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2003 VBA SURVEY OF MEDICAL EXAMINERS’ AND CORONERS’ PROCESS IN IDENTIFICATION OF UNCLAIMED REMAINS FOR VETERAN STATUS
Conducted for the: Department of Veterans Affairs Veterans Benefits Administration Compensation and Pension Service Veterans Services Staff Conducted by: Schulman, Ronca, & Bucuvalas, Inc. 8403 Colesville Road, Suite 820 Silver Spring, MD 20910
May 23, 2003
TABLE OF CONTENTS
Executive Summary....................................................................................................................... 1 Background....................................................................................................................................3 Methodology...................................................................................................................................4 Detailed Findings........................................................................................................................ 10 Recommendations......................................................................................................................20
TABLES AND FIGURES
TABLES Table 1: CDC Death Investigation Systems by State.................................................... 5
Table 2: Initial and Revised Number of Jurisdictions by State...................................... 7
Table 3: Response by Mode............................................................................................ 8
Table 4: Response Rate by State.................................................................................... 9
Table 5: Why a Determination of Veterans Status was Not Made in Every Case of an Identified, Unclaimed Decedent by Frequency of Verification............................................................................. 11
Table 6: Medical Examiners/Coroners Reporting 51 or More Identified, Unclaimed Decedents in the Last 12 Months........................... 14
Table 7: Medical Examiners/Coroners Reporting 11 or More Identified, Unclaimed Decedents Identified as Veterans in the Last 12 Months.................................................................................... 15
FIGURES Figure 1: Frequency of Attempts to Verify Veteran Status......................................... 10
Figure 2: Number of Unclaimed Decedents in Last 12 Months................................. 12
Figure 3: Length of Time Records on Identified, Unclaimed Decedents Kept............................................................................................ 16
Figure 4: Percept of Offices Currently Attempting to Verify Veteran Status by How Often Verification Attempted – January 1997 to August 2001...................................................................... 17
Figure 5: Organization Contacted to Verify Veteran Status....................................... 18
EXECUTIVE SUMMARY
The Compensation and Pension (C&P) Service of the Veterans Benefits Administration (VBA), Department of Veterans Affairs (VA), conducted The Survey of Medical Examiners and Coroners to determine the process they use to ascertain the veteran status of decedents whose remains are unclaimed. The survey was precipitated by a recent incident in Chicago where local authorities did not contact VA prior to burying the decedents who were subsequently identified as veterans. This incident sparked a congressional inquiry concerning the process used by VA to ensure that remains of unclaimed veterans received the respect they have earned. This study was designed to gather basic information on the relative number of unclaimed decedents throughout the nation in a year and the current steps that medical examiners, coroners, and others who have the responsibility for the disposition of these remains take to determine the veteran status of the decedents. The major findings of this study were: · The responsibilities typically thought of as being under the authority of a medical examiner or coroner may be assigned to a justice of the peace or, in rural areas, to a county sheriff, who may or may not have the additional title of coroner.
· The number of people who serve in this function appears to be constantly changing.
· Only 15% of medical examiners and coroners reported that they attempted to verify the veteran status of identified, unclaimed decedents all of the time during the period from January 1997 to August 2001. Conversely, 75% never made such an attempt.
· The most common reason for not attempting to verify the veteran status of identified, unclaimed decedents during this period was that there were no such cases. This reason was mentioned by 65% of those asked this question.
· While only 6% of the jurisdictions reporting any identified unclaimed decedents had 51 or more such cases, this group accounted for 61% of all cases reported.
· More than half (54%) of all jurisdictions reported that they kept records on identified, unclaimed decedents. Most (69%) of those keeping records, reported that records are kept indefinitely.
· Currently, over one in three (36%) of jurisdictions reported that they attempt to verify the veteran status of identified, unclaimed decedents compared to the 17% who made such an attempt all (15%) or most (2%) of the time between January 1997 and August 2001. Among those jurisdictions that had at least one identified, unclaimed decedent in the last 12 months, three in five (60%) currently attempt to verify veteran status.
· Verification requests are most often (57%) made to the Department of Veterans Affairs with an additional 27% of such requests made to various state and county offices.
BACKGROUND The Veterans Services Staff, C&P Service was charged with surveying the nation’s medical examiners and coroners (ME/C) to determine the process they use to ascertain the veteran status of identified decedents whose remains were unclaimed. Secretary of Veterans Affairs Anthony J. Principi directed this survey after the unclaimed remains of individuals in Chicago, who were in fact veterans, were buried in pauper graves. The local authorities had not contacted the VA to determine the veteran status of the decedents. This incident sparked a congressional inquiry concerning the process used by VA to ensure that unclaimed remains of veterans are buried in veteran cemeteries. Before VA could develop an effective outreach program for medical examiners/coroners that will make sure that the unclaimed remains of veterans are given the respect they have earned, there needed to be an understanding of the level of knowledge among the ME/C professionals throughout the nation about both the need to identify the veteran status of unclaimed decedents and the process of how this can be done in an effective and timely manner. This study was designed to meet these needs.
METHODOLOGY The first step in the study was to develop a complete list of medical examiners, coroners, and others who serve this function throughout the nation. While no such list exists in one place, the Centers for Disease Control (CDC) maintain a count of those who are responsible for the determination of deaths as part of their Death Investigation System. Prior to the start of this study, the CDC Death Investigation System reported that there were 3,158 individuals with this responsibility.[1] The CDC count had grown to 3,184 at the time that this study began. This was the number of individuals for whom an attempt was made to obtain contact information (name, address, phone number, etc.). The distribution of ME/Cs by state is shown in Table 1, next page. Lists of ME/Cs were available from a variety of sources. Several states had this information on their Web site or a linked Web site. Other states provided this information in electronic format upon request. In a few states, government directories of all office holders were purchased and the appropriate information was key-entered into the master database. Lastly, a small number of lists were provided by the chair of the state professional association of ME/Cs. Throughout the study, the number of jurisdictions continued to change. This came about for three reasons. First, the list from several states reported a different number of jurisdictions (more or less) than anticipated. These states were contacted to confirm that the list was complete. TABLE 1
Second, in several states, the same medical examiner is responsible for more than one county. Specifically, nine states have a total of 16 multi-county jurisdictions covering 48 counties. Third, Texas, with 846 jurisdictions, is in the midst of consolidating. A total of nine such consolidations have been identified during this study. However, it should be kept in mind that there may be additional consolidations among the 185 jurisdictions that did not respond to this survey. Table 2, next page, shows the number of jurisdictions initially anticipated as well as the reduced number of jurisdictions found at the conclusion of this study. ME/Cs were initially sent a short questionnaire by mail on January 14, 2003. (A copy of the questionnaire appears in Appendix A.) A second mailing was sent to those who did not respond to the first mailing on February 16. The cover letter asked respondents to mail the completed questionnaire in the enclosed envelope or to fax their questionnaire to the offices of the survey contractor, Schulman, Ronca & Bucuvalas, Inc. (SRBI). In addition, there were also instructions on completing the questionnaire via the Internet.
TABLE 2
Individuals who had not responded to either of the mailings, and for whom we did not have a fax number or e-mail address, were contacted by phone beginning February 26. A fax containing the cover letter (with Internet response instructions) and questionnaire were sent to 428 individuals on February 28. E-mails were sent to 75 non-responders, including 19 who had received a fax, on March 6. The instructions in the e-mail advised this group to print the questionnaire and fax the completed response to SRBI as well as instructions on how to respond via the Internet. Those who did not respond to the fax or e-mail were also contacted by phone. A five-call protocol was used in the telephone phase. That is, up to five attempts were made to contact an individual. Once contacted, interviewers would complete the interview, make an appointment to complete the interview, or get the name of a more appropriate individual to complete the interview. If the name and phone number of a different person was offered, the process would begin again with 5 attempts made to contact the new individual. Interviews were completed with 2,409 ME/Cs as a result of these efforts. Table 3 shows the number of responses by mode of contact. TABLE 3
Response rates by state are shown in Table 4, next page.
TABLE 4
DETAILED FINDINGS The questionnaire used for this study was designed to collect basic information on the proportion of medical examiners and coroners (ME/C) who do attempt to ascertain the veteran status of identified, unclaimed decedents, as well as obtaining a measure of the proportion who should attempt identification but do not for whatever reason. The first question asked how often an attempt was made to determine the veteran status of identified but unclaimed remains during a four and one-half year period beginning in January 1997. January 1997 was selected because of the implementation of a new work design within the Veteran Service Centers. This new design merged Veterans Service and Adjudication into Business Process Reengineering (BPR) Teams. August 2001 constitutes the data that C&P Service requested the regional offices review their outreach to the ME/C community. The results of this question are shown in Figure 1. FIGURE 1
Only one in four ME/C had ever attempted to identify a decedent during this period. Specifically, only 15% tried to determine veteran status all of the time. Those ME/Cs who did not attempt to determine the veteran status every time the situation arose were asked why they did not try to ascertain if the decedent was a veteran in every case. The results are shown in Table 5. TABLE 5
-- None. * Less than 0.5%. + Detail may not sum to 100% due to rounding. Overall, the most mentioned reason for not determining veteran status in all cases was that the situation never occurs. This reason was sited by 65% of all ME/Cs who were asked this question and 72% of those who never attempted to determine veteran status during the specified time period. One in four (24%) of those who rarely made such an attempt, and 2% overall, gave as a reason that they rarely have a case of an identified but unclaimed decedent.[2] Approximately one in ten, overall, received information on the veteran status of the decedent from a funeral home (6%), the family (2%), or some other source (2%). An equal proportion said that obtaining this information was not their responsibility (5%), they were new in the position and had no experience (3%), or they were not aware that they should or could obtain information on the veteran status of decedents. When asked specifically, only one in five (19%) reported that they had any cases of an identified, unclaimed decedent in the last 12 months. The number of such cases among this group is reported in Figure 2. FIGURE 2
Among the 450 jurisdictions who reported at least one identified, unclaimed decedent in the last 12 months, over one in four (27%) had only one such case and almost one in five (18%) had only two cases. Slightly less than four in five (78%) had 10 or fewer cases. Only one in 20 (6%) had 51 or more cases of this type in the last 12 months. ME/Cs who reported at least 51 cases are listed in Table 6 (next page).
TABLE 6
In total, these 450 jurisdictions reported a total of 7,048 identified, unclaimed decedents. Three-fifths of the total (61%) came from those jurisdictions with 51 or more cases, while 16% came from jurisdictions with 21 to 50 cases and 9% came from jurisdictions with 11 to 20 cases. Jurisdictions with 10 or less cases, accounting for 77% of jurisdictions reporting at least one case, reported only 14% of the cases. Jurisdictions reporting at least one case were asked how many of the identified, unclaimed decedents were verified as veterans. Overall, in only 912 of the 7,048 cases (13%) was the decedent verified as a veteran. TABLE 7
More than half (54%) of the jurisdictions reported that they currently keep records on identified, unclaimed decedents. As can be seen in Figure 3, more than two in three (69%) of those who keep records, keep them indefinitely. One in 20 (6%) keep these records 11 or more years (where the end year was specified), 12% keep the records from 6 to 10 years, and 8% keep them 5 years or less. FIGURE 3
Currently, less than two in five (36%) attempt to verify the veteran status of all identified, unclaimed decedents. It is possible to compare the current practice with what took place between January 1997 and August 2001 (see Figure 1, page 10). This comparison is shown in Figure 4, below. FIGURE 4
More than four in five (85%) ME/C offices which reported attempting to verify the veteran status of all identified, unclaimed decedents in the earlier period currently make such an attempt as well. This proportion remains constant for those who made such an attempt most of the time (86%) and drops to 70% currently for those who made such an attempt some of the time between January 1997 and August 2001. Among those who rarely or never made such an attempt previously, they are at least making some attempts currently, 38% and 23% respectively. When this analysis is limited only to those jurisdictions which have had at least one identified, unclaimed decedent in the last 12 months, the proportion who currently attempt to verify veteran status in these cases increases to 60%. The last series of questions asked jurisdictions if they currently attempt to verify the veteran status of identified, unclaimed decedents. Slightly more than one in three (36%) reported that they currently do attempt to verify veteran status. Those who do make an attempt were asked the name of the organization they contact. FIGURE 5
Less than three in five (57%) who attempt to verify the veteran status of identified, unclaimed decedents contact a VA office. Most mentions were VA in general (29%) with others specifying medical centers or clinics (11%), regional offices or benefits personnel (12%), or other VA areas such as cemeteries or VA police (5%). Over one in four (27%) mentioned state (4%) or county (21%) veterans offices, or other county offices such as the clerk or sheriff (2%). Family or funeral homes were mentioned by 4% while Veterans Service Organizations, such as the American Legion or Veterans of Foreign Wars, were mentioned by 3%. Other mentions, including the Social Security Administration, military bases, National Personnel Records Center, local hospitals, county offices or social services, etc., were mentioned by 9% of those who verify veteran status.
RECOMMENDATIONS The following recommendations are made with the understanding that while it is important to make sure that every veteran is treated with the respect they have earned in the service of our country, currently there is no legislative mandate requiring ME/Cs to verify veteran status for each identified, unclaimed decedent. Nonetheless, VA must rely on the various medical examiners and coroners to initiate a request. Further, given the Federal fiscal realities in which we live, some of these recommendations may be beyond current resources. Nonetheless, we have attempted to make this list as extensive as possible.
· The jurisdictions listed in Tables 6 and 7 of this report either have a large number of identified but unclaimed decedents or a large number of decedents for whom veteran status was confirmed. These jurisdictions could be contacted periodically throughout the year with information on the importance of identifying veterans, the services that can be provided by VA to determine veteran status, the procedure to go through, and the name and phone number of the local VA office to contact. Information on other related functions of the Department could also be sent that, while not directly related to their work, would be of interest to them. The goal is to reinforce the fact that VA can be of service.
· Augment the list developed above by the largest counties not represented. The assumption here is that large counties will have large numbers of both identified and unidentified unclaimed decedents.
· Send at least one informational mailing to all medical examiners and coroners throughout the nation.
· Prepare presentations and displays appropriate for the various organizations whose members are responsible for the disposal of unclaimed decedents. These organizations would include national and state level medical examiners, coroners, sheriffs, funeral directors, etc.
· Prepare articles for the publications of the organizations mentioned above covering the same information.
· Prepare a series of talking points that can be inserted into presentations of senior VA, national and local officials, as appropriate.
· Keep track of the number of requests to verify the veterans status of decedents which can be reported in VA publications and reports to the Congress. If sufficiently large, the data can be reported by state and/or county. This information would show the Congress that many ME/Cs around the country do contact VA on a regular basis to verify the veteran status of decedents. This item shows how all of the outreach translates into increased information about this service among ME/Cs.
· VA regional offices should keep track of changes in medical examiners, coroners, justices of the peace and sheriffs in their service areas. As elections or appointments take place where new individuals assume these offices, VA should send a note of congratulations together with information detailing the service which can be provided by VA in this area.
· Develop a protocol with the FBI and/or other organizations for the identification of all unclaimed decedents through the use of fingerprints. Once identified, the possibility to determine the veteran status of a decedent could take place.
Finally, a second survey gathering information on the awareness of, use of, and satisfaction with VA programs to assist local jurisdictions with the determination of veteran status should be conducted in 3 to 5 years. This will give sufficient time for any new program to take hold. As part of the preparation for the survey, a series of focus group sessions, cognitive interviews, and other methodological techniques should be held in conjunction with appropriate organizational meetings to make sure that the questionnaire is completely understood by potential respondents. Given the fact that the majority of the counties are small and rarely have an identified, unclaimed decedent, the use of sampling can substantially reduce the cost of any future survey.
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