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Witness Testimony of John Medve, Executive Director, Office of the U.S. Department of Veterans Affairs-U.S. Department of Defense Collaboration, Office of Policy and Planning, U.S. Department of Veterans Affairs

Good afternoon Chairwoman Buerkle, Ranking Member Michaud, and Members of the Subcommittee. I am John Medve, Executive Director, Office of VA-DoD Collaboration within the Office of Policy and Planning. I am pleased to be here today to discuss the Federal Recovery Coordination Program (FRCP) and the progress that has been made in addressing improvements recommended by the Government Accountability Office (GAO).

The FRCP is a designed to complement existing military service-and VA-provided case management, support, and transition coordinators.  FRCP is specifically charged with providing seamless support from the Sevicemember’s arrival at the initial Medical Treatment Facility (MTF) in the United States through the duration of their recovery, rehabilitation, and reintegration. The FRCP staff at the policy level coordinates with its DoD counterparts under the umbrella of the Senior Oversight Committee. The FRCP is an integral part of VA and DoD efforts to address issues raised about the coordination of care and transitions between the two departments for recovering Service members. On behalf of its clients, Federal Recovery Coordinators (FRCs) work closely with clinical and non-clinical care and case managers from the military services, the VA, and the private sector as part of their Recovery Team. FRCs are master’s degree-prepared nurses and clinical social workers who support severely wounded and ill Servicemembers, Veterans and their families by advocating in all clinical and non-clinical aspects of recovery. FRCs work with relevant military service and VA programs, the individual’s interdisciplinary clinical team, and all case managers. Based on a client’s goals, with input from all care providers and coordinators, the FRC creates a Federal Individual Recovery Plan (FIRP). FRCs oversee and coordinate all clinical and non-clinical care identified in the FIRP. To show greater transparency with Servicemembers and Veterans, the FIRP is available through the eBenefits portal 24 hours-a-day, seven days-a-week.

GAO issued a report in March 2011 containing four VA recommendations.  VA concurred with the recommendations and has taken action to implement each of them.  GAO’s first recommendation was that VA establish adequate internal controls regarding FRCs’ enrollment decisions to ensure that referred Servicemembers and Veterans who need FRC services are enrolled in the program. GAO also recommended that FRCP leadership require FRCs to record in the Veterans Tracking Application (VTA) the factors considered in making the enrollment decision, develop and implement a methodology and protocol for assessing the appropriateness of enrollment decisions, and refine the methodology as needed. VA concurred with this recommendation and immediately implemented more stringent internal controls to include management review of all enrollment decisions and documentation of decision determinations in VTA to ensure that referred Servicemembers and Veterans who need FRC services are offered enrollment in FRCP.

Potential clients referred to FRCP are evaluated to determine the individual’s medical and non-medical needs and requirements in order to recover, rehabilitate, and reintegrate to the maximum extent possible. A key component in the FRCP evaluation process is the clinical training and experience of the FRCs and their professional judgment of whether an individual would benefit from FRCP care coordination. In general, Servicemembers and Veterans whose recovery is likely to require a complex array of specialists, transfers to multiple facilities, and long periods of rehabilitation are offered enrollment in FRCP.

Following a referral, FRCs consider a wide range of issues in determining whether an individual meets enrollment criteria. The first consideration is whether the referred individual meets the broad Senior Oversight Committee (SOC) eligibility criteria. The SOC criteria covers Servicemembers or Veterans who are: in an acute care setting within a military treatment facility; diagnosed or referred with spinal cord injury, burns, amputation, visual impairment, traumatic brain injury and/or Post Traumatic Stress Disorder; considered at risk for psychosocial complication; or self or Command referred based on perceived ability to benefit from a recovery plan.  FRCs then conduct a comprehensive record review to include all relevant and available health and benefit information. They document the medical diagnoses and conditions. They conduct a risk assessment; identify anticipated treatment and rehabilitation needs; determine the individual’s access to care and level of support; identify any issues with medications or substance abuse; assess the current level of physical and cognitive functioning; and review financial, family, military, and legal issues. They also discuss the individual with interdisciplinary clinical team members, clinical and non-clinical case managers, and others who might provide insight into the various issues and challenges the Servicemembers or Veterans and their families face. Finally, and most importantly, the FRCs interview the referred individual and family members. Based on all input, the FRCs determine whether to recommend enrollment of the referred individual into the FRCP.  The FRCs then present the case for their recommendation to a member of the FRCP leadership team for final approval.  The results of the final decision are documented in the FRCP data management system.  FRCP enrollment is entirely voluntary. Individuals who are not enrolled are directed to alternative resources that are appropriate for their level of need. FRCP continues to review and refine the enrollment process and establish and document protocols as recommended by GAO. FRCP has completed the first phase of an intensity tool designed to add further consistency to the enrollment decision process. Testing was completed in late summer and we began using the tool on all new referrals earlier this month.

GAO’s second recommendation was to complete development of a workload assessment tool that will enable the program to assess the complexity of services needed by enrollees and the amount of time required to provide services to improve management of FRCs’ caseloads. FRCP embarked on the development of a service intensity tool that would fulfill the workload assessment requirements of the GAO recommendation and further tie the assessment to enrollment decisions.  FRCP dedicated substantial time and research into the development and testing of its service intensity tool.  Several comprehensive sessions with FRCs, analysts, and FRCP management were held to develop the tool, validate assumptions, conduct reliability testing and refine the scoring mechanisms.  As noted in VA’s original response to GAO, this process will likely be completed by summer 2012. The first phase of the tool was launched program-wide.  FRCP will further analyze the results as we continue development of the second phase which will be used to assess the amount of time required to provide services.  In the interim, FRCP is testing other caseload management strategies.  Currently, FRCP is evaluating the feasibility of establishing intensity levels within the active client population to meet the needs of clients and improve management of FRC caseloads.

GAO’s third recommendation to VA was to clearly define and document the FRCP’s decision making process for determining when and how many FRCs VA should hire to ensure that subsequent FRCP leadership can understand the methods currently used to make staffing decisions.  VA concurred with the recommendation and documented the formula used to determine the number of FRC positions required. These positions are based on an analysis of the anticipated number of referrals, the rate of enrollment, the number of clients made inactive, and a target caseload range of between 25-35 per FRC. Upon completion of the service intensity tool, FRCP will modify this equation to reflect the average intensity points allowed per FRC instead of the current caseload range.

GAO’s fourth and final recommendation was to develop and document a clear rationale for placement of FRCs, which should include a systematic analysis of data, such as referral locations, to ensure that FRC placement decisions are strategic in providing maximum benefit for the program’s population.  VA concurred with this recommendation and is developing a systematic analysis to inform future placements. The original placement of FRCs was guided and directed by an October 2007 Memorandum of Understanding, signed by the Secretary of Defense and the Acting Secretary of Veterans Affairs, which required that FRCs be placed at MTFs where significant numbers of wounded, ill, or injured Servicemembers were located. As the program grew, the FRCs spread to additional locations.  FRC placement is guided by four factors: replacement for FRCs who leave the program, supplementation of existing FRCs based on documented need, creation of a national FRCP network to optimize coordination, and specific requests for FRCs to better serve the wounded, ill, and injured population of Servicemembers and Veterans.

Thanks to the flexibility of the program, VA has made significant progress in implementing the GAO’s recommendations during these past six months.  FRCP is continuously improving and provides a unique service to severely wounded, ill, and injured Servicemembers, Veterans, and their families. FRCP is not redundant with existing support programs in VA and DoD, but rather complementary as stated in its establishing Memorandum of Understanding (MOU).

FRCP was established specifically to provide care coordination across VA and DoD for the most complex cases.  FRCs assist clients by coordinating health care and benefits from DoD, VA, and other federal agencies as well as state, local and private entities.   Most coordination and case management support is facility-based. This is not true for FRCs. Once assigned, a FRC will continue to support a client regardless of where the client is located. This philosophy provides an invaluable level of consistency for a client at time when care needs and transitions can be overwhelming. Feedback suggests FRCP clients are extremely satisfied with the services provided by FRCs. FRCs assist clients in overcoming systems barriers, ensure smooth transitions, educate clients concerning complex benefits and services, and help them navigate across the many systems, programs, and agencies to obtain necessary services and benefits. These needs continue to exist for the FRCP client population.  FRCs clinical backgrounds combined with an intensive and comprehensive education on programs and services available to Servicemembers and Veterans make them uniquely qualified to provide the care coordination services necessary for successful recovery and reintegration.

Beginning next month, FRCP will pilot a new data management system.  Efforts are already underway to ensure that the data collected and stored in the new internet-based platform is capable of being shared throughout VA and DoD. Additionally, VA is engaged in an Information Sharing Initiative (ISI) with DoD.  ISI is designed to further support smooth transitions between DoD and VA.  ISI will provide care coordinators and case managers the ability to track benefits applications, benefits processing status, and benefits awards. It will also provide visibility of all clinical and non-clinical care plans and provide the ability to view a shared calendar for Servicemember and Veterans appointment scheduling.

In an effort to ensure VA is providing the greatest level of coordinated support to the wounded, ill, and injured population, VA recently established an internal Wounded, Ill, and Injured Task Force to examine current VA programs and ensure appropriate resources, programs, and services are available to our wounded, ill, and injured populations. A goal of the Task Force is to ensure effective access to and delivery of health care and benefits.

Many wounded, ill and injured Servicemembers, Veterans and their families are confused by the number and types of case managers and baffled by benefit eligibility criteria as they move through DoD’s and VA’s complex systems of care on the road to recovery, rehabilitation, and reintegration. The FRCP was envisioned to be the consistent resource available to these individuals through care and recovery -a consistent resource that would help them understand the complexities of the medical care provided and the array of benefits and services available to assist in recovery. Currently, the FRCP provides clinical and non-clinical care coordination for wounded, ill or injured Servicemembers, Veterans and their families with severe and complex medical and social problems. The FRCP provides alignment of services, coordination of benefits, and resources across DoD, VA and the private sector by managing transitions and providing system navigation for clients.

Our clients tell us the program works best when FRCs are included early in the Servicemember’s recovery and prior to the first transition, whether that transition is from inpatient to outpatient or from one facility to another. Once assigned, a FRC will continue to support a client regardless of where the client is located. This consistency of coordination is important for individuals with severe and complex conditions who require multiple DoD, VA and private health providers and services. FRCs remain in contact with their clients as long as they are needed, whether for a few months or a lifetime.

This concludes my statement, and I am happy to answer any questions you may have.