[Federal Register Volume 87, Number 61 (Wednesday, March 30, 2022)]
[Notices]
[Pages 18481-18484]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2022-06735]
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DEPARTMENT OF VETERANS AFFAIRS
Implementation of the PAWS for Veterans Therapy Act
AGENCY: Department of Veterans Affairs.
ACTION: Notice.
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SUMMARY: The Department of Veterans Affairs (VA) is publishing this
notice to inform the public about how it is implementing the Puppies
Assisting Wounded Servicemembers for Veterans Therapy Act.
DATES: This notice is effective on March 30, 2022.
FOR FURTHER INFORMATION CONTACT: Stacey Pollack, 810 Vermont Avenue NW,
Washington, DC 20420; 202-461-4174. This is not a toll-free telephone
number.
SUPPLEMENTARY INFORMATION: The Puppies Assisting Wounded Servicemembers
for Veterans Therapy Act (hereinafter referred to as ``the Act'') was
signed into law by the President on August 25, 2021, (Pub. L. 117-37,
135 stat. 329). Section 2 of the Act requires VA to conduct a pilot
program to provide canine training to eligible veterans diagnosed with
posttraumatic stress disorder (PTSD) as an element of a complementary
and integrative health program for such veterans. This notice provides
information on how VA will implement the requirements of section 2 of
the Act and is not a solicitation for public comment or request for
information regarding VA's implementation of section 2 of the Act, as
outlined below. Therefore, responses to this notice may not be used to
inform VA's implementation of section 2 of the Act, and VA will not
address such responses. A brief summary of the provisions in section 2
of the Act follows.
Summary of Provisions in Section 2 of the Act
Section 2(a) requires that VA, not later than February 21,
2022, commence the conduct of a pilot program to provide canine
training to eligible veterans diagnosed with PTSD as an element of a
complementary and integrative health program for such veterans.
Section 2(b) requires that the pilot program conducted
under subsection (a) be carried out for a 5-year period beginning on
the date of the commencement of the pilot program, by not fewer than 5
VA medical centers (VAMC) located in geographically diverse areas.
Section 2(c) requires that, in carrying out the pilot
program required under subsection (a), VA must seek to enter into
agreements with nongovernmental entities that VA determines have the
demonstrated ability to provide the canine training specified in
subsection (a).
Section 2(d) establishes certain conditions for inclusion
in any agreements under subsection (c).
Section 2(e) establishes that a veteran who has
participated in the pilot program under subsection (a) may adopt a dog
that the veteran assisted in training during the pilot program if the
veteran and the veteran's health provider, in consultation with the
entity that provided the canine training with respect to that dog under
the pilot program, determine that it is in the best interest of the
veteran. This section also includes language regarding the
responsibility of the entity that provided the canine training under
the pilot program to provide follow-up training support for the life of
the dog, if the veteran who participated in the pilot program adopts
the dog under this subsection.
Section 2(f) establishes that participation in the pilot
program under subsection (a) may not preclude a veteran from receiving
any other medical care or treatment for PTSD furnished by VA for which
the veteran is otherwise eligible.
Section 2(g) establishes data collection requirements
based on veterans' participation in the pilot program and such other
factors as VA determines appropriate.
Section 2(h) establishes VA's reporting requirements
associated with the pilot program.
Section 2(i) requires the Comptroller General to brief and
report to Congress on the methodology of the pilot program.
Section 2(j) establishes definitions, for purposes of
section 2, for the following terms: Accredited service dog organization
(SDO), eligible veteran and service dog training instructor.
Implementation of the Pilot Program
VA's implementation of the pilot program will reflect the following
considerations:
Canine Training
Section 2(a) provides that VA must conduct a pilot program to
provide canine training to eligible veterans diagnosed with PTSD as an
element of a complementary and integrative health program for such
veterans. The term canine training is not defined in the Act, and VA
has not otherwise defined this term. However, the term canine training
is characterized in the Act as ``an element of a complementary and
integrative health program'' for veterans participating in the pilot
program. The Act similarly does not contain a definition of the term
complementary and integrative health (CIH); however, VA's internal
policy defines CIH as a group of diverse medical and health care
approaches and practices that are not considered to be part of
conventional or allopathic medicine. See Veterans Health Administration
(VHA) Directive 1137(2), Provision of Complementary and Integrative
Health (May 18, 2017; amended July 2, 2021).
Based on its experience, VA has distinguished the following two
types of CIH: Treatment services and well-being services. Unlike
treatment services, well-being services are often practices offered
outside of a clinical setting and involve a practitioner or instructor
teaching veterans to advance their sense of well-being and improve
their quality of life.
VA is implementing the canine training under the pilot program as
an element of CIH well-being services. CIH well-being services are
those activities that a veteran may complete without the need for
assistance from a health care
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professional or in a clinical setting and that may advance the
veteran's sense of well-being and improve the veteran's quality of
life. Because the canine training will be considered CIH well-being
services, it is not a direct clinical intervention, and the training
does not involve the provision of health care. This will allow more
veterans to participate in canine training; thereby, affording more
veterans potential well-being benefits.
Commencement and Duration of the Pilot Program
Section 2(a) requires that, not later than 180 days after the date
of the enactment of the Act, VA must commence the conduct of a pilot
program. As the Act was signed into law on August 25, 2021, VA was
required to commence the conduct of a pilot program by February 21,
2022. By this date, VA selected the pilot program sites and initiated
efforts at the sites to begin implementing the pilot program and to
ensure VA staff are aware of the canine training to be conducted under
the pilot program. However, the actual canine training did not begin by
that date. VA is still working to form agreements with nongovernmental
entities that will furnish the canine training. For purposes of section
2(b)(1), VA considers the date the pilot program commenced as February
21, 2022.
Veteran Participation in the Pilot Program
Section 2(j)(2) defines the term eligible veteran to mean a veteran
who is enrolled in VA's patient enrollment system under 38 U.S.C. 1705
(regulated under 38 CFR 17.36), and who has been recommended for
participation in the pilot program by a qualified mental health care
provider or clinical team based on medical judgment that the veteran
may benefit from such participation with respect to the PTSD symptoms
of the veteran. In other words, to participate in the pilot, a veteran
must meet three threshold conditions for eligibility; namely, the
veteran must be (1) enrolled in the VA health care system; (2)
diagnosed with PTSD; and (3) recommended by a VA mental health care
provider or VA clinical team.
Section 2 does not define or characterize the phrase ``qualified
mental health care provider or clinical team.'' Rather than define
qualifications, VA interprets this phrase to mean that a VA mental
health care provider or VA clinical team must recommend a veteran for
participation in the pilot program. Limiting the recommendation to VA
providers will allow VA to assess more consistently each veteran that
may want to participate under the same criteria and will allow for more
consistent collection of data, as required under section 2(g)(1)(B)-
(D). Veterans, who receive care from non-VA providers under the
Veterans Community Care Program and who wish to participate in the
pilot program, can discuss the program with their non-VA provider but
will need to obtain a recommendation from a VA mental health care
provider or VA clinical team. Veterans interested in participating in
the pilot program, who are receiving care from non-VA providers, should
contact the participating VAMC where they receive care or authorization
for non-VA care, for more information on how to participate in the
pilot program.
Before a VA mental health care provider or VA clinical team can
recommend the veteran for participation in the program, the veteran
must have had an appointment with a primary care, mental health, whole
health, recreation therapy or social work provider within the previous
3 months. VA will also require veterans participating in the program to
remain engaged with one or more of these clinical areas; to remain
engaged, a veteran must have an appointment at least once every 3
months until they have completed the pilot program. Section 2(j)(2)(B)
requires a qualified mental health care provider or clinical team to
form a medical judgment that participation in the pilot program may
benefit the veteran with respect to the veteran's PTSD. Having regular
appointments (at least 1 every 3 months) is essential to ensure that
this judgment is still accurate. If a veteran who is interested in
participating in the pilot program has not been seen for an appointment
within the last 3 months, the veteran can schedule an appointment with
a VA provider to begin the recommendation and screening process.
Once the veteran has had this appointment, the veteran can then be
screened for participation. This screening will be performed by a
licensed independent VA mental health care provider to confirm the
diagnosis of PTSD through a clinical assessment and determine
suitability for participation in the pilot program. This screening must
occur within 3 months prior to the first canine training session. This
may require subsequent screening in some cases; for example, if a
veteran was screened and recommended for participation in the pilot
program on January 1, but the veteran is unable to participate in the
program until July 31, due to limited space or other issues, the
veteran may need to be screened again prior to participation. This
screening would not necessarily require the veteran to schedule another
appointment with the licensed independent VA mental health care
provider; although, a review of the veteran's medical chart may be
sufficient. The licensed independent VA mental health care provider
will make a clinical determination as to which, if any, reassessments
are necessary for participation, and whether such reassessments require
a direct interaction (either in person, by phone or by telehealth) with
the veteran. VA will make every effort to ensure that all screening is
completed in a timely manner and as conveniently as possible for the
veteran. As noted above, screening must be performed by VA mental
health care providers and recommendations must be from VA providers or
clinical teams; meaning, that if VA were unable to offer a screening
within the designated access standards under 38 CFR 17.4040, that would
not authorize the veteran to elect to receive care in the community.
These screenings would not constitute the delivery of medical services
under such access standards. This also means that the screening will
impose no copayment obligation on the veteran. The screenings entail
clinical decision making and the exercise of medical judgment, as may
occur in a research study or other clinical programs. We note; however,
that the pilot program is not a research study.
In the screening, VA providers will assess veterans for criteria
that would suggest that participation in the pilot program may not be
appropriate, including, but not limited to frequent aggressive
behaviors or homicidal ideation that may make it unsafe for the veteran
to be with a dog or co-morbid diagnoses that would make training with a
dog difficult or not feasible (e.g., psychosis, delusions, certain
cognitive impairment). We are stating these additional elements to
explain to the public how qualified VA mental health care providers or
clinical teams will make recommendations for participation in the pilot
program. Once the veteran has been screened, VA will refer eligible
veterans to the accredited SDO, as described below, for canine
training. Given these organizations' limited capacity, not all veterans
who meet eligibility criteria may be able to participate in the
program. There will be a ``pilot champion'' at each of the five pilot
sites; the pilot champion will be a VA staff member serving as a
liaison between the VAMC and the SDO
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furnishing canine training, pursuant to an agreement described in
section 2(c).
The canine training model will have veterans engage in both basic
obedience and other training of a dog, so that the dog may eventually
become, in most cases, a service dog for another individual.
Participating in the canine training may improve veterans' self-
efficacy and increase their sense of purpose and self-worth. For
example, participating veterans may work to train a dog to establish
trust, build a relationship and practice socializing, and through that
process, those veterans may better recognize and learn to optimally
regulate their own emotional arousal to train the dog. These sessions
are typically conducted in small group classes and will be overseen by
a certified service dog training instructor. VA clinical staff will not
accompany a veteran to attend canine training under the pilot program.
The canine training sessions under the pilot program will typically
meet once a week for 8 weeks, and participating veterans may work with
multiple dogs and other veterans within their small group as a form of
social engagement.
Selection of VA Sites
Section 2(b)(2) requires VA to ensure that the pilot program is
carried out by not fewer than five VAMCs located in geographically
diverse areas. In selecting the five pilot program sites, VA first
considered the geographic proximity of VAMCs to accredited SDOs,
because the nongovernmental entities that would provide the canine
training under section 2(c) are further required to be an accredited
SDO under section 2(d)(1). Section 2(j)(1) of the Act defines
accredited SDO as an organization described in section 501(c)(3) of the
Internal Revenue Code of 1986 that: (1) Provides service dogs to
veterans with PTSD and (2) is accredited by an accrediting organization
with demonstrated experience, national scope and recognized leadership
and expertise in the training of service dogs and education in the use
of service dogs (as determined by VA). VA recognizes the expertise and
national scope of the following two organizations that accredit SDOs
under its regulations in 38 CFR 17.148(c)(1): Assistance Dogs
International (ADI) and International Guide Dog Federation (IGDF).
Between ADI-accredited and IGDF-accredited SDOs, only ADI-accredited
SDOs provide the type of instruction discussed earlier. Therefore, VA
considered the proximity of VAMCs to ADI-accredited SDOs, for purposes
of identifying potential pilot program sites.
VA next considered VAMCs near ADI-accredited SDOs that expressed
interest in participating in the pilot program for 5 years and would be
able to conduct assessments and recommend veterans to the pilot
program, as well as conduct other programmatic aspects of the pilot
(such as data collection required under section 2(g)). Of the VAMCs
that met the criteria above, VA then considered five sites that would
be in geographically diverse areas, as required by section 2(b)(2). VA
attempted to consider VAMCs that were in different Veterans Integrated
Service Networks (VISN), which are VA's designated regional systems of
care in the country. Given these factors, VA identified the following
five VAMCs as the required pilot program sites under section 2(b)(2):
Palo Alto, California; Anchorage, Alaska; Asheville, North Carolina;
West Palm Beach, Florida; and San Antonio, Texas.
Agreements With Entities To Furnish Canine Training
Section 2(c) requires VA to seek to enter into agreements with
nongovernmental entities that VA determines can provide canine training
under the pilot program, and section 2(d) establishes minimum required
conditions to be included in any such agreements. Section 2(d)(1)
further establishes that any agreements formed between VA and a
nongovernmental entity will include a certification from the entity
that it is an accredited SDO. We reiterate from the discussion earlier
in this notice, in accordance with section 2(j)(1), as well as VA's
knowledge and recognition of ADI-accredited SDOs providing service dogs
to veterans with PTSD, that VA will seek to enter into agreements under
section 2(c) with ADI-accredited SDOs. Because section 2 does not
confer any grant or cooperative agreement authority under which VA may
conduct the pilot program, VA has engaged directly with ADI-accredited
entities that are located near the five VA pilot sites, to gauge
interest and determine their ability to furnish canine training under
the pilot, to include Dogs for Life; Paws for Purple Hearts; and
Warrior Canine Connection. VA anticipates the agreements formed with
these entities will establish that SDOs will furnish canine training as
in-kind services. The agreements further will include all conditions as
required under section 2(d) and additional terms necessary. VA is
entering into this agreement with SDOs that have the experience
necessary to provide this model of training. In this manner, the
agreements would reflect VA's understanding that these SDOs provide
canine training to veterans at no cost to veterans. VA does not
envision forming agreements under section 2(c) that would create any
additional cost for VA or the veteran in terms of payment for the
canine training.
Adoption of a Dog
Section 2(e) establishes that a veteran who has participated in the
pilot may adopt a dog that the veteran assisted in training as part of
the pilot program, if the veteran and veteran's provider (in
consultation with the SDO that provided the canine training under the
pilot program) determine that it is in the best interest of the
veteran. The language in section 2(e) establishes a permissive
authority related to adoption of a dog and does not compel the
provision of a dog to a veteran. ADI-accredited organizations that will
be furnishing the canine training under the pilot program train and
pair qualified service dogs with individuals with disabilities and do
not necessarily participate in the adoption of dogs.
Because the adoption provision in section 2(e) is permissive, and
because the ADI-accredited organizations that will furnish canine
training under the pilot program may not necessarily participate in the
adoption of dogs, VA will not implement the adoption provisions under
section 2(e). Determinations about whether it is in the best interest
of a veteran to adopt a dog extends beyond VA providers' scope of
licensure, the VA Scope of Practice and their sphere of clinical
expertise. This does not prevent any veteran from independently seeking
to adopt a dog; however, such adoption would not be an adoption under
section 2(e)(1). Any veteran seeking to be prescribed a service dog and
subsequent service dog benefits, instead of merely adopting a dog,
would have to be separately evaluated by VA under the criteria in
section 17.148 and prescribed a service dog, prior to owning the dog,
to be considered for service dog benefits.
Beneficiary Travel
The canine training under the pilot is not considered examination,
treatment or care for purposes of qualifying for reimbursement or
payment of beneficiary travel (BT) expenses, should a veteran eligible
for BT benefits need to travel to receive the canine training. Although
BT benefits will not be available for any travel that may be associated
with the canine training under the pilot, we believe in many cases that
veterans who would participate in the pilot will be able to transport
themselves. Other
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transportation options, such as the Volunteer Transportation Network,
may also be available.
Appeals
During the course of the pilot program, disagreements may arise
regarding veteran participation. We anticipate that the vast majority
of these disagreements will be subject to VA's clinical appeals
process, as set forth currently in VHA Directive 1041, Appeal of
Veterans Health Administration Clinical Decisions (September 28, 2020).
The clinical appeals process applies to a written request for higher
review of one or more medical determinations. Medical determinations
usually concern the need for and appropriateness of specific types of
medical care and treatment for an individual and generally include
decisions by an appropriate health care professional based on their
medical judgment.
Eligibility to participate in the pilot program is limited, by
section 2(j)(2), to veterans who are: (1) Enrolled in the VA health
care system; (2) diagnosed with PTSD; and (3) recommended for
participation in the pilot program by a qualified mental health care
provider or clinical team, based on medical judgment that the veteran
may benefit from such participation with respect to the diagnosed PTSD
of the veteran. While determinations of whether a veteran is enrolled
in the VA health care system are administrative and not clinical, such
matters are typically easily discernable and do not entail much
dispute. Disagreements with administrative decisions are appealable to
the Board of Veterans' Appeals. However, diagnosis of PTSD and a
recommendation concerning the need for, and the appropriateness of,
specific types of medical care and treatment, based on medical
judgment, are decisions that are clinical in nature and therefore
subject to the clinical appeals process in VHA Directive 1041.
Throughout the course of the pilot program, SDOs providing the
canine training will have the discretion and authority to determine
whether they will provide training to a veteran at a particular time. A
veteran who is disruptive; incapable of or unwilling to follow
directions; or presents a danger to themselves or others (including the
dogs being trained) could be denied the ability to participate in the
program on at least a temporary basis. In any of these situations, such
information will be relayed to the pilot champion, who will coordinate
with the provider or clinical team responsible for the initial
recommendation for participation to determine if that recommendation is
still applicable. If the provider's or team's medical judgment changes,
based on this or any other information, such that they no longer
recommend the veteran's participation, that decision would be a
clinical decision appealable under VHA Directive 1041. If the SDO
determines it will not or cannot provide the canine training for other
reasons, such as limited resources or other constraints, the SDO and VA
will attempt to ensure that eligible veterans who have been recommended
for participation are able to do so at a later time. Participation will
generally be granted on a first-come, first-served basis.
Signing Authority
Denis McDonough, Secretary of Veterans Affairs, approved this
document on March 23, 2022 and authorized the undersigned to sign and
submit the document to the Office of the Federal Register for
publication electronically as an official document of the Department of
Veterans Affairs.
Luvenia Potts,
Regulation Development Coordinator, Office of Regulation Policy &
Management, Office of General Counsel, Department of Veterans Affairs.
[FR Doc. 2022-06735 Filed 3-29-22; 8:45 am]
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