Publicly Released: November 12, 2021
Objective
The objective of this evaluation was to determine whether the Department of Defense (DoD) provided suicide prevention resources for transitioning Service members as required by Presidential Executive Order 13822, Presidential Executive Order on Supporting Our Veterans During Their Transition From Uniformed Service to Civilian Life.
Background
The DoD continues to face the challenge of preventing suicides by DoD military personnel. Each Military Service seeks to address suicide prevention with efforts such as training, data collection and analysis, and strategic communications about suicide‑related behaviors. The Joint Action Plan created in response to Executive Order 13822 implemented several initiatives targeting mental health care and suicide prevention, particularly for transitioning Service members, to include mental health screenings on all Service members before they transition. Additionally, DoDI 6490.10 requires that health care providers “arrange for an appropriate transfer of care at the time of transiting to another command or out of military service.”
For the purpose of this evaluation, a transitioning Service member includes all individuals with a planned or pending separation from active duty military service. This definition extends to cover individuals completing service commitment contracts, retiring, or undergoing medical evaluations boards or administrative separation proceedings.
Finding
The DoD did not screen for suicide risk or provide uninterrupted mental health care to transitioning Service members as required by Federal and DoD guidance. Specifically, we determined that the DoD did not establish and implement oversight of Mental Health Assessment (MHA) and suicide risk screening processes for transitioning Service members. We further determined that DoDI 6490.10 lacks a clear definition of a warm handoff, provider training protocols, standardized documentation methods, and oversight procedures to ensure compliance. The overall DoD approaches and services for arranging continuity of mental health care are not resulting in uninterrupted care for all Service members.
The DoD did not establish and implement oversight of MHA and suicide risk screening processes because the Defense Health Agency (DHA) and Military Services did not include a mental health assessment and suicide risk screening as part of the Separation History and Physical Exam (SHPE), which is the only medical exam required to be administered to the transitioning Service member population. Additionally, the DoD and Military Services relied on expired policy to govern suicide risk screening and referral processes.
The DoD did not implement a warm handoff approach, as required by DoDI 6490.10, to create continuous mental health care during the transition from the Military Health System (MHS) to the Veterans Health Administration (VHA) because DoD policy is reliant on Service members and automatic systems to initiate a transition of mental health care from the MHS to the VHA. Failure to identify suicide risk and arrange for uninterrupted mental health care in transitioning Service members may result in a lack of mental health care for transitioning Service members and jeopardize patient safety.
Recommendations
We recommend that the Assistant Secretary of Defense for Health Affairs (ASD[HA]), in coordination with the Director of the Defense Health Agency (DHA) and the Services’ Surgeons General, establish consistent policies and procedures to manage suicide risk screening and referral as part of the medical process for transitioning Service members. At a minimum, the policies and procedures should designate an organization to have responsibility for the clinical implementation of the policy and designate an organization to have oversight responsibility for mental health assessment.
We recommend that the Director of the DHA, in collaboration with the Director of the DoD and Veterans Affairs Collaboration Office, identify the causes for the breaks in arranging for continuous mental health care for Service members in care who are transitioning from the MHS to the VHA; create and implement solutions to increase the number of Service members who have continuous care arranged between the MHS and the VHA at the time of transition; and provide support, time, and budget resources to initiatives intended to improve the quality of the warm handoff of care.
Management Comments and Our Response
The Under Secretary of Defense for Personnel and Readiness (USD[P&R]), responding for the ASD(HA), agreed with the recommendation that the ASD(HA) designate an organization to be responsible for the clinical implementation of the policy and oversight responsibility for mental health assessment processes for transitioning Service members. Comments from the USD(P&R) partially addressed the recommendation. The USD(P&R) did not designate an organization to be responsible for the clinical implementation of the policies and procedures to manage suicide risk screening and referral as part of the medical process for transitioning Service members, nor did the USD(P&R) designate an organization to have oversight responsibility for mental health assessment processes for transitioning Service members. Therefore, these recommendations are unresolved.
The USD(P&R), responding for the ASD(HA), agreed with the recommendation that the ASD(HA) establish a standard mental health assessment and suicide risk screening process to be used by all Services. Comments from the USD(P&R) addressed all specifics of the recommendation. Therefore, this recommendation is resolved but will remain open.
Both the USD(P&R), responding for the ASD(HA), and the DHA Director agreed with the recommendation that the DHA Director identify the causes for the breaks in arranging for continuous mental health care for transitioning Service members, create and implement solutions to increase the number of Service members who have continuous care arranged between the military health system and the Veteran’s Health Administration or civilian mental health providers at the time of transition, and determine the resources required to implement policy and training that improves the quality and consistency of the warm handoff of care. Comments from the USD(P&R) addressed all specifics of the recommendation. Therefore, this recommendation is resolved but will remain open.
This report is the result of Project No. D2021-DEV0PB-0025.000.