Review of VHA’s Screening and Evaluation of Traumatic Brain Injury in Post-9/11 Veterans

The VA Office of Inspector General (OIG) initiated a national review in December 2024 to evaluate components of Veterans Health Administration’s (VHA’s) screening and evaluation processes for traumatic brain injury (TBI) in veterans who separated from active duty after September 11, 2001, (9/11), and received VA medical care. 

For the study period of veterans who separated from active duty after 9/11 through March 31, 2025, who engaged in VA medical care, the OIG determined VHA screened 94.4 percent of veterans for possible deployment-related TBI. However, approximately half of the veterans who agreed to a comprehensive TBI evaluation (evaluation) did not receive the assessment. To assess more recent performance, from October 1, 2023, through September 30, 2024, the OIG found VHA improved the completion rate of evaluations. However, of the completed evaluations, over half were not performed within the required time frame. The OIG identified factors impeding evaluation completion such as staff not placing an evaluation consult and scheduling difficulties. The OIG found the Polytrauma System of Care provides additional resources through telehealth; however, those resources were not maximized. Additionally, the design of the evaluation template is restricted to one-time use following a positive TBI screen, preventing its use after subsequent separation and positive TBI screen.

The OIG made three recommendations: reviewing the TBI evaluation referral process, developing a uniform referral method for the utilization of Polytrauma System of Care resources, and reviewing the one-time use limitation of the evaluation template to consider revisions that would allow another evaluation for veterans who screen positive for deployment-related TBI after a subsequent separation. The Under Secretary for Health concurred with recommendations 1 and 2 and concurred in principle with recommendation 3, agreeing to collaborate with VHA national program offices, enhance resource sharing, and ensure documentation of evaluations.