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Returning Home from Iraq and Afghanistan: Preliminary Assessment of Readjustment Needs of Veterans, Service Members, and their Families 5 THE CURRENT RESPONSE This chapter briefly describes many of the programs that were in place prior to Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) or that have been developed specifically in response to the many challenges being faced by those returning from OEF and OIF and their families. While previous chapters and Appendix B allude to the many problems related to access to care, this chapter simply catalogues the available programs without any attempt to evaluate them. The chapter is divided into two main sections. The first section provides a structural overview of the Department of Defense (DOD) and the Department of Veterans Affairs (VA) health-care and benefits systems. The second section describes a sample of the federal programs and services that are available to meet the readjustment needs of returning OEF and OIF service members, veterans, and their families. The chapter does not present a comprehensive inventory of all available federal programs, nor does it present the numerous state and local programs that have been developed to meet the needs of these populations. Additionally, the committee did not explore services provided by private institutions, nor did it explore the feasibility of public-private partnerships. Those issues might be examined in the committee’s phase 2 report. OVERVIEW OF FEDERAL BENEFITS AVAILABLE TO SERVICE MEMBERS, VETERANS, AND THEIR FAMILIES US troops are entitled to various benefits, such as health care, disability benefits, employment assistance, and education. This section describes the systems that are in place in DOD and VA to provide those benefits. The Department of Defense Most DOD programs designed to meet the needs of returning OEF and OIF military personnel are overseen by the Office of the Under Secretary of Defense for Personnel and Readiness (USD(P&R)). That office is responsible for ensuring the readiness of the total force, including oversight of health affairs, training, morale, welfare, and quality-of-life matters for the active-duty, reserve, and National Guard components and their dependents. Four USD(P&R) offices are responsible for those programs: the Office of the Assistant Secretary of Defense for Health Affairs (ASDHA), the Office of the Deputy Under Secretary of Defense for Military
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Returning Home from Iraq and Afghanistan: Preliminary Assessment of Readjustment Needs of Veterans, Service Members, and their Families Community and Family Policy, the Office of the Assistant Secretary of Defense for Reserve Affairs, and the Office of the Deputy Under Secretary of Defense for Military Personnel Policy. Health Care The ASDHA oversees the Military Health System (MHS), which encompasses the coordinated efforts of the medical departments of the Army, Navy, Marine Corps, Air Force, Coast Guard, and Joint Chiefs of Staff; the Combatant Command surgeons; and private-sector health-care providers, hospitals, and pharmacies (DOD Directive 5136.01, June 4, 2008). The primary goal of the MHS is to provide emergency and long-term casualty care and to maintain the health readiness of military personnel by promoting physical and mental fitness and healthy behaviors. In addition, the MHS ensures the delivery of health care to all DOD service members, retirees, and their families. To support all those activities, the MHS devotes substantial resources to education of its medical personnel and to research and development to advance military medicine (DOD, 2009; Task Force on the Future of Military Health Care, 2007). The MHS provides direct care to most active-duty service members through military treatment facilities (MTFs) and clinics. The direct care is supplemented by care purchased from the civilian sector. Retirees and dependent family members (see Box 5.1) of active-duty service members are also eligible to receive care at an MTF on a space-available basis; priority is given to those enrolled in TRICARE Prime.1 Worldwide, the MHS direct-care infrastructure includes 59 military hospitals, 413 medical clinics, and 413 dental clinics (TMA, 2009b), and employs over 44,000 civilians and 89,000 military personnel (Jansen, 2009). Responsibility for delivering health care to garrisoned and deployed troops remains with the health departments of the individual services—Army, Navy,2 and Air Force—which also retain considerable autonomy in the management of their own facilities and personnel. Of some 9.3 million eligible beneficiaries, by 2010, 43% will be active-duty personnel and their dependents, and 57% will be retirees and their dependents (Jansen, 2009). In 2007, 41% of all DOD eligible beneficiaries used direct care, 19% used care purchased through the TRICARE provider network, 25% used Medicare providers, and 14% used other civilian provider networks or VA services. Active-duty personnel and their dependents relied more heavily on direct care and purchased care; 58% used direct care, 32% used purchased care, and 9% used other civilian care (Andrews et al., 2008). DOD health benefits are delivered through the TRICARE program, which is available to active-duty and reserve-component members, military retirees, and their dependent family members under one of several plans. To enroll in any TRICARE plan, service members, their families, and retirees must first establish eligibility through the Defense Enrollment Eligibility Reporting System (DEERS). Active-duty and retired service members, including National Guard and reserve members activated for at least 30 days, are automatically registered in DEERS, but individual service members are responsible for registering their family members, updating their status, and ensuring that their information is current and correct (TMA, 2009c). Active-duty service members, including members of the reserve components activated for at least 30 days, are required to enroll in TRICARE Prime. Eligible service members may also enroll their dependent family members in TRICARE Prime, but dependents may choose to pay extra to enroll in TRICARE Extra, a preferred provider option–like benefit, or seek coverage through a 1 TRICARE Prime is a point-of-service health-maintenance organization that covers 100% of care at MTFs or any civilian provider that is a member of the TRICARE network. 2 The medical department of the Navy oversees health-care delivery for the Marine Corps.
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Returning Home from Iraq and Afghanistan: Preliminary Assessment of Readjustment Needs of Veterans, Service Members, and their Families civilian health-insurance provider. Members of the selected reserve3 components who are not activated may choose to enroll themselves or their families in TRICARE Reserve Select, a premium-based option (Andrews et al., 2008). Service members leaving the military and their dependents are usually eligible for transitional TRICARE coverage. Active-duty members leaving the military under other than adverse conditions and their dependent family members can receive 18 months of coverage through the Continued Health Care Benefit Program (CHCBP). Children and spouses who were enrolled in TRICARE and lose eligibility can receive CHCBP coverage for up to 36 months. Deactivated National Guard and reserve members who were called to active duty for at least 30 days and separating active-duty members who do not qualify for the CHCBP are usually eligible to receive health-care coverage for 180 days through the Transitional Assistance Management Program (TMA, 2009d). BOX 5.1 Family in the Military Context Multiple definitions of family operate in the Department of Defense (DOD), each tied to specific regulatory requirements. The most common definition defines eligibility for military identification cards, which are necessary for access to health care, military exchanges, and a variety of supportive services for families. Military identification cards are currently issued to spouses and unmarried children of service members, with exceptions and additional categories defined by children’s ages, student status, or special needs and by whether the marriage ends in divorce or in death of the service member while on active duty. Spouses and unmarried children of reserve-component members are covered while the service member is on active duty for more than 30 consecutive days (TMA, 2006). Stepchildren may or may not qualify for military identification cards, depending on such factors as age, student status, and the circumstances of the biologic parents. Other military programs have adopted more inclusive definitions of family. For example, the Yellow Ribbon Reintegration program permits participation by service members’ spouses, children, parents, grandparents, siblings, and significant others (USD(P&R), 2008). In light of the fact that only about half of military members are married, new rules recently issued for the Family and Medical Leave Act expand previous definitions of family caregivers to include adult children’s parents and other kin (US Department of Labor, 2009a). In practice, some family members do not receive supportive services even when policy permits it. For example, the DOD Task Force on Mental Health (2007) recognized that military family members have difficulty in obtaining treatment for some psychologic health problems because of gaps in provider networks. In addition, families that do not conform to military definitions may have difficulty in obtaining needed services. For example, grandparents who move to military installations to care for children during parents’ deployment may have difficulty in obtaining access to military services, and this can be especially challenging in overseas locations. 3 The selected reserve includes those members of the ready reserve who train throughout the year and participate in annual active-duty training exercises. The individual ready reserve and the inactive National Guard form the other two components of the ready reserve.
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Returning Home from Iraq and Afghanistan: Preliminary Assessment of Readjustment Needs of Veterans, Service Members, and their Families The MHS must meet statutory access standards for its TRICARE beneficiaries. The wait time for an appointment must be less than 4 weeks for a well-patient visit or a specialty-care referral, less than 1 week for a routine visit, and less than 24 hours for an urgent-care visit.4 The MHS tracks access to care metrics for all its beneficiaries and releases monthly reports.5 In addition to frequent periodic performance reports, TRICARE presents annual reports to Congress, in which TRICARE beneficiary access is compared with civilian benchmarks. In general, TRICARE beneficiaries report lower satisfaction with their health care than their civilian counterparts (60.0% versus 72.6% in FY 2008, when respondents were defined as satisfied if they rated their health care at 8 or higher on a 10-point scale) (TMA, 2009a); and active-duty service members and their families report lower satisfaction with their ability to obtain care than their retired counterparts (64% versus 72% reporting that obtaining care is “not a problem”) (Task Force on the Future of Military Health Care, 2007; TMA, 2009a). Disability-Benefits Process Disability benefits are provided if an injured service member qualifies. If it can be reasonably determined that a service member is not fit to resume normal duty, the service member is referred to the Medical Evaluation Board (MEB) (Task Force on Returning Global War on Terror Heroes, 2007). The MEB, composed of one or more medical officers, decides, on the basis of medical evidence and DOD guidance and regulations, whether the member meets the standards for being retained on active duty. Decisions by the MEB take a standard 30 days. If it decides that the member does not meet retention standards, he or she is referred to the Physical Evaluation Board (PEB), which includes at least one medical officer and one personnel officer. Within 40 days, the PEB decides whether the member is fit for duty, should be placed on temporary disability retired status, or should be separated with or without benefits (Figure 5.1). Military personnel who are discharged without benefits from DOD may still apply for disability benefits through VA (as discussed later in this chapter). Health-Information System The success of any health-care system rests not only on its physical infrastructure and care providers but on how it collects, maintains, transfers, and processes health information, especially patient records. Because of the diverse and often adverse environments in which the MHS is responsible for providing care, DOD faces many challenges in tracking and maintaining health records for all its personnel. 4 CFR §199.17(p)(5)(ii). 5 Available on the TRICARE Operations Center Web site, http://mytoc.tma.osd.mil/AccessToCare/TOC/ATC.htm (accessed January 15, 2010).
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Returning Home from Iraq and Afghanistan: Preliminary Assessment of Readjustment Needs of Veterans, Service Members, and their Families FIGURE 5.1 Physical Evaluation Board process. SOURCE: Reproduced from VA Task Force on Returning Global War on Terror Heroes (2007). DOD’s heterogeneous mixture of medical records and health-information databases presents a structural challenge in implementing an effective health-information system. Historically, each MTF has maintained its own individual health database; in addition, information on ancillary services—including pharmaceutical, laboratory, and radiology—is usually entered into a system separate from inpatient documentation, so two separate databases must be merged to create a unified patient medical record (Fravell, 2007). Further complicating the system is the difficulty inherent in transferring medical records from combat zones to
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Returning Home from Iraq and Afghanistan: Preliminary Assessment of Readjustment Needs of Veterans, Service Members, and their Families stateside providers. The telecommunication infrastructure in combat zones may be insufficient to support a Web-based electronic medical record in those areas, and this requires transfer of records, some of which might be on paper, from database to database. The more often records must be transferred, merged, and reformatted, the greater the risk that patient health information will be lost or not transferred in a timely manner (Fravell, 2007). In addition to those structural challenges, DOD must ensure compliance with record-keeping requirements. Before the current conflicts began, the FY 1998 National Defense Authorization Act already required that DOD establish a medical tracking system for all service members who were deployed overseas, including predeployment and postdeployment medical examinations. The law also stipulated that records of the medical examinations be stored in a centralized location, and it called for DOD to put in place a quality-assurance program to ensure compliance. Although DOD is required by statute to collect health information through predeployment and postdeployment assessments, it lacks sufficient oversight to ensure full compliance with the requirement. For example, in 2007 the Government Accountability Office (GAO) found that “DOD is not well-positioned to determine or assure Congress that active and reserve component service members are medically and mentally fit to deploy and to determine their medical and mental condition upon return” (GAO, 2007a). Compliance with requirements to complete predeployment and postdeployment health assessment is a particular issue in the National Guard and reserve components, which typically do not maintain a cohesive unit structure on return from deployment (GAO, 2007b). The lack of unified electronic medical records in DOD has impeded record-sharing with VA. Because of incompatibility between the DOD and VA systems, when service members separate from the military and enter VA, their DOD health records do not transfer to VA providers. Several groups have recommended that DOD and VA develop a system that allows for medical record-sharing (GAO, 2008a; Office of the Surgeon Multinational Force–Iraq and Office of the Surgeon General United States Army Medical Command, 2008; Task Force on Returning Global War on Terror Heroes, 2007), and efforts to develop cooperative information-sharing and interoperability of medical records between DOD and VA have been going on for over a decade (GAO, 2008a). GAO finds that coordination between VA and DOD to provide medical information6 in real time is still lacking (GAO, 2008a,b). Although the departments have mounted initiatives to improve coordination (for example, the Bidirectional Health Information Exchange), a true system-wide electronic exchange of patient records remains elusive. DOD and VA are working to create a joint virtual lifetime electronic record that will track administrative and medical information for every service member for life, beginning on the day that the member enters military service (White House Office of the Press Secretary, 2009); it is unclear how long it will take to realize this goal. The Department of Veterans Affairs VA is composed of three main branches: the Veterans Health Administration (VHA), the Veterans Benefits Administration (VBA), and the National Cemetery Administration. As a single entity, VA has the goal of providing health-care services, disability compensation, pensions, education assistance, home-loan assistance, life insurance, vocational rehabilitation and training, 6 In 1998, President Clinton issued a directive requiring VA and DOD to develop a computer-based patient record system that would efficiently exchange information between the departments.
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Returning Home from Iraq and Afghanistan: Preliminary Assessment of Readjustment Needs of Veterans, Service Members, and their Families and burial benefits to veterans and their families (VA, 2009g). As of 2008, VA employed a total of 288,658 to serve the 23.8 million veterans in the United States; Vietnam veterans made up the largest fraction: 33%, or 7.9 million veterans (VA, 2009d). Of the 23.8 million, 2.1 million (7.5%) were women. The total number of dependents, including children and spouses of living and deceased veterans, was 37 million. Health Care VHA is the largest component of VA and provides medical and rehabilitation services to veterans; it employed about 96,000 health-care professionals in FY 2008. It also provides medical training to medical students, residents, fellows, and other health-care providers. In FY 2009, Congress appropriated $44.5 billion to VHA for health care and research; this was 45% of VA’s total obligations of $98.7 billion. According to data from FY 2008, there were 7.84 million VHA enrollees—about 30% of the veteran population (IOM, 2009; VA, 2009d). As of March 2008, over 868,000 OEF and OIF service members (including National Guard and reserves) had left active duty and became eligible for VA services (GAO, 2008c). From October 2001 to January 2009, 425,538 (49%) OEF and OIF veterans enrolled in the VA system (63% from the Army, 13% Marine Corps, 12% Air Force, and 12% Navy). Of those veterans, 53% were in the active component, and 47% were in the reserve component. About 48% of the veterans are single, 45% married, 5% divorced, and 2% widowed (data provided by VA on request by the committee, September 2009). Eligibility and Enrollment Before January 2008, combat veterans were typically eligible for benefits and health care for only 2 years after discharge. However, with the enactment of the National Defense Authorization Act (PL 110-181), veterans who served in a combat theater (including National Guard and reserves) after November 11, 1998, and were discharged or released for reasons other than dishonorable on or after January 28, 2003, now have 5 years from their date of discharge to enroll in and obtain health-care coverage from VA. That includes all OEF and OIF veterans. Determination of enrollment eligibility is made through an eight-step process (Figure 5.2), which begins when the veteran7 completes and submits the Application for Health Benefits (VA Form 10-10EZ). In 7–10 days, a decision letter is sent to the veteran stating his or her enrollment eligibility (Task Force on Returning Global War on Terror Heroes, 2007). Effective January 28, 2003, OEF and OIF veterans who enroll within the first 5 years after separating from the military are eligible for enhanced enrollment placement into priority group 6 (see Chapter 2, Table 2.5) for 5 years after discharge. Injuries or conditions related to combat service are treated by the VA health-care system free of charge. 7 Some veterans are exempt from enrollment requirements if they meet particular criteria: a service-connected disability rating of at least 50%, discharge from military service less than 1 year ago because of a service-connected disability that VA has not yet rated, or the veteran is seeking VA care for a service-connected disability only (Panangala, 2007).
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Returning Home from Iraq and Afghanistan: Preliminary Assessment of Readjustment Needs of Veterans, Service Members, and their Families FIGURE 5.2 VA health-care enrollment process. NOTE: VistA = Veterans Health Information Systems and Technology Architecture8; VAMC = VA medical center. SOURCE: VA Task Force on Returning Global War on Terror Heroes (2007). After the designated 5 years, enrolled veterans are placed in the appropriate priority group (see Table 2.6) on the basis of income and disability; placement determines the extent of coverage and copayment amounts. Each year, VA determines whether appropriations are adequate to cover all priority groups; if not, those in the lowest groups may lose coverage (Panangala, 2007; VA, 2008a). On July 1, 2009, the VA Health Resource Center began an outreach campaign to increase awareness of VA eligibility, enrollment procedures, and benefits for recently discharged OEF and OIF veterans and their families (VA, 2009h). In general, VHA does not provide health-care services or coverage to spouses or dependents of veterans (IOM, 2009; VA, 2009d). However, in accordance with the Veterans’ Mental Health and Other Care Improvements Act of 2008 (S. 2162, 110th Congress), if VA services, such as marriage and family counseling or mental health care, are necessary for the proper treatment of a veteran, various family members will have access. Previously, family 8 The success of VHA has been attributed partially to the use of a single, integrated health-information system, the Veterans Health Information Systems and Technology Architecture (VistA). Starting in 1985, the system, used at all health-care facilities, allows a patient’s comprehensive clinical and administration information to be accessed at any VA health-care location. A notable component of VistA is the Computerized Patient Record System, which allows a health-care provider to view a patient’s full medical record, including active problems, current and past medications, hospitalizations, clinical history, electronic medical chart and imaging information, and other components vital to managing a patient’s care (Panangala, 2007).
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Returning Home from Iraq and Afghanistan: Preliminary Assessment of Readjustment Needs of Veterans, Service Members, and their Families members were allowed to take part in such services if they were initiated during a veteran’s hospitalization and continued only if necessary for hospital discharge. VA may provide health-care benefits to spouses and children of veterans in a few select circumstances through the Civilian Health and Medical Program, in which VA shares the costs of medically or psychologically necessary health-care services with eligible beneficiaries. To use that program, one cannot be eligible for TRICARE and must meet the following criteria: be a spouse or child of a veteran who is rated permanently or entirely disabled because of a service-connected injury or be a surviving spouse or child of a veteran who died from a VA-rated service-connected disability or in the line of duty (most are eligible for and use TRICARE in the latter circumstance) (VA, 2009i). Veterans Integrated Service Networks Health care is delivered through the 23 geographically divided veterans integrated service networks (VISNs), which manage 153 VA medical centers (VAMCs), 765 community-based outpatient clinics, and 230 vet centers (see Table 5.1) (VA, 2009d). The various components provide a wide spectrum of medical services, including inpatient and outpatient care, rehabilitation and mental health care, complex specialty care, and pharmaceutical benefits and distribution. They are each managed by a VISN director who reports to the deputy under secretary for health for operations and management (IOM, 2009). Veterans who qualify (see Table 2.5) can get care on a fee-for-service basis. TABLE 5.1 Veterans Integrated Service Networks and Numbers of Facilitiesa VISN Hospitals and Medical Centers Community-Based Outpatient Clinics Other Outpatient Clinics Vet Centers Other Facilitiesb VISN 1: New England 11 18 0 21 0 VISN 2: Upstate New York 6 29 0 6 0 VISN 3: New Jersey, New York 8 28 0 12 1 VISN 4: Stars and Stripes 12 47 0 13 0 VISN 5: VA Capitol 5c 15 0 9 0 VISN 6: Mid-Atlantic 8 13 5 10 — VISN 7: Southeast 9 31 3 9 0 VISN 8: Sunshine 8c 39 8 19 2 VISN 9: Mid-South 9 30 6 11 0 VISN 10: Ohio 5 29 3 6 0 VISN 11: Partnership 8 23 22 9 0 VISN 12: Great Lakes 7 0 33 9 0 VISN 13 and 14: now 23 — — — — — VISN 15: Heartland 9 42 1 7 0 VISN 16: South Central 11 32 14 13 0 VISN 17: Heart of Texas 7c 18 11 9 0 VISN 18: Southwest 7 41 1 14 0 VISN 19: Rocky Mountain 6c 37 2 14 0 VISN 20: Northwest 9c 26 1 15 2
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Returning Home from Iraq and Afghanistan: Preliminary Assessment of Readjustment Needs of Veterans, Service Members, and their Families VISN Hospitals and Medical Centers Community-Based Outpatient Clinics Other Outpatient Clinics Vet Centers Other Facilitiesb VISN 21: Sierra Pacific 8 9 26 20 0 VISN 22: Desert Pacific 5 29 5 11 1 VISN 23: Midwest 12 40 3 14 0 Total 170 576 144 251 6 aAs of April 10, 2009. bIncludes domiciliaries, federal hospitals, rehabilitation facilities, posttraumatic-stress-disorder clinics, and care facilities. cIncludes at least one VA health-care system in addition to the medical centers. SOURCE: IOM (2009). Adapted from VA (2009b). Veterans Affairs Medical Centers The medical centers, in addition to providing clinical care for acute conditions, provide a variety of other programs specifically tailored to OEF and OIF veterans and their families, including polytrauma treatment, rehabilitation, postdeployment counseling, mental-illness programs, and education sessions (GAO, 2008c). Every medical center uses a care-management team, case managers, and transition patient advocates who help arriving OEF and OIF veterans to navigate through the VA health-care system and coordinate present and long-term care (VA, 2009k). Vet Centers The Vet Center Program, known formally as the Readjustment Counseling Service, was established by Congress in 1979 to provide services to Vietnam veterans who were still experiencing substantial readjustment challenges. Since then, vet-center eligibility has been extended to combat veterans of other conflicts, including most recently in 2003 to all OEF and OIF veterans and their family members and federally activated National Guard and reserve personnel. Vet centers are community-based nonmedical VA facilities that offer access to a broad array of social services for veterans and their families. Examples of services offered are individual and group counseling, marital and family counseling, medical referrals, assistance in applying for VA benefits, employment counseling and referral, alcohol and drug assessments, information regarding community resources, military sexual-trauma counseling and referral, and community outreach and education. Bereavement counseling is available for surviving family members of veterans who lost their lives while on active duty (VA, 2009l). As of April 2009, there were 230 vet centers; they are located in every state, Puerto Rico, Guam, and the US Virgin Islands (VA, 2009d); 23 of the centers were added in 2007 and 20089 (Panangala, 2007), and VA plans to bring the total number to 299 by the end of 2010 (VA, 2009c). Most vet centers are staffed by one or two full-time counselors and are managed by a team leader who reports directly to one of the seven regional counseling-service managers, who in turn reports to the chief readjustment-counseling officer at VA headquarters (Panangala, 2007). 9 Site selections are approved through the Office of the Under Secretary of Health after review of US Census Bureau and Defense Manpower Data Center demographic data.
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Returning Home from Iraq and Afghanistan: Preliminary Assessment of Readjustment Needs of Veterans, Service Members, and their Families The committee heard anecdotal reports (see Appendix B) that OEF and OIF veterans view vet centers as places for older veterans, particularly from the Vietnam War, that are not equipped to meet the needs of the younger generations. To connect with returning troops better, starting in 2004 the vet centers hired 100 OEF and OIF veterans as outreach workers and have focused efforts on or near active military out-processing stations and at National Guard and reserve sites. Beginning in October 2008, VA also introduced a fleet of 50 mobile vet centers— 38-foot motor coaches that have spaces for confidential counseling—to supplement the existing vet centers and to expand service to veterans in geographically dispersed rural areas (VA, 2008b, 2009c). From the start of hostilities in 2001 through the end of 2008, vet centers received over 85,000 veterans for in-center visits and contacted an additional 260,000 at outreach events (Frame and Batres, 2009). Disability Compensation and Survivor Benefits The Disability Compensation Program provides monetary benefits to eligible veterans who were injured or exacerbated an injury during active duty; compensation amounts are based on individual disability ratings (from 10 to 100%) (VA, 2009m). As of March 31, 2009, 3 million veterans were receiving disability compensation, of whom 268,926 had a 100% disability rating; 69% of those who filed claims received service-connected–disability compensation (VA, 2009d). In addition, the Veterans Pension Program is offered to veterans who are over 65 years old or fully and permanently disabled because of active-duty service and whose family income is below a set threshold that is modified each year (VA, 2009n). In an effort to expedite claims processing and to ensure that veterans are covered at time of discharge, VA offers a predischarge program, which allows service members to apply for disability compensation up to 180 days before discharge or retirement from active duty. In addition, on December 2008, VA began a 1-year program, implemented in 10 regional offices, called the Fully Developed Claim Pilot Program to test the feasibility of processing compensation, burial, and survivor benefits within 90 days of receiving a completed claim. In 2007, the average time for finalizing disability claims for OEF and OIF veterans was 110 days (VA, 2009d). Surviving spouses and dependents are generally eligible for death pension benefits if family income does not exceed a specified amount. In addition, Dependency and Indemnity Compensation is a tax-free monthly paid benefit based on such factors as income and number of dependents. Numerous state benefits are also available and vary by geographic location. In addition, family members of deceased service members and veterans have access to such programs as the Vocational Rehabilitation and Employment Services, education assistance, Home Loan Guaranty, Vet Center Bereavement Counseling, and a life-insurance settlement (VA, 2009o). The Tragedy Assistance Program for Survivors (www.taps.org), founded in 1994, is the most comprehensive online resource for those dealing with the loss of a service member. Resources are provided in the form of pamphlets and publications, an online support community, seminars and other events, and information on finding regional support groups. Because of its partnership with VA, it also provides information on obtaining bereavement counseling at local vet centers.
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Returning Home from Iraq and Afghanistan: Preliminary Assessment of Readjustment Needs of Veterans, Service Members, and their Families through DOL’s Unemployment Compensation for Ex-Servicemembers program (US Department of Labor, 2009b). The program is administered by the states as agents of the federal government, so eligibility and the amount and duration of the benefit vary by state. Several states also provide unemployment benefits for military spouses who must quit their jobs to accompany their service-member spouses on a military transfer assignment (Whittaker, 2006). Online Programs and Services With the growing importance of the Internet as a means of outreach and a source of information, especially among the relatively young military population, DOD, and to a lesser extent VA, have placed key programs and services online, where they are available to any service member, family member, or other interested party. Those Internet-based services generally cover a variety of issues from mental health problems to employment support but are limited mostly to providing information and education materials. Although they can reach a very broad audience at relatively low cost, it should be noted that accessing the information depends entirely on the initiative of individuals, and it is possible that many will not see the information provided by the sites. Military OneSource, an official DOD program that began with the Marine Corps in 2002 and was expanded to serve the entire US military in 2004, provides free 24-hour information and referrals to more than 5 million active-duty military personnel, National Guard and reserve members (regardless of activation status), and their immediate families (provided to the committee by the Department of the Army, August 31, 2009). The service is provided through several avenues, including e-mail, a toll-free telephone number, and a Web site. Users can request referral to private and confidential12 in-person counseling, which is generally available at a nearby location, at no cost to the service members; this counseling is nonmedical and focused on acute issues and their short-term solutions, including family support, emotional support, debt management, legal issues, education, relocation, parenting, and stress (DOD Task Force on Mental Health, 2007). Military OneSource does not release information about users of the service except in cases of child abuse, spousal abuse, elder abuse, or threats of harm to self or others (provided to the committee by the Department of the Army, August 31, 2009). MilitaryHOMEFRONT (www.militaryhomefront.dod.mil) is the official Military Community and Family Policy Web site for program and policy information. The Web site provides quick access to programs, benefits, and policies for service members and their families, leaders, and service providers. Visitors can search the MilitaryINSTALLATIONS directory to find programs and services offered at individual military installations; access a social-networking feature called HOMEFRONTConnections, which provides a password-protected forum for service members, family members, and others who provide support to the military to share their experiences and ideas; or use the “Plan My Move” application to access tools that allow a military family to get information about the area to which they are relocating and create a personalized relocation plan. The site also gives information about the Casualty Assistance Program, which provides support to severely injured service members and counsels families of deceased, unaccounted-for, or missing service members. Each service branch oversees its own casualty-assistance operations, but generally each branch assigns a casualty-assistance officer to the family of every deceased service member. That officer works closely with the family to help 12 Counselors must report family maltreatment, threats of harm to self or others, substance abuse, and illegal activities. These reports are made to the appropriate military and civilian authorities.
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Returning Home from Iraq and Afghanistan: Preliminary Assessment of Readjustment Needs of Veterans, Service Members, and their Families to make necessary arrangements, navigate the administrative paperwork, and identify and process all entitlements and benefits for which the family is eligible. The DCoE’s Deployment Health Clinical Center launched its Web site, www.PDHealth.mil, on January 31, 2001, to assist busy clinicians in the delivery of postdeployment health care. It is a source of deployment-related health information for healthcare providers, service members, veterans, and family members. It is also the primary source of communication and support for the implementation of the DOD–VA Post-Deployment Health Clinical Practice Guideline. The Web site introduced the guideline to all MTFs. The Web site contains information on all deployments and deployment support; specific diseases and emerging health concerns; provider-education and patient-education materials; news and information, and a Web-navigable version of the guideline, including online measures and clinical tools to assist in implementing it. The Clinicians Page contains information on updates to the guideline and on supporting guidelines. PDHealth also has an online newsletter, Deployment Health News, which is published each business day and draws from publicly available sources to provide articles on health issues related to military service, deployments, and homeland security. Run by the DCoE’s National Center for Telehealth and Technology, the AfterDeployment.org Web site provides online self-assessment and self-help tools and information on where to find care and support for such issues as combat stress and triggers, conflict at work, reconnecting with family and friends, depression, anger, sleep problems, substance abuse, stress management, children and deployment, spiritual guidance, living with physical injuries, and health and wellness. To help veterans to access their health-care information, obtain a better understanding of their health issues, and explore opportunities to improve their health by working with providers in achieving this goal, VA has a Web-based system, MyHealtheVet. This service is available to all veterans, regardless of whether they are enrolled in the VA system; a veteran simply needs to visit a VAMC to verify identity and set up an account with a login and password (VA, 2008c). Participating veterans are given access to key portions of their electronic medical records in a Web site area called “eVAault,” a secure and private location where they are able to view their medical history, add information in a “self-entered” section, and share records with providers in and outside VA with the goal of promoting continuity of care. The Web site also has a mechanism for ordering prescription refills, setting up clinic appointments, and viewing reminders. Service members returning from deployment in OEF and OIF, their families, and any other interested parties are able to access oefoif.va.gov, which provides a wide array of information on readjustment to civilian life. Sponsored by VA, the site familiarizes the user with VA resources and benefits; social networking sites, such as blogs, Facebook, Twitter, YouTube, and Second Life; and telephone numbers for accessing detailed information on such topics as benefits, education and training, life insurance, and health care. Programs to Assist in the Transition Out of the Military In addition to the stresses related to deployment, the transition out of the military is a critical time for veterans, especially those experiencing health issues related to deployment to OEF or OIF. On returning to civilian life, veterans no longer have the direct access to health care
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Returning Home from Iraq and Afghanistan: Preliminary Assessment of Readjustment Needs of Veterans, Service Members, and their Families and other support services that they had while on active duty. Parallel services can be accessed through VA, although veterans must enroll to receive those benefits. Such programs as the Transition Assistance Program (TAP) and the Transition Assistance Advisors have been created to bridge the gap from active duty to civilian life. The TAP is a cooperative effort of DOD, DOL, and VA designed to assist military personnel and their family members as they transition out of active-duty service. Transition assistance offices administer TAP services and are on major military installations, generally at the family support service center for Air Force, Navy, and Marine Corps installations and at career and alumni program centers for Army installations. The TAP supplements on-site locations through its Web site, www.TurboTAP.org, which offers information and select services on line. For active-duty service members, the TAP provides a four-step program that consists of preseparation counseling, a 2½-day employment workshop run by DOL, a 4-hour VA benefits briefing, and an optional 2-hour briefing on special benefits for veterans who have service-connected disabilities. After completion of those activities, service members can ask for one-on-one counseling sessions and employment assistance through their branch of service. The TAP also offers a series of briefings for demobilizing National Guard and reserve members, including a 2-hour preseparation counseling session for service members returning from OEF and OIF, a DOL briefing on the Uniformed Services Employment and Reemployment Rights Act, and a VA benefits briefing that also discusses benefits for veterans who have service-connected disabilities. Members of the reserve component are invited to participate in events sponsored by the Yellow Ribbon Reintegration Program (discussed below), where they will receive additional information on VA and other available services. For severely wounded service members, a social worker at an MTF is assigned to each veteran in the Polytrauma System of Care. The social worker makes contact with the case manager at the PRC facility to transfer medical records and information. Communication is maintained with the case manager to track the service member’s status. Programs for National Guard and Reserve Members, Women, Minority-Group Members, and the Homeless National Guard and Reserves Members of the National Guard and reserve components face unique challenges on their return from deployment to OEF and OIF. Unlike active-duty service members who return to their assigned bases, where they have access to the full support structure available on military installations, National Guard and reserve members face what appears to be a more complex transition back to their civilian lives, in which they must deal with the stresses of reconnecting with their families and returning to their civilian employment. In addition, the communities to which reservists return are unevenly prepared to provide care for service-related conditions. A number of programs and measures are in place to assist members of the reserve component, as described below. There are services specifically for assisting families of the National Guard and reserves to navigate their unique challenges. For example, the Joint Family Support Assistance Program, which was authorized by the National Defense Authorization Act of 2007, is designed to deliver
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Returning Home from Iraq and Afghanistan: Preliminary Assessment of Readjustment Needs of Veterans, Service Members, and their Families mobile family-support services to geographically dispersed military families, especially to the National Guard and reserve components (DOD Office of Military Community and Family Policy, 2009). The program is operated through Military OneSource and coordinates with the services and federal, state, and local entities. Program staff offer nonmedical counseling and education to individuals, families, and groups; assistance in locating child care; financial education and counseling; on-demand support for deployment-related events, such as reunion ceremonies and predeployment meetings; and community capacity-building to enhance local resources and support. DOD chartered the Employer Support of the Guard and Reserve (ESGR) program in 1972 to support members of the National Guard and reserve in employment. The ESGR program works to educate reservists and employers about their rights and responsibilities and to promote a good relationship between employers, reserve-component commanders, and service members. Some 4,500 volunteers organized into 55 ESGR field committees conduct employer-support programs, including informational briefings, mediation, and recognition of employers whose policies support or encourage participation in the National Guard and reserve; in 2009, the ESGR program briefed 162,000 employers. Those volunteers are also tasked with engaging reservists both before and after deployment; in 2009, the program briefed 443,000 service members (Employer Support of the Guard and Reserve, 2009). Each service runs various programs to assist its reservists in finding employment in the civilian sector. For example, the Army Reserve Employer Partner Initiative is designed to formalize the relationship between the Army reserve and the private sector. The two entities share the goals of strengthening the community and supporting Army reserve soldiers and families. Through the initiative, Army reserve soldiers get two careers—one with the Reserve and the other with an employer partner—and the Army believes that this provides stability to families and gives soldiers additional possibilities for achieving both their civilian and military career goals (provided to the committee by the Department of the Army, August 31, 2009). The Yellow Ribbon Reintegration Program (DOD Yellow Ribbon Program, 2009) was launched in 2009 to provide support to underserved National Guard and reserve members and their families throughout the deployment process. In the first 9 months, the reserve components hosted more than 1,367 Yellow Ribbon events, which reached an estimated 133,000 reservists and their family members. The program helps reservists to understand their benefits and entitlements as they transition in and out of active-duty status, and it links them to services provided through other sources, including Military OneSource, vet centers, and TRICARE. The Yellow Ribbon Reintegration Program is run through the Office of the Assistant Secretary of Defense for Reserve Affairs. Women Attention to the unique needs of female veterans was first formalized in November 1983 with the establishment of the Advisory Committee on Women Veterans (PL 98-160). That committee was tasked to review VA programs, health care, and research projects to ensure that they cater to and meet the needs of the growing female veteran population; as a consequence of the reviews, recommendations were implemented to modify and add programs and services (VA, 2009v).
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Returning Home from Iraq and Afghanistan: Preliminary Assessment of Readjustment Needs of Veterans, Service Members, and their Families In 1992, VHA became authorized to provide counseling to female veterans for sexual assault (male veterans were offered counseling services in 1999) (Kimerling et al., 2007); in addition, passage of the Veterans Health Improvement Act in 2004 (PL 108-422) granted VA authority to permanently extend military sexual-trauma counseling and treatment to veterans who experience severe or threatening forms of sexual harassment and sexual assault during military service (VA, 2009v). To screen for military sexual trauma, VHA implemented a universal screening program; if a patient tests positive, medical or psychologic treatment related to military sexual trauma is provided free of charge regardless of VA benefit eligibility. Each VA hospital is required to have a designated coordinator to oversee military sexual-trauma–related issues (Kimerling et al., 2007). The Center for Women Veterans was created by PL 103-446 in November 2004. Congress established the center to ensure that women have equal access to and awareness of services and benefits without encountering discrimination and to respond to sex-specific needs by creating and implementing programs that cater to the population. Examples of services geared toward women’s health promotion and treatment are breast and gynecologic care, hormone-replacement therapy, contraception, fertility counseling, and prenatal and child care. Each VAMC employs a program manager who acts as liaison and information source for service members (VA, 2009v). Minority Groups The Center for Minority Veterans was established as a part of the Office of the Secretary in 1994 under PL 103-446. It has been serving as a facilitator to help veterans to be aware of and to access VA benefits and services. A coordinator is available in each state’s regional office and health-care facility to provide assistance and information (VA, 2009w). The Homeless Starting in 1993 with VA, state, and community collaboration, the Community Homelessness Assessment, Local Education and Networking Groups program (mandated by PL 102-405, 103-446, and 105-114) has worked to identify needs of homeless veterans and ways to bring about change to fill gaps in care (Kuhn and Nakashima, 2009). It was designed to be a periodic and continuing assessment that surveyed VA staff, community providers, and homeless veterans to learn what needs are being met and what barriers remain in such categories as mental and physical health, long-term housing, job assistance, financial support, and substance abuse (Kuhn and Nakashima, 2009). Some specific programs that are available to homeless veterans are VA’s Homeless Providers Grant and Per Diem Program, the Compensated Work Therapy Transitional Residence program, and the Domiciliary Care for Homeless Veterans Program. The Homeless Providers Grant and Per Diem Program works with community agencies to develop and sustain transitional housing and support services for homeless veterans (VA, 2010). The Compensated Work Therapy Transitional Residence program is a vocational-rehabilitation program that provides supervised transitional housing with joint employment for veterans who are homeless, disabled, or otherwise substantially disadvantaged. Veterans work for pay through Compensated Work Therapy and use some of their earnings to pay for accommodations; the average length of stay is 174 days. Recently, a public law added supported employment to Compensated Work Therapy to assist veterans in obtaining outside employment while maintaining the support structure of
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Returning Home from Iraq and Afghanistan: Preliminary Assessment of Readjustment Needs of Veterans, Service Members, and their Families Compensated Work Therapy (VA, 2009x). Domiciliary Care for Homeless Veterans is a residential-treatment program for veterans who have clinical and psychosocial problems. Some 5,000 veterans are treated each year; on the average, veterans remain in a facility for 4 months. Before departing, veterans consult with counselors about social issues and community reintegration. SUMMARY This chapter summarizes the array of services and programs that are available to service members, veterans, and family members to help meet readjustment needs. A few themes emerged in the review of these programs, particularly in relation to the identification, accessibility, and coordination of services; difficulties in overcoming practical, cultural, and policy barriers; deficits in the tracking of people; and the evaluation of programs. While the number of programs is impressive, there does not appear to be any evaluation of the effectiveness of communication about the availability of programs, nor any information about whether the redundancy of programs is beneficial in meeting the needs of those individuals and groups they are meant to serve; finally it is unclear whether the programs are evaluated, in general, for their effectiveness in meeting the needs of service members, veterans, or family members. The committee recommends that the Department of Defense and the Department of Veterans Affairs oversee coordination and communication of the multitude of programs that have been created in response to the needs of Operation Enduring Freedom and Operation Iraqi Freedom service members, veterans, and their family members in an effort to maximize their reach and effectiveness. The committee also recommends that there be independent evaluation of these programs with standardized evaluation designs and assessment of outcomes. REFERENCES Andrews, K., K. Bencio, J. Brown, L. Conwell, C. Fahlman, and E. Schone. 2008. Health Care Survey of DOD Beneficiaries 2008 Annual Report. Washington, DC: Mathematica Policy Research, Inc. http://www.tricare.mil/survey/hcsurvey/downloads/hcsdb_2008_final.pdf (accessed November 15, 2009). Cross, D. 2009. VHA Overview. Presentation to the Institute of Medicine, March 2009. Defense Finance and Accounting Service. 2009. National Call to Service Bonus. http://www.dfas.mil/army2/bonuses/nationalcalltoservicebonus.html (accessed June 8, 2009). Department of the Army. 2007. Army Suicide Event Report (ASER), Calendar Year 2007. Tacoma, WA: Suicide Risk Management & Surveillance Office, Army Behavioral Health Technology Office. DOD (Department of Defense). 2009. About the MHS. Department of Defense. http://www.health.mil/aboutMHS.aspx (accessed July 6, 2009).
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Returning Home from Iraq and Afghanistan: Preliminary Assessment of Readjustment Needs of Veterans, Service Members, and their Families Henning, C. A. 2007. CRS Report to Congress: Military Support to the Severly Disabled: Overview of Service Programs. Washington, DC: Congressional Research Service. IOM (Institute of Medicine). 2009. Combating Tobacco Use in Military and Veteran Populations. Washington, DC: The National Academies Press. Jansen, D. J. 2009. Military Health Care: Question and Answers. Washington, DC: Congressional Research Service. RL33537. http://www.fas.org/sgp/crs/misc/RL33537.pdf (accessed July 7, 2009). Kimerling, R., K. Gima, M. W. Smith, A. Street, and S. Frayne. 2007. The Veterans Health Administration and military sexual trauma. American Journal of Public Health 97(12):2160-2166. Kuhn, J. H., and J. Nakashima. 2009. Community Homelessness Assessment, Local Education and Networking Group (Chaleng) for Veterans: The Fifteenth Annual Progress Report on Public Law 105-114, Services for Homeless Veterans Assessment and Coordination. http://www1.va.gov/homeless/docs/CHALENG_15th_Annual_CHALENG_Report_FY2008.pdf (accessed January 19, 2010). Marine Corps Wounded Warrior Regiment. 2009. Talking Points. http://www.woundedwarriorregiment.org/files/resources/files/fitt/fact_sheets/TalkingPoints.pdf (accessed January 4, 2009). MHN Government Services. 2009. Military & Family Life Consultant (MFLC) Program. https://www.mhngs.com/app/programsandservices/mflc_program.content (accessed January 19, 2010). MilitaryHOMEFRONT. 2009. Child Care. http://www.militaryhomefront.dod.mil/portal/page/mhf/MHF/MHF_HOME_1?section_id=20.40.500.94.0.0.0.0.0 (accessed October 2, 2009). Office of the Surgeon Multinational Force–Iraq and Office of the Surgeon General United States Army Medical Command. 2008. Mental Health Advisory Team V (MHAT-V) Operation Iraqi Freedom 06-08: Iraq; Operation Enduring Freedom 8: Afghanistan. Washington, DC: Department of the Army. Oxman, T. E., A. J. Dietrich, J. W. Williams Jr., and K. Kroenke. 2002. A three-component model for reengineering systems for the treatment of depression in primary care. Psychosomatics 43(6):441-450. Panangala, S. V. 2007. Veterans Health Care Issues. Washington, DC: Congressional Research Service. Real Warriors Campaign. 2009. About Us. http://www.realwarriors.net/aboutus (accessed December 15, 2009). Rehabilitation Outcomes Research Center. 2007. VA Healthcare Atlas FY 2005. Washington, DC: VA. http://www.rorc.research.va.gov/health_care_atlas.cfm (accessed July 14, 2009). RESPECT-Mil. 2010. About RESPECT-Mil. http://www.pdhealth.mil/respect-mil/index1.asp, (accessed January 19, 2010). Tanielian, T., and L. H. Jaycox. 2008. Invisible Wounds of War: Psychological and Cognitive Injuries, Their Consequences, and Services to Assist Recovery. Arlington, VA: RAND Corporation.
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Returning Home from Iraq and Afghanistan: Preliminary Assessment of Readjustment Needs of Veterans, Service Members, and their Families Task Force on Returning Global War on Terror Heroes. 2007. Task Force Report to the President: Returning Global War on Terror Heroes. Washington, DC: VA. http://www1.va.gov/taskforce/ (accessed July 9, 2009). Task Force on the Future of Military Health Care. 2007. Future of Military Health Care: Final Report. Washington, DC: Department of Defense, Defense Health Board. http://www.dodfuturehealthcare.net/ (accessed July 6, 2009). TMA (TRICARE Management Activity). 2006. Fact sheet: TRICARE Eligibility. http://www.tricare.mil/Factsheets/print.cfm?id=174 (accessed September 14, 2009). TMA. 2009a. Evaluation of the TRICARE Program, FY 2009 Report to Congress. TMA. 2009b. What is TRICARE? http://www.tricare.mil/mybenefit/home/overview/WhatIsTRICARE (accessed October 1, 2009). TMA. 2009c. DEERS. http://www.tricare.mil/DEERS (accessed July 6, 2009). TMA. 2009d. Transitional Assistance Management Program. http://www.tricare.mil/mybenefit/home/overview/SpecialPrograms/TAMP? (accessed November 17, 2009). USD(P&R) (Under Secretary of Defense [Personnel and Readiness]). 2008. Directive-Type memorandum (DTM) 08-029: Implementation of the Yellow Ribbon Reintegration Program within Family Readiness Programs. http://www.dtic.mil/whs/directives/corres/pdf/DTM-08-029.pdf (accessed September 27, 2009). US Department of Labor. 2009a. Fact sheet 28A: The Family and Medical Leave Act Military Family Leave Entitlements. http://www.dol.gov/esa/whd/regs/compliance/whdfs28a.pdf (accessed September 13, 2009). US Department of Labor. 2009b. Unemployment Compensation for Ex-servicemembers. http://workforcesecurity.doleta.gov/unemploy/ucx.asp (accessed December 15, 2009). VA (Department of Veterans Affairs). 2008a. A Summary of VA Benefits for National Guard and Reserve Personnel. IB-10-164. http://www1.va.gov/vhapublications/ViewPublication.asp?pub_ID=1138 (accessed January 15, 2010). VA. 2008b. VA to Deploy Mobile Counseling Centers Across America (press release, October 22). http://www1.va.gov/opa/pressrel/pressrelease.cfm?id=1604 (accessed January 15, 2010). VA. 2008c. My HealtheVet Frequently Asked Questions. http://www.health-evet.va.gov/faqs.asp, (accessed December 8, 2009). VA. 2009a. Federal Benefits for Veterans, Dependents and Survivors: 2009 Edition. Washington, DC: VA. http://www1.va.gov/opa/vadocs/FedBen.pdf (accessed June 9, 2009). VA. 2009b. Locations: Veterans Health Administration. http://www2.va.gov/directory/guide/division_flsh.asp?dnum=1 (accessed April 9, 2009). VA. 2009c. Performance Summaries by Strategic Objective, FY2009. http://www4.va.gov/budget/docs/report/PartII/FY2009-VAPAR_Part_II.pdf (accessed January 15, 2010). VA. 2009d. Stats at a Glance: VA Benefits and Health Care Utilization, April 2009. http://www1.va.gov/vetdata/ (accessed July 9, 2009).
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Returning Home from Iraq and Afghanistan: Preliminary Assessment of Readjustment Needs of Veterans, Service Members, and their Families VA. 2009e. Summary of VA Treatment Programs for Substance Use Problems. www.mentalhealth.va.gov/oefoif/files/VA_SUD.doc (accessed January 19, 2010). VA. 2009f. VA Polytrauma System of Care: Frequently Asked Questions. http://www.polytrauma.va.gov/faq.asp?FAQ#FAQ1 (accessed June 8, 2009). VA. 2009g. Veterans Services. http://www.va.gov/landing2_vetsrv.htm (accessed January 15, 2010). VA. 2009h. Returning Service Members (OEF/OIF): Welcome Home and Outreach. http://www.oefoif.va.gov/WelcomeHomeOutreach.asp (accessed September 25, 2009). VA. 2009i. CHAMPVA. http://www4.va.gov/hac/forbeneficiaries/champva/champva.asp, (accessed September 10, 2009). VA. 2009j. VA Networks. http://www.vacareers.va.gov/networks.cfm (accessed September 10, 2009). VA. 2009k. How Do I Get Help?. http://www.oefoif.va.gov/HowDoIGetHelp.asp (accessed September 23, 2009). VA. 2009l. Vet Center Home. http://www.vetcenter.va.gov/ (accessed August 15, 2009). VA. 2009m. VA Disability Compensation. http://www.vba.va.gov/bln/21/compensation (accessed January 15, 2010). VA. 2009n. Veterans Pension Program. http://www.vba.va.gov/bln/21/pension/vetpen.htm (accessed August 8, 2010). VA. 2009o. VA Survivor Benefits. http://www.vba.va.gov/survivors/vabenefits.htm (accessed August 9, 2009). VA. 2009p. VA Polytrauma System of Care. http://www.polytrauma.va.gov/facility_locations.asp (accessed September 4, 2009). VA. 2009q. VA Suicide Prevention. http://www.mentalhealth.va.gov/suicide_prevention/index.asp (accessed September 25, 2009). VA. 2009r. PTSD Treatment Programs in the U.S. Department of Veterans Affairs. http://www.ptsd.va.gov/public/pages/va-ptsd-treatment-programs.asp (accessed August 20, 2009). VA. 2009s. Vocational Rehabilitation & Employment Service. http://www.vba.va.gov/bln/vre/vrs.htm (accessed September 29, 2009). VA. 2009t. Independent Living Program. http://www.vba.va.gov/bln/vre/ilp.htm (accessed September 29, 2009). VA. 2009u. VECS Factsheet. http://www4.va.gov/VECS/factsheet.asp (accessed January 19, 2010). VA. 2009v. VA Center for Women Veterans. http://www1.va.gov/WOMENVET/ (accessed September 10, 2009). VA. 2009w. Center for Minority Veterans Home. www1.va.gov/centerforminorityveterans (accessed September 4, 2009). VA. 2009x. Compensated Work Therapy: Information for Veterans. http://www.cwt.va.gov/veterans.asp (accessed December 16, 2009).
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Returning Home from Iraq and Afghanistan: Preliminary Assessment of Readjustment Needs of Veterans, Service Members, and their Families VA. 2010. Grant and Per Diem Program. http://www1.va.gov/HOMELESS/GPD.asp (accessed January 19, 2010). VA Office of the Inspector General. 2009. Evaluation of Suicide Prevention Program Implementation in Veterans Health Administration Facilities, January–June, 2009. Washington, DC. http://www4.va.gov/oig/54/reports/VAOIG-09-00326-223.pdf (accessed January 19, 2010). Watkins, K. 2008. Navy Safe Harbor Command Brief: Taking Care of Our Wounded, Ill, and Injured Sailors and Their Families. http://www.cffc.navy.mil/fltcm-news/goodgouge/Safe%20Harbor-%20Command%20Brief.pdf (accessed August 9, 2009). White House Office of the Press Secretary. 2009. Press Release: President Obama Announces the Creation of a Joint Virtual Lifetime Electronic Record (April 9). http://www.whitehouse.gov/the_press_office/President-Obama-Announces-the-Creation-of-a-Joint-Virtual-Lifetime-Electronic-Reco/ (accessed January 15, 2010). Whittaker, J. M. 2006. Unemployment Compensation (Insurance) and Military Service. Washington, DC: Congressional Research Service. http://digital.library.unt.edu/ark:/67531/metacrs8955/ (accessed January 19, 2010).