[House Hearing, 113 Congress]
[From the U.S. Government Publishing Office]
VA'S CAREGIVER PROGRAM: ASSESSING CURRENT PROSPECTS AND FUTURE
POSSIBILITIES
=======================================================================
HEARING
before the
SUBCOMMITTEE ON HEALTH
of the
COMMITTEE ON VETERANS' AFFAIRS
U.S. HOUSE OF REPRESENTATIVES
ONE HUNDRED THIRTEENTH CONGRESS
SECOND SESSION
__________
WEDNESDAY, DECEMBER 3, 2014
__________
Serial No. 113-94
__________
Printed for the use of the Committee on Veterans' Affairs
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Available via the World Wide Web: http://www.fdsys.gov
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COMMITTEE ON VETERANS' AFFAIRS
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
JACKIE WALORSKI, Indiana
DAVID JOLLY, Florida
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
Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public
hearing records of the Committee on Veterans' Affairs are also
published in electronic form. The printed hearing record remains the
official version. Because electronic submissions are used to prepare
both printed and electronic versions of the hearing record, the process
of converting between various electronic formats may introduce
unintentional errors or omissions. Such occurrences are inherent in the
current publication process and should diminish as the process is
further refined.
C O N T E N T S
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Wednesday, December 3, 2014
Page
VA's Caregiver Program: Assessing Current Prospects and Future
Possibilities.................................................. 1
OPENING STATEMENTS
Hon. Dan Benishek, Chairman...................................... 1
Hon. Julia Brownley, Ranking Member.............................. 2
WITNESSES
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
And
Margaret Kabat, Acting National Director, Caregiver
Support Program, VHA, U.S. Department of Veterans
Affairs
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
VA'S CAREGIVER PROGRAM: ASSESSING CURRENT PROSPECTS AND FUTURE
POSSIBILITIES
----------
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.
OPENING STATEMENT OF CHAIRMAN DAN BENISHEK
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
quantified.
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.
OPENING STATEMENT OF RANKING MEMBER JULIA BROWNLEY
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.
STATEMENT OF RANDALL B. WILLIAMSON
Dr. Benishek. Mr. Williamson, please proceed with your
testimony.
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
living.
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
visits.
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
benefits.
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
veterans.
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
compromised.
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.
STATEMENT OF RAJEEV RAMCHAND
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
PTSD.
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
competence.
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
process?
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
workload.
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
that.
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
utilization.
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
terms.
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
definition?
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
you.
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
program.
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
different.
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.
Chairman.
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
working?
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
caregivers----
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
here?
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
here.
Dr. McCarthy.
STATEMENT OF MAUREEN McCARTHY, M.D., DEPUTY CHIEF, PATIENT CARE
SERVICES, VETERANS HEALTH ADMINISTRATION, U.S. DEPARTMENT OF
VETERANS AFFAIRS, ACCOMPANIED BY MICHAEL KILMER, CHIEF
CONSULTANT OF CARE MANAGEMENT AND SOCIAL WORK, VETERANS HEALTH
ADMINISTRATION, U.S. DEPARTMENT OF VETERANS AFFAIRS, AND
MARGARET KABAT, ACTING NATIONAL DIRECTOR, CAREGIVER SUPPORT
PROGRAM, VETERANS HEALTH ADMINISTRATION, U.S. DEPARTMENT OF
VETERANS AFFAIRS
STATEMENT OF MAUREEN McCARTHY, M.D.
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
program.
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
testimony.
[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
applications.
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
work.
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
questions.
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
long?
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
that.
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
VA?
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,
Chair.
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
afterwards.
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
well.
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
information.
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
then?
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
hassle----
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
that.
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
back.
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
injuries.
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
country.
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
well.
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
Appendix]
[Whereupon, at 11:50 p.m., the subcommittee was adjourned.]
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