The Road to Reintegration: Status and Continuing Support of the U.S. Air Force's Wounded, Ill, and Injured

Background and Purpose

The U.S. Air Force wanted to understand the well-being of airmen who experience injuries and illness of sufficient severity to call into question their continued Air Force service. Its initial focus was on those injured in combat or hostile-related situations; however, over time, it broadened its focus to include all wounded, ill, and injured airmen. In addition, the Air Force wanted to assess the challenges that impede their reintegration into society in the long term, with an eye toward improving services provided and enabling wounded airmen to become fully functioning members of society. It also wanted to take advantage of ongoing research into how best to do so. To begin the process of gaining this insight, the Air Force asked RAND Project AIR FORCE (PAF) for assistance in gauging the current status of the Air Force's wounded warriors, including their use of and satisfaction with the Air Force programs designed to serve them. Accordingly, PAF surveyed the Air Force's wounded warriors for the first time in 2011 (Sims et al., 2015) and the second time in 2014 (Sims et al., 2016). In this study we present the findings from the third survey in this series, which was fielded in 2016. To address the challenges identified, we offer recommendations for the Air Force's consideration.

Methods

At the request of the Air Force, we focused on airmen enrolled in the Air Force Wounded Warrior (AFW2) program. Our cohort includes 713 airmen injured in combat or as a result of hostile action, as well as those with other injuries or illnesses that were severe enough to warrant out-processing from the Air Force; 38 percent, or 270, responded. Given our population of interest, we expected high prevalence and severity of psychosocial challenges as was documented in previous research among the combat injured (Sims et al., 2015; Sims et al., 2016). Additionally, given the proportion of airmen whose injuries are related to combat, our sample includes airmen with a higher prevalence of mental health challenges relative to the broader Air Force population.

For our previous efforts, we developed a model that informed a survey to assess well-being on a range of critical indicators and services designed to enhance well-being, such as the AWF2 program (Sims et al., 2015). In previous surveys, we assessed the domains of psychological health, interpersonal relationships, unemployment, financial stability, and utilization and perceptions of the AWF2 program, all of which we retained for the current effort. For this survey, we added new questions to assess physical health and utilization and perceptions of more recently developed Air Force programs that may be available to these airmen: Recovering Airmen Mentorship Program (RAMP), Military Adaptive Sports Program, Education and Employment Initiative (E2I), and Operation Warfighter, as well as the more-established Transition Assistance Program (TAP) and Airman and Family Readiness Centers. In sum, this investigation represents an independent study to determine the array and extent of the needs of intended program recipients, assess how well the programs meet these needs, and provide suggestions for program improvement.

Findings

Mental or Physical Health Problems Were Frequent

As expected for our population of airmen being considered for medical retirement, the vast majority of airmen reported having been diagnosed with both physical and psychological health conditions, with 91 percent reporting at least two conditions (out of the 19 for which we surveyed). High percentages of airmen reported diagnoses for physical or mental conditions (90 and 80 percent, respectively). In addition, current symptoms of mental health problems were common, as more than two-thirds of airmen screened positive for current post-traumatic stress disorder (PTSD) or depression (68 percent).

Airmen Received Care in Multiple Locations, but Most Often in a Military Treatment Facility

The health care landscape that these airmen must navigate is complex. Almost half of those with physical conditions reported ten or more health care visits over the past year. They were seen in a variety of locations, with the most frequent being a military treatment facility (MTF) (68 percent). Of those who screened positive for current mental health conditions (i.e., PTSD or depression), 91 percent reported having received treatment over the past year, and three-quarters received both medication and therapy. As with health care for physical conditions, treatment for mental health conditions was most commonly received at MTFs.

For Physical and Mental Health Conditions, About One-Third of Airmen Reported Difficulty in Getting Treatment, and Reported Barriers to Care

For both physical and mental health conditions, one-third of airmen reported experiencing difficulty obtaining treatment at some point in the past year. Of these airmen, the most common barriers to obtaining treatment were difficulty scheduling an appointment, not knowing where to get help or who to see, believing in one's own ability to handle the problem, and believing that the care available is not of very good quality. Specific to mental health care, commonly endorsed institutional and cultural barriers included the belief that getting help could harm their career (44 percent), concerns about loss of respect from friends and family (33 percent), loss of respect from supervisors (26 percent), and related concerns over getting or keeping a security clearance (31 percent).

Coordination of Care Among Providers Was Uneven

Only 37 percent of those who reported having seen two or more providers in the past year were assigned a lead care coordinator.¹ Sources of help with care coordination included the airmen themselves (80 percent), health providers such as doctors (50 percent), and care coordination professionals such as (nonfederal) Air Force Recovery Care Coordinators (RCCs) (25 percent). Only half reported that their providers were usually or always aware of other care provided, and 16 percent reported they never were. While more than half of respondents were satisfied with their care coordination, a substantial minority (23 percent) were either dissatisfied or very dissatisfied.

A Substantial Minority of Airmen Did Not Have a Primary Supporter

A primary supporter is the person who most often helps an airman deal with problems that come up. These were typically spouses or partners (49 percent). For most airmen with a primary supporter, the same person provided the greatest sense of emotional security and well-being (85 percent). Of those who did not have a primary supporter (17 percent), 42 percent said it was either because they had no one available or because desired help was not obtained.

The Unemployment Rate Among Airmen Who Were Not Serving Was High

The unemployment rate was 41 percent, excluding airmen currently serving (and hence employed) and who were not in the workforce, such as those who reported that they were disabled and not working, retired, or seeking an education. The most frequently reported barriers among those who were not employed were feeling uncomfortable or anxious when thinking about working, feeling not physically capable, or lacking confidence in themselves and their abilities.

Satisfaction with Air Force Nonmedical Case Management Was Generally High

The AWF2 program was widely utilized, with 74 percent saying they received at least one type of help or service. Of those who received services, 87 percent indicated they were overall satisfied with the program. Despite the overall positive perceptions of AWF2 program users, there were some aspects of the AWF2 program that were perceived less favorably by users. For example, 27 percent of airmen who had received services from AWF2 reported having been contacted no more than once every few months by an AWF2 case manager and, of these airmen, more than half (58 percent) considered this amount of contact insufficient.

Rates of uptake of other programs varied widely, ranging from 5 percent for RAMP to 77 percent for TAP. Some programs were relatively more recently developed, which might help to explain their lower rates of uptake. In addition, some programs have restricted eligibility or may appeal to a narrower subset of airmen than others. Finally, even if an airman is eligible for a given program, actual uptake depends on individual goals and desires. Programs with sufficiently high uptake to permit assessment of perceptions, such as TAP, E2I, and the Military Adaptive Sports Program, were regarded favorably by program users. Many airmen (60 percent) had also taken advantage of the offerings at Airman and Family Readiness Centers, and of those, 92 percent reported overall satisfaction with services received.

Conclusions and Recommendations

Below we describe our conclusions and recommendations, which are grouped into medical and nonmedical care.

Medical

• Consider providing assistance from a professional with a designated care coordination role to improve care coordination outcomes. While more than half of respondents were satisfied with their care coordination, a substantial minority (23 percent) were either dissatisfied or very dissatisfied. Most airmen reported gaps in care coordination, with only 37 percent having been assigned a lead care coordinator and one-quarter of airmen receiving assistance with care coordination from a care coordination professional such as an RCC. Airmen who had received care coordination assistance from a professional, such as an RCC, reported greater satisfaction with care coordination than those who had not. Although this correlational finding does not indicate that assistance from a care coordination professional causes greater satisfaction with care coordination, it is consistent with the idea that care coordination professionals may have beneficial effects on care coordination outcomes.
• Continue consideration of system capacity and navigability initiatives to address the complexity and lack of capacity of the health care system. The complexity and lack of capacity of the health care system are persistent problems in the treatment of both physical and psychological conditions. The complexity of the health care system is underscored by the findings that most airmen had received health care in multiple settings in the past year, and that not knowing where to get help or who to see was a commonly endorsed barrier to care for both physical and psychological conditions. The lack of system capacity, which has been identified as a critical issue in other recent studies, is further highlighted in the current study by the finding that difficulty scheduling an appointment was a commonly endorsed barrier to receiving health care for both physical and psychological conditions.
• Continue efforts to collect and publicize data on the quality of care provided and engage airmen in discussions of treatment options. Concern about the quality of care available to airmen was also commonly endorsed as a barrier to seeking treatment for both physical and mental conditions. To inform airmen's decisions about the treatment options that are best for them, we recommend continuing efforts to collect and publicize data on the quality of care provided and engage airmen in discussions of treatment options.
• Consider revising Department of Defense (DoD) policies on the confidentiality of mental health treatment. Concerns regarding confidentiality deterred some airmen from seeking treatment because they believed it would engender negative perceptions among their peers or limit their ability to keep or obtain a security clearance. We recommend, as have others, that DoD consider revising its policies on military mental health confidentiality standards for service members in order to align more closely with those applied in the civilian sector.

Nonmedical

• Connect airmen with social support deficits to available resources that provide social support and integrate family and friends into airmen's recovery process. Almost one in five in our survey reported lacking a primary supporter. Individuals with social support reported that it is integrated into many important activities of reintegration. Thus, while relatively few airmen reported not having primary supporters, providers should be aware that deficits in social support are an issue for some airmen, and should seek to make services available that are designed to alleviate these deficits. They should also continue to integrate family members and friends into airmen's recovery.
• Continue providing employment assistance to transitioning airmen. Those airmen who are not currently serving have a high unemployment rate. It is difficult to find employment before leaving military service. Airmen who responded to our survey were at the point of transition, and are very likely to need employment assistance. The Air Force employment programs that we assessed are viewed by those who have used them as being helpful and addressing some of the common barriers to employment.
• Continually assess the uptake and performance of new programs for wounded airmen and consider revisions or discontinuation as warranted. Although many nonmedical programs offered by the Air Force enjoyed high saturation among respondents, and many also had reportedly high satisfaction, some programs had lower uptake. This may be due to a variety of reasons but suggests continued monitoring is warranted. For those whose uptake is consistently low and whose eligibility is not commensurately restricted to a particularly vulnerable subgroup, it may be worthwhile to consider marketing initiatives to increase awareness. Moreover, assessment of the benefit of programs should be ongoing. Programs or services with both low uptake and low efficacy may warrant revisions or discontinuation.