[House Hearing, 113 Congress]
[From the U.S. Government Publishing Office]




                               before the

                         SUBCOMMITTEE ON HEALTH

                                 of the

                     U.S. HOUSE OF REPRESENTATIVES


                             SECOND SESSION


                      WEDNESDAY, DECEMBER 3, 2014


                           Serial No. 113-94


       Printed for the use of the Committee on Veterans' Affairs


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                     JEFF MILLER, Florida, Chairman

DOUG LAMBORN, Colorado               MICHAEL H. MICHAUD, Maine, Ranking 
GUS M. BILIRAKIS, Florida, Vice-         Minority Member
    Chairman                         CORRINE BROWN, Florida
DAVID P. ROE, Tennessee              MARK TAKANO, California
BILL FLORES, Texas                   JULIA BROWNLEY, California
JEFF DENHAM, California              DINA TITUS, Nevada
JON RUNYAN, New Jersey               ANN KIRKPATRICK, Arizona
DAN BENISHEK, Michigan               RAUL RUIZ, California
TIM HUELSKAMP, Kansas                GLORIA NEGRETE McLEOD, California
MIKE COFFMAN, Colorado               ANN M. KUSTER, New Hampshire
BRAD R. WENSTRUP, Ohio               BETO O'ROURKE, Texas
PAUL COOK, California                TIMOTHY J. WALZ, Minnesota
                       Jon Towers, Staff Director
                 Nancy Dolan, Democratic Staff Director

                         SUBCOMMITTEE ON HEALTH

                    DAN BENISHEK, Michigan, Chairman

DAVID P. ROE, Tennessee              JULIA BROWNLEY, California, 
JEFF DENHAM, California                  Ranking Member
TIM HUELSKAMP, Kansas                CORRINE BROWN, Florida
BRAD R. WENSTRUP, Ohio               RAUL RUIZ, California
JACKIE WALORSKI, Indiana             GLORIA NEGRETE McLEOD, California
DAVID JOLLY, Florida                 ANN M. KUSTER, New Hampshire

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                            C O N T E N T S


                      Wednesday, December 3, 2014


VA's Caregiver Program: Assessing Current Prospects and Future 
  Possibilities..................................................     1

                           OPENING STATEMENTS

Hon. Dan Benishek, Chairman......................................     1
Hon. Julia Brownley, Ranking Member..............................     2


Randall B. Williamson, Director, Healthcare GAO..................     3
    Prepared Statement...........................................    34

Rajeev Ramchand, Senior Behavioral Scientist, RAND Corporation...     5
    Prepared Statement...........................................    45

Maureen McCarthy M.D., Deputy Chief, Patient Care Services, VHA, 
  U.S. Department of Veterans Affairs............................    18
    Prepared Statement...........................................    52

    Accompanied by:

        Michael Kilmer, Chief Consultant of Care Management and 
            Social Work, VHA, U.S. Department of Veterans Affairs
        Margaret Kabat, Acting National Director, Caregiver 
            Support Program, VHA, U.S. Department of Veterans 

                             FOR THE RECORD

Disabled American Veterans Submitted by Adrian Atizado...........    59

Paralyzed Veterans of America....................................    66

Wounded Warrior Project..........................................    75

Veterans of Foreign Wars Submitted by Aleks Morosky..............    84


                      Wednesday, December 3, 2014

             U.S. House of Representatives,
                    Committee on Veterans' Affairs,
                                    Subcommittee on Health,
                                                   Washington, D.C.
    The subcommittee met, pursuant to notice, at 10:00 a.m., in 
Room 334, Cannon House Office Building, Hon. Dan Benishek 
[chairman of the subcommittee] presiding.
    Present: Representatives Benishek, Roe, Denham, Huelskamp, 
Wenstrup, Walorski, Jolly, Brownley, Brown, Ruiz, and Kuster.


    Dr. Benishek. The subcommittee will come to order. Good 
morning, and thank you all for joining us today for our 
oversight hearing entitled ``The VA's Caregiver Program: 
Assessing Current Prospects and Future Possibilities.'' 
According to a recent RAND Corporation report, there are 
approximately 5.5 million military or veteran caregivers 
providing care to active duty servicemembers or veterans that 
if provided by home health attendants instead would cost our 
country more than $13 billion. Though that number is 
staggering, the real value caregivers provide cannot be 
    For veterans who have been severely wounded in service to 
our country, caregivers are lifelines. For the Department of 
Veterans Affairs, caregivers are increasingly important 
partners. They are there when VA cannot be and they function in 
ways a government bureaucracy will never be able to, filling in 
gaps, picking up the slack, and supporting the day-to-day 
recovery and rehabilitation of wounded veterans on a 24-hour, 
7-days-a-week basis, often to the detriment of their own 
physical, mental and financial health and stability.
    In recognition of the services caregivers provide and the 
sacrifices they endure, Congress passed public law 111-163, the 
Caregivers and Veterans Omnibus Health Services Act of 2010. 
This law created two programs of comprehensive caregiver 
support; one general program available to caregivers of 
veterans of all eras, and one targeted program available to 
caregivers of post-9/11 veterans only. This targeted program 
called the Family Caregiver Program will be our primary focus 
this morning. And through our work, I hope to discuss both 
where the program is today and where it needs to go tomorrow.
    In a report issued in September, the Government 
Accountability Office found significant issues with the current 
management of the Family Caregiver Program and by extension, 
with the services it provides to family caregivers and to 
severely wounded veterans. According to GAO, VA's initial 
estimates for the Family Caregiver Program were significantly 
off base with a number of approved family caregivers in place 
today, more than triple what the VA originally estimated.
    VA's staffing and workload projections for the Family 
Caregiver Program were similarly inaccurate, leading to 
caregiver support coordinators at some VA medical centers with 
caseloads of up to 251 caregivers, and application backlogs 
numbering in the hundreds in some locations.
    Exacerbating these problems, the GAO also found that the 
Caregiver Support Program office was unable to readily access 
workload numbers and other important data about the program, 
making effective oversight of the program nearly impossible.
    These issues led the GAO to conclude that after 3 years of 
operations, it is clear that the VA needs to formally reassess 
and restructure key aspects of the Family Caregiver Program.
    Make no mistake, while challenges abound and must be 
overcome, the Family Caregiver Program is critical to providing 
the support of services that caregivers and veterans they serve 
require, and it must be strengthened and improved, not 
abandoned or left to fester.
    What is more, as our veteran service organizations express 
so eloquently in their statements for the record, as we examine 
how to reassess and restructure the current Family Caregiver 
Program, we must also examine ways to potentially expand it to 
be more inclusive of caregivers for pre-9/11 veterans. The 
services these caregivers provide, while different in some 
important ways, is no less important and no less worthy of our 
appreciation and our support.
    However, it troubles me that the VA's report to Congress 
last year and potential expansion of the post-9/11 caregiver 
program stated that estimating accurate participation rates in 
cost estimates for an expanded version of the program would be 
challenging and inexact. To proceed with a program expansion 
without taking all potential costs and resource requirements 
into account, would pose risk of compromising other aspects of 
the VA's core mission.
    Making the Family Caregiver Program a long-term viable 
program for those caregivers who contribute so much to the 
quality of life for our disabled veterans would require 
diligent effort and close coordination with the VA, our service 
organization partners and others. This morning's hearing is 
just the start of that work. I look forward to continuing it in 
the 114th Congress.
    With that, I now recognize Ranking Member Brownley for any 
opening statement she may have.


    Ms. Brownley. Thank you, Mr. Chairman, and good morning. I 
would like to thank everyone for attending today's hearing. As 
ranking member of the Health Subcommittee, I certainly take 
seriously our responsibility to conduct oversight of veterans' 
health administration programs to ensure that they are working 
as intended, and that is to improve the lives of veterans and 
their families.
    In 2010, Congress passed the Caregivers and Veterans 
Omnibus Health Services Act, which established the Department 
of Veterans Affairs Family Caregiver Program. Today, the 
subcommittee will examine findings and recommendations from two 
very important reports from GAO and RAND Corporation that were 
released this year on VA's caregiver program.
    I look forward to learning more about how VHA will manage 
its IT strategic needs and to discussing ways that we can work 
together to improve caregiver programs at the Department of 
Veterans Affairs and other Federal agencies.
    In my view, the subcommittee should also explore the 
feasibility and cost associated with expanding the caregiver 
program to family caregivers of pre-9/11 veterans.
    Mr. Chairman, this issue is an important one and I thank 
you very much for holding this hearing today. However, given 
the scope of the program and the magnitude of the issue, I 
would ask that we could possibly have a follow-up hearing. To 
be held so that we may address other concerns that have been 
raised by the veterans service organizations and other 
important stakeholders.
    Again, I want to thank our panelists for participating 
today and I look forward to your testimony. With that, I will 
yield back the balance of my time.
    Dr. Benishek. Thank you. Joining us on our first panel is 
Randy Williamson, Director of Health Care for the Government 
Accountability Office. Mr. Rajeev Ramchand, Senior Behavioral 
Scientist for the RAND Corporation. Thank you both for being 
here this morning.


    Dr. Benishek. Mr. Williamson, please proceed with your 
    Mr. Williamson. Good morning, Chairman Benishek, Ranking 
Member Brownley, and members of the subcommittee. I am pleased 
to be here today to discuss GAO's review of the VA Family 
Caregiver Program. For many veterans who are severely injured 
while serving in the military, caregivers are most often family 
members who provide vital assistance for tasks of everyday 
    My testimony today focuses on how VA has implemented its 
Family Caregiver Program, including how it has managed the 
higher-than-expected demand for caregiver services and the 
resulting impact on VA medical centers, and ultimately on 
caregiver applicants, and veterans alike.
    The VA established its Family Caregiver Program in 2011, 
and VA is expected to spend over $300 million on this program 
in fiscal year 2015. In designing the program, VA originally 
estimated about 4,000 caregivers would be approved for the 
program by September 2014.
    Based on that estimate, VA established a staffing model for 
the program, which included placing a caregiver support 
coordinator at each VAMC. In turn, each medical center was 
expected to provide physicians, nurses and other clinical and 
administrative staff with only limited reimbursement from the 
program to carry out essential functions, such as conducting 
medical assessments for eligibility and making quarterly home 
    As of November 2014, over 18,000 caregivers have been 
approved for their Family Caregiver Program, about 4-1/2 times 
the original estimate. The unexpected surge of caregiver 
applications, which has averaged about a 1,000 a month since 
the program begun, has caused severe workload problems at many 
VAMCs and has ultimately delayed some caregivers and veterans 
from receiving timely approval determination and program 
    For example, physicians and nurses at many VAMCs who 
already have heavy patient workloads are not able to timely 
complete all essential tasks needed to qualify caregivers for 
the program. Many VAMCs are unable to timely complete the 
application process for the program in the 45 days it is 
supposed to take. We found that 65 VAMCs were taking more than 
90 days to process applications. At one hospital we visited, 
they had over 400 unprocessed applications, some stating back 
to June 2013.
    Also, the workload of caregiver coordinators at VAMCs 
varies widely, ranging from 6 to 251 caregivers served. And at 
54 VAMCs, caregiver coordinators had more than 100 caregivers 
per each coordinator.
    Coordinators told us that the--caregivers told us that the 
amount of time that VA caregiver coordinators can devote to 
them is often crucial to their success in effectively assisting 
    The heavy workload at many VAMCs due to higher-than-
expected demand for caregiver services and the time needed to 
process caregiver applications and appeals, and provide other 
services is yet another example where VA is stretching 
available resources at its medical centers to the potential 
detriment of veterans.
    While the VA has taken incremental steps to address 
problems with the program, many VA facilities still face 
daunting challenges to best serve caregivers and veterans. At 
the program level, the VA needs to make major improvements. 
First, VA program managers need to readily access accurate and 
complete data to systematically and routinely monitor the 
effects of the caregiver program on the limited resources at 
its medical centers and make adjustments where necessary.
    Currently, the VA must struggle with the very labor-
intensive Web-based system that was developed quickly under 
then-existing constraints and was designed to manage a 
relatively low volume of information for what was conceived to 
be a much smaller program. The VA is uncertain how long it will 
take before a new system can be developed.
    Second, VA's caregiver program managers need to 
fundamentally reexamine the program and consider modifications 
that streamline the application and home visit processes, 
identify ways to improve staffing support for the caregiver 
program at VAMCs, and assess the overall impact that the 
program is having in improving the well-being of our Wounded 
Warrior veterans.
    Until these issues are properly addressed and resolved, the 
quality and scope of caregiver services and ultimately the 
well-being of veterans served will likely continue to be 
    This concludes my opening remarks.

    [The prepared statement of Mr. Randall Williamson appears 
in the Appendix]

    Dr. Benishek. Thank you very much, Mr. Williamson. Mr. 
Ramchand, please proceed with your testimony.


    Mr. Ramchand. Thank you, Chairman Benishek, Ranking Member 
Brownley, and members of the subcommittee for inviting me to 
testify today. My name is Rajeev Ramchand, I am a senior 
behavioral scientist at RAND, and for the past 10 years, I have 
been studying post traumatic stress disorder and suicides among 
servicemembers and veterans.
    Earlier this year, my colleagues and I turned our attention 
to the men and women who are caring for our Nation's wounded, 
ill and injured veterans, our veteran caregivers. Today, I am 
going to present five key findings from our research and 
highlight recommendations for better serving this population of 
hidden heroes.
    First, as were mentioned in the opening remarks, our 
Nation's veteran caregivers are a large group who services save 
the Nation billions of dollars each year. It is also a diverse 
group and a most pronounced difference is between those 
assisting veterans who served before and after September 11th.
    There are 4.4 million pre-9/11 veteran caregivers. These 
caregivers are mostly adult children taking care of their 
parents who are suffering from conditions associated with 
aging, like dementia or cardiovascular disease. In contrast, 
there are 1.1 million post-9/11 veteran caregivers. These 
caregivers are young men and women taking care of their 
spouses, neighbors taking care of a friend, or parents taking 
care of their children. These veterans they are caring for have 
conditions largely associated with their service in Iraq and 
Afghanistan, 60 percent have a behavioral health condition like 
    Organizations wanting to serve all veteran caregivers must 
offer services that meet the needs of both groups. In some 
cases, it may be better to avoid offering services altogether 
to certain sub groups, if it is not possible to do so with 
    Second, while there are over 100 organizations currently 
offering services to caregivers, not all programs are available 
to all caregivers. Programs like the VA Program of 
Comprehensive Assistance for Family Caregivers offers services 
exclusively to post-9/11 caregivers. However, there are many 
organizations across the country only available to caregivers 
assisting people over the age of 60 or with Alzheimer's 
disease, thereby excluding most post-9/11 caregivers.
    In addition, some organizations offer services only to 
family caregivers, which excludes 25 percent of post-9/11 
caregivers who are friends taking care of a buddy.
    Third, caregiving affects caregivers' health and economic 
well-being. Depression is significantly higher among caregivers 
than among non caregivers, and the time spent performing 
caregiving duties is directly linked to the likelihood that a 
caregiver will be depressed. Respite provides temporary breaks 
from caregiving duties and can directly mitigate the risk of 
depression among caregivers.
    In addition, over half of veteran caregivers have wage 
jobs, but their caregiving duties frequently require that they 
take unpaid time off work, cut back work hours or quit working 
altogether. Employers can adopt policies that protect against 
discrimination in recruiting, hiring and promoting caregivers. 
They can also accommodate caregivers by offering flexible work 
schedules and employee assistance programs. These efforts 
protect against some of the economic consequences caregivers 
face, but they also benefit employers to increase productivity 
and retention.
    This leads to my fourth point that supporting veteran 
caregivers on any--does not rely solely on any single entity, 
but requires coordinated action. This means that the private 
sector needs to work with the public sector, local, State, and 
Federal Governments also need to be coordinated. Within the 
Federal Government, DoD, VA, HHS and Department of Labor all 
play prominent roles. Coordination across these entities 
through things like the interagency workgroups or tasks forces 
and Federal commissions could enhance the alignment and quality 
of services to support veteran caregivers.
    The final point I would like to make is on the value of 
research. Very few studies exist or are currently being 
conducted that evaluate caregiver support services. Continued 
funding of organizations that serve veteran caregivers should 
be predicated upon evidence that the services they offer are 
providing value. This requires research to identify which 
services reduce caregiver burden and which are ultimately 
improving veteran care.
    There is a need to better support America's veteran 
caregivers. We may need to expand existing programs, but 
efforts are also needed to engage entities across the country 
to play closer attention to these hidden heroes.
    Thank you again for inviting me to testify. I am happy to 
answer your questions.

    [The prepared statement of Mr. Rajeev Ramchand appears in 
the Appendix]

    Dr. Benishek. Thank you very much for your testimony. I 
yield myself 5 minutes for questions.
    Mr. Ramchand, a couple of things you said perked my 
interest, the first one I want to mention is this coordination 
of all the sources of available help basically. How does that 
happen? How would you suggest that that happens? I mean that is 
a real problem as I see it as well and I am glad you brought it 
up, but where is that occurring. The VA doesn't seem to be 
leading in that. What is your idea?
    Mr. Ramchand. I think this idea of interagency work groups, 
especially between the DoD and the VA, if we just start there, 
eligibility requirements for the Scattle program and the VA 
program of comprehensive assistance to family caregivers, they 
have different eligibility requirements. So ensuring that 
people can have seamless continuity between when their 
caregivers serving as member of the Armed Forces, then a 
veteran, and then somebody into old age, an older veteran, 
because many of these post-9/11 veterans who require caregiving 
support are going to require that support for quite a long 
time. So I think that the need for coordination across these 
entities is profound, and I think that there are targeted ways 
and issues that they can address in that alignment.
    Dr. Benishek. Tell me how I should make that happen Mr. 
Ramchand? Explain to me how I can get the DoD and VA to have 
the same medical record. Do you understand what I am saying? 
How do I go about doing that, making that happen?
    Mr. Williamson, do you have any ideas?
    Mr. Williamson. Well, supposedly they have interagency 
working groups that would help make that transition, but Mr. 
Ramchand is correct, the DoD caregiver program has different 
eligibility requirements, probably more stringent than the VA. 
The DoD covers more different kinds of injuries and illnesses 
than VA, but basically making that transition from one program 
to the other can be difficult. Although, when we looked at both 
programs we didn't hear that as one of the major problems.
    Dr. Benishek. Mr. Ramchand, one of the other things you 
said was you mentioned that some time you thought it would be 
better if there was no assistance offered, I didn't quite 
understand what you meant there.
    Mr. Ramchand. If we can't offer services that meet the 
unique needs of certain caregiving groups, they can become 
frustrated by the organizations, lose confidence, stop seeking 
care altogether. So for example, if a program is currently 
designed only to serve persons with traumatic brain injury or 
Alzheimer's disease, including now in that program, a new group 
of caregivers who are taking care of people with very different 
injuries, mental health problems, if they can't serve this 
group with competence, if they don't recognize that this group 
of caregivers also have unique needs, are we really providing 
value by then opening the services to that group if we can't 
meet them where they are.
    Dr. Benishek. I understand. Do either one of you know 
exactly what the assessment is that the coordinator provides 
when they go--I assume that these people are doing home visits 
on a quarterly basis and then assessing what is going on by 
talking to the caregiver and the veteran, and trying to assist 
them with many other assets that they have. How long does that 
take? I am sure there is a lot of variability, but can you kind 
of talk about that a little bit?
    Mr. Williamson. Now, are you talking about the application 
    Dr. Benishek. I am actually talking about the coordinator 
who has 251 cases, are these coordinators going to the home and 
then assessing what is happening and the status of the veteran 
and the caregiver in recommending changes? What exactly happens 
in that process?
    Mr. Williamson. Nurses from the VAMCs actually go into 
homes and make quarterly visits--or are supposed to anyway--and 
do an assessment, provide counseling to the caregivers and the 
vets about their particular issues, medical issues.
    Dr. Benishek. Did you talk to caregivers?
    Mr. Williamson. Yes.
    Dr. Benishek. What was their----
    Mr. Williamson. Actually, most of them have much 
trepidation before their first visit because they think the 
nurse is going to come in and take away their benefits. 
Actually, the caregivers we talked to were very complimentary 
of that service, they thought it was a very valuable services.
    Dr. Benishek. Were there lots of complaints about not 
having access to the coordinator?
    Mr. Williamson. That--having access to coordinators is 
another issue, because--yes, caregivers told us that is a big 
problem in those areas where the caregivers have a large 
    Dr. Benishek. All right, I am out of time. Ms. Brownley.
    Ms. Brownley. Thank you, Mr. Chairman.
    Mr. Ramchand, you said in your opening comments that 
military caregivers are saving billions of dollars. And the VA 
says that they really can't recommend expanding the program 
until we really sort of wrestle with and look to expanding 
resources within the VHA budget.
    So my question is to you is does RAND have any indications 
that the program really will pay for itself, similar to the 
homeless programs by reducing the needs of medical care, any 
analysis relative to that?
    Mr. Ramchand. No, we don't. This was outside the scope of 
our project primarily we didn't evaluate the VA program, nor 
did we evaluate any other specific program. But in addition to 
that, not much research has evaluated those programs to make 
those conclusions and those cost benefit calculations.
    And so, I think that is why research is so important to 
start evaluating these programs and really showing that they 
are providing value, whether that is reduced medical visits, 
improve preventive care among caregivers themselves, because 
then we can actually start qualifying the savings these 
programs are having.
    Ms. Brownley. Has RAND evaluated any other caregiver 
programs outside of the VA to evaluate cost effectiveness and 
perhaps cost savings?
    Mr. Ramchand. Not to my--I can get back to you on that, but 
to my knowledge in the past 5 years when I have been heavily 
involved in this space, I haven't seen any research looking at 
    Ms. Brownley. Okay. Another question, I believe that your 
study estimated that there are 5.5 million military caregivers. 
In the VA's 2013 report, they estimate 49,000 to 105,000 
veterans eligible for fiscal year 2014, if the program was 
expanded to all the eras. So can you reconcile those figures 
for me at all?
    Mr. Ramchand. Well, our estimate of 5.5 million is a 
probability sample. We went out to households and looked 
specifically for military caregivers. Now, our criteria for 
quantifying the number of military caregivers was a little bit 
less restrictive than the VA's eligibility requirements for 
their programs. So for example, the VA it has to be a family 
member or somebody who is not related but who lives with the 
veterans or plans to live with the veteran, for example. We 
didn't impose that requirement, and in fact, many of our post-
9/11 caregivers don't live with the veteran.
    There is also restrictions on activities of daily living, 
the amount of time that people spend. We didn't have such 
requirements when we quantified the number of military 
caregivers. So we have somewhat of a loser definition than the 
VA is using to make the calculations of programming 
    Ms. Brownley. Thank you very much. And Mr. Williamson, 
given the VA's IT history that we have heard a lot about in 
this committee, what challenges do you believe the VHA will 
encounter in coming up with a strategic IT solution to address 
this data management issue?
    Mr. Williamson. Well, as you know, our prime recommendation 
was on developing an IT system that would provide data that 
would let the program better manage and monitor. We think that 
is vital.
    You are right, the history in the past in VA as far as 
developing and implementing IT programs has not been good in 
many respects. I don't think the program knows, we don't know 
when that new system that we recommended will be rolled out, or 
when it will be developed.
    They have designated a project manager, they haven't got 
the funding yet, they said they identified funding, but they 
haven't actually got that funding in hand yet. So----
    Ms. Brownley. Do you know if there are any off-the-shelf 
systems that private industry uses that would be similar?
    Mr. Williamson. I am not an IT expert. I think that is 
something you could probably ask VA and they could give you a 
better idea.
    Ms. Brownley. Thank you. I yield back, Mr. Chairman.
    Dr. Huelskamp. [Presiding.] I now yield myself 5 minutes 
for questions. I would like to follow up on the excellent IT 
questions for either witness, but a little background, if you 
would, Mr. Williamson, how did they create the system they have 
been using for the last 3-1/2 years? Can you describe that? And 
is it part of a current system that we found in this committee 
again, again has plenty of difficulties.
    Mr. Williamson. You are talking about the IT system?
    Dr. Huelskamp. Yes.
    Mr. Williamson. Well, when they designed the program--
again, it was designed for 4,000 caregivers--it was a small 
program and it was a Web-based system that didn't generate data 
reports that they need on a routine and systematic way. So they 
rolled that out and then when we came along and started this 
review in 2013, they realized and recognized, and we recognized 
that they just didn't have the data. Only recently have they 
generated a report that will give them an idea at each VAMC 
where the bottleneck and the problems with timeliness lie.
    Dr. Huelskamp. Thank you. I am looking at what the VA's 
reported on that and their health care utilization review for 
veterans talks about how the program has decreased hospital 
admissions by 30 percent and hospital length of stay by 2-1/2 
days. How do they generate that data if the system is as 
antiquated or doesn't generate that type of data? Do you know 
how they are providing that data or getting those numbers?
    Mr. Williamson. We didn't look at that report, but I think 
it was an actuarial-type of study that they did, and while we 
can't vouch for the numbers, because we didn't look at them, it 
is not surprising that you would see the benefits of the 
caregiver program in the sense of having a positive affect on 
hospital admissions and length of stay.
    Dr. Huelskamp. The gentleman from RAND, well-known for 
working with numbers, not yourself but the entity, any 
information or insight about trying to translate for us as 
policymakers, this is the impact of the program, and do you 
have any insight on that and how VA might have generated these 
particular claims?
    Mr. Ramchand. No, I don't have--again, like I said, we 
didn't look exclusively at that VA program. In terms of 
evaluation, and our comments about research, and the importance 
of research, it is not just for outside entities to look at 
organizations, but also continuous quality improvements that 
agencies can evaluate how they are performing, that is critical 
for all of these programs.
    Dr. Huelskamp. I appreciate that and look forward to the VA 
clarifying where the information and data arrived from. As the 
committee knows and the witnesses particularly others from the 
GAO pointed out that difficulties with an IT system. Those of 
us on the subcommittee and the full committee trusting the data 
we are given, in this case have no idea where it would come 
from given the integrated system in which this is continuing to 
function. So with that, I am going to yield back and next 
recognize Representative Kuster for 5 minutes of questions.
    Ms. Kuster. Thank you so much for being here today. I am 
very familiar with the caregiver issue, my father well into his 
70s was caring for my mother at home with Alzheimer's and was 
able to keep her at home for 4 years. But the physical toll on 
him then landed him in the hospital with hip replacement and 
other things.
    So what I want to focus in on is the cost benefit analysis. 
And I don't know if you got to this, in the private sector, 
there has been a lot that has been studied about keeping people 
in the home as compared to the cost of institutional expense 
with the 24/7 care. And I am wondering do you have any 
conclusions or was that outside the parameters of your study, 
given that we are guardians of the taxpayers funds. I consider 
myself a frugal Yankee for New Hampshire, how can we be saving 
going forward by helping to support caregivers and keeping our 
veterans in the home?
    Mr. Ramchand. That is an excellent question. It was outside 
the scope of our study to do such a cost benefit analysis, but 
what we did was look at the hours caregivers spent providing 
care and estimate what would that be if it were a home health 
aide attendant that was providing that level of care and that 
is where we came up with our estimates in the billions of 
dollars. And other studies that have looked at caregivers, the 
value of caregiving has also provided estimates in the billions 
of dollars of the value.
    In terms now of the benefits of programs, again, and I hate 
to keep saying this, but the research just isn't rich enough 
that shows--for example, if somebody has respite care, whether 
that is one day a week or 4 hours a week or a week every year 
that provides some time away, does that reduce their risk of 
depression? Does that reduce the risk of some of these chronic 
conditions associated with actually caregiving? You could start 
calculating that cost benefit, but the research is really 
needed to start looking at what these benefits are in real 
    Ms. Kuster. I appreciate that. And I think the respite--
just from our personal experience, the respite is critical, 
because without that, it is very difficult to keep going, but 
with that, I think you can keep going, you know. And given that 
particularly the family caregivers, there is a lot of love too 
that is not calculable.
    I am wondering did you look at the cost and I think you had 
a conclusion that statistically significant decrease in average 
monthly inpatient utilization by eligible veterans 
participating in comprehensive programs. Did you look at, 
again, the savings for, and I think this is your report--I am 
sorry, about how you are able to keep people from the hospital, 
from the institutional care, did you look at that issue?
    Mr. Ramchand. We didn't look at that. I don't know if that 
is from our report.
    Ms. Kuster. It may be a July 2013, is that--expansion of 
family caregiver assistance--this may be a VA report.
    Mr. Ramchand. That may be a VA report, sorry.
    Ms. Kuster. No, no. Do you have any recommendations about 
that, about eligibility, like in terms of who should be 
included, how do you make this determination? You said you used 
a broader definition. Would you recommend expanding the 
    Mr. Ramchand. I think in some cases--as part of our 
research we did conduct an environmental scan where we talked 
not just to government organizations, but nonprofits who are 
operating in this space. And eligibility criteria is something 
that they definitely struggle with, especially with serving 
military servicemembers and veterans.
    So for example, if an organization is geared toward family 
members, should they start including in their caregiving 
support services, neighbors and friends, or extended family or 
what constitutes the definition of family becomes an issue, 
does the person need to live with the individual. All these 
issues of eligibility become--so our recommendation in our 
report is for alignment and for careful consideration of 
eligibility. And when possible, it should not be really based 
on these factors, family membership or age of the person they 
are caring for, but really what the caregiver is doing, what 
their day-to-day routines look like in helping that veteran 
function in society.
    Ms. Kuster. Sure. Thank you so much. My time is up, thank 
    Dr. Huelskamp. Congressman, thank you. I now yield to 
Congressman Jolly for 5 minutes of questions.
    Mr. Jolly. Thank you, Mr. Chairman, I appreciate it. Thank 
you all for being here this morning.
    I belief in the RAND report, you mentioned 120 caregiver 
organizations, the VA just being one of them. General 
question--I understand asking an accomplished researcher to 
answer generally hopefully doesn't offend your senses, but the 
current performance within the VA, would you consider it a 
leading model, are there best practices at the VA as currently 
adopted or other organizations that perhaps you've seen as you 
have studied the issue for many years.
    Mr. Ramchand. We didn't evaluate the VA's program so I 
can't attest to how it is performing, or whether caregivers are 
satisfied. In terms of the scope of things that they offer 
compared to some of the other programs, it is one of the more 
comprehensive by its name.
    Respite care, only nine organizations we identified offer 
respite care. A stipend, only three organizations offer a 
stipend, the DoD, the VA and one nonprofit, respite services. 
So it does seem comprehensive relative to the other programs 
that we identified.
    Mr. Jolly. It appears to be one of the leading models, I 
would think. The challenges for either one of you would appear 
to be kind of the traditional challenges in terms of capacity, 
and resources. And I suppose that also limits some of the 
eligibility considerations as well. Would you identify those as 
traditional challenges?
    Mr. Williamson. Right, I think the capacity issues and 
workload issues getting through that--the cumbersome 
application process, the time it takes and so on. What I would 
say to the VA, we have evaluated the program and as far as the 
benefits it offers, in addition to the stipend and so on, the 
caregivers who is have no other insurance are eligible for 
CHAMPVA, which gives them health insurance, reimbursement cost 
for travel of the caregiver and veteran to medical facilities. 
There are a number of benefits. It probably is the, or one of 
the top models out there.
    Mr. Jolly. It is the greatest challenges in resources? So I 
get that the processing delays for 45 days or 90 days or so 
forth. Obviously there is always practices that can be improved 
in any management structure, but is it also a resource 
limitation for the program?
    Mr. Williamson. It can be, because again, the workload of 
the caregiver coordinators----
    Mr. Jolly. But is there also resources limitation for the 
    Mr. Williamson. It can be because the workload of the 
caregiver coordinators, that is a direct hindrance. If it is a 
high workload, it is a direct hindrance to the caregiver who is 
trying to contact him or her about questions they have which 
they need answered.
    Mr. Jolly. That question of scale, I guess a number of the 
VSOs have advocated for expansion of the current program, the 
VFW in particular talking about expanding to others outside of 
the post-9/11 generation, Wounded Warrior, I believe, or some 
of the others have talked about loosening some of the 
eligibility restrictions for making eligibility a little 
easier--if we are talking about resource limitations currently, 
those issues of expanded eligibility would seem unfortunately a 
far stretch right now, right? We would have to talk about a 
dramatic escalation and investment in the program?
    Mr. Williamson. As you are aware, the CBO last year issued 
a report, and CBO said if VA increased the eligibility for 
their Family Caregiver Program to veterans of all eras, that it 
would result in an additional 70,000 caregivers being eligible 
and result in $9.5 billion outlay over 5 years. Adding 70,000 
eligible caregivers to the current 18 would quadruple. It would 
in, many areas, caregiver coordinators and the VAMCs are 
already overwhelmed. So I think before we talk about expansion, 
it might be good to get VA's house in order of what they have 
going now.
    Mr. Jolly. And one last question just to clarify. Mr. 
Ramchand, you said this a few times, we don't actually have 
data to know if it is a net cost savings or not. Because you 
could make the argument if it is a cost savings ultimately, 
then expanding the program pays dividends, but we don't 
currently have a cost benefit analysis.
    Mr. Williamson. Not that I am aware of.
    Mr. Ramchand. Nor do we have really a cost saving benefit 
analysis of any caregiving support program.
    Mr. Jolly. Right. So we would first need that research to 
then determine whether or not expansion--first step would be 
the research.
    Thank you, Mr. Chairman, I yield back.
    Dr. Huelskamp. Thank you, Congressman. I yield to my 
colleague from Indiana for 5 minutes of questions.
    Ms. Walorski. Thank you, Mr. Chairman.
    Just to follow up on this question of resources, and that 
was my question as well--I love, I love home health care. And I 
think as we look at an aging baby boomer generation, and I 
experienced it in my own family of taking care of my father 
with hospice and with all of these community resources that are 
available. And my question was, and I appreciate the answer was 
this is not just a question of resources, because--would it not 
have to take a change in attitude of the VA itself to want to 
emerge into something that large? If the resources were 
available, would the VA do that today? Would they literally 
say, okay, here is the need, we have 5 million people, we have 
the resources to match it we are going to quadruple the 
program, hire the 70,000 providers. Is that something the VA 
would do or is that anywhere on their priority list from the 
work that you have done on the question?
    Mr. Ramchand. So you will have to ask the VA on their 
priority list. What we know from our research is that this one-
size-fits-all approach is not necessarily going to work. The 
program right now is really geared towards this group of 
younger veterans who have chronic conditions that will probably 
persist for a long time, the program may need to be adapted in 
very critical ways to care for, as you said, perhaps more home 
health aid. A group of people who may be suffering from 
conditions associated with aging, which may be very, very 
    Ms. Walorski. I also have a question about that, I have a 
constituent Darryl and Lisa Stump, in my district in Indiana. 
We just became involved with their case a week ago, and Mr. 
Stump passed away Saturday. And this is all over this issue of 
family advocacy, home health care, no other options, and the VA 
refused to pay virtually every option that would be on the 
books. They refused, they brought him back home. The wife his 
been caring for him by herself, had to quit her job, they are 
living on disability. She has become basically the caregiver, 
doctor, hospice worker, all of the above just because of being 
turned down so many times. He died.
    But one of the things that we have found in trying to 
advocate even for constituents is this letter of the law 
interpretation of HIPPA with the VA's interpretation. So the VA 
is there to provide all the direction, if they are 100 percent 
disabled Agent Orange, which this constituent was, wasn't 
receiving probably even half the services that were available 
to him just because of lack of knowledge or being turned down 
once by the VA and being too tired, no respite care, just being 
turned under by taking care of their loved one.
    We have so many issues with this issue if you are not the 
veteran calling in for help, you get can't get any medical 
advice, you get can't get any medical services. And basically 
the answer is I want to talk to the veteran. If the veteran is 
suicidal, I still want to talk to the veteran. If the veteran 
is not mentally competent, I still want to talk to the veteran.
    When it comes to this whole issue of somebody advocating 
for you, say it is your spouse or it is your neighbor, or it is 
your cousin being the advocate, what have you found it has been 
like with trying to get information out of the VA to even help 
the person that they are supposedly helping? Do they get a 
clearance with the VA to be able to access all the medical 
information, since oftentimes the spouse doesn't even know 
their name is on file.
    Mr. Ramchand. So the VA is probably a better place to 
answer when they assign somebody a primary caregiver what 
records that actually permits them to have access to. In our 
recommendation and our research, we heard the same complaint 
that you are raising a lot, and we did make a recommendation to 
make health care environments more caregiver friendly. This 
means really educating physicians and other health care 
providers about really kind of what HIPPA allows and doesn't 
allow to better care for their caregivers, because we know that 
talking to the caregivers to ensure that whatever is being 
prescribed for caring for that veteran can be adhered to, 
because oftentimes it requires the caregiver to actually follow 
through with the adherence.
    Ms. Walorski. Right. My concern for the pre-9/11 group is 
that oftentimes, especially if you are looking at Agent Orange 
you are looking at senior citizens, you are looking at seniors 
going from the baby boomer generation with a lot of the same 
kind of chronic conditions, same kind of chronic symptoms, 
dying of the same types of conditions because of Agent Orange.
    And it seems that--back to your point--if you could almost 
put groups together that says, you know, this is the kind of 
care these folks are going to need because quite often they 
have the same kind of symptoms, they have lung cancer, they 
have COPD, they have things that become so prohibitive and so 
they need a lot of the same kind of care. They need oxygen, 
they need regular interaction with doctors.
    I guess my final question is: When it comes to this issue 
of rural health, and rural telehealth, and the things that the 
VA is doing fairly well within rural areas, is that something 
that you see as a benefit, does that kind of roll into this 
whole thing of family members becoming advocates and trying to 
help keep them out of long-term facilities?
    Mr. Ramchand. In our research, we actually couldn't 
longitudinally look and see who was in a long-term facility and 
who wasn't. We really didn't see much difference between 
caregivers who live in rural areas and those who live in 
metropolitan areas, nor were we really able to evaluate whether 
the organizations currently serving caregivers are more 
prevalent in kind of rural areas or metropolitan areas.
    Ms. Walorski. I appreciate your research. I yield back, Mr. 
    Dr. Huelskamp. I recognize my colleague from Florida, Ms. 
Brown, for questions.
    Ms. Brown. Thank you. I guess let me just say that my State 
of Florida has a program that they work with the families and 
provide them like 20 hours of care to help relieve the 
caregivers. Is there some other programs around the country 
like this, because it is very helpful to relieve people? They 
can come in as sitters so they can go to the doctor, the 
grocery store and other things like that.
    Mr. Ramchand. Sure, that is respite care. There is around--
we identified in our organization, in our research of 120 
organizations, nine that are currently offering respite care, 
but we acknowledge that within States, there are lots of 
different respite options and respite groups for the State.
    So there are definitely programs out there. One of the most 
underutilized programs among caregivers relative to things like 
caregiving training or caregiver social support. And we heard 
in our conversations with people who are caring for individuals 
with mental health conditions like PTSD, that the respite may 
be need to be tailored or tweaked a little bit. So that it 
isn't necessarily that a stranger can come into the house and 
take care, or a volunteer, even if that person is vetted, can 
take care of an individual with these cognitive difficulties. 
It may need to be respite provided by a family member and 
provisions to pay for their travel to the house so that they 
can actually provide that care. So that we have to be really 
conscious--again, it is not this one-size-fits-all program.
    Ms. Brown. The implementation of the bill that we passed, 
how is that working?
    Mr. Williamson. Excuse me, now?
    Ms. Brown. The bill that just passed the Congress 
pertaining to caregivers.
    Mr. Williamson. It has--yes, the VA program has, for people 
that are in the Family Caregiver Program, has 30-day minimum of 
provision for respite care.
    Ms. Brown. I am trying to find out how is the program 
    Mr. Williamson. I am sorry, I am not understanding.
    Ms. Brown. Is the program working the way we intended?
    Mr. Williamson. Oh, okay, I got you now, I am sorry. The 
program, I think, because it has grown so quickly, is not 
working as efficiently as planned. It has still got a lot of 
the elements that you put into it, but what I would say is that 
it has grown so rapidly, and especially as people talk about 
expansion, that we need to--or the VA needs to think about 
fundamentally reexamining the process that they have set up, 
the staffing models, the eligibility requirements, the 
application process, the workload, benchmarks they have set for 
their coordinators, a number of things that need to be done.
    Ms. Brown. Are there some other recommendations that you 
would make?
    Mr. Williamson. Yes, we made several recommendations, and 
the VA is actually moving out to deal with them. The major 
recommendation we made was to come up with a new IT system to 
provide them better data to monitor and manage a program, that 
is one of the main things.
    The other aspect is once you have that data, then you have 
to have mechanisms and processes in place to analyze that data, 
identify bottlenecks, streamline, to have a strategy for 
dealing with those things. So those things are not, at this 
point, probably well thought out, because they are still trying 
to get the data, but I think down the road that is where they 
will have to go.
    Ms. Brown. Thank you. I yield back the balance of my time.
    Dr. Huelskamp. Thank you. I yield to Congressman Wenstrup 
for 5 minutes of questions.
    Dr. Wenstrup. Thank you, Mr. Chairman. Help me understand 
how this whole program is set up and working. In other words, 
is there a 1 on 1 between the doctor and the patient 
periodically to evaluate the level of care that is necessary? 
What type of care needs to be administered? You know, some 
people may only need assistance 1 hour a day, and other people 
may need 24 hours.
    Mr. Williamson. Correct.
    Dr. Wenstrup. So how is that decided? Who is the 
coordinator? What is the oversight? How often is it 
reevaluated, assuming some people might get better?
    Mr. Williamson. The coordinator at HVAMC will review 
applications for eligibility. After that determination has been 
made, the veteran will see a physician, usually his or her 
primary physician. And they will evaluate that veteran's needs 
for caregiving services.
    And the veteran then will be--if caregiver services are 
needed, they are put into one of three tiers, a high which is 
needing 40 hours a week, and a low which is needing about 10 
hours a week, and you get a stipend based on that amount.
    Then there is a home visit made to the veteran's residents 
where the caregiver resides. And that would be to evaluate 
whether the caregiver is capable, and the house is well 
equipped, it is safe and so on. So that is kind of the process. 
And then final determination is made. Training is provided to 
the caregiver, core training. And then after that, a nurse 
makes home visits every 3 months or so to evaluate how it is 
going, to answer any questions and so on. That is how the 
process works.
    Dr. Wenstrup. So when it comes to the caregivers, whether 
it is family or friends or whatever the case may be, as the 
caregiver, why do they need to be so restricted as far as HIPPA 
violations, et cetera, as far as really being part of the care 
and maybe calling with a question? Why can't we include them 
within the loop of being able to know what is going on with the 
person they are caring for, even though they are not maybe an 
RN or M.D.?
    Mr. Williamson. Yeah. Well, HIPPA is very strange sometimes 
in that regard, but 75 percent of the caregivers are spouses, 
and another 12 percent or so are family members. So where a 
spouse is involved, one would think that caregivers, if they 
are the caregiver, they should be involved with their spouse in 
decisions, and a lot of them have durable power of attorneys 
and have that kind of right. But we heard the same complaint 
from caregivers we talked to. I don't know why, there must be 
some reason perhaps the VA can shed some light on that one when 
they testify.
    Dr. Wenstrup. But you would recommend that it be addressed?
    Mr. Williamson. Oh, I think so, because a lot of people 
have mental issues, TBI or PTSD, and they have memory loss. 
They have real serious issues, and you need somebody there as 
your advocate, that is usually your spouse in these cases, and 
they are--the veteran may not be capable of doing that.
    Dr. Wenstrup. What are the maybe extreme differences that 
you are seeing from pre- and post-9/11 patients besides just 
aging differences? I know you mentioned Agent Orange effects 
and things like that. Are there other things that are 
drastically different between the two populations?
    Mr. Ramchand. Yes. They are different with respect to the 
tasks they are providing. So let's start demographically, they 
are younger, a lot of them are spouses. We also have this new 
group of parents taking care of their children who have been 
wounded, ill or are injured. The children are single so they 
don't have a spouse necessarily, so there are demographic 
differences. We see the people that they are caring for, the 
conditions they are caring for are very different, so as 
opposed to, as you said, the chronic conditions associated with 
aging. We have high rates of back pain, but also behavioral 
health conditions. There are differences in the tasks they 
perform. So they may not be helping as much with the post-9/11 
    Dr. Wenstrup. I am thinking more of war-related maladies.
    Mr. Ramchand. Sure. So the post-9/11 caregivers are 
generally taking care of somebody who has a condition that is 
related to service relative to the pre 9/11. So we asked in our 
report when we surveyed what conditions did the people have, 
and for each condition they checked, whether it was related to 
their service. And so, it is not the most precise measure, but 
at the same time, overwhelmingly, the post-9/11 caregivers are 
caring for conditions that are war-related and the pre-9/11 
caregivers--many of them have hearing loss that they associate 
with war, chronic pain that they associate with their service, 
but many are also caring for these comorbid conditions that 
happen as you age.
    Dr. Wenstrup. True. Just one quick question, you talked 
about, there has been talk about needing more research. Is most 
of the research that you think is necessary more of cost 
benefit type of research? What other things might be included 
    Mr. Ramchand. So the cost benefit, the evaluation of 
programs, make sure that they are providing value and also 
longitudinal studies of caregivers and veterans themselves. Our 
study was a cross sectional kind of snapshot, but we think that 
these things will change. We really talk about a spiraling or a 
seesaw effect where if a caregiver's health is affected then it 
affects the care that they provide the veteran, and it worsens 
their health, and then their demands become greater on the 
caregiver. So you see it somewhat spiraling out of control 
without intervention or without stopping.
    Dr. Wenstrup. Thank you, I yield back.
    Dr. Huelskamp. Thank you, Congressman. Any additional 
questions of this panel? Ms. Kuster.
    Ms. Kuster. I just want to make a quick comment and it may 
be more appropriate for the next panel. I don't see why they 
don't have a medical authorization. There is not a problem with 
HIPPA. You can sign a medical authorization to authorize any 
person. It doesn't have to be a family member, it is a legal 
document, you are entitled to view my records. So we can ask 
the VA, but I think we can get to the bottom of that.
    Dr. Huelskamp. Thank you, I appreciate the panel for being 
here and your hard work, you are now dismissed, or excused.
    Now welcome our second and final panel to the witness 
table, joining us from the VA is Dr. Maureen McCarthy, Deputy 
Chief, Patient Care Services for the VHA. Dr. McCarthy is 
accompanied by Michael Kilmer, the chief consultant of Care 
Management and Social Work, and Margaret Kabat, Acting National 
Director for the Caregiver Support Program. Thank you for being 
    Dr. McCarthy.

                        VETERANS AFFAIRS


    Dr. McCarthy. Chairman Huelskamp, Ranking Member Brownley, 
and distinguished members of the House Committee on Veterans' 
Affairs, thank you for the opportunity to discuss VA's efforts 
regarding our Caregiver Support Program. I am joined today by 
Mr. Michael Kilmer, chief consultant for care management and 
social work services, and Ms. Meg Kabat, acting national 
director of the Caregiver Support Program. And thank you, 
Chairman Benishek.
    Caregivers truly are a special group of people, as any one 
of us who has had a loved one needing caregiver support well 
knows. Their sacrifices and stresses are many, and they clearly 
deserve support in their roles.
    Central to our mission in caring for those who have borne 
the battle, VHA recognizes the crucial role that family 
caregivers play. They are partners in helping veterans as they 
recover from injury and illness, in the daily lives of veterans 
in the community, and in helping veterans remain at home.
    VA is dedicated to providing caregivers with the support 
and services they need. The Caregivers and Veterans Omnibus 
Health Services Act of 2010, also referred to as the Caregiver 
Law, has allowed VHA to provide unprecedented support and 
services to approved family caregivers of eligible veterans.
    We now have at least one caregiver support coordinator at 
every medical center, a national caregiver support line, a Web 
site dedicated to family caregivers, and a peer support 
mentoring program. Last year we began a Building Better 
Caregivers program and now even have an alumni group for the 
    For approved family caregivers of eligible veterans who are 
seriously injured in the line of duty on or after 9/11, the 
Caregiver Law allows for additional services. These include a 
stipend of support to the caregiver, enrollment in CHAMPVA 
health care if the caregiver has no other health care, and, if 
eligible, expanded respite care benefits, mental health 
services, and travel benefits.
    In this law, caregiver financial assistance is to be 
provided only if the Secretary determines it is in the best 
interests of the eligible veteran to do so. That has been key 
in establishing caregiver support as a treatment decision. The 
law specifically states the relationship between VHA and the 
caregiver is not an employment relationship, and it 
specifically does not create an entitlement to any assistance 
or support. This is consistent with the intent of maximizing 
independence of the veteran, and therefore requires ongoing 
reevaluations of the continued need for caregiver support.
    VA has been accepting applications for the program of 
comprehensive assistance since May of 2011. By the end of 
fiscal year 2014, there were over 17,500 family caregivers 
actively participating in the program. Over 20,000 have 
participated since the program began.
    For the role of caregiving, VA has trained more than 22,000 
family caregivers of post-9/11 veterans and has provided 
CHAMPVA medical coverage to more than 4,800 primary family 
caregivers who did not have other healthcare coverage. By 
October 31, over 39,000 applications had been processed.
    The goal of the comprehensive program for assistance is to 
help veterans reach their highest level of functioning. GAO was 
recently asked to examine VHA's implementation of this program. 
The report examined how VA is implementing the program, and 
resulted in three recommendations.
    In response to the first recommendation, VA identified 
fiscal year 2015 funding to support the development of a new IT 
solution. Additional steps are also being taken to stabilize 
the current system, allowing the field to improve data capture 
and data integrity. This will permit the program office to 
better monitor workload across the country and identify needs 
and best practices.
    For the second recommendation, VHA made the policy decision 
to use home visits to monitor the well-being of program 
participants, as is contemplated under the Caregiver Law. Due 
to feedback from veterans, their caregivers, as well as the 
field, we established a work group to evaluate our policy for 
monitoring the well-being of program participants. The work 
group is currently meeting, and we anticipate formal 
recommendations for changes this spring.
    To address the third recommendation, we established a 
Partnered Evaluation Center. This center reviews the program's 
impact on the health and well-being of both caregiver and 
veteran participants. VA anticipates preliminary findings from 
this group will be available in mid-2015.
    As you know, the RAND Corporation submitted its Hidden 
Heroes report in March. Their recommendations affirm the 
current services and supports we offer. The valuable input from 
both GAO and RAND provide us with further insight into the 
Caregiver Support Program and allow us to better understand how 
we can strengthen the support and services we provide.
    In September 2013, we sent the Expansion of Family 
Caregiver Assistance Report to the committee, as requested. VHA 
believes the expansion of the program to caregivers of eligible 
veterans of all eras would make the program more equitable, but 
VA would need additional resources to fund the expansion.
    In conclusion, Mr. Chairman, caregiving is truly a labor of 
love, and VA recognizes the crucial role that caregivers play 
in helping veterans remain in the communities they defended, 
surrounded by those they love. VA is dedicated to promoting the 
health and well-being of caregivers who care for our Nation's 
veterans through education, resources, support, and services. I 
thank Congress for your support as we continuously improve the 
services and supports we provide for America's veterans and 
their caregivers.
    This concludes my testimony, and my colleagues and I are 
prepared to answer any questions you or other members of the 
committee may have.
    Dr. Benishek. Thank you, Dr. McCarthy. Appreciate your 

    [The prepared statement of Dr. Maureen McCarthy appears in 
the Appendix]

    Dr. Benishek. I will yield myself 5 minutes for questions.
    So how long is it going to take to get this caseload number 
for the coordinators into shape here? Two hundred fifty-one 
seems like an excessive number. So can you give me a date when 
that is going to be ready?
    Dr. McCarthy. So as I understand your question, you are 
saying there is a variety of caseload numbers that the various 
what we call the CSCs, the caregiver support coordinators 
manage, and some manage more than others, and you are asking 
how long it will take?
    What we have done is we have monitored the workload, we 
have increased by over 70 percent the number of caregiver 
support coordinators, we are working with the individual 
medical centers and helping with the processing of the 
    Dr. Benishek. What is the plan? I mean, it is very nice 
that you are here and you stated all very laudable goals in 
your testimony, but from what I understand the facts, that 
there is backlogs, at certain centers up to 400 people who have 
applied and hadn't had a response. There are some coordinators 
that have 251 people on their caseload. That seems like an 
excessive amount. And all the things you said are great, but 
when is this going to get fixed, is the question I am asking.
    Dr. McCarthy. Well, sir, we did mention that there were 
over 39,000 applications filed and 18,000 approved. As of 
November 5, there are 3,400 that are pending. Of those, some 
are pending less than 45 days. That would be about 36 percent.
    What the application process involves and why people 
perceive delays is that that processing in the application 
requires the veteran and the caregiver to apply, it requires an 
evaluation by the caregiver support coordinator, and as I 
mentioned, it is a treatment team issue. So the treatment team, 
the primary care team that is involved with the veteran has to 
make a decision about whether the support for the caregiver 
would be beneficial to the veteran. So all of that does take a 
significant amount of time.
    There are some applications that are pending, and we are 
aware of that and we have offered support to the individual 
facilities that have those delays. But it is a cumbersome 
process, because we want to make sure that this is consistent 
with what is best for the treatment for the veteran.
    Dr. Benishek. According to the VA's report to Congress last 
year, the potential expansion of the family caregiver program 
to pre-9/11 veterans under the current resource framework poses 
the risk of compromising resources needed for its core veteran 
health mission. And you mentioned too that additional resources 
may be needed in your testimony today.
    Taking that and the findings that we had today from the GAO 
and the RAND into account, do you still believe that the 
expansion of the family caregiver program to pre-9/11 veterans 
is operationally feasible and advisable?
    Dr. McCarthy. I believe it is operationally feasible and 
advisable, but I do think it is going to take some time to make 
it happen. We wouldn't want to set up a program ahead of when 
we have the resources available to make it happen as seamlessly 
as possible for the veterans and the caregivers. So it would 
take additional caregiver support coordinators, but in addition 
we would really need to look at resources about funding the 
stipends and the other kinds of support services that are 
available to them.
    Dr. Benishek. Did you have an estimate, then, in the number 
of veterans that would potentially be in the program as it 
exists today? I mean, because obviously your first assessment 
for the number of veterans was off by a factor of four, as I 
understand. So what is the potential for the numbers in the 
next, say, 4 years?
    Dr. McCarthy. For our current program as it is right now?
    Dr. Benishek. Yes.
    Dr. McCarthy. Well, the number of applications we are 
getting every month is 500. We had anticipated that the number 
of applications would eventually reach a plateau, but that 
hasn't happened. The issue about being really catastrophically 
disabled, we had anticipated that it would level off, but some 
of the signature wounds of this war are things that may not 
really show up till later. We have very many veterans with 
mental health conditions who are eligible for the caregiver 
program, and I am not sure we had anticipated that there would 
be that many.
    But nevertheless, that is what we are here to provide, and 
we are doing what we can. We have IT solutions in the works, we 
have reorganization of how we will do the evaluations of the 
program and so forth in the works, and we do have the research 
ongoing to identify what are the evidence-based treatments that 
    Dr. Benishek. Thank you, Dr. McCarthy.
    I will yield 5 minutes to Ms. Brownley.
    Ms. Brownley. Thank you, Mr. Chairman.
    Dr. McCarthy, I wanted to just ask, in the earlier 
testimony I think it was uncovered that probably the first 
thing that the VA should probably do is research and to look at 
the cost-benefit and trying to understand what the potential 
savings might be vis-a-vis a caregiver-in-home situation versus 
institutionalization. And so I am just wondering if that is in 
the plan, to begin to do that analysis?
    Dr. McCarthy. Yes. Thank you. And I wanted to clarify 
something. First of all, we do have this partnered research 
group going on with our QUERI organization, which is part of 
our Office of Research and Development.
    I did want to clarify the source of the data for the 
information about decrease in admission rates. That was from 
the Office of the Actuary and it was a retrospective look back 
for a particular veteran 6 months before the caregiver program 
served that veteran and the caregiver and 6 months later, and 
that was actually where the data came from, from that analysis 
that showed a 30 percent decrease in inpatient admissions and a 
2.5 decrease in length of stay for those that were admitted.
    But, besides that, yeah, the QUERI program is ongoing, and 
we are anticipating some information from them in spring of 
this year.
    Ms. Brownley. In spring of this year?
    Dr. McCarthy. Yes, ma'am.
    Ms. Brownley. And some kind of information, what does that 
mean exactly? Will we have kind of a full assessment and really 
understand what the cost-benefits are in dollars and cents so 
that we can begin to evaluate the current program and begin to 
evaluate expansion of the program?
    Dr. McCarthy. I will turn to Meg.
    Ms. Kabat. Thank you. So we have partnered with VA 
researchers at the Durham VA, and they are doing this work for 
us. It will involve looking at healthcare utilization, actually 
comparing the healthcare utilization of similar veterans who 
are not in the program to those who are in the program. So 
there is that comparison group, not just straight pre and post.
    I am not a researcher, I am a social worker, but I am told 
by our researchers that it takes quite a period of time to 
really have a very strong cost-benefit analysis. But that is 
one of the goals, is to really begin to look at the full cost, 
so to look at the cost of all the services that we are 
providing, but also to look at the cost of time of the staff 
involved and all those kinds of pieces.
    Their full report will be available in the spring of 2016, 
but in 2015 we will begin to see some of the beginnings of 
those results. There will be a survey of caregivers 
participating, so we will be able to get feedback from them as 
well about what services they believe are the most helpful.
    Ms. Brownley. Thank you.
    Dr. McCarthy, you mentioned, I think, in your testimony in 
terms of one of your recommendations in terms of moving forward 
that you reached out to some VSO organizations. Certainly in 
our oversight responsibilities here on the committee we have 
talked a lot about accountability in various VA programs across 
the spectrum, and I think for all of us the ultimate threshold 
for a program that is working well is veteran satisfaction.
    So I am very curious to know what kind of outreach you are 
doing to VSOs in terms of monitoring and evaluating and 
modifying. It sounds like you are making some changes 
forthcoming. But if you could describe to me exactly what you 
are doing and how you are integrating working with the VSOs and 
veteran satisfaction and the veterans that we are serving in 
this program.
    Ms. Kabat. We certainly meet with VSOs on a regular basis, 
we participate in conferences and work groups with many 
different VSOs. With the advent of the Elizabeth Dole 
Foundation, my office is very involved in working with the 
Elizabeth Dole fellows, and meet with them on a regular basis 
to get their feedback and talk to them about various aspects of 
the program and get their input as well. So we really welcome 
that kind of interaction, as well as nonprofit organizations 
who are focused on caregiving, especially for those who are 
maybe caregivers of older veterans, because we want their input 
as well as we expand our services, not just the Program of 
Comprehensive Assistance, but other services that we provide to 
that group as well.
    Ms. Brownley. Thank you.
    And I yield back.
    Dr. Benishek. Dr. Roe, I will yield 5 minutes for your 
    Dr. Roe. Thank you.
    And thank you all for being here today, and I am sorry I 
missed part of your testimony. But would you, Dr. McCarthy, 
would you walk me through, if I am a veteran family, for the 
record, just walk through how I would go about this process of 
obtaining the family caregiver and how long it actually takes?
    Dr. McCarthy. So typically this might start if you were 
still in DoD. We have field-based individuals who assist with 
the process as it begins in their transition from DoD to VA.
    The name of those individuals, Michael?
    Mr. Kilmer. Our VA liaisons for health care.
    Dr. McCarthy. Right, they are called our VA liaisons for 
health care, and they start the process as it goes forward.
    What the individuals need to do is complete an application, 
both the caregiver and the veteran, or servicemember at that 
point, who needs the care. That application is reviewed by the 
caregiver support coordinator. The caregiver support 
coordinator looks at issues such as eligibility, and 
specifically related to the eligibility as defined in the 
legislation, and then also refers the case then to the 
treatment team for the veteran, which makes an assessment if 
providing this kind of support for the caregiver is consistent 
with the treatment goals for the veteran. And this is as the 
veteran is now transitioning into VA. It would be the VA 
primary care team that would make that assessment.
    Dr. Roe. So how long would that take?
    Dr. McCarthy. I don't have an exact number.
    Dr. Roe. Is it a month or 2 months or 6 months, or how 
    Dr. McCarthy. It would be several months typically, but 
there are some that have taken longer.
    Dr. Roe. Why does that take so long?
    Dr. McCarthy. We don't have the actual roadblock kind of 
plots that we want to have, and our new IT system will help us 
with that. But what we are aware of is that sometimes there are 
issues with both the veteran and the caregiver completing the 
application, and sometimes there are issues with the caregiver 
completing some online training. But often it is that the 
treatment team has to actually make the visit and ensure that 
the veteran and the caregiver, it is a good fit for the 
treatment plan for the veteran.
    Dr. Roe. So if I am a veteran in Pinedale, Wyoming, and I 
try to get help, and have a family caregiver, it may take me 
months, may take a year, right?
    Dr. McCarthy. Well, I am not sure. I am sorry. I don't know 
where Pinedale, Wyoming, is, but I do know that there is an 
elaborate kind of telehealth program that reaches out through 
that VISN, and some of the care is provided directly and some 
of it----
    Dr. Roe. Look my question is, if I am a veteran out there, 
it doesn't matter, it is 100 percent me. So it is me and my 
family, I need the help. How long does it take to get help, is 
what I am saying? It takes a long time, apparently. I think 
that is what Dr. Benishek was asking. And in one VA, I was 
noticing there were 400 people, that we have a program here, it 
is like the Post-9/11 GI Bill, it doesn't do any good if you 
can't get it. And that got implemented pretty quickly. It is a 
great program, I think. But if it is not being implemented for 
veterans, it doesn't do them any good to have a name out there 
and they can't benefit, utilize it, I mean.
    Dr. McCarthy. I do to make note that the stipends that are 
paid to the family members are retroactive to the date of 
application. And so, yes, there are delays, but the financial 
support they need, they need at the time----
    Dr. Roe. At the time.
    Dr. McCarthy [continuing]. I recognize that, but we do have 
the ability to do it retroactively.
    Dr. Roe. I know on the homeless program, the coordinators 
are 25 to 1, it would be 1 coordinator up to 25 homeless 
veterans that they would see. And I agree with Dr. Benishek on 
this, is that up to, whatever, is it 250, there is no way in 
the world that a coordinator could coordinate that care for 250 
people, I don't think.
    So is it just a lack of hiring people who are qualified 
social workers, for instance, that are qualified to do this, or 
there are not enough of them, or what is the hold up on that?
    Ms. Kabat. I think there are various pieces. I think it is 
important to remember that the caregiver support coordinator is 
not a member of the veteran's treatment team. So the veteran 
may be receiving assistance from a whole cadre of other 
providers, case managers and others within the system.
    We are also doing other things besides hiring additional 
caregiver support coordinators. We have expanded access, for 
example, to our current IT system to administrative staff 
within VA at the discretion of the medical center so that the 
caregiver support coordinator is really focused on moving those 
applications through the process.
    The other thing that we have done at the national level is 
funded caregiver support programming, so building better 
caregivers that Dr. McCarthy mentioned, our peer support 
mentoring program, all of those kinds of things that our 
caregiver support line provides, education and training, so 
that the caregiver support coordinators can refer caregivers to 
those kinds of supportive services and continue to focus on 
that application.
    Dr. Roe. My time has expired, but as I understand it, the 
veterans are very pleased with this once they are in the 
program. Am I correct on that?
    Dr. McCarthy. That is our impression.
    Dr. Roe. What is the possibility of the capacity of the VA 
to expand this? Because, look, I am a Vietnam era veteran, and 
we are getting old, fast, and the World War II veterans are 
already there, and it is not to them. If you expanded it, do 
you have any idea the scope of that if it were to be expanded 
to pre-9/11?
    Dr. McCarthy. We did this report in September of 2013 that 
we submitted, and calculating the actual numbers is 
challenging. We went one route and got one range, and we went 
another route using a different kind of calculation based on 
who needs aid and attendance through the VBA program and so 
forth, got another. We estimated somewhere between $1.8 billion 
and $3.8 billion, but we don't have an exact number, just like 
we didn't when we started this program.
    Dr. Roe. Okay. Thank you. I yield back
    Dr. Benishek. Thank you.
    Ms. Brown, 5 minutes for questions.
    Ms. Brown. Thank you.
    I guess if you have never experienced a caregiver, which I 
have, their role, like you say, is life saving to the family, 
whether it is helping a person with their medication, their 
personal hygiene, making sure they eat their meals on time. It 
is just all kinds of issues. And I think one of the things, as 
we go back, and the DoD, starting when you release that person, 
to make sure that that caregiver is a part of the team. And you 
indicated that many of the players are the wives, the spouses, 
or their parents. How come we can't have a training program 
working with them from the beginning so that there would not be 
this delay?
    And I have to mention that the State of Florida really does 
have a good program in this area and that the caregivers, they 
have to meet so often and they go through a certain amount of 
training. Have we thought about doing something like that?
    Dr. McCarthy. We do. And we have an excellent program. We 
partner with Easter Seals, which teaches the program, the main 
program that orients the caregivers. And then we have the 
online training, we have all kinds of online resources, 
caregiver support resources, we have all kinds of things like 
    But, yes, there is access to that training right away. And 
they don't have to be post-9/11 caregivers to have access to 
that. If you go to www.caregiver--all one word--.va.gov, you 
can have access to a lot of resources.
    Ms. Brown. I know you all think everybody have online.
    Dr. McCarthy. I know.
    Ms. Brown. I know. I know everybody has it. But some people 
are not online----
    Dr. McCarthy. Right. So I have the phone number to call for 
caregiver support. And I was trying to figure out why we don't 
have a mnemonic to make it easier, but I will just read it to 
you. It is 1-855-260-3274, and that is our caregiver support 
line. And that is actually a----
    Ms. Brown. Try it again.
    Dr. McCarthy. Yes, ma'am. I am sorry. 1-855-260-3274. And 
so that is a great starting point. We get over 200 calls a day 
in there, and they can help with finding the right caregiver 
support coordinator.
    The online Web site does it by ZIP code, so that would help 
the family in Wyoming, but also the caregiver support line 
would help with access to resources.
    Ms. Brown. But you mentioned, someone mentioned earlier 
that many of the caregivers were spouses or parents, and they 
are not a part of the medical team, but they are there from the 
beginning. So I don't understand why it can't be interfaced at 
that point.
    Dr. McCarthy. Well, we have a release of information 
program. Every medical center has an office, but there are 
forms that people fill out for release of information.
    I am a psychiatrist in the VA, and the patients that I 
treat, I encourage them up front to have them sign a release of 
information so I can speak with their family members, and that 
has worked out extremely well.
    I think it takes some planning. It is also part of our 
application process for caregiver support to have those 
releases of information signed, which should allow for that 
kind of communication.
    Ms. Brown. And so you are having that with the DoD from the 
very, very beginning when they are transferring out of DoD into 
    Dr. McCarthy. I am going to yield to Mr. Kilmer.
    Mr. Kilmer. That is a very good question. We actually have 
43 nurse and social workers embedded at 21 military treatment 
sites, and they are there to serve as that bilingual bridge 
between VA and DoD and to serve as that transition from DoD to 
VA as a member transitions from being an active duty 
servicemember to being a veteran. So they proactively identify 
people who are eligible for the Caregiver Support Program, and 
that application process is a part of that referral process 
over to the VA.
    Ms. Brown. I guess, when they leave DoD at one point, they 
don't feel that they necessarily need the Veteran 
Administration at a certain time, but now we are making it more 
mandatory, or I don't know how we are doing it.
    Mr. Kilmer. That is a very good observation, and it is 
something that we see on a daily basis, because obviously if 
you are being medically separated from the military, let's face 
it, you really don't want to leave. As a veteran myself, I know 
what it is like to be in service. And to leave under conditions 
where you are being medically separated, probably involuntarily 
so, you really don't want to go to the VA, you want to stay 
with your military brothers and sisters.
    Ms. Brown. Right, right, right, right.
    Mr. Kilmer. So those are conversations that our VA liaisons 
have quite frequently and are very sensitive to, even as to 
when to engage in that conversation of talking about coming 
over to the VA.
    Ms. Brown. Okay. I yield back the balance of my time, 
    Dr. Benishek. Dr. Wenstrup.
    Dr. Wenstrup. Thank you, Mr. Chairman.
    This program, like so many others, always have the best of 
intentions in taking care of our troops any way we can and 
things sounds good, and then we encounter problems, whether it 
is a shortage of providers or whatever the case may be, 
funding, whatever the case may be. We always want to make sure 
that it is working. And we talked a little bit today about 
further research being needed to really evaluate the situation.
    And I think on that, we don't necessarily have to research 
it on a whole nationwide level, but start small, maybe pick a 
couple of areas or regions where we can actually do an 
evaluation of the effectiveness and try and find the flaws and 
then see if it is nationwide, rather than taking on a research 
project of the entire Nation, I think would be to our benefit. 
And we should be looking at the quality of care, the quality of 
life pre and post the caregiving situation. And we should be 
able to tell pre and post what the cost is, for example, per 
patient, per year, per diagnosis, and then what the after cost 
is once they have gotten the care.
    And those are the things that I think we can focus on in a 
small level, in small regions, and if we push forward in that 
direction, we can then try to craft and perfect the situation 
throughout the country. But I would hope that we are not 
looking at it like, oh, we want to take on this project of 
research and cross the entire Nation, but maybe take a small 
section and see how we can make it better.
    That is just a suggestion I have, and I will welcome any 
thoughts you may have on that.
    Dr. McCarthy. I appreciate that very much. And I also 
appreciate our colleague from the RAND Foundation who talked 
about research will require long-term kind of evaluations. I 
mentioned that we expect a report in the spring, and obviously 
it is not that kind of long-term evaluation, but I will mention 
that some of the scales that people use for caregiver burden, 
the Zarit Burden scale and so forth, are things that are used 
in this program as well. So there is that kind of data that can 
be tracked as well.
    Dr. Wenstrup. Yeah, especially capturing what we have 
before they begin the program too and then what we see 
    Dr. McCarthy. Yeah.
    Dr. Wenstrup. Thank you. I yield back.
    Dr. Benishek. Ms. Kuster.
    Ms. Kuster. Thank you, Mr. Chair.
    And thank you, all of you.
    I want to start by commending, this sounds like a pretty 
impressive program to get off the ground, and certainly the 
goal of it. I had spoken previously about a personal family 
situation in my family, and my father, a World War II vet, who 
had cared for my mother at home. So I am very, very familiar 
with the limitations and the complications of home care, but I 
think it is significant, and I want to commend my colleagues 
for recognizing and passing this law, the value of the 
caregiver. I think previously this was uncompensated entirely.
    Having said that, I want to focus in, this is from the 
Wounded Warrior testimony that we received, or comments that we 
received, about wide variability in determinations of 
eligibility and support. I am curious. So 39,000 filed, 18,000 
had been approved. That seems like a relatively high rate of 
ineligibility. Like, a family that has gotten to this place 
that is asking for this kind of help, I think we want to err on 
the side of trying to be supportive. I mean, the bottom line to 
this entire program is that these people have gone off to 
defend our freedom, and none of these families anticipated this 
change in their lives.
    So I am just wondering, and in particular their testimony 
is very interesting about the distinction, this is TBI, PTSD, 
that type of thing, and how that impacts the hours of care that 
are required, the type of care that is required, supervision. 
We talk a lot in this committee about suicide risk. Could you 
just comment on what the denials were and sort of how we can do 
better with that?
    Dr. McCarthy. Certainly. Thank you for that question. Our 
veterans are sometimes very strong at communicating to us what 
they want. We have a high rate of denial for pre-9/11 veterans 
who have wanted to file applications to make the point that 
they feel like the services should be available to them as 
    Ms. Kuster. So it is a message to Congress. Well, consider 
it received.
    Dr. McCarthy. Yeah.
    Ms. Kuster. Okay. I can certainly understand.
    Dr. McCarthy. That is our largest group. In addition, we 
have denials related to--well, let me let Meg handle this, 
because she analyzes this regularly.
    Ms. Kuster. Sure.
    Ms. Kabat. We also have a high number of denials related to 
illness, because illness is not included in the eligibility.
    Ms. Kuster. So it needs to be service related rather than--
    Ms. Kabat. No. The legislation actually states an injury in 
the line of duty. So a veteran who has a significant illness 
cannot participate in the program unless they also----
    Ms. Kuster. Even if it is service connected?
    Ms. Kabat. Correct. Right.
    Dr. McCarthy. Could we give an example of that?
    Ms. Kuster. We should make a correction then.
    Dr. McCarthy. So our PVA organization partners have 
advanced this and we support what they are saying. The spinal 
cord injured veterans are allowed to be part of the program, 
but veterans who suffer terribly with amyotrophic lateral 
sclerosis, ALS, and multiple sclerosis are not eligible for the 
program by definition. We would support amending the 
legislation to include them.
    Ms. Kuster. Okay. That sounds very important. Are there any 
other categories like that?
    Ms. Kabat. No. I mean, certainly there are caregivers who 
apply, and we spend a lot of time, caregivers and veterans will 
spend time talking about the importance of really helping 
veterans get to their highest level of independence. And 
sometimes caregivers and veterans choose not to participate 
because they came in with the idea that this was another 
benefit in the suite of benefits that VA provides and are not 
interested in the home visits and other kinds of things. So 
people do withdraw applications as well.
    Ms. Kuster. Thank you. And the other piece of this, and it 
is connected, but it is the calculation of the stipend. And 
obviously there is a bottom-line impact, so I am happy to have 
the VA be frugal with taxpayer dollars, but I am concerned 
about an issue that they raised with regard to because they 
have been seeking independence and they have been seeking to 
manage the activities of daily living and maybe made 
significant improvement with regard to their physical 
disabilities so that they don't need assistance, and yet they 
still have mental health issues, outbursts, suicidal 
tendencies, depression, whatever, that they need the continuum 
of care. And it sounds like that issue may need to be addressed 
in the regulations.
    Dr. McCarthy. So first off, it is really hard for some 
veterans to understand that this is not a benefit or an 
entitlement, but it is part of their treatment plan. And it is 
also important to keep in mind that the focus is on 
independence. And so when people drop down one of our three 
tiers, it is not that we are trying to penalize them or have 
them be less compensated, have the caregivers be less 
compensated, but it is more a focus on the increasing 
independence that the veteran may or may not be acquiring. So 
if the physical needs change or if the mental health needs 
change, then that would necessitate, as part of the 
reevaluation, moving through the tiers.
    Now, inherent in the tiers are some problems. We calculate 
things based on 40 hours. And any one of us that has lived with 
a situation where a caregiver is required knows that it is many 
more than 40 hours, particularly for a spouse or a family 
member with whom the veteran lives.
    But that said, we don't want to foster dependence, and so 
that is why it is a complicated program as a treatment decision 
fostering independence and yet supporting caregivers. The whole 
goal is to keep the folks out of institutions and at the same 
time encouraging independence.
    And so we may get into disagreements about it, but when we 
reviewed the legislation and reviewed the implementation, it 
really is focused on the independence of the veteran and 
fostering that independence and providing the caregiver support 
to help keep them as independent as possible.
    Ms. Kuster. I am just suggesting a balance. But my time is 
well over. I apologize. And thank you.
    Dr. Benishek. Ms. Walorski.
    Ms. Walorski. Thank you, Mr. Chairman.
    And, Dr. McCarthy, I appreciate you all being here. And I 
just wanted to ask you the follow-up that I was talking with 
Mr. Rand about. It seems like there are many cases in my 
district where the VA does not appropriately communicate with 
the caregivers in citing HIPAA, the privacy laws. It seems like 
VA is being overzealous in the application of HIPAA, which then 
the domino effect creates difficulty with the caregiver to know 
what to do, any kind of direction.
    Can you just talk about or shed light on if the VA is doing 
anything to improve education on privacy laws so that 
caregivers given appropriate information regarding the 
treatment so nothing slows the process down? And I appreciate, 
again, the RAND Corporation's research into that.
    And I just wanted to read one little quick story. We have a 
handout from Wounded Warriors, and I just want to read this, 
because it goes right in hand with the things we hear in our 
district, it is this kind of a story. It says, ``My husband was 
interviewed by his VA physician, but I was not allowed to go in 
and assist him and help him remember things and help give an 
accurate picture of his functioning and health.'' Goes on to 
say, I am the caregiver, and I am blocked out of all this 
    In our district, we have a lot of cases where the answer 
from the VA comes back and says, well, they are not listed on 
the form as an approved person to get that information, but 
then they are. So could you just shed light on is there 
information going on, on privacy laws?
    Dr. McCarthy. So there is a lot of education that VA staff 
are required to do, and every year there is intense education 
about privacy, and our computer access is restricted if we 
don't do it. It is a very strong education requirement.
    That very well describes the purposes of release of 
information and so forth. The caregiver application process, 
the releases are signed. My suggestion is carry it with you, 
make a copy and carry it with you and have it be set up that it 
is in an ongoing way. That is how it best works.
    I too am the relative of a veteran and had to navigate the 
system, and so appreciate what you are talking about. But 
fortunately it was for my father and I was allowed to have 
access to what I needed to advocate for him for.
    But I apologize for what happened with the family that you 
spoke of, and we are happy to take that for the record and look 
into it if you want.
    Dr. McCarthy. But nevertheless, the issue is the release of 
information is really the bottom line, and my advice to the 
caregivers would be carry it with you.
    Ms. Walorski. Can I ask you this, though? And I appreciate 
that, and that is a good idea and we can certainly recommend 
that. But a lot of times when a physician calls back and wants 
to speak to the veteran, in some cases they, if there is not a 
speaker phone available or something like that, just say, 
having to put you on speaker, a lot of times we have situations 
where spouses are fighting for their--in many cases these are 
husbands fighting for wives, wives fighting for husbands--and 
you are on a telephone. And they say, look, I have got the 
signed paper, I have got this, I have got that. What do they do 
    And then also my question, on that 800 number, that 
caregiver 800 number, is that something that we can give out to 
a spouse that----
    Dr. McCarthy. Absolutely.
    Ms. Walorski [continuing]. Who is in the middle of that 
    Ms. Kabat. Yes.
    Ms. Walorski [continuing]. With a family member, so they 
call that customer hotline, the caregiver hotline?
    Dr. McCarthy. Yes. The caregiver support line, yeah. Yes.
    Ms. Walorski. Okay.
    Dr. McCarthy. And we are fielding 200 a day.
    Ms. Walorski. Yes.
    Dr. McCarthy. Go ahead.
    Ms. Kabat. I would add that in my work with other 
organizations like the Caregiver Action Network, even in some 
preliminary work that the Institute of Medicine is doing on 
caregiving as a national issue, this issue of HIPAA really cuts 
across all of caregiving, not just for veterans. And certainly 
my office, the Caregiver Support Program, we really believe 
that part of our role is to provide additional education about 
the role of caregivers to our providers and to ensure that they 
do become part of the treatment team.
    One of things we are talking about is in our residency 
programs and some of our other medical services talking about 
caregivers when folks are part of VA's training programs to 
ensure that they begin to understand, whether or not they stay 
within VA, how important it is to include that caregiver on the 
phone or in the appointment.
    Ms. Walorski. I appreciate that. And my final question is 
just to get an idea, back to this whole IT issue and looking 
and searching and being able to get this new database 
management system, what is the time line on that? When will you 
be up and running with the type of a system that you needed to 
manage this program?
    Dr. McCarthy. So the system that was developed was kind of 
piggybacked on another system that was working for something 
else, and anticipated 4,000 and we are at way more than that. 
So at the same time that there was recognized the need to 
expand, there was recognized also a need for a new system. So 
we have two processes going on kind of simultaneously, one to 
is kind of fix what we have while we are developing a new 
system, and the two are being rolled up, there is money that 
has been allocated. I don't know if you are familiar with the 
PMAS system and all that for the IT approvals, but it is past 
the first phase, it is now at the point of the next approval, 
and then we will go into planning and development as part of 
    Ms. Walorski. What does that put us at? Does it put us at 
2015, 2016, 2017?
    Dr. McCarthy. Go ahead.
    Ms. Kabat. So the current goal is to have the fix, or the 
rescue as we are currently calling it, in place by the end of 
this year and then a new system in fiscal year 2016.
    Certainly this is work that we have been doing now for 
several years. We had an initial document with all of the 
requirements completed even before we started taking 
applications in 2011. So at this point, what we have been able 
to do is garner some support around specific reports that we 
need and really focusing in on workload and targeting, being 
able to identify sites where the application process is taking 
longer than 90 days. And I actually have some staff working 
fairly diligently with specific medical centers to improve that 
time it takes to take applications.
    Ms. Walorski. Okay. I appreciate it, Mr. Chairman. I yield 
    Dr. Benishek. Thank you for your questions, Ms. Walorski. 
And it is sort of similar to the same question I asked, is that 
when you ask them for a date, it is very hard to get a date out 
of the VA. And all the stuff you say is great, but it is hard 
to hold you guys to a date, and that is one of the frustrations 
that we have here in this committee.
    So I want to thank you for being here today.
    Ms. Brown. Mr. Chairman, I have just one question.
    Dr. Benishek. Yeah. Absolutely. Go ahead.
    Ms. Brown. Yeah. I do have one follow-up question, because 
as far as the caregivers are concerned, you indicated it is a 
physical ailment or a condition related to the war.
    Dr. McCarthy. An injury, but it can be like a traumatic 
brain injury or post-traumatic stress disorder or a mental 
condition as well as what we traditionally think of physical 
    Ms. Brown. Well, we have 22, we talk about it, veterans 
committing suicide. How does that fit into identifying that 
person that needs that particular kind of care and training? I 
mean, to me that is a major question as to how we are going to 
stop this major problem that we are experiencing in the 
    Dr. McCarthy. And we wouldn't disagree with you, and we 
have been before the committee before talking about suicide 
prevention. And caregivers are key in this for so many of our 
veterans. I certainly have treated many veterans whose spouses 
have been responsible for helping them to stay alive for 40, 50 
years after the war, and sometimes they see me together and 
sometimes I see them individually, but nevertheless, I talk to 
the spouses about what they go through as well. And just like 
people talk about the emotional numbing that people feel with 
PTSD, the spouses feel the same. And the spouses will say 
things to the effect like that veteran is not the only one in 
the house that has PTSD. As a result of that person's PTSD, I 
have some. And certainly that is the case.
    So a program like this provides things like specific 
education about PTSD for the caregiver, which is really 
valuable for them to know, to know, oh, it is not that they are 
mad at me, it is not this, it is not that; it is that 
condition. Maybe it is an anniversary date. Maybe there was a 
trigger when we went to the grocery store. The spouses will ask 
why does someone with PTSD have to go to Wal-Mart at 3 in the 
morning. And it is really that they can't stand the crowds, and 
that is why they go. And so the paint gets picked out and the 
spouse gets upset that it is not the color that they wanted.
    I am sorry. I am just giving you an example of what the 
families are going through. And so having caregivers around to 
prevent the suicide is really, really important, because they 
are partners, and they are our partners, but more importantly, 
they are their spouse's partner in addressing the unknown that 
comes back to them after the war.
    Ms. Brown. Well, my question is, are they a part of the 
denial? No?
    Ms. Kabat. No. The law actually states injured in the line 
of duty on or after September 11, including traumatic brain 
injury, psychological trauma, and other mental health 
disorders. So certainly if someone is experiencing anxiety or 
depression to the point where they require the assistance of 
another caregiver for supervision and protection.
    And I do want to clarify that we, in terms of the scoring 
that goes on, the physical issues around activities of daily 
living and the issues around supervision and protection, mood 
regulation, those kinds of things, are treated equally, they 
are not weighed separate--well, they are weighed separately, 
but they are balanced in terms of the ability. So we certainly 
have many veterans in the program who are completely capable of 
all of their activities of daily living, but really can't be 
left in the home alone because of safety reasons, poor 
judgment, short-term memory, who qualify for the program as 
    And I just want to add one thing. One of the things we have 
been able to do with this program is to provide really specific 
training on specific areas. So, for example, we have used the 
VA TV system. We had groups of caregivers all over the country 
gather in their local medical center, about 300 participated, 
and we had a subject matter expert on post-traumatic stress in 
our TV studio here in D.C. and so the caregivers watched live a 
presentation about PTSD and then the caregiver support 
coordinators would call in and ask questions live.
    And so they were really questions, as Dr. McCarthy is 
saying, on things like, when he wakes up in the middle of the 
night screaming, do I touch him, and really getting the kind of 
information that they needed. And we were able to record those 
sessions, and so now we can provide them on DVD to other 
caregivers who were not able to attend in person.
    Ms. Brown. Okay. Thank you.
    Thank you, Mr. Chairman.
    Dr. Benishek. Well, if there are no other questions, you 
are excused.
    Ms. Kabat. Thank you, sir.
    Dr. Benishek. I ask unanimous consent that all members have 
5 legislative days to revise and extend their remarks and 
include extraneous material. Without objection, so ordered.
    Dr. Benishek. I would like to thank all the witnesses and 
the audience members for joining us this morning at today's 
hearing. And the hearing is now adjourned.

    [The statements submitted for the record appear in the 
    [Whereupon, at 11:50 p.m., the subcommittee was adjourned.]