This is the accessible text file for GAO report number GAO-08-1025R entitled 'Defense Health Care: Oversight of Military Services' Post- Deployment Health Reassessment Completion Rates Is Limited' which was released on September 4, 2008. This text file was formatted by the U.S. Government Accountability Office (GAO) to be accessible to users with visual impairments, as part of a longer term project to improve GAO products' accessibility. Every attempt has been made to maintain the structural and data integrity of the original printed product. Accessibility features, such as text descriptions of tables, consecutively numbered footnotes placed at the end of the file, and the text of agency comment letters, are provided but may not exactly duplicate the presentation or format of the printed version. The portable document format (PDF) file is an exact electronic replica of the printed version. We welcome your feedback. Please E-mail your comments regarding the contents or accessibility features of this document to Webmaster@gao.gov. This is a work of the U.S. government and is not subject to copyright protection in the United States. It may be reproduced and distributed in its entirety without further permission from GAO. Because this work may contain copyrighted images or other material, permission from the copyright holder may be necessary if you wish to reproduce this material separately. GAO-08-1025R: United States Government Accountability Office: Washington, DC 20548: September 4, 2008: Congressional Addressees: Subject: Defense Health Care: Oversight of Military Services' Post- Deployment Health Reassessment Completion Rates Is Limited: Military servicemembers engaged in combat tours in Afghanistan and Iraq are at risk of developing combat-related mental health conditions, including post-traumatic stress disorder (PTSD). In many cases, signs of potential mental health conditions do not surface until months after servicemembers return from deployment. In 2004, Army researchers published a series of articles that indicated a significant increase in the number of servicemembers reporting mental health concerns 90 to 120 days after returning from deployment, compared with mental health concerns reported before or soon after deployment.[Footnote 1] These findings led the Department of Defense (DOD) in March 2005 to develop requirements and policies for the post-deployment health reassessment (PDHRA) as part of its continuum of deployment health assessments for servicemembers. PDHRA is a screening tool for military servicemembers; it is designed to identify and address their health concerns--including mental health concerns--90 to 180 days after return from deployment. Servicemembers answer a set of questions about their physical and mental health conditions and concerns, and health care providers review the answers and refer servicemembers for further evaluation and treatment if necessary. A November 2007 study showed that a larger number of servicemembers indicated mental health concerns on their PDHRAs than on assessments earlier in their deployment cycles.[Footnote 2] Although DOD established PDHRA requirements and policies, it gave the military services discretion to implement them to meet their unique needs as long as the services adhere to the requirements and policies. DOD oversees the military services' compliance with PDHRA requirements through its deployment health assessment quality assurance program and is required to report on the quality assurance program annually to the Armed Services Committees of the House of Representatives and Senate. [Footnote 3] In June 2007, we reported that DOD's oversight of its deployment health assessments does not provide DOD or Congress with the information needed to evaluate DOD and the military services' compliance with deployment health assessment requirements.[Footnote 4] That report is part of a body of work in which we identified weaknesses in DOD's quality assurance program.[Footnote 5] The Senate Committee on Armed Services directed us to review DOD's oversight of PDHRA, and the House Committee on Armed Services and 11 senators also expressed interest in this work.[Footnote 6] In this report, we focus on how DOD ensures that servicemembers complete the PDHRA.[Footnote 7] Specifically, we discuss how well DOD's quality assurance program oversees the military services' compliance with the requirement that they ensure that servicemembers complete the PDHRA. To evaluate how well DOD's quality assurance program oversees the military services' compliance with the requirement that they ensure servicemembers complete the PDHRA, we reviewed DOD's policies for PDHRA and its deployment health assessment quality assurance program. [Footnote 8] We also reviewed our June 2007 report on the implementation of DOD's quality assurance program, which is based on 2005 and 2006 data. We interviewed officials from DOD and the military services to determine whether the process and procedures DOD's quality assurance program uses to oversee the military services' compliance with deployment health assessments have changed since our 2007 report. In addition, we analyzed all quarterly reports submitted to DOD's quality assurance program from the four services for 2007. We also analyzed the four reports the military services submitted to DOD's quality assurance program for the first quarter of 2008, and the July 2008 monthly report from the Armed Forces Health Surveillance Center (AFHSC).[Footnote 9] All of these reports are submitted to DOD's quality assurance program. Furthermore, we used these interviews and documents to gain additional knowledge of and clarification on the instructions and guidance for PDHRA. We conducted our work from February 2008 through July 2008, in accordance with generally accepted government auditing standards. Those 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. Results in Brief: DOD's quality assurance program has limitations and does not allow the department to accurately assess whether the military services ensure that servicemembers complete the PDHRA. DOD's quality assurance program relies on quarterly reports from each military service, monthly reports from AFHSC, and site visits to military installations to oversee the military services' compliance with deployment health assessment requirements, including completion of PDHRA. Each of these sources of information has limitations. The military services' quarterly reports and the monthly reports from AFHSC do not provide the information DOD needs to accurately assess the military services' PDHRA completion rates, which would allow DOD to determine if the military services have ensured that servicemembers completed the PDHRA. These reports do not allow DOD to calculate a completion rate because they do not provide essential information, such as the total number of servicemembers who returned from deployment and should have completed the PDHRA in that quarter or month. Furthermore, DOD cannot use information collected from site visits to validate the services' quarterly reports because the small number of site visits constitutes an insufficient sample for validation purposes. In our 2007 report, we recommended that DOD make enhancements to its quality assurance program, which would allow the department to better evaluate compliance with deployment health requirements. Although DOD concurred with the recommendation included in the 2007 report, as of June 2008, the department had not implemented the recommendation. As a result, DOD's quality assurance program cannot provide decision makers with reasonable assurance that servicemembers complete PDHRA. Overall, DOD concurred with our report's findings and conclusions; however, DOD identified several items in the report that it addressed in written comments. DOD suggested that the function of oversight is beyond the scope of the quality assurance program. Additionally, DOD commented that the department is taking steps that it believes will resolve some of the issues we note in this report. However, DOD did not provide us with relevant details or evidence pertaining to these efforts. We believe that oversight is an essential function of the quality assurance program and that the program currently does not receive the information necessary to perform this function. Background: Screenings and assessments of servicemembers' physical and mental health status are to occur at several times during the deployment cycle. These assessments are the pre-deployment health assessment, the post-deployment health assessment (PDHA), and PDHRA. (See enclosure I for a description of the purpose and timing of these assessments.) DOD developed requirements that all military services must follow when administering the PDHRA, although DOD allows the military services flexibility in administering the assessment based on their unique needs and organizations. In administering the PDHRA, all services use a standardized form that contains demographic and health care screening questions. The health screening questions focus on servicemembers' current physical and mental health conditions and concerns. (See enclosure II for a copy of the PDHRA form.) Servicemembers are given the option of answering the health screening questions. DOD's PDHRA requirements are:[Footnote 10] * Military services must ensure that servicemembers complete the PDHRA within 90 to 180 days after returning from deployment.[Footnote 11] DOD has designated the PDHRA as a "commander program," meaning that unit commanders at military installations are responsible for ensuring that their servicemembers complete PDHRAs within this time frame. * Servicemembers' PDHRA forms are to be reviewed by a health care provider--including primary care physicians, physician assistants, and nurse practitioners--who must certify that the assessments were reviewed by signing the form. * Health care providers are to interview servicemembers who report any health concerns on their PDHRA forms. * After the PDHRA form is reviewed, it is to be placed in a servicemember's military health record. A copy of the completed PDHRA form is also to be submitted electronically by the military services to DOD's Defense Medical Surveillance System (DMSS). The system is a central repository of medical surveillance data for the U.S. armed forces that is operated by AFHSC. DOD established a deployment health quality assurance program in January 2004 to ensure that servicemembers receive deployment health assessments as required.[Footnote 12] Although DOD's program predates the PDHRA, DOD uses the quality assurance program to oversee compliance with PDHRA requirements.[Footnote 13] As of June 2008, DOD's quality assurance program was staffed with one full-time equivalent position. [Footnote 14] DOD'S Deployment Health Quality Assurance Program Cannot Accurately Assess Military Services' PDHRA Completion Rates: DOD's quality assurance program relies on multiple sources of data to oversee the military services' compliance with deployment health requirements, including completion of PDHRAs. Taken individually or as a whole, these data do not allow the department to accurately assess whether PDHRAs are being completed. The military services' quarterly reports to DOD's quality assurance program do not provide the information DOD needs to accurately assess PDHRA completion rates for each of the military services. DOD's quality assurance policy requires the services to report (1) the number of servicemembers who deployed and returned from deployment and (2) the number of post-deployment health assessments completed, including PDHRAs. This information is essential to help DOD accurately determine completion rates of PDHRAs, as well as other deployment health assessments, across the military services. In our 2007 report, we recommended that the Assistant Secretary of Defense for Health Affairs enforce the requirement for the services to provide consistent information on all deployment health requirements on a quarterly basis. Although DOD concurred, we found that the data included in the quarterly reports for 2007 and the first quarter of 2008 remain inconsistent and incomplete. Because DOD does not provide specific standards for collecting and reporting this required information, there are inconsistencies within a service and among the services in what information is included in each quarterly report. For example, we found inconsistencies within the Army's four quarterly reports for 2007: * In the first quarter, the Army reported on samples ranging from 30 to 50 servicemembers who should have completed the PDHRA at eight installations. * The second quarter report included information on a sample of 91 servicemembers who should have completed the PDHRA at one installation. * In its third quarter report, the Army did not include any information on deployment health assessments, including PDHRA, citing time constraints, competing events, and personnel changes. * The fourth quarter report included information on deployment health assessments, except for PDHRA, for a sample of 143 servicemembers at one installation. An Army official told us that these servicemembers had recently returned from deployment and were not in the 90 to 180 day time frame for completing the PDHRA. Additionally, information included in the quarterly reports varies among the services. For example, in contrast to the Army's quarterly reports, we found that the Air Force did not include PDHRA in its quarterly reports for 2007. In its 2008 first quarter report, the Air Force reported on the aggregate number--over 50,000--of all of its servicemembers who had returned from deployment and should have completed PDHRAs since March 2004. Additionally, the military services do not consistently include PDHRA in their quarterly reports. For example, 6 of the 16 2007 quarterly reports that we reviewed did not include any information on the PDHRA. The absence of such data hampers the department's ability to compare compliance across the military services and within each military service across time. The DOD quality assurance program manager told us that she was aware of the inconsistencies in the military services' quarterly reports and said that she does not have the authority to enforce the two reporting requirements for the military services' quarterly reports. Additionally, AFHSC is required to report monthly to DOD's quality assurance program on servicemembers' deployment health assessments, including PDHRAs, but as of June 2008, these reports did not include all of the information DOD's quality assurance program needs to accurately assess PDHRA completion rates. These reports include the number of servicemembers who have completed the health assessment. This number is based on the number of completed PDHRAs submitted by each military service to AFHSC's DMSS database. As we reported in 2007, DOD does not require AFHSC to report the number of servicemembers who should have completed deployment health assessments.[Footnote 15] As a result, we recommended in 2007 that DOD provide AFHSC with specific reporting requirements for the reports, which would include identifying the total number of servicemembers who returned from deployment and who should have completed PDHRAs. In its comments, DOD stated that it would work with AFHSC to specify reporting requirements, such as the total number of servicemembers who returned from deployment, in order to get a more accurate picture of compliance. However, as of June 2008, the department had not specified reporting requirements for AFHSC's reports. While the quality assurance program manager does not obtain the total number of servicemembers who returned from deployment from AFHSC, the PDHRA program manager determines this number using a DOD database. Using this number and the number of completed PDHRAs from AFHSC, the PDHRA program manager determines a PDHRA completion rate for each service and makes this information available to the DOD quality assurance program manager. However, service-wide PDHRA completion rates are not included in DOD's quality assurance program's annual report to DOD and Congress. The DOD quality assurance program manager conducts a site visit to one installation per service per year to validate whether the information that the military services provide in their quarterly reports is correct, but we believe findings from the site visits, as currently conducted, should not be used for this purpose.[Footnote 16] During the site visits, servicemembers' medical records are reviewed to determine whether the required deployment health assessments, including PDHRAs, are in these records. Since the PDHRA is a commander program, the implementation can vary from one installation to another within a service, depending on an installation's unique needs and resources. Because of this potential variation among installations, DOD's quality assurance program cannot use one installation as a sufficient sample for validation of the information the military services include in their quarterly reports. Agency Comments and Our Evaluation: DOD reviewed a draft of this report and provided written comments, which appear in enclosure III. Overall, DOD concurred with our report's findings and conclusions and identified several items in the report that DOD addressed in its written comments. DOD suggested that oversight can include supervision or management, and consequently, this function would be beyond the scope of a quality assurance program. DOD noted that the actual management and execution of PDHRAs are the responsibility of commanders and the Military Health System. We acknowledge in our report that commanders bear responsibility for implementing the program. However, DOD's quality assurance program is required by statute to evaluate the success of DOD's deployment health assessment system in ensuring that servicemembers receive these assessments. PDHRA is one of DOD's deployment health assessments, and as such, we believe oversight is an important part of evaluating the success of the system. DOD stated that the key to assessing PDHRA compliance across the services is to ensure that the military services provide complete and accurate information to DOD's enterprisewide systems of record. To that end, DOD stated that it is working to develop high quality data feeds from the military services to DOD's databases that contain its systems of record and that DOD continues to work on improving the completeness and accuracy of the military services' data. However, DOD did not provide relevant details pertaining to these efforts or set a date by which these efforts are to be fully implemented. Therefore, it is essential that the quality assurance program receives complete and accurate information from the services in their quarterly reports in order to assess PDHRA completion rates and report them to decision makers. Also, DOD stated that site visits are not conducted to validate information provided in the services' quarterly reports, but are intended to allow DOD to understand the military services' operations and to provide staff assistance in a nonthreatening fashion. However, DOD's 2004 quality assurance program policy establishes that site visits are intended to complement and validate service deployment health quality assurance program reports. Although an additional policy of the quality assurance program was issued in 2007, it explicitly states that it expands deployment health quality assurance activities pursuant to the 2004 policy. The 2007 policy states that periodic on- site visits and reviews may serve as monitoring mechanisms for deployment health assessments. We stated in this report that the site visits as currently conducted should not be used for validation purposes. As DOD acknowledged, its site visits cannot possibly provide the volume of data necessary to validate the information contained in the services' databases. DOD pointed out that given the differences of combat and operations among the services, it is unlikely that the quarterly reports from each service would ever look the same over time. The flexibility afforded to each service in its quarterly reports is noted in this report. However, we maintain that each quarterly report should contain consistent information on all deployment health assessments that can be used by DOD's quality assurance program to help DOD accurately determine completion rates of deployment health assessments across the military services. In comments to our June 2007 report, DOD agreed with our recommendation to provide specific reporting requirements to the Army Medical Surveillance Activity (AFHSC's title prior to February 2008). DOD has now stated that AFHSC has developed a detailed compliance methodology using DOD-level data sources, and as a result, there is no need to modify AFHSC's reporting requirements. At the time of our 2008 review, DOD asserted that the compliance method was being performed by the PDHRA program manager and not through AFHSC, as we noted in this 2008 report. In commenting, DOD did not provide relevant details or evidence pertaining to this effort. We maintain that AFHSC's monthly reports to DOD's quality assurance program should include the information necessary, including the total number of servicemembers who returned from deployment and should have completed PDHRAs, in order for the quality assurance program to accurately assess and report PDHRA completion rates to decision makers. In response to our statement that deployment health assessments are used for surveillance purposes, DOD responded that all deployment health assessments are primarily intended to maintain or improve servicemembers' health and incidentally used for surveillance purposes. We made changes in our report as appropriate to reflect this. We are sending copies of this report to the Secretary of Defense and appropriate congressional committees and addressees. We will also provide copies to others upon request. In addition, the report is available at no charge on the GAO Web site at [hyperlink, http://www.gao.gov]. If you or your staff have any questions about this report, please contact me 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 report. GAO staff who made major contributions to this report are listed in enclosure IV. Signed by: Randall B. Williamson: Director, Health Care: List of Congressional Addressees: The Honorable Carl Levin: Chairman: The Honorable John McCain: Ranking Member: Committee on Armed Services: United States Senate: The Honorable Ike Skelton: Chairman: The Honorable Duncan Hunter: Ranking Member: Committee on Armed Services: House of Representatives: The Honorable Daniel K. Akaka: United States Senate: The Honorable Wayne Allard: United States Senate: The Honorable Christopher S. Bond: United States Senate: The Honorable Barbara Boxer: United States Senate: The Honorable Tom Harkin: United States Senate: The Honorable Joseph I. Lieberman: United States Senate: The Honorable Claire McCaskill: United States Senate: The Honorable Patty Murray: United States Senate: The Honorable Barack Obama: United States Senate: The Honorable Ken Salazar: United States Senate: The Honorable Bernard Sanders: United States Senate: [End of correspondence] Enclosure I: Timing and Purpose of DOD Deployment-Based Health Assessments: Table 1: DOD Deployment-Based Health Assessments: Name: Pre-deployment health assessment; Purpose and description: * To record general information about servicemembers' health to identify any health concerns that may need to be addressed prior to deployment and can be used for surveillance purposes; * A health care provider is to review the pre-deployment health assessment, which is completed by servicemembers. If the provider identifies any health concerns that may affect servicemembers' ability to deploy, the provider may refer servicemembers for a further evaluation; * Required by the National Defense Authorization Act for Fiscal Year 1998.[A]; Timing: Within 60 days prior to deployment. Name: Post-deployment health assessment (PDHA); Purpose and description: * To identify and refer servicemembers with health concerns as a result of deployment; * A health care provider is to review the PDHA, which is completed by servicemembers and conduct an interview to discuss any deployment- related health concerns, including mental health concerns, with servicemembers. If necessary, the provider may refer servicemembers for further evaluation; * Required by the National Defense Authorization Act for Fiscal Year 1998.[A]; Timing: Within 30 days before or 30 days after return from deployment. Name: Post-deployment health reassessment (PDHRA); Purpose and description: * To focus on servicemembers' health concerns that emerge over time after return from deployment; * A health care provider is to review the completed PDHRA, which is completed by servicemembers, and if necessary conduct an interview to discuss any deployment-related health concerns, including mental health concerns, with servicemembers. If necessary, the provider may refer servicemembers for further evaluation; * Initiated by DOD in 2005; Timing: Within 90 to 180 days after return from deployment. Source: DOD. [A] National Defense Authorization Act for Fiscal Year 1998, Pub. L. No. 105-85, § 765(a)(1), 111 Stat. 1629, 1826 (1997) (codified as amended at 10 U.S.C. § 1074f). [End of table] Enclosure II: Sample Post-Deployment Health Reassessment Form: This form must be completed electronically. Handwritten forms will not be accepted. Post-Deployment Health Re-Assessment (PDHRA): Privacy Act Statement Authority: 10 U.S.C. 136. 1074f. 3013, 5013. 8013 and E.O. 9337. Principal Purpose(S): To assess your state of health after deployment in support of military operations and to assist military healthcare providers in identifying and providing present and future medical care you may need. The information you provide may result in a referral for additional healthcare that may include medical, dental or behavioral healthcare or diverse community support services. Routine Use(S): In addition to those disclosures generally permitted under 5 U.S.C. 552a(b) of the Privacy Act, to other Federal and State agencies and civilian healthcare providers, as necessary, in order to provide necessary medical care and treatment. Disclosure: Voluntary. if not provided, healthcare Will Be furnished, but comprehensive care may not be possible. Instructions: Please read each question completely and carefully before entering your response or marking your selection. You Are Encouraged To Answer Each Question. Withholding or providing inaccurate information may impair a healthcare provider's ability to identify health problems and refer you to appropriate sources for additional evaluation or treatment. If you do not understand a question, please ask for help. Please respond based on your most recent deployment. Demographics: Last Name: First Name: Middle Initial: Social Security Number: Date of Birth: Today's Date: Date arrived theater: Date departed theater: Gender: Male: Female: Marital Status: Never Married: Married: Separated: Divorced: Widowed: Service Branch: Air Force: Army: Navy: Marine Corps: Coast Guard: Civilian Employee: Other: Status Prior to Deployment: Active Duty: Selected Reserves - Reserve - Unit: Selected Reserves - Reserve - AGR: Selected Reserves - Reserve - IMA: Selected Reserves - National Guard - Unit: Selected Reserves - National Guard - AGR: Ready Reserves - IRR: Ready Reserves - ING: Civilian Government Employee: Other: Pay Grade: E1: E2: E3: E4: E5: E6: E7: E8: E9: O1: O2: O3: O4: O5: O6: O7: O8: O9: O10: W1: W2: W3: W4: W5: Other: Location of Operation: To what areas were you mainly deployed (land- based operations more than 30 days)? Please mark all that apply, including the number of months spent at each location. Country 1: Months: Country 2: Months: Country 3: Months: Country 4: Months: Country 5: Months: Since return from deployment I have: Maintained/returned to previous status: Transitioned to Selected Reserves: Transitioned to IRR: Transitioned to ING: Retired from Military Service: Separated from Military Service: Current Contact Information: Phone: Cell: DSN: Email: Address: Total Deployments in Past 5 Years: 1, 2, 3, 4, 5 or more; 0IF: OEF: Other: Current Unit of Assignment: Current Assignment Location: Point of Contact who can always reach you: Name: Phone: Email: Mailing address: DD Form 2900, Jan 2008: Previous Edition is Obsolete: 1. Overall, how would you rate your health during the PAST MONTH? Excellent: Very Good: Good: Fair: Poor: 2. Compared to before your most recent deployment, how would you rate your health in general now? Much better now than before I deployed: Somewhat better now than before I deployed: About the same as before I deployed: Somewhat worse now than before I deployed: Much worse now than before I deployed: 3. During the past 4 weeks, how difficult have physical health problems (illness or injury) made it for you to do your work or other regular daily activities? Not difficult at all: Somewhat difficult: Very difficult: Extremely difficult: 4. During the past 4 weeks, how difficult have emotional problems (such as feeling depressed or anxious) made it for you to do your work take care of things at home, or get along with other people? Not difficult at all: Somewhat difficult: Very difficult: Extremely difficult: 5. Since you returned from deployment, about how many times have you seen a healthcare provider for any reason, such as in sick call, emergency room, primary care, family doctor, or mental health provider? No visits: 1 visit: 2-3 visits: 4-5 visits: 6 or more: 6. Since you returned from deployment, have you been hospitalized? Yes: No: 7. During your deployment, were you wounded, injured, assaulted or otherwise physically hurt? Yes: No: If no, skip to Question 8. 7a. If Yes, are you still having problems related to this wound, assault, or injury? Yes: No: Unsure: 8. In addition to wounds or injuries you listed in question 7, do you currently have a health concern or condition that you feel is related to your deployment? Yes: No: Unsure: If No, skip to Question 9. 8a. If YES. please mark the item(s) that best describe your deployment- related condition or concern: Fever: Cough lasting more than 3 weeks: Trouble breathing: Bad headaches: Generally feeling weak: Muscle aches: Swollen, stiff or painful joints: Back pain: Numbness or tingling in hands or feet: Trouble hearing: Ringing in the ears: Watery, red eyes: Dimming of vision, like the lights were going out: Chest pain or pressure: Dizzy, light headed, passed out: Diarrhea, vomiting, or frequent indigestion/heartburn: Problems sleeping or still feeling tired after sleeping: Trouble concentrating, easily distracted: Forgetful or trouble remembering things: Hard to make up your mind or make decisions: Increased irritability: Taking more asks such as driving faster: Skin diseases of rashes: Other (please list): 9a. During this deployment, did you experience any of the following events? (Mark all that apply] (1) Blast or explosion (IED, RPC, land mine, grenade: Yes: No: (2) Vehicular accident/crash ,any vehicle, including aircraft): Yes: No: (3) Fragment wound or bullet wound above your shoulders: Yes: No: (4) Fall: Yes: No: (5) Other event for example, a sports injury to your head); Describe: 9b. Did any of the following happen to you, or were you told happened to you, immediately after any of the events you just noted in question 9a? (Mark all that apply): (1) Lost consciousness or got "knocked out:" Yes: No: 2) Felt dazed, confused, or "saw stars:" Yes: No: (3) Didn't remember the event: Yes: No: (4) Had a concussion: Yes: No: (5) Had a head injury: Yes: No: 9c. Did any of the following problems begin or get worse after the events you noted in question 9a.? (Mark all that apply): Memory problems or lapses: Yes: No: Balance problems or dizziness: Yes: No: Ringing in the ears: Yes: No: Sensitivity to bright lights: Yes: No: Irritability: Yes: No: Headaches: Yes: No: Sleep problems: Yes: No: 9d. In the past week, have you had any of the symptoms you indicated in 9c? (Mark all that apply): Memory problems or lapses: Yes: No: Balance problems or dizziness: Yes: No: Ringing in the ears: Yes: No: Sensitivity to bright lights: Yes: No: Irritability: Yes: No: Headaches: Yes: No: Sleep problems: Yes: No: 10. Do you have any persistent major concerns regarding the health effects of something you believe you may have been exposed to or encountered while deployed? If No, skip to question 11. Yes: No: 10a. If yes, please mark the item(s) that best describe your concern: Animal bites: Animal bodies (dead): Chlorine gas: Depleted uranium (If yes, explain): Excessive vibration: Fog oils (smoke screen): Garbage: Human blood, body fluids, body parts, or dead bodies: Industrial pollution: Insect bites: Ionizing radiation: JP8 or other fuels: Lasers: Loud noises: Paints: Pesticides: Radar/Microwaves: Sand/dust: Smoke from burning trash or feces: Smoke from oil fire: Solvents: Tent heater smoke: Vehicle Or truck exhaust fumes: Other exposures to toxic chemicals or materials. such as ammonia, nitric acid, etc. (If yes, explain): 11. Since return from your deployment, have you had serious conflicts with your spouse, family members, close friends, or at work that continue to cause worry or concern? Yes: No: Unsure: 12. Have you ever had any experience that was so frightening, horrible, or upsetting that, in the past month, you: a. Have had nightmares about it or thought about it when you did not want to? Yes: No: b. Tried hard not to think about it or went out of your way to avoid situations that remind you of it? Yes: No: c. Were constantly on guard, watchful, or easily startled? Yes: No: d. Felt numb or detached from others, activities, or your surroundings? Yes: No: 13a. In the past month, Did you use alcohol more than you meant to? Yes: No: 13b. In the Past Month, have you felt that you wanted to or needed to cut down on your drinking? Yes: No: 13c. How often do you have a drink containing alcohol? Never: Monthly or less: 2 to 4 times a month: 2 to 3 times a week: 4 or more times a week: 13d. How many drinks containing alcohol do you have on a typical day when you are dunking? 1 or 2: 3 or 4: 5 or 6: 7 to 9: 10 or more: 13e. How often do you have six or more drinks on one occasion? Never: Less than monthly: Monthly: Weekly: Daily: 14. Over the past month, have you been bothered by the following problems? Little interest or pleasure in doing things: Not at all: Few or several days: More than half the days: Nearly every day: Feeling down, depressed, or hopeless: Not at all: Few or several days: More than half the days: Nearly every day: 15. Would you like to schedule a visit with a healthcare provider to further discuss your health concern(s)? Yes: No: 16. Are you currently interested in receiving information or assistance for a stress, emotional or alcohol concern? Yes: No: 17. Are you currently interested in receiving assistance for a family or relationship concern? Yes: No: 18. Would you like to schedule a visit with a chaplain or a community support counselor? Yes: No: Health Care Provider Only: Provider Review and Interview: 1. Review symptoms and deployment concerns identified on form: Confirmed screening results as reported: Screening results modified amended, clarified during interview: 2. Ask behavioral risk questions. Conduct risk assessment. a. Over the past month, have you been bothered by thoughts that you would be better off dead or hurting yourself in some way? Yes: No: IF yes, about how often have you been bothered by these thoughts? Very few days: More than half of the time: Nearly every day: b. Since return from your deployment, have you had thoughts or concerns that you might hurt or lose control with someone? Yes: No: Unsure: 3. If member reports positive or unsure response to 2a. or 2b,, conduct risk assessment. a. Does member pose a current risk for harm to self or others? No, not a current risk: Yes, poses a current risk: Unsure: b. Outcome of assessment: Immediate referral: Routine follow-up: Referral not indicated: 4. Alcohol screening result: No evidence of alcohol-related problem; Potential alcohol problem (positive response to either question 13a or 13b, and/or Audit-C (questions 13c.-e.) score of 4 or more for men or 3 or more for women): Refer to PCM for evaluation: Yes: No: 5. Traumatic Brain Injury (TBI) risk assessment: No evidence of risk based on responses to questions 9.a.-d: Potential TBI with persistent symptoms, based on responses to question 9d. Refer for additional evaluation: Yes: No: 6. Record additional questions or concerns identified by patient during interview: Assessment and Referral: After my interview with the service member and review of this form, there is a need for further evaluation and follow- up as indicated below. (More than one may be noted for patients with multiple concerns): 7. Identified Concerns: Physical symptoms: Minor concern: Major concern: Already under care (yes/no): Exposure Symptoms: Minor concern: Major concern: Already under care (yes/no): Depression symptoms: Minor concern: Major concern: Already under care (yes/no): PTSD symptoms: Minor concern: Major concern: Already under care (yes/no): Anger/Aggression: Minor concern: Major concern: Already under care (yes/no): Suicidal Ideation: Minor concern: Major concern: Already under care (yes/no): Social/Family Conflict: Minor concern: Major concern: Already under care (yes/no): Alcohol Use: Minor concern: Major concern: Already under care (yes/no): Other: Minor concern: Major concern: Already under care (yes/no): 8. Referral information: a. Primary Care, Family Practice: Within 24 hours: Within 7 days: Within 30 days: b. Behavioral Health in Primary Care: Within 24 hours: Within 7 days: Within 30 days: c. Mental Health Specialty Care: Within 24 hours: Within 7 days: Within 30 days: d. Other specialty care: Audiology: Within 24 hours: Within 7 days: Within 30 days: Cardiology: Within 24 hours: Within 7 days: Within 30 days: Dentistry: Within 24 hours: Within 7 days: Within 30 days: Dermatology: Within 24 hours: Within 7 days: Within 30 days: ENT: Within 24 hours: Within 7 days: Within 30 days: GI: Within 24 hours: Within 7 days: Within 30 days: Internal Medicine: Within 24 hours: Within 7 days: Within 30 days: Neurology: Within 24 hours: Within 7 days: Within 30 days: OB/GYN: Within 24 hours: Within 7 days: Within 30 days: Ophthalmology: Within 24 hours: Within 7 days: Within 30 days: Optometry: Within 24 hours: Within 7 days: Within 30 days: Orthopedics: Within 24 hours: Within 7 days: Within 30 days: Pulmonology: Within 24 hours: Within 7 days: Within 30 days: Urology: Within 24 hours: Within 7 days: Within 30 days: e. Case Manager, Care Manager: Within 24 hours: Within 7 days: Within 30 days: f. Substance Abuse Program: Within 24 hours: Within 7 days: Within 30 days: g. Health Promotion, Health Education: Within 24 hours: Within 7 days: Within 30 days: h. Chaplain: Within 24 hours: Within 7 days: Within 30 days: i. Family Support Community Service: Within 24 hours: Within 7 days: Within 30 days: j. Military OneSource: Within 24 hours: Within 7 days: Within 30 days: k. Other: Within 24 hours: Within 7 days: Within 30 days: l. No referral made: 9. Comments: I certify that this review process has been completed. 10. Provider's signature and stamp: Ancillary Staff/Administrative Section: 11. Member was provided the following: Health Education and Information: Health Care Benefits and Resources Information: Appointment Assistance: Service member declined to Complete form: Service member declined to complete interview assessment: Service member declined referral for services: LOD: Other: 12. Referral was made to the following healthcare or support system: Military Treatment Facility: Division/Line-based medical resource: VA Medical Center or Community Clinic: Vet Center: TRICARE Provider: Contract Support: Community Service: Other: None: [End of section] Enclosure III: Comments from the Department of Defense: The Assistant Secretary Of Defense: Health Affairs: 1200 Defense Pentagon: Washington, DC 20301-1200: Mr. Randall B. Williamson: Acting Director, Health Care: U.S. Government Accountability Office: 441 G Street, N.W. Washington, DC 20548: Dear Mr. Williamson: This is the Department of Defense (DoD) response to the Government Accountability Office (GAO) draft report, GAO-08-1025R, "Defense Health Care: Oversight of Military Services' Post-Deployment Health Reassessment Completion Rates is Limited," dated July 31, 2008 (GAO Code 290686). Thank you for the opportunity to review and provide comments. Overall, we concur with the draft report's findings and conclusions. Although there were no formal recommendations, there are several items in the report that we would like to address. A recurrent theme in this report is that DoD's quality assurance (QA) program is unable to accurately assess whether post-deployment health reassessments (PDHRAs) are completed and fails to adequately "oversee" the PDHRA program. Possibly this is a matter of semantics, but some dictionaries define oversight to include supervision or management, which would be beyond the scope of a QA program. The actual management and execution of the program is the responsibility of the commanders and the Military Health System. This GAO report suggests that PDHRA compliance cannot be accurately assessed without the military Services providing consistent and complete information to the Deployment Health QA program office. The real key is in the military Services providing complete and accurate information to the enterprise-wide systems of record that have been identified, such as the Defense Manpower Data Center (DMDC) and the Defense Medical Surveillance System (DMSS). From these systems, accurate compliance calculations will be available at any time, to both the Services and the QA office, eliminating redundant reporting. To this end, DoD has been working hard since November 2007 to develop high quality data feeds from the Services to DMDC and DMSS. Given the past criticisms DoD has received for accepting Service data at face value, this seems the only way to ensure accurate compliance monitoring. In addition, DoD does not conduct site visits as a core mechanism for validating quarterly Service QA input. Site visits allow us to get a feel for the operational realities of force health protection and to provide staff assistance in a nonthreatening fashion. Such visits cannot possibly provide the volume of data necessary to validate the information contained in Service and DoD databases; hence, our emphasis is on analyzing and improving those systems, as mentioned above. Regarding "... inconsistencies within a Service and among the Services, ..." you highlight the differences between the Army's 2007 quarterly reports and differences between the Army and the other Services. Given the non-homogenous nature of combat operations among the Services (deployments of large versus small units versus individual augmentees, variable tour lengths, etc.), it is unlikely the reports would ever look the same over time. The report also emphasizes the failure of DoD to "... work with Armed Forces Health Surveillance Center (AFHSC) to specify reporting requirements ..." The situation has changed considerably since the GAO- 07-831 report. The AFHSC was not officially established until February 2008. In the meantime, the AFHSC staff has developed a detailed compliance assessment methodology using DMSS and other DoD-level data sources, as you mention. Consequently, there hasn't been any need to modify the other routine AFHSC reports that were designed to match those produced for the Department of Defense Forms 2796, per customer needs. Finally, there is one important misstatement (enclosure 1) that needs correction. In the pre-deployment health assessment section, you mention that this assessment is performed for "surveillance purposes." This is incorrect. All three of the deployment-health assessments were designed as clinical encounters with the primary goal of maintaining or improving the Service member's health. The self-reporting tools (DD Forms 2795, 2796, and 2900) were designed as clinical support tools. We simply do our best to leverage the information on the forms for surveillance purposes. Thank you for the opportunity to review and comment on the draft report. My points of contact for additional information are Colonel Kenneth Cox, who may be reached at Kenneth.Cox1@ha.osd.mil or (703) 578- 8524, and Mr. Gunther Zimmerman, who may be reached at Gunther.Zimmerman@tma.osd.mil or (703) 681-4360. Sincerely, Signed by: S. Ward Casscells, MD: Enclosure: As stated [End of section] GAO Contact and Staff Acknowledgments: GAO Contact: Randall B. Williamson, (202) 512-7114 or williamsonr@gao.gov: Acknowledgments: In addition to the contact named above, Mary Ann Curran, Assistant Director; Martha Fisher; Drew Long; Jasleen Modi; Lisa Motley; and Samantha Poppe made key contributions to this report. [End of section] Footnotes: [1] P. D. Bliese, K. M. Wright, A. B. Adler, et al., Screening for Traumatic Stress Among Re-Deploying Soldiers, U.S. Army Medical Research Unit-Europe Research Report 2004-001 (Heidelberg, Germany: USAMRU-E, 2004) and C. W. Hoge, C. A. Castro, S. C. Messer, et al., "Combat Duty in Iraq and Afghanistan, Mental Health Problems, and Barriers to Care," The New England Journal of Medicine, 351, (2004.) [2] C.S. Milliken, J.L. Auchterlonie, C.W. Hoge, "Longitudinal Assessment of Mental Health Problems Among Active and Reserve Component Soldiers Returning From the Iraq War," Journal of the American Medical Association, 298(18) (2007):2141-2148. [3] 10 U.S.C. § 1073b(a). [4] GAO, Defense Health Care: Comprehensive Oversight Framework Needed to Help Ensure Effective Implementation of a Deployment Health Quality Assurance Program, [hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-07- 831] (Washington, D.C.: June 22, 2007). [5] GAO, Military Personnel: Top Management Attention is Needed to Address Long-standing Problems with Determining Medical and Physical Fitness of the Reserve Force, [hyperlink, http://www.gao.gov/cgi- bin/getrpt?GAO-06-105] (Washington, D.C.: Oct. 27, 2006); GAO, DOD Civilian Personnel: Greater Oversight and Quality Assurance Needed to Ensure Force Health Protection and Surveillance for Those Deployed, [hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-06-1085] (Washington, D.C.: Sept. 29, 2006); GAO, Defense Health Care: Force Health Protection and Surveillance Policy Compliance Was Mixed, but Appears Better for Recent Deployments, [hyperlink, http://www.gao.gov/cgi- bin/getrpt?GAO-05-120] (Washington, D.C.: Nov. 12, 2004); and GAO, Defense Health Care: Quality Assurance Process Needed to Improve Force Health Protection and Surveillance, [hyperlink, http://www.gao.gov/cgi- bin/getrpt?GAO-03-1041] (Washington, D.C.: Sept. 19, 2003). [6] S. Rep. No. 110-77, at 360 (2007). [7] For purposes of this report, "servicemembers" include active duty and Reserve components. [8] DOD's policy delegates the responsibility for executing the quality assurance program to the Deputy Assistant Secretary of Defense for Force Health Protection and Readiness. In this report, we refer to this quality assurance program as "DOD's quality assurance program." [9] AFHSC is a DOD agency that performs comprehensive medical surveillance and reporting on rates of diseases and injuries among servicemembers. AFHSC operates the Defense Medical Surveillance System (DMSS), which contains data on diseases and medical events and longitudinal data on personnel and deployments, including deployment health assessments. Each of the military services is required to electronically submit completed PDHRAs to DMSS. [10] Assistant Secretary of Defense for Health Affairs Memorandum, "Post-Deployment Health Reassessment," (Mar. 10, 2005), and Department of Defense Instruction 6490.03, Section E4.A3.2.12, "Deployment Health," (Aug. 11, 2006). [11] Servicemembers who are deployed overseas for more than 30 continuous days to locations without permanent military treatment facilities are required to complete PDHRA. It is the commander's decision whether servicemembers who do not meet the criteria complete these health assessments. [12] The quality assurance program was required by the National Defense Authorization Act for Fiscal Year 1998, Pub. L. No. 105-85, § 765(a)(1), 111 Stat. 1629, 1826 (1997) (codified as amended at 10 U.S.C. § 1074f(d)). [13] DOD's policy and implementing guidance for the program is contained in a 2004 policy memorandum, Assistant Secretary of Defense for Health Affairs, "Policy for Department of Defense Deployment Health Quality Assurance Program," (Jan. 9, 2004). DOD subsequently issued additional guidance for the quality assurance program in 2007. DOD Instruction 6200.05, "Force Health Protection (FHP) Quality Assurance (QA) Program," (Feb. 16, 2007). [14] According to DOD's quality assurance program manager, other DOD and military services staff provide analytical assistance to the quality assurance program as needed. [15] [hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-07-831]. [16] Site visits are planned, coordinated, and conducted jointly by staff members from DOD's quality assurance program and the services' medical department. [End of section] GAO's Mission: The Government Accountability Office, the audit, evaluation and investigative arm of Congress, exists to support Congress in meeting its constitutional responsibilities and to help improve the performance and accountability of the federal government for the American people. 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