This is the accessible text file for GAO report number GAO-14-676 
entitled 'Veterans Affairs: Better Understanding Needed to Enhance 
Services to Veterans Readjusting to Civilian Life' which was released 
on September 10, 2014. 

This text file was formatted by the U.S. Government Accountability 
Office (GAO) to be accessible to users with visual impairments, as 
part of a longer term project to improve GAO products' accessibility. 
Every attempt has been made to maintain the structural and data 
integrity of the original printed product. Accessibility features, 
such as text descriptions of tables, consecutively numbered footnotes 
placed at the end of the file, and the text of agency comment letters, 
are provided but may not exactly duplicate the presentation or format 
of the printed version. The portable document format (PDF) file is an 
exact electronic replica of the printed version. We welcome your 
feedback. Please E-mail your comments regarding the contents or 
accessibility features of this document to Webmaster@gao.gov. 

This is a work of the U.S. government and is not subject to copyright 
protection in the United States. It may be reproduced and distributed 
in its entirety without further permission from GAO. Because this work 
may contain copyrighted images or other material, permission from the 
copyright holder may be necessary if you wish to reproduce this 
material separately. 

United States Government Accountability Office: 
GAO: 

Report to Congressional Addressees: 

September 2014: 

Veterans Affairs: 

Better Understanding Needed to Enhance Services to Veterans 
Readjusting to Civilian Life: 

GAO-14-676: 

GAO Highlights: 

Highlights of GAO-14-676, a report to congressional addressees. 

Why GAO Did This Study: 

Over the next 6 years, over 1 million servicemembers are expected to 
leave the military. As was the case with past generations of veterans, 
the transition from military to civilian life can be challenging for 
post-9/11 veterans as well. Over the last several years, veterans' 
struggles to successfully readjust to civilian life have been the 
subject of numerous Congressional hearings. 

Providing support and services for transitioning veterans is a key 
issue facing the nation. This report examines what is known about (1) 
the extent to which veterans experience difficulties during their 
readjustment to civilian life; and (2) how VA assists veterans in 
their readjustment, as well as what challenges and opportunities 
exist. GAO conducted a literature search, interviewed VA and DOD 
officials, and held eight nongeneralizable discussion groups with a 
total of 45 veterans and family members. GAO also conducted interviews 
with relevant officials at VA facilities in four states. GAO selected 
these sites based on diversity of military service branches in a local 
area, geography, a high concentration of veterans, and proximity to VA 
resources. 

What GAO Found: 

While many veterans who served in the military after September 11, 
2001, have successfully readjusted to civilian life with minimal 
difficulties in the first few years after they were discharged, others 
have experienced difficulties, according to veterans GAO heard from in 
discussion groups and studies GAO reviewed. These readjustment 
difficulties include financial and employment, relationships, legal, 
homelessness, and substance abuse. According to VA's strategic plan, 
one of its strategic objectives is to improve veteran wellness and 
economic security, and it states that the ultimate measure of VA's 
success is the veteran's success after leaving military service. 
However, there is limited and incomplete data to assess the extent to 
which veterans experience readjustment difficulties. Therefore, it is 
not known to what extent veterans are facing one or a combination of 
problems when they readjust to civilian life. There is relatively more 
information available on the number of veterans who had a physical or 
mental condition within a few years of leaving the military. For 
example, one 2010 study shows that 32 percent of recently-separated 
veterans were diagnosed by either the Department of Defense (DOD) or 
the Department of Veterans Affairs (VA) with a disease or injury of 
the musculoskeletal system. In this and other studies reviewed by GAO, 
estimates for Post-Traumatic Stress Disorder (PTSD) varied from 10 to 
12 percent. According to these studies, some groups of veterans—those 
who had served in combat and younger veterans—were more likely than 
others to experience readjustment difficulties or be diagnosed with a 
mental health condition. 

While an array of VA benefits and services are available during a 
veteran's first few years out of the military, GAO has identified long-
standing challenges with VA's delivery and management of this support. 
Specifically, VA provides a wide range of services and benefits 
through several programs, such as education, health care, counseling, 
employment, home loans, and insurance. VA informs veterans of these 
benefits and services before they leave military service through 
outreach and education. However, GAO's prior work over the last decade 
has shown that VA has struggled for years to, among other issues, (1) 
provide timely access to medical appointments, (2) make timely 
disability compensation decisions, and (3) coordinate the transfer of 
medical records from DOD. GAO has made numerous prior recommendations 
to address these issues, and VA has taken some actions to implement 
them; however, some recommendations remain unaddressed, and GAO 
continues to monitor VA's progress. Agency officials and veterans GAO 
spoke with during this review suggested additional actions that VA can 
implement to improve its assistance for transitioning veterans. For 
example, a few VA staff suggested that VA conduct additional research 
to identify veterans who are predisposed to PTSD and better understand 
why some veterans do not use VA services. Veterans at all of the sites 
GAO visited suggested that it would be beneficial for separating 
servicemembers to have additional time to adjust to the idea of being 
a civilian and relearning what civilian life is like. Without 
comprehensive information on the difficulties experienced by recently-
separated veterans, VA cannot assess risks to achieving its objectives 
and may be missing opportunities to enhance assistance to veterans by 
not providing needed services early in the veteran's readjustment 
process. 

What GAO Recommends: 

GAO recommends that VA take steps to better understand the 
difficulties faced by readjusting veterans and use this information to 
determine how best to enhance its benefits and services for these 
veterans. VA concurred with GAO's recommendation and described its 
recent efforts and plans for improvement. 

View [hyperlink, http://www.gao.gov/products/GAO-14-676]. For more 
information, contact Daniel Bertoni, (202) 512-7215, bertonid@gao.gov. 

[End of section] 

Contents: 

Letter: 

Background: 

Veterans Experience Difficulty When Readjusting to Civilian Life but 
Extent Is Unknown: 

VA Offers an Array of Services to Readjusting Veterans, but Long-
Standing Weaknesses Hinder Available Support: 

Conclusions: 

Recommendation for Executive Action: 

Agency Comments and Our Evaluation: 

Appendix I: Objectives, Scope, and Methodology: 

Appendix II: Comments from the Department of Veterans Affairs: 

Appendix III: GAO Contact and Staff Acknowledgments: 

Related GAO Products: 

Tables: 

Table 1: Selected Types of VA Benefits and Services Available to 
Veterans Transitioning to Civilian Life: 

Table 2: Studies We Reviewed: 

Table 3: GAO Visits to VA Facilities, by State, City, and Facility 
Visited: 

Figure: 

Figure 1: Difficulties Faced by Readjusting Veterans: 

Abbreviations: 

DOD: U.S. Department of Defense: 

FRCP: Federal Recovery Coordination Program: 

IDES: Integrated Disability Evaluation System: 

MST: Military Sexual Trauma: 

OEF: Operation Enduring Freedom: 

OIF: Operation Iraqi Freedom: 

OND: Operation New Dawn: 

PDIC: Post-Deployment Integrated Care Initiative: 

PTSD: Post-Traumatic Stress Disorder: 

TAP: Transition Assistance Program: 

TBI: Traumatic Brain Injury: 

VA: U.S. Department of Veterans Affairs: 

VHA: Veterans Health Administration: 

VOW Act: VOW to Hire Heroes Act of 2011: 

VR&E: Vocational Rehabilitation and Employment: 

VSO: veteran service organization: 

WWA: Wounded Warrior Act: 

YRRP: Yellow Ribbon Reintegration Program: 

[End of section] 

United States Government Accountability Office: 
GAO:
441 G St. N.W. 
Washington, DC 20548: 

September 10, 2014: 

Congressional Addressees: 

From 2014 to 2020, the U.S. Department of Veterans Affairs (VA) 
anticipates that over 1 million servicemembers will join the 2.3 
million veterans who have already left the military since the 
terrorist attacks of September 11, 2001. As has been the case with 
past generations of veterans, making the transition from military to 
civilian life can be challenging for post-9/11 veterans as well. While 
the U.S. Department of Defense (DOD) has a role in assisting 
servicemembers with preparing for their transition, it is primarily 
VA's role to assist veterans after they separate from the military and 
begin readjusting to civilian life. To that end, VA administers a wide 
variety of benefits and services for veterans including health care, 
education benefits, and disability compensation benefits. While many 
veterans have made the readjustment without major difficulty, others 
may struggle with physical and mental health problems, financial 
difficulties, and unemployment. In the past few years, veterans 
experiencing these struggles have been the subject of numerous 
Congressional hearings and have received prominent media attention. In 
addition, GAO has issued multiple reports on this subject, and has 
designated supporting transitioning veterans as a key issue facing the 
nation. 

We have prepared this report under the Comptroller General's authority 
as part of a continued effort to help policymakers better understand 
how veterans readjust into civilian life and the challenges VA faces 
in serving them. We defined the readjustment period as the first 5 
years after a veteran separates from the military. For this review we 
examined what is known about: (1) the extent to which veterans 
experience difficulties during their readjustment to civilian life, 
and (2) how VA assists veterans in their readjustment, as well as what 
challenges and opportunities exist. 

To examine the extent to which veterans experience difficulties during 
their readjustment to civilian life, we conducted a literature search 
and interviewed relevant officials. More specifically, we searched for 
studies published in books, reports, and peer-reviewed journals 
published from September 2001 to May 2013 that described difficulties 
experienced by veterans; categorized and screened the sources; and 
then identified reliable quantitative information on the difficulties 
presented. We screened over 500 articles and identified 18 that had 
reliable quantitative information that was relevant for our review. 
[Footnote 1] We also interviewed officials from VA and DOD, as well as 
representatives from veteran service organizations. In examining how 
VA assists veterans in their readjustment, and what challenges and 
opportunities exist, we reviewed VA's strategic plan, annual 
performance reports, and other documents, and visited four sites: San 
Diego, California; Baltimore, Maryland; Fayetteville, North Carolina; 
and San Antonio, Texas. We selected these sites based on geographic 
diversity, diversity of military services (i.e., Army, Navy, Air 
Force, and Marines) in a local area, a high concentration of veterans 
among the local population, and proximity to VA resources. At each 
location, we visited a VA Medical Center and Readjustment Counseling 
Service (Vet Center) and interviewed relevant program officials, 
representatives, and veterans. At three locations, we visited the 
closest VA regional office. We also held eight nongeneralizable 
discussion groups with 45 veterans and family members. 

We conducted this performance audit from March 2013 to September 2014 
in accordance with generally accepted government auditing standards. 
These 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. For more 
information on our scope and methodology, see appendix I. 

Background: 

VA's Role in Supporting Veterans during Their Readjustment to Civilian 
Life: 

VA administers a wide range of programs that provide benefits and 
services to eligible veterans who seek out the agency for assistance 
as they readjust to civilian life. For example, VA offers health care, 
disability compensation, educational benefits, life insurance, 
vocational rehabilitation services, and home loans. [Footnote 2] In 
2014, VA requested $152 billion to support its programs that provided 
benefits and services to veterans.[Footnote 3] Of this amount, VA 
requested an estimated $58 billion for medical care for veterans, 
including almost $7 billion in mental health care.[Footnote 4] VA also 
requested an estimated $58.6 billion in disability compensation 
benefits to veterans with disabilities that resulted from their 
military service.[Footnote 5] 

VA and DOD have coordinated in assisting servicemembers in their 
readjustment to civilian life. For example, the Wounded Warrior Act 
(WWA) required VA and DOD to jointly develop and implement a 
comprehensive policy on improvements to the care, management, and 
transition of recovering servicemembers.[Footnote 6] The WWA also 
states that recovering servicemembers and their families should be 
fully informed of the services that are offered to them. In addition, 
the WWA required that the policy include provisions related to the 
tracking of recovering servicemembers to conduct oversight of their 
care, management, and transition. In 2009, DOD and VA began developing 
the Virtual Lifetime Electronic Record Initiative, to share health, 
benefit, and administrative data, such as personnel records and 
military history records securely. The VOW to Hire Heroes Act of 
2011(VOW Act) made several changes to the Transition Assistance 
Program (TAP), a program that provides departing servicemembers 
counseling and offers employment assistance and information on federal 
veteran benefits, among other things.[Footnote 7] Concurrent with this 
Act, the administration initiated a redesign of TAP. The law also 
generally required servicemembers to attend TAP prior to separating 
from their service. The VOW Act required departing servicemembers to 
participate in a workshop on finding employment as part of TAP, among 
other changes. Other provisions of the VOW Act include allowing 
servicemembers to apply for civilian federal government positions as 
veterans prior to separating from the military, ensuring the program 
is tailored to individuals and the 21st century job market. 

Furthermore, VA and DOD collaborated in the development of several 
programs for servicemembers to receive VA disability compensation. The 
Benefits Delivery at Discharge program provides separating and 
retiring servicemembers the ability to apply for VA disability 
compensation when they have between 60 and 180 days remaining on 
active duty. Similarly, through the Quick Start program, VA and DOD 
provide the same service for those servicemembers who have less than 
60 days remaining on active duty. In addition, VA collaborates with 
DOD to operate the Integrated Disability Evaluation System 
(IDES).[Footnote 8] IDES consolidates VA's and DOD's separate 
disability rating decisions into a single VA rating-decision and 
requires staff to perform outreach and nonclinical case management and 
explain VA results and processes to servicemembers.[Footnote 9] 

Characteristics of Veterans Readjusting to Civilian Life: 

Since September 11, 2001, the U.S. military has seen a shift in the 
demographics of those who have served in combat. Of the 2.1 million 
servicemembers who have deployed in support of Operation Enduring 
Freedom, Operation Iraqi Freedom, and Operation New Dawn 
(OEF/OIF/OND), about 12 percent were women, and 33 percent were 
members of the National Guard or Reserves.[Footnote 10] By comparison, 
during the Persian Gulf War in 1990, 6.8 percent of servicemembers 
were women, and 16 percent were members of the National Guard or 
Reserves. During the Vietnam War, about 0.2 percent of servicemembers 
were women and only 0.4 percent were members of the National Guard or 
Reserves. 

Moreover, veterans who have left the military since September 11, 
2001, like veterans from prior eras, have had varied years of service 
and military experiences. They may have served for 20 years or more in 
the military and never served in combat, or they may have only served 
for a year or two. As of fiscal year 2012, more than 1.4 million 
veterans who have been receiving military retiree payments were in the 
military for 20 or more years. Between October 2001 and December 2012, 
more than 1.6 million servicemembers who served during OEF/OIF/OND had 
become veterans.[Footnote 11] Among that population, about 900,000 had 
used VA's health care services and over 600,000 were receiving 
disability compensation benefits. 

The Readjustment Process for Veterans: 

When serving in the military, many servicemembers become accustomed to 
its culture and structure of discipline and hierarchy and giving 
priority to the group over the individual. During their service, all 
members of the military are employed and receive regular paychecks; 
medical care; and other benefits, such as housing allowances. Once 
they leave the military and become veterans, they must learn to become 
a civilian again. They are responsible for finding a job, going back 
to school, obtaining health insurance, child care, and finding a place 
to live, among other life activities. If veterans are also recovering 
from their war experiences, it can compound the difficulty they 
experience in successfully completing their readjustment. 

Veterans Experience Difficulty When Readjusting to Civilian Life but 
Extent Is Unknown: 

Readjusting Veterans May Experience a Range of Economic, Social, and 
Other Difficulties: 

Veterans we spoke to and VA officials confirmed that veterans face a 
variety of difficulties related to readjusting to civilian life, 
including financial and employment, relationships, legal difficulties, 
homelessness, and substance abuse. One of VA's strategic objectives is 
to improve veteran wellness and economic security. VA's strategic plan 
also states that the ultimate measure of its success is the veteran's 
success after leaving military service. However, there is limited and 
incomplete data available to assess the extent to which these veterans 
are affected by these difficulties. Therefore, it is not known to what 
extent veterans are facing one or a combination of these problems when 
they readjust to civilian life. 

Figure 1: Difficulties Faced by Readjusting Veterans: 

[Refer to PDF for image: illustration] 

Difficulties Faced by Readjusting Veterans: 
Relationships; 
Homelessness; 
Substance abuse; 
Financial and employment; 
Legal difficulties. 

Source: GAO analysis. GAO-14-676. 

[End of figure] 

Financial and employment. Some veterans in our discussion groups at 
three of the four sites we visited said that they and several of their 
peers struggled financially in the time period immediately following 
their discharge, particularly if they had a family to support. VA 
officials confirmed that some veterans have experienced a range of 
difficulties after separating from the military, especially if they 
had no source of income as they readjust to civilian life. One of the 
veterans we spoke to said that his income dropped by four-fifths when 
he lost his military pay and benefits and could not find anything but 
a minimum wage job. Other veterans at one of the sites we visited 
described the challenge of paying for their living expenses during 
long waits for civilian employment or VA benefits to be processed. 
According to a 2008 study that examined unemployment among OEF/OIF 
veterans who had separated from the military by the end of 2006, 
veterans had a higher unemployment rate (6.5 percent) than nonveterans 
(4.7 percent).[Footnote 12] Veterans at three of the four sites we 
visited reported experiencing financial difficulties as they started 
civilian employment or received benefits. Several veterans we 
interviewed said they had applied for VA benefits in order to support 
themselves and endured lengthy waits for a VA decision. VA officials 
at two of the sites we visited and veterans at three of the sites 
mentioned that many veterans faced difficulties with the costs of 
civilian life, particularly housing, food, transportation, and child 
care. In particular, VA officials at one site we visited told us that 
veterans found the Post-9/11 G.I. Bill's benefits for attending 
college were not enough to cover living expenses, especially during 
months that veterans do not attend school, such as during a summer 
break.[Footnote 13] However, during our review we found no 
comprehensive data that identified the extent to which readjusting 
veterans experienced financial difficulties. 

Relationships. As they work to readjust to civilian life, many 
veterans can experience relationship difficulties. Several veterans at 
three of the sites we visited said that they had difficulty adjusting 
to family life, and often felt that they could not inform their 
families of their struggles. Those who had talked to their families 
felt that their family members did not understand them very well. One 
veteran reported unintentionally assaulting his wife during nightmares 
while sleeping; another said he was reluctant to spend time 
individually with his children for fear of becoming angry and losing 
control. VA officials at two of the four sites we visited noted that 
they are seeing many veterans with marital issues and at one VA 
medical center, officials told us that some veterans seem to have no 
support system in place. However, during our review we found no 
studies or comprehensive data that identified the extent to which 
readjusting veterans experienced this issue. 

Legal problems. Some veterans recently separated from the military 
also face legal difficulties, including being arrested, convicted of a 
crime, and sentenced to serve time in jail. Although we found some 
data related to this issue, these may not represent the extent that 
veterans experience legal difficulties. For example, according to a 
2007 report from the Department of Justice, there were an estimated 
5,280 OEF/OIF veterans who had separated from the military between 
2002 and 2004 who were incarcerated in either state or federal 
correctional facilities in 2004.[Footnote 14] Those data might 
represent an undercount, as one VA official tasked with outreach to 
veterans in correctional settings told us that not all veterans 
disclose their veteran status when they go to jail. In some areas, 
there are veterans treatment courts designed to serve the unique needs 
of veterans in the criminal justice system. According to VA, there 
were 257 veterans courts in the United States in 2013. 

Homelessness. Some veterans who experience major difficulties in their 
readjustment to civilian life may also become homeless. A national 
study of VA administrative records noted that after controlling for 
baseline risk factors (i.e., military service characteristics, 
demographic characteristics, behavioral health diagnosis categories, 
and diagnosis of Traumatic Brain Injury), service in OEF/OIF war zones 
significantly increased the risk for becoming homeless, compared to 
veterans who had served elsewhere.[Footnote 15] Military pay grade, as 
a proxy for socioeconomic status of veterans was a strong risk factor 
for becoming homeless. Substance use and psychotic disorders 
significantly increased the risk of becoming homeless. According to 
both VA officials at two of the sites we visited, as well as some of 
the veterans we interviewed, these veterans experience difficulties, 
which included not being able to find a job, developing a substance-
abuse problem (including sometimes becoming addicted to medications 
that they were prescribed), difficulties with family relationships, 
being arrested, or becoming homeless. Challenges with readjusting to 
civilian life and the risk of becoming homeless may be particularly 
pronounced for some women veterans, as we reported in 2011.[Footnote 
16] However, during our review we found no comprehensive data that 
identified the extent to which readjusting veterans were experiencing 
homelessness. 

Substance abuse. Some readjusting veterans have substance-abuse 
problems, which also makes a transition into civilian life difficult. 
We found relatively more information on the extent of this problem. 
For example, according to a study of OEF/OIF veterans seeing a primary 
care physician through the VA in fiscal years 2006 and 2007, about 13 
percent of men and 6 percent of women were diagnosed with a substance 
use disorder.[Footnote 17] Of the 1,508 OEF/OIF veterans that 
responded to a national survey of VA clinic users about their clinical 
experiences in fiscal year 2005, 605 (40 percent) screened positive 
for risky drinking, either hazardous drinking or alcohol 
abuse/dependence. Additionally, 345 (23 percent) screened positive for 
binge drinking, and 328 (22 percent) screened positive for possible 
alcohol abuse.[Footnote 18] Another study's authors noted that 
veterans may use alcohol and drugs to self-medicate for pain, mental 
health conditions, and other conditions.[Footnote 19] Other studies 
have shown that substance abuse occurs, with some frequency, alongside 
mental health conditions.[Footnote 20] Some of the veterans and VA 
officials we spoke with at one site said that veterans were sometimes 
afraid to take their prescribed medications, or believed that the 
medications were not working (especially on pain symptoms). Some 
veterans turned to alcohol and illegal drugs to manage their physical 
or emotional pain. Other veterans said that the use of prescribed 
medication, particularly painkillers, causes addiction, sleepiness, or 
other side effects. VA officials at two of the sites we visited 
reported that some veterans appear at VA facilities seeking help for 
physical or mental conditions, including a substance abuse problem 
that must also be treated. A study with a small sample of veterans 
found that those who experienced any type of trauma were far more 
likely to screen positive for substance abuse than those who had not 
experienced any type of trauma.[Footnote 21] 

A Sizable Minority of Post 9-11 Veterans Have Physical and Mental 
Health Conditions: 

A sizable minority of veterans who have served since September 11, 
2001, had physical or mental health conditions in the first few years 
of their readjustment to civilian life. Although the literature we 
reviewed provided a limited perspective of veterans' early 
readjustment experiences, a number of physical health conditions 
emerged, particularly musculoskeletal problems and pain, which can 
contribute to difficulties in integrating back into civilian life. 
Physical health conditions are the most common for recently-separated 
veterans. According to a 2010 study, 32 percent of veterans had been 
diagnosed by either DOD or VA with diseases of the musculoskeletal 
system and connective tissues after separating from the military, and 
about 27 percent had been diagnosed with diseases of the nervous 
system and sense organs.[Footnote 22] Other studies that focused on 
OEF/OIF veterans receiving health care through VA show that between 43 
and 49 percent reported some level of pain, with the majority of this 
group reporting moderate to severe pain[Footnote 23]--a level of pain 
that was more likely to interfere with functional activities. VA 
officials at two of the four sites we visited told us that reports of 
pain were common, and it was a difficult problem for VA and veterans 
to manage. Studies also found that pain was frequently associated with 
other physical and mental health conditions.[Footnote 24] 

In studies we reviewed, a broad range of estimates exist for the 
percentage of readjusting veterans that experienced various mental 
health conditions, depending on the scope and method of the study, 
[Footnote 25] at least one-quarter of readjusting OEF/OIF veterans had 
such conditions, and the most prominent--Post-Traumatic Stress 
Disorder (PTSD) and depression--might affect their ability to 
successfully readjust to civilian life for a variety of reasons. 
According to a 2010 VA study conducted by its Office of Inspector 
General, about 28 percent of recently-separated veterans were 
diagnosed by VA or DOD with a mental disorder or psychosocial problem 
[Footnote 26] after their separation from the military, including 10 
percent who were diagnosed with PTSD and about 3 percent who had 
Traumatic Brain Injury (TBI).[Footnote 27] Other studies estimated 
that 10 to 12 percent of post-9/11 veterans were diagnosed with PTSD. 
[Footnote 28] These percentages do not include veterans who sought 
treatment for their mental health conditions from private providers or 
who have not sought treatment at all. For readjusting OEF/OIF 
veterans, estimates of PTSD for the studies in our review generally 
ranged from 13 to 18 percent.[Footnote 29] VA officials at two sites 
and veterans at one site said PTSD and other mental health conditions, 
in some instances, made it difficult for some veterans to keep a job 
or relate to family members. VA officials at all four sites, as well 
as veterans at one site, reported that some veterans believe that 
employers will turn them down for certain jobs or their security 
clearance will be in jeopardy due to past or current mental 
conditions, particularly PTSD. VA officials at two of the sites we 
visited said that many veterans feel stigmatized about seeking mental 
health treatment. Officials added that, in many cases, mental health 
problems are only identified--and the possibility of treatment 
discussed--after some veterans seek VA treatment for their physical 
health conditions. 

Many veterans with mental health conditions have screened positive for 
other conditions or received more than one diagnosis. More 
specifically, a 2007 study of recently-separated veterans who were 
diagnosed with a mental health condition by VA shows that 56 percent 
of them had more than one mental health diagnosis.[Footnote 30] 
Another study noted that high percentages of veterans who sought 
treatment had both PTSD and depression.[Footnote 31] Veterans who had 
experienced trauma were far more likely to screen positive for 
depression than those who had not experienced trauma.[Footnote 32] VA 
officials at two sites we visited also mentioned the effects of 
Military Sexual Trauma (MST) on victims, including the sense of 
betrayal that results. Victims are often reluctant to divulge such 
incidents (whether in the military or after separation). If military 
commanders ignored victims' allegations, VA officials said that it 
creates a second betrayal. Experiences with MST may lead to PTSD and 
depression. Finally, VA officials at one site we visited mentioned 
that experiencing both physical and mental health conditions at the 
same time were challenging during their readjustment. A 2008 study 
noted that the severity of PTSD was significantly associated with 
poorer physical health functioning, even after accounting for 
demographic factors, combat and chemical exposure, and health risk 
behaviors.[Footnote 33] Also, another study found that a significantly 
larger proportion of veterans suffering from headaches, in comparison 
to those without headaches, had experienced physical injury and 
screened positive for depression and PTSD.[Footnote 34] 

Veterans with Certain Characteristics May Be More Likely to Experience 
Difficulties: 

Some groups of veterans may be more likely to experience readjustment 
difficulties or be diagnosed with a physical or mental condition than 
others. In a study we reviewed, veterans with combat exposure were 
almost four times more likely to be diagnosed with PTSD than those 
without combat exposure. This study found that veterans who had served 
in ground units of the Army or Marines had PTSD rates that were 3.7 
times higher than those who had served in the Navy or Air Force. 
[Footnote 35] Another study that tracked OEF/OIF veterans seeking 
treatment with the VA shows that younger veterans of active duty 
service were at a higher risk for diagnoses of PTSD or mental health 
compared with active duty veterans at least 40 years old, which the 
authors attribute to younger veterans more likely being at lower rank 
and having had greater combat exposure.[Footnote 36] 

Studies we reviewed showed that younger veterans experienced higher 
rates of mental health diagnoses and alcohol abuse than older 
veterans. One study reported that veterans of younger age groups were 
at a higher risk of receiving PTSD and other mental health diagnoses 
compared with those in the oldest age group (at least 40 years of 
age).[Footnote 37] Another study indicated that younger veterans were 
more likely to engage in binge drinking than older veterans. Age was 
also significantly associated with screening positive for possible 
alcohol abuse.[Footnote 38] Some VA officials we spoke to on our site 
visits stated that many young veterans have difficulties in finding a 
job and a place to live. They may also deny they have a problem, 
refuse to seek help, or only do so after their lives have turned for 
the worse. VA officials we spoke to said that some young people joined 
the military to escape economic or social difficulties at home may 
return to civilian life to find that some of their difficulties 
remained. Also, VA officials told us that if veterans had certain 
problems before they joined the military, such as mental health or 
substance abuse problems, they will probably have them after they 
leave the military. 

Studies we reviewed provided varying results regarding any differences 
in the readjustment experience by other demographic characteristics 
such as gender, race, and ethnicity. One study found that PTSD was 
less frequently diagnosed in female veterans than in male veterans 
(9.9 percent versus 11.3 percent), but depression was more frequently 
diagnosed (12.2 percent vs. 7.5 percent).[Footnote 39] Another study 
found that PTSD was again diagnosed less frequently for female 
veterans than male veterans at 28.2 percent and 35.7 percent, 
respectively; the prevalence of substance abuse diagnosed was 6.2 
percent for females and 12.5 percent for males. The prevalence of PTSD 
and substance abuse together was 3.8 percent and 8.1 percent, 
respectively, for females and males.[Footnote 40] Another study found 
that female veterans were less likely to screen positive for binge 
drinking.[Footnote 41] However, another study reported that the 
proportion of patients with possible PTSD symptoms did not vary 
substantially according to gender or race.[Footnote 42] One study 
found that differences across these demographic groups of OEF/OIF vets 
regarding risk for receiving mental health or PTSD diagnoses were 
minimal.[Footnote 43] 

VA Offers an Array of Services to Readjusting Veterans, but Long-
Standing Weaknesses Hinder Available Support: 

VA Offers a Range of Benefits and Services to Veterans Early in the 
Readjustment Process: 

VA offers assistance to servicemembers before they leave military 
service by informing them through outreach and education on the range 
of benefits and services available to them. The types of benefits and 
services VA offers range from education to health care and life 
insurance to burial and memorial benefits. VA officials told us they 
use VA liaisons and outreach efforts, including the Transition 
Assistance Program (TAP). According to VA officials, VA liaisons are 
located on many military bases and play a key role in educating 
servicemembers about VA benefits and services. More specifically, VA 
liaisons assist with transferring individuals to Veterans Health 
Administration (VHA) health care facilities and provide information to 
servicemembers, veterans, and their families about VHA health care 
services. TAP provides information on services that are available, 
including services and benefits offered through the VA, either while 
servicemembers are on active duty or after they have separated from 
the military. TAP also provides separating servicemembers with 
counseling and information on available employment assistance and 
other federal benefits, identifies servicemembers who did not meet the 
TAP career readiness standards, and provides referral to the 
appropriate federal partners for additional supports and services. 
[Footnote 44] In addition, VA officials told us National Guard and 
Reserve members can learn about VA services and benefits through the 
Yellow Ribbon Reintegration Program (YRRP). YRRP connects 
servicemembers, families, and communities with resources using the 
YRRP website, newsletter, and YYRP-sponsored events. According to 
officials, YRRP is designed to make individuals aware of the supports 
and services available to them.[Footnote 45] 

Table 1: Selected Types of VA Benefits and Services Available to 
Veterans Transitioning to Civilian Life: 

Education Benefits through the Post-9/11 GI Bill: 

Health Care Services through VA Medical Facilities; 
* PTSD Counseling; 
* Polytrauma Network; 
* Suicide Prevention. 

Counseling Services through the Vet Center; 

Monetary Benefits through Disability Compensation; 

Vocational Rehabilitation and Employment Services: 
* Job Training; 
* Independent Living. 

VA Home Loans; 

VA Life Insurance: 
* Veteran Group Life Insurance; 
* Service Disabled Veteran Life Insurance. 

Burial and Memorial Benefits and Services. 

Source: VA. GAO-14-676. 

[End of table] 

VA reaches out to veterans through a variety of activities and tools. 
Veterans can learn about VA, for example, through mobile Vet Centers, 
Welcome Home events, as well as community events. Mobile Vet Centers, 
which are customized recreational vehicles, allow VA staff the ability 
to travel to communities to provide information and render counseling 
services to veterans, especially to veterans living in rural 
areas.[Footnote 46] Welcome Home events are held at VA medical centers 
and offer health screenings and disseminate VA benefits information.VA 
also educates veterans and family members through the VA website and 
uses various social media outlets including Facebook™ and Twitter™. 

Although VA reaches out to veterans in a number of ways, 
servicemembers and veterans must take the initiative to register for 
VA benefits and services either online, by mail, over the phone using 
a toll-free number, or they can do so in person at a VA medical 
facility or regional office. Veterans can also work with veteran 
service organizations (VSO) to apply for VA benefits and services. 
VSOs act as advocates for veterans during their application for 
benefits and can assist them with obtaining medical records and 
explaining the benefits and services that VA offers.[Footnote 47] 
Senior VA officials told us that VA conducts outreach to veterans, but 
ultimately it is up to the veteran to sign up for the benefits and 
services. In recent years, VA has encouraged servicemembers and 
veterans to apply for VA benefits, such as medical care and disability 
compensation, using the agency's eBenefits system. eBenefits is 
designed to enable veterans, servicemembers, and families to learn 
about and manage their military and veterans benefits and personal 
information online. Many VA officials told us they encourage 
servicemembers and veterans to apply for benefits through this system. 
[Footnote 48] Officials from one medical facility we visited told us 
that one of the advantages of using eBenefits is that it allows 
veterans to search for the benefits and services they could be 
entitled to from their residence, instead of having to come to a VA 
facility. 

For veterans who were wounded, became ill, or injured as a result of 
their service, VA offers specific benefits and services. Disability 
compensation is a monetary benefit paid to veterans with disabilities 
that were the result of their military service. This benefit award is 
based on the severity of disability.[Footnote 49] The Vocational 
Rehabilitation and Employment (VR&E) program helps eligible veterans 
prepare for, obtain, and maintain suitable employment or achieve 
independence in daily living. VR&E offers job training, education, 
employment, job coaching, and independent living services.[Footnote 
50] For veterans receiving health care services for their medical 
conditions, VA offers prosthetic equipment such as home respiratory 
therapy, artificial limbs, wheelchairs, and optical and electronic 
devices for visual impairments.[Footnote 51] Veterans who suffer with 
mental health conditions, such as PTSD or depression, may receive 
mental health treatment and counseling services at VA medical centers 
and Vet Centers. 

For the most severely wounded, ill, and injured servicemembers and 
veterans, VA provides intensive case management services. Under the 
Federal Recovery Coordination Program (FRCP), VA serves servicemembers 
and veterans with complex medical or social problems which may include 
traumatic brain injury, amputation, burn, spinal cord injury, 
blindness, PTSD, as well as those considered at risk for psychosocial 
complications. Federal Recover Coordinators advocate in all clinical 
and non-clinical aspects of recovery, rehabilitation, and 
reintegration and participate in the development of a Federal 
Individual Recovery Plan to provide coordination of care and benefits 
through the continuum of care. VA also operates Polytrauma 
Rehabilitation Centers that provide integrated inpatient 
rehabilitation to address a variety of health issues including 
physical, cognitive, emotional adjustment, and health and wellness. 
The centers serve patients who are in prolonged states of reduced 
consciousness, including coma. 

For veterans of the Iraq and Afghanistan conflicts, VA provides 
additional benefits and services. These individuals may be eligible to 
receive education benefits through the Post-9/11 GI Bill which 
provides participants up to 36 months of education benefits to defray 
the costs of post-secondary degrees, technical training, and other 
expenses, such as books and supplies, and housing, among other costs. 
Veterans who served in combat generally are eligible to receive 5 
years of free health care through the VA.[Footnote 52] In addition, 
all post-9/11 veterans who enter the VA health care system are 
referred to the Operation Enduring Freedom(OEF)/Operation Iraqi 
Freedom (OIF)/Operation New Dawn (OND) Care Coordination Program, 
which screens these veterans to determine if and the extent to which 
care is needed and assists them with accessing VA and community 
resources.[Footnote 53] These screenings are designed to identify 
combat veterans and the degree of care that is needed to treat their 
medical conditions. If the screenings indicate case management is 
needed, veterans are referred to the Post-Deployment Integrated Care 
Initiative (PDIC). The PDIC provides an integrated approach to health 
care by treating the veteran with physical and mental health care, and 
social work simultaneously, rather than identifying and treating one 
problem at a time. According to program managers, this approach 
provides patient-centered care and increased coordination between 
providers. It also includes a comprehensive psychosocial and medical 
intake process for combat veterans with full integration of all 
services as well as regular meetings by medical care providers to 
discuss patient care and system issues. VA officials told us that 
while only veterans who have experienced combat situations are 
eligible to receive care through PDIC, VHA is exploring the 
possibility of expanding this practice to all veterans. 

Lengthy Wait Times for Benefits and Services, among Other Factors, Can 
Hinder Veterans' Readjustment: 

VA's Continuing Service Provision Challenges: 

Medical care. VA continues to face long-standing challenges in 
providing some benefits and services in a timely way, which can hinder 
veterans as they readjust to their civilian lives. Our past reports, 
as well as reports by VA, have highlighted the continuing challenges 
VA faces in ensuring veterans are able to access medical care. For 
over a decade we have reported on continuing issues with VA medical 
service delivery including, in 2004, we found that some veterans in 
Chattanooga, Tennessee, encountered difficulties with accessing VA's 
inpatient and outpatient health care services. We recommended that VA 
explore alternatives to further improve access to health care for 
these veterans by expediting the opening of additional VA medical 
facilities.[Footnote 54] Subsequently, VA reviewed Chattanooga 
veterans' access to inpatient and outpatient health care and opened 
two clinics. However, in 2009, VA reported that its facilities were 
unable to keep up with a steady increase in the demand for outpatient 
care services, leading to veterans not being able to access medical 
care. The report noted that VA added new guidance and performance 
measures to help alleviate excessive wait times for medical 
appointments.[Footnote 55] In 2011, we found that veterans were 
hindered from accessing mental health care from VA in part because of 
difficulty in scheduling appointments.[Footnote 56] Although VA 
reported that they were making improvements toward achieving timely 
access to medical appointments, in 2012, we found that medical 
appointment wait times reported by VHA were unreliable. We recommended 
that VA improve the reliability of its medical appointment wait time 
measures, ensure medical centers consistently implement the scheduling 
policy, and require medical centers to allocate staffing resources 
based on scheduling needs.[Footnote 57] VA reported revising its 
scheduling policy and developing a training module that schedulers 
were required to complete, implementing revised wait time measures, 
and studying options to better understand staffing level gaps. That 
same year, VA's Office of Inspector General found that VA had 
overstated its success in providing veterans with timely appointments 
for mental health treatment. 

In 2014, VA completed an audit to determine if broader, more systemic 
problems existed and found multiple deficiencies with VA's appointment 
scheduling practices for medical care.[Footnote 58] However, veteran 
complaints about long wait times persist. VA officials and veterans 
also told us during our site visits that veterans continued to wait a 
long time to see VA physicians. At two of the four medical facilities 
we visited, VA officials told us that veterans have expressed 
frustration with how long it was taking to see a physician. Officials 
from one of the medical centers told us that there are long wait times 
to get appointments and some veterans stop using VA services because 
of the lack of timely appointments. Veterans from three of the four 
sites we visited complained about the lengthy wait times to see their 
physicians. One veteran told us that VA does not give veterans a 
choice of appointment times, and added this can be problematic if one 
is employed or attending school. He also told us that veterans do not 
want to miss these appointments because it can take months to 
reschedule. 

Disability compensation. We have reported for over 10 years, and we 
heard confirmations during interviews with VA officials and veterans, 
on the continuing challenge VA faces in processing disability 
compensation in a timely fashion. For example, in 2003, we found that 
while VA acted to improve the timeliness of its disability claims 
processing, the agency remained far from achieving its goals.[Footnote 
59] At a 2008 congressional hearing, we testified that despite VA 
taking steps to improve its disability claims process, challenges 
remained in reducing the backlog and wait times for processing claims. 
[Footnote 60] In 2012, we reported that the number of days to process 
disability compensation benefits was increasing and recommended that 
VA partner with other federal agencies to reduce timeframes and ensure 
the development of a robust backlog plan.[Footnote 61] VA agreed with 
our recommendations and reported initiating a pilot program to 
centralize records requests and published a strategic plan to 
eliminate the disability compensation claims backlog. While VA 
addressed several of our recommendations, we concluded that additional 
follow up would be needed. In fiscal year 2014, VA reported that 58 
percent of veterans experienced wait times that were longer than its 
goal of 125 days and the average time to complete a claim was 378 
days.[Footnote 62] For veterans, especially those in the beginning 
phases of their readjustment, making timely decisions on disability 
compensation benefits can potentially lessen the accompanying 
financial transition difficulties. Veterans from three of the sites we 
visited pointed to claims processing timeliness as a factor in their 
difficulty with readjusting to civilian life. For example, one female 
veteran told us that VA took 15 months to process her claim, and 
during this time, she was unable to support herself and had to reside 
with her family. Another veteran told us he has been waiting 2 years 
for his disability compensation to be processed, has run out of 
unemployment benefits, and is now on the verge of becoming homeless. 

Post-9/11 GI Bill. Since the Post-9/11 GI Bill was implemented in 
2009, VA has had challenges informing veterans about the program and 
protecting them from questionable recruiting practices by some post-
secondary schools. In 2011, we reported that veterans wanted more 
information about the program, including how to compare Post-9/11 GI 
Bill benefits with other VA education benefits, as well as the effect 
of dropping or adding classes. We recommended that VA develop 
performance measures for outreach to servicemembers and veterans and 
for the quality of information provided by its Right Now Web service. 
We also recommended VA consider developing and maintaining an online 
policy manual for the Post-9/11 GI Bill, and provide updates to school 
certifying officials nationwide.[Footnote 63] VA addressed some of our 
recommendations but we concluded that additional monitoring of its new 
outreach performance measures was needed, and we continued to urge VA 
to measure the quality of its Right Now Web service. In 2014, we 
reported that VA's response to protecting veterans from schools that 
were using inappropriate or aggressive recruiting practices was not 
always sufficient. More specifically, we found that while VA offered 
education counseling services to students, applying for the services 
was difficult and not all veterans were aware of its availability. We 
concluded that if veterans are not better protected and informed, they 
may end up using their educational benefits on programs that do not 
meet their career goals and recommended that VA improve outreach and 
accessibility of its education counseling services.[Footnote 64] VA 
agreed with our recommendation and noted that it was taking additional 
steps to enhance the outreach and delivery of its education counseling 
services. 

VA's Continuing Issues Collaborating with DOD: 

Integrated Disability Evaluation System. Similarly to VA's Disability 
Compensation, VA and DOD's Integrated Disability Evaluation System 
(IDES) has had difficulty with making timely decisions on 
servicemembers' claims for VA disability compensation. In 2010, we 
testified that the time to make decisions on IDES claims was affected 
by insufficient staffing and VA and DOD medical staff disagreeing over 
servicemember diagnoses.[Footnote 65] In 2011, we found that as 
program participation increased, so did the processing times for 
benefits. We recommended that VA and DOD develop a system-wide IDES 
monitoring mechanism.[Footnote 66] VA reported upgrading the IDES 
tracking system to include data fields that can capture, monitor and 
report when diagnostic disagreements occur, but we are continuing to 
monitor the tracking system to determine whether the agency can 
effectively monitor cases with diagnostic disagreements. In 2012, we 
reported that the processing times for decisions made for IDES claims 
continued to increase. We recommended that VA ensure care coordination 
and disability evaluation issues are fully resolved by the agencies 
and that its partners have sustained leadership attention and 
collaboration to ensure continuity of care and seamless transition for 
servicemembers.[Footnote 67] VA agreed with our recommendation and 
reported that the agency had established a committee with DOD to 
address comprehensive overhaul of the care coordination process. In 
2013, VA reported that 16 percent of servicemembers were awarded VA 
disability compensation benefits within 30 days of their discharge 
from the service.[Footnote 68] Being able to provide compensation 
benefits to veterans shortly after they were discharged from the 
service would bring greater financial security, thereby reducing the 
risk for negative outcomes such as bankruptcy and homelessness. 

Electronic medical records. In addition, VA continues to face long-
standing problems coordinating with DOD on sharing electronic medical 
records. Developing a method for sharing electronic health records 
that can be accessed throughout a patient's military and veteran 
status is particularly important. This method can help ensure greater 
availability of health care information for servicemembers and 
veterans at the time and place of care. Since 1998, VA and DOD have 
tried different ways to enable the sharing of electronic servicemember 
medical records, but our past reports and VA reports have shown 
ongoing challenges. For example, in 2003, we found that VA faced 
problems in developing an information technology strategy for sharing 
information with DOD on patients and that VA and DOD continued to 
operate separate information technology systems.[Footnote 69] A 2008 
VA report noted that service treatment records continued to be 
transferred from DOD to VA by paper copy because the infrastructure to 
transfer the records electronically had not yet been built and its 
current efforts to have a health information exchange had one or more 
serious flaws.[Footnote 70] In 2011, VA highlighted its efforts to 
address the incompatibility between VA and DOD electronic health 
records systems by attempting to create a virtual lifetime electronic 
record,[Footnote 71] but we found impediments persisted in the 
agencies' efforts to electronically view or exchange health 
information. Our report cited insufficient real-time and electronic 
access to comprehensive health information possibly delaying the 
receipt of care and benefits. We recommended that VA ensure electronic 
sharing of health records issues are fully resolved by the agencies 
and its partners have sustained leadership attention and collaboration 
to ensure continuity of care and seamless transition for 
servicemembers.[Footnote 72] VA agreed with our recommendations, and 
reported establishing a committee to review the care coordination of 
servicemembers; however, VA did not identify actions it would take to 
address electronic sharing of health records. In 2013, VA and DOD 
testified that their long-term plans for sharing medical record data 
were too expensive to continue and that they were exploring a 
different strategy.[Footnote 73] Veterans from all of the sites we 
visited told us of the difficulties they had with obtaining copies of 
their medical records. For example, one veteran told us that his 
medical records were not centrally located, making it difficult for 
him to collect his full record. Without medical records describing the 
treatment veterans received while in the military, VA faces 
difficulties with ensuring continuity of care when veterans transition 
to VA's health system. 

Medication. VA has also had long-standing problems collaborating with 
DOD on managing medications during veterans' readjustments. As early 
as, 2002, we found there was an increased risk for patient medication 
errors because VA and DOD had separate and uncoordinated information 
and formulary systems--lists of available medicines. We recommended 
that VA and its partner improve its capabilities for sharing 
electronic information.[Footnote 74] VA had agreed with our 
recommendations and in fiscal 2007 it had started to deploy a system 
to view patient medication and allergy information. However, in 2003, 
we reported that VA and DOD providers and pharmacists were still 
unable to electronically access health information to aid in making 
medication decisions for veterans, such as verifying drug allergies 
and interactions.[Footnote 75] A decade later, in 2013, we again found 
that VA's and DOD's efforts in managing servicemember medications 
during their transition of care were somewhat limited because not all 
DOD military treatment facilities offered such transition assistance. 
We recommended that VA and DOD identify and apply best practices for 
managing servicemembers' medication needs during transitions of 
care.[Footnote 76] While both agencies agreed with our 
recommendations, VA and DOD did not identify any actions to address 
them. During our site visits, one veteran at a medical facility told 
us how medications that were prescribed by DOD medical staff were not 
forwarded to VA, resulting in him being prescribed different 
medications. As our previous work has found, medication management is 
critical to effective continuity of care for servicemembers 
transitioning out of the military because of the potential adverse 
health effects that could arise if not taken as intended.[Footnote 77] 

Agency Officials and Veterans Report a Range of Challenges and 
Opportunities to Better Support Readjusting Veterans: 

During our interviews with agency officials and discussions with 
veterans and other stakeholder groups, we heard a number of challenges 
that VA faces in helping veterans during the readjustment experience. 
First, although VA has an agreement with DOD to let VA know when 
servicemembers are leaving the military,[Footnote 78] some VA 
officials told us it can be difficult to identify recently separated 
veterans, including those who may be experiencing readjustment 
difficulties, because they did not know who was leaving the military. 
Second, at two of the sites we visited, veterans we spoke with told us 
they separated too quickly from the military without the time they 
needed to prepare for certain aspects of civilian life, such as 
finding a job, making sure they were financially stable, or becoming 
better acquainted with what VA offered. Third, we repeatedly heard 
from VA official and veterans that some veterans may hesitate to use 
VA services. For example, officials at one site we visited told us 
that some younger veterans do not want to be diagnosed as having PTSD 
because it will keep them from entering certain civilian careers, such 
as homeland security. Officials at two of the sites we visited told us 
that some veterans try to manage their own issues or problems, instead 
of seeking assistance. At one of the sites we visited, veterans told 
us they hesitated to enroll in VA services because they did not want 
to ask for help. Lastly, VA officials told us that despite an 
increased effort to educate National Guard and Reserve members, before 
and after they demobilize, some are likely being missed. Should these 
veterans not receive VA's assistance in a timely way, any difficulties 
they may be experiencing during their readjustment to civilian life 
may worsen. 

In light of the difficulties we heard, several VA officials suggested 
ways that VA could improve its support to veterans with an elevated 
risk of experiencing a difficult readjustment. First, some called for 
additional VA research. At one site we visited, VA officials suggested 
there were opportunities to research ways to identify individuals who 
are predisposed to PTSD as well as conducting a study on reasons 
veterans are not using VA services. Second, in discussing the issue of 
the speed of transition out of the military, VA officials at one site 
we visited suggested establishing a "buffer zone" that would allow 
servicemembers time to readjust to being a civilian, before they are 
discharged from the military. Such a buffer zone has the potential to 
enhance VA's ability to reach out to servicemembers before they become 
veterans, assess their needs, and prepare the appropriate services for 
when they leave. While this effort would need to be developed and 
coordinated with DOD, veterans at all of the sites we visited noted 
that having time to adjust to the idea of being a civilian and 
relearning what civilian life is like would be beneficial. 

Consistent with the importance that VA's strategic plan places on 
veterans' success after leaving military service, the opportunity to 
possibly better serve veterans at risk for having readjustment 
difficulties could also be informed by the approach VA takes to 
support ill and injured veterans. For example, veterans who enter the 
OEF/OIF/OND Care Coordination Program receive a full mental health 
assessment. These assessments inform case managers about the 
difficulties veterans are facing and helps inform where they refer 
veterans for further assistance. Senior VA officials told us the 
assessments conducted by the OEF/OIF/OND Care Coordination Program can 
be used as gateways to provide veterans, who are experiencing 
difficulties such as, TBI, depression, and alcohol abuse, with an 
integrated treatment approach. These officials added that the goal is 
to treat veterans holistically, rather than offering mental, physical 
and social work care separately. Similarly, the FRCP was designed to 
coordinate clinical and nonclinical services for the most seriously 
wounded, ill, or injured. Servicemembers and veterans who are enrolled 
in the program are offered assistance with developing a plan that sets 
recovery goals and then guides them through the continuum of care of 
medical treatment and stabilization, rehabilitation, and community 
reintegration. FRCP employs dedicated care coordinators to guide 
servicemembers, veterans, and their families through the complex 
systems of health care, services, and benefits provided by DOD, VA, 
other federal agencies, and the private sector. To the extent that VA 
does not consider this approach for veterans likely to experience 
difficult transitions, especially those with known risk factors, some 
veterans may be left to themselves to deal with the after effects of 
combat. Importantly, some veterans we spoke with said that obtaining 
support early in the readjustment process is crucial because veterans 
who receive assistance immediately after separating from the military 
may have a better chance of achieving a successful readjustment. 
According to Standards for Internal Control in the Federal Government, 
agencies should identify risks, estimate the risk's significance, 
assess the likelihood of its occurrence, and decide how to manage the 
risk and what actions should be taken.[Footnote 79] If service 
provision to veterans who are likely to have difficulty is not 
occurring as early as possible, VA could be missing an opportunity to 
use its resources most efficiently and effectively. That is, if 
veterans do not receive the fullness--or any-
-of the support they need, the difficulties that emerge early in the 
readjustment process may worsen, resulting in potentially greater harm 
to the veteran and putting the agency at risk for an increase in the 
amount of resources it must then provide in the veteran's readjustment 
process. 

Conclusions: 

As over 1 million servicemembers separate from the military over the 
next 6 years, many will rely upon the programs administered by VA for 
support during their transition. For some veterans, this transition 
will go smoothly and without major difficulty. For others, however, 
the first few years after they leave the military will be difficult. 
Even though hundreds of articles, studies, and reports have been 
written about the experiences of veterans, relatively few discuss how 
recently separated veterans are adjusting to civilian life, and the 
issue of how well veterans are faring is still not well understood. 
Meanwhile, despite VA's network of outreach efforts and the range of 
benefits and services it administers, many veterans continue to 
struggle to access support, and the agency continues to face long-
standing challenges in providing benefits in a timely manner. And, 
while the Transition Assistance Program may help identify some of 
those at risk for having a difficult readjustment, the program does 
not cover the breadth of issues many veterans face once they leave the 
military. As a result, some veterans who need support may be missed. 
However, until VA has a better understanding of the needs of recently-
separated veterans, and which veterans may be more likely to face 
difficulties, it is difficult to know what steps VA should take. For 
instance, if many veterans face multiple problems that need to be 
addressed across its organizational boundaries, from health care, 
disability, and employment services, then more coordinated case 
management services may be needed. If veterans wait too long to seek 
out the help they need, then an effort to identify and target veterans 
for early intervention may be needed. If VA discovers severe struggles 
exist among a relatively narrow but identifiable small group of 
veterans during the initial years of civilian life, then VA is better 
positioned to take an early and cost-effective approach to helping 
rebuild lives. For veterans, having timely access to programs and 
services may improve their chances of having positive health, 
economic, and social outcomes. For VA, better-supported veterans may 
be less likely to end up in need of more intensive care and case 
management services over time, which would put less strain on VA's 
limited resources. 

Recommendation for Executive Action: 

We recommend that the Secretary of Veterans Affairs take steps to 
better understand both the difficulties faced by readjusting veterans 
and the characteristics of those who may be more likely to face such 
difficulties, and use the results to determine how best to enhance its 
benefits and services to these veterans. 

Agency Comments and Our Evaluation: 

We provided a draft of this report to VA for review and comment. In 
its written comments, reproduced in appendix II, VA generally agreed 
with our conclusions and concurred with our recommendation. VA also 
described its recent efforts and plans for improvement. For example, 
VA described its implementation of recent changes to the Transition 
Assistance Program, now known as the Transition Goals, Plans, Success 
program, and its plans to use an upcoming longitudinal evaluation to 
inform policy changes and program improvements. VA also provided 
technical comments that were incorporated, as appropriate. 

We are sending copies of this report to appropriate congressional 
committees, the Secretary of Veterans Affairs, and other interested 
parties. In addition, the report is available at no charge on the GAO 
website at [hyperlink, http://www.gao.gov]. 

If you or your staff have questions about this report, please contact 
me at (202) 512-7215 or bertonid@gao.gov. Contact points for our 
Offices of Congressional Relations and Public Affairs may be found on 
the last page of this report. Key contributors to this report are 
listed in appendix III. 

Signed by: 

Daniel Bertoni: 
Director, Education, Workforce, and Income Security Issues: 

List of Addressees: 

The Honorable Carl Levin: 
Chairman: 
The Honorable James Inhofe: 
Ranking Member: 
Committee on Armed Services: 
United States Senate: 

The Honorable Howard P. "Buck" McKeon: 
Chairman: 
The Honorable Adam Smith: 
Ranking Member: 
Committee on Armed Services: 
House of Representatives: 

The Honorable Michael H. Michaud: 
Ranking Member: 
Committee on Veterans' Affairs: 
House of Representatives: 

[End of section] 

Appendix I: Objectives, Scope, and Methodology: 

The objectives of this review were to examine what is known about (1) 
the extent to which veterans experience difficulties during their 
readjustment to civilian life, and (2) how VA assists veterans in 
their readjustment, and what challenges and opportunities exist. To 
address these objectives, we conducted a literature search, 
interviewed relevant officials from VA and DOD, reviewed VA's 
strategic plan, annual performance reports, and other documents, 
visited four locations with VA facilities, and held eight discussion 
groups with 45 veterans and family members. We also interviewed 
national representatives from the Wounded Warrior Project and Disabled 
American Veterans. We focused on the initial readjustment period, and 
for the purposes of this review defined it as the first 5 years after 
a veteran separates from the military. The scope of this review was 
active, reserve, and National Guard OEF/OIF/OND-era veterans who 
separated from military service after September 11, 2001. Active 
servicemembers and veterans of the Coast Guard were outside the scope 
of this study. While the readjustment period for each veteran may 
vary, and some may continue to experience difficulties beyond the 
first few years, we focused our review on the initial readjustment 
period. 

Literature Search: 

We conducted an extensive search for studies on the difficulties faced 
by readjusting veterans, and then screened the studies in two phases. 
The purpose of the first phase was to identify the range and types of 
difficulties experienced by post-9/11 veterans in the first few years 
after they separated from the military. The purpose of the second 
phase was to identify the percentage of veterans who experienced each 
difficulty we identified, and the characteristics of the veterans who 
experienced them. 

We conducted electronic searches of over 30 databases. Key databases 
searched include ArticleFirst, CINAHL, Electronic Collections Online, 
Education Resources Information Center, MEDLINE, National Technical 
Information Service, PolicyFile, ProQuest, PsycINFO, SciSearch, Social 
Sciences Abstracts, Sociological Abstracts, and WorldCat. We searched 
for English-language documents published between September 2001 and 
May 2013, using Boolean search phrases designed to capture 
difficulties experienced by veterans within our scope, including 
variations of the words "veteran", "challenge", "problem", "civilian", 
"transition", "discharge", "return", "re-entry" or "re-integration", 
"Iraq", Afghanistan", "Enduring Freedom", and "war on terror", From 
these sources, we identified 401 documents that were potentially 
relevant to our review. 

For the first phase, we reviewed the titles and abstracts for each of 
the 401 documents and for additional documents we identified by 
searching GAO and the Congressional Research Service's report 
databases and conducting general Internet searches. We looked for 
common themes and developed a list of issues or themes about veterans' 
readjustment difficulties. One analyst performed these review tasks, 
and then another analyst verified the results. They discussed any 
disagreements on the reviews, screenings, and themes, and worked with 
a third analyst to resolve any remaining disagreements. We presented 
this list to VA officials and veterans during our interviews and site 
visits and asked whether we had identified the types of difficulties 
faced by recently transitioned veterans. In general, the officials and 
veterans agreed that our list captured the range and types of 
difficulties faced by recently transitioned veterans, and we made a 
few additions based on these interviews. 

For the second phase, we screened out documents that were not 
published books, peer-reviewed journals, state or federal government 
reports, or reports from associations and research organizations 
(e.g., RAND). We started with the same 401 documents from our original 
literature search and screened out 114 documents that were from the 
following sources: unpublished papers, dissertations and theses, 
general news articles, conference papers, and hearings. 

We reviewed the titles and abstracts of the remaining 287 documents 
and excluded 179 that focused exclusively on out-of-scope individuals 
or unambiguously used methods that would not provide relevant 
prevalence information. Our screening criteria also excluded articles 
that did not report data from the population relevant to this 
engagement (U.S. military veterans who had already transitioned from 
the military to civilian life after 2001); collected data from case 
studies, focus groups, or other qualitative methods or in a single 
U.S. county or city; or were non-empirical theory or opinion articles. 
Two analysts (one with content expertise and one with methodological 
expertise) independently reviewed each document's title and abstract 
according to a detailed coding manual to indicate whether it should be 
included for further review or excluded based on one of the screening 
criteria. Initial disagreements between analysts were resolved through 
discussion. When in doubt, a document was included rather than 
excluded during this abstract review. 

We then reviewed the remaining 108 documents in a more detailed 
screening step. Two analysts with the same mix of expertise as above 
reviewed the complete documents and excluded articles that did not 
meet any of the screening criteria above, did not report any 
quantitative data relevant to our review, or did not report data for 
recently-transitioned veterans (i.e., those who had transitioned from 
the military to civilian life within 5 years previous to the start of 
the study's data collection). Additionally, documents that included 
reviews of the literature but did not collect new data (referred to as 
"review articles" hereafter) were cataloged but excluded at this 
stage. Initial coding disagreements between analysts were resolved 
through discussion. When in doubt, a document was included rather than 
excluded during this step. Only 13 documents met all our screening 
criteria for a full review. 

We then examined the bibliographies of those 13 documents along with 
the bibliographies of 24 review articles and identified 136 additional 
potentially relevant documents. Then, using the same exclusion 
criteria noted above, one analyst coded each document and a second 
analyst reviewed each document and concurred or did not concur with 
the initial coding. Disagreements were resolved through discussion. 
When in doubt, a document was included rather than excluded at this 
step. We excluded 124 of these documents, which resulted in 12 
additional documents to fully review. 

Two analysts then conducted a full review of the 25 documents (13 from 
the original search and 12 from the second search) to extract relevant 
prevalence and characteristic information and identify important 
caveats for our uses of the results. We excluded an additional seven 
documents during our full review stage, thus leaving 18 of them that 
met our inclusion criteria. The studies that were included are shown 
in table 2. We have described the limitations of the results for our 
use of individual studies within the body of this report. 

Table 2: Studies We Reviewed: 

N. Afari, L. Harder, N. Madra, P. Heppner, T. Moeller-Bertram, C. King, 
and D. Baker, "PTSD, combat injury, and headache in veterans returning 
from Iraq/Afghanistan," Headache, vol. 49 (2009): 1267-1276. 

D. Baker, P. Heppner, N. Afari, S. Nunnink, M. Kilmer, A. Simmons, L. 
Harder, and B. Bosse, "Trauma Exposure, Branch of Service, and Physical 
Injury in Relation to Mental Health Among U.S. Veterans Returning From 
Iraq and Afghanistan," Military Medicine, vol. 174 (Aug. 2009): 773-
778. 

P. Calhoun, J. Elter, E. Jones, Jr., H. Kudler, and K. Straits-Troster, 
"Hazardous alcohol use and receipt of risk-reduction counseling among 
US veterans of the wars in Iraq and Afghanistan," Journal of Clinical 
Psychiatry, vol. 69, no. 11 (Nov. 2008): 1686-1693. 

R. Gironda, M. Clark, J. Massengale, and R. Walker, "Pain among 
veterans of Operations Enduring Freedom and Iraqi Freedom," Pain 
Medicine, vol. 7, no. 4, (2006): 339-343. 

S. Haskell, C. Brandt, E. Krebs, M. Skanderson, R. Kerns, and J. 
Goulet. "Pain among veterans of Operations Enduring Freedom and Iraqi 
Freedom: Do women and men differ?" Pain Medicine, vol. 10, no. 7, 
(2009): 1167-1173. 

D. Helmer, M. Rossignol, M. Blatt, R. Agarwal, R. Teichman, and G. 
Lange, "Health and Exposure Concerns of Veterans Deployed to Iraq and 
Afghanistan," Journal of Occupational and Environmental Medicine, vol. 
49, no. 5 (May 2007): 475-480. 

M. Jakupcak, M. Tull, M. McDermott, D. Kaysen, S. Hunt, T. Simpson, 
"PTSD symptom clusters in relationship to alcohol misuse among Iraq and 
Afghanistan war veterans seeking postdeployment VA health care," 
Addictive Behaviors, vol. 35 (2010): 840-843. 

H. Kang and K. Hyams, "Mental Health Care Needs among Recent War 
Veterans," New England Journal of Medicine, vol. 352, no. 13 (March 31, 
2005): 1289. 

S. Metraux, L. Clegg, J. Daigh, D. Culhane, and V. Kane, "Risk Factors 
for Becoming Homeless Among a Cohort of Veterans Who Served in the Era 
of the Iraq and Afghanistan Conflicts, American Journal of Public 
Health, vol. 103, no. S2 (2013): S255-S261. 

D. Nazarian, R. Kimerling, and S. Frayne, "Posttraumatic Stress 
Disorder, Substance Use Disorders, and Medical Comorbidity Among 
Returning U.S. Veterans," Journal of Traumatic Stress, vol. 25 (April 
2012): 220-225. 

K. Seal, D. Bertenthal, C. Miner, S. Sen, and C. Marmar, "Bringing the 
War Back Home: Mental Health Disorders Among 103788 US Veterans 
Returning From Iraq and Afghanistan Seen at Department of Veterans 
Affairs Facilities," Archives of Internal Medicine, vol. 167 (March 12, 
2007): 476-482. 

K. Seal, D. Bertenthal, S. Maguen, K. Gima, A. Chu, and C. Marmar. 
"Getting Beyond 'Don't Ask; Don't Tell': an Evaluation of U.S. Veterans 
Administration Postdeployment Mental Health Screening of Veterans 
Returning from Iraq and Afghanistan," American Journal of Public 
Health, vol. 98, no. 4 (April 2008): 714-720. 

K. Seal, T. Metzler, K. Gima, D. Bertenthal, S. Maguen, and C. Marmar, 
"Trends and risk factors for mental health diagnoses among Iraq and 
Afghanistan veterans using department of veterans affairs health care, 
2002-2008," American Journal of Public Health, vol. 99, no. 9 (Sept. 
2009): 1651-1658. 

T. Stecker, J. Fortney, R. Owen, M. McGovern, and S. Williams, "Co-
Occurring Medical, Psychiatric, and Alcohol-Related Disorders Among 
Veterans Returning from Iraq and Afghanistan," Psychosomatics, vol. 51, 
no. 6 (Nov. - Dec. 2010): 503-507. 

U.S. Department of Veterans Affairs, Office of Inspector General, Audit 
of Veterans Benefits Administration Transition Assistance for 
Operations Enduring and Iraqi Freedom Service Members and Veterans, 
Report No. 06-03552-169 (Washington, D.C.: July 17, 2008). 

U.S. Department of Veterans Affairs, Office of Inspector General, 
Review of Combat Stress in Women Veterans Receiving VA Health Care and 
Disability Benefits, Report No. 10-01640-45 (Washington, D.C.: Dec. 16, 
2010). 

J. Walker, "Employment Characteristics of Gulf War-era II Veterans in 
2006: a Visual Essay," Monthly Labor Review (May 2008): 3-13. 

Source: GAO. GAO-14-676. 

[End of table] 

Visits to VA Facilities: 

We visited VA facilities in four locations across the United States. 
We selected the locations based on a number of factors including; 
geographic diversity, a mix of military services with bases in the 
area (i.e., Army, Navy, Air Force, or Marines), a high concentration 
of veterans among the local population, and close proximity to VA 
facilities. At each of the selected locations, we visited one VA 
Medical Center and one Vet Center. In three of the four locations, we 
visited VA regional offices that were closest to the VA Medical 
Center. At the VA Medical Centers, we spoke with officials from the 
OEF/OIF/OND Care Coordination Program and the Post Deployment 
Integrated Care Initiative as these programs specifically serve 
readjusting veterans. Similarly, Vet Centers serve readjusting 
veterans, and at each of those facilities we spoke with counselors and 
senior Vet Center staff. At the regional offices we spoke with 
officials from Disability Compensation, Vocational Rehabilitation and 
Employment (VR&E), homeless coordinator programs as well as senior 
regional office officials. We included Disability Compensation and 
VR&E because these programs serve large numbers of veterans, including 
readjusting veterans. We included homeless coordinators because VA 
offers specific programs for veterans at risk of becoming homeless, 
which is one of the difficulties we identified through our initial 
research. 

Table 3: GAO Visits to VA Facilities, by State, City, and Facility 
Visited: 

State: California; 
City: San Diego; 
VA facility visited: 
VA San Diego Healthcare System; 
San Diego Vet Center; 
San Diego Regional Benefit Office. 

State: Maryland; 
City: Baltimore; 
VA facility visited: 
Baltimore VA Medical Center; 
Baltimore Vet Center. 

State: North Carolina; 
City: Fayetteville; 
VA facility visited: 
Fayetteville VA Medical Center; 
Fayetteville Vet Center. 

State: North Carolina; 
City: Winston-Salem; 
VA facility visited: 
Winston-Salem Regional Benefit Office. 

State: Texas; 
City: Houston; 
VA facility visited: 
Houston Regional Benefit Office. 

State: Texas; 
City: San Antonio; 
VA facility visited: 
Audie L. Murphy Memorial Veterans Hospital; 
San Antonio NW Vet Center. 

Source: GAO. GAO-14-676. 

[End of table] 

At each VA Medical Center and Vet Center, we conducted 
nongeneralizable discussion groups with veterans to gain a better 
understanding of their experiences with readjusting to civilian life. 
VA officials from each center invited veterans who had separated from 
the military within the last few years and who served during the 
OEF/OIF era (since September 11, 2001). At each location we visited we 
conducted two group discussions with veterans with between two and 
eight veterans attending each discussion. At two of the discussion 
groups, family members were present and a total of 45 veterans and 
family members participated. At the start of each discussion group we 
asked the veterans to rate how well they felt prepared for their 
transition from military to civilian life. We also asked them to rate 
the level of difficulty they had with employment, getting the right 
health care, being healthy, going back to school, getting along with 
family and friends, managing finances, getting assistance from VA, 
avoiding legal trouble, and finding a place to live. We used their 
responses to guide the discussions to gain a qualitative understating 
for why veterans experienced difficulties with their readjustment and 
what VA could do to better assist them. We conducted interviews with 
representatives from veteran service organizations at three of the 
four locations we visited because of their experience in working with 
veterans including representatives from American Legion, AmVets, 
Disabled American Veterans, the Military Order of the Purple Heart and 
Veterans of Foreign Wars. 

We conducted this performance audit from March 2013 to September 2014 
in accordance with generally accepted government auditing standards. 
These 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. 

[End of section] 

Appendix II: Comments from the Department of Veterans Affairs: 

Department Of Veterans Affairs: 
Washington DC 20420: 

August 13, 2014: 

Mr. Daniel Bertoni: 
Director, Education Workforce and Income Security: 
U.S. Government Accountability Office: 
441 G Street, NW: 
Washington, DC 20548: 

Dear Mr. Bertoni: 

The Department of Veterans Affairs (VA) has reviewed the Government
Accountability Office's (GAO) draft report, "Veterans Affairs: Better
Understanding Needed to Enhance Services to Veterans Readjusting to 
Civilian Life" (GAO-14-676). VA generally agrees with GAO's 
conclusions and concurs with GAO's recommendation to the Department. 

The enclosure specifically addresses GAO's recommendation and provides
technical comments to the draft report. VA appreciates the opportunity 
to comment on your draft report. 

Sincerely, 

Signed by: 

Jose D. Riojas: 
Chief of Staff: 

Enclosure: 

Department of Veterans Affairs (VA) Response to Government 
Accountability Office (GAO) Draft Report: 

"Veterans Affairs: Better Understanding Needed to Enhance Services to
Veterans Readjusting to Civilian Life" (GAO-14-676): 

GAO Recommendation: The Acting Secretary of Veterans Affairs take 
steps to better understand both the difficulties faced by readjusting 
veterans and the characteristics of those who may be more likely to 
face such difficulties, and use the results to determine how best to 
enhance its benefits and services to these veterans. 

VA Comment: Concur. The Department of Veterans Affairs (VA) supports and
engages in a philosophy of continuous improvement with respect to the 
benefits and services provided to Veterans and their families. As 
noted by GAO in its report, VA provides an expansive scope of programs 
and services to meet the ever-changing and varied needs of our Veteran 
population. One area where VA identified the need for closer 
examination was in the coordination of all these programs and services,
especially for those who are in need of complex care. Coordination is 
necessary not only within VA but also across Department lines with our 
partners in the Department of Defense (DoD). 

VA established the Office of Interagency Care and Benefits 
Coordination (ICBC) in early 2014. One of ICBC's functions is to 
provide support for the VA/DoD Interagency Care Coordination Committee 
(IC3). The IC3, in coordination and consultation with the more than 50 
programs in its Community of Practice, is undertaking a quality case 
review evaluation. This longitudinal evaluation will employ case 
studies of Servicemembers and Veterans to identify best practices as 
well as potential gaps in programs and services required for a 
successful readjustment to civilian life. The results of this 
examination will be used to inform policy changes and program 
improvements to reduce difficulties faced by readjusting Veterans. 

VA, in partnership with DoD, Department of Labor (DoL), and Small 
Business Administration, recently implemented significant changes to 
improve the Transition Assistance Program, now known as the Transition 
Goals, Plans, Success (GPS) Program. Transition GPS facilitates a 
better identification of Servicemembers, who may have transition 
issues, and prepares Servicemembers to be better prepared for the
adjustment to civilian life, including by enabling them to access 
appropriate support from VA and DoL programs after they leave the 
military. Transition GPS upgraded career counseling to include 
individualized assessments and a collaborative Veterans' training,
mentoring, and placement program. It also resulted in the revamping of 
VA benefits briefings with improved quality of instruction to better 
inform Servicemembers on earned benefits. Servicemembers also have an 
increased opportunity to identify the specific benefits for which they 
are eligible. Transition GPS is also now mandatory, to include Guard 
and Reserve component Servicemembers demobilizing after 180 days or more
of active service. 

New and expanded services include: 

* Enhanced VA Benefits Briefings: Comprehensive benefits workshops
covering the entire spectrum of VA benefits available to 
Servicemembers and Veterans. 

* Individual Transition Plan: Customized roadmap to tailor individual 
needs for success after leaving service. 

* Employment Workshop: DoL Specialists assist with translating 
military skills and training for civilian jobs. 

All of these segments confirm the objectives of the career readiness 
standards have been met to ensure each Servicemember has established a 
viable plan to successfully achieve transition goals and connect with 
the proper resources as they become Veterans. 

Servicemembers may also elect to participate in an optional VA-
sponsored, 2-day Career Technical Training Track (CTTT), as part of 
the Transition GPS Program. It is one of three Servicemember-selected 
tracks, with the other two focusing on education for those wishing to 
pursue a college degree or entrepreneurship for those wishing to start 
their own business. The CTTT assists Servicemembers and spouses 
wishing to transition into technical fields which may require 
additional credentials but not a 4-year degree, upon departing the 
military. Servicemembers pursuing further technical training will 
receive guidance on utilizing their VA education benefits and help in 
selecting schools and technical fields with an emphasis on topics, 
such as selection of a reputable career and technical training school, 
the application process from start to finish, and how to use 
certification finder Web tools to identify licensed occupations. 

[End of section] 

Appendix III: GAO Contact and Staff Acknowledgments: 

GAO Contact: 

Daniel Bertoni, bertonid@gao.gov or (202) 512-7215: 

Staff Acknowledgments: 

In addition to the contact named above, Brett Fallavollita (Assistant 
Director); Paul Schearf (Analyst-In-Charge), Janina Austin, David 
Chrisinger, Lorraine Ettaro, Jeffrey Fiore, David Forgosh, Ashley 
McCall, Sheila McCoy, Michael Silver, Almeta Spencer, Roger Thomas, 
Karin Wallestad, James Whitcomb, and Paul Wright made key 
contributions to this report. 

[End of section] 

Related GAO Products: 

Military Sexual Trauma: Improvements Made, but VA Can Do More to Track 
and Improve the Consistency of Disability Claim Decisions. [hyperlink, 
http://www.gao.gov/products/GAO-14-477]. Washington, D.C.: June 9, 
2014. 

VA Education Benefits: VA Should Strengthen Its Efforts to Help 
Veterans Make Informed Education Choices. [hyperlink, 
http://www.gao.gov/products/GAO-14-324]. Washington, D.C.: May 13, 
2014. 

Transitioning Veterans: Improved Oversight Needed to Enhance 
Implementation of Transition Assistance Program. [hyperlink, 
http://www.gao.gov/products/GAO-14-144]. Washington, D.C.: March 5, 
2014. 

VA Education Benefits: Student Characteristics and Outcomes Vary 
across Schools. [hyperlink, http://www.gao.gov/products/GAO-13-567]. 
Washington, D.C.: July 25, 2013. 

VA Health Care: Additional Steps Needed to Strengthen Beneficiary 
Travel Program Management and Oversight. [hyperlink, 
http://www.gao.gov/products/GAO-13-632]. Washington, D.C.: July 15, 
2013. 

VA Education Benefits: VA Needs to Improve Program Management and 
Provide More Timely Information to Students. [hyperlink, 
http://www.gao.gov/products/GAO-13-338]. Washington, D.C.: May 22, 
2013. 

Electronic Health Records: Long History of Management Challenges 
Raises Concerns about VA's and DOD's New Approach to Sharing Health 
Information. [hyperlink, http://www.gao.gov/products/GAO-13-413T]. 
Washington, D.C.: February 27, 2013. 

VA Health Care: Reliability of Reported Outpatient Medical Appointment 
Wait Times and Scheduling Oversight Need Improvement. [hyperlink, 
http://www.gao.gov/products/GAO-13-130]. Washington, D.C.: December 
21, 2012 (and related testimonies, 

[hyperlink, http://www.gao.gov/products/GAO-13-363T], February 13, 
2013; and [hyperlink, http://www.gao.gov/products/GAO-14-679T], June 
9, 2014). 

Veteran Homelessness: VA and HUD Are Working to Improve Data on 
Supportive Housing Program. [hyperlink, 
http://www.gao.gov/products/GAO-12-726]. Washington, D.C.: June 26, 
2012. 

Veterans' Disability Benefits: Timely Processing Remains a Daunting 
Challenge. [hyperlink, http://www.gao.gov/products/GAO-13-89]. 
Washington, D.C.: December 21, 2012 (and related testimony, 
[hyperlink, http://www.gao.gov/products/GAO-13-453T], May 13, 2013). 

Recovering Servicemembers and Veterans: Sustained Leadership Attention 
and Systematic Oversight Needed to Resolve Persistent Problems 
Affecting Care and Benefits. [hyperlink, 
http://www.gao.gov/products/GAO-13-5]. Washington, D.C.: November 16, 
2012. 

DOD and VA Health Care: Medication Needs during Transitions May Not Be 
Managed for All Servicemembers. [hyperlink, 
http://www.gao.gov/products/GAO-13-26]. Washington, D.C.: November 2, 
2012. 

VA and DOD Health Care: Department-Level Actions Needed to Assess 
Collaboration Performance, Address Barriers, and Identify 
Opportunities. [hyperlink, http://www.gao.gov/products/GAO-12-992]. 
Washington, D.C.: September 28, 2012. 

Defense Health: Coordinating Authority Needed for Psychological Health 
and Traumatic Brain Injury Activities. [hyperlink, 
http://www.gao.gov/products/GAO-12-154]. Washington, D.C.: January 25, 
2012. 

Homeless Women Veterans: Actions Needed to Ensure Safe and Appropriate 
Housing. [hyperlink, http://www.gao.gov/products/GAO-12-182]. 
Washington, D.C.: December 23, 2011. 

VA Mental Health: Number of Veterans Receiving Care, Barriers Faced, 
and Efforts to Increase Access. [hyperlink, 
http://www.gao.gov/products/GAO-12-12]. Washington, D.C.: October 14, 
2011. 

Veterans' Education Benefits: Enhanced Guidance and Collaboration 
Could Improve Administration of the Post-9/11 GI Bill Program. 
[hyperlink, http://www.gao.gov/products/GAO-11-356R]. Washington, 
D.C.: May 5, 2011. 

DOD and VA Health Care: Federal Recovery Coordination Program 
Continues to Expand but Faces Significant Challenges. [hyperlink, 
http://www.gao.gov/products/GAO-11-250]. Washington, D.C.: March 23, 
2011. 

VA Education Benefits: Actions Taken, but Outreach and Oversight Could 
Be Improved. [hyperlink, http://www.gao.gov/products/GAO-11-256]. 
Washington, D.C.: February 28, 2011. 

VA Health Care: VA Spends Millions on Post-Traumatic Stress Disorder 
Research and Incorporates Research Outcomes into Guidelines and Policy 
for Post-Traumatic Stress Disorder Services. [hyperlink, 
http://www.gao.gov/products/GAO-11-32]. Washington, D.C.: January 24, 
2011. 

VA Health Care: Reporting of Spending and Workload for Mental Health 
Services Could Be Improved. [hyperlink, 
http://www.gao.gov/products/GAO-10-570]. Washington, D.C.: May 28, 
2010. 

VA Health Care: VA Has Taken Steps to Make Services Available to Women 
Veterans, but Needs to Revise Key Policies and Improve Oversight 
Processes. [hyperlink, http://www.gao.gov/products/GAO-10-287]. 
Washington, D.C.: March 31, 2010. 

Veterans' Disability Benefits: VA Has Improved Its Programs for 
Measuring Accuracy and Consistency, but Challenges Remain. [hyperlink, 
http://www.gao.gov/products/GAO-10-530T]. Washington, D.C.: March 24, 
2010. 

Recovering Servicemembers: DOD and VA Have Made Progress to Jointly 
Develop Required Policies but Additional Challenges Remain. 
[hyperlink, http://www.gao.gov/products/GAO-09-540T]. Washington, 
D.C.: April 29, 2009. 

VA National Initiatives and Local Programs that Address Education and 
Support for Families of Returning Veterans. [hyperlink, 
http://www.gao.gov/products/GAO-09-22R]. Washington, D.C.: October 22, 
2008. 

VA and DOD Health Care: Efforts to Provide Seamless Transition of Care 
for OEF and OIF Servicemembers and Veterans. [hyperlink, 
http://www.gao.gov/products/GAO-06-794R]. Washington, D.C.: June 30, 
2006. 

Military and Veterans' Benefits: Enhanced Services Could Improve 
Transition Assistance for Reserves and National Guard. [hyperlink, 
http://www.gao.gov/products/GAO-05-544]. Washington, D.C.: May 20, 
2005. 

DOD and VA: Systematic Data Sharing Would Help Expedite 
Servicemembers' Transition to VA Services. [hyperlink, 
http://www.gao.gov/products/GAO-05-722T]. Washington, D.C.: May 19, 
2005. 

[End of section] 

Footnotes: 

[1] We screened out articles that did not report original quantitative 
information on the prevalence of transition difficulties or 
characteristics of the types of veterans who have these difficulties; 
were not methodologically rigorous, such as surveys that did not 
select a representative sample of veterans; or did not report data for 
recently transitioned veterans. We defined recently transitioned 
veterans as those who were within the first 5 years after their 
separation from the military. For more detailed information on our 
screening criteria, see appendix I. 

[2] Generally, in order to receive VA benefits and services, the 
veteran's character of discharge or service must be under other than 
dishonorable conditions (e.g., honorable, under honorable conditions, 
general). However, individuals receiving undesirable, bad conduct, and 
other types of dishonorable discharges may qualify for VA benefits 
depending on a determination made by VA. In addition, specific VA 
benefits and services may have additional eligibility criteria. 

[3] VA, Department of Veterans Affairs, Fiscal Years 2015 President's 
Budget Request: Volume I, Summary (2014). 

[4] VA, Department of Veterans Affairs, Fiscal Years 2015 President's 
Budget Request: Volume II, Medical Programs and Information Technology 
Programs (2014). 

[5] VA, Department of Veterans Affairs, Fiscal Years 2015 President's 
Budget Request: Volume III, Benefits and Burial Programs and 
Departmental Administration (2014). 

[6] The Wounded Warrior Act was enacted as part of the National 
Defense Authorization Act for Fiscal Year 2008. For requirements in 
the Act related to the comprehensive policy to be jointly developed 
and implemented by DOD and VA, see Pub. L. No. 110-181, tit. XVI, § 
1611, 122 Stat. 3, 430, 433. The Act defines a "recovering service 
member" as a member of the Armed Forces, including the National Guard 
or Reserve, who is undergoing medical treatment, recuperation, or 
therapy and is in an outpatient status while recovering from a serious 
injury or illness related to the member's military service. See 122 
Stat. 432. 

[7] [7] Pub. L. No. 112-56, tit. II, 125 Stat. 711, 712. The VOW Act 
was enacted amid concerns about the effectiveness of TAP and 
indicators that some post-9/11 veterans were having difficulty 
transitioning to civilian employment. The administration called on DOD 
and VA to lead the Veterans Employment Initiative Task Force, which 
oversaw the design and development of the revised TAP. Other agencies 
participating on the Veterans Employment Initiative Task Force include 
the Department of Labor, the Department of Education, the Office of 
Management and Budget, the Office of Personnel Management, and the 
Small Business Administration (SBA). DOD provides guidance and 
monitors compliance with TAP provisions, and Department of Labor 
facilitates the employment workshop. A new TAP governance structure, 
established in October 2013, steers implementation of TAP and will 
modify the program, as needed, through 2016. The new governance 
structure is co-led by DOD and Department of Labor and co-chaired by 
VA and the Department of Labor. 

[8] The IDES merges DOD and VA processes, so that servicemembers begin 
the VA disability claim process while they undergo their DOD 
disability evaluation, rather than sequentially, with the goal for 
them to receive VA disability benefits shortly after leaving military 
service. DOD established Directive-Type Memorandum with VA in 2011 
that stated the IDES medical examinations would include general 
examinations that were to be performed by VA staff in accordance with 
VA disability compensation and pension standards. The resulting 
examinations would be used to assess VA disability rating 
determinations and assist military departments with determining 
servicemembers' fitness for duty. 

[9] In 2012, we reported, DOD and VA had deployed IDES at 139 DOD 
Military Treatment Facilities in the United States and other 
countries. GAO, Recovering Servicemembers and Veterans: Sustained 
Leadership Attention and Systematic Oversight Needed to Resolve 
Persistent Problems Affecting Care and Benefits, [hyperlink, 
http://www.gao.gov/products/GAO-13-5] (Washington, D.C.: Nov. 16, 
2012). 

[10] Operation Enduring Freedom began October 7, 2001, and is still 
ongoing. Operation Iraqi Freedom began March 19, 2003, and ended 
August 31, 2010. Operation New Dawn began September 1, 2010, and ended 
December 15, 2011. 

[11] Of the 1.6 million OEF/OIF/OND veterans, over 900,000 were former 
active duty and about 700,000 were Reserve and National Guard. 

[12] J. Walker, "Employment Characteristics of Gulf War-era II 
Veterans in 2006: a Visual Essay," Monthly Labor Review (May 2008): 3, 
10. The unemployment rates cited applied to both OEF/OIF veterans 
(regardless of where they had served) and nonveterans, between the 
ages of 18 and 54. 

[13] Often referred to as the Post-9/11 G.I. Bill, the official name 
of the law is the Post-9/11 Veterans Educational Assistance Act of 
2008. See Pub. L. No. 110-252, tit. V, 122 Stat. 2323, 2357. 

[14] M. Noonan and C. Mumola, "Veterans in State and Federal Prison, 
2004," U.S. Department of Justice, Office of Justice Programs, Bureau 
of Justice Statistics, NCJ 217199 (May 2007): 9. Based on the sampling 
error estimates provided in the report, we calculated that at the 95 
percent confidence level, there were between 2,944 and 7,616 OEF/OIF 
veterans who had separated from the military between 2002 and 2004 who 
were incarcerated in either state or federal correctional facilities 
in 2004. 

[15] S. Metraux, L. Clegg, J. Daigh, D. Culhane, and V. Kane, "Risk 
Factors for Becoming Homeless Among a Cohort of Veterans Who Served in 
the Era of the Iraq and Afghanistan Conflicts," American Journal of 
Public Health, vol. 103, no. S2 (2013): S256, S258, S259. 

[16] GAO, Homeless Women Veterans: Actions Needed to Ensure Safe and 
Appropriate Housing. [hyperlink, 
http://www.gao.gov/products/GAO-12-182] (Washington, D.C.: Dec. 23, 
2011). 

[17] D. Nazarian, R. Kimerling, and S. Frayne, "Posttraumatic Stress 
Disorder, Substance Use Disorders, and Medical Comorbidity Among 
Returning U.S. Veterans," Journal of Traumatic Stress, vol. 25 (April 
2012): 221, 224. Results from a sample of veterans who sought 
treatment cannot be generalized to a broader population of veterans 
(particularly those that had not sought VA treatment). 

[18] P. Calhoun, J. Elter, E. Jones, Jr., H. Kudler, and K. Straits-
Troster, "Hazardous alcohol use and receipt of risk-reduction 
counseling among US veterans of the wars in Iraq and Afghanistan," 
Journal of Clinical Psychiatry, vol. 69, no. 11 (Nov. 2008): 1688 -
1689. The study used data extracted from the VA outpatient Survey of 
Healthcare Experiences of Patients (SHEP), which was a stratified 
random sample of VA clinic users from fiscal year 2005. SHEP was 
mailed monthly to a sample of VA outpatients who had a VA clinic visit 
in the past 60 days and who had not been surveyed during the same 
fiscal year. During FY 2005, surveys were mailed to 7,156 OEF/OIF vets 
who met the SHIP criteria; 164 (2.3 percent) were returned as 
undeliverable. A total of OEF/OIF 1,508 veterans responded to the 
fiscal year 2005 SHEP survey with complete answers to the alcohol use 
standardized instrument, which were used to assess hazardous drinking 
and possible alcohol use disorder leaving a response rate to the 
alcohol use instrument of 22 percent (1,508 of 7,320). The results of 
self-reported screening do not represent diagnoses. Some participants 
may have reported answers that are false positives or false negatives. 

[19] N. Afari, L. Harder, N. Madra, P. Heppner, T. Moeller-Bertram, C. 
King, and D. Baker, "PTSD, combat injury, and headache in veterans 
returning from Iraq/Afghanistan," Headache, vol. 49 (2009): 1272, 1273. 

[20] K. Seal, D. Bertenthal, S. Maguen, K. Gima, A. Chu, and C. 
Marmar, "Getting Beyond 'Don't Ask: Don't Tell': an Evaluation of U.S. 
Veterans Administration Postdeployment Mental Health Screening of 
Veterans Returning from Iraq and Afghanistan," American Journal of 
Public Health, vol. 98, no. 4 (April 2008): 717, and T. Stecker, J. 
Fortney, R. Owen, M. McGovern, and S. Williams, "Co-Occurring Medical, 
Psychiatric, and Alcohol-Related Disorders Among Veterans Returning 
from Iraq and Afghanistan," Psychosomatics, vol. 51, no. 6 (Nov. - 
Dec. 2010): 505. 

[21] D. Baker, P. Heppner, N. Afari, S. Nunnink, M. Kilmer, A. 
Simmons, L. Harder, and B. Bosse, "Trauma Exposure, Branch of Service, 
and Physical Injury in Relation to Mental Health Among US Veterans 
Returning From Iraq and Afghanistan," Military Medicine, vol. 174 
(Aug. 2009): 775. 

[22] Department of Veterans Affairs, Office of Inspector General, 
Review of Combat Stress in Women Veterans Receiving VA Health Care and 
Disability Benefits, Report No. 10-01640-45 (Washington, D.C.: Dec. 
16, 2010): 28, 29. The percentages reported are only for the cohort of 
veterans discharged between July 2005 and September 2006, and 
therefore may not be representative of the prevalence rates for all 
OEF/OIF veterans who discharged after September 2001 and sought 
treatment by the end of the study. 

[23] S. Haskell, C. Brandt, E. Krebs, M. Skanderson, R. Kerns, and J. 
Goulet, "Pain among veterans of Operations Enduring Freedom and Iraqi 
Freedom: Do women and men differ?" Pain Medicine, vol. 10, no. 7, 
(2009): 1169.; R. Gironda, M. Clark, J. Massengale, and R. Walker, 
"Pain among veterans of Operations Enduring Freedom and Iraqi 
Freedom," Pain Medicine, vol. 7, no. 4, (2006): 340, 341; and Stecker, 
et al., "Co-Occurring Medical, Psychiatric, and Alcohol-Related 
Disorders," 504, 505. 

[24] Stecker, et al., "Co-Occurring Medical, Psychiatric, and Alcohol-
Related Disorders," 505. D. Helmer, M. Rossignol, M. Blatt, R. 
Agarwal, R. Teichman, and G. Lange, "Health and Exposure Concerns of 
Veterans Deployed to Iraq and Afghanistan," Journal of Occupational 
and Environmental Medicine, vol. 49, no. 5 (May 2007): 478, 479. 

[25] Authors of these studies acknowledged the limitations of 
generalizing the results from a sample of veterans who sought 
treatment to a broader population of veterans (particularly those that 
had not sought VA treatment). Estimates could be influenced by 
methodologies that tended to include either veterans' self-reported 
conditions or a review of clinical records. Although the veterans in 
the studies typically completed one or more questionnaires that had 
been previously validated, self-reported data do not reflect diagnoses 
by clinical professionals and a social desirability factor could lead 
to underreporting of certain sensitive problems or inflated symptom 
reporting in an effort to seek benefits, such as disability 
compensation. 

[26] VA, Office of Inspector General, Review of Combat Stress, 19. 
These are the combined totals of mental health diagnoses and V-codes 
that represent psychosocial or behavioral problems. (V-codes identify 
problems that are a focus for mental health treatment, but are not 
considered mental health diagnoses.) 

[27] According to a joint DOD-VA clinical guideline, TBI can be caused 
by such things as a person's head being struck by an object, the head 
striking an object, or a blast or explosion, among other things. Its 
clinical signs include a loss of or a decreased level of 
consciousness, loss of memory, confusion, disorientation, slowed 
thinking, or neurological problems (weakness, loss of balance, and 
change in vision). The most common type of TBI is called 
concussion/mild TBI, and typical symptoms fall into one or more of the 
categories of physical, cognitive, or behavioral/emotional problems. 
VA and DOD, VA/DoD Clinical Practice Guideline for Management of 
Concussion/Mild Traumatic Brain Injury (Washington, D.C.: April 2009): 
7, 9, 10, 21. Studies that we reviewed that included TBI discussed its 
mental health-related symptoms and its occurrence together with PTSD 
or depression in some veterans. 

[28] Stecker et al., "Co-Occurring Medical, Psychiatric, and Alcohol-
Related Disorders": 505. Haskell et al., "Pain Among Veterans." 

[29] One study we reviewed reported that 28 percent of women veterans 
and 36 percent of men in their study were diagnosed with PTSD. The 
study's authors limited the population of veterans to those who had 
two or more primary care visits in two fiscal years and classified a 
patient as having PTSD if the patient's record had at least one 
instance of diagnosed PTSD. D. Nazarian, Posttraumatic Stress 
Disorder, "Substance Use Disorders, and Medical Comorbidity," 221. 

[30] K. Seal, D. Bertenthal, C. Miner, S. Sen, and C. Marmar, 
"Bringing the War Back Home: Mental Health Disorders Among 103788 US 
Veterans Returning From Iraq and Afghanistan Seen at Department of 
Veterans Affairs Facilities," Archives of Internal Medicine, vol. 167 
(Mar. 12, 2007): 478, 479. 

[31] K. Seal et al., "Getting Beyond 'Don't Ask: Don't Tell'," 716, 
717. 

[32] D. Baker et al., "Trauma Exposure, Branch of Service, and 
Physical Injury," 775, 776, 778. 

[33] M. Jakupcak, J. Luterek, S. Hunt, D. Conybeare, and M. McFall, 
"Posttraumatic Stress and its Relationship to Physical Health 
Functioning in a Sample of Iraq and Afghanistan War Veterans Seeking 
Postdeployment VA Health Care," Journal of Nervous and Mental Disease, 
vol. 196, no. 5 (May 2008): 427. 

[34] Afari et al., "PTSD, Combat Injury, and Headache," 1271. 

[35] H. Kang and K. Hyams, "Mental Health Care Needs among Recent War 
Veterans," New England Journal of Medicine, vol. 352, no. 13 (March 
31, 2005): 1289. 

[36] Seal et al., "Bringing the War Back Home," 478-479. 

[37] Seal et al., "Bringing the War Back Home," 478-479, 480. 

[38] Calhoun et al., "Hazardous Alcohol Use," 1689. 

[39] Haskell et al., "Pain Among Veterans," 1169. 

[40] Nazarian et al., "Posttraumatic Stress Disorder, Alcohol Use 
Disorders, and Medical Comorbidity," 221. 

[41] Calhoun et al., "Hazardous Alcohol Use," 1689. 

[42] Kang and Hyams, "Mental Health Care Needs," 1289. 

[43] Seal et al., "Bringing the War Back Home," 478. 

[44] We recently reported on the status of implementing key components 
of the TAP program. We recommended that DOD improve its oversight and 
implementation of TAP by working with partner agencies to develop a 
written strategy for evaluating the program, take action to gauge 
participation in TAP, and collect data about National Guard and 
Reserve members' experiences with the timing and location of TAP 
workshops. DOD agreed with our recommendation to work with partner 
agencies to develop a written strategy for evaluating the program and 
stated that its continuing support for interagency collaboration is 
formalized in a memorandum of understanding among the agencies 
administering TAP. DOD disagreed with our recommendations to gauge 
participation levels and collect data on National Guard and Reserve 
members. GAO, Transition Veterans: Improved Oversight Needed to 
Enhance Implementation of Transition Assistance Program, [hyperlink, 
http://www.gao.gov/products/GAO-14-144] (Washington, D.C.: Mar. 5, 
2014). 

[45] In 2012, the YRRP, provided information and resources, including 
VA-related information and resources, to more than 240,000 National 
Guard and Reserve members. 

[46] Mobile Vet Centers are operated by Vet Centers. Vet Centers offer 
post-deployment adjustment counseling for veterans--who experienced 
combat situations, had sexual trauma, or witnessed the death of 
another soldier--as well as their families. Mobile Vet Centers have 
counseling rooms, satellite systems, and computer equipment. In 2013 
there were 70 Mobile Vet Centers operating across the United States. 

[47] Some veteran service organizations are recognized, or chartered, 
by the Secretary of Veterans Affairs for preparing, presenting, and 
prosecuting claims under laws administered by VA. 

[48] VA reports that more than 2.8 million veterans have registered 
through eBenefits from 2009 to 2013. 

[49] VA's ratings are made in 10 percent increments, from 0 to 100 
percent. Generally, VA does not pay disability compensation for 
disabilities rated at 0 percent. As of 2013, basic monthly payments 
ranged from $129 for a veteran with 10 percent disability to $ 2,816 
for a veteran with 100 percent disability and no dependents. 

[50] In 2013, VA reported VR&E served about 124,000 participants. 

[51] Prosthetic & Sensory Aids Service (PSAS) provides support to 
optimize health and independence of the veteran through the provision 
of prosthetic and orthotic services, sensory aids, medical equipment, 
and other support services. 

[52] Such veterans are not subject to copays for services received for 
conditions potentially related to their combat service. The 5-year 
period generally begins on the date of discharge or separation of the 
service member from active duty. 

[53] According to VA officials, the OEF/OIF/OND Care Coordination 
Program has enrolled more than 800,000 veterans. 

[54] GAO, VA Health Care: Access for Chattanooga-Area Veterans Needs 
Improvement. [hyperlink, http://www.gao.gov/products/GAO-04-162] 
(Washington, D.C.: Jan. 30, 2004). 

[55] VA, 2009 Performance and Accountability Report (Nov. 16, 2009). 

[56] GAO, VA Mental Health: Number of Veterans Receiving Care, 
Barriers Faced, and Efforts to Increase Access. [hyperlink, 
http://www.gao.gov/products/GAO-12-12] (Washington, D.C.: Oct. 14, 
2011). 

[57] GAO, VA Health Care: Reliability of Reported Outpatient Medical 
Appointment Wait Times and Scheduling Oversight Need Improvement. 
[hyperlink, http://www.gao.gov/products/GAO-13-130] (Washington, D.C.: 
Dec. 21, 2012). 

[58] VA, Access Audit System-Wide Review of Access: Results of Access 
Audit Conducted May 12, 2014 through June 3, 2014, accessed June 17, 
2014, [hyperlink, 
http://www.va.gov/health/docs/VAAccessAuditFindingsReport.pdf]. 

[59] GAO, Major Management Challenges and Program Risks: Department of 
Veterans Affairs, [hyperlink, http://www.gao.gov/products/GAO-03-110] 
(Washington, D.C.: January 2003). 

[60] GAO, Veterans' Disability Benefits: Claims Processing Persist 
while VA Continues to Take Steps to Address Them. [hyperlink, 
http://www.gao.gov/products/GAO-08-473T] (Washington, D.C.: Feb. 14, 
2008). 

[61] GAO, Veterans' Disability Benefits: Timely Processing Remains a 
Daunting Challenge, [hyperlink, http://www.gao.gov/products/GAO-13-89] 
(Washington, D.C.: Dec. 21, 2012). 

[62] VA, 2013 Performance and Accountability Report (Dec. 16, 2013). 

[63] GAO,VA Education Benefits: Actions Taken, but Outreach and 
Oversight Could Be Improved (Washington, D.C.: Feb. 28, 2011). 

[64] GAO, VA Education Benefits: VA Should Strengthen Its Efforts to 
Help Veterans Make Informed Education Choices. [hyperlink, 
http://www.gao.gov/products/GAO-14-324] (Washington, D.C.: May 13, 
2014). 

[65] GAO, Military and Veterans Disability System: Preliminary 
Observations on Evaluation and Planned Expansion of DOD/VA Pilot, 
[hyperlink, http://www.gao.gov/products/GAO-11-191T] (Washington, 
D.C.: Nov. 18, 2010). 

[66] GAO, Military and Veterans Disability System: Pilot Has Achieved 
Some Goals, but Further Planning and Monitoring Needed, [hyperlink, 
http://www.gao.gov/products/GAO-11-69] (Washington, D.C.: Dec. 6, 
2010). 

[67] [hyperlink, http://www.gao.gov/products/GAO-13-5]. 

[68] VA, 2013 Performance and Accountability Report (Dec. 16, 2013). 

[69] [hyperlink, http://www.gao.gov/products/GAO-03-110]. 

[70] VA, 2008 Performance and Accountability Report (Nov. 17, 2008). 

[71] VA, 2011 Performance and Accountability Report (Nov. 15, 2011). 

[72] [hyperlink, http://www.gao.gov/products/GAO-13-5]. 

[73] VA and DOD, Electronic Health Record U-Turn: Are VA and DOD 
Headed in the Wrong Direction?, testimony before the House Committee 
on Veterans' Affairs. Serial No. 113-6, February 27, 2013. 

[74] GAO, VA and Defense Health Care: Increased Risk of Medication 
Errors for Shared Patients, [hyperlink, 
http://www.gao.gov/products/GAO-02-1017] (Washington, D.C.: Sept. 27, 
2002). 

[75] [hyperlink, http://www.gao.gov/products/GAO-03-110]. 

[76] GAO, DOD and VA Health Care: Medication Needs During Transitions 
May Not Be Managed for All Servicemembers, [hyperlink, 
http://www.gao.gov/products/GAO-13-26] (Washington, D.C.: Nov. 14, 
2012). 

[77] [hyperlink, http://www.gao.gov/products/GAO-13-26]. 

[78] Specifically, the memorandum of understanding states DOD shall 
provide information to VA upon the separation or discharge of an 
individual from military service for the purpose of determining 
eligibility for, or entitlement to, benefits under laws administered 
by the Secretary of Veterans Affairs. 

[79] GAO, Standards for Internal Control in the Federal Government, 
[hyperlink, http://www.gao.gov/products/GAO/AIMD-00-21.3.1] 
(Washington, D.C.: November 1999). 

[End of section] 

GAO's Mission: 

The Government Accountability Office, the audit, evaluation, and 
investigative arm of Congress, exists to support Congress in meeting 
its constitutional responsibilities and to help improve the 
performance and accountability of the federal government for the 
American people. GAO examines the use of public funds; evaluates 
federal programs and policies; and provides analyses, recommendations, 
and other assistance to help Congress make informed oversight, policy, 
and funding decisions. GAO's commitment to good government is 
reflected in its core values of accountability, integrity, and 
reliability. 

Obtaining Copies of GAO Reports and Testimony: 

The fastest and easiest way to obtain copies of GAO documents at no 
cost is through GAO's website [hyperlink, http://www.gao.gov]. Each 
weekday afternoon, GAO posts on its website newly released reports, 
testimony, and correspondence. To have GAO e-mail you a list of newly 
posted products, go to [hyperlink, http://www.gao.gov] and select 
"E-mail Updates." 

Order by Phone: 

The price of each GAO publication reflects GAO's actual cost of 
production and distribution and depends on the number of pages in the 
publication and whether the publication is printed in color or black 
and white. Pricing and ordering information is posted on GAO's 
website, [hyperlink, http://www.gao.gov/ordering.htm]. 

Place orders by calling (202) 512-6000, toll free (866) 801-7077, or 
TDD (202) 512-2537. 

Orders may be paid for using American Express, Discover Card, 
MasterCard, Visa, check, or money order. Call for additional 
information. 

Connect with GAO: 

Connect with GAO on facebook, flickr, twitter, and YouTube.
Subscribe to our RSS Feeds or E mail Updates. Listen to our Podcasts.
Visit GAO on the web at [hyperlink, http://www.gao.gov]. 

To Report Fraud, Waste, and Abuse in Federal Programs: 

Contact: 
Website: [hyperlink, http://www.gao.gov/fraudnet/fraudnet.htm]; 
E-mail: fraudnet@gao.gov; 
Automated answering system: (800) 424-5454 or (202) 512-7470. 

Congressional Relations: 

Katherine Siggerud, Managing Director, siggerudk@gao.gov: 
(202) 512-4400: 
U.S. Government Accountability Office: 
441 G Street NW, Room 7125: 
Washington, DC 20548. 

Public Affairs: 

Chuck Young, Managing Director, youngc1@gao.gov: 
(202) 512-4800: 
U.S. Government Accountability Office: 
441 G Street NW, Room 7149: 
Washington, DC 20548. 

[End of document]