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96–137 2016

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 

( 

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 

GUS M. BILIRAKIS, Florida, Vice-Chairman 

DAVID P. ROE, Tennessee 

BILL FLORES, Texas 

JEFF DENHAM, California 

JON RUNYAN, New Jersey 

DAN BENISHEK, Michigan 

TIM HUELSKAMP, Kansas 

MIKE COFFMAN, Colorado 

BRAD R. WENSTRUP, Ohio 

PAUL COOK, California 

JACKIE WALORSKI, Indiana 

DAVID JOLLY, Florida 

MICHAEL H. MICHAUD, Maine, Ranking 

Minority Member 

CORRINE BROWN, Florida 

MARK TAKANO, California 

JULIA BROWNLEY, California 

DINA TITUS, Nevada 

ANN KIRKPATRICK, Arizona 

RAUL RUIZ, California 

GLORIA NEGRETE MCLEOD, California 

ANN M. KUSTER, New Hampshire 

BETO O’ROURKE, Texas 

TIMOTHY J. WALZ, Minnesota 

JON TOWERS, Staff Director 

NANCY DOLAN, Democratic Staff Director 

SUBCOMMITTEE ON HEALTH 

DAN BENISHEK, Michigan, Chairman 

DAVID P. ROE, Tennessee 

JEFF DENHAM, California 

TIM HUELSKAMP, Kansas 

BRAD R. WENSTRUP, Ohio 

JACKIE WALORSKI, Indiana 

DAVID JOLLY, Florida 

JULIA BROWNLEY, California, Ranking 

Member 

CORRINE BROWN, Florida 

RAUL RUIZ, California 

GLORIA NEGRETE MCLEOD, California 

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. 


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C O N T E N T S 

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 


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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. 


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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 adVerDate Aug 31 2005 08:54 Feb 02, 2016 Jkt 000000 PO 00000 Frm 00006 Fmt 6633 Sfmt 6633 Y:\96-137.TXT PAT

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ministration 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 


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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. 


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[THE PREPARED STATEMENT OF MR. RANDALL WILLIAMSON AP- PEARS 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 wellbeing. 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. 


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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. 


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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 


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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. 


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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. 


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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 


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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. 


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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. 


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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 


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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 longterm 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 proVerDate Aug 31 2005 08:54 Feb 02, 2016 Jkt 000000 PO 00000 Frm 00018 Fmt 6633 Sfmt 6633 Y:\96-137.TXT PAT

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vide 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 


VACREP180 with DISTILLER
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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. 


VACREP180 with DISTILLER
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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 post9/11 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. 


VACREP180 with DISTILLER
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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. 


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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 wellbeing 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. 


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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 wellbeing 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. 


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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-α-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. 


VACREP180 with DISTILLER
22 

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 


VACREP180 with DISTILLER
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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 elaboVerDate Aug 31 2005 08:54 Feb 02, 2016 Jkt 000000 PO 00000 Frm 00027 Fmt 6633 Sfmt 6633 Y:\96-137.TXT PAT

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rate 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? 


VACREP180 with DISTILLER
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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 


VACREP180 with DISTILLER
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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 efVerDate Aug 31 2005 08:54 Feb 02, 2016 Jkt 000000 PO 00000 Frm 00030 Fmt 6633 Sfmt 6633 Y:\96-137.TXT PAT

VACREP180 with DISTILLER
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fectiveness 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 


VACREP180 with DISTILLER
28 

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. 


VACREP180 with DISTILLER
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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 


VACREP180 with DISTILLER
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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. 


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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. 


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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 WalMart 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 


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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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