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Witness Testimony of Karen Guice, M.D., MPP, U.S. Department of Veterans Affairs, Executive Director, Federal Recovery Coordination Program

Good morning Chairwoman Buerkle, Ranking Member Michaud, and Members of the Committee. My name is Karen Guice and I am the Executive Director of the Federal Recovery Coordination Program (FRCP), a joint DoD/VA program, administered by VA.

On March 23, 2011, the Government Accountability Office (GAO) report released its report on the FRCP, along with four recommendations for program improvement. VA concurred with the recommendations and I welcome this opportunity to discuss the steps taken since the GAO report was issued. I would also like to share with you some of the current and planned approaches to the FRCP’s challenges with outreach, referral, enrollment, communication and staffing in our continuing collaboration with DoD to provide comprehensive care coordination to severely wounded, ill or injured Servicemembers and Veterans.  

Background

The Departments of Defense and Veterans Affairs signed two memoranda of understanding (MOU, August 31, 2007 and October 30, 2007) establishing FRCP as a joint program and providing operational parameters. The program was specifically charged with providing seamless support from the time a Servicemember arrived at the initial Military Treatment Facility (MTF) in the United States through care and rehabilitation, regardless of whether the goal was to return to military duty or transition to Veteran status.

As required by the MOUs, Federal Recovery Coordinators (FRCs) are master’s prepared nurses and social workers who provide support by acting as advocates in all clinical and non-clinical aspects of recovery. FRCs work with the 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, the FRC creates a Federal Individualized Recovery Plan (FIRP).  FRCs have delegated authority for oversight and coordination of all clinical and non-clinical care identified in the FIRP. 

Specific FRCP eligibility criteria were approved by the DoD/VA Senior Oversight Committee (SOC) in October 2007 and included those Servicemembers or Veterans who received acute care at MTFs; those diagnosed with specific injuries or conditions; those considered at risk for psychosocial complication; and those self or Command-referred based on perceived ability to benefit from a recovery plan.

FRCs are a unique resource for those with severe and complex medical and/or social problems. They coordinate benefits and health care as Servicemembers and Veterans heal, aligning information and services to deliver support at the right time and in the right order. FRCs do not provide direct medical care, issue military orders, or transport clients to appointments. Instead, they rely on case managers, both clinical and non-clinical, as well as interdisciplinary healthcare team members and Servicemembers’ units, for those activities. FRCs anticipate needs and coordinate among service and benefits providers to ensure smooth transitions for their clients, whether the transition is between two hospitals or two agencies, in keeping with the intent of the MOUs signed by the Departments’ Secretaries to create a single joint program for care coordination.

In 2008, the National Defense Authorization Act (NDAA) required the creation of a recovery coordination program. This program, the Recovery Coordination Program (RCP), was implemented as a DoD-specific program for non-clinical case management. Recovery Care Coordinators (RCC) are assigned to and employed by the Military Services, with the Office of Wounded Warrior Care and Transition Policy providing program policies.

Although FRCP and RCP provide different services, in an effort to align responsibilities and roles with appropriate levels of RCP or FRCP support, the SOC approved three categories of service. Category 1 individuals were those whose recovery was essentially guaranteed and for whom only medical case management and relevant health care providers were necessary for full recovery. Category 2 individuals were those whose recovery had a high probability of requiring at least 180 days and for whom the addition of a non-clinical case manager or RCC appeared appropriate to assist with service delivery. Category 3 individuals were those with severe and complex medical problems and who had a high probability of leaving military service. Individuals identified for this latter category were to be assigned to FRCP. These service categories and assignment requirements were incorporated into the DoD Instruction 1300.24 which governs the DoD RCP. Because these categories are more administrative than operational, accurate category assignment to FRCP or RCP has been difficult.

GAO Recommendations

The first of four GAO recommendations stated that the FRCP should establish adequate internal controls to ensure that referred Servicemembers and Veterans who need FRC services are enrolled in the program. VA concurred with this recommendation.

Evaluation of potential FRCP clients is based on an assessment of 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 referred to the 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 with the broad SOC eligibility criteria. 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 enroll the referred individual; FRCP enrollment is entirely voluntary. Individuals who are not enrolled are directed to alternative resources that are appropriate for their level of need.

Any program’s enrollment criteria should reflect its charge and mission. For the FRCP, the original eligibility criteria and program’s defined scope were broad, as specified in the MOUs and approved by the SOC. Following the NDAA 2008 requirement for DoD to create the RCP, and the SOC’s approval of the three service categories, the FRCP’s scope narrowed to reflect only a Category 3 designation. Since then, the FRCP has been capturing information, based on case experience, to help refine enrollment criteria. The FRCP will use this information, along with a service intensity measurement tool (the development of which is discussed later in this testimony) to define an eligibility protocol within the program’s data management system. In the meantime, the FRCP requires all FRCs to discuss each enrollment decision with the FRCP management. The FRCP management makes the final eligibility decision to ensure enrollment consistency. All enrollment decisions are clearly documented in the FRCP data management system. This interim solution was implemented immediately following issuance of the GAO report.

While the FRCP can ensure that all referred severely wounded, ill or injured Servicemembers and Veterans who would benefit from care coordination are enrolled, the FRCP does not have visibility of all who might be eligible. The FRCP, as currently structured, is a voluntary referral program and, as such, relies on the identification and referral of those who might benefit from the FRCP services by others (case managers, Command, Wounded Warrior Programs, etc.). While the original MOUs do not specify a specific category of wounded, ill or injured, the FRCP was relegated to care coordination for severely or catastrophically wounded, ill or injured once the RCP became operational. Absent a defined, automatic referral process aligned with the DoDI 1300.24 or the original intent of the MOUs, the FRCP has relied on outreach activities and demonstrated outcomes to inform the referral process.

One way for the FRCP to increase referrals is through a robust outreach effort to ensure program awareness. Part of this effort has been to provide iterative, informational stakeholder briefings. In 2008, the FRCP conducted 17 outreach efforts and presentations to a variety of audiences, including MTF personnel, DoD and VA program personnel, and external stakeholders. In 2009 and 2010, the FRCP conducted almost 100 outreach activities each year. In the first quarter of calendar year 2011, the FRCP has conducted 34 informational briefings, on target to exceed previous outreach effort by 25 percent.

The FRCP has created a variety of materials to assist with these outreach efforts. Program brochures are provided to potential clients and families, as well as to participants in the FRCP informational briefings. These brochures are also provided to other groups for distribution upon request. Along with the brochures, the FRCP developed posters and banners for use at conferences or presentations. The FRCP has a 1-800 line for program referrals; approximately 30 percent of received calls either refer an individual or request more information about the program. The FRCP is in the process of creating a specific webpage within the VA’s website which will contain program and contact information.

In addition to these outreach efforts, last year the FRCP conducted a “look back” project to identify Veterans who might still benefit from care coordination. This project required access to data for Servicemembers and Veterans who: 1) served in the Armed Services since 9/11/2001; 2) were severely wounded, ill or injured; and 3) met the program’s eligibility criteria. No single data source had sufficient information to determine this population; instead, the FRCP identified 7 different data sets from DoD and VA, which were cleaned and merged to create a single set of over 40,000 individuals. Within the merged dataset, certain data elements were selected as a substitutes or “proxies” to narrow the list to those more likely to meet the FRCP program criteria. FRCs then contacted these identified individuals and identified only 35 who might still require care coordination.

Currently, the FRCP’s most common source of referral is from a DoD or VA clinical case management program or a member of an interdisciplinary clinical team. Ten percent of all FRCP clients have been referred by a Service wounded warrior program and one percent of referrals have originated from a DoD Recovery Care Coordinator. In contrast, 38 percent of all FRCP referrals are from clinical case managers or members of an interdisciplinary clinical team.

The FRCP has been criticized for the inability to provide client lists to the various case management and military services wounded warrior programs. All federal agencies, and their programs, must comply with the various laws and regulations protecting personally identifiable and health information.  Until recently, the FRCP was not able to provide other agencies’ programs with information about clients because the FRCP data management system had not gone through a Systems of Records Notification (SORN) process. With the SORN now in place, the FRCP has clearly prescribed federal guidelines for the sharing of information as well as disclosure rules. The FRCP is currently in the process of identifying the information required by other programs so that appropriate data transfer agreements can be developed.

In addition, the FRCP is an active participant in a DoD/VA information sharing initiative (ISI). The ISI is currently working on an electronic transfer of information between and among case management/care coordination programs within the two departments. Six specific information items have been identified for exchange. These items are: 1) Names, titles and affiliations of all case/care managers/coordinators assigned to a Servicemember or Veteran; 2) Ability to track benefits applications, benefits processing status and benefits awards across the DoD and VA; 3) Visibility of all care, recovery or transition plans (medical and non-medical); 4) Ability to view and schedule appointments through a shared calendar for Servicemembers and Veterans; 5) Role-based visibility of relevant injury or illness information; and 6) Role-based visibility of a shared Servicemember and Veteran problem lists to help identify qualifying benefits. Requirements for these data transfers are in varying stages of development, with an anticipated exchange of case manager information by September 2011.

GAO recommended that FRCP should complete development of a workload assessment tool. VA concurred with this recommendation.

Care coordination is essential to the effective management of severely wounded, ill or injured Servicemembers and Veterans, and determining the appropriate caseload for each FRC is critical. Since care coordination is a relatively new concept, particularly as implemented across and within federal agencies, no guidelines or service intensity measurement tools currently exist to accurately provide a balanced range of cases. The current FRCP caseload target range of 25-35 cases was based on a review of other programs’ caseload ratios, along with relevant literature, and the awareness that not all clients will need the same intensity of coordination.

A system intensity measurement tool will measure how much time and effort a FRC uses to identify ongoing care and required benefit needs for a client. By collecting uniform information for these activities, the FRCP can improve resource allocation, determine patterns of need, target those service areas where the need is critical, and measure stabilization over time. The FRCP can also use the system intensity measurement scores to define with improved precision those referred individuals who would benefit from care coordination, as well as those individuals whose needs can be met with alternative resources.

Developing such a tool is a labor intensive task that requires development and testing, along with validity and reliability assessments. FRCs are currently participating in a process to validate assumptions, complete a scoring algorithm, and measure inter-rater reliability prior to full field testing of a new service intensity measurement scheme. Completing the development of this tool may require a year or more of intense effort.

GAO recommended that FRCP should better document how hiring decisions are made. VA concurred with this recommendation.

The FRCP continues to grow in client volume and program referrals. In fiscal year (FY) 2008, the program received an average of 25 referrals per month. In FY 2009, the average number of referrals increased to 37 per month, and in FY 2010 the average increased to 50 per month. Of those referred in 2010, 68 percent were enrolled (Active), 18 percent required minimal assistance (Assist), and 14 percent were redirected to other resources. In FY 2008, the program had enrolled and cared for 226 Servicemembers and Veterans. In FY 2010 alone, that number had more than doubled to 598. The current number of Active clients is 736 with an average FRC caseload between 30-33 clients.

To determine the number of FRC positions required, the FRCP management considers the number of referrals, the rate of enrollment, the number of clients made inactive, and a benchmark range of 25-35 cases per FRC. The FRCP has established an equation based on these elements and incorporated it into the program’s operating plan. Upon completion of the service intensity measurement tool, the FRCP will modify this equation to reflect the average intensity points allowed per FRC instead of the current arbitrary 25-35 benchmark case range. The FRCP will update staffing processes and plans in the annual business operation planning document.

Currently, 22 FRCs are working at six military treatment facilities, four VA medical centers, and two Wounded Warrior Program headquarters. FRCs are supported by a VA Central Office staff that includes an Executive Director, two Deputies (one for Benefits and one for Health), an Executive Assistant, an Administrative Officer, and two Staff Assistants. In the past, the FRCP has received personnel support at VA Central Office from the U.S. Public Health Service and DoD. While the Navy has designated an individual for detail to FRCP, in accordance with the MOU, no other military support is currently forthcoming.

GAO’s final recommendation was that the FRCP should develop and document a rationale for Federal Recovery Coordinator (FRC) placement. VA concurred with this recommendation.

The FRCP will develop a FRC placement strategy based upon a systematic analysis of data over the next six months. The FRCP’s initial placement was guided and directed by the MOU, which required that FRCs be placed at MTFs where significant numbers of wounded, ill or injured Servicemembers were located. As the program has grown, and given the current requirement for a single FRC to remain assigned to a client for optimal care coordination and consistency, the FRCP has considered alternative 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 in order to better serve the wounded, ill and injured population of Servicemembers and Veterans.  The actual placement of FRCs is based on a case-by-case negotiation for space and support.

Conclusion

Many believe that the FRCP is a redundant program; others suggest that because the FRCP is administered by VA and is not in the military services’ chain of command that the FRCP should only provide support for Veterans. There are numerous programs that that support Servicemembers and Veterans with recovery. Each of the military services has programs that provide lifetime support Servicemembers from the time of injury or diagnosis through recovery. For example, the Marines provide a RCC for every wounded, ill or injured Marine with additional support, command, and control provided through the Wounded Warrior Regiment. The Army provides the Warrior Care and Transition Program for case management and command and control, along with the Army Wounded Warrior (AW2) Program for the most seriously wounded ill or injured Soldiers and Veterans. The Air Force Warrior and Survivor Care Program and Air Force RCCs care for wounded, ill and injured Airmen. The Navy has the Safe Harbor Program and the Special Operations Command has the Care Coalition.

Each MTF provides clinical case managers for both inpatient and outpatient case management; TRICARE also provides case managers. The Veterans Health Administration (VHA) has the Operation Enduring Freedom/Operation Iraqi Freedom/Operation New Dawn(OEF/OIF/OND) clinical case managers at each VA medical center, who assist OEF/OIF/OND Servicemembers and Veterans navigate the VA’s health care system. In addition, there are VHA Liaisons at many MTFs, along with Polytrauma Nurse Liaisons, who coordinate the transfer of Servicemembers to VA’s health services and programs.

VA also provides home-based primary care; blind, Traumatic Brain Injury (TBI), and spinal cord rehabilitation programs; the homeless program, caregiver support personnel, and more. Each of these programs provides case management, many of them for the lifetime of the Veteran. VBA has vocational rehabilitation and the benefits assistance program with additional case managers providing support to the Servicemember and Veteran. In addition, there are many other programs, such as the Defense Center of Excellence In-Transition Program, the National Guard Transition Assistance Advisor, Defense and Veterans Brain Injury Center’s Recovery Coordinators, who also provide case management activities for wounded, ill or injured Servicemembers.

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 the DoD’s and VA’s complex systems of care on the road to recovery. The FRCP was envisioned to be the single point of contact for these individuals through care and recovery; a single point of contact 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 is the only joint DoD/VA program that 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. 

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. One FRC will stay with that individual throughout all subsequent transitions, coordinating benefits and services as needed. 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 lifetime or a few weeks. FRCs involvement is voluntary and, when used as envisioned, collaborative. However, FRCP cannot carry out this mission without active support from the DoD, including all military services, the VA, and Congress.

In closing, program evaluation, whether by Congress or by an investigative body such as GAO, is a vital part of program growth and maturation. The FRCP is grateful to the GAO for their comprehensive review and to the Subcommittee Members for this opportunity to discuss continued challenges.

Thank you and I look forward to your questions.