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United States Government Accountability Office Washington, DC 20548 January 25, 2008 Congressional Requesters Subject: VA and DOD Health Care: Administration of DOD’s Post-Deployment Health Reassessment to National Guard and Reserve Servicemembers and VA’s Interaction with DOD Congress’s long-standing interest in health care services for servicemembers returning from deployment has grown regarding National Guard and Reserve servicemembers because they , are being activated in numbers not seen s
    United States Government Accountability Office Washington, DC 20548  January 25, 2008Congressional RequestersSubject: VA and DOD Health Care: Administration of DOD’s Post-Deployment Health Reassessment to National Guard and Reserve Servicemembers and VA’s Interaction with DOD  Congress’s long-standing interest in health care services for servicemembers returning fromdeployment has grown regarding National Guard and Reserve servicemembers because theyare being activated in numbers not seen since World War II. 1,2 For servicemembers who havebeen deployed overseas—whether National Guard, Reserve, or active duty—the Departmentof Defense (DOD) has developed a continuum of programs to assess servicemembers’ healthneeds by obtaining information on their health concerns. One health assessment isadministered before deployment, another about the time servicemembers return fromdeployment, and a third 90 to 180 days after deployment, which is called the post-deploymenthealth reassessment (PDHRA). DOD directed the PDHRA to be implemented in June 2005 inresponse to studies that showed that health concerns were emerging several months afterservicemembers’ return from deployment. 3 One intent of the PDHRA is to identifyservicemembers’ health concerns with a specific emphasis on screening for mental healthand to assess whether servicemembers need referrals for further evaluation. PDHRAs canresult in referrals being made to military treatment facilities, TRICARE providers, 4 chaplains, 1 See Related GAO Products at the end of this report. 2 Between September 2001 and October 2007, nearly 620,000 National Guard and Reserveservicemembers have been activated in support of the Global War on Terrorism. 3 For purposes of this report, we define servicemembers to include members of the National Guard andReserves who fall under DOD’s continuum of care because of their active duty service overseas, evenif they are no longer on active duty at the time the PDHRA is administered. 4 DOD provides health care through TRICARE—a regionally structured program that uses civiliancontractors to maintain provider networks to complement health care services provided at militaryhospitals and clinics, commonly referred to as military treatment facilities. While servicemembers areon active duty, DOD manages where they receive their care—at a military treatment facility, aTRICARE civilian provider, or a VA medical facility. GAO-08-181R DOD’s Post-Deployment Health Reassessment  Military OneSource, 5 or Department of Veterans Affairs (VA) facilities, such as VA medicalcenters, VA community clinics, and Vet Centers. 6  Congressional interest in health care services for National Guard and Reserveservicemembers returning from deployment has increased because of their large numbersand because they have reported post-deployment mental health concerns at a higher ratethan their active duty counterparts, though this varies by military service. 7 Related to thisinterest, you asked us to describe the administration of the PDHRA to National Guard andReserve servicemembers. 8 This report describes (1) how DOD administers the PDHRA toNational Guard and Reserve servicemembers and what information it obtains and (2) how VAinteracts with DOD in the PDHRA process for these servicemembers and the information VAobtains.Our work focused on National Guard (federally activated) and Reserve servicemembers fromthe military services who have been deployed overseas greater than 30 days to locationswithout a permanent military treatment facility. 9 National Guard servicemembers includedthe Army National Guard and the Air National Guard. Reserve servicemembers included Army Reserve, Navy Reserve, Air Force Reserve, and Marine Corps Reserve. We did notinclude Coast Guard Reserve servicemembers since they represent less than 1 percent of the population of activated Reserve and National Guard servicemembers.To describe how DOD administers the PDHRA to National Guard and Reserveservicemembers and what information it obtains, we interviewed and obtained documentsfrom relevant DOD officials from the Force Health Protection and Readiness Program in theOffice of the Assistant Secretary of Defense (Health Affairs), the Army Medical Surveillance Activity, and each of the military services identified above. In addition, we interviewed andobtained documents from the health care contractor DOD uses to administer the PDHRA toNational Guard and Reserve servicemembers. Further, we obtained completion and referraldata from PDHRA administrations conducted from June 2005 through January 1, 2008. We 5 For National Guard, Reserve, and active duty servicemembers and their families, Military OneSource provides educational products on the Web and counseling on a variety of topics by phone and face toface. 6  VA’s integrated health care system provides primary care, specialized care, and related medical andsocial support services. VA medical centers provide a broad range of inpatient and outpatient medicalservices, including mental health services, to servicemembers and veterans meeting eligibility criteria. VA community clinics provide medical services, which may include mental health services, on anoutpatient basis in local communities. Vet Centers provide mental health services, includingreadjustment counseling, to all veterans who served in any combat zone. 7 Colonel Charles W. Hoge, M.D., Director of Division of Psychiatry and Neuroscience, Walter Reed Army Institute of Research provided this comparative information in September 28, 2006, testimonybefore the Committee on Veterans’ Affairs, Subcommittee on Health, House of Representatives. 8 You asked us to describe the administration of the PDHRA either in requests focused on this subjector in requests for this information as part of a larger body of work. As requested, we are alsoconducting work on related issues for which we plan to issue additional reports. 9 For purposes of this report, we consider the National Guard to be federally activated when it is performing a federal mission conducted under the command and control of the President andmobilized under authority contained in Title 10, U.S. Code. These mobilization authorities include, forexample, 10 U.S.C. § 12302 and § 12304. GAO-08-181R DOD’s Post-Deployment Health Reassessment   2  assessed the reliability of those data by reviewing system documentation, interviewingknowledgeable agency officials, and testing the data to search for incorrect or missing values.We determined the data were sufficiently reliable for the purposes of this report. To describehow VA interacts with DOD in the PDHRA process for these servicemembers, weinterviewed, and collected supporting documentation from VA officials from the Office of Seamless Transition, Office of Readjustment Counseling, Office of Mental Health, and Veterans Integrated Service Networks (VISN) offices. 10 We also interviewed and obtaineddocuments from DOD’s contractor officials and relevant DOD officials from the Force HealthProtection and Readiness Program in the Office of the Assistant Secretary of Defense (Health Affairs), the Army Medical Surveillance Activity, and each of the military services identifiedabove.In addition, to address both objectives, we observed in-person administrations of PDHRAs to Army National Guard servicemembers in Kinston, North Carolina, during a weekend meeting(called a drill weekend) and to Army Reserve servicemembers in Indianapolis, Indiana,during a drill weekend. We chose these sites because they are located in different regions of the country and located in areas with respectively smaller and larger populations. We visited Army National Guard and Reserve units because they comprised about 80 percent of deployed National Guard (federally activated) and Reserve servicemembers at the time of ourreview (July 2007). While this sample of site visits allowed us to learn about many importantaspects of PDHRA administrations, the information does not permit us to generalize aboutPDHRA administrations departmentwide. At these sites, we met with and collectedsupporting documentation from officials responsible for administering the PDHRA andofficials from VA medical centers, a VA community clinic, and Vet Centers. We conducted ourwork from April 2007 through January 2008 in accordance with generally acceptedgovernment auditing standards. Results in Brief  DOD uses a health care contractor in all but a small number of cases to administer thePDHRA to National Guard and Reserve servicemembers either in person or by telephonethrough a call center. Specifically, DOD contracts with a company that providesadministrative staff and health care providers—physicians, physician’s assistants, and nurse practitioners—to administer the assessments. The PDHRA form asks for demographicinformation—such as the servicemember’s date of birth, gender, and marital status—andhealth information that can lead to referrals for additional evaluation. For example, thePDHRA asks servicemembers questions about the occurrence of nightmares, conflicts withfamily and friends, and increased alcohol use. Servicemembers who answer affirmatively tothese questions may receive a referral for further evaluation for mental health conditions,such as post-traumatic stress disorder or alcohol abuse. These referrals result from in-personor telephone discussions that take place between the servicemember and the health care provider during the PDHRA administration. Of the about 156,000 PDHRAs completed byNational Guard and Reserve servicemembers from June 2005 through January 1, 2008, nearly46 percent resulted in referrals for further evaluation for physical or mental health concerns. 10 The VA health care system is organized into 21 geographically defined regions, or VISNs, that havebudget and management responsibilities for VA facilities in their geographic area. GAO-08-181R DOD’s Post-Deployment Health Reassessment   3   According to our discussions with VA and DOD officials, VA officials interact with DODofficials in the PDHRA process in several ways and receive information aboutservicemembers from DOD. Through coordination with DOD, VA officials are generally present when PDHRAs are administered to National Guard and Reserve servicemembersduring drill weekends, whether the PDHRAs are administered in person or by telephonethrough a call center. VA interaction with DOD also occurs when servicemembers arereferred to a VA facility. VA staff provide servicemembers with information about VA benefitsand help them make appointments at VA facilities. 11 Information VA receives from DODincludes the location of PDHRA administrations, numbers of servicemembers referred to VAfacilities, and the PDHRAs of individual servicemembers who access VA health care. Of theNational Guard and Reserve servicemembers referred through the PDHRA process for either physical or mental health concerns from June 2005 through January 1, 2008,47 percent (almost 34,000) were referred to VA facilities. VA and DOD concurred with a draft of this report. Background  Almost all National Guard and Reserve servicemembers serve in the military on a part-timebasis while maintaining a civilian career. When not deployed, they usually meet 1 weekend amonth for a drill weekend and 2 weeks a year for annual training. Commanding officers areresponsible for ensuring that servicemembers in their military units are medically ready to bedeployed. As part of that effort, they are responsible for having servicemembers in their unitcomplete deployment health assessments.DOD’s deployment-related continuum of health care includes three health assessments,which are used to determine whether further evaluation is needed for servicemembersdeployed overseas greater than 30 days to locations without a permanent military treatmentfacility. 12 They do not diagnose medical conditions. The pre-deployment health assessment isdocumented on Department of Defense Form 2795 and is administered within 60 days beforedeployment. It is a mandatory health assessment for most servicemembers deployingoverseas. The post-deployment health assessment is documented on Department of DefenseForm 2796 and must be completed between 30 days prior to leaving a deployment locationand within 30 days after returning from deployment. It is a mandatory health assessment forservicemembers returning from deployment. The PDHRA is documented on Department of Defense Form 2900 (DD 2900) and is administered 90 to 180 days after returning fromdeployment. 13 (See encl. I.) While it is mandatory that DOD offer servicemembers theopportunity to participate in the PDHRA, servicemembers are only required to answer limiteddemographic questions; they are not required to answer any of the health questions. Further,those who have left the military have the option to complete the PDHRA but are not requiredto do so. 11  VA provides a range of benefits to eligible veterans, including disability compensation and pensions,education benefits, and hospital and medical care. 12 It is the commander’s decision whether servicemembers who do not meet the criteria complete thesehealth assessments. 13  Although a new DD 2900 dated September 2007 has been developed, it had not been implemented asof January 7, 2008. This report refers to the DD 2900 dated June 2005. GAO-08-181R DOD’s Post-Deployment Health Reassessment   4
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