This is the accessible text file for GAO report number GAO-08-181R
entitled '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' which was released on
January 25, 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.
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 since World War II.[Footnote 1],[Footnote 2] For
servicemembers who have been deployed overseas--whether National Guard,
Reserve, or active duty--the Department of Defense (DOD) has developed
a continuum of programs to assess servicemembers' health needs by
obtaining information on their health concerns. One health assessment
is administered before deployment, another about the time
servicemembers return from deployment, and a third 90 to 180 days after
deployment, which is called the post-deployment health reassessment
(PDHRA). DOD directed the PDHRA to be implemented in June 2005 in
response to studies that showed that health concerns were emerging
several months after servicemembers' return from deployment.[Footnote
3] One intent of the PDHRA is to identify servicemembers' health
concerns with a specific emphasis on screening for mental health and to
assess whether servicemembers need referrals for further evaluation.
PDHRAs can result in referrals being made to military treatment
facilities, TRICARE providers,[Footnote 4] chaplains, Military
OneSource,[Footnote 5] or Department of Veterans Affairs (VA)
facilities, such as VA medical centers, VA community clinics, and Vet
Centers.[Footnote 6]
Congressional interest in health care services for National Guard and
Reserve servicemembers returning from deployment has increased because
of their large numbers and because they have reported post-deployment
mental health concerns at a higher rate than their active duty
counterparts, though this varies by military service.[Footnote 7]
Related to this interest, you asked us to describe the administration
of the PDHRA to National Guard and Reserve servicemembers.[Footnote 8]
This report describes (1) how DOD administers the PDHRA to National
Guard and Reserve servicemembers and what information it obtains and
(2) how VA interacts with DOD in the PDHRA process for these
servicemembers and the information VA obtains.
Our work focused on National Guard (federally activated) and Reserve
servicemembers from the military services who have been deployed
overseas greater than 30 days to locations without a permanent military
treatment facility.[Footnote 9] National Guard servicemembers included
the Army National Guard and the Air National Guard. Reserve
servicemembers included Army Reserve, Navy Reserve, Air Force Reserve,
and Marine Corps Reserve. We did not include 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 Reserve
servicemembers and what information it obtains, we interviewed and
obtained documents from relevant DOD officials from the Force Health
Protection 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 identified above. In
addition, we interviewed and obtained documents from the health care
contractor DOD uses to administer the PDHRA to National Guard and
Reserve servicemembers. Further, we obtained completion and referral
data from PDHRA administrations conducted from June 2005 through
January 1, 2008. We assessed the reliability of those data by reviewing
system documentation, interviewing knowledgeable 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 describe how VA interacts with DOD in the PDHRA process for
these servicemembers, we interviewed, 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.[Footnote 10] We
also interviewed and obtained documents from DOD's contractor officials
and relevant DOD officials from the Force Health Protection 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 identified above.
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 our review (July 2007). While this sample
of site visits allowed us to learn about many important aspects of
PDHRA administrations, the information does not permit us to generalize
about PDHRA administrations departmentwide. At these sites, we met with
and collected supporting documentation from officials responsible for
administering the PDHRA and officials from VA medical centers, a VA
community clinic, and Vet Centers. We conducted our work from April
2007 through January 2008 in accordance with generally accepted
government auditing standards.
Results in Brief:
DOD uses a health care contractor in all but a small number of cases to
administer the PDHRA to National Guard and Reserve servicemembers
either in person or by telephone through a call center. Specifically,
DOD contracts with a company that provides administrative staff and
health care providers--physicians, physician's assistants, and nurse
practitioners--to administer the assessments. The PDHRA form asks for
demographic information--such as the servicemember's date of birth,
gender, and marital status--and health information that can lead to
referrals for additional evaluation. For example, the PDHRA asks
servicemembers questions about the occurrence of nightmares, conflicts
with family and friends, and increased alcohol use. Servicemembers who
answer affirmatively to these 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-person
or telephone discussions that take place between the servicemember and
the health care provider during the PDHRA administration. Of the about
156,000 PDHRAs completed by National Guard and Reserve servicemembers
from June 2005 through January 1, 2008, nearly 46 percent resulted in
referrals for further evaluation for physical or mental health
concerns.
According to our discussions with VA and DOD officials, VA officials
interact with DOD officials in the PDHRA process in several ways and
receive information about servicemembers from DOD. Through coordination
with DOD, VA officials are generally present when PDHRAs are
administered to National Guard and Reserve servicemembers during drill
weekends, whether the PDHRAs are administered in person or by telephone
through a call center. VA interaction with DOD also occurs when
servicemembers are referred to a VA facility. VA staff provide
servicemembers with information about VA benefits and help them make
appointments at VA facilities.[Footnote 11] Information VA receives
from DOD includes the location of PDHRA administrations, numbers of
servicemembers referred to VA facilities, and the PDHRAs of individual
servicemembers who access VA health care. Of the National 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-time basis while maintaining a civilian career. When
not deployed, they usually meet 1 weekend a month for a drill weekend
and 2 weeks a year for annual training. Commanding officers are
responsible for ensuring that servicemembers in their military units
are medically ready to be deployed. As part of that effort, they are
responsible for having servicemembers in their unit complete 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 servicemembers deployed overseas greater than 30 days to
locations without a permanent military treatment facility.[Footnote 12]
They do not diagnose medical conditions. The pre-deployment health
assessment is documented on Department of Defense Form 2795 and is
administered within 60 days before deployment. It is a mandatory health
assessment for most servicemembers deploying overseas. The post-
deployment health assessment is documented on Department of Defense
Form 2796 and must be completed between 30 days prior to leaving a
deployment location and within 30 days after returning from deployment.
It is a mandatory health assessment for servicemembers returning from
deployment. The PDHRA is documented on Department of Defense Form 2900
(DD 2900) and is administered 90 to 180 days after returning from
deployment.[Footnote 13] (See encl. I.) While it is mandatory that DOD
offer servicemembers the opportunity to participate in the PDHRA,
servicemembers are only required to answer limited demographic
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 required to do so.
While the pre-and post-deployment health assessments were established
in response to legislation, the PDHRA was created independently by
DOD.[Footnote 14] In 2004, researchers published articles that
indicated servicemembers reported a significant increase in mental
health concerns 90 to 120 days after returning from deployment compared
with mental health concerns reported before or just after
deployment.[Footnote 15] In response, DOD developed the PDHRA process
to provide identification of health concerns during this post-
deployment time frame and to assess whether servicemembers need
referrals for further evaluation. DOD and international health experts
worked jointly with VA mental health experts to develop the DD 2900.
Veterans who have served in combat in certain conflicts, including
those from the National Guard and Reserves, are presumed to be eligible
for VA health care services for any condition for 2 years from the date
of separation from military service, even if there is insufficient
medical evidence to conclude that the condition is attributable to
military service.[Footnote 16] This 2-year presumptive eligibility
includes those National Guard and Reserve members who have left active
duty and returned to their units. If veterans do not enroll until after
the 2-year presumptive period, they will be subject to the same
eligibility and enrollment rules as other veterans, who generally have
to prove that a medical problem is connected to their military service
or that they have incomes below certain thresholds.[Footnote 17]
PDHRA, Administered in Person or through a Call Center, Provides DOD
with Servicemembers' Health Information:
DOD generally administers the PDHRA to National Guard and Reserve
servicemembers using a health care contractor either in person or by
telephone through a call center, depending on the number of individuals
being assessed.[Footnote 18] DOD officials said their contract
officials generally administer the PDHRA in person when they can
achieve economies of scale, that is, when a sufficient number of
servicemembers--at least 60--are scheduled for an assessment at a drill
location. At in-person administrations, contractor personnel--
including administrative staff and health care providers--go to the
drill location. Contractor officials stated that most PDHRAs are
administered to Army National Guard servicemembers in person because
they generally deploy in large enough groups.
According to DOD officials, when fewer than 60 servicemembers are being
assessed, PDHRAs are administered by telephone through a call center
operated by DOD's health care contractor. Contractor officials
indicated that the Air National Guard and the Army, Navy, and Marine
Corps Reserves typically use the call center because they tend to
deploy servicemembers in small groups. DOD officials told us that for
administrations using the call center, commanding officers decide
whether servicemembers complete PDHRAs by phone during a drill weekend
or during their personal time.
Whether administered in person or through the call center, the DD 2900
consists of two sets of questions--one set answered by servicemembers
and the other by health care providers. Servicemembers answer the first
set of questions online. These questions ask about servicemembers'
demographics--such as the servicemember's date of birth, gender, and
marital status--and health concerns. The second set of questions is
completed by a health care provider--typically a physician, physician's
assistant, or nurse practitioner. The provider discusses with the
servicemember answers from the first set of questions and uses that
information to answer the second set of questions, which ask the
provider to assess servicemember's health concerns and make referrals
if needed.[Footnote 19]
DOD obtains information from the PDHRA process that can lead to
referrals for additional evaluations. For example, the PDHRA includes
questions about the occurrence of nightmares, conflicts with family and
friends, and increased alcohol use. Servicemembers who answer
affirmatively to these questions may need further evaluation for mental
health conditions, such as post-traumatic stress disorder or alcohol
abuse. Of the about 156,000 DD 2900s completed by National Guard and
Reserve servicemembers between June 2005 and January 1, 2008, about 46
percent resulted in referrals for further evaluation for physical or
mental health concerns.
VA Interacts with DOD in the PDHRA Process and Receives PDHRA
Information from DOD:
According to our discussions with VA and DOD officials, VA officials
interact with DOD in the PDHRA process in several ways. VA staff
routinely attend when PDHRAs are to be administered in person. DOD's
health care contractor provides VA's senior military liaison with
information about the location and schedule as well as the number of
National Guard and Reserve servicemembers expected to be assessed.
Local VA officials told us that when they are scheduled to attend a
PDHRA in-person administration, they contact the unit's commanding
officer or the officer's representative to obtain information on the
unit's combat experiences and to coordinate the number of VA staff and
materials needed for the number of servicemembers scheduled to complete
PDHRAs. At our site visits, we observed officials from VA medical
centers and Vet Centers providing servicemembers with information about
VA benefits, enrolling servicemembers in the VA, and helping
servicemembers make appointments at VA facilities. At our Indianapolis
site visit, local VA officials provided Army Reserve servicemembers
with appointment contact information for VA facilities located not only
in Indiana but also in Arizona, California, Georgia, Illinois,
Kentucky, Michigan, Ohio, and Texas for servicemembers who lived
outside of Indiana.[Footnote 20] VA officials we interviewed at
headquarters, the VISN, and the local office noted that PDHRA
administrations provide one of the best ways for VA to give information
about their benefits to National Guard and Reserve servicemembers.
VA officials told us they also interact with DOD when the PDHRA is
administered through the call center. When units schedule PDHRA
administrations using the call center during drill weekends, VA
officials told us they generally coordinate in the same ways as they do
for in-person PDHRA administrations. For example, a headquarters
official said local VA officials usually go to the unit's location to
provide educational materials about VA benefits, enroll servicemembers
in VA, and help them make appointments at VA facilities. Officials at
VA headquarters and a VISN indicated that VA officials also provide
educational materials for servicemembers who complete PDHRAs using the
call center when the assessments are not administered on a drill
weekend. For example, for a unit in Jacksonville, Florida, a VISN
official sent the unit's commanding officer packets of information for
distribution to the servicemembers at the unit's next drill weekend.
The information included VA enrollment forms and brochures about VA
benefits. Regardless of whether the PDHRA is administered during a
drill weekend, VA and DOD interact when servicemembers are referred to
VA facilities. According to VA headquarters and DOD officials, the
contractor's call center personnel will either connect servicemembers
directly to a VA facility or give them information to contact the
facility themselves. Following the telephone interview, call center
personnel mail servicemembers a brochure about VA benefits for National
Guard and Reserve servicemembers, a copy of their DD 2900, and contact
information for the VA senior military liaison to assist them if they
experience problems getting an appointment at a VA facility.
Through interaction with DOD officials, VA officials obtain PDHRA
information about servicemembers referred to VA and individual
servicemembers' DD 2900s when they access VA health care. Each month,
VA receives a report that provides monthly and cumulative totals of
servicemembers referred, including servicemembers referred to VA
facilities. For example, the January 1, 2008, report showed that of the
number of servicemembers referred from June 2005 through January 1,
2008, nearly 34,000 (47 percent) were referred to VA facilities for
either physical or mental health concerns. For mental health concerns,
more than 11,000 servicemembers were referred to VA medical centers or
clinics and over 16,000 were referred to Vet Centers.[Footnote 21] VA
also receives a weekly report that lists the location of all in-person
PDHRA administrations during the past week and shows the number of
referrals to VA from each PDHRA administration. Further, when
servicemembers obtain health care from VA, VA officials have access to
individual servicemembers' DD 2900s. DOD provides VA with electronic
access to servicemembers' DD 2900s, according to headquarters VA and
DOD officials. In addition, servicemembers may provide VA officials
with paper copies of their DD 2900s.
Agency Comments:
VA and DOD reviewed a draft of this report. VA stated in an e-mail
response that it agreed with the facts presented in the report as they
pertain to VA, and had no additional comments. DOD stated that it
concurred with the report's findings and conclusions. DOD asked that we
clarify in the first paragraph that the focus of the report is National
Guard and Reserve servicemembers, and we made revisions to do so. DOD
also provided technical comments which we incorporated where
appropriate. DOD's comments are reprinted in enclosure II.
We are sending copies of this report to the Secretary of Veterans
Affairs and the Secretary of Defense and appropriate congressional
committees. We will also make copies available 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 questions about this report, please contact
me at (202) 512-7114 or kanofm@gao.gov. Contact points for our Office
of Congressional Relations and Public Affairs may be found on the last
page of this report. GAO staff members who made key contributions to
this report are listed in enclosure III.
Signed by:
Marjorie Kanof:
Managing Director, Health Care:
Enclosures - 3:
List of Requesters:
The Honorable Michael H. Michaud:
Chairman Subcommittee on Health:
Committee on Veterans' Affairs:
House of Representatives:
The Honorable Daniel K. Akaka:
Chairman:
Committee on Veterans' Affairs:
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:
The Honorable Peter Welch:
House of Representatives:
[End of section]
Enclosure 1: Department of Defense Form 2900:
Post-Deployment Health Reassessment (PDHRA):
Authority: 10 U.S.C. 136 Chapter 55. 1074f, 3013, 5013, 8013 and E.O.
9397:
Principal Purpose: To assess your state of health after deployment in
support of military operations and to assist military healthcare
providers, including behavioral health providers, in identifying
present and future medical care needs you may have. The information you
provide may result in a referral for additional healthcare that may
include behavioral healthcare.
Routine Use: To other Federal and State agencies and civilian
healthcare providers as necessary in order to provide necessary medical
care and treatment. Responses may be used to guide possible referrals.
Disclosure: Disclosure is voluntary.
Instructions: Please read each question completely and carefully before
making your selections. Provide a response for each question. If you do
not understand a question, ask the administrator. Please respond based
on your Most Recent Deployment.
Demographics:
Last Name:
First Name:
MI:
DOB (dd/mm/yyyy):
Today's Date (dd/mm/yyyy):
Date arrived theater (mm/yyyy):
Date departed theater (mm/yyyy):
Social Security Number:
Gender:
Male:
Female:
Service Branch:
Air Force:
Army:
Navy:
Marine Corps:
Coast Guard:
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:
001:
002:
003:
004:
005:
006:
007:
008:
009:
010:
W1:
W2:
W3:
W4:
W5:
Other:
Marital Status:
Never Married:
Married:
Separated:
Divorced:
Widowed:
Location of Operation:
Iraq:
Afghanistan:
Kuwait:
Qatar:
Bosnia/Kosovo:
SW Asia - other:
Africa:
South America:
North America:
Australia:
Europe:
On a ship:
Other:
Since return from deployment I have:
Maintained/returned to previous status:
Transitioned to Selected Reserves:
Transitioned to Ready Reserves:
Retired from Military Service:
Separated from Military Service:
Current Contact Information:
Phone:
Cell:
DSN:
Email:
Address:
Total Deployments in Past 5 Years:
OIF:
1:
2:
3:
4:
5 or more:
OEF:
1:
2:
3:
4:
5 or more:
Other:
1:
2:
3:
4:
5 or more:
Current Unit of Assignment:
Current Assignment Location:
Point of Contact who can always reach you:
Name:
Phone:
Email:
Mailing Address:
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. 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:
Over 6 visits:
4. Since you returned from deployment, have you been hospitalized?
Yes:
No:
5. During your deployment, were you wounded, injured, assaulted or
otherwise physically hurt?
Yes:
No:
If NO, skip to Question 6.
5a. IF YES, are you still having problems related to this wound,
assault, or injury?
Yes:
No:
Unsure:
6. Other than wounds or injuries, do you currently have a health
concern or condition that you feel is related to your deployment? IF
NO, skip to Question 7.
6a. IF YES, please mark the item(s) that best describe your deployment-
related condition or concern:
Chronic cough:
Redness of eyes with tearing:
Runny nose:
Dimming of vision, like the lights were going out:
Fever:
Chest pain or pressure:
Weakness:
Dizziness, fainting, light headedness:
Headaches:
Difficulty breathing:
Swollen, stiff or painful joints:
Diarrhea, vomiting, or frequent indigestion:
Back pain:
Problems sleeping or still feeling tired after sleeping:
Muscle aches:
Difficulty remembering:
Numbness or tingling in hands or feet:
Increased irritability:
Skin diseases or rashes:
Taking more risks such as driving faster:
Ringing of the ears:
Other::
7. 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 8.
7a. IF YES, please mark the item(s) that best describe your concern:
DEET insect repellent applied to skin:
Paints:
Pesticide-treated uniforms:
Radiation:
Environmental pesticides (like area fogging):
Radar/microwaves:
Flea or tick collars:
Lasers:
Pesticide strips:
Loud noises:
Smoke from oil fire:
Excessive vibration:
Smoke from burning trash or feces:
Industrial pollution:
Vehicle or truck exhaust fumes:
Sand/dust:
Tent heater smoke:
Blast or motor vehicle accident:
JP8 or other fuels:
Depleted Uranium (if yes, explain):
Fog oils (smoke screen):
Solvents:
Other:
8. Since return from your deployment, have you had serious conflicts
with your spouse, family members, close friends, or at work that
continue to cause you worry or concern?
Yes:
No:
Unsure:
9. Have you had any experience that was so frightening, horrible, or
upsetting that, In The Past Month, you:
a. Have had any 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:
10. a. In the Past Month, did you use alcohol more than you meant to?
Yes:
No:
b. In the Past Month, have you felt that you wanted to or needed to cut
down on your drinking?
Yes:
No:
11. Over the Past Month, have you been bothered by the following
problems?
a. Little interest or pleasure in doing things?
Not at all:
Few or several days:
More than half the days:
Nearly every day:
b. Feeling down, depressed, or hopeless?
Not at all:
Few or several days:
More than half the days:
Nearly every day:
12. If you checked off any problems or concerns on this questionnaire,
how difficult have these problems 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:
13. Would you like to schedule a visit with a healthcare provider to
further discuss your health concern(s)?
Yes:
No:
14. Are you currently interested in receiving information or assistance
for a stress, emotional or alcohol concern?
Yes:
No:
15. Are you currently interested in receiving assistance for a family
or relationship concern?
Yes:
No:
16. Would you like to schedule a visit with a chaplain or a community
support counselor?
Yes:
No:
Health Care Provider Only:
Service Member's Social Security Number:
Date (dd/mm/yyyy):
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.
a. Over the Past Month, have you been bothered by thoughts that you
would be better off dead or of 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 Yes Or Unsure to behavioral risk questions, 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, referred:
b. Outcome of assessment:
Immediate referral:
Routine follow-up referral:
Referral not indicated:
4. 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.)
5. Identified Concerns:
Physical Symptom:
Minor Concern:
Major Concern:
Already Under Care, Yes:
Already Under Care, No:
Exposure Concern:
Minor Concern:
Major Concern:
Already Under Care, Yes:
Already Under Care, No:
Depression Symptoms:
Minor Concern:
Major Concern:
Already Under Care, Yes:
Already Under Care, No:
PTSD Symptoms:
Minor Concern:
Major Concern:
Already Under Care, Yes:
Already Under Care, No:
Anger/Aggression:
Minor Concern:
Major Concern:
Already Under Care, Yes:
Already Under Care, No:
Suicidal Ideation:
Minor Concern:
Major Concern:
Already Under Care, Yes:
Already Under Care, No:
Social/Family Conflict:
Minor Concern:
Major Concern:
Already Under Care, Yes:
Already Under Care, No:
Alcohol Use:
Minor Concern:
Major Concern:
Already Under Care, Yes:
Already Under Care, No:
Other:
Minor Concern:
Major Concern:
Already Under Care, Yes:
Already Under Care, No:
None:
6. Referral Information:
a. No referral made:
b. Immediate/emergent care:
c. Primary Care, Family Practice:
d. Specialty Care:
e. Behavioral Health in Primary Care:
f. Mental Health Specialty Care:
g. Case Manager, Care Manager:
h. Substance Abuse Program:
i. Health Promotion, Health Education:
j. Other Healthcare Service:
k. Chaplain:
l. Family Support, Community Service:
m. Military OneSource:
n. Other:
7. Comments:
8. Provider:
a. Name {Last, First):
b. Signature and stamp:
ICD-9 Code for this visit: V70.5_6:
Ancillary Staff/Administrative Section:
9. 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:
Other:
10. Referral 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 enclosure]
Enclosure 2: Comments from the Department of Defense:
Comments from the Department of Defense:
The Assistant Secretary Of Defense:
Health Affairs:
1200 Defense Pentagon:
Washington, DC 20301-1200:
January 3, 2008:
Ms. Laurie E. Ekstrand:
Director, Health Care:
U.S. Government Accountability Office:
441 G Street, NW:
Washington, DC 20548:
Dear Ms. Ekstrand:
This is the Department of Defense (DoD) response to the Government
Accountability Office (GAO) draft report, GAO-08-181R, "VA and DoD
Health Care: Administration of DoD's Post-Deployment Health
Reassessment to National Guard and Reserve Service Members and VA's
Interaction with DoD," dated November 9, 2007 (GAO Code 290600).
Thank you for the opportunity to review the draft report. Overall, I
concur with the draft report's findings and conclusions. However, I do
wish to identify some additional information to help clarify portions
of the report. The title clearly states that this report is limited to
National Guard and Reserve Service members. However, the opening line
of the report states, "For servicemembers who have deployed—including
National Guard and Reserve— ..." This establishes a total force mindset
among the readers. Although a footnote defines "servicemembers," not
everyone is diligent about reading footnotes, and it is not until the
bottom of the second page that the report states, "Our work focused on
National Guard (federally activated) and Reserve Service members..." To
minimize confusion, I suggest clearly identifying the focus of the
study in the opening paragraph of the report. Additional technical
comments are attached for your consideration.
The Department appreciates your review of this important matter to help
ensure that the appropriate level of health care can be provided to the
Service members who have so valiantly served their country.
My points of contact on this issue are Colonel Kenneth Cox, Force
Health Protection and Readiness (Functional) at (703) 575-2678, and Mr.
Gunther Zimmerman (Audit Liaison) at (703) 681-4360.
Sincerely,
Signed by:
S. Ward Casscells, MD
Enclosure: As stated:
Government Accountability Office Draft Report Dated November 9, 2007:
Government Accountability Office-08-181R:
(Government Accountability Office Code 290600):
"VA and DoD Health Care: Administration of DoD's Post-Deployment Health
Reassessment to National Guard and Reserve Service members and VA's
Interaction with DoD"
Department of Defense Comments Technical Comments:
Page 2, "Recent congressional interest has centered on National Guard
and Reserve Service members because they are being activated in numbers
not seen since World War II and have reported post-deployment mental
health concerns at a higher rate than their Active Duty counterparts."
This cannot be generalized across all Services.
Recommend: That the Government Accountability Office (GAO) modify the
above narrative statement to accurately reflect that there are
differences in the degree of elevation regarding mental health concerns
in the Components. A suggested statement is provided below.
"Recent congressional interest has centered on National Guard and
Reserve Service members because they arc being activated in numbers not
seen since World War II and have often reported post-deployment mental
health concerns at a higher rate than their Active Duty counterparts,
though the increase varies with the Component. For instance, the Air
National Guard actually reports mental health concerns 1 percent less
often than the Active Air Force, though this is not a significant
difference. At the other extreme, the Army National Guard and Army
Reserve Components report such concerns 10 percent more often than the
Active Army."
Page 9, "Following the telephone interview, call center personnel mail
servicemembers a brochure about VA benefits for National Guard and
Reserve servicemembers, a copy of their DD 2900 and contact information
for the VA senior military liaison to assist them if they experience
problems getting an appointment at a VA facility."
Recommend: We suggest that GAO clarify the above narrative statement. A
suggested revised statement is provided: "Following the telephone
interview, call center personnel mail Service members a brochure about
Veterans Affairs (VA) benefits for National Guard and Reserve Service
members, a copy of their DD 2900, and contact information for the
Military Liaison Coordinator in the VA Office of Seamless Transition to
assist them if they experience problems getting an appointment at a VA
facility."
[End of enclosure]
Enclosure 3: GAO Contact and Staff Acknowledgments:
GAO Contact:
Marjorie Kanof, (202) 512-7114 or kanofm@gao.gov:
Acknowledgments:
In addition to the contact named above, key contributors to this report
were James C. Musselwhite, Jr., Assistant Director; Rebecca Abela;
Laurie E. Ekstrand; Hannah Fein; Cynthia Forbes; and Julianna Weigle.
[End of enclosure]
Related GAO Products:
Defense Health Care: Comprehensive Oversight Framework Needed to Help
Ensure Effective Implementation of a Deployment Health Quality
Assurance Program. GAO-07-831. Washington, D.C.: June 22, 2007.
VA and DOD Health Care: Efforts to Provide Seamless Transition of Care
for OEF and OIF Servicemembers and Veterans. GAO-06-794R. Washington,
D.C.: June 30, 2006.
Post-Traumatic Stress Disorder: DOD Needs to Identify the Factors Its
Providers Use to Make Mental Health Evaluation Referrals for
Servicemembers. GAO-06-397. Washington, D.C.: May 11, 2006.
VA and DOD Health Care: VA Has Policies and Outreach Efforts to Smooth
Transition from DOD Health Care, but Sharing of Health Information
Remains Limited. GAO-05-1052T. Washington, D.C.: September 28, 2005.
Defense Health Care: Occupational and Environmental Health Surveillance
Conducted During Deployments Needs Improvement. GAO-05-903T.
Washington, D.C.: July 19, 2005.
Defense Health Care: Improvements Needed in Occupational and
Environmental Health Surveillance During Deployments to Address
Immediate and Long-Term Health Issues. GAO-05-632. Washington, D.C.:
July 14, 2005.
Defense Health Care: Force Health Protection and Surveillance Policy
Compliance Was Mixed, but Appears Better for Recent Deployments. GAO-
05-120. Washington, D.C.: November 12, 2004.
Gulf War Illnesses: Federal Research Efforts Have Waned, and Research
Findings Have Not Been Reassessed. GAO-04-815T. Washington, D.C.: June
1, 2004.
Department of Veterans Affairs: Federal Gulf War Illnesses Research
Strategy Needs Reassessment. GAO-04-767. Washington, D.C.: June 1,
2004.
Defense Health Care: DOD Needs to Improve Force Health Protection and
Surveillance Processes. GAO-04-158T. Washington, D.C.: October 16,
2003.
Defense Health Care: Quality Assurance Process Needed to Improve Force
Health Protection and Surveillance. GAO-03-1041. Washington, D.C.:
September 19, 2003.
VA and Defense Health Care: Progress Made, but DOD Continues To Face
Military Medical Surveillance System Challenges. GAO-02-377T.
Washington, D.C.: January 24, 2002.
VA and Defense Health Care: Progress and Challenges DOD Faces in
Executing a Military Medical Surveillance System. GAO-02-173T.
Washington, D.C.: October 16, 2001.
[End of section]
Footnotes:
[1] See Related GAO Products at the end of this report.
[2] Between September 2001 and October 2007, nearly 620,000 National
Guard and Reserve servicemembers 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 and Reserves who fall under DOD's
continuum of care because of their active duty service overseas, even
if 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 civilian contractors to maintain provider networks to
complement health care services provided at military hospitals and
clinics, commonly referred to as military treatment facilities. While
servicemembers are on active duty, DOD manages where they receive their
care--at a military treatment facility, a TRICARE civilian provider, or
a VA medical facility.
[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 to face.
[6] VA's integrated health care system provides primary care,
specialized care, and related medical and social support services. VA
medical centers provide a broad range of inpatient and outpatient
medical services, including mental health services, to servicemembers
and veterans meeting eligibility criteria. VA community clinics provide
medical services, which may include mental health services, on an
outpatient basis in local communities. Vet Centers provide mental
health services, including readjustment 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, testimony before 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 subject or in requests for this information as
part of a larger body of work. As requested, we are also conducting
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 and mobilized under
authority contained in Title 10, U.S. Code. These mobilization
authorities include, for example, 10 U.S.C. § 12302 and § 12304.
[10] The VA health care system is organized into 21 geographically
defined regions, or VISNs, that have budget and management
responsibilities for VA facilities in their geographic area.
[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 these health assessments.
[13] Although a new DD 2900 dated September 2007 has been developed, it
had not been implemented as of January 7, 2008. This report refers to
the DD 2900 dated June 2005.
[14] The pre-and post-deployment health assessments were established in
response to a provision in the National Defense Authorization Act for
Fiscal Year 1998. See Pub. L. No. 105-85, § 765(a)(1), 111 Stat. 1629,
1826-27 (codified as amended as 10 U.S.C. § 1074f). The Assistant
Secretary of Defense for Health Affairs directed all military services
to conduct health reassessments of servicemembers at 90 to 180 days
post-deployment. He directed implementation plans to begin 90 days
after March 10, 2005.
[15] 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 (Boston, MA: The New England Journal of Medicine, 351,
2004).
[16] To be eligible, the veteran must have served in combat during a
period of war after the Persian Gulf War or against a hostile force
during a period of hostilities after November 11, 1998. See 38 U.S.C. §
1710(e)(1)(D); VHA Directive 2005-020, Determining Combat Veteran
Eligibility (June 2, 2005). "Hostilities" is defined as an armed
conflict in which servicemembers are subjected to danger comparable to
the danger encountered in combat with enemy armed forces during a
period of war, as determined by the Secretary of VA. See 38 U.S.C. §
1712A(a)(2)(B). Eligibility under 38 U.S.C. § 1710(e)(1)(D) does not
extend, however, to veterans whose disabilities are found to have
resulted from a cause other than the service described in the statute.
H.R. 1585, the National Defense Authorization Act for Fiscal Year 2008,
contains a provision that would extend the length of the presumptive
eligibility for certain combat veterans. The House and Senate approved
this bill in December, 2007. However, on December 27, 2007, the
President issued a memorandum indicating his disapproval of H.R. 1585
and declined to sign the legislation.
[17] See 38 U.S.C. §§ 1705, 1710; 38 C.F.R. § 17.36 (2007).
[18] The Air National Guard requires the PDHRA to be administered in
person by a military provider to servicemembers assigned to the
Personnel Reliability Program. In addition, since the Air Force
Reserves are small in number and co-located on an Air Force Base with
active duty servicemembers, their PDHRAs are usually administered in
person by a military provider.
[19] The Army National Guard and Army, Navy, and Marine Corps Reserves
all require servicemembers to speak with a health care provider.
However, most of the Air National Guard and all Air Force Reserve
servicemembers are not required to speak with a provider if they report
no health concerns on the DD 2900.
[20] Because of personnel shortages in Reserve units that are
deploying, it has been necessary to transfer servicemembers from units
that are not deployed into the deploying unit. The deploying units may
or may not be located in the same state as the nondeploying units.
[21] Servicemembers may be referred to both a VA medical center and a
Vet Center so these numbers cannot be combined to determine the total
number of individual servicemembers referred.
[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.
GAO examines the use of public funds; evaluates federal programs and
policies; and provides analyses, recommendations, and other assistance
to help Congress make informed oversight, policy, and funding
decisions. GAO's commitment to good government is reflected in its core
values of accountability, integrity, and reliability.
Obtaining Copies of GAO Reports and Testimony:
The fastest and easiest way to obtain copies of GAO documents at no
cost is through GAO's Web site [hyperlink, http://www.gao.gov]. Each
weekday, GAO posts newly released reports, testimony, and
correspondence on its Web site. To have GAO e-mail you a list of newly
posted products every afternoon, go to [hyperlink, http://www.gao.gov]
and select "Subscribe to Updates."
Order by Mail or Phone:
The first copy of each printed report is free. Additional copies are $2
each. A check or money order should be made out to the Superintendent
of Documents. GAO also accepts VISA and Mastercard. Orders for 100 or
more copies mailed to a single address are discounted 25 percent.
Orders should be sent to:
U.S. Government Accountability Office:
441 G Street NW, Room LM:
Washington, D.C. 20548:
To order by Phone:
Voice: (202) 512-6000:
TDD: (202) 512-2537:
Fax: (202) 512-6061:
To Report Fraud, Waste, and Abuse in Federal Programs:
Contact:
Web site: [hyperlink, http://www.gao.gov/fraudnet/fraudnet.htm]:
E-mail: fraudnet@gao.gov:
Automated answering system: (800) 424-5454 or (202) 512-7470:
Congressional Relations:
Gloria Jarmon, Managing Director, JarmonG@gao.gov:
(202) 512-4400:
U.S. Government Accountability Office:
441 G Street NW, Room 7125:
Washington, D.C. 20548:
Public Affairs:
Chuck Young, Managing Director, youngc1@gao.gov:
(202) 512-4800:
U.S. Government Accountability Office:
441 G Street NW, Room 7149:
Washington, D.C. 20548: