Ronald P. Hudak, JD, PhD * ; Christine Morrison * ; Mary Carstensen ; COL James S. Rice, MS USA * ; SGM Brent R. Jurgersen, USA *

MILITARY MEDICINE, 174, 6:566, 2009 The U.S. Army Wounded Warrior Program (AW2): A Case Study in Designing a Nonmedical Case Management Program for Severely Wounded, Injured, and Ill Service Members and Their Families Ronald P. Hudak, JD, PhD * ; Christine Morrison * ; Mary Carstensen ; COL James S. Rice, MS USA * ; SGM Brent R. Jurgersen, USA * ABSTRACT This case study describes the innovative and unique U.S. Army Wounded Warrior Program (AW2), which provides nonmedical case management to the most severely wounded, injured, and ill soldiers and their families. The study describes the program and identifies the features for a successful nonmedical case management program of an identified population who has complex medical needs. Although the article focuses primarily on the role of the AW2 advocate, key components of the program are discussed, including successful initiatives as well as areas that required adjustment. The lessons learned are identified as well as recommendations for future nonmedical case management initiatives. INTRODUCTION The purpose of this case study is to describe the innovative and unique U.S. Army Wounded Warrior Program (AW2), which provides nonmedical case management to the most severely wounded, injured, and ill soldiers, their family members, and caregivers for as long as it takes. Although this case study focuses primarily on the role of the AW2 advocate, key components of the program are discussed, including successful initiatives as well as areas that required adjustment. The lessons learned are identified as well as recommendations for future nonmedical case management initiatives. The AW2 program had its genesis in January 2004 when an Army task force was created for the purpose of assisting grievously wounded soldiers returning from the War on Terror. 1. Within a short period, the Army leadership agreed that there was a need for a program that would respond to the needs of seriously-wounded soldiers who were returning from Operations Iraqi Freedom and Enduring Freedom (OIF/OEF). Therefore, on April 30, 2004, the U.S. Army introduced an initiative, the Disabled Soldier Support System (DS3), to enhance the care and support of severely wounded warriors and their families. The name was changed to the Army Wounded Warrior Program in November 2005 on the basis of feedback from soldiers to leaders saying that they did not want to be called disabled. The change also more clearly identified the population served by the program. This population included not only those soldiers who had been severly wounded, but also those soldiers with severe injuries and illnesses. 2 *200 Stovall Street, Alexandria, VA 22332. 3354 Lakeside View Drive, Falls Church, VA 22041. The views expressed are those of the authors. No official support or endorsement by the Department of the Army or the Department of Defense are provided or should be inferred. This manuscript was received for review in October 2008. The revised manuscript was accepted for publication in February 2009. The focus of the AW2 program is the Warrior Ethos, that is, to never leave a fallen comrade. The AW2 mission is to ensure the holistic well-being of the severely wounded, injured, and ill soldiers and their family members. Similar to other health professionals, the AW2 program utilizes a nonmedical case management model, which guides severely wounded, injured, and ill soldiers from their evacuation through treatment, rehabilitation, return to duty or military retirement, and, ultimately, transition into the civilian community. 3 Therefore, AW2 s support system is there for the soldier for as long as it takes. To ensure a holistic approach to the care and transition of Army warriors, the AW2 program is a component of the U.S. Army s system to care for all wounded warriors and their families, regardless of the severity of wounds, injuries, or illnesses. Therefore, active duty AW2 soldiers are assigned to a warrior transition unit (WTU) for command and control purposes to ensure that they focus on healing before returning to duty or transitioning to veteran status. The other military services have similar programs to provide nonmedical case management for its injured service members. Specifically, the U.S. Marine Corps has the Wounded Warrior Regiment, 4 the U. S. Air Force has the Air Force Wounded Warrior Program, which was formerly called Palace Hart (Helping Airmen Recover Together), 5 and the U.S. Navy has Safe Harbor. 6 These programs provide individualized support designed and managed to meet the needs of their service members and families. PROGRAM DESCRIPTION The AW2 program supports soldiers who suffer from severe wounds, injuries, or illnesses incurred in the line of duty after September 10, 2001 in support of the Global War on Terror (GWOT). Since the program s inception, eligible soldiers were those who received, or are expected to receive, a 30% or higher disability rating from the Army in one of the follow- 566 MILITARY MEDICINE, Vol. 174, June 2009

ing categories: Blindness/Vision Loss; Amputation; Spinal Cord Injury and Paralysis; Severe Burns; Severe Hearing Loss/Deafness; Permanent Disfigurement; Traumatic Brain Injury (TBI); Post Traumatic Stress Disorder (PTSD); and/ or Fatal, Incurable Disease with Limited Life Expectancy. In 2008, the Program expanded eligibility by supporting Soldiers who have received, or are expected to receive, a 50% or higher combined disability rating from the Army because of combat or combat-related injuries. The top three conditions are PTSD (25%), amputation (21%) and TBI (19%). The program has grown substantially since its inception. In the first year, 2004, there were 340 soldiers. In 2005, there were 909 soldiers, which grew to 1,476 in 2006. By 2007, there were 2,432 soldiers. By the end of 2008, approximately 4,000 soldiers were eligible for the support provided by AW2. 7 The program grows by approximately 50 soldiers per month. Approximately 76% of the soldiers are in the active Army component while 16% are from the National Guard component. The remaining 8% are Reserve component soldiers. It should be noted that, because the program s mission is to support the soldier and family for as long as it takes, the attrition from the program is not expected to be substantial. Therefore, it is expected that the program s growth will continue to be cumulative. Regardless of their Army component, the AW2 population includes soldiers who are undergoing recovery and rehabilitation, awaiting Medical Evaluation Board (MEB)/Physical Evaluation Board (PEB) results, have returned to duty by being declared fit for duty, have been medically retired, or returned to duty in a continuation on active duty (COAD) or continuation on active Reserves (COAR) status. The COAD/COAR status is approved for approximately 3% of the AW2 soldiers. This is a unique opportunity for AW2 soldier s whose disability is a result of combat or terrorism and who have between 15 and 20 years or service or are qualified in a critical skill or shortage military occupational specialty (MOS). The cost of the program is approximately 20 million dollars per year. The cost includes civilian pay, facilities, supplies, equipment, two annual training programs, and five contracts. Until FY 2010, the funding has been through the Global War on Terror (GWOT) source. However, beginning in FY 2010, the funding will be through the Department of Defense s Planning, Programming, Budget, and Execution System. ORGANIZATION The AW2 program consists of a headquarters element and five components. The headquarters include the leadership of the program and consist of five military and three civil service personnel. The first component is an operations element of four military and 19 civil service and one contract personnel that include Veterans Affairs liaisons, finance specialists, human resources specialists, medical specialists, operations specialists, and a career cell that focuses on education and employment opportunities. It also manages the innovative, tailor-made, Web-based Wounded Warrior Accountability System (WWAS), which interfaces with numerous Department of the Army and Defense databases as well as enables advocates and the leadership to enter nonmedical case log notations. The second component is a plans, policies, and procedures element of two military and four civil service personnel to review and initiate change to processes, policies, regulations and law, as well as conduct quality assurance activities. The third component is a strategic communications element of two military, four civil service, and three contract personnel for outreach including public relations, strategic partnerships, and Website management. The fourth component is a contact center to provide contact, referral, and investigative outreach to soldiers and families. The final component is an advocates element that provides individualized support for soldiers and their families. This element is the largest of the program and includes 49 civil service and 89 contract personnel. ADVOCATES The advocates are the keystone of the program. An advocate is assigned to a soldier as soon as the soldier is admitted to a hospital with a qualifying condition. As reflected in Figure 1, at this point, the soldier has begun his/her first of the six phases of the Wounded Warrior lifecycle. The AW2 Advocate also works with the soldier regarding returning to active duty, staying in the National Guard or Reserves, or medically retiring. A critical feature of the AW2 program is that, as reflected in Figure 1, the AW2 advocate is the only resource that remains with the soldier and family throughout all six phases. Advocates are located so that soldier and family members can physically meet them and to ensure that the advocates are immersed in, and knowledgeable of, community-based resources. Therefore, advocates are located in various sites on military installations. Some are in the Soldier Family Assistance Centers (SFAC), a facility housing many service providers dedicated to wounded soldiers and their families. Advocates may also be in the hospitals or the WTUs. Other advocates are located in Veterans Affairs medical centers (VAMCs) and polytrauma centers to support those soldiers who have medically retired and are not living near a military installation or require medical attention beyond the capabilities of the military medical treatment facilities. Experience has shown that having advocates physically located within VA facilities has expanded soldiers awareness of VA benefits as well as increasing awareness of the AW2 program by local VA personnel. The advocates duties are comprehensive and challenging. Advocates represent the soldier and family members in all facets of the soldier s recovery and transition life cycle. This includes frequent communications with soldiers and their families to proactively address and mitigate issues they encounter as well as anticipate on the basis of experience. As indicated in Figure 2, advocates provide a holistic approach to supporting soldiers and their families by serving as local resource experts, benefits advisers, military transition specialists, education and career guides, and life coaches. Advocates are also the face of the AW2 program. As such, they conduct outreach initiatives with local nonprofit MILITARY MEDICINE, Vol. 174, June 2009 567

FIGURE 1. Wounded warrior lifecycle. FIGURE 2. Holistic nonmedical case management. organizations, media, employers, and veterans organizations to explain the program and increase awareness of mutual opportunities and benefits. As Figure 3 indicates, the advocate seeks to ensure that the soldier and family receive all benefits to which they are entitled. On any given day, advocates may be working on the following issues: Facilitate a Traumatic Injury Servicemembers Group Life Insurance (TSGLI) application. Educate employers regarding employment opportunities. Explain the program to a local not-for-profit organization. Coordinate 5-year active duty career plan. Provide side-by-side comparisons of medical retirement pay and VA disability compensation. 568 MILITARY MEDICINE, Vol. 174, June 2009

FIGURE 3. Federal benefits. Negotiate transition among federal agencies. Prepare families for fiduciary responsibility of their soldier s pay. Assist with financial counseling. Coordinate an award ceremony. Assist with a soldier or family member s citizenship. Assist with employment and education opportunities. Throughout these interactions, advocates coordinate with the WTU and the SFAC because advocates do not provide command and control of soldiers nor provide services offered by the SFAC. Similarly, the advocates coordinate with other entities including recovery care coordinators and ombudsmen to ensure an integrated approach to the issues of the soldier and family. The number of advocates has grown to over 120 to meet the needs of the soldiers and their families. Although the work load goal is one advocate for every 30 soldiers, this work load is adjusted to reflect the needs of individual soldiers and families. As other studies indicate, experience has clearly shown that each soldier s needs, regardless of medical condition or location, are different and require careful assessment and attention by the advocate on an ongoing basis. 8 Regardless of the size of the caseload, each advocate is required to contact every soldier at least once a month to share information, identify potential needs and risks, and reinforce the AW2 program s willingness to provide support. The advocate is required to resolve any issue within 10 days or elevate the issue to headquarters. Approximately one-third of the advocates are government employees while the remaining advocates are contract employees. This offers the leadership flexibility to maintain a core of experienced government advocates while expanding or reducing contract advocates to quickly respond to the needs of the soldiers. For example, a sudden increase in the number of AW2 soldiers in a particular location can be addressed by quickly hiring contract advocates. Contract employees also enhance the ability of the program to respond to shortterm challenges, for example, moving an advocate to support a soldier with a particularly acute issue. Lastly, the position descriptions of contract employees can quickly be amended to respond to changing requirements of the program. All new advocates attend a 2-week training session. As research suggests, significant attention is given to developing relationships as well as interpersonal communication skills including interviewing and listening techniques. 9 The training also provides a wide range of subject matter experts whom the advocate may contact on an as-needed basis to resolve problems, e.g., VA counselors. Post-training requires the advocate to make contact with a number of local resources to enhance professional, interpersonal relationships. PROGRAM SUCCESS As the literature suggest, performance measurements are appropriate to measure successful outcomes. 10 The AW2 program has demonstrated that it is achieving its vision of ensuring that wounded warriors and their families are self sufficient, contributing members of our communities by applying five outcome measurements. First, a telephonic survey of all soldiers is conducted by the quality assurance staff. This survey queries the soldiers on all MILITARY MEDICINE, Vol. 174, June 2009 569

aspects of the program including whether needs are being met, how well they know the program, as well as how satisfied they are with the program s benefits and their advocate. Second, a random survey is conducted quarterly by a contractor. This survey is anonymous and also queries the soldiers regarding satisfaction with the program and his/her advocate. Third, the staff conducts an annual symposium. Four annual symposia have been conducted averaging over 50 soldiers and their families. These symposia solicit feedback from soldiers and their families on how to improve services and benefits to them throughout the Wounded Warrior life cycle. The top issues and recommendations are forwarded to the Army s senior leadership, as well as the VA s senior leadership. These recommendations have contributed to a number of policy changes and legislative initiatives, e.g., increasing the special adaptive housing grant, revising the Combat-Related Special Compensation Program, and improving the benefits package for nondependent primary caregivers of severely wounded soldiers. Fourth, specific criteria focus on the success of soldiers after return to either active duty or transition to the civilian community. One particular criterion is the promotion rate. For example, a recent Sergeant First Class Promotion Board had a 32.3% select rate for AW2 soldiers while the Army overall select rate was 28.2%. Another criterion is whether medically retired soldiers have been successful when seeking employment or education. Recent successes include soldiers being hired by corporations such as Disney World Resort and Raytheon. Similarly, a number of soldiers are attending a free-tuition program at Kansas University. The National Organization on Disability (NOD), in collaboration with the AW2 program, has an initiative to assist AW2 soldiers with employment opportunities. The final criterion is the actual personal contact by advocates with soldiers on a recurring basis. Advocates performance standards require that every soldier be contacted at least once a month, that all issues are addressed within 10 working days, and that all new soldiers are met within the first 3 days of entering the program. These contacts and subsequent actions are recorded in the database and reviewed by the leadership. LESSONS LEARNED With 4 years of experience, and a number of adjustments regarding operational and policy issues, the AW2 program leadership has learned a number of lessons that should be considered by any organization considering the implementation of a nonmedical case management program. One of the most significant lessons learned is that the skills, knowledge, and abilities required of the advocate are not easy to categorize in a position description because the role of the advocate is multifaceted and complex. A successful advocate combines the skills of a counselor, ombudsman, social worker, benefits advisor, negotiator, marketer as well as a first sergeant, sergeant major, and platoon leader. Some outstanding advocates are retired senior NCOs without the formal education in social sciences. However, they possess years of successful interactions with soldiers in stressful situations. Conversely, other successful advocates are civilian case managers who typically have had some experience working the military, e.g., military spouse, VA, or Department of Defense family advocate, with a passion to support injured, wounded, or ill soldiers. Likewise, assumptions and judgments should not be made regarding the career or educational aspirations of AW2 soldiers and their family members. For a variety of reasons, some soldiers change their minds a number of times when offered jobs or educational opportunities. Similarly, some job environments may be too stressful after the soldier begins work or continuation of therapy may hinder full-time employment. Even before seeking employment or education, soldiers and family members may be challenged to determine where to live to meet ongoing medical needs. Therefore, the advocate must be prepared to re-engage with a soldier and family over months or years. Soldiers and family members yearn for normalcy. Highprofile stories, congratulatory or ceremonial events, and special consideration may not be desired by some soldiers who wish to get on with their lives. Similarly, all family members, including children of all ages, are affected by the soldier s medical condition. Therefore, education, employment, or social events should be developed for individual members of the family as well as for the family as a unit. Soldiers and family members desire a single point of contact for nonmedical issues. From the moment that the AW2 soldier arrives at the military hospital, he/she is greeted by well-meaning and caring clinicians, the chain of command, and others including volunteers all of whom have a business card and a request to call if I can help. The reality is that the soldier and family often become confused as to who can really help. They simply do not know whom to turn to and often ask the same question to a number of personnel. The final lesson learned is that the program s staff must be prepared to respond to unfavorable publicity in the most rapid, accurate, and complete manner possible. For example, a small number of AW2 soldiers have experienced hardships and unfortunate events that should not have occurred. In reviewing these events, it is not clear that there are predictors that could assist in avoiding these activities. In fact, any number of reasons can cause these events. Some are within the control of the program, e.g., pay was changed without notice, the advocate did not maintain a sufficient level of interaction, and offers of free or subsidized housing or transportation were not monitored. Other events were beyond the program s reach, e.g., criminal activity or spousal abuse. In all instances, it is essential to have the program s strategic communications fully and quickly respond to the local community s (and national) media. It is also essential for the advocate to make contact, including 570 MILITARY MEDICINE, Vol. 174, June 2009

physically meeting with the soldier and/or family, as soon as possible. RECOMMENDATIONS The lessons learned should be extrapolated into specific recommendations for consideration by senior leadership when designing a nonmedical case management program similar to the AW2 program. Because the advocate is so critical to the success of the program, one of the most important recommendations is to prospectively ensure that the qualifications for the advocates are carefully assessed before hiring is commenced. Because the strongest asset of an advocate is a highly developed set of interpersonal skills, position descriptions should be sufficiently flexible to ensure that a wide range of qualifying backgrounds is considered. This is particularly important because a mix of contract and government advocates should be maintained. This affords optimal management flexibility in shifting of locations and response time to unique issues. Soldiers and their family members should be contacted on a recurring basis regarding employment, educational, and media opportunities. Experience indicates that even if the soldiers and family members have expressed their desire to not change where they live or what they are doing, they should be contacted because opportunities arise that they may not have previously considered. For example, an educational institution may offer a fully subsidized education and soldiers may now be at a point where they wish to gain additional skills. A single point of contact should be designated for all nonmedical support to minimize conflicting advice. For example, even within the AW2 program, soldiers can still seek assistance from a myriad of resources including the SFAC personnel, recovery care coordinator, WTU chain of command, and ombudsman. This single point of contact can also be extremely helpful in coordinating staff when unfavorable publicity occurs. Finally, any new program should be implemented with an established charter, memoranda of agreement, and supporting mandates including authority to execute a stand-alone budget and to establish office space at the host location. Similarly, this charter should explicitly identify whether the proponent of this initiative is to be a human resource or medical organization. This focus may have profound impact on how the program is viewed to other entities within the organization. In addition, the charter should include authority to seek nongovernmental funds to support initiatives, e.g., family support activities, conferences, and outreach activities. CONCLUSION The last line in the Warrior Ethos is extremely pertinent: Never leave a fallen comrade. This is more than a battlefield ethos. The nation can rest assured the Army will be there and do whatever it takes to assist severely wounded, injured, and ill soldiers and their families during and after the recovery process. The AW2 program addresses the fact that these soldiers and their families are confronting unrelenting challenges as they rebuild their lives. They have made great sacrifice and may need assistance for the rest of their lives. They deserve nothing but the best from our nation. The AW2 program provides that level of excellence. REFERENCES 1. U.S. Army Wounded Warrior Program : Information Paper: Expansion of Army Wounded Warrior (AW2) Eligibility Criteria. May 21, 2008. 2. U.S. Army Wounded Warrior Program. Available at http://aw2portal. com/mission.aspx; accessed September 27, 2008. 3. Brown HD : Transition from the Afghanistan and Iraqi battlefields to home: an overview of selected war wounds and the federal agencies assisting soldiers regain their health. AAOHN J 2008 ; 56 (8) : 343 6. 4. U.S. Marine Corps Wounded Warrior Regiment. Available at https:// www.manpower.usmc.mil/pls/portal/url/page/m_ra_home/wwr; accessed September 27, 2008. 5. U.S. Air Force Palace Hart. Available at http://www.af.mil/news/story.asp?id=123046952; accessed September 27, 2008. 6. U.S. Navy Safe Harbor. Available at http://www.npc.navy.mil/command Support/SafeHarbor; accessed September 27, 2008. 7. U.S. Army Wounded Warrior Program: Introduction to the U.S. Army Wounded Warrior Program, Briefing, January 2009. 8. Hobbs K : Reflections on the culture of veterans. AAOHN J 2008 ; 56 (8) : 337 41. 9. Davis JD, Engel CC, Mishkind M, et al : Provider and patient perspectives regarding health care for war-related health concerns. Patient Educ Couns 2007 ; 68 (1) : 52 60. 10. Hoelzer S, Waechter W, Stewart A, Liu R, Schweiger R, Dudeck J : Towards case-based performance measures: uncovering deficiencies in applied medical care. J Eval Clin Pract 2001 ; 7 (4) : 355 63. MILITARY MEDICINE, Vol. 174, June 2009 571