Staying Power: Army's Wounded Care Program Transformed for Future, General Says

By Fred W. Baker III
American Forces Press Service

Nov. 7, 2008 - Brig. Gen. Gary Cheek, the Army's assistant surgeon general for warrior care and transition, recently spoke with American Forces Press Service about the Army's transformed wounded warrior care program. What follows is a question-and-answer session from that interview.

Q. It has been a little more than a year since the first wounded warrior brigade was stood up at Walter Reed Army Medical Center. Tell me how you think the model is doing and, overall, how you think the Army is doing in taking care of wounded warriors.

A. It is a tremendous program. We have literally completely transformed our rehabilitative care ... as we transition the soldier from inpatient care to either going back to the Army or civilian life.

To some degree we've never really fully had what I would call a rehabilitative capability in the Army on the scale of what we're doing now. Once we became engaged in the two wars now, when we started to look for those rehabilitative capabilities, they really didn't exist. I don't know that we have it exactly the way we want it yet, but I think we're at a point of irreversible momentum to where we will get these things really up, designed, functioning with the policies in place to make them a terrific system.

Q. So, do you think the triad of care and the warrior transition unit models are working for the Army?

A. Really when you look at what was going on at Walter Reed [before February 2007 when the Washington Post news articles exposed a breakdown in wounded warrior care there] it was really just a microcosm of the entire Army and our systems. I don't want to point too sharp a stick at it ... but it was not a system that we needed to properly take care of soldiers.

We were hit pretty hard about the facilities. But that's really only a small part of it. We had really no leadership structure. We were actually using an NCO that was in charge of those soldiers who was himself a cancer patient. We had no structure, no military discipline, no requirements for formation. We had soldiers that were not wearing uniforms, not getting hair cuts, growing beards, and really left to their own devices.

If you were a soldier trying to work the system and hang out there as long as you want, that was great. If you were a soldier who wanted to get better and get back to his unit, it was frustrating. It was difficult.

We didn't take good care of the families. We weren't watching out for the soldiers. We did not have the traditional military structure and leadership that soldiers are accustomed to. We also really didn't know what was going on. We weren't really checking and measuring how we were doing.

And that has completely changed. Now, by contrast, we have the 35 warrior transition units. We did consider going back to the rehab center concept ... but the reason we didn't want to do that is because we felt that to properly rehabilitate a soldier, it's best to have him close to his home, his family, his comrades. We wanted a system that was more adaptable.

We stood up the military unit with the familiar things like company commanders, and first sergeants and squad leaders and platoon sergeants and added to that some medical management capability with a nurse case manager and primary care physician.

All in all, I think we are off to a tremendous start to this program and we continue to adjust and revise.

Q. Do you think that that discipline helps them re-associate with the Army and focuses their intent on healing?

A. Absolutely. These are soldiers. And for a soldier, the things like the Uniform Code of Military Justice, the standards, the customs and the courtesies all apply. That leadership has to take into account the conditions ... unique to that soldier. Of course they will use judgment when dealing with those soldiers. We want to have discipline. We don't want it to be overly harsh. We want it to be appropriate.

The discipline I think is key and it is a big part of their rehabilitation and healing. That same discipline is also going to be pushing them to follow the instructions of their providers, their therapists and making their appointments.

Q. You've had some difficulty with the staffing the transition units. I know there are some initiatives to get that up to 100 percent. How is that going?

A. Is important for us to have the cadre right and the ratios should be at 100 percent and that's what we're moving toward. But I think there are some key misperceptions. The first one is, yes we have over 12,000 soldiers in this program ... but it is not 12,000 catastrophically wounded soldiers from theater. About one-third were evacuated from theater ... the other 66 percent really have come from our units ... a soldier in a car accident, a soldier who has cancer, a soldier with a sports injury, a soldier injured in training. Seventy-five percent of those 12,000 are combat veterans. We have a moral obligation to take care of all of them and that's what we'll do.

But the important thing is the cadre that looks after those soldiers is more to manage their care. It's not that they're being denied medical care. It's not that they're not being taken care of or supervised. They are.

The methods we were using to staff those cadres ... were just not agile enough to keep up with the growth. We've changed the way we're doing that. We have mandated to stay up with these ratios based on the population. We have brought in our commanders at the major command level ... all around the world, all of our installation commanders ... and we really came to a common azimuth that we're all responsible for this and we're going to keep this straight.

The main thing I would say is that even when the cadre's strengths were below the ratios we had set, I do not believe that had a major impact on the care provided to those soldiers.

As every day passes, the warrior transition units and the services, the medical care, the discipline, all the things we provide will get better and stronger with time.

Q. What was the rationale behind bringing in all wounded, ill and injured soldiers into the program, because it would seem to create more of an issue with barracks and staffing?

A. I suppose we could consider a special program for only our wounded soldiers, but then when I have a soldier who has three combat tours and he's injured in a motorcycle accident, he's not eligible. Do we not have an obligation to take care of him?

It is really about the severity of the wound, the illness or the injury. How bad is the medical condition of that soldier? That's what gains entry into this system.

We're going to tighten our criteria a bit. We have a significant number of soldiers in our warrior transition units that have a long-term problem, but with rather routine rehabilitative needs. In the future, we will more than likely keep that soldier in his unit and use traditional leadership to supervise him and the medical care provided to do that. We want to make our warrior transition units focus on those that need that intense managed care.

In the end, ...we didn't stand them up to ride focused, intense management of soldiers with fairly simple issues that don't require that. As the pendulum swings, we're going to bring it back but we're going to bring it back very carefully.

Q. How is your access to senior Army leadership and what is the priority for wounded warrior care?

A. I would say our support from the senior leaders of the Army is enormous. I easily have direct access to any of them should I need to bring up an issue. Typically it works the other way around. They typically call me and I go there quite often.

Q. Is the Army able to change its policies and procedures fast enough to accommodate the needs of wounded warriors?

A. I would say yes, but I would also say we have to be very careful. You want to be very wary of a knee-jerk reaction.

We are pretty agile, but we have to be very careful I think because the second- and third-order effects of making policy changes sometimes are not apparent. Our decision, for example, to bring a lot of our medical evaluation board soldiers into the WTUs had that beneficial effect for deploying units in that it removed them from their books and allowed them to get more personnel. And to some degree it brought these soldiers together where we could help expedite their board process .... The second-order effects were we had this explosion in our population and we had this great challenge of getting our cadre up to strength. And when we finally stepped back and looked at this population, we determined that ... this was designed to provide focused managed care and a lot of soldiers we brought in don't need that.

Q. Can you talk about streamlining the board process and where the Army is with its pilot program?

A. This is a process that's been around for probably 50 years. It's a very deliberate process that makes sure we do it right and that the best interests of the soldier are protected. So that process has got a lot of checks along the way to make sure we don't misstep.

We have looked hard at eliminating some of the duplicative paperwork. We're also going to automate this system. By January, we will be able to do this in an automated fashion which should help us considerably. The pilot brings the VA and the Army together to do a single physical. We used to do two.

What we would really like to see is the Army not to be in the disability business. The Army's decision really ought to be about fitness to serve or not. You can either stay in the Army or not, based upon your physical condition. The disability decision, we would rather have that be in the Veterans Affairs. Let them make the decision of the disability and work that.

For the soldier, he or she wants to make sure that they retain medical benefits for the family, to not have any degradation of pay ... and be as physically capable as they can. The MEB and our process really doesn't necessarily look after those interests. There will be some disappointed ... soldiers.

So until we can resolve that, we are left with this system which unfortunately puts us in a bit of an adversarial relationship with the solder.

Q. So are you saying that you would like to see that fall entirely to the VA? The soldier transitions to the VA, and the VA assigns the benefits and the compensation?

A. Right, and of course that's a sticky point because that gives the VA to some degree the keys to the kingdom to get into the ... Department of Defense's money. But ... it is the way the law is structured right now, so this is not a policy we can change. But it is one we often discuss with Congress and we say we would like this law changed.

But as long as we cooperate on the physical, it seems to me we can make some progress here, but within limits.

Q. The Army has begun leaning forward in allowing [seriously wounded] soldiers to stay on active duty if they choose. Why?

A. For any soldier who has been wounded in combat who wants to continue on active duty, we have yet to say 'no.' That's not a policy. I just know that to be a fact. Every one of those is done on a case-by-case basis.

We have a tremendous positive track record for great servants who have been grievously wounded in combat [and continued on active duty]. When we look at the history of the service that has been done by some of those who have made those kinds of sacrifices, I think keeping them in the Army has a lot of merit. They have a lot to offer.

I was sitting at lunch with a group of soldiers and one soldier told me how deeply appreciative he was of the transition assistance he was getting. He was being medically separated from the Army, but in the time he was in the WTU, he was able to take college courses and he was able to get coordinated to attend college [after he separated]. And he really was very complimentary of how he had been treated and helped and counseled through that process.

Across the table, another soldier said, "You know I am returning to duty and I really didn't get much at all."

From his perspective, we were putting more effort to get soldiers out of the Army than we were to keep soldiers in the Army. Boy, that was like a smack right on the forehead.

This gave me new energy to work that. We want to place a retention NCO in each of our WTU battalions and build a retention program to encourage our soldiers to stay in the Army. In particular, we may have a soldier who is medically unqualified for his current specialty, but we may be able to find another way to use his or her talents in another specialty.

We went to the AW2 symposium ... I spoke to those soldiers there and asked how many would like to be a cadre member. And a number of them were very interested in doing that. So I think we have a resource right there alone just for our own warrior transition units where these soldiers can serve. They can teach in schools. In many cases, they do continue to serve in their MOS and deploy to combat.

Q. What feedback are you getting from the troops and the families?

A. The feedback I get from families ... is really spectacular. I think especially for those families when they first arrive ... There's a lot of reticence and uneasiness about the condition of their loved one. But they are embraced immediately. So they are put at ease very quickly and taken great care of. For many of them, their challenges lie ahead, but at least we get them through that very difficult period where there's a lot of unfamiliarity with the military and the situation they're stepping into. We're doing a great job there.

From the soldiers, it's not all milk and honey. Soldiers are going to tell you the things they like and don't like. For many of them, they are greatly appreciative of this concept. Many of them are very, very complimentary of their cadre. Others are perhaps less so. But you will find that anywhere in the Army. But, by and large, they recognize the investment, the attention and the focus of the Army.

We also ask them about their level of care. Generally speaking, from the surveys we do, we range just under 80 percent satisfaction. Our goal is to get everybody over 80 percent and we have made incremental progress towards that.

Q. You talk about building an enduring program. Can you define that and tell me why you are designing the program this way?

A. We need an enduring program for the Army that is adaptable, expandable, collapsible and responsive to the needs of the soldiers.

We have a program that is fairly adaptable. And we've proven we can expand it, though it was uneven for sure. I think we're in a much better position now to handle future growth. We really haven't done much to figure out how to collapse this down. When Iraq and Afghanistan go away, we should return to the steady state of illnesses and injuries that soldiers typically get ....


Right now we have 35 warrior transition units and nine communities based healthcare organizations. We are fairly confident that about 26 of those 35 are what I would call permanent warrior transition units. The other nine we're not so sure about.

I want to look harder at the community based health care organizations approach. That's one that is very easily expandable provided those civilian capabilities are there.
We've asked for funding to build 21 warrior transition complexes at various posts, camps and stations in the United States. Right now, the office of the Secretary of Defense supports us for about half of those. Ultimately, Congress will decide how they would fund that.

Nothing says it's enduring like a complex that's built to be dedicated for this mission. And the first one will be started at the end of this fiscal year at Fort Riley, Kan., where we will build the barracks, the administrative headquarters and the soldier and family assistance center in close proximity to the hospital. We will have an excellent facility that takes care of wounded, ill and injured soldiers at that installation. We will get another major start on at least another eight in fiscal year 2009.

Q. Is there anything else you would like to add?

A. I'm just very concerned that America is getting a false impression. They think we have hundreds of thousands of wounded soldiers. They think we have 12,000 amputees or worse in our warrior transition units. There are only 1,500 Purple Heart recipients. The number of amputees for the Army is less than 800.

Yeah, we have challenges out there. But the progress we've made is just spectacular. And the care we're providing the soldiers, the organization, the cadre, is all superb.

I think there's basically a misunderstanding of Army culture. We open ourselves up. We candidly ask for criticism. We work to improve it because that's what we want to do. No one seems to want to believe that we could love soldiers as much as we do. We are soldiers. This is a spectacular program and it's going to get better and better all the time.

(Editor's note: This is the third article an AFPS special report, Staying Power: Seriously Wounded Warriors Return to the Fight).