Benefits Advocates and FRCs.
Our Senior Benefit Advocates and the FRCs work together on a daily
basis to assist veterans and their families. National Service Officers
can be a great resource to the FRC for referrals, information on VA
benefits and programs, and getting the word out about the FRCP within
the veteran community.
FRC Caseloads
The second recommendation from the GAO report encouraged ``complete
development of the FRCP's workload assessment tool that will enable the
program to assess the complexity of services needed by enrollees and
the amount of time required to provide services to improve the
management of FRCs' caseloads.'' PVA believes that monitoring and
managing the level of complexity and size of FRC caseloads is extremely
important to adequately addressing the needs and concerns of veterans
and servicesmembers enrolled in the FRCP.
No matter how well prepared and trained an FRC may be, he or she
will not be able to effectively help veterans and servicemembers to
their best ability if they are spread too thin and overwhelmed with an
unreasonable caseload. Conversely, an FRC managing a smaller caseload
of enrollees with polytraumatic and severe injuries will need fewer
cases to provide adequate attention and assistance to those veterans
and servicemembers. That said, a work load assessment tool is
absolutely necessary to ensuring that FRCs are available to hear the
concerns and needs of veterans and servicemembers and provide
appropriate assistance during the recovery and rehabilitation
processes.
As it is a goal of the FRCP to meet the individualized needs of
veterans and servicemembers, each case will be unique and require
different levels of attention. These factors must be taken into
consideration if FRCs are expected to provide timely quality assistance
that is truly helpful to servicemembers and their families.
Hiring FRCs
The third recommendation, to ``clearly define and document the
FRCP's decision-making process for determining when and how many FRCs
VA should hire to ensure that subsequent FRCP leadership can understand
the methods currently used to make staffing decisions, '' is an area of
serious concern for PVA. Adequate staffing of the FRCP is essential for
providing servicemembers with timely, quality care.
PVA believes that in conjunction with the aforementioned FRC
caseloads, the staffing of FRCs is another area of concern that must be
assessed to determine if current staffing levels are adequate to meet
veterans' and servicemembers' needs. With such a limited number of
FRCs, issues involving transportation and distance have the potential
to hinder access to FRCP services for many veterans in rural areas, and
thus, become threats to continuity of care. Further, developing a
decision-making tool to determine when and how many FRCs should be
hired has the potential to increase the program retention.
If FRC caseloads are manageable, and the FRCs believe that they can
actually help veterans and servicemembers, it is likely that employee
job-satisfaction will be high, and FRCs will continue performing their
duties. This will lead to adequate staffing of the program, which will
allow for FRCs and enrollees to develop effective long-term
relationships. It is these relationships that can help veterans and
servicemembers adjust to life after a severe or catastrophic injury.
Placement of FRCs
The final GAO recommendation calls for the FRCP to ``develop and
document a clear rationale for the placement of FRCs, which should
include a systematic analysis of data, such as referral locations, to
ensure that future FRC placement decisions are strategic in providing
maximum benefit for the program's population.'' PVA believes that all
veterans and servicemembers who are injured, ill, or wounded have
earned access to the FRCP. We understand that as a new program, time is
needed to create, implement, and assess the inner-workings of such a
comprehensive initiative.
As recommendations for improvement are provided to VA leadership,
we strongly encourage both VA and DoD to utilize existing care-delivery
models such as telehealth and teleconferencing, or electronic enrollee
accessible programs like My HealtheVet to meet with and communicate
with veterans and servicemembers in areas that do not have reasonable
access to an FRC.
Particularly, PVA encourages VA to develop an outreach strategy for
veterans living in rural areas to make certain that they are aware of
the FRCP and have access to an FRC if necessary. Specifically, we ask
that as the program expands, VA, DoD, and Congress consider placing
FRCs in locations where veterans with disabilities are already seeking
services such as VA spinal cord injury centers or amputation centers of
care. Developing a clear rationale for the placement of FRCs will help
ensure that those who have paid a significant price in service to our
country are not only aware of the resourceful programs available to
them, but also have the opportunity to participate in them.
In conclusion, PVA would like to thank the Committee for their
continued Congressional oversight of this extremely important program
and recommends that FRCP leadership periodically survey veterans and
servicemembers, and their families, to identify areas for improvement.
There are numerous lessons to be learned and an abundance of
opportunities for development.
PVA appreciates the emphasis this Subcommittee has placed on
reviewing the care being provided to the most severely disabled
veterans and servicemembers. Navigating through two of America's
largest bureaucracies is a daunting task, but it can be particularly
overwhelming when doing so after incurring a catastrophic injury such
as a spinal cord injury, amputation, or as a polytrauma patient.
Providing veterans with professional guidance and stability during this
process gives them the resources to make informed decisions involving
their health care and benefits and focus on their recovery and future
endeavors.
PVA would like to once again thank this Subcommittee for the
opportunity to testify today, and we look forward to working with you
to continue to improve the Federal Recovery Coordination Program. Thank
you.
Prepared Statement of Commander Rene A. Campos,
USN (Ret.), Deputy Director, Government Relations,
Military Officers Association of America
EXECUTIVE SUMMARY
The Military Officers Association of America (MOAA) was extremely
troubled by the findings in the Government Accountability Office's
(GAO) report, GAO-11-250, issued March 2011, titled, ``DoD and VA
Health Care; Federal Recovery Coordination Program Continues to Expand
but Faces Significant Challenges,'' and even more disappointed by the
testimony presented to this Subcommittee at the May 13, 2011 hearing on
the Federal Recovery Coordination Program (FRCP).
Further, MOAA found the September 12, 2011 letter signed by the
Deputy Secretary of VA and DoD to the Subcommittee's May 26 letter
requesting their plan for implementing GAO's recommendations and
analysis of how the FRCP and DoD's Recovery Coordination Program (RCP)
could be integrated indicates to us more of a `business as usual'
approach rather than a roadmap of specifics that show the Departments'
sense of urgency in addressing these issues in the immediate future.
MOAA's assessment of the current state of the FRCP supports GAO's
findings and centers around three key areas.
Many of the issues identified in the GAO report are similar to
those in the Defense Department's RCP. We believe strongly the FRCP and
RCP are victims of much larger systemic problems in wounded warrior
care across the Departments of Defense (DoD) and Veterans Affairs (VA).
These systemic issues inhibit uniformity and consistency of operations
to achieve a state of seamless transition, and include:
Lack of systematic compliance, accountability, and
oversight;
Limitations on information sharing, accuracy of
information, and communications; and,
Multiple segregated policies, programs, and services that
are duplicative, inefficient, ineffective, and add to the already
confusing bureaucratic morass.
Recommendations:
MOAA fully concurs with the four recommendations outlined in the
GAO's report.
Additionally, we offer the following recommendations to improve the
FRCP and address the larger systemic issues that exist in delivering
care coordination between and within the DoD and VA:
Revise and expand Sec. 1611 of Public Law 110-181 to
mandate a single, joint VA-DoD program, establishing an office for
managing, coordinating and assisting severely wounded, ill, and injured
servicemembers, veterans and their families through recovery,
rehabilitation, and reintegration. Direct DoD to adopt and fully
integrate VA's FRCP policy and procedures outlined in VA Handbook 0802,
March 23, 2011.
Future hearings related to wounded warrior care
coordination should be joint hearings before both the Veterans Affairs
and Armed Services Committees.
An outside entity should be commissioned to evaluate the
FRCP and RCP, assess how the programs function and operate within the
context of the 10 major VA and DoD wounded warrior programs, and
collect feedback from recovering warriors and family members on how to
provide simpler ways for wounded warriors and their families to access
care and services during transition.
Require VA and DoD medical and benefit systems to expand
outreach and communication efforts to help increase awareness of all
wounded warrior programs.
Conduct periodic needs assessment surveys to gather
information from wounded warriors and their families on ways to improve
programs and identify unmet needs.
MADAM CHAIRMAN AND DISTINGUISHED MEMBERS OF THE SUBCOMMITTEE, on
behalf of the 370,000 members of the Military Officers Association of
America (MOAA), I am grateful for the opportunity to present testimony
on MOAA's observations concerning the Federal Recovery Coordinator
Program (FRCP).
MOAA does not receive any grants or contracts from the Federal
Government.
MOAA thanks the Subcommittee for its commitment to enhancing the
Department of Veterans Affairs (VA) care and support to our Nation's
wounded, ill and injured and their families so they experience no loss
of continuity in care, and their transition is as seamless as possible.
Our Association also commends the Subcommittee for its leadership,
persistent oversight and sense of urgency on the critical topic of care
coordination for the heroes and the families these programs are
intended to support.
FRCP and RCP Issues
While the focus of this hearing is on the FRCP, it is not possible
to have a discussion on the program without including the DoD Recovery
Coordination Program (RCP) since the two programs are interrelated and
are seen as fulfilling the same roles and responsibilities in their
respective agencies.
To better understand the two programs, it is helpful to look back
at the timelines and purposes for establishing them.
The Senior Oversight Committee (SOC) implemented the FRCP
through two Memorandums of Understanding (MOU) between the VA and DoD.
The first MOU was signed by the Secretary of Veterans
Affairs and the Secretary of Defense on August 31, 2007,
requiring the establishment of the FRCP.
On October 31, 2007, the VA released a statement
announcing the agency and DoD had signed an agreement (October
30), establishing the FRCP to help ``ensure medical services
and other benefits are provided to seriously wounded, injured
and ill active duty servicemembers and veterans.''
The program supported one of the recommendations of the President's
Commission on Care for America's Returning Wounded Warriors, better
known as the Dole-Shalala Commission.
The MOU further ``defined the FRCP, designated the Federal Recovery
Coordinators (FRCs) as the `ultimate resource' for monitoring the
implementation of services for wounded, ill and injured servicemembers
and veterans enrolled in the FRCP. VA would provide the coordinators in
collaboration with DoD, to coordinate services at military treatment
facilities, services between the two Departments, private-sector
facilities.''
On January 28, 2008, the President signed into law the
National Defense Authorization Act for Fiscal Year 2008 (P.L. 110-181),
directing VA and DoD to jointly develop and implement a comprehensive
policy on improvements to care, management, and transition of
recovering servicemembers not later than July 1, 2008.
As part of this joint policy, recovery care coordinators were to
be assigned to recovering servicemembers. Their duties were to include
``overseeing and assisting the servicemember's course through the
entire spectrum of care, management, transition, and rehabilitation
services available from the Federal Government, including assistance
and services provided by the DoD, VA, Department of Labor, and the
Social Security Administration.''
On December 1, 2009, DoD Instruction 1300.24 established
the RCP. The instruction assigns Commanders of Military Departments'
Wounded Warrior Programs overall responsibility for the management of
their individual RCPs. Further, the instruction requires recovering
servicemembers to be referred to the appropriate RCP, either the DoD
RCP or the FRC.
On March 23, 2010, VA Handbook 0802 established
procedures for the FRCP--a combined initiative of VA and DoD to assist
severely wounded, ill and injured post-9/11 servicemembers, veterans
and their families through recovery, rehabilitation, and reintegration
into their home community.
In the handbook, VA defines the RCC as ``an individual assigned by
the military services to recovering servicemembers whose period of
recovery is anticipated to exceed 180 days, but who are likely to
return to active duty. RCCs' duties include assisting servicemembers as
they process through the DoD system of benefits and care.''
The fact that the FRCP was the first care coordination program
jointly created and implemented by the two agencies and was to be the
`ultimate resource for wounded warriors and their families with
questions or concerns about VA, DoD or other Federal benefits' would
lead one to believe that the program would be institutionalized and
should serve as a model for other VA-DoD collaboration.
While both VA and DoD care coordination programs boast of being
joint, the reality is both are managed and operated in the opposite
manner, separate and distinct from each other as was clearly stated by
VA and DoD FRC and RCP officials at the May 13 hearing. During the
hearing:
The VA official concurred with the GAO recommendations,
mentioning that many in DoD/Service wounded warrior programs refer to
the FRCP as a VA program and think the FRCP should only care for
wounded warriors when they become or are about to become veterans.
The DoD official talked about the RCP being directed by
Congress and that FRCs and RCCs serve similar purposes, but cover
different categories of wounded warriors--RCCs are assigned, day one.
The official pointed to the RCP instruction that indentifies when the
FRCs come into the DoD process to provide more comprehensive care.
While DoD told the Subcommittee they were willing to bring the FRCs
earlier into the process, the Department was quite clear that they
``wanted control over their people,'' and so did the military services.
The latter statement sums up the problem quite succinctly. Rather
than fulfill the objective of jointness and seamlessness, the various
bureaucracies too often end up putting their organizational interests
ahead of those of wounded members and families.
A recent letter signed by the Deputy of Secretary of VA and DoD on
September 12, corroborates our view that the two agencies continue to
operate as separate programs, struggling to implement the joint program
they committed to over 4 years ago when the agency's leadership signed
the first MOU establishing the FRCP program in October of 2007.
Comments such as:
``In order to ensure the capabilities are in place to
address these (GAO) recommendations, we are in the process of
evaluating the care coordination resources and capabilities of VA and
DoD so that the necessary personnel are available with the appropriate
skill levels to support the wounded, ill and injured population.
The Departments recognize that the FRCP and RCP are
complementary, not redundant programs.
While we concur in principle that the establishment of a
single recovery coordination program may be the preferred course of
action to provide fully integrated care and coordination services for
the wounded, ill and injured servicemembers, veterans and their
families, we are still in the process of working out the details for
the Senior Oversight Committee.''
Clearly, the two Departments have not been able to fix these policy
and programmatic gaps on their own these last 4 years--and, unlikely to
do so in the immediate future without some sort of immediate outside
intervention and oversight. Wounded warriors and their families are
struggling and need help now--the last thing they want to hear
policymakers say is that `we are working on the problem and we will
have a plan in place soon.'
So today, wounded, ill and injured servicemembers, disabled
veterans and their families are once again faced with trying to
understand the complexities, nuances, and navigate two more separate
programs in the VA and DoD systems, including unique and fragmented
service care coordination programs in each of the Military Departments.
Simply put, the programs that were built to be joint and help them
navigate the complicated processes have themselves become parochial and
part of the navigation problem.
The current FRCP and RCP policies are opaque, confusing and
incongruent with the intent of Congress. The VA and DoD were supposed
to jointly develop and implement a comprehensive policy on improvements
to care, management, and transition of recovering servicemembers, but
have in fact developed separate and independent programs.
While the FRCP was operational January 2008, program procedures
weren't published until this year, March 2011. Additionally, DoD did
not publish its RCP policy until December 2008, well past the July 1,
2008 congressional deadline.
The Department of Defense Recovering Warrior Task Force, 2010-2011
Annual Report, published September 2, 2011, highlights a significant
number of program deficiencies, recommending the need to ``standardize
and clearly define the roles and responsibilities of the RCC, FRC, non-
medical care manager, VA Liaison for Health care, and VA Polytrauma
Case Managers serving a recovering warrior and his or her family.
Standardize the criteria for who is eligible to be assigned to a RCC
(or Army Wounded Warrior (AW2) Advocate) and FRC.''
While both the FRCP and RCP programs have deficiencies, MOAA hears
far less complaints and far more compliments for the FRCP. VA's policy
and procedures also tend to be more comprehensive and easier to
understand than DoD's RCP regulations.
MOAA urges the Subcommittee to revise and expand Sec. 1611 of Public
Law 110-181 to mandate a single, joint VA-DoD program and establish an
office for managing, coordinating and assisting severely wounded, ill,
and injured servicemembers, veterans and their families through
recovery, rehabilitation, and reintegration. DoD should be directed to
adopt and fully integrate VA's FRCP policy and procedures outlined in
VA Handbook 0802, March 23, 2011.
Systemic Issues
Many of the broad departmental issues plaguing both VA and DoD
systems are also impacting and limiting the FRCP, the RCP and likely
the 10 other major wounded warrior programs cited by GAO at the May
hearing. The persistent problems with information sharing, and the
long-standing issues of inadequate collaboration between the agencies
are well documented and alive and well today. These issues continue to
impede progress and prevent VA and DoD from effectively and efficiently
serving our most vulnerable servicemembers and disabled veterans who
critically need these support services.
MOAA believes strongly that the key systemic issues which inhibit
uniformity and consistency of operations to achieve a state of seamless
transition include:
Lack of systematic compliance, accountability, and
oversight;
Limitations on information sharing, accuracy of
information, and communications; and,
Multiple segregated policies, programs, and services that
are duplicative, inefficient, ineffective, and add to the already
confusing bureaucratic morass.
The DoD Recovering Warrior Task Force highlighted similar themes in
its report (Department of Defense Recovering Warrior Task Force, 2010-
2011 Annual Report):
``Disparities exist across recovering warrior (RWs) programs and
policies in the Headquarters or Department vision and in the way in
which those programs and policies are implemented in the field and
experienced by RWs and their families. Clear, consistent, and accurate
information does not reliably reach RWs about the programs and policies
intended to support them. Also, parity of care across the services has
not been achieved. From language used to services offered, eligibility
criteria, and staffing requirements, the services implement policies
and programs differently. There also are significant differences in the
experiences of Active Component (AC) RWs, Reserve Component (RC) RWs
healing at Active Duty installations, and RC RWs receiving community-
based care.''
While much has improved in the last 2 years as the FRCP expanded to
meet workload and improve seamless transition between the two programs,
MOAA is very concerned that VA and DoD systems still struggle with
basic terminology, policy, management, and technological system
differences after more than a decade of war.
The impact of these system failures can have a profound impact on
the medical outcomes and the quality of life our wounded warriors and
their families will experience. The impact and experiences of these
individuals today continue to be all over the map, regardless of the
time frame of the injuries.
One caregiver whose loved one was injured early in 2010
told the Senate Veterans Affairs Committee of the difficulties in
transitioning out of the military at a hearing this past July, ``. . .
Coordination of care for her wounded warrior has also been a problem.
There seem to be so many coordinators that they are actually not all on
the same page and sometimes doing things opposite of each other. Though
she was trying to help, I rarely got to see our FRC, who seemed to have
too many people she was responsible for. The lack of communication also
extended to benefits and programs . . . ,'' she said.
To another caregiver, the mother of her severely disabled
son, ``Our FRC is affectionately called our `Wonderful FRC!' It is as
simple as that, yet, what she has done, and continues to do for our
family is nothing short of miraculous and a Godsend. She has taken care
of every aspect of my son's care back to 2008 when he was critically
injured. Not only has the FRC provided excellent care and has been my
son's number one advocate, she has been supportive and an inspiration
to me as my son's primary caregiver--and I know she must be the same to
the dozen or more wounded warriors families she also cares for each and
every day.''
Another wounded warrior couple whose servicemember was
injured in 2009 and was first introduced to their RCC at the time of
their medical board, was provided no information about the FRCP. This
spouse told us, ``We completely trust our RCC, though things were a
little rocky at first--now he has our full trust! Financially, the
transition has been difficult. Her wounded warrior is on the Temporary
Duty Retirement List (TDRL) . . . The military has taken months to
reevaluate her husband's condition, and the family no longer has the
financial resources while on active duty. The TDRL process and
navigating the medical and benefits systems has been a battle from the
beginning of his injury--no one has been there to explain the
process.''
Wounded, ill and injured servicemembers, disabled veterans and
families deserve the very best care and support from systems that are
simple, transparent and accessible. They don't want more policies or
programs to further bog down the progress--they just want the systems
to do their job--and to fulfill the obligations, promises and
commitments made to them.
MOAA urges Congress to provide the necessary leadership in:
Ensuring that future hearings related to wounded warrior
care coordination are joint hearings that include both the Veterans
Affairs and Armed Services Committees.
Commissioning an outside entity to evaluate the FRCP and
RCP, to include how the programs operate within the context of the 10
major VA and DoD wounded warrior programs and collection of feedback
from recovering warriors and family members on how to develop simpler
ways for wounded warriors and their families to access services and
support during transition.
Requiring VA and DoD medical and benefit systems to
expand outreach and communication efforts to help increase awareness of
all wounded warrior programs.
Conducting periodic needs assessment surveys to gather
information from wounded warriors and their families to improve
programs and identify unmet needs.
Conclusion
MOAA is grateful to the Subcommittee for your leadership in
supporting our wounded, ill and injured servicemembers, disabled
veterans and their families who have ``borne the battle'' in defense of
the Nation.
Prepared Statement of Hon. Russ Carnahan, a
Representative in Congress from the State of Missouri
Chairwoman Buerkle, Ranking Member Michaud, and Members of the
Subcommittee, thank you for hosting this hearing to discuss expansion
and revision of the Federal Recovery Coordination Program (FRCP).
Providing support to those who were injured or became ill in service to
our country is of paramount importance. Today's hearing facilitates a
conversation between Congress and those with knowledge of what needs to
be done to ensure our Nation's heroes receive the most expedient and
effective assistance in their time of need.
In 2007, following reports of poor outpatient care from Walter Reed
Medical Center, the Department of Defense (DoD) and the Veteran's
Administration (VA) jointly created FRCP to coordinate clinical and
nonclinical services for recovery, rehabilitation and reintegration of
wounded, ill or severely injured servicemembers and Veterans. While the
program continues to expand, practices must be reviewed to ensure that
our servicemembers and Veterans across the country uniformly receive
the best care possible.
A recent Government Accountability Office (GAO) report found
concern with the client referral system employed by FRCP. Eligible
patients are not being identified in existing DoD and VA databases
because records are currently not coded to classify veterans and
servicemembers as ``severely wounded, ill, and injured.'' The program
relies solely on referrals to identify qualified individuals. Also,
FRCP is understaffed and there is no current system to place new hires
and delegate caseload. Additionally, FRCP has been confronted with
problems in communicating patient information from DoD and VA
facilities to supporting organizations.
I look forward to hearing from our witnesses on ways we can
overcome challenges facing the Federal Recovery Coordination Program
and expand services to ensure comprehensive care for our Nation's
heroes.
MATERIAL SUBMITTED FOR THE RECORD
U.S. Department of Defense
INSTRUCTION
NUMBER 1300.24
December 1, 2009
USD(P&R)
SUBJECT: Recovery Coordination Program (RCP)
References: See Enclosure 1
1. PURPOSE. In accordance with the authority in DoD Directive
(DoDD) 5124.02 (Reference (a)) and the guidance in sections 1611, 1614,
and 1648 of Public Law 110-181 (Reference (b)), this Instruction:
a. Establishes policy, assigns responsibilities, and
prescribes uniform guidelines, procedures, and standards for
improvements to the care, management, and transition of
recovering servicemembers (RSMs) across the Military
Departments.
b. Establishes the RCP evaluation process to provide for a
coordinated review of the policies, procedures, and issues of
the program.
c. Incorporates and cancels Under Secretary of Defense for
Personnel and Readiness (USD(P&R)) Directive-type Memorandum
08-049 (Reference (c)).
2. APPLICABILITY. This Instruction applies to:
a. OSD, the Military Departments (including the Coast Guard at
all times, including when it is a Service in the Department of
Homeland Security by agreement with that Department), the
Office of the Chairman of the Joint Chiefs of Staff and the
Joint Staff, the Combatant Commands, the Office of the
Inspector General of the Department of Defense, the Defense
Agencies, the DoD Field Activities, and all other
organizational entities within the Department of Defense.
b. The Joint Task Force National Capital Region Medical
(JTFCapMed).
c. RSMs as defined in the Glossary, regardless of component or
duty status.
d. Eligible family members of RSMs as defined in the Glossary.
3. DEFINITIONS. See Glossary.
4. POLICY. It is DoD policy that:
a. The RCP shall be established to provide program and policy
oversight of DoD resources necessary to ensure uniform care and
support for RSMs and their families when the RSM has been
wounded or injured or has an illness that prevents him or her
from providing that support. Implementation of uniform
guidelines, procedures, and standards for the care, management,
and transition of RSMs shall ensure consistent, high quality
medical and non-medical care for RSMs and their families.
b. DoD programs established for the benefit of RSMs and their
families shall comply with DoD RCP policies and support the
needs of the RSM.
c. All RSMs shall be eligible to receive uniform standard
support, resources, and access to programs, whether members of
the Army, Navy, Air Force, Marine Corps, or Coast Guard.
5. RESPONSIBILITIES. See Enclosure 2.
6. PROCEDURES. Enclosures 3 through 7 provide overarching
procedures and requirements for the administration, implementation, and
management of the RCP.
7. INFORMATION REQUIREMENTS
a. The collection, use, and dissemination of personally
identifiable formation (PII) shall be administered in
compliance with DoDD 5400.11 (Reference (d)) and DoDD 5411.11-R
Reference (e)).
b. Collection of PII from immediate family members and non-
dependent family members must be preceded by provision of an
appropriate privacy act statement as required by Reference (e).
8. RELEASABILITY. UNLIMITED. This Instruction is approved for
public release and is available on the Internet from the DoD Issuances
Web Site at http://www.dtic.mil/whs/directives.
9. EFFECTIVE DATE. This Instruction is effective immediately.
Gail H. McGinn
Deputy Under Secretary of Defense (Plans)
Performing the Duties of the Under Secretary of
Defense for Personnel and Readiness
Enclosures
1. 1. References
2. 2. Responsibilities
3. 3. Program Management
4. 4. Recovery Coordination Process
5. 5. Transition Procedures
6. 6. Workload and Supervision Procedures
7. 7. RCP Evaluation Procedures
Glossary
__________
TABLE OF CONTENTS
REFERENCES
RESPONSIBILITIES
USD(P&R)
ASD(HA)
SECRETARIES OF MILITARY DEPARTMENTS
PROGRAM MANAGEMENT
SURGEONS GENERAL OF THE MILITARY DEPARTMENTS
COMMANDER, JTFCAPMED
COMMANDERS, WOUNDED WARRIOR PROGRAMS
RTs
Composition
Overarching Roles and Responsibilities
RCC Responsibilities
MCCM Responsibilities
NMCM Responsibilities
RECOVERY COORDINATION PROCESS
SERVICEMEMBER SCREENING
CATEGORY ASSIGNMENT
DESIGNATED CAREGIVERS
CRP
FAMILY SUPPORT
Response to Family Needs
Medical Support for Non-Dependent Family Members
Advice and Training Services
Financial Assistance and Job Placement Services
TRANSITION PROCEDURES
TRANSITION FROM DoD CARE AND TREATMENT TO VA CARE, TREATMENT, AND
REHABILITATION
TRANSITION FROM DoD CARE AND TREATMENT TO CIVILIAN CARE, TREATMENT,
AND REHABILITATION
RETURN TO DUTY
MEDICAL SEPARATION OR RETIREMENT
TRANSITION SUPPORT
Transition From DoD Care
Separation or Retirement
7WORKLOAD AND SUPERVISION PROCEDURES
WORKLOAD
RCCs and NMCMs
MCCMs
SUPERVISION
RCP EVALUATION PROCEDURES
STAFF ASSISTANCE VISITS
EVALUATION PROGRAM
GLOSSARY
ABBREVIATIONS AND ACRONYMS
DEFINITIONS
TABLE
Servicemember Care Coordination Categories
__________
ENCLOSURE 1
REFERENCES
a. DoD Directive 5124.02, ``Under Secretary of Defense for
Personnel and Readiness (USD(P&R)),'' June 23, 2008
b. Sections 1611, 1614, and 1648 of Public Law 110-181, ``The
National Defense Authorization Act for Fiscal Year 2008,'' January 28,
2008
c. Directive-Type Memorandum (DTM) 08-049, ``Recovery Coordination
Program: Improvements to the Care, Management, and Transition of
Recovering Servicemembers (RSMs),'' January 19, 2009 (hereby canceled)
d. DoD Directive 5400.11, ``DoD Privacy Program,'' May 8, 2007
e. DoD Regulation 5400.11-R, ``DoD Privacy Program,'' May 14, 2007
f. DoD Centers of Excellence for Psychological Health and
Traumatic Brain Injury, ``Suicide Assessment Five Step Evaluation and
Triage (SAFE-T),'' 2007
g. Assistant Secretary of Defense for Health Affairs Memorandum,
``TRICARE Policy for Access to Care and Prime Service Area Standards,''
February 21, 2006
h. Parts A and B of Volume I of the Joint Federal Travel
Regulations, current edition
i. Secretary of Defense Memorandum, ``DoD Housing Inspection
Standards for Medical Hold and Holdover Personnel,'' September 18, 2007
j. TRICARE Management Activity, ``Medical Management Guide,''
January 2006
k. Public Law 104-191, ``Health Insurance Portability and
Accountability Act of 1996,'' August 21, 1996
l. Chapter 61 and section 1145 of title 10, United States Code
m. DoD Directive 1332.18, ``Separation or Retirement for Physical
Disability,'' November 4, 1996
n. DoD Directive 1332.35, ``Transition Assistance for Military
Personnel,'' December 9, 1993
o. DoD Instruction 1100.13, ``Surveys of DoD Personnel,'' November
21, 1996
p. Chapter 77 of title 38, United States Code
__________
ENCLOSURE 2
RESPONSIBILITIES
1. USD(P&R). The USD(P&R) shall be responsible for RCP policy and
program oversight and shall:
a. Execute RCP policy and program oversight through the
USD(P&R) Office of Wounded Warrior Care and Transition Policy
(WWCTP). The WWCTP shall:
1. Administer the RCP and provide oversight of its
implementation and guidance for continuous process improvement
pursuant to Reference (a).
2. Coordinate with the Assistant Secretary of Defense for
Health Affairs (ASD(HA)) regarding programs that support RSMs
and their families when preparing RCP policy.
b. Oversee all RSM support programs throughout the Department
of Defense and adjust RCP policy and procedures as necessary.
c. Oversee the development of core training conducted by the
WWCTP for the Military Department recovery care coordinators
(RCC).
d. Oversee Military Department development ofpolicies and
procedures that are uniform and standardized across the
Military Departments to provide services and resources for RSMs
and their families.
e. Coordinate with the VA to develop and implement
administrative processes, procedures, and standards for
transitioning RSMs from DoD care and treatment to VA care,
treatment, and rehabilitation that are consistent with
Enclosure 5 of this Instruction.
2. ASD(HA). The ASD(HA), under the authority, direction, and
control of the USD(P&R), shall:
a. Provide RSMs with timely access to inpatient and outpatient
medical and behavioral health services through DoD facilities,
purchased care, or in coordination with the VA.
b. Ensure that policies and procedures for RSM medical care
case managers (MCCMs) are developed, implemented, and
consistent across the Military Departments.
c. Establish uniform professional qualifications, including
education and training, for MCCMs identified to become members
of the RSM recovery team (RT).
d. Ensure that MCCM workload is delineated based on the
medical constraints and requirements of the RSMs served.
e. Develop medically appropriate training for RCCs, MCCMs, and
non-medical care managers (NMCMs) that addresses detection,
notification, and tracking of early warning signs of post-
traumatic stress disorder, suicidal or homicidal thoughts or
behaviors, and other behavioral heath concerns among RSMs.
Ensure such training includes procedures for the appropriate
specialty consultation and referral following detection of such
signs in accordance with DoD Centers of Excellence for
Psychological Health and Traumatic Brain Injury publication
(Reference (f)) for initiating behavioral health early warning
sign notification and tracking procedures.
f. Coordinate with the VA to develop and implement medically
related processes, procedures, and standards for transitioning
RSMs from DoD care and treatment to VA care, treatment, and
rehabilitation that address:
1. RSM transition without gaps in medical care or the
quality of medical care, benefits, and services to the maximum
extent feasible.
2. RSM enrollment in the VA health care system.
3. Assignment of DoD and VA case management personnel in
military treatment facilities (MTFs) VA medical centers, and
other medical facilities caring for RSMs.
4. Integration of DoD and VA medical care and management of
RSMs during transition, to include the accommodation of VA
medical personnel in DoD facilities as required to participate
in the needs assessments of RSMs.
5. VA access to the health records of RSMs receiving or
anticipating receipt of care and treatment in VA facilities.
6. Utilization of a joint separation and evaluation physical
examination that meets the DoD and VA requirements for
disability evaluation of RSMs.
7. Measurement of RSM and family satisfaction with the
quality of health care for RSMs provided by the Department of
Defense to facilitate appropriate oversight of such care and
services by leadership. (This measurement is separate from that
conducted by the WWCTP in the annual RCP evaluation described
in Enclosure 7 of this Instruction.) Measured results shall be
reported to the WWCTP.
3. SECRETARIES OF THE MILITARY DEPARTMENTS. The Secretaries of the
Military Departments shall:
a. Ensure RSM care, management, and transition policies are
uniform and standardized.
b. Establish uniform procedures for tracking RSMs that
facilitate:
1. Locating RSMs.
2. Tracking RSM attendance at medical care, physical exam,
and evaluation appointments and scheduling additional
appointments as needed.
3. Tracking RSM progress through medical and physical
evaluation boards (PEBs).
c. Ensure their RCPs are extended to include RSMs in their
Reserve Components (RC) and inc2rporate all program services,
to include identifying RSMs, assigning RSMs to RCCs, and
preparing recovery plans.
d. Establish and appropriately resource their Military
Department RCP elements, wounded warrior programs, and family
support programs.
e. Ensure that wounded warrior and family support programs
execute the policies of this Instruction.
f. Exercise the authority to:
1. Grant waivers to the maximum number of RSM cases assigned
to RCCs and NMCMs as described in subparagraph 1.a.(2) of
Enclosure 6.
2. Grant RSM requests to continue on duty after being found
unfit for duty as described in paragraph 3.b. of Enclosure 5.
g. Ensure the Surgeons General comply with the requirements of
section 1 of Enclosure 3.
h. Authorize access to basic outpatient and inpatient medical
and behavioral health services through DoD facilities for
members of families who are providing support to RSMs and who
are not otherwise eligible for care as dependents (e.g.,
parents, siblings) and are providing support to RSMs.
__________
ENCLOSURE 3
PROGRAM MANAGEMENT
1. SURGEONS GENERAL OF THE MILITARY DEPARTMENTS. The Surgeons
General of the Military Departments shall:
a. Establish policies and procedures to ensure compliance with
this Instruction within their respective components and MTFs.
b. Provide appropriately trained medical personnel in
accordance with Reference (a) to support RSM care management
throughout the continuum of care.
c. Ensure that installation medical directors provide
oversight of the medical care delivered to RSMs.
d. Ensure that MTF commanders facilitate access to family
support services within MTFs, and between MTFs and local family
service entities (e.g., childcare).
e. Ensure that RSMs have the highest priority for appointments
to non-urgent and other health care services in DoD MTFs and
for any purchased care medical services. Ensure RSMs receive
referrals to other DoD, VA, or purchased care providers if
appointments are not available within the MTF that meet TRICARE
access standards in accordance with ASD(HA) Memorandum
(Reference (g)).
2. COMMANDER, JTFCAPMED. The Commander, JTFCapMed, shall ensure
compliance with this Instruction within the JTFCapMed area of
responsibility.
3. COMMANDERS, WOUNDED WARRIOR PROGRAMS. Commanders shall:
a. Have overall responsibility for the management of their
Military Department RCP, and shall maintain operational,
tactical, and administrative control of their RCP and non-
medical personnel to ensure they execute the roles and
responsibilities in this Instruction.
b. Ensure that RSMs are referred to the appropriate RCP,
either the DoD RCP or the Federal Recovery Coordination Program
(FRCP), established by the Department of Defense and/or the VA.
c. Provide appropriately trained RCCs, NMCMs, and other non-
medical members of the RT, in accordance with Reference (b), to
support RSM care management throughout the continuum of care.
d. Conduct Military Department-specific training for their
RCCs, MCCMs, and NMCMs, provide a certificate of completion to
those who have attended the training, and forward a roster of
attendees' names to the WWCTP training office.
e. Establish work and duty assignments for RSMs, with the
recommendation of appropriate medical and non-medical
authorities, that support recovery, rehabilitation, and
reintegration, and that may include training and education
tailored to the abilities of RSMs.
f. Assist RSMs in obtaining needed medical care and services
by providing transportation and subsistence in accordance with
parts A and B of Volume 1 of the Joint Federal Travel
Regulations (Reference (h)).
g. Ensure RSMs have access to educational and vocational
training and rehabilitation opportunities at the earliest
possible point in their recovery.
4. RTs
a. Composition. All RTs shall include the RSM's Commander,
RSM; an RCC or a Federal recovery coordinator (FRC); an MCCM;
and an NMCM. They may also include medical professionals such
as primary care managers, mental health providers, physical and
occupational therapists, and others such as PEB liaison
officers, VA military services coordinators, chaplains, and
family support program representatives.
b. Overarching Roles and Responsibilities. RT members shall:
1. Complete Military Department-specific training prior to
independently assuming the duties of their positions, and comply with
continuing education requirements.
2. Collaborate with the RCC and other RT members to develop the
comprehensive recovery plan (CRP), evaluate its effectiveness in
meeting the RSM's goals, and readjust it as necessary to accommodate
the RSM's changing objectives, abilities, and recovery status.
3. Determine the RSM's location of care based primarily on the
RSM's medical care needs, with consideration given to the desires of
the RSM and family and/or designated caregiver. Provide the RSM and
family or designated caregiver options for care locations during
development of the CRP that address:
a. The RSM's medical care and non-medical support needs.
b. Capabilities required for the RSM's care.
c. The availability of DoD, VA, or civilian facilities with
appropriate capabilities and accreditation or licensure.
4. Determine the appropriate course of action for the RSM when he
or she is located at an MTF, specialty medical care facility, military
quarters, or leased housing that is found to be deficient in accordance
with Secretary of Defense Memorandum (Reference (i)); this course of
action may be temporary or permanent based on the deficiency and the
RSM's needs.
5. Reevaluate the needs of the RSM in accordance with the options
for care locations if relocation is required.
6. Facilitate the most expeditious appointment available for the
RSM for non-urgent care to include appointments for follow-up and/or
specialty care, diagnostic referral and studies, and surgery.
7. Allow the RSM to waive the TRICARE standards for access to care
detailed in the TRICARE Management Activity guide (Reference (j)) when
either of these circumstances occur:
a. No appointment is available that meets access standards
within DoD MTFs or the TRICARE program.
b. Travel is required beyond the TRICARE catchment area, and
the health care provider has determined that travel will not
adversely affect the health of the RSM.
8. Document in writing, and maintain in the RSM's records, any
situation in which the RSM waives a standard for access to care.
c. RCC Responsibilities. The RCC shall:
1. Complete uniform core training conducted by WWCTP, and
Military Department-specific training conducted by the
cognizant wounded warrior program prior to assuming the duties
of their positions.
2. Have primary responsibility for development of the CRP, in
conjunction with the RT, and assist the commander in overseeing
and coordinating the services and resources identified in the
CRP.
3. Ensure, in coordination with the Secretary of the Military
Department concerned, that the RSM and family and/or designated
caregiver have access to all medical and non-medical services
throughout the continuum of care.
4. Minimize delays and gaps in treatment and services.
5. Provide a hard copy of the CRP to the RSM and family and/or
designated caregiver upon completion and whenever changes are
made to the document. Review and update the CRP in person (when
possible) with the RSM and family or designated caregiver as
frequently as necessary based on the RSM's needs and during
transition phases in the RSM's care (change in location or
familial, marital, financial, job, medical, or retirement
status).
6. Facilitate and monitor the execution of services for the
RSM across the continuum of care as documented in the recovery
plan, to include services available from the Department of
Defense, the VA, the Department of Labor, and the Social
Security Administration.
7. Coordinate the transfer of an updated CRP to, and directly
communicate with, appropriate medical and non-medical personnel
should the RSM be moved to a different location for care.
8. Close out the CRP when the RSM has met all goals or
declines further support and retain all documents according to
applicable Military Department policies.
d. MCCM Responsibilities. MCCMs shall:
1. Ensure the RSM understands his or her medical conditions
and treatments and receives appropriate coordinated health
care.
2. Assist the RSM and family or designated caregiver in
understanding the RSM's medical status during care, recovery,
and transition.
3. Assist the RSM in receiving well-coordinated prescribed
medical care during all phases of the continuum of care.
4. Conduct periodic reviews of the RSM's medical status. When
possible, reviews shall be conducted in person with the RSM and
family or designated caregiver.
e. NMCM Responsibilities. The NMCM shall:
1. Work within established service program procedures to
ensure the RSM and family or designated caregiver gets needed
non-medical support such as assistance with resolving
financial, administrative, personnel, and logistical problems.
2. Provide feedback on the effectiveness of the CRP in meeting
the RSM's personal goals.
3. Communicate with the RSM and family or designated caregiver
regarding non-medical matters that arise during care,
management, and transition; assist the RSM in resolving non-
medical issues.
4. Assist the RSM with finding the resources to maintain or
improve his or her welfare and quality of life.
__________
ENCLOSURE 4
RECOVERY COORDINATION PROCESS
1. SERVICEMEMBER SCREENING
a. In accordance with standard medical practice,
servicemembers shall be screened for medical and psychosocial
needs upon initial presentation to a medical care provider. For
servicemembers who are unlikely to return to duty within a
specific period of time determined by their Military
Departments wounded warrior program, care and support needs
will be assessed by their wounded warrior programs using
standardized tools for RCP category assignment and enrollment.
b. Servicemembers may self-refer to the RCP or be referred by
their command, medical care provider, Military Department
wounded warrior program, or the Wounded Warrior Resource
Center.
2. CATEGORY ASSIGNMENT
a. The Military Departments shall use the care coordination
categories shown in the table or a similar process standardized
within their wounded warrior program to determine an initial
care coordination category.
Table.
Servicemember Care Coordination Categories
------------------------------------------------------------------------
------------------------------------------------------------------------
Category 1 (CAT 1) Has a mild injury
or illness
Is expected to
return to duty within a
time specified by his or
her Military Department
Receives short-term
inpatient medical treatment
or outpatient medical
treatment and/or
rehabilitation
------------------------------------------------------------------------
Category 2 (CAT 2) Has a serious
injury or illness
I unlikely to
return to duty within a
time specified by his or
her Military Department
May be medically
separated from the military
------------------------------------------------------------------------
Category 3 (CAT 3) Has a severe or
catastrophic injury or
illness
Is highly unlikely
to return to duty
Will most likely be
medically separated from
the military
------------------------------------------------------------------------
b. Servicemembers who are determined to be CAT 2 and CAT 3 or
who fall within their equivalent Military Department's wounded
warrior program's standardized care coordination categories are
RSMs.
c. A CAT 2 RSM who is enrolled in the RCP shall be assigned an
RCC and an RT. The Military Department wounded warrior program
shall assign the RCC to provide assistance for the RSM's
recovery, rehabilitation, and transition activities.
d. All CAT 3 RSMs shall be enrolled in the FRCP and shall be
assigned an FRC and an RT. The FRC will coordinate with the RCC
and RT to ensure the needs of the RSM and his or her family are
identified and addressed.
e. An RSM assigned to CAT 2, who later meets the criteria for
CAT 3, shall be placed in CAT 3 and an FRC shall be assigned.
f. An RSM assigned to CAT 3, who later meets the criteria for
CAT 2, shall be placed in CAT 2. The FRC shall remain with the
RSM until such time as the FRC and RSM and family agree that
the services of the FRC are no longer needed.
g. An RSM assigned to CAT 1, who later meets the criteria for
CAT 2 or 3, shall be placed in the appropriate category and
assigned an RCC, FRC, and an RT as required by the category.
3. DESIGNATED CAREGIVERS. RSMs who do not have or want immediate
families (spouse or children) to support them with their recovery shall
be permitted to designate another individual as a caregiver. The
caregiver may be a friend, fiancee or fiance, co-worker, member of the
family who is not a military dependent, etc. RSMs may also decide that
he or she does not want to designate a caregiver.
4. CRP
a. All RSMs enrolled in a Military Department RCP shall
receive a CRP. (RSMs assigned an FRC shall also receive a
Federal individual recovery care.) The RSM, family or
designated caregiver, and RT members will create action steps
for accomplishing plan goals that must be specific, measurable,
and achievable within an agreed upon time frame. In addition to
the action to be taken, action steps shall contain these data
elements:
1. An identified point of contact for each step.
2. A list of the support and resources available to the RSM
and family or designated caregiver for each action, including
the location of the support and resources.
a. The RSM and family or designated caregiver, and the RCC
shall review the CRP and sign the document, demonstrating their
understanding of the plan and commitment to its implementation.
b. The Military Departments may customize the CRP based on
internal requirements, provided the criteria in paragraphs 4.a.
and 4.b. of this enclosure are met.
5. FAMILY SUPPORT
a. Response to Family Needs. The NMCM shall:
1. Identify any immediate family needs upon first
interaction with the family. Needs may include lodging,
transportation, medical care, finances, or childcare.
2. Contact the appropriate family support programs to obtain
services and resources that respond to the identified family
needs. This initial interface with family support services and
resources is key to ensuring the RSM's family is appropriately
supported.
3. nsure key family needs are addressed in relevant goals in
the recovery plan.
2. Medical Support for Non-Dependent Family Members. The RCC
or FRC, MCCM, and NMCM, in coordination with the Secretary of
the Military Department concerned or designee, shall facilitate
non-dependent family member access to medical care at DoD MTFs.
The RCC or FRC, MCCM, and NMCM shall facilitate non-dependent
family member access to non-Federal care providers as needed
(not at Government expense). In general, medical care and
counseling may be provided at a DoD MTF on a space-available
basis when:
1. The family member is on invitational travel orders to
care for the RSM.
2. The family member is issued non-medical attendant orders
to care for the RSM.
3. The family member is receiving per diem payments from the
Department of Defense while caring for the RSM.
c. Advice and Training Services. Advice and training services
include, but are not limited to, financial counseling, spouse
employment assistance, respite care information, and childcare
assistance. When the family has arrived at the treatment
facility, the NMCM, RCC, or FRC should provide information on
services and resources available through the National Resource
Directory (https://www.nationalresourcedirectory.org), the
Wounded Warrior Resource Center Call Center (1-800-342-9647)
and Web Site (http://www.woundedwarriorresourcecenter.com), and
the Wounded, Ill, and Injured Compensation and Benefits
Handbook (http://tricare.mil/mybenefit/Download/Forms/
Compensation-Benefits-Handbook.pdf).
d. Financial Assistance and Job Placement Services. The RT
shall:
1. Identify any loss of income and financial challenges
facing the RSM's family.
2. Ensure the recovery plan identifies benefits,
compensation, services (such as job placement services), and
resources from Federal, State, and local agencies and non-
profit organizations for which the RSM's family is eligible.
__________
ENCLOSURE 5
TRANSITION PROCEDURES
1. TRANSITION FROM DoD CARE AND TREATMENT TO VA CARE, TREATMENT,
AND REHABILITATION
a. Prior to transition of the RSM to the VA, the RCC (assisted
by the RT) shall ensure that all appropriate care coordination
activities, both medical and non-medical, have been completed,
including:
1. Notification to the appropriate VA point of contact (such
as a Transition Patient Advocate) when the RSM begins physical
disability evaluation process, as applicable.
2. Scheduling initial appointments with the Veterans Health
Administration system.
3. Transmittal of the RSM's military service record and
health record to the VA. The transmittal shall include:
a. The RSM's authorization (or that of an individual
legally recognized to make medical decisions on behalf of the
RSM) for the transmittal in accordance with Public Law 104-191
(Reference (k)). The RSM may have authorized release of his or
her medical records if he or she applied for benefits prior to
this point in the transition. If so, a copy of that
authorization shall be included with the records.
b. The RSM's address and contact information.
c. The RSM's DD Form 214, ``Certificate of Release or
Discharge from Active Duty,'' which shall be transmitted
electronically when possible, and in compliance with Reference
(d).
d. The results of any PEB.
e. A determination of the RSM's entitlement to
transitional health care, a conversion health policy, or other
health benefits through the Department of Defense, as explained
in section 1145 of title 10, United States Code (U.S.C.)
(Reference (l)).
f. A copy of requests for assistance from the VA, or of
applications made by the RSM for health care, compensation and
vocational rehabilitation, disability, education benefits, or
other benefits for which he or she may be eligible pursuant to
laws administered by the Secretary of Veterans Affairs.
4. Transmittal of the RSM's address and contact information
to the department or agency for veterans affairs of the State
in which the RSM intends to reside after retirement or
separation.
5. Update the CRP for the RSM's transition that shall
include standardized elements of care, treatment requirements,
and accountability for the plan. The CRP shall also include:
a. Detailed instructions for the transition from the DoD
disability evaluation system to the VA disability system.
b. The recommended schedule and milestones for the RSM's
transition from military service.
c. Information and guidance designed to assist the RSM in
understanding and meeting the schedule and milestones.
b. The RCC and RT shall:
1. Consider the desires of the RSM and the family or
designated caregiver when determining the location of the RSM's
care, treatment, and rehabilitation.
2. Coordinate the transfer to the VA by direct communication
between appropriate medical and non-medical staff of the losing
and gaining facilities (e.g., MCCM to accepting physician).
2. TRANSITION FROM DoD CARE AND TREATMENT TO CIVILIAN CARE,
TREATMENT, AND REHABILITATION
a. Prior to transition of the RSM to a civilian medical care
facility, the RCC (assisted by the RT) shall ensure that all
care coordination activities, both mdical and non-medical, have
been completed, including:
1. Appointment scheduling with civilian medical care
facility providers.
2. Transmittal of the RSM's health record to the civilian
medical care facility. The transmittal shall include:
a. The RSM's authorization (or that of an individual
legally recognized to make medical decisions on behalf of the
RSM) for the transmittal in accordance with Reference (i).
b. A determination of the RSM's entitlement to
transitional health care, a conversion health policy, or other
health benefits through the Department of Defense, as explained
in section 1145 of Reference (l).
b. Transmittal of the RSM's address and contact information.
c. Preparation of detailed plans for the RSM's transition, to
include standardized elements of care, treatment requirements,
and accountability of the CRP.
d. The RCC and RT shall:
1. Consider the desires of the RSM and the family or
designated caregiver when determining the location of the RSM's
care, treatment, and rehabilitation.
2. Coordinate the transfer by direct communication between
appropriate medical and non-medical staff of the losing and
gaining facilities (e.g., RCC to FRC, MCCM to accepting
physician).
3. RETURN TO DUTY
a. An RSM who is found fit for duty by a PEB shall be returned
to duty in accordance with the policies and procedures of the
Military Department concerned.
b. In accordance with DoDD 1332.18 (Reference (m)), an RSM may
request to continue on permanent limited duty status or active
duty in the Ready Reserve after being found unfit for duty. The
Secretary of the Military Department concerned may grant such
requests based on a determination that the needs of the Service
and the RSM's service obligation, special skills, experience,
or reclassification justifies the continuation. Transfer of the
RSM to another Service may also be considered.
c. Members of the RC who are not designated as RSMs, who are
released from active duty and are returned to their units, and
who are entitled to non-urgent medical care for injuries or
illnesses incurred while on active duty are required to
coordinate authorization for medical care and schedule
appointments through their units and the Military Medical
Support Office.
4. MEDICAL SEPARATION OR RETIREMENT
a. Upon medical retirement, the RSM will receive the same
benefits as other retired members of the Military Departments.
This includes eligibility for participation in TRICARE and to
apply for care through the VA.
b. An RSM who is enrolled in the RCP and subsequently placed
on the temporary disability retired list shall continue to
receive the support of an RCC, including implementation of the
recovery plan, until such time as the wounded warrior program
determines that the services and resources necessary to meet
identified needs are in place through non-DoD programs.
5. TRANSITION SUPPORT
a. Transition From DoD Care. The RT shall provide transition
support to the RSM and family or designated caregiver before,
during, and after relocation from one treatment or
rehabilitation facility to another or from one care provider to
another. Transition preparation will occur with sufficient
advance notice and information that the upcoming change in
location or caregiver is anticipated by the RSM and family or
designated caregiver, and will be documented in the CRP.
b. Separation or Retirement. Once the PEB determines that the
RSM will not return to duty:
1. The RT shall:
a. Work with the RSM and family or designated caregiver to
prepare for the transition to retirement and veteran status.
b. Ensure transition plans are written prior to the time
of separation for RSMs being retired or separated pursuant to
chapter 61 of Reference (l).
2. The RCC or FRC shall:
a. Discuss with the RSM his or her short- and long-term
personal and professional goals such as employment, education,
and vocational training, and the rehabilitation needed to meet
those goals; identify the options and transition activities in
the CRP.
b. Ensure the RSM, as appropriate, has received the mandatory
pre-separation counseling and has the opportunity to attend the
VA benefits briefing and to participate in the Disabled
Transition Assistance Program (TAP) and the Department of Labor
TAP Employment Workshop. Encourage the RSM to establish a TAP
account through the Internet at http://www.TurboTAP.org, as
outlined in DoDD 1332.35 (Reference (n)).
c. Ensure RCRSMs have the opportunity to participate in the
Benefits Delivery at Discharge Program as appropriate.
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ENCLOSURE 6
WORKLOAD AND SUPERVISION PROCEDURES
1. WORKLOAD
a. RCCs and NMCMs
1. The wounded warrior program shall assign RCCs and NMCMs a
maximum of 40 RSMs to serve. The actual number assigned will
depend on the acuity of the RSMs' medical conditions and
complexity of their non-medical needs.
2. A waiver will be required by the Secretary of the
cognizant Military Department or such individual as delegated
the authority by the Secretary if the maximum number of RSM
cases assigned to an RCC or NMCM is exceeded. Waivers shall not
exceed 120 days.
b. MCCMs. Guidance on MCCM workload shall be established by
the ASD(HA), in accordance with section 2 of Enclosure 2.
2. SUPERVISION
a. The Military Departments will provide supervision for the
RCCs and NMCMs employed by their wounded warrior programs.
1. Supervisors of RCCs and NMCMs shall be military officers
in the grade of O-5 or O-6, or civilian employees of equivalent
grade.
2. The occupational specialty of persons appointed to
supervise RCCs and NMCMs is at the discretion of the Military
Departments.
b. Supervisors of MCCMs shall be Military Department medical
officers in the grade of O-5 or O-6, or civilian employees of
equivalent rank or grade within the MCCM's chain of command.
1. The Surgeons General will oversee the MCCMs employed in
the Military Health care System.
2. The medical occupational specialty of supervisors of
MCCMs is at the discretion of the Military Department Surgeons
General.
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ENCLOSURE 7
RCP EVALUATION PROCEDURES
1. STAFF ASSISTANCE VISITS
a. The WWCTP shall conduct only staff assistance visits from
the effective date of this Instruction to 1 year after its
effective date to allow the Military Departments to implement
the RCP and fully staff the wounded warrior programs.
b. The WWCTP shall provide a planned visit schedule, subject
to change, to the Military Departments within 30 days from the
effective date of this Instruction.
2. EVALUATION PROGRAM
a. The WWCTP shall:
1. Develop and conduct an annual, formal RCP evaluation
across the Military Departments using existing DoD assessment
tools and information found in DoD Instruction 1100.13
(Reference (o)), to measure compliance with Reference (b)
requirements.
2. Conduct a baseline evaluation beginning 1 year from the
effective date of this Instruction, and from 6 months of the
date of the baseline evaluation shall initiate a recurring
program evaluation schedule.
3. Encourage the Military Departments to conduct internal
evaluations as well.
b. The RCP evaluation shall focus on the care, management, and
transition process of the RSM. The evaluation will include, at
a minimum:
1. A review of RCC roles and responsibilities.
2. A review of the maximum number of RSMs that RCCs and
NMCMs are allowed to serve.
3. An assessment of RSM, veteran, and family experiences
with the RCP.
c. The WCCTP shall use the results of the evaluation to
implement improvements to the RCP and ensure quality in the
delivery of health care services to the RSM and family. The
resulting modifications to RCP care, management, and transition
processes or procedures will be reflected in a change to or
revision to this Instruction.
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GLOSSARY
PART I. ABBREVIATIONS AND ACRONYMS
ASD(HA)-Assistant Secretary of Defense for Health Affairs
CAT-category
CRP-comprehensive recovery plan
DoDD-DoD Directive
FR-Federal recovery coordinator
FRCP-Federal Recovery Coordination Program
JTF-CapMed Joint Task Force Capital Region Medical
MCCM-medical care case manager
MTF-military treatment facility
NMCM-non-medical care manager
PEB-physical evaluation board
RC-Reserve Component
RCC-recovery care coordinator
RCP-recovery coordination program
RSM-recovering servicemember
RT--recovery team
TAP-Transition Assistance Program
U.S.C.-United States Code
USD(P&R)-Under Secretary of Defense for Personnel and Readiness
VA-Department of Veterans Affairs
WWCTP-Office of Wounded Warrior Care and Transition Policy
PART II. DEFINITIONS
These terms and their definitions are for the purpose of this
Instruction.
acuity. The level of severity or urgency of an RSM's medical
condition as related to the need for certain care or treatment.
eligible family member. An RSM's spouse, child (including
stepchildren, adopted children, and illegitimate children), parent or
person in loco parentis, or sibling on invitational travel orders or
serving as a non-medical attendee while caring for the RSM for more
than 45 days during a 1-year period.
FRC. An individual assigned by the VA to serve as the ultimate
point of contact for an RSM and family or designated caregiver to
ensure the RSM medical and non-medical needs are met.
FRCP. The program established by the Department of Defense and the
VA to provide management and oversight of the resources needed to
coordinate care and support to RSMs through recovery, rehabilitation,
and reintegration.
invitational travel orders. Military travel orders that allow an
RSM's family to travel and stay with the RSM during treatment and
recovery after suffering a wound, illness, or injury.
recovery plan. A patient-centered plan prepared by an RT, RSM, and
family or designated caregiver with medical and non-medical goals for
recovery, rehabilitation, and transition, as well as personal and
professional goals, and the identified services and resources needed to
achieve the goals.
RSM. A member of the military services who is undergoing medical
treatment, recuperation, or therapy and is in an inpatient or
outpatient status, who incurred or aggravated a serious illness or
injury in the line of duty, and who may be assigned to a temporary
disability retired or permanent disability retired list due to the
Military Department's disability evaluation system proceedings.
TAP. A program designed to ease the transition of servicemembers
from military service to the civilian workforce and community.
temporary disability retired list. A disposition finding by a PEB
for an RSM who has one or more Service unfitting conditions that were
incurred in the line of duty and that have a combined rating of 30
percent or higher, and who is considered not stable as a result.
transition. A process that may include:
Leaving military service by way of discharge, separation, or
retirement.
Release from active duty (REFRAD) for RC members.
Transfer from the military health care system to the VA health
care system.
VA. The Federal agency responsible for providing a wide range of
programs and services to servicemembers and veterans as required by
chapter 77 of title 38, U.S.C. (Reference (p)). The VA includes, among
other components, the Veterans Health Administration and the Veterans
Benefits Administration.
wounded warrior program. A system of support and advocacy to guide
and assist the RSM and family or designated caregiver through
treatment, rehabilitation, return to duty, or military retirement and
transition into the civilian community. Each Military Department has a
unique wounded warrior program that addresses its servicemembers'
needs.