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United States Government Accountability Office: 
GAO: 

Testimony: 

Before the Subcommittee on Health, Committee on Veterans' Affairs, 
House of Representatives: 

For Release on Delivery: 
Expected at 10:00 a.m. EDT: 
Friday, May 13, 2011: 

Federal Recovery Coordination Program: 

Enrollment, Staffing, and Care Coordination Pose Significant 
Challenges: 

Statement of Randall B. Williamson:
Director, Health Care: 

GAO-11-572T: 

Chairwoman Buerkle, Ranking Member Michaud, and Members of the 
Subcommittee: 

I am pleased to be here today as you discuss the challenges facing the 
Federal Recovery Coordination Program (FRCP)--a program that was 
jointly developed by the Departments of Defense (DOD) and Veterans 
Affairs (VA) following critical media reports of deficiencies in the 
provision of outpatient services at Walter Reed Army Medical Center. 
This program was established to assist "severely wounded, ill, and 
injured" Operation Enduring Freedom (OEF) and Operation Iraqi Freedom 
(OIF) servicemembers, veterans, and their families with access to 
care, services, and benefits.[Footnote 1] Specifically, the program's 
population was to include individuals who had suffered traumatic brain 
injuries, amputations, burns, spinal cord injuries, visual impairment, 
and post-traumatic stress disorder. From January 2008--when FRCP 
enrollment began--to May 2011, the FRCP has provided services to a 
total of 1,665 servicemembers and veterans; of these, 734 are 
currently active enrollees. 

As the first care coordination program[Footnote 2] developed 
collaboratively by DOD and VA, the FRCP is more comprehensive in scope 
than clinical or nonclinical case management programs. It uses Federal 
Recovery Coordinators (FRC) who are either senior-level registered 
nurses or licensed social workers to monitor and coordinate both the 
clinical and nonclinical services needed by program enrollees by 
serving as a link between case managers of multiple programs. Unlike 
case managers, FRCs have planning, coordination, monitoring, and 
problem-resolution responsibilities that encompass both health 
services and benefits provided through DOD, VA, other federal 
agencies, states, and the private sector. 

The FRCs' primary responsibility is to work with each enrollee along 
with his or her family and clinical team to develop a Federal 
Individual Recovery Plan, which sets individualized goals for recovery 
and is intended to guide the enrollee through the continuum of care. 
[Footnote 3] As care coordinators, FRCs are generally not expected to 
directly provide the services needed by enrollees. However, FRCs may 
provide services directly to enrollees in certain situations, such as 
when they cannot determine whether a case manager has taken care of an 
issue for an FRCP enrollee, when asked to resolve complex problems, or 
when making complicated arrangements. 

The FRCP is administered by VA, and FRCs are VA employees. Since 
beginning operation in January 2008, the FRCP has grown considerably 
but experienced turmoil in its early stages, including turnover of 
staff and management. At present, there are 22 FRCs who have been 
located at various military treatment facilities, VA medical centers, 
and the headquarters of two military wounded warrior programs. While 
the FRCs are physically located at certain facilities, their enrollees 
are scattered throughout the country and may not be receiving care at 
the facility where their assigned FRC is located. 

My testimony is based on our March 2011 report,[Footnote 4] which 
examined several FRCP implementation issues: (1) whether 
servicemembers and veterans who need FRCP services are being 
identified and enrolled in the program, (2) staffing challenges 
confronting the FRCP, and (3) challenges facing the FRCP in its 
efforts to coordinate care for enrollees. 

To obtain information about these challenges, we conducted more than 
170 interviews of the following groups: FRCs; FRCP leadership, which 
includes the Executive Director, the Deputy Director for Health, and 
the Deputy Director for Benefits; leadership officials with DOD and VA 
case management programs, including leadership officials from each 
military service's wounded warrior program; and medical facility 
directors and staff at DOD and VA medical facilities. We interviewed 
the FRCs individually to learn about challenges they have encountered, 
using comprehensive interviews of the 15 FRCs who were working in the 
FRCP in or before December 2009 and limited interviews of the 5 FRCs 
who were hired in January 2010. To develop an understanding about how 
clinical and nonclinical officials and staff interact with the FRCs, 
we conducted site visits and telephone interviews with program 
officials at DOD and VA headquarters and medical facility staff at the 
DOD and VA medical facilities where FRCs are located.[Footnote 5] 

We performed content analysis of the qualitative information obtained 
from the FRCs, DOD and VA program officials, and medical facility 
staff by grouping their responses by topic and then identifying 
response patterns. Content analysis of qualitative information 
obtained from DOD and VA program officials and medical facility staff 
was conducted using a software package, which enabled us to analyze 
responses to specific interview topics for a large number of 
interviews. However, the results from our site visits and interviews 
cannot be generalized because while all DOD and VA facilities could 
potentially interact with FRCs, our review focused on facilities where 
FRCs are located as well as some facilities where FRCs have 
significant interaction. In addition, we obtained and reviewed 
documentation related to the FRCP, including VA's October 2009 
handbook on care management of OEF and OIF veterans; the FRCP Standard 
Operating Procedures; the FRCP fiscal year 2010 operating plan; and 
draft FRCP procedures, such as the VA handbook on the FRCP.[Footnote 6] 

We conducted the performance audit for our report from September 2009 
through March 2011 and updated certain data elements in May 2011 for 
this testimony, 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. 

In summary, we found that while the FRCP has overcome some early 
setbacks, it currently faces challenges related to the enrollment of 
potentially eligible individuals, determination of FRC staffing needs 
and placement, and the FRCP's ability to coordinate care for enrollees. 

* Challenges in identifying potentially eligible individuals. It is 
unclear whether all individuals who could benefit from the FRCP's care 
coordination services are being identified and enrolled in the 
program. Because neither DOD nor VA medical and benefits information 
systems classify servicemembers and veterans as "severely wounded, 
ill, and injured," FRCs cannot readily identify potential enrollees 
using existing data sources. Instead, the program must rely on 
referrals to identify eligible individuals. Once these individuals are 
identified, FRCs must evaluate them and make their enrollment 
determinations--a process that involves considerable judgment by FRCs 
because of broad criteria. However, FRCP leadership does not 
systematically review FRCs' enrollment decisions, and as a result, 
program officials cannot ensure that referred individuals who could 
benefit from the program are enrolled and, conversely, that the 
individuals who are not enrolled are referred to other programs. 

* Challenges in determining staffing needs and placement decisions. 
The FRCP faces challenges in determining staffing needs, including 
managing FRCs' caseloads and deciding when VA should hire additional 
FRCs and where to place them. According to the FRCP Executive 
Director, appropriately balanced caseloads (size and mix) are 
difficult to determine because there are no comparable criteria 
against which to base caseloads for this program because of its unique 
care coordination activities. The program has taken other steps to 
manage FRCs' caseloads, including the use of an informal FRC-to-
enrollee ratio. Because these methods have some limitations, the FRCP 
is developing a customized workload assessment tool to help balance 
the size and mix of FRCs' caseloads, but it has not determined when 
this tool will be completed. In addition, the FRCP has not clearly 
defined or documented the processes for making staffing decisions in 
FRCP policies or procedures. As a result, it is difficult to determine 
how staffing decisions are made, or how these processes could be 
sustained during a change in leadership. Finally, the FRCP's basis for 
placing FRCs at DOD and VA facilities has changed over time, and the 
program lacks a clear and consistent rationale for making these 
decisions, which would help ensure that FRCs are located where they 
could provide maximum benefit to current and potential enrollees. 

* Challenges in coordinating with other VA and DOD programs and 
supporting FRCs. A key challenge facing the FRCP concerns the 
coordination of services by the large number of DOD and VA programs 
that support wounded servicemembers and veterans. Although these 
programs vary in terms of the severity of the injuries among the 
servicemembers and veterans they serve and the specific types of 
services they coordinate, many programs have similar functions and are 
involved in similar types of activities. Table 1 illustrates the key 
characteristics of major DOD and VA programs and the activities in 
which they are involved. 

Table 1: Characteristics of Major Department of Defense (DOD) and 
Department of Veterans Affairs (VA) Programs for Seriously and 
Severely Wounded Servicemembers and Veterans: 

Program name: VA/DOD Federal Recovery Coordination Program (FRCP); 
Program characteristics: 
Program description: Joint DOD/VA initiative that coordinates clinical 
and nonclinical services and benefits across federal, state, and 
private entities for recovering servicemembers, veterans, and their 
families; 
Severity of enrollees' injuries[A]: Severe; 
Title of care coordinator or case manager: Federal Recovery 
Coordinator (FRC); 
Type of services provided: 
Lifetime follow-up: [Check]; 
Clinical: [Check]; 
Non-clinical: [Check]; 
Recovery plan: [Check]. 

Program name: DOD Recovery Coordination Program; 
Program characteristics: 
Program description: DOD program that coordinates nonclinical services 
and benefits for recovering servicemembers; 
Severity of enrollees' injuries[A]: Serious; 
Title of care coordinator or case manager: Recovery Care Coordinator; 
Type of services provided: 
Lifetime follow-up: [Check]; 
Clinical: [Empty]; 
Non-clinical: [Check]; 
Recovery plan: [Check]. 

Program name: Army Warrior Transition Units; 
Program characteristics: 
Program description: Army unit that provides complex outpatient case 
management for servicemembers requiring more than 6 months of medical 
treatment; 
Severity of enrollees' injuries[A]: Serious to severe; 
Title of care coordinator or case manager: Triad of nurse case 
manager, squad leader, and physician; 
Type of services provided: 
Lifetime follow-up: [Empty]; 
Clinical: [Check]; 
Non-clinical: [Check]; 
Recovery plan: [Check]. 

Program name: Military wounded warrior programs[B]; 
Program characteristics: 
Program description: Programs operated by the military services that 
help manage servicemembers' recovery process, including the Army 
Wounded Warrior Program, Marine Wounded Warrior Regiment, Navy Safe 
Harbor, Air Force Warrior and Survivor Care Program, and Special 
Operations Command's Care Coalition; 
Severity of enrollees' injuries[A]: Serious to severe; 
Title of care coordinator or case manager: Case manager or Advocate 
(title varies by service); 
Type of services provided: 
Lifetime follow-up: [Check]; 
Clinical: [Empty]; 
Non-clinical: [Check]; 
Recovery plan: [Check]. 

Program name: VA OEF/OIF Care Management Program[C]; 
Program characteristics: 
Program description: VA program that facilitates the transition of 
care from military to VA medical facilities and the coordination of 
clinical and nonclinical services for OEF/OIF servicemembers and 
veterans; 
Severity of enrollees' injuries[A]: Mild to severe; 
Title of care coordinator or case manager: Case manager, Transition 
Patient Advocate[D]; 
Type of services provided: 
Lifetime follow-up: [Check]; 
Clinical: [Check]; 
Non-clinical: [Check]; 
Recovery plan: [Check]. 

Program name: VA Spinal Cord Injury and Disorders Program; 
Program characteristics: 
Program description: VA system of care that provides a coordinated 
continuum of services for servicemembers and veterans with spinal cord 
injuries; 
Severity of enrollees' injuries[A]: Mild to severe; 
Title of care coordinator or case manager: Nurse, social worker; 
Type of services provided: 
Lifetime follow-up: [Check]; 
Clinical: [Check]; 
Non-clinical: [Check]; 
Recovery plan: [Check]. 

Program name: VA Polytrauma System of Care; 
Program characteristics: 
Program description: VA system of specialized facilities that provides 
comprehensive, individually tailored rehabilitation to servicemembers 
and veterans with multiple injuries; 
Severity of enrollees' injuries[A]: Serious to severe; 
Title of care coordinator or case manager: Social work and nurse case 
managers; 
Type of services provided: 
Lifetime follow-up: [Check]; 
Clinical: [Check]; 
Non-clinical: [Check]; 
Recovery plan: [Check]. 

Source: GAO analysis of DOD and VA program information. 

Note: The characteristics listed in this table are general 
characteristics of each program; individual circumstances may affect 
the enrollees served and services provided by specific programs. 

[A] For the purposes of this table, we have categorized the severity 
of enrollees' injuries according to the injury categories established 
by the DOD and VA Wounded, Ill, and Injured Senior Oversight 
Committee. Servicemembers with mild wounds, illness, or injury are 
expected to return to duty in less than 180 days; those with serious 
wounds, illness, or injury are unlikely to return to duty in less than 
180 days and possibly may be medically separated from the military; 
and those who are severely wounded, ill, or injured are highly 
unlikely to return to duty and also likely to medically separate from 
the military. These categories are not necessarily used by the 
programs themselves. 

[B] FRCs placed at the headquarters of Special Operations Command's 
Care Coalition and Navy Safe Harbor coordinate clinical and 
nonclinical care for enrollees in these two programs and for other 
FRCP enrollees. 

[C] OEF/OIF refers to Operation Enduring Freedom and Operation Iraqi 
Freedom. 

[D] An OEF/OIF care manager supervises the case managers and 
transition patient advocates and may also maintain a caseload of 
wounded veterans. 

[End of table] 

Many recovering servicemembers and veterans are enrolled in more than 
one program. For example, in September 2010, approximately 84 percent 
of FRCP enrollees were also enrolled in a military service wounded 
warrior program. However, limitations on information sharing among the 
programs has resulted in duplication of services and enrollee 
confusion, prompting two military wounded warrior programs to cease 
making referrals to the FRCP. Specifically, the FRCP could not share 
certain enrollee data maintained on its information system with staff 
of non-VA programs because VA had not completed public disclosure 
actions necessary to enable the sharing of this information. In 
January 2011, VA completed the process needed to resolve this issue. 
In addition, incompatibility among information systems used by 
different case management programs limits data sharing as information 
about enrollees cannot be easily transferred among these systems. 
Although the ultimate solution to information system incompatibility 
is beyond the capacity of the FRCP to resolve, the program has 
initiated an effort to improve information exchange. 

Finally, FRCs identified several types of logistical problems that 
have affected their ability to carry out their responsibilities. These 
issues center around (1) provision of equipment such as computers, 
printers, landline telephones, and BlackBerrys; (2) technology support 
such as equipment maintenance, software upgrades, and systems 
security; and (3) private workspace at medical facilities. 

Overall, as the first joint care coordination program for DOD and VA, 
the FRCP represents a new patient support paradigm for the 
departments. Because of its unprecedented nature, the program cannot 
refer to preexisting data or policies and procedures to manage the 
program, and as a result, FRCP leadership had to develop management 
processes as the program was being implemented and has largely relied 
on informal processes to oversee and manage key aspects of the 
program. However, now that the program has been operating for several 
years and continues to grow, it has become apparent that the program 
would benefit from more definitive management processes to strengthen 
program oversight and decision making. 

As a result of our examination of the FRCP, we recommended that the 
Secretary of Veterans Affairs direct the Executive Director of the 
FRCP to take actions to establish adequate internal controls regarding 
FRCs' enrollment decisions, to complete development of the workload 
assessment tool for FRCs' caseloads, and to document procedures to 
strengthen FRC staffing and placement decisions. In their comments on 
our report, DOD stated that it continues to increase its collaboration 
with VA, and VA generally agreed with our conclusions and concurred 
with our recommendations to the Secretary. 

Chairwoman Buerkle, Ranking Member Michaud, and Members of the 
Subcommittee, this completes my prepared statement. I would be pleased 
to respond to any questions you or other members of the subcommittee 
may have. 

Contacts and Acknowledgments: 

For further information about this testimony, please contact Randall 
B. Williamson at (202) 512-7114 or williamsonr@gao.gov. Contact points 
for our Offices of Congressional Relations and Public Affairs may be 
found on the last page of this testimony. Individuals who made key 
contributions to this testimony include Bonnie Anderson, Assistant 
Director; Frederick Caison; Elizabeth Conklin; Deitra Lee; and Lisa 
Motley. 

[End of section] 

Footnotes: 

[1] OEF, which began in October 2001, supports combat operations in 
Afghanistan and other locations, and OIF, which began in March 2003, 
supports combat operations in Iraq and other locations. Since 
September 1, 2010, OIF is referred to as Operation New Dawn. 

[2] According to the National Coalition on Care Coordination, care 
coordination is a client-centered, assessment-based interdisciplinary 
approach to integrating health care and social support services in 
which an individual's needs and preferences are assessed, a 
comprehensive care plan is developed, and services are managed and 
monitored by an identified care coordinator. 

[3] The continuum of care consists of three phases: acute medical 
treatment and stabilization, rehabilitation, and reintegration--either 
a return to active duty or to the civilian community as a veteran. 

[4] GAO, 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.: Mar. 23, 
2011). 

[5] These facilities included Walter Reed Army Medical Center; 
National Naval Medical Center; Brooke Army Medical Center; Naval 
Medical Center-San Diego; Naval Hospital Camp Pendleton; Eisenhower 
Army Medical Center; and the VA medical centers in Houston, Texas; 
Providence, Rhode Island; and Tampa, Florida. In addition, we visited 
three VA medical centers with which FRCs have significant interaction--
the facilities in Richmond, Virginia; Augusta, Georgia; and San Diego, 
California. At the end of calendar year 2010, following the completion 
of our site visits, the FRCP placed two FRCs at the VA medical center 
in Richmond. 

[6] The FRCP Handbook was finalized on April 1, 2011. 

[End of section] 

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