DoD, GAO Reports Show Lack of Resources, Personnel Slowing Necessary Veterans Health Care Changes

Yesterday, the Pentagon released a report [pdf] to Congress:

Dr. S. Ward Casscells, assistant defense secretary for health affairs, said that the military is committed to making the changes needed "to provide the highest possible level of care and support to our military community." But the military will not rush the reforms and run the risk of "ineffective reactions," the report said.

Among the reforms that the Defense Department won't rush are improvements in the psychological screening of active-duty troops. The task force had recommended that all service members undergo an "annual psychological health needs assessment," conducted by a trained professional who would promptly refer troubled troops to mental health clinicians.

Gates' office said that the military will expand annual health screenings to ensure that troops' mental well-being is evaluated, but the report did not offer specifics, and it set a completion date of "beyond May 2008." The report said that the changes in screening would be made gradually, during a "three-year evaluation project."

Similarly, the Defense Department said that it was working to put in place psychological screening for new recruits, as the task force recommended, but that change also is months away.

Meanwhile, the Government Accountability Office released a report [pdf] today adding weight to a recent post showing even high-visibility troops continue to slip through the cracks while the DoD and VA attempt to play catch-up.

Of course, things in a large organization like the military can't change overnight. But delays in implementing the Dole-Shalala Commission recommendations translate to very real hardships for our military families who have already had to endure a lot.

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From the Hartford Courant:

Soldiers' advocates and some members of Congress have been calling for tighter pre- and post-deployment psychological screening of troops for more than two years - before the task force was created by Congress.

Last year, a series in The Courant that detailed lapses in the screening and treatment of soldiers with psychological problems - sometimes with tragic consequences, such as suicide - prompted Congress to push for improvements in care. In response, the Defense Department issued new guidelines last winter that set standards for deciding whether service members with psychiatric problems should be deployed and kept in combat.

In the new report to Congress, the Defense Department said that efforts to improve mental health "early intervention" have been hampered by a lack of resources.

"Although we have put in place some early intervention practices, such as our deployment health assessment and education programs, most prevention and protection efforts have come at the expense of clinical care, calling on our clinicians to do `double duty,'" the report said. "In the long-term, this business practice is unsupportable and ineffective. A change is clearly needed to make psychological fitness an equal priority to psychological treatment."

In the report, the Defense Department said that it will soon hire up to 200 military mental health professionals to work on stateside bases, to begin to ease a shortage that the task force called critical. The Army also is in the process of hiring about 260 civilian behavioral-health care workers, officials said.

With the shortfalls, it's no wonder that the military is having a hard time meeting the needs of physically or psychologically wounded returning veterans.

From USA Today:

U.S. military personnel are still receiving substandard treatment from the government, according to a new report from the Government Accountability Office.

As of the middle of this month, the agency's review showed that half of the Warrior Transition Units had "significant shortfalls" of doctors, nurses and other caregivers who to treat wounded soldiers.

Stats from another USA Today article:

The Army announced in June it would hire 200 civilian psychiatrists, psychologists, psychiatric nurses and social workers. It later raised that to 265, a 23% increase in those job categories for the Army. By last week, the Army had filled 40% of the jobs. ...

The shortage in Army uniformed therapists is having an impact on the Iraq war, where Navy and Air Force counselors are helping the army treat soldiers. The number of mental health providers has not kept pace with the additional 30,000 U.S. troops sent to Iraq this year, according to Army statistics provided to USA TODAY. In addition, the Army says some mental health counselors are burned out by their war experience.

"Medical providers are fatigued by the strains of the caring for injured soldiers and soldiers suffering from the psychological effects of deployment, including PTSD," says Col. Elspeth Ritchie, psychiatric consultant to the Army surgeon general, referring to post-traumatic stress disorder. "We are planning to put additional providers at each major installation specifically to support providers."

Experienced therapists continue to leave the military for better-paying and less stressful jobs in the private sector. The Navy, for example, expects to lose a dozen of its 88 psychiatrists this fiscal year and 25 of 116 psychologists, according to data released at a Marine Corps conference in June. Incentives have been created to keep or recruit new psychiatrists and psychologists, including retention bonuses and college loan repayment offers. ...

The Army is preparing a recruiting program aimed at older physicians and mental health providers, aged 48 to 60. They would allow for enlistments of only two years, Army Col. Larry Bolton says.

Meanwhile, the level of mental health care in the Iraq war zone — as a ratio of providers to troops — is the lowest since 2004, Army statistics show. Care has dropped from one counselor per 668 troops last year to one for every 743 this year.

From the Associated Press:

Many of the current [Warrior Transition Unit] staffers, said John Pendleton, author of the report, are borrowed, presumably temporarily, from other offices. Ultimately, hundreds more nurses, social workers and mental health specialists will be needed to handle such issues as traumatic brain injuries and post traumatic stress disorder, he said.

The GAO also noted that the Pentagon and the Veterans Affairs Departments were behind schedule in starting a pilot program under which the two departments would adopt a single medical examination and a single disability rating performed by the VA.

"We are seven months into this process and we are just now getting off the ground," said Rep. John Tierney, D-Mass., chairman of the Oversight and Government Reform subcommittee on national security. "Why has it taken so long to get going on that?" ...

Retired Adm. Patrick Dunne, the VA's assistant secretary for policy and planning, told the hearing that the pilot program to set up a unified disability evaluation system should be completed by the second quarter of 2008. If successful, it will be expanded beyond the Washington capital region to become universal.

Rep. Tom Davis, R-Va., top Republican on the panel, said his office hears every week from wounded soldiers stuck in an evaluation system they don't understand and that is complicated by different ratings coming out of the Defense Department and the VA. "Having to run that double gauntlet causes additional pain and confusion, literally adding insult to injury. That has to stop."

The GAO report's summary:

While efforts are under way to respond to both Army-specific and systemic problems, challenges are emerging such as staffing new initiatives. The Army and the Senior Oversight Committee have efforts under way to improve case management--a process intended to assist returning servicemembers with management of their care from initial injury through recovery.

Case management is especially important for returning servicemembers who must often visit numerous therapists, providers, and specialists, resulting in differing treatment plans. The Army's approach for improving case management for its servicemembers includes developing a new organizational structure--a Warrior Transition Unit, in which each servicemember would be assigned to a team of three key staff--a physician care manager, a nurse case manager, and a squad leader.

As the Army has sought to staff its Warrior Transition Units, challenges to staffing critical positions are emerging. For example, as of mid-September 2007, over half the U.S. Warrior Transition Units had significant shortfalls in one or more of these critical positions. The Senior Oversight Committee's plan to provide a continuum of care focuses on establishing recovery coordinators, which would be the main contact for a returning servicemember and his or her family. This approach is intended to complement the military services' existing case management approaches and place the recovery coordinators at a level above case managers, with emphasis on ensuring a seamless transition between DOD and VA.

At the time of GAO's review, the committee was still determining how many recovery coordinators would be necessary and the population of seriously injured servicemembers they would serve.

As GAO and others have previously reported, providing timely and consistent disability decisions is a challenge for both DOD and VA. To address identified concerns, the Army has taken steps to streamline its disability evaluation process and reduce bottlenecks. The Army has also developed and conducted the first certification training for evaluation board liaisons who help servicemembers navigate the system.

To address more systemic concerns, the Senior Oversight Committee is planning to pilot a joint disability evaluation system. Pilot options may incorporate variations of three key elements: (1) a single, comprehensive medical examination; (2) a single disability rating done by VA; and (3) a DOD-level evaluation board for adjudicating servicemembers' fitness for duty. DOD and VA officials hoped to begin the pilot in August 2007, but postponed implementation in order to further review options and address open questions, including those related to proposed legislation.

Fixing these long-standing and complex problems as expeditiously as possible is critical to ensuring high-quality care for returning servicemembers, and success will ultimately depend on sustained attention, systematic oversight by DOD and VA, and sufficient resources.

Worthy of repeating the bottom line once more: Sustained attention, systemic oversight, and sufficient resources are the keys to success for our returning troops.


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