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[House Hearing, 112 Congress]
[From the U.S. Government Publishing Office]

         IMPLEMENTATION OF CAREGIVER ASSISTANCE: MOVING FORWARD

=======================================================================

                                HEARING

                               before the

                         SUBCOMMITTEE ON HEALTH

                                 of the

                     COMMITTEE ON VETERANS' AFFAIRS
                     U.S. HOUSE OF REPRESENTATIVES

                      ONE HUNDRED TWELFTH CONGRESS

                             FIRST SESSION

                               __________

                             JULY 11, 2011

                               __________

                           Serial No. 112-23

                               __________

       Printed for the use of the Committee on Veterans' Affairs

                                _____

                  U.S. GOVERNMENT PRINTING OFFICE
68-452                    WASHINGTON : 2011
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                     COMMITTEE ON VETERANS' AFFAIRS

                     JEFF MILLER, Florida, Chairman

CLIFF STEARNS, Florida               BOB FILNER, California, Ranking
DOUG LAMBORN, Colorado               CORRINE BROWN, Florida
GUS M. BILIRAKIS, Florida            SILVESTRE REYES, Texas
DAVID P. ROE, Tennessee              MICHAEL H. MICHAUD, Maine
MARLIN A. STUTZMAN, Indiana          LINDA T. SANCHEZ, California
BILL FLORES, Texas                   BRUCE L. BRALEY, Iowa
BILL JOHNSON, Ohio                   JERRY McNERNEY, California
JEFF DENHAM, California              JOE DONNELLY, Indiana
JON RUNYAN, New Jersey               TIMOTHY J. WALZ, Minnesota
DAN BENISHEK, Michigan               JOHN BARROW, Georgia
ANN MARIE BUERKLE, New York          RUSS CARNAHAN, Missouri
TIM HUELSKAMP, Kansas
Vacancy
Vacancy

            Helen W. Tolar, Staff Director and Chief Counsel

                                 ______

                         SUBCOMMITTEE ON HEALTH

                ANN MARIE BUERKLE, New York, Chairwoman

CLIFF STEARNS, Florida               MICHAEL H. MICHAUD, Maine, Ranking
GUS M. BILIRAKIS, Florida            CORRINE BROWN, Florida
DAVID P. ROE, Tennessee              SILVESTRE REYES, Texas
DAN BENISHEK, Michigan               RUSS CARNAHAN, Missouri
JEFF DENHAM, California              JOE DONNELLY, Indiana
JON RUNYAN, New Jersey

Pursuant to clause 2(e)(4) of rule XI of the Rules of the House, public 
hearing records of the Committee on Veterans' Affairs are also 
published in electronic form. The printed hearing record remains the 
official version. Because electronic submissions are used to prepare 
both printed and electronic versions of the hearing record, the process 
of converting between various electronic formats may introduce 
unintentional errors or omissions. Such occurrences are inherent in the 
current publication process and should diminish as the process is 
further refined.

                            C O N T E N T S

                               __________

                             July 11, 2011

                                                                   Page
Implementation of Caregiver Assistance: Moving Forward...........     1

                           OPENING STATEMENTS

Chairwoman Ann Marie Buerkle.....................................     1
    Prepared statement of Chairwoman Buerkle.....................    29
Hon. Michael H. Michaud., Ranking Democratic Member..............     2
    Prepared statement of Congressman Michaud....................    29

                                 ______

                               WITNESSES

U.S. Department of Veterans Affairs:

  Cheryl Cox, LCSW, Caregiver Support Coordinator, Syracuse 
    Department of Veterans Affairs Medical Center................    12
  Mary Fullerton, LCSW, Caregiver Support Coordinator, North 
    Florida/South Georgia Veterans Healthcare System.............    14
  Deborah Amdur, LCSW, ACSW, Chief Consultant, Care Management 
    and Social Work Service, Veterans Health Administration......    22
      Prepared statement of Ms. Amdur............................    37

                                 ______

  Schulz, Debbie, Friendswood, TX................................     3
    Prepared statement of Ms. Schulz.............................    30
  Wounded Warrior Project, Anna Frese, Director, Warrior Support 
    Program......................................................    10
    Prepared statement of Ms. Frese..............................    33

                                 ______

                       SUBMISSIONS FOR THE RECORD

Disabled American Veterans, Adrian Atizado, Assistant National 
  Legislative Director, statement................................    40
Iraq and Afghanistan Veterans of America, Tom Tarantino, Senior 
  Legislative Associate, statement...............................    47
National Military Family Association, Barbara Cohoon, Ph.D., 
  R.N., Government Relations Deputy Director, statement..........    50
Paralyzed Veterans of America, statement.........................    56
Wounded Warrior Project, statement...............................    59

                                 ______

                   MATERIAL SUBMITTED FOR THE RECORD

Post-Hearing Questions and Responses for the Record:

  Hon. Michael H. Michaud, Ranking Democratic Member, 
    Subcommittee on Health, Committee on Veterans' Affairs to 
    Deborah Amdur, LCSW, Chief Consultant, Care Management and 
    Social Work, Veterans Health Administration, U.S. Department 
    of Veterans, letter dated July 13, 2011, and VA responses....    72

 
         IMPLEMENTATION OF CAREGIVER ASSISTANCE: MOVING FORWARD

                              ----------                              

                         MONDAY, JULY 11, 2011

             U.S. House of Representatives,
                    Committee on Veterans' Affairs,
                                    Subcommittee on Health,
                                                    Washington, DC.
    The Subcommittee met, pursuant to notice, at 4:00 p.m., in 
Room 334, Cannon House Office Building, Hon. Anne Marie Buerkle 
[Chairwoman of the Subcommittee] presiding.
    Present: Representatives Buerkle, Roe, Benishek, Runyan, 
and Michaud.

            OPENING STATEMENT OF CHAIRWOMAN BUERKLE

    Ms. Buerkle. Good afternoon. The Subcommittee on Health 
will come to order.
    Four months ago today, this Subcommittee held our first 
hearing of the year to discuss why the U.S. Department of 
Veterans Affairs (VA) had failed to implement the Caregivers 
Assistance component of Public Law 111-163. At that hearing, it 
was clear to me that VA must go back and address some serious 
deficiencies with the Department's initial implementation plan, 
particularly the strict eligibility requirements, in order to 
get this important program up and running.
    I think we all agreed that day at that hearing, that time 
is of the essence, and our veterans and their caregivers need 
us now, not later.
    Today we meet again to determine the progress the 
Department has made in those intervening months to adjust its 
implementation plan and to do right by our veterans and their 
caregivers who have already given so much to us all. In 
response to the concerns of Members, advocates and 
stakeholders, VA changed its eligibility requirements and 
expedited the implementation of caregivers' benefits by 
publishing an interim final rule (IFR) on May 5, 2011. The IFR 
allowed the Department to accelerate the Federal rulemaking 
process by immediately implementing the program prior to the 
consideration of public comments and the issuance of a final 
rule.
    As the daughter of a full-time caregiver, I understand the 
profound impact injury can have, not only on the patient or the 
injured but also upon his or her family. Time is of the essence 
for these families, many of whom have sacrificed their 
personal, professional and financial security in order to take 
on full-time caregiving responsibilities for their veteran 
family member. We owe it to these men and women to get it 
right, and we will not rest until we do.
    Today we will hear from Debbie Schulz, a full-time 
caregiver for her son Steven who was injured in Iraq in 2005. 
She will speak to her experience applying for and obtaining 
services from VA.
    We will assess the actions VA has taken to date to meet the 
intent of the law and the changes that still need to be 
considered prior to issuing the final rule.
    I want to express our appreciation on behalf of the Health 
Subcommittee to all of you for being here today. I am very much 
looking forward to our discussion.
    I now yield to the Ranking Member, Mr. Michaud, for any 
opening statements he might have.
    [The prepared statement of Chairwoman Buerkle appears on 
p. 29.]

          OPENING STATEMENT OF HON. MICHAEL H. MICHAUD

    Mr. Michaud. Thank you very much, Madam Chair.
    I would like to thank you for holding this very important 
hearing today on the Caregivers and Veterans Omnibus Health 
Care Service Act of 2010. Today's hearing is a follow-up to a 
March 11, 2011, Subcommittee on Health hearing on this very 
important issue where concerns were raised regarding delays in 
the roll-out of the implementation plan. The narrow criteria 
and the eligibility for the benefits was a major concern of 
this Committee.
    At the beginning of July, the Department of Veterans 
Affairs issued its very first payment to family caregiver 
veterans. These family caregivers were the first to complete 
their caregiver training under this comprehensive assistance 
for family caregivers program, and VA will send out more than 
$430,000 in stipend payments to nearly 200 recipients this 
month alone.
    I am pleased that the veterans and caregivers are finally 
beginning to receive some of the services required under the 
law that we passed. I am pleased that the criteria for 
eligibility of these benefits have been expanded to be more in 
line with what Congress intended.
    However, I would also like to hear more from the witnesses 
today about how the plan is being implemented in the field, 
what issues remain, and what oversight is being conducted by 
Central Office, and how can we ensure that this program 
successfully is implemented so that veterans and their 
caregivers receive the critical benefits without further delay.
    The testimony we have received contains many concerns with 
the interim final rule, and I would like to hear from the VA on 
incorporating some of the suggestions in the final rule.
    So, Madam Chair, once again, I want to thank you very much 
for having this hearing and look forward to continue to keep an 
eye on what's happening as we move forward with the caregivers 
legislation.
    And I yield back the balance of my time.
    [The prepared statement of Congressman Michaud appears on 
p. 29.]
    Ms. Buerkle. Thank you very much. I would like to now 
invite our first panel to the witness table. Joining us this 
afternoon is Debbie Schulz. Debbie is a full-time caregiver for 
her son, Steven, who was wounded in Fallujah in 2005 when an 
improvised explosive device (IED) hit the Humvee in which he 
was traveling.
    Ms. Schulz, I know that this has been a very personal 
crusade for you, and we thank you so much for taking the time 
to come here today to give us your testimony and to answer our 
questions. Please go ahead with your opening statement.

    STATEMENT OF DEBBIE SCHULZ, FRIENDSWOOD, TX (CAREGIVER)

    Ms. Schulz. Chairwoman Buerkle, Ranking Member Michaud and 
Members of the Subcommittee, thank you for allowing me to share 
with you the experience I have had with the Caregiver 
Assistance Program, and for your vital leadership in pressing 
to assure that the law is properly implemented.
    Great progress has been made toward this, and my son Steven 
and I are already benefitting from the program. I am grateful 
for the assistance. And as Steven's caregiver, I cannot 
overemphasize the program's importance to his ongoing recovery 
and continued well-being.
    But while the program has helped us, I can see where gaps 
in the VA regulation will and already have created problems for 
caregivers.
    Our journey, as you have said, began 6 years ago when 
Steven suffered a severe traumatic brain injury (TBI) on April 
19, 2005. He was in Fallujah when the IED exploded outside his 
Humvee. He was 20 years old. The injury left him with many 
physical and cognitive deficits. He has profound left-sided 
weakness with no functional use of his left arm. He walks 
slowly and only with assistance. Shrapnel blinded his right 
eye, and his brain does not perceive the left field of vision.
    In certain situations, Steven may need a wheelchair or use 
it for convenience, but he can't push it on his own because of 
the profound weakness on his left side. And a power chair is 
not used because of his visual deficits.
    Steven's thinking is somewhat slower, and due to the 
frontal lobe damage, he has some impaired impulse control. And 
he might blurt out things that are inappropriate. His affect is 
flat, and he has difficulty interpreting social cues. His 
speech is often difficult to understand. His attention span is 
short, and he has some memory problems. Without the ability to 
think, what do I do next, he does not feel comfortable being 
left alone for more than 30 minutes at a time.
    Steven's life has changed since his injury, and of course, 
my life has too. I had been working as a special education 
teacher when he was injured. My husband and I, then 51 and 49, 
were preparing to become empty nesters. Instead, I became 
Steven's primary caregiver, advocate, life skills coach, 
chauffeur, secretary, bookkeeper, teacher, drill instructor, 
medical assistant, physical, occupational, speech therapist and 
on and on.
    Leaving the workforce has created a financial hardship, and 
our world and that of our then 18-year-old daughter and 15-
year-old son has changed profoundly.
    I applied for the Caregiver Program on May 9, having been 
alerted by my VA social worker and others. Getting the 
application and completing it was easy. The one glitch I 
encountered was an alarming uncertainty regarding CHAMPVA 
health coverage, which was contingent on having no other 
insurance. With my health coverage about to be terminated, I 
felt trapped in an awkward limbo that went unresolved for 
several weeks. I was led to think I would not be eligible for 
CHAMPVA unless there was a total break in my coverage.
    Within days of applying for the caregiver program, I was 
advised that the VA had received the application and the next 
step was to complete training and have a home visit. After I 
completed both of those, I received verbal confirmation that I 
had been approved.
    On July 5, I received my first stipend check. I assume from 
the amount, that it represents a maximum payment. But unlike 
other caregivers, I have not received any written or verbal 
notice on how many hours were approved and have no specific way 
of knowing whether those determinations were appropriate.
    We caregivers do stay in touch with one another, and I do 
have concerns about how the rules may affect many others. VA, 
to its credit, has implemented a streamlined system for 
processing applications. But it's important that the 
determinations and decisions are fair and appropriate, not 
simply fast.
    In preparing my remarks, I spoke with many other 
caregivers, and already disparities in determinations are being 
found. The weak link, in my view, are flaws in the rules VA 
published in early May. The stipend is a good example of this. 
For the many families for whom finances are tight, the stipend 
is very important. But it is clear to me that the rules for 
determining the stipends need work. For example, I know a 
veteran who suffered the same injury as Steven but made a 
better recovery physically. Though he has far fewer physical 
limitations than Steven, he still has post-traumatic stress 
disorder (PTSD) and TBI cognitive issues. But his wife will get 
a stipend that only covers 10 hours of caregiving a week, 
amounting to about $15 a day.
    In our case, VA's methodology resulted in scoring Steven's 
needs at a relatively high level, and I believe this is 
probably because he needs assistance with both physical and 
cognitive issues. Since VA's scoring methodology calls for 
scoring each different impairment, his total score would be 
higher than say a veteran who has just cognitive issues. The 
fallacy in this methodology is that a veteran with TBI whose 
extreme lack of judgment, for example, makes him a safety risk, 
is not just a safety risk for 10 hours a week.
    Caregiver friends of mine in this situation are almost 
always by their veterans' side providing oversight and 
assistance. There's something badly wrong with the methodology 
that results in a conclusion that a veteran who is a safety 
risk, whether it be for suicidality, impaired judgment or other 
circumstances, needs only 10 or 25 hours of caregiving a week. 
Clearly, these rules need close scrutiny, and some need some 
major change.
    In closing, let me thank you, on behalf of my family and 
other caregivers across the country, for your sincere efforts 
to make this program a success. The problems I've highlighted 
in my remarks and in my full statement can be solved. Doing so 
will strengthen the program and improve the well-being of our 
wounded warriors.
    Thank you for the privilege of testifying, and I would be 
happy to answer any questions you may have.
    [The prepared statement of Ms. Schulz appears on p. 30.]
    Ms. Buerkle. Thank you very much for your testimony here 
today. I know I speak for all of my Subcommittee Members as 
well, thank you for what you do for your son, and please extend 
our gratitude to him for his service and sacrifice on behalf of 
this Nation.
    Ms. Schulz. I will. Thank you.
    Ms. Buerkle. I would like to just talk a little bit about 
the application process. You mentioned that you felt that it 
was streamlined and seemed pretty efficient.
    Ms. Schulz. Yes.
    Ms. Buerkle. At what point after you applied, did you start 
to feel, if you felt any, some obstacles or some difficulties?
    Ms. Schulz. Well, I think at this initial phase, it was 
really pretty easy. And I have to give the VA credit for 
getting it up and going. Where it broke down was in the 
communicating back to me. For instance, I still haven't 
received how many hours, I haven't received any sort of written 
or really verbal notification of--I just received a check.
    And for other caregivers, it may be important if, say, they 
got approved for 10 hours, they need to know that, so if they 
don't agree, they can then have some recourse to come back and 
say, we need to rethink this or appeal it.
    So, in my case, it was pretty efficient. The home visit 
wasn't exactly what I hoped for. But aside from that, I think 
the process was good.
    Ms. Buerkle. Do you know if the decision to participate in 
caregivers' assistance and for you to be able to get a stipend, 
was contingent upon the home visit or were there any other 
factors?
    Ms. Schulz. My understanding, and of course, I am no 
expert, but my understanding was it was the home visit as well 
as his care team. And I am real lucky in that our VA care 
coordinator has been working with Steven since he was first 
injured. She was his social worker from the early days, so she 
knows our situation and knows the care team.
    Ms. Buerkle. Have you used any of the respite services that 
the Caregivers Assistance Program provides?
    Ms. Schulz. Not since the Caregiver Act has been 
implemented. I have used in the past, and it has been 
cumbersome and less than ideal for my situation. I am hoping 
that with this Caregivers Act, that it will be age appropriate 
and it will be home based to the needs of what the veteran 
needs.
    The program that I have used previously, you know, they can 
come out. They can work Monday through Friday. They can work 9 
to 5. Well, when I am gone, that doesn't always fit my life. I 
mean, like I am here now, and my youngest son is actually doing 
the caregiving. But if we had to, you know, juggle schedules, 
and he may have to work--he works part time--I might need 
somebody to cover evenings. I might need, you know, other times 
besides between 9 to 5. So I am hoping that with this new 
program, that it will take into account the real needs of the 
veteran.
    Ms. Buerkle. Thank you.
    Ms. Schulz, you mentioned that you noticed some 
disparities, from other caregivers that you talked to about the 
process and maybe some of them received an explanation for how 
much of a stipend they were receiving. What were the other 
disparities? My concern is that there is not a standardized 
effort here, and that the process needs standardizing.
    Ms. Schulz. And that is exactly my concern. While the 
application process has been easy for most people to get in, 
there have been instances of, well, let's just say, within the 
State of Texas, within 200 miles of me, another caregiver, 
whose son has a TBI, as well as a spinal cord injury, is unable 
to transfer out of his wheelchair by himself, cannot dress 
himself, and she was awarded 25 hours of caregiving a week. She 
received written notice. She knew--that's how I found out the 
treatment team was supposed to do the determination because she 
told me her PACT team. I didn't know what that was. So I learn 
a lot from other caregivers. But she told me that her PACT team 
made the determination, and she got 25 hours a week. How can 
that be right? And that sort of disparity is really 
discouraging to caregivers and veterans.
    Some of the other disparities in just how things are 
playing out. Another veteran applied, his wife applied, and 
they couldn't get a doctor, the VA social worker couldn't get a 
doctor to sign off on the initial application. His primary care 
doctor at the VA wouldn't sign off it. This is a veteran who 
has a TBI, as well as a spinal cord injury and hearing loss, 
and she is his caregiver and has been for several years. And I 
couldn't understand that. That's the type of disparity that 
really worries me and other caregivers.
    Ms. Buerkle. Thank you very much.
    My time has expired. I now yield 5 minutes to the Ranking 
Member, Mr. Michaud.
    Mr. Michaud. Thank you very much, Madam Chair.
    You mentioned that the home visit wasn't what you expected 
it to be. What did you expect the home visit to be? And why, is 
there anything that stuck out that they did that they should 
not have done or----
    Ms. Schulz. Well, my understanding of the home visit was to 
make sure that the home was appropriate and to also assess my 
needs as well as Steven's needs. And being a social worker in 
another life, I know, sort of how assessments should go, so 
that may have jaded me.
    But he came in and didn't know who the veteran was. He 
thought I was the veteran at first. And I was, like, no Steven. 
So he had not read the chart, which was a sort of red flag to 
me.
    The second thing was after he was doing, going through 
making sure I know about infection control, nutrition, all 
these things that I have been doing for 6 years now, and Steven 
has obviously been healthy and happy and at a good weight, not 
overweight or underweight, then he asked me if I know about 
catheter care. And Steven has never been at home with a 
catheter. Now for some veterans, that's an issue and I would 
need to know that. But I would like for the VA to realize that 
those home visits are a real chance to come out and see what 
the needs of the veteran and the caregiver are. That's what I 
was expecting.
    Mr. Michaud. As the VA starts to roll out its peer support 
mentoring program over the next year, do you have any 
suggestions on how this program should be implemented?
    Ms. Schulz. I have to be honest. I don't know what the peer 
support monitoring program is. Is that other veterans that will 
be----
    Mr. Michaud. Yes.
    Ms. Schulz. I have not heard about it.
    Mr. Michaud. Okay. Do you find that the VA hotline and 
caregiver Web site is user friendly? Have you used that?
    Ms. Schulz. I used the hotline initially when it first was 
announced at the VA program, and they were not ready to be 
answering questions at that time. They maybe rolled it out a 
little prematurely because the questions were all about the 
Caregiver Act and when it was going to be implemented, and they 
did not know at the time.
    And I find it easier, actually, and more effective to call 
directly to my son's social worker, who is now the care 
coordinator, or to my son's Federal recovery coordinator.
    Mr. Michaud. Do you think that the outreach to spread the 
word about the caregiver program has been sufficient?
    Ms. Schulz. I think that is an area where the VA has done 
excellent work because the day it was available, I had calls 
from my social worker and also an email, and there was also 
lots of information that was out in the public. It was on the 
social media sites, and so I think that that was an area they 
did very well in.
    Mr. Michaud. You had mentioned that the timeliness of 
getting approved was pretty quick. The implementation was not 
as good as possible. The VA has been trying to get them 
completed within 30 days. Was your process completed within 
that time frame?
    Ms. Schulz. It was close. It was very close. I have to say 
this is the fastest I have ever seen the VA move.
    Mr. Michaud. And my last question, if you had to make one 
change within the system, what would be the change that you 
would suggest?
    Ms. Schulz. One change? You are going to limit me? I think 
I would really tighten up those disparities so that that 
artificial cap of hours, because there are lots of veterans 
that need more than 40 hours. And what are we doing for them? 
And how can you--I mean, that disparity is so discouraging. And 
so really, working on that rule to get that right so that it is 
not just an artificial and so it is right across the country.
    Mr. Michaud. Great. Well, thank you very much, and please 
thank your son for me for his service to this great Nation of 
ours. I want to thank you, as well, for all the efforts that 
you are putting in to taking care of your son, as well as being 
here today to let us know how we can improve the legislation 
that was enacted. I yield back the balance of my time.
    Ms. Buerkle. Thank you.
    I now yield 5 minutes to the gentleman from Michigan, Dr. 
Benishek.
    Mr. Benishek. Thank you, Madam Chairman.
    Ms. Schulz, thank you so much for coming today. I just had 
a few questions to kind of clarify your situation. It seems 
like you must have had a relationship with the VA through your 
social worker that you know there and you have been taking care 
of. I mean, this is not the fellow that came out to review your 
situation for the home visit; this is somebody else then, 
right?
    Ms. Schulz. He was an RN that worked with the spinal cord 
unit is all I know, and I don't know if it is a new position 
for him, but he had not read the chart and had no relationship 
with us.
    Mr. Benishek. So did somebody come to your house to sort of 
evaluate? I mean, it would seem like your social worker that 
you have been working with would know what you are doing with 
your son on a daily basis, the care that he requires. So did 
somebody come out to just see how it's going at the house to 
observe you for a day or anything like that? No?
    Ms. Schulz. Well, yes. I mean, he came out to the house, 
and I have heard instances where they went through the 
refrigerator. I heard one veteran who was told they didn't have 
enough food in the house. This particular RN did not look at 
our pantry, did not look in our refrigerator, but asked if we 
had smoke detectors, you know, basic safety things, which, you 
know, 6 years ago, would have made sense to me when he was 
very, very frail, and he was first sent home. At this point it 
was a little insulting, actually.
    But I think that a home visit could be a real opportunity 
to find out what the veteran needs and what the caregiver 
needs.
    Mr. Benishek. Right. Do you have an ongoing conversation 
with the VA about what is happening with your son? Is it 
through the social worker? I mean, do you speak to them on a 
weekly basis then?
    Ms. Schulz. Not weekly. Probably, we talk to our Federal 
recovery coordinator once a month. I contact his social worker 
as needed. We see his doctors, depending on which doctor, 
probably every 3 to 6 months.
    Mr. Benishek. All right. How far away are you from a 
veteran facility that your son could get care? Where does he 
have to go to get care?
    Ms. Schulz. Our VA is about 30, 35 miles from us.
    Mr. Benishek. Okay. Is there anybody coming in to help you 
do any of this care on a regular basis? Is there a physical 
therapy or anything involved?
    Ms. Schulz. No. Not coming to the house, no.
    Mr. Benishek. It just seems to me that there should be a 
little more teamwork involved in helping the care progress, or 
and then, you know, making sure that you can get the proper 
amount of hours, I mean, just observing what you do on a daily 
basis it seems like it would be fairly easy to figure out by 
just observing what you do for a day or even a half a day. And 
it is a little disappointing to me to hear that you didn't get 
a letter explaining what the benefit would be.
    Ms. Schulz. And that has, I just have to share with you. 
That has always been my contention. If somebody from the VA 
came and spent 4 hours with me, especially early, early on, 
because I was requesting help back then and it wasn't 
available, they would know just how much and how needy he was.
    So for future veterans, I think your point is exactly 
right. Somebody needs to really assess what the veteran needs 
are in a home setting, and that teamwork is crucial.
    Mr. Benishek. Well, it just seems to me that there could be 
with the social worker that, you know, a mechanism for you to 
communicate what you need and maybe somebody could come to the 
house occasionally to help you or give you a morning off or 
something like that.
    Ms. Schulz. Prior to this law, nothing was available that 
was appropriate for this young age veteran who is active and 
doing things but needs help in everything he does. But the home 
help assistance that was offered to me was not age appropriate. 
It was not reliable. It was just not right for him, and most 
young veterans. It is set up for a geriatric population.
    Mr. Benishek. Right. How do you communicate with the other 
caregivers that you have been in contact with? Are these people 
that you have met at the hospital, during your going back----
    Ms. Schulz. People we have met at the hospital, at 
different veterans functions, just along the road you meet 
other veterans, and we use social media and telephone and e-
mail.
    Mr. Benishek. Okay. Well, I really appreciate your coming 
and giving us a picture of what you are going through here. I 
think it can be helpful going forward to, not only for 
yourself, but other caregivers throughout the country. So I 
really do appreciate you coming.
    And I yield back the remainder of my time.
    Ms. Buerkle. Thank you, Dr. Benishek.
    I now yield 5 minutes to the gentleman from New Jersey, Mr. 
Runyan.
    Mr. Runyan. Thank you, Madam Chair.
    And Ms. Schulz, thank you for the time you spend taking 
care of your son and for his service to this great country. You 
said earlier you really don't know what you are entitled to, 
you have gotten no communication back from the VA. Do you even 
know if you have a correct rating? Have you reached out to them 
since this process, from them--not even, like you said, you 
don't have a written or a verbal commitment from them. Have you 
reached out to them to see if they just forgot about you?
    Ms. Schulz. I have not, because I received the check on 
July 5 and so I was doing holiday stuff and so I have not 
emailed them.
    Mr. Runyan. Okay. Because, you know, going into some of 
your further testimony, and even some of the questions you have 
asked, it has been kind of--in the VA Committee, we always talk 
about the stakeholders being involved. And I think you have 
brought it up with the home inspection, it is a premier 
opportunity for that to happen, to really see what is going on 
there. And you know, it is not about--well, it seems like the 
VA approach is, well, you are not going to be entitled to this 
because you don't have this need, that need, this need. It is 
more of yourself, seeing the relationship between you and your 
son, not as mother and son, as caretaker and patient. And I 
think that is a unique opportunity that we really need to look 
at.
    Off the top of your head, do you have a round about number 
of how many hours you put in a week to actually take care of 
your son?
    Ms. Schulz. That is a tough question because if we are in 
the home environment, he may be sitting at his computer, 
working on stuff, and I am not really having to do anything. 
But say we are out somewhere, like if he would have come with 
me up here, somebody needs to be right there by him all the 
time because he can get lost and confused. But I would say 
anywhere from 50 to 60 hours a week is realistic. And mind you 
that Steven is not someone who needs hour-to-hour medical care. 
His is just safety, supervision and redirection.
    Mr. Runyan. Well, I think that raises the point where you 
say, you know, they want to cap hours. You know, depending on 
how active and how, whether they are out of the home, whether 
they are physically able to be out of the home. You can have 
the mental challenges with the TBI, the PTSD, that kind of 
stuff but physically be able to interact in society, but you 
need help with that.
    So I think going more towards a stakeholder approach, and 
having stories like yours is only going to help this process. 
And I think the VA really needs to be open to that and take a 
better approach on it. So I thank you for that.
    And Madam Chair, I yield back.
    Ms. Buerkle. Thank you again, Ms. Schulz.
    Unless anyone else has any further questions of our 
witness, thank you again for taking the time to come here today 
and answer our questions and testify before us.
    Ms. Schulz. Thank you so much.
    Ms. Buerkle. Thank you.
    And with that, I will ask Ms. Frese to begin her testimony.
    I would ask at this time that our second panel join us at 
the witness table. Also, with us this afternoon is Anna Frese, 
the Director of the Family Support Program for the Wounded 
Warrior Program (WWP); Ms. Cheryl Cox, the Caregiver Support 
Coordinator for the Syracuse VA Medical Center; and Ms. Mary 
Fullerton, the Caregiver Support Coordinator for the North 
Florida/South Georgia VA Healthcare System. Thank you all very 
much for joining us this afternoon.

 STATEMENTS OF ANNA FRESE, DIRECTOR, WARRIOR SUPPORT PROGRAM, 
 WOUNDED WARRIOR PROJECT; CHERYL COX, LCSW, CAREGIVER SUPPORT 
 COORDINATOR, SYRACUSE DEPARTMENT OF VETERANS AFFAIRS MEDICAL 
     CENTER, U.S. DEPARTMENT OF VETERANS AFFAIRS; AND MARY 
 FULLERTON, LCSW, CAREGIVER SUPPORT COORDINATOR, NORTH FLORIDA/
 SOUTH GEORGIA VETERANS HEALTHCARE SYSTEM, U.S. DEPARTMENT OF 
                        VETERANS AFFAIRS

                    STATEMENT OF ANNA FRESE

    Ms. Frese. Chairwoman Buerkle, Ranking Member Michaud and 
Members of the Subcommittee, thank you for inviting Wounded 
Warrior Project to testify today regarding the implementation 
of the Caregiver Assistance Program. The program's success is 
important to me, not only as WWP's Director of Family Support 
and liaison to family caregivers, but also as a long time 
advocate for my brother, Eric, whose injuries in Iraq led to 
his need for round-the-clock care due to severe brain injury.
    Let me thank this Committee for all it has done in shaping 
the caregiver law and jumpstarting and accelerating a process 
that now is directly helping members of families and insisting 
on full implementation of the law.
    Overall, I know VA has faced challenges in implementing 
this new program and that many dedicated staff worked hard to 
launch it. The process has gone relatively smoothly for numbers 
of families. Some have encountered problems, and other are 
waiting for applications to be processed.
    But I am really most concerned about VA's implementing 
regulation published on May 5 because it still fails to get 
some issues right. As a result, some deserving families will 
likely be denied help. Others will probably not get the 
extensive help they should, and many others were discouraged 
from even applying.
    VA's rule is a big improvement over the initial 
implementation plan. WWP has submitted extensive comments on 
VA's rule. But let me highlight just a few of the problems, 
many of which relate to warriors with TBI and mental health 
conditions.
    As currently written, eligibility criteria do not 
adequately address the need for caregiving as it applies to 
warriors with severe mental health conditions. Typically, where 
such a condition is really severe, a family feels that that 
they can't leave a warrior alone. But each case differs. But 
often, the warrior lacks full cognition or judgment to be fully 
aware of danger. In other cases, behavior may be marked by a 
lack of impulse control or might otherwise leave a family 
fearful of possible suicide risk or violence. In these kinds of 
instances, a family member typically stays with the veteran for 
much of the time to ensure the warrior's safety. Where those 
behaviors are due to TBI, VA's eligibility rule seems workable.
    But where the same safety risk is due to PTSD, depression 
or anxiety, it seems much less likely that VA will provide 
caregiver assistance under the new rules.
    A second area of concern is how VA's eligibility criteria 
are being applied around the country. WWP recently conducted a 
survey to understand families' experiences under the new 
program. Among the findings, the survey suggests there is a 
wide variability from facility to facility as to who makes 
eligibility determinations and how they are made.
    Let me share an example. One caregiver has provided almost 
constant care and supervision for her husband, who suffers from 
PTSD and traumatic brain injury; 11 days after applying for 
caregiver assistance, a VA nurse practitioner contacted her to 
advise her that the application had been denied. Without either 
reviewing the veteran's medical records or consulting his 
longstanding care team, the nurse concluded on the basis of the 
veteran's compensation and pension exam records that he did not 
need assistance in performing activities of daily living and, 
thus, wasn't eligible.
    Among her many errors was to overlook the fact that 
eligibility could solely be based on the need for supervision 
or protection. Luckily, this situation ended favorably, but 
only because a VA employee took--another VA employee--took the 
initiative to intervene. The case illustrates the inherent 
problem of the rule which is altogether vague as to how 
clinical eligibility determinations should be made and who is 
to make them.
    This and other cases also raise the question, how can a 
veteran or caregiver appeal an adverse medical or legal 
decision? The implementing regulation is completely silent on 
this issue. We believe it is essential that VA establish 
systematic recourse for those caregivers who may be denied 
benefits in error. But feedback from caregivers indicates they 
are unaware of where to turn in the event that they disagree 
with VA determination.
    Since caregivers generally can no longer work outside of 
the home and often care for loved ones on a full-time basis, 
the stipend was to provide some financial support. Let me offer 
an example to highlight what we see as flaws in the way the 
rule works regarding the amount of the stipend. Take the case 
of a veteran who sustained a severe TBI but, after a lengthy 
rehabilitation, is able to perform all activities of daily 
living. But the TBI manifests itself in severe mood swings, 
sometimes aggressive violent outbursts. Because he can't 
control these behaviors, even with medication, his wife must be 
with him full time.
    Applying VA's current rating skill, which measures need for 
assistance on a scale of zero to four, this veteran might get a 
score of four in three different areas, inability to self-
regulate, safety risk, and inability to plan or organize. But 
because the veteran doesn't need assistance in any other areas, 
he or she would get a total score of 12, which under the VA 
rule means the veteran is deemed to need only 10 hours a week 
of caregiver assistance. Yet, the veteran actually needs full-
time support.
    In closing, we do commend the VA for the substantial 
improvements they have made and for the speed in which they 
launched the program. We also believe flaws in the interim rule 
must be corrected to ensure that the programs fulfills the 
intent of the Congress and promise of the law.
    WWP looks forward to working with the VA and this Committee 
on that shared goal. Thank you.
    [The prepared statement of Ms. Frese appears on p. 33.]
    Ms. Buerkle. Thank you very much, Ms. Frese.
    Ms. Cox.

                 STATEMENT OF CHERYL COX, LCSW

    Ms. Cox. Good afternoon, Chairwoman Buerkle and Members of 
the Committee. Thank you for the invitation to discuss the 
Caregiver Support Program, established in title 1 of Public Law 
111-163, as implemented at the Syracuse VA Medical Center.
    My name is Cheryl Cox, and I am the Caregiver Support 
Coordinator at the Syracuse VA. I have been a clinical social 
worker at the VA for 4 years and was the ambulatory care social 
worker prior to becoming the caregiver support coordinator. I 
received my Master of Social Work from the State University of 
New York at Buffalo in 1993, and have over 18 years of 
experience working in mental health and medical settings.
    The care provided by family caregivers is essential in 
allowing our veterans to maintain as much independence as 
possible, remaining at home in their community, surrounded by 
their loved ones. I am truly honored to be a part of the 
groundbreaking Caregiver Support Program.
    Throughout my career, I have been fortunate to work with 
caregivers and am truly impressed with their tireless 
dedication and the level of care they provide. To date, the 
Syracuse VA Medical Center has received seven applications for 
the Family Caregiver Program. I am working with these veterans 
and their family caregivers as well as their medical team to 
complete the application process. Our first caregivers who have 
completed the caregiver training are expected to have their 
home visits and complete the process within the next week or 2.
    Throughout the initial implementation, I cannot say enough 
about Syracuse's Operation Enduring Freedom/Operation Iraqi 
Freedom (OEF/OIF) team and the support we have received from 
leadership, both at the local and national levels. In advance 
of accepting applications, our local OEF/OIF team identified 
potential eligible veterans and caregivers. Our team worked 
together to contact these veterans and caregivers to ensure 
that they were receiving all possible benefits and services, 
and to assist them with the application for this new program. 
Throughout April, the National Caregivers Support Office 
provided several key training sessions for the caregiver 
support coordinators on the program and application process.
    Since I began working at the VA, I have had the privilege 
of meeting and working with caregivers of veterans from all 
eras. In my role as an ambulatory care social worker, I have 
assisted numerous caregivers with information on VA and 
community programs and services, assisted with transitions to 
varying levels of care, and provided other forms of support. I 
am continually impressed with their dedication to their loved 
ones, and I am honored to be able to provide support to them.
    Through the Caregiver Support Program, I have had the 
opportunity to do intensive case management with those applying 
for the enhanced benefits. Again, these caregivers and the 
sacrifices they make never cease to amaze me. One young wife of 
a veteran comes to mind. This veteran suffered a gunshot wound 
to the head by sniper fire while serving in Iraq. He continues 
to have seizures, memory impairment and vision loss. Following 
his initial hospitalization and treatment, he spent 6 months in 
a traumatic brain injury center in Richmond, Virginia. His wife 
shared how she did not leave his side the entire time, juggling 
care for their two small children, who were 11 and 5 at that 
time. She has remained by his side as his wife, advocate and 
devoted caregiver. She has not been able to work outside the 
home due to her commitment to her husband and providing the 
care he needs. She has been very appreciative of the support 
and recognition this program provides.
    The Caregiver Support Line in Canandaigua has been 
operational since February of this year. It is an important 
part of this program, as it gives caregivers a place to turn 
for information and support. I have received several referrals 
from the support line to assist caregivers and families of 
veterans from all eras with questions regarding VA services and 
programs. In my role as the Caregiver Support coordinator, I 
have been able to provide assistance in leading them to 
appropriate VA and community resources while providing much 
needed support.
    Facilitywide, I have been actively providing education to 
staff on the Caregiver Support Program and exploring ways in 
which to reach out to as many caregivers as possible. Over the 
next few months, Syracuse will establish a Caregiver Support 
Advisory Board, and I will be implementing a support group for 
caregivers. I look forward to providing ongoing support to 
these unsung heroes.
    Thank you again for the opportunity to discuss Syracuse's 
implementation of the Caregiver Support Program.
    Ms. Buerkle. Thank you very much.
    Ms. Fullerton.

               STATEMENT OF MARY FULLERTON, LCSW

    Ms. Fullerton. Good afternoon, Chairwoman Buerkle, and 
Members of the Committee. Thank you for inviting me here to 
share how North Florida/South Georgia Veterans Health System 
has been implementing the family Caregiver Support Program.
    I have focused much of my career as a social worker working 
with veterans and their family caregivers, and it has been a 
wonderful opportunity to have been selected and serve as the 
full-time Caregiver Support Coordinator.
    VA Central Office has provided comprehensive training to 
the caregiver support coordinators, the teams and the services 
who are involved in this process.
    Additionally, Veterans Integrated Services Network (VISN) 8 
has regularly scheduled teleconferences where the caregiver 
support coordinators are informed about the program 
implementation, as well as offering a forum to ask questions. 
Experts have been brought in to help the caregiver support 
coordinators identify and better understand specific diagnoses, 
such as post-traumatic stress disorder.
    North Florida/South Georgia Veterans Health System 
leadership is very supportive of the Caregiver Support Program. 
I meet regularly with the patient aligned care teams to 
streamline the implementation processes for this program by 
discussing the role of the home-based primary care, traumatic 
brain injury mental health concerns, among others. I also meet 
regularly with our Medical Administration Services regarding 
benefit criteria, and I am working with volunteer services to 
identify additional ways we can support our veterans and their 
caregivers.
    Through July 1st of this year, North Florida/South Georgia 
Veterans Health System has received 23 applications for the 
primary family Caregiver Support Program. Nine of these 
applications are in process; 14 did not meet the program 
eligibility criteria. Of those that did not meet the 
eligibility criteria, six were injured before 9/11; one is on 
active duty without a date of discharge; five did not require 
the continuous and approved caregiver support services; and two 
experienced injuries that were not incurred or aggravated in 
the line of duty.
    My first application was with a veteran and his wife who 
live in South Georgia. He and his wife have been married for a 
number of years and have two wonderful children. This veteran 
experienced four blast injuries and lost consciousness during 
mortar blasts. As a result, he developed severe migraines and 
seizures. He has constant headaches. And when the migraines are 
severe, the pain is debilitating.
    He also experiences post-traumatic stress disorder, 
traumatic brain injury, visual impairment, tinnitus, loss of 
taste and smell, and multiple other problems. His wife was 
working full time as a teacher but has quit her job to take 
care of her husband full time at home. She openly states that 
what she does for her husband is inspired by the love that they 
share. She accepts the loss of her career with no regrets about 
her caregiving role. Currently their only income is from Social 
Security Disability and his VA benefits. She and I have 
discussed that no amount of money could purchase the type of 
care that she personally provides for her husband. Their VA 
OEF/OIF/Operation New Dawn case managers have been very active 
in this veteran's care, identifying supportive services for the 
whole family.
    The wife has shared how thankful she is for the current 
services being provided to the family. She has already 
participated in the Easter Seals training and felt that it was 
very beneficial. She is also very appreciative of the financial 
support, which will be paid directly to her.
    The application process for the Family Caregiver Program is 
only a part of the Caregiver Support Coordinator's role. I 
receive and respond to referrals from the VA Caregiver Support 
Line, and as of June 30 of this year, I had received over 100 
referrals. The majority of these referrals were Vietnam and 
World War II veterans and their caregivers. I follow up with 
these callers within 30 days and again at 60 days to see if I 
can provide additional assistance and offer supportive 
counseling and referrals for VA and community services.
    I also am involved in community outreach and coordinate 
care with agencies that provide additional services and support 
to the veterans and their caregivers. In May, I coordinated the 
eighth annual resource fair held at the VA. These were 
community agencies as well as VA services.
    Again, I appreciate the opportunity to talk with you today 
and would like to thank you for your ongoing support to our 
veterans and their families.
    Ms. Buerkle. Thank you very much. At this time, I will 
yield myself 5 minutes for questions.
    Ms. Frese, I would like to start with you, if you would. If 
you could change one thing with this program, where do you see 
a deficiency or something that needs to be changed?
    Ms. Frese. I think one of the issues is one that Debbie, 
Ms. Schulz, mentioned previously in dealing with the 
determination of the stipend and the range of hours. So I won't 
be redundant on that, but I think that is something that 
definitely attention needs to be brought to.
    I think the second thing is the eligibility, the mental 
health eligibility criteria. The IFR sets a much higher 
standard for eligibility with the current Global Assessment of 
Functioning (GAF) score in cases involving psychological trauma 
or other mental health conditions than for any other condition. 
And there seems to be a disparity in the needs for the mental 
health compared to the different physical disabilities that 
others may be having.
    The amount of hours the family caregivers are providing, I 
think, regardless of either the mental health condition or a 
physical disability remain the same. There is the need there. 
And I also hear from others that because seeing that GAF score 
and the eligibility criteria, it has dissuaded many from 
applying, just not understanding that they still may be 
eligible. And it also can create a misunderstanding with some 
of the professionals that they work with. The education with 
that eligibility criteria would be greatly helpful for the 
family members applying but also for some of the VA personnel 
that come into contact with the families, where there is a need 
and they would benefit from this program.
    Ms. Buerkle. Thank you.
    Ms. Cox, and Ms. Fullerton, what is the biggest complaint 
that you hear from both the veterans and the caregivers 
themselves? And, how would you suggest remedying them?
    Ms. Cox. I can tell you, in Syracuse, one of the biggest 
challenges has been the question about illness versus injury, 
and right now in the interim rule, it is specific to an injury 
that was incurred or aggravated on or after 9/11. And we do 
have caregivers that are providing significant amounts of care 
to veterans based on an illness that they may be service-
connected for, and under the regulation, they are not eligible, 
so that is what I am hearing the most about.
    Ms. Buerkle. Thank you. Ms. Fullerton.
    Ms. Fullerton. Quite honestly, ours has been going fairly 
well. I haven't heard any complaints. We focus on the veterans 
and working with the caregivers trying to meet their needs. We 
are lucky that we have open communication with all the team 
members that we can discuss if there were any issues coming up. 
I know that finances is probably the number one concern with 
these families, and it is really rewarding to be able to get 
them help that way.
    Ms. Buerkle. Thank you.
    This is maybe for Ms. Cox and Ms. Fullerton. If a veteran 
is denied access to the program, is there an appeal process? Do 
you know of anyone who has been denied and appealed and was 
successful?
    Ms. Cox. I can speak for Syracuse. We have had one that was 
denied. I did send a letter to the veteran and the caregiver 
explaining the appeals process and encouraged them to appeal if 
they feel like that is in their best interest. To date, they 
have not actually appealed the process.
    But I can say that I have worked closely with that family 
to let them know about the other services that they may be 
eligible for. And at this point, they may not be eligible for 
the stipend and some of the enhanced benefits, but we do have 
other services, like home-based primary care and home health 
aides that they could utilize.
    Ms. Buerkle. Thank you.
    Ms. Fullerton.
    Ms. Fullerton. We have had a few denials. I have talked 
with the caregivers and the veterans regarding what the denials 
were based on. They understand that it is a team decision; that 
we take into consideration their primary care, their OEF/OIF 
case managers, any mental health providers that are involved in 
that process. When I explain the criteria and the severity of 
illness and the need for the essential caregiver, they 
understand that. I do explain when they are denied that there 
is an appeals process, and they are more than welcome to go 
through that, and I would help to walk them through that.
    Ms. Buerkle. Thank you very much.
    At this time, I yield to the Ranking Member, Mr. Michaud.
    Mr. Michaud. Thank you very much, Madam Chair.
    When the caregiver is going through the process, do they 
participate in the clinical assessment at the start of the 
process?
    Ms. Fullerton. Actually, my experience I have had one wife 
that asked to be part of the clinical evaluation with her 
primary care provider, and he welcomed that. You know, they 
said, by all means, for them to be there. Most of the providers 
actually know the wives and, I say wives--that is who are our 
caregivers, the majority of them--know both of them. So they 
have been very open to have them part of that.
    Ms. Cox. And in Syracuse, we have used a team approach, so 
most, actually all, of the veterans that have applied have been 
closely case managed by our OEF OIF team. They know them very 
well, so we have worked with them and their primary care 
doctor, and then if they have other components, like mental 
health, so we have done it really as a team to make sure that 
we are being as inclusive as possible.
    Mr. Michaud. But it is not required that you be inclusive?
    Ms. Cox. It is not required, but once we receive the 
initial application, the caregiver support coordinator is 
expected to contact the caregiver to do an initial assessment 
within 2 days. So when I do that, I do elicit from the 
caregiver the kinds of things that they are assisting the 
veterans with so that I can bring that back to the team and 
assist with the clinical eligibility.
    Mr. Michaud. Ms. Frese, have you found it, among the 
individuals that you talked to, that it is a problem that the 
caregiver is not part of the clinical assessment process?
    Ms. Frese. I think it makes the most sense, as you heard 
again from Ms. Schulz herself, that the majority of these 
families, many of the families have been doing this for an 
extended period of time and have a very established treatment 
team, and so it seems to make most sense that with the receipt 
of an application from that caregiver, that that treatment team 
would be questioned or involved from the beginning and the 
caregiver would be part of that.
    The surveys that we had sent out and received back, it is 
not--that is an inconsistency that we did receive back, that 
the majority, there is not an active involvement in working 
with a team and understanding where the decision process is 
coming, how it has been made, who is involved and coming down 
to the endpoint of determining the number of hours of where 
that came from.
    Mr. Michaud. Thank you.
    Ms. Fullerton, you mentioned that you received a lot of 
training from the VA for case workers. However, we heard Ms. 
Schulz mention in her testimony that the case worker came there 
and thought that she was the veteran, so evidently, they did 
not read the case, so I have to question the training, or is it 
just this one individual that did not do his or her work?
    Ms. Fullerton. At North Florida/South Georgia, the home-
based primary care team is the one that is going to be doing 
that initial assessment and the monitoring. They are very well 
trained to work with the veterans and the caregivers in the 
home. I have talked to them personally about every veteran that 
is coming through the training system that would be coming up, 
and they have been able to access the records, and we have 
talked about what the needs are. And that is considered a very 
supportive visit. They have a template that they would be 
filling out to make sure the home is safe and that the veteran 
and the caregiver understands the training that they have and 
if they have any supports with that, but it is going to be a 
person that is very familiar with coming into the home and will 
know that veteran, if not face to face, will know their record. 
We have had two veterans that actually are followed by home-
based primary care, so they are very familiar, which is nice.
    Mr. Michaud. I guess I would be concerned hearing Ms. 
Schulz' testimony when she did not have a very good home visit 
and, in fact, that they didn't know who the veteran was. I 
guess that is a little concerning about the training. Maybe it 
is just this one individual.
    My next question actually for Ms. Cox and Ms. Fullerton, as 
the VA rolls out its peer support monitoring program over the 
next year, whether it is veteran to veteran or caregiver to 
caregiver, do you have any suggestions to how the program 
should be implemented?
    Ms. Cox. I guess I would have to think about that a little 
bit. But I know that, you know, as social workers and as 
caregiver supports programs, we are generally involved in 
support groups, and so if we could assist with facilitating or 
giving input into how those groups work and what works best 
that might be helpful. And I would imagine we would have a 
piece of assisting in the implementation.
    Mr. Michaud. Thank you very much, Madam Chair.
    Ms. Buerkle. Thank you.
    I now yield 5 minutes to the gentleman from Michigan, Dr. 
Benishek.
    Mr. Benishek. Thank you, Madam Chairman.
    Well, it seems that Ms. Cox and Ms. Fullerton have a little 
different experience than Ms. Schulz related to us here. I 
mean, it sounds as if you are relating to me a much better 
evaluation than Ms. Schulz related to us.
    Do you have an ongoing communication then, like, more often 
than once a month, with the patients? I mean, I just think, 
from the testimony, there is a lot of variability here in the 
care. I just wanted to know, is there someone here that we 
could find out more about that variability in care?
    Ms. Cox. I believe Ms. Amdur will talk to the clinical 
eligibility and the assessment.
    But I can say, in Syracuse, we have had seven applications. 
So it is on the--I don't want to say the lower end, but I 
really have time to be in contact with the caregivers that are 
applying for the program in Syracuse.
    And I did hear Ms. Schulz's concerns about the home visit. 
And I agree, it really shouldn't happen like that. But I think 
we are working together with the teams and trying to do the 
best that we can for the veterans and the caregivers to get 
them the services they need.
    We also have weekly calls across the Nation, national 
calls, where we receive ongoing support and training. And, at 
the local level, we have biweekly calls in our network. So we 
are communicating with the other caregiver support 
coordinators, trying to make sure that we are on the same page.
    Mr. Benishek. Ms. Frese, do you have any support with a 
caregiver support coordinator? I mean, have you worked with 
people like Ms. Cox and Ms. Fullerton, in your experience?
    Ms. Frese. I have not had direct contact with the caregiver 
support coordinators. In my family's experience, my mother has 
completed the application and has had contact with them. And in 
visiting with the families, you know, I think----
    Mr. Benishek. You are not very far along in the process, is 
that what I am getting from you?
    Ms. Frese. Our family is not, but I think, you know, in 
hearing from Debbie as well, VA launched this program quickly. 
And WWP has heard from caregivers that the--there have been 
many positive actions with the caregiver support coordinators. 
And that has maybe been one of the first positive contacts with 
the VA at that beginning stage. They were informative in the 
beginning with the 800-number. Maybe not----
    Mr. Benishek. Well, yeah----
    Ms. Frese [continuing]. The best prepared, but at least the 
coordinators were informed.
    But I think we are looking at--you know, the success of 
this program depends on the framework that has been 
established. And the framework has serious holes in it, such as 
we addressed with the mental health eligibility and the 
determination for the stipend.
    Mr. Benishek. So, then, does every medical center end up 
having a caregiver support coordinator then?
    Ms. Cox. We do, yes.
    Ms. Fullerton. We have an alternate, as well. So if we are 
here, we have an alternate that has gone through the same 
training and is involved in the phone calls, so they can kind 
of step in and be us for a while.
    Mr. Benishek. All right. Well, I understand this is all 
still pretty new, but I think it is going to involve a little 
continued monitoring, as far as I can see, to make sure that 
the results that you two are seeing reflect what is going on 
throughout the system. So I look forward to continuing 
oversight of this process.
    I will give back the rest of my time. Thank you.
    Ms. Buerkle. Thank you, Dr. Benishek.
    I now yield 5 minutes to gentleman from New Jersey, Mr. 
Runyan.
    Mr. Runyan. Thank you, Madam Chair.
    And, ladies, thank you for your testimony.
    Ms. Cox, you might have more of a background on this, but I 
was curious: As we are trying to find the proper number of 
hours to care to disability, is there anything in the private 
sector, whether it is county statistics, maybe Alzheimer's 
Association, are there organizations like that that have 
formulas?
    Ms. Cox. Not that I am aware of, to date. And I think that 
this program is pretty groundbreaking. I don't know of other 
community agencies that actually pay a stipend to caregivers to 
provide that care. So I am not really aware of a specific 
formula that would help identify the----
    Mr. Runyan. But not so much to--not so tied to a dollar 
amount, but just the needs of hours.
    Ms. Cox. Uh-huh.
    Mr. Runyan. Not aware of any?
    Ms. Cox. Yeah, not that I am aware of.
    Mr. Runyan. Because I know, dealing with that--I, frankly, 
have had two family members have Alzheimer's disease and pass 
from it--I know how difficult that can be. And I currently have 
one with dementia that is going through the same deal and also 
going through the process, which raises another question.
    When you do have a brain injury early on, you may not need 
medical treatment for it, but, obviously, as we move down the 
road and we age, it is a precursor to early-onset dementia or 
Alzheimer's, which is going to require things like this. I 
think having the ability to--I don't know if the VA is going to 
be able to pull out these numbers and be able to do that type 
of stuff early on.
    But I was just asking, with your background of--they were 
out there, and obviously not. And I think that obviously one of 
the questions we have, is: How do we get this, and how do, you 
know, we make it across the board? Because there are exceptions 
to every rule----
    Ms. Cox. Right.
    Mr. Runyan [continuing]. And everybody needs to be treated 
fairly. I guess we don't.
    And that is really all I had. I yield back the remainder of 
my time.
    Ms. Buerkle. Thank you, Mr. Runyan.
    I now yield to the gentleman from Tennessee, Dr. Roe.
    Mr. Roe. Thank you.
    And thank you all for being here.
    And, Ms. Schulz, I read your testimony here, and it is very 
compelling. But back to what Congressman Runyan is saying, 
there probably are some private-sector models if you look, for-
profit and non-for-profit health care organizations that are 
caregivers. They don't provide a technician or a nurse or an 
LPN, but they go and they wash clothes and help. So there are 
probably some models out there. And I don't know that that 
would be helpful, but I would look.
    And, certainly, it is 24/7. I will give you just one brief 
example of someone I know who was shot through the neck in 
1968, and his wife was told that he would probably live 7 
years. He is still alive. And he is alive because of his 
caregiver. She was 19 years old with an 11-month-old child when 
that happened. And she is still taking care of him today.
    And I think, Ms. Frese, your point about including these 
people--they are experts. When the professionals like me and 
the medical system, told her that her husband would live 7 
years and he has lived over 40, I think I would listen to those 
folks. So I think that is a great point you make, that they 
should be brought in and questioned about what they have been 
doing. You obviously have been doing something right. So I 
would definitely do that.
    What are the biggest hurdles that you have found so far in 
doing this? I know, as Dr. Benishek said, this is new 
territory. So what is the biggest frustration hurdle you have 
had so far?
    Ms. Cox. So, just to reiterate, the biggest challenge for 
me as a clinician, because I want to support these caregivers 
and I want them to have what they need to continue to provide 
this care, has been the illness versus injury and that it 
excludes some caregivers that provide significant amounts of 
physical care to our veterans.
    Mr. Roe. Okay.
    Ms. Fullerton. I have worked in geriatrics quite a long 
time, and I have heard a number of things from the vets that 
are not within this 9/11 era and that they are doing the same 
type caregiving. And it is a little bit frustrating that this 
program is not open to them. I have encouraged them that they 
will hopefully be considered at some time.
    I make sure that I refer them to as many as services as 
there are. They are eligible for the respite program regardless 
of what era they are, you know, for in-home respite. So, make 
sure they have the supports they can. But to not be recognized 
financially has been difficult.
    Mr. Roe. I agree with you. I mean, this caregiver that I am 
speaking of, she is a hero to me. I mean, she has saved the 
taxpayers millions of dollars with the care. She gave up a 
career. What is so frustrating for me for her is that, not only 
is she not included in this bill, she also couldn't be in the 
workforce and gather time with Social Security.
    And you know that her husband's life expectancy--he is 
about 69 years old now--is not going to be as long as hers will 
be. And I don't know how we make that right, but we need to 
make that right. That is something that, when I first heard 
that situation, I thought, that is a wrong that needs to be 
corrected. And I don't know how we do that.
    But I agree with you, that is one that I have seen 
personally. And there probably are many, many others. And that 
is not taking care of a veteran who is a senior who has 
diabetes and so forth. It had nothing to do with service-
connection through an injury that occurred in--whether it was 
World War II, Korea, Vietnam, wherever, Desert Storm, it 
doesn't matter. So I agree with you.
    I thank you all for being here.
    And I yield back the balance of my time.
    Ms. Buerkle. Thank you very much.
    Unless any of my colleagues have additional questions, 
thank you all very much for your testimony here today. You are 
now excused.
    And, at this point, we will ask our third and final panel 
to come to the witness table.
    Representing the Department is Ms. Deborah Amdur, the Chief 
Consultant for Care Management and Social Work for the Veterans 
Health Administration. Accompanying Ms. Amdur is Mr. Keith A. 
Welsh, the Director of the National Caregiver Support Program.
    I welcome both of you today, and we look forward to hearing 
your testimony.
    Ms. Amdur, you may proceed.

STATEMENT OF DEBORAH AMDUR, LCSW, ACSW, CHIEF CONSULTANT, CARE 
      MANAGEMENT AND SOCIAL WORK SERVICE, VETERANS HEALTH 
     ADMINISTRATION, U.S. DEPARTMENT OF VETERANS AFFAIRS; 
    ACCOMPANIED BY KEITH A. WELSH, LCSW, DIRECTOR, NATIONAL 
CAREGIVER SUPPORT PROGRAM, VETERANS HEALTH ADMINISTRATION, U.S. 
                 DEPARTMENT OF VETERANS AFFAIRS

    Ms. Amdur. Thank you.
    Chairwoman Buerkle, Ranking Member Michaud, and 
distinguished Members of the Committee, thank you for the 
opportunity to discuss the progress VA has made in implementing 
the provisions of title I of the Caregivers and Veterans 
Omnibus Health Services Act of 2010.
    I would like to acknowledge our family caregivers, Ms. 
Frese and Ms. Schulz, who came to share their experiences 
today, and acknowledge the veterans that they provide care for.
    With me is Keith Welsh, our National Caregiver Program 
Director.
    When we appeared before you in March, you asked us if we 
would be providing services and support to families by July. I 
am happy to report that we are delivering the benefits and 
services created under the Caregivers Act. We are providing 
family members who have taken on the responsibility to be the 
primary family caregiver with stipends, and we are training 
hundreds of family caregivers to deliver the support our 
veterans need.
    Many VA staff members have worked very hard to get this 
program up and running because we understand the key role that 
family members fill in supporting a veteran's independence and 
wellbeing.
    Earlier this year, we heard your concerns and the concerns 
of the veterans service organizations and revised our plans for 
implementing the program in response. We made a special effort 
to be explicit that eligible veterans with traumatic brain 
injuries and significant mental health challenges would qualify 
for these benefits. And we developed a broader set of 
eligibility criteria consistent with the law that will allow 
several thousand veterans to qualify. We estimate approximately 
3,600 veterans and servicemembers will meet the criteria that 
we have adopted in the interim final rule published on May 5th.
    Today, we are processing more than 1,400 applications and 
have over 300 primary family caregivers who have completed the 
approval process, which includes comprehensive training and a 
follow-up home visit. Once approved, we are providing them with 
stipends and health care benefits if they are eligible, 
retroactive to the date of their initial application.
    VA has trained several hundred family caregivers already, 
and we continue to train more every day. Training is available 
in person at VA medical centers and community locations, 
through self-study by book and DVD, and an online option will 
be available starting next week.
    In implementing this program, we have developed a hybrid 
model that has centralized many of the administrative functions 
while decentralizing clinical decision-making. This approach 
ensures that our experts in the field are able to focus on 
addressing the specific needs of each veteran while delivering 
consistent health care and stipend benefits to designated and 
eligible primary family caregivers. This approach allows us to 
monitor the status of applications across the system. It will 
also make it easier to identify any variations that occur in 
delivery of the benefit.
    We have provided comprehensive training to VA caregiver 
support coordinators and clinicians who are responsible for 
determining a veteran's eligibility for the program. However, 
recognizing that this is a new benefit and effort, VA is 
monitoring these decisions to ensure that we are consistent in 
how we apply the program criteria.
    We are continuing to reach out to eligible veterans and 
encourage them to apply. We have contacted Post-9/11 veterans 
currently receiving aid and attendance benefits from VA to 
recommend that they submit an application for the Family 
Caregiver Assistance Program. We appreciate the Committee's 
efforts to help us spread the word about this program as well.
    Looking forward, we will continue to review the public 
comments we received concerning the interim final rule. The 
window for submitting comments closed on July 5th, and our 
final rule will either continue the program as implemented or 
revise it based upon our considerations of these comments.
    VA will also continue to provide the array of services 
already available to eligible and enrolled veterans and their 
caregivers, including such programs and services as home-based 
primary care, our caregiver support line, home telehealth, 
respite care, and our new caregiver Web site, which provides a 
wealth of information and resources for caregivers, veterans, 
families, and the public.
    Evidence-based support programs and a peer-support 
mentoring program are in development and will be rolled out 
over the next 12 months to provide further assistance to our 
family caregivers.
    Although we have only recently initiated this program, we 
have received a great deal of positive feedback from veterans 
and their caregivers on the services that we are delivering and 
the support that VA professionals in the field are providing. 
We appreciate the Committee's support as we continue to work to 
deliver the benefits that veterans and their caregivers have 
earned.
    Thank you for inviting me here today to share the progress 
that we have made. I am prepared to answer your questions at 
this time.
    [The prepared statement of Ms. Amdur appears on p. 37.]
    Ms. Buerkle. Thank you very much.
    At this time, I will yield myself 5 minutes for questions.
    You were here during Ms. Schulz's testimony. She talked to 
us about just receiving the stipend payment with no explanation 
of the benefit or the stipend. And I am interested to hear why 
that isn't explained to the caregiver, how you don't 
rationalize or justify what it is they are being paid and how 
you are allocating that stipend?
    Ms. Amdur. As our caregiver support coordinators indicated, 
we did provide and continue to provide extensive training to 
those in the field who are implementing the actual program and 
benefits. And we have heard the concerns, and take them very 
seriously, that we need to have more transparency in terms of 
how decisions are made.
    And so we are first reminding our caregiver support 
coordinators that they need to make sure that they are sharing 
very openly with the family caregivers and the veterans the 
basis on which decisions are made. We are also in the process 
of developing a letter, which will be included with the letter 
that is currently sent that notifies the family caregiver and 
veteran of their eligibility for the program. And that will 
include an explanation of how the determination was made.
    Ms. Buerkle. When will that be implemented so we can be 
assured that all the caregiver assistants are receiving this 
information?
    Ms. Amdur. We are really working to implement that 
immediately. We feel it is extremely important.
    The other thing that I think is really essential here is 
that we are sure that everybody is well-informed about the 
appeals process and the fact that, you know, we are very open 
to that. Certainly, we know our clinicians are very interested 
in hearing if there are concerns about the eligibility 
assessment process and are very supportive of individuals 
appealing the decisions and reconsidering them.
    I do want to let you know that we, as I said, have concerns 
about inter-rater reliability: 152 medical centers; we want to 
ensure that these criteria are being implemented across the 
board in an appropriate manner. So we do have a quality 
assessment measure under way. We have asked alternate 
clinicians to review not just the eligibility assessment forms 
that have been completed but also the medical records in order 
to compare whether they would reach the same conclusion as the 
team that has done the initial assessment.
    I can share with you the results of our initial assessment 
of 50 records. Eighty-four percent were consistent with the 
eligibility and had no difference in the tier level.
    Sixteen percent of them had a difference in the tier level 
that was determined, but, actually, it was in the veteran's 
favor. And this is what we expected. I mean, we know that our 
clinicians want to do the best possible for all of these 
veterans and their caregivers, so it wasn't surprising to us 
that they may have ranked something higher than a second 
review.
    There were three that were scored lower. We have looked 
into those cases. One of them we felt, you know, there were 
serious concerns and have asked for a reconsideration of that 
particular case.
    Ms. Buerkle. Thank you.
    In the instance where the veteran is denied and then they 
appeal, I understand there is an appeals process. Is it the 
same reviewing body that goes through the criteria? Or does it 
go to a higher level, as it would in a court?
    Ms. Amdur. It does. VA has a clinical appeals process that 
has been in existence for a long time, and it is that process 
that we are using. The case is reviewed by the chief of staff 
at the medical center and clinicians that he or she will 
determine should be involved in that. But they are not the 
clinicians who made the original determination.
    Ms. Buerkle. Thank you.
    Ms. Amdur. If the family is still uncomfortable with that 
decision, we then will bump it up to the VISN level and 
eventually to Central Office, where we would convene a board to 
re-review.
    Ms. Buerkle. Thank you.
    There are a lot of concerns that have been raised regarding 
the fact that this stipend and this reimbursement to the 
caregiver should be made retroactive because the VA failed to 
enact this in a timely manner pursuant to the statute. And, I 
just would like to have you speak to that issue.
    Ms. Amdur. We have had that issue reviewed. It has been 
discussed and under consideration. You know, my understanding 
at this point was that the determination was that we would 
backdate to the time of the initial applications.
    But, certainly, we will, along with other things, look at 
that as well, because it is one of the comments that we 
received in the commentary on the IFR. We are taking those very 
seriously. They are under review at this point, and we will 
certainly respond to them in our response with the final rule.
    Ms. Buerkle. I see my time has expired. Just one quick 
question.
    If you are talking about--is that a case-by-case, making it 
retroactive? Or is that just--that would be something, you look 
at all the comments and you make the decision that, no, 
everyone should be reimbursed retroactively because it wasn't 
their fault that this was delayed?
    Ms. Amdur. I think we would absolutely make a decision like 
that consistent across the board.
    Ms. Buerkle. Thank you very much.
    I yield now to the Ranking Member, Mr. Michaud.
    Mr. Michaud. Thank you very much, Madam Chair.
    In reading the Paralyzed Veterans of America's written 
testimony, they question the commitment the VA has to this 
particular program, citing lack of funding in 2012. Trying 
figure out exactly what the money is, it is hard to figure out. 
Can you tell us what the budget request is and how you arrived 
at that number?
    Ms. Amdur. Certainly.
    In our 2012 budget, our projected need was for $158 
million. It was based upon our calculations of the potential 
number of individuals that would be eligible and the services 
and benefits that would be provided to them, as well as 
inclusion of services and benefits that would be provided under 
the provision of the law for general caregivers.
    We are looking on a regular basis in terms of our rate of 
new applications that we are receiving. We will be in a better 
position to make a firm determination once we get closer to the 
end of this fiscal year. But we have been assured that we will 
have that amount of funding and what is needed in order to be 
in full implementation in 2012.
    Mr. Michaud. And would you be able to provide the Committee 
the number of requests that you receive for services when you 
have the final number?
    Ms. Amdur. Absolutely. I would also be very happy, sir, to 
come on a regular basis and brief all of you, if that would be 
helpful to the Committee.
    Mr. Michaud. I asked the other panel--and there is no 
policy, or it is not in the rules, but are family caregivers 
able to participate in the in-person clinical assessment? It 
appears that they have been, but, here again, this might not be 
consistent throughout the VA system. Do you see a problem with 
making that a part of the process?
    Ms. Amdur. Not at all. I think that our clinicians do 
recognize that the family caregivers have extremely valuable 
information in terms of what the care needs of that individual 
veteran are and that we really need to be getting their input.
    As our caregiver support coordinators shared, I mean, many 
of these families are very well known to our clinical teams. 
They have been working with them for many years, in some cases. 
And so I think that they really do know and understand and are 
regularly communicating with the family caregivers.
    But we will absolutely make sure that that message is sent 
out loud and clear, that their input needs to be considered and 
they need to participate in that evaluation process, yes.
    Mr. Michaud. You had mentioned, as did the previous panel, 
about the comprehensive training that VA employees receive. 
What is really astonishing, though--and I heard Ms. Schulz's 
testimony about her home visit; it wasn't what she thought it 
would be. I mean, just one of the basic things I still can't 
get over is where someone mistook her for the veteran. That 
seems to be very basic. Evidently, he didn't even read what he 
was supposed to, and so I would question the training, or is it 
this just one employee that----
    Ms. Amdur. I, too, found that extremely concerning, believe 
me. As a clinician, you know, who has done home care, I know 
the importance of certainly making sure you are well-read in 
terms of the case and the individual that you are visiting and 
know and understand as much as you can about the situation 
before you go into that home.
    And, you know, one of the things that we have relied on our 
colleagues in the veterans service organizations is, when they 
do hear about cases like this--and we greatly appreciate her 
sharing this--it gives us an opportunity to go back to that 
particular facility and really look at what their internal 
systems are.
    In general, I think that we certainly have received some 
very positive input in terms of the home visits, descriptions 
that they felt that the team that came in or the individual 
that came in was a true ally to them, that they felt a great 
sense of understanding; it was very validating to have somebody 
in the home really recognize what their experiences have been.
    So, you know, important, again, to go back to those 
individual situations where the experience is not what it 
should be and an opportunity to retrain and revisit how they 
are implementing.
    Mr. Michaud. Thank you very much. I think that is extremely 
important, because I have also heard a lot of positive comments 
from caregivers as far as the program. But you always are going 
to get individuals out there who are not doing what they should 
have been doing, and those are the ones that will tend to be 
highlighted over and over again. So I am very glad to see that 
you are taking it seriously in trying to solve the problem 
before it gets worse.
    Ms. Amdur. Absolutely. Thank you.
    Mr. Michaud. Thank you.
    I yield back, Madam Chair.
    Ms. Buerkle. Thank you very much.
    I now yield to the gentleman from New Jersey, Mr. Runyan.
    Mr. Runyan. Thank you, Madam Chair.
    And thank you for your testimony.
    I just wanted to revisit, really, two questions. One 
previously I think had been asked, but the other one dealing 
with home inspections and it being an opportunity for a 
caretaker, in the comfort of their own home, to really have a 
lot of our stakeholder input in it.
    Ms. Amdur. Yes.
    Mr. Runyan. I don't know if it was you or one of the other 
panelists mentioned a checklist. You know, that is all great, 
but it is the interaction, the ability to take these ideas back 
to the VA and really know the needs. Obviously, the VA has the 
needs; that is the checklist. But we need to expand that.
    Is there a process there to have that implemented?
    Ms. Amdur. Oh, absolutely. And I think that the majority of 
our folks who are out there doing these home visits are well-
seasoned clinicians who are, on a regular basis, in veterans' 
homes and do understand the importance, that this is not a 
policing activity; they are there to really sit down with that 
veteran and family caregiver, talk about where they are, what 
they need, are there other services that we need to bring in 
that home, other equipment.
    And, you know, again, I am alarmed at what was shared, but 
we also have folks who are really sharing with us, on blogs and 
emails and so forth, that they have found an experience that 
was quite different, which is what we certainly would promote.
    Mr. Runyan. Thank you.
    And going back to the same question I asked Ms. Cox, about 
finding, you know, everybody has their own needs, whether it is 
hours or something else--in your testimony, you brought up your 
partnership with Easter Seals. And are there statistics out 
there from non-profits, you know, publicly available statistics 
that say, this is how many hours a day we spend with a person 
in this condition?
    Ms. Amdur. Actually, the National Alliance for Caregiving 
completed a study of caregivers of veterans, which was 
published in January of this past year. And that has been 
extremely helpful for us, because it did provide us with some 
data, not just about caregivers in general, but about veteran 
caregivers. I believe, in that study, the average amount of 
time that a family caregiver was providing care, direct care, 
was about 20, 21 hours a week, if I recall. But, you know, 
there are studies out there, and we certainly are looking at 
them and also getting input from our family caregivers.
    One of the things, though, that is important to us is that 
we don't want our family caregivers to feel that they have to 
report hours to us. That is not what is intended here. There is 
a process, an assignment of a stipend amount, the idea being 
that they don't need to be reporting those hours on a regular 
basis. That doesn't mean we don't want to take into account the 
amount of hours that they are providing. But, again, you know, 
this is something in recognition of the overall sacrifices that 
they are making.
    Mr. Runyan. Very well. And mostly because they are usually 
on call 24 hours a day because they happen to be in the home, 
which, frankly, saves us millions, billions of dollars a year.
    Ms. Amdur. Without question.
    Mr. Runyan. Thank you very much.
    I yield back the balance of my time.
    Ms. Buerkle. Thank you very much.
    If there are no further questions, I move that Members have 
5 legislative days to revise and extend their remarks and 
include extraneous materials.
    Without objection, so ordered.
    Once again, on behalf of the Health Subcommittee, I would 
like to thank all of you for being here today and for your 
testimony.
    We will continue to monitor the progress of the VA 
regarding the Caregivers Assistance Program. As we have 
consistently said, time is of the essence, because our men and 
women deserve this. They deserve us to act responsibly and to 
provide for the folks who are willing to give them care in 
their home and maintain that high level of care that Dr. Roe 
spoke of, we need to be there for them quickly--yesterday, 
pretty much.
    So we will continue to monitor this. We will have another 
hearing probably within the next 3 months, and we will stay on 
top of this so we can assure our veterans and the people who 
need our services that they will get them.
    Thank you all very much. This hearing is now adjourned.
    Ms. Amdur. Thank you.
    [Whereupon, at 5:29 p.m., the Subcommittee was adjourned.]

                            A P P E N D I X

                              ----------                              

       Prepared Statement of Hon. Ann Marie Buerkle, Chairwoman, 
                         Subcommittee on Health
    Good morning. The Subcommittee will come to order.
    Four months ago today, this Subcommittee held our first hearing of 
the year to discuss why the Department of Veterans Affairs (VA) had 
failed to implement the caregiver assistance program as required by 
Public Law 111-163.
    At that hearing, it was clear to me that VA must go back and 
address serious deficiencies with the Department's initial 
implementation plan, particularly the strict eligibility requirements, 
and get this important program up and running.
    Today, we meet again to determine the progress the Department has 
made in the intervening months to adjust its implementation plan and do 
right by our veterans and their caregivers who have already given so 
much.
    In response to the concerns of Members, advocates and stakeholders, 
VA changed its eligibility requirements and expedited the 
implementation of caregiver benefits by publishing an Interim Final 
Rule (IFR) on May 5, 2011. The IFR allowed the Department to accelerate 
the Federal rulemaking process by immediately implementing the program 
prior to the consideration of public comments and issuing a final rule.
    As the daughter of a full-time caregiver, I understand the profound 
impact injury can have not only on the injured, but also on his or her 
loved ones.
    Time is of the essence for these families--many of whom have 
sacrificed their personal, professional, and financial security in 
order to take on full-time caregiving responsibilities for their 
veteran family member. We owe it to these men and women to get it right 
and we will not rest until we do.
    Today, we will hear from Debbie Schulz, a full-time caregiver for 
her son Steven who was injured in Iraq in 2005. She will speak to her 
experience applying for and obtaining services from the VA.
    We will assess the actions VA has taken to date to meet the intent 
of the law and the changes that need to be considered prior to issuing 
the final rule.
    Thank you all for being with us this morning. I am very much 
looking forward to our discussion.
    I now yield to the Ranking Member, Mr. Michaud, for any opening 
statement he may have.
                                 
   Prepared Statement of Hon. Michael H. Michaud, Ranking Democratic 
                     Member, Subcommittee on Health
    Thank you, Madam Chair.
    I would like to thank you for holding today's hearing on Public Law 
111-163, the Caregivers and Veterans Omnibus Health Services Act of 
2010. Today's hearing follows up on a March 11, 2011, Subcommittee on 
Health hearing on this very same issue where concerns were raised 
regarding the delays in the rollout of the implementation plan, the 
narrowing of criteria for eligibility of these benefits, and next 
steps.
    At the beginning of July, the Department of Veterans Affairs issued 
its very first payments to family caregivers of veterans. These family 
caregivers were the first to complete their caregiver training under 
the program of Comprehensive Assistance for Family Caregivers, and VA 
will send out more than $430,000 in stipend payments to nearly 200 
recipients this month alone.
    I am pleased that veterans and caregivers are finally beginning to 
receive some of the services required by P.L. 111-163, and I am pleased 
that the criteria for eligibility for these benefits have been expanded 
to be more in line with the original intent of Congress. However, I 
would like to hear more from our witnesses today about:

      How the plan is being implemented in the field;
      What issues remain;
      What oversight is being conducted from Central Office; 
and
      How we can ensure that this program is successfully 
implemented so that veterans and their caregivers receive these 
critical benefits without further delay.

    The testimony we received contained many concerns with the interim 
final rule and I would like to hear more from VA on incorporating some 
of these suggestions in the final rule.
    Madam Chair, thank you again for holding this hearing, the second 
in a series of hearings to assist in our oversight of the 
implementation of P.L. 111-164. As we continue to monitor this issue, 
we will work to actively engage VA as we move forward.
    I yield back.
                                 
          Prepared Statement of Debbie Schulz, Friendswood, TX
    Chairman Buerkle, Ranking Member Michaud, and Members of the 
Subcommittee,
    Thank you for allowing me to share with you my experience with VA's 
implementation of the comprehensive caregivers assistance program. 
Thank you too for your leadership in pressing VA to implement this 
important law so that congressional intent is fully realized. Much 
progress has at last been made, though--based on my experience and what 
I have heard from other caregivers whom I've met over the years since 
my son's injury--I believe VA will need to go further.
    As a caregiver for my son, Steven K. Schulz, USMC ret., I cannot 
adequately express how important this program will be to his ongoing 
recovery and continued well-being. If fully and properly implemented, 
the law will assure that he will be able to stay in his home with age-
appropriate supports and his family will be able to continue to provide 
the care that Steven needs on a daily basis. Because of Steven's severe 
brain injury, incurred in 2005 while serving in Iraq, I have not 
returned to my employment as a high school teacher. While this has 
allowed Steven the benefits of being cared for at home rather than in a 
long-term care facility, it has been a financial hardship to our 
family, and has diminished my retirement benefits. The implementation 
of the caregiver assistance program has brought both joys and concerns. 
The joys are that the program is up and running, the application 
process was easy and well advertised, and each VA has a point of 
contact for caregivers. As one mom of a veteran 8 years post injury 
said, ``Out of all the applications, assessments, programs we have been 
involved with in the past 8 years, this was the easiest, least 
stressful for us to date.'' I have several concerns, though. Given that 
many caregivers have left the workforce, I'm particularly concerned 
about VA's implementation of the stipend. VA's methodology to determine 
the number of hours of caregiver assistance required for purposes of a 
monthly stipend payment is very flawed. VA has also set an artificial 
cap that limits a stipend to a maximum of 40 hours per week. This is 
concerning for the many caregivers who provide nearly round-the-clock 
care. I also see evidence of disparity between VA facilities and how 
provisions for CHAMPVA services are administered. Like many other 
caregivers, I've also been concerned about the limited access to 
information on how clinical decisions regarding the program are made as 
well as a dearth of information on how to appeal any determination 
under the program--whether it is a question of basic eligibility or a 
VA determination that a veteran only needs a very limited number of 
hours of caregiving per week.
Life Before and After Injury
    But first I want to share with you some background information 
about my son and his injuries. My son, Steven K. Schulz, was injured 
April 19, 2005 in Fallujah, Iraq, when an improvised explosive device 
went off outside the Humvee in which he was riding. He was 20 years 
old, unmarried, and my oldest son. The resulting traumatic brain injury 
was severe and life-altering. We have been on a bumpy road of recovery 
for the last 6-plus years. I say ``we,'' because it has been a family 
effort to assure that Steven has gotten the supports and treatment he 
needed. I hope that explaining the gravity of his injuries will 
illustrate how critical the proper implementation of this important law 
is, not just for Steven Schulz but for many, many other veterans and 
their families whose lives have been turned upside down after 
sustaining severe injuries.
    Steven's brain injury has left him with many physical and cognitive 
deficits. He has profound weakness on his left side, with no functional 
use of his left arm. He walks slowly and with assistance of a service 
dog, cane, or person. He cannot sustain walking longer than three 
blocks, over lawns or uneven terrain, if multiple flights of stairs are 
encountered, or in very busy environments. He is blind in his right eye 
due to shrapnel, and his brain does not perceive the left field of 
vision (hemionopsia). This leaves him with a very narrow visual field 
and monovision. Steven uses a wheelchair for long distances and when he 
is not wearing his adaptive equipment at home, but because of the 
profound weakness of his left side, moving in a wheelchair is very slow 
and inefficient, and assistance is required. Because of his vision 
deficits, he is not a candidate for a motorized wheelchair.
    Steven's thinking is slower, his thought process takes longer and 
initiating and sustaining conversation or ideas is difficult. Due to 
his frontal lobe damage, his impulse control, although much improved 
since immediately after injury, often causes him to say aloud any 
thoughts or ideas prior to filtering, even if the thought is mean, 
insensitive, or vulgar. His affect is often very flat and without 
expression, and he has difficulty interpreting social cues. His speech 
is difficult to understand as he talks rapidly and does not enunciate 
very well. Steven's attention span is very short. Although it has 
improved over the years, he still cannot attend to a 30-minute 
television show. Steven can read, but no longer enjoys it. He has some 
memory problems. The ability to initiate activities was severely 
altered. Because of this initiation problem, Steven has to be guided 
through most all activities of daily life. Without the ability to 
think, ``what do I do next,'' being left alone is very problematic. 
Steven does not feel comfortable being left alone more than 30 minutes.
    What about the future? Since very early in his rehabilitation, 
Steven has told his therapist that he wants the normal things, ``a 
wife, children, and to drive a car.'' He now accepts that he will 
likely never drive a car because of his visual deficits, but he is 
still looking for that wife. We have seen marked improvements from the 
early injury, but we are realistic about the dream of returning to his 
pre-injury self.
    How has my life changed? Prior to his injury on April 19, 2005, I 
worked as a special education teacher at Friendswood High School. 
Before I started teaching, I had worked as a psychiatric social worker 
for 9 years for the State of Texas. Both of these careers prepared me 
for some of the realities of traumatic brain injury, but not the 
realities of becoming a caregiver. My husband, 51 and I, 49, were 
preparing to become ``empty nesters,'' were sprucing up our house, and 
generally doing well when the blast occurred. TBI affects the whole 
family for a very long time, most likely a lifetime. My daughter, 
Elaine, was 18 years old, in her first year of college, and my youngest 
son, Clay, was 15 years old, a sophomore in high school when that bomb 
blasted. This type of injury changes a family. They went from typical 
teens to mature beyond-their-years young adults. I became Steven's 
primary caregiver, advocate, life skills coach, chauffer, secretary, 
bookkeeper, teacher, drill instructor, medical assistant, physical/
occupational/speech therapist and his mom. That blast changed the 
fabric of our family.
My Experience with the Caregiver Assistance Implementation
    I applied for the Caregiver Program on May 9th, the first day it 
was available. I was called by Steven's social worker at the Houston VA 
and reminded that the program was accepting applications, and had seen 
reminders on many social network sites, and in some veteran related 
media. Getting the application online was easy and equally easy to 
complete. I faxed the application to make sure it arrived promptly. As 
I was filling out the application I knew that my health insurance was 
being terminated, but I didn't have a firm date. When I asked the 
social worker if I should indicate that I have insurance or instead 
explain that it was being terminated. I was instructed that I could not 
apply for CHAMPVA unless I was without insurance. The CHAMPVA document 
I received clearly stated that you are not eligible for CHAMPVA if you 
have access to insurance through COBRA. That alarmed me since I could 
theoretically obtain COBRA coverage, but the astronomical cost would 
make eating unaffordable.
    Within several days of applying for the caregiver program, I 
received a phone call saying the application had been received and the 
next step was to complete a training program, and then a home visit. 
The only training available to me at that time was a home-based 
workbook, which was fine with me, because frankly, after care giving 
for 6 years the thought of sitting for 2 days hearing things I had 
already been taught was not appealing. The workbook was fine, but again 
a redundancy and somewhat insulting to have to complete. I would 
strongly suggest that future applicants be ``grandfathered'' as trained 
if they have been caregivers for several years. Let me acknowledge, 
though, that one of my fellow caregivers (7 years post-injury) went to 
the classroom training and very much enjoyed meeting fellow caregivers.
    On May 15, I received notice that my health insurance had been 
terminated effective April 30, 2011. I notified the social worker and 
she had me fax the termination letter to her and she forwarded it to 
the application center. The disturbing implication here is that I was 
led to believe that I was not eligible for CHAMPVA until I had a lapse 
in coverage.
    The most disturbing aspect of the whole process was the home visit. 
The RN sent to assess our home did not even know who the veteran was. 
When I introduced myself to the RN and told him Steven was not yet home 
as he had gone out with his brother and would be back shortly, the RN 
asked, ``Steven is your caregiver?'' The RN clearly had not read any 
medical records pertaining to this home visit. Later in the interview, 
he went on to lecture me about how I must take care of myself, but 
offered no solutions aside from asking my family to ``relieve me of my 
burden.'' The home assessment made sure we had smoke detectors, that I 
knew about infection control, that I knew about nutrition and meal 
preparation, and that I had been instructed in the proper care of a 
catheter. Steven had not had a catheter since his earliest 
hospitalization, and never as an outpatient. This kind of inept 
assessing did not inspire confidence. My understanding was that the 
home visit was to assess both veteran and caregiver for needs. That was 
certainly not accomplished during that visit.
    About a week later, I received verbal confirmation that I was 
approved for the program with no other details available at that time. 
This lack of detail was upsetting, because I had no way of knowing how 
the determination had been made, if it was accurate, or if I had 
recourse to appeal the decision if it was adverse in any way. I 
certainly did not know who had made the decision. I was hopeful that 
the evaluation and determinations had been made by Steven's treatment 
team who has worked with him over the last 6 years, as they have a 
fairly clear idea of his needs. July 1st I received my CHAMPVA card and 
booklet. July 5th I received my first stipend check. As of this writing 
I have not received written notice of how many hours were deemed 
appropriate. Guessing by the stipend amount, Steven was in the upper 
tier, but the fact that I have to guess, when others have been provided 
that information, illustrates the lack of consistent information 
provided from one VA medical center to another.
Concerns
    When Steven first came home from the hospital, he needed 24/7 care. 
Not because he was on a ventilator, had a feeding tube, or was unable 
to move or speak, but because his thinking was so confused that he 
forgot his leg was not working, or he could not figure out what to do. 
He needed assistance to use the bathroom every 2 hours around the clock 
for the first year. I share this with you because setting an artificial 
cap of 40 hours per week assumes that the caregiver actually stops 
providing needed care because 40 hours has been reached. Luckily for 
us, we trained Steven's bladder and brain to ``sleep through the 
night'' again. But that is just one example of why, the VA must address 
that often times 40 hours is not enough for the veteran. For veterans 
who do have ventilators, feeding tubes, or cannot move or speak, they 
still must be attended to throughout the night. Their issues will not 
learn to sleep through the night. For those caregivers, I ask that 
their struggle be properly quantified by the VA and the caregiver 
assistance program.
    Social media has been a wonderful avenue for veterans and 
caregivers to connect with others and alleviate their social isolation 
and share information about benefits, programs, and ways to navigate 
the systems of DoD/VA/TRICARE. Because of all this sharing, the 
disparities between how programs are administered often become very 
apparent. VA programs have been rife with regional disparities of how 
services are delivered. I would like to say that this new program is 
free of such disparities but that is not the case. Already, within our 
VISN I can report one caregiver received a full documentation as to the 
stipend she would receive; her secondary caregivers were interviewed 
and given ID cards. I have not gotten such documentation and the 
secondary caregiver I put on the application has not had any VA 
notification at all. These are small items, but within a 200-mile 
radius, vastly different experiences. The biggest disparities seem to 
be in how veterans are rated to quantify how many hours will be 
assigned to a caregiver. One example, a veteran with the same injury as 
Steven, a severe TBI, but he made a better physical recovery, can walk 
further with a cane, has better balance, can drive locally, but has 
PTSD issues on top of TBI cognitive issues. He was allowed 10 hours of 
caregiving a week. How can 2 hours a day Monday thru Friday be enough 
time for this veteran? Never mind the weekend when oversight and care 
is still needed. For veterans with ``safety and supervision needs'' 10 
hours cannot be appropriate.
    With finances an ongoing struggle, I'm of course very happy and 
relieved to be receiving a stipend. It will make an enormous 
difference. But I am concerned about other caregivers. The VA's 
methodology for determining roughly how much care a veteran needs is 
crude at best. In our case, it resulted in ``scoring'' Steven's needs 
at a relatively high level. But, I believe, that this is because he 
needs assistance with respect to both physical limitations as well as 
cognitive and behavioral challenges. Since VA's scoring methodology 
calls for aggregating each different impairment, his ``score'' would 
generally be higher than for another veteran with TBI who is limited 
``only'' in a few cognitive and behavioral domains. The fallacy in this 
methodology is that a veteran with TBI whose extreme lack of judgment, 
for example, makes him a safety-risk is not simply a safety-risk for 10 
hours a week. Caregiver-friends of mine in this situation must be 
almost constantly at the veteran's side. Yet the way in which the VA 
regulation calls for determining the extent of needed-caregiving, for 
purposes of determining the amount of the caregiver stipend, fails to 
recognize that the potentially overwhelming nature of a traumatic brain 
injury, for example, may require full-time caregiving whether or not it 
manifests itself in many different kinds of limitation or impairment.
    One dear friend, Cheryl Lynch, founder of American Veteran's with 
Brain Injuries, and a mother of a veteran with TBI proposes a simple, 
yet brilliant way of solving the issues of stipend calculations: 
differentiate between ``some of the time,'' ``most of the time'' and 
``all of the time.'' Apply these terms to the veteran, do they need 
help/oversight some of the time, most of the time, or all of the time? 
Develop a check list around the ADL's (activities of daily living) and 
IADL's (independent activities of daily living), and answer the 
question, ``does the veteran need assistance in this area some of the 
time, most of the times, or all of the time.'' ``Some of the time'' 
would be someone who can get dressed and do many of his tasks on his 
own, yet needs to have `someone' available for oversight and in case 
things go wrong. ``Most of the time'' would be someone like Steven who 
without oversight cannot function day to day. ``All of the time'' would 
be someone who without the help of others cannot function hour to hour. 
I also think that there is room to have spaces in between so the 
veteran would be moved to the higher rating because of specifics, like 
seizures, suicide risks, safety, etc. A rating like this would also 
eliminate the artificial setting of an hourly rate. The need for 
flexibility in ratings is crucial, because veterans with TBI, PTSD, or 
mental health issues may have flare-ups in their conditions resulting 
in decreased abilities. Right now there does not seem to be consistent 
application as to why VA considers any particular veteran to need 10 
vs. 25 vs. 40 hours of caregiving, and that is a BIG problem.
    In closing, let me thank you on behalf of my family and other 
caregivers across the country for your sincere efforts to make this 
program a success. The problems I've highlighted can be solved. Doing 
so will not only strengthen this important program, but improve the 
well-being of our wounded warriors.
    Thank you for the privilege of testifying. I would be happy to 
answer any questions you might have.
                                 
 Prepared Statement of Anna Frese, Director, Warrior Support Program, 
                        Wounded Warrior Project
    Chairman Buerkle, Ranking Member Michaud, and Members of the 
Subcommittee,
    Thank you for inviting Wounded Warrior Project to testify today 
regarding the implementation of the caregiver assistance program. The 
program's success is important to me not only as the Director of 
Wounded Warrior Project's (WWP) Family Support Program and liaison to 
our family caregivers, but also as a long time advocate for my brother 
Eric whose injuries in Iraq led to his need for round-the-clock care 
due to severe brain injury.
    While caring for severely wounded warriors--sometimes for years and 
without assistance--many caregivers have left their jobs, exhausted 
savings, and suffered tremendous strain to their own health in order to 
provide the very best care for their loved ones. The need to provide 
caregivers access to mental health services, respite options, health 
coverage and some modest financial support has been real and pressing.
    Let me acknowledge the critically important role this Committee has 
played--not only in shaping the caregiver law--but in jump-starting and 
accelerating a process that in the last weeks began providing long-
awaited help to numbers of families. We are equally grateful for your 
insistence that VA's plan complies fully with the law.
    I was honored to appear before this Committee at a hearing in June 
2009 on ``Meeting the Needs of Family Caregivers of Veterans'' and 
explain how drastically our family's life was changed by my brother's 
injuries and his total-care needs. My parents are one of the many 
families who have hoped for years for the establishment of a caregiver-
support program. As the program has been implemented, however, they 
experienced some real ambivalence.
    My family's experience is telling. They did not apply immediately 
as others had, but delayed because of concerns about one rigid aspect 
of the VA program. VA requires home visits every 3 months to monitor 
the veteran's well-being. In my family's case, however, a VA-provided 
speech therapist works with Eric twice weekly in the home. With those 
visits and Eric's seeing his VA primary care physician and three other 
VA-provided physicians routinely every 2 to 3 months, VA is certainly 
able to confirm his well-being. My family questioned the need under the 
circumstances for additional home visits by new staff who don't know 
Eric or the family. Ultimately, they did finally apply but the home-
visit issue frankly still rankles. Their application is still in 
process.
    Overall, I know VA faced challenges in implementing this new 
program, and that many dedicated staff worked hard to launch it. The 
process has gone relatively smoothly for numbers of families, while 
some have encountered problems. I have worked with many others who are 
still in limbo, waiting for applications to be processed and unsure of 
what comes next.
    But I'm really most concerned about VA's implementing regulation 
(which governs the determination and delivery of benefits to 
caregivers) because it still fails to get some issues right. As a 
result, some families will likely be shut out; others will likely not 
get the level of help the law requires. What is quite clear is that the 
rules discouraged many from even applying.
    Let me acknowledge that VA's implementing rule is a marked 
improvement over its initial implementation plan. But unfortunately 
that regulation needs a lot more work. Let me illustrate by discussing 
several of our concerns with VA's eligibility criteria, inconsistency 
in how eligibility is determined, and how the stipend is calculated.
Eligibility Criteria and Mental Health
    As you know, traumatic brain injury and PTSD are the signature 
wounds of this war. Many of the problems I hear about regarding VA's 
implementation are from wives and moms of warriors with those invisible 
wounds. Typically, because of the severity of one or both of those 
conditions--these family members feel they can't leave their warrior 
alone. Each case differs. But often, the warrior lacks full cognition 
or judgment to be fully aware of danger. In other instances, a 
warrior's behavior may be erratic, may be marked by lack of impulse-
control, or might even reflect a level of anxiety such that the 
individual sleeps with a weapon under his pillow or otherwise leaves 
family fearful of possible suicide-risk. In these kinds of instances, a 
family member typically stays with the veteran for much of the time to 
ensure the warrior's safety. Where those behaviors are due to traumatic 
brain injury, VA's eligibility rule appears to cover such 
circumstances. But in instances where that same safety risk or other 
similar problem is due to PTSD, depression or anxiety, it seems much 
less likely that VA will provide caregiver assistance under its new 
rules.
    In contrast, the law very clearly addresses circumstances involving 
the veteran's safety or related vulnerability. It states that a need 
for caregiver assistance can be based on a veteran's ``need for 
supervision or protection.'' That criterion would address the full 
range of situations I've described. But in the case of a veteran who 
has PTSD, depression or anxiety, VA has unnecessarily established a 
separate, much more restrictive rule. In the case of a veteran with 
PTSD or other war-related mental health condition, VA's rule says the 
veteran must be bedridden, delusional, or virtually suicidal to be 
eligible for caregiver-assistance. And unlike a veteran with a physical 
impairment, who may be eligible if only a few hours of help daily are 
needed, a veteran with a mental health condition must require 
``constant supervision.'' This kind of disparity is not only unfair, it 
is inconsistent with the provisions of the caregiver law which draw no 
distinction between TBI and PTSD, for example.
Clinical Determinations
    A second area of concern is how VA's eligibility criteria are being 
applied at medical centers around the country. WWP recently conducted a 
survey to understand the experience of families who have applied for 
assistance under the new caregiver program. Among the findings, the 
survey responses suggest that there is variability from facility to 
facility as to who determines a veteran's need for caregiver 
assistance, as well as frequent failure to communicate to caregivers 
how these eligibility determinations are made. Asked their 
understanding of who determines a veteran's need for caregiver-
assistance, more than one in five caregivers expressed the 
understanding that it was the primary care physician; one in four 
responded that it was the clinical team; while more than four in ten 
were unsure. Almost one in five respondents indicated that VA has not 
explained the process or criteria they will use to determine the 
veteran's need for caregiving assistance. Feedback from caregivers 
going through the application process suggests that the breakdown in 
communication is not only occurring between VA and veterans and their 
caregivers, but also between VA Central Office and the field.
    Let me share one example. For the past several years, a caregiver 
has provided almost constant care and supervision for her husband who 
suffers from PTSD, traumatic brain injury, and persistent short-term 
memory stemming from injuries. The caregiver submitted an application 
for caregiver assistance when it became available on May 9th and was 
contacted for the first time by a nurse practitioner on May 20th and 
advised that the application had been denied. The nurse, without either 
reviewing the veteran's medical records or consulting the veteran's 
longstanding care team, ``determined'' on the basis of the veteran's 
compensation and pension examination records that he didn't need 
assistance in performing activities of daily living--and thus 
concluded, accordingly, that he was not eligible. Among the many errors 
involved was to overlook the fact eligibility could be based solely on 
a need for supervision or protection, and that these decisions are to 
be made by an interdisciplinary team.
    The veteran's occupational therapist was surprised by the decision 
and lack of dialogue, and drove to the VAMC for an in-person meeting 
with the nurse practitioner, after which the eligibility decision was 
ultimately reversed. While this story ended favorably, it offers a 
stark illustration of problems other families have encountered with 
vague VA rules on clinical eligibility determinations. In this 
instance, but for a very dedicated and well informed occupational 
therapist and psychiatrist, this certainly could have ended 
differently, with much greater distress and headache for the caregiver 
and veteran.
    Another survey respondent's experience highlights the risk of error 
in what may be a too-brief clinical assessment. Let me quote:

        ``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. His physician had only seen him a couple of times, we 
        were told this was the reason he was going in for an interview/
        assessment. The assessment was supposed to provide the 
        understanding of my warrior's needs. Since I was not there, and 
        my warrior does not recall the entire interview, I do not know 
        if the doctor really got a good understanding of the 
        situation.''
Appeals
    While the above-cited cases may be outliers, they do raise the 
question, how can a veteran or caregiver appeal an adverse medical or 
legal decision. The implementing regulation is completely silent on 
this important issue. Yet it is essential that VA establish systematic 
recourse for those caregivers and wounded warriors who may be unduly 
denied benefits. Initial feedback WWP has received from caregivers 
indicates that they are unaware of where to turn in the event that they 
disagree with a VA determination. This is an issue VA must address as 
more veterans and their caregivers apply for this benefit, particularly 
given the potential for error.
Stipend Calculations
    Another particularly problematic area relates to determining the 
amount of a stipend VA will provide a family member designated as the 
primary caregiver. Since many caregivers can no longer work outside the 
home and often care for their loved ones on a full-time basis, the 
stipend was to provide some modest level of financial assistance (tied 
to the area wage rate of a home health aide).
    The law directs VA to develop a methodology for calculating the 
amount of a stipend which is to be based on the amount and degree of 
personal care services the family member provides. But the scoring 
methodology VA has developed is deeply flawed, particularly for those 
whose need for caregiving is based on a need for supervision and 
protection. In other words, the methodology does not provide a reliable 
tool for gauging the caregiving needs of a veteran with traumatic brain 
injury, PTSD, or depression.
    Specifically, under VA's criteria, a veteran's need for caregiver 
assistance is rated on a scale of 0-4 for each of seven criteria 
associated with need for assistance with activities of daily living and 
the need for supervision. With respect to each criterion (such as need 
for assistance in performing a particular activity of daily living; 
having difficulty with planning and organizing; or posing a safety 
risk), VA clinicians are to assess the degree to which the veteran 
needs assistance in that particular domain, from having no need for 
assistance (scored as ``0'') to needing total assistance (scored as 
``4''). The number of hours of caregiving-assistance a warrior needs is 
determined based on how high they score on these measures.
    A couple of illustrations may be helpful. Take the case of a 
veteran who sustained a severe traumatic brain injury in an IED blast, 
but after a lengthy rehabilitation is able to independently perform all 
activities of daily living and has no serious cognitive deficits. In 
this case, the lasting impact of his TBI manifests itself in severe 
mood swings and sometimes aggressive and violent outbursts. Because he 
is unable to control these behaviors, even with the assistance of 
medication, he is unable to work and his wife accompanies him 
everywhere. She helps him avoid the problems his behavior may cause, 
get to his medical appointments and maintain some level of social 
interaction.
    In another case, a veteran has lost several buddies after multiple 
tours to Iraq, and suffers now from severe chronic depression. While he 
has no physical limitations, he is utterly without energy, has 
difficulty even getting out of bed, cannot concentrate on tasks, and 
experiences feelings of hopelessness. Medications have not alleviated 
his symptoms, he is largely homebound, and his mother maintains 
virtually full-time watch to be sure that he doesn't harm himself.
    Applying VA's current rating scale, in both cases the veteran might 
score a ``4'' based on total inability to self-regulate, perhaps 
another ``4'' based on safety risk, and another ``4'' based on 
inability to plan or organize. In each case, though, with no other 
pertinent areas of needed assistance, the total score would be ``12.'' 
The VA rule, however, states that a veteran with an aggregate score 
between 1 and 12 is presumed to need only 10 hours/week of caregiver 
assistance. The rule makes no allowance for rebutting that presumption.
    These examples are real; let me share the frustration expressed by 
one of the respondents in our caregivers' survey as she explained that 
the scoring system fails to take into account the gravity of her 
husband's needs:

        ``I was told that my husband scored in the low Tier level I, 
        with an 11. This only allows 10 hours [of caregiving] a week, 
        approximately $426 a month. I don't agree with this because my 
        husband needs continuous supervision due to his TBI, PTSD, 
        mental health and also sometimes 2-3 days a week requires bed 
        rest due to physical pain. So 10 hours a week is like about 
        1.42 hours a day. I have to help him remember to take 
        medications 3 times daily, assist with cooking, driving, 
        medical appointments, just overall supervision for his safety. 
        10 hours a week is nowhere near the time I spend caring for 
        him.''

    These scenarios clearly reflect how important it is that VA revises 
the current stipend-calculation methodology. What is clear is that 
requiring a high aggregate score across multiple criteria makes no 
sense when a single deficit or impairment may dictate a need for total 
care. Does it make any sense, for example, that a veteran who cannot be 
left alone at all for safety reasons--and has no other limitations--
should be deemed to need only about an hour and a half of caregiving 
help daily?
    It is not unusual that a veteran who has sustained a severe 
traumatic brain injury, for example, may regain lost function in many 
domains, have no physical limitations, and may still need to have a 
loved one close by on a more or less full-time basis because of a 
single issue--whether it is erratic behavior, severely impaired 
judgment, or safety. In the case of a veteran whose condition creates a 
need for supervision or protection it makes little sense for VA to 
assume that a need for full-time caregiving can only exist when the 
veteran has multiple needs. This system reflects a fundamental 
underestimation of both traumatic brain injury and mental health 
conditions like PTSD.
    The problems with the stipend actually go deeper. Even in 
circumstances where a veteran is deemed to need total assistance, VA 
sets a cap on the stipend amount--limiting any caregiver's stipend 
based on the presumption that 40 hours a week of care would be 
provided. VA's rule does not address the fact that our wounded 
warriors' needs rarely conform to a 9-5 business day, and makes no 
provision for those additional hours of likely needed caregiving.
    We understand that the intent of this cap is that caregivers 
shouldn't have to work unreasonably long hours, and that additional 
care would be provided by others, such as home health aides. Yet the 
rule is silent on this. Can caregivers count on it? Even if VA were 
generally to provide such assistance, veterans and caregivers who 
reside in rural areas are not likely to have access to such sources of 
care. Given these realities, we have urged VA to revisit the issue and 
lift the cap where needed so that the stipend amount more reasonably 
reflects the hours of caregiving actually provided.
Program strengths and weaknesses
    While WWP believes that VA must make changes to its final 
regulation (and submitted extensive recommendations on July 5th in 
response to VA's Federal Register notice regarding its VA's interim 
final rule), we also recognize the progress VA has made over the past 
several months in launching this multi-faceted program.
    Many caregivers who responded to our survey commented favorably on 
the ease of filing the initial application and the timeliness with 
which VA had made contact with caregivers and veterans after the 
initial submission. VA did make training accessible to caregivers by 
providing the option of using a self-guided workbook. This tool offered 
an easy approach to clearing a requirement. But the workbook was 
simplistic, and for those seeking more specialized instruction it was 
disappointing. It would be helpful in the future for VA to ascertain 
early-on what individual training needs a caregiver-applicant has, and 
tailor training to meet those needs.
    Among those surveyed who had reached the stage of a VA home 
assessment, many respondents commented that VA employees had been 
professional, thorough, and appeared to be genuinely invested in the 
health of both the veteran and the caregiver. One respondent 
characterized the home visit as the most positive interaction she has 
had with VA employees to date.
    Yet despite these positive experiences, caregivers tended to have 
greater frustration with what appears for many to have been regarding 
the different steps involved in processing their application, who is 
making decisions, how decisions will be made, and how erroneous 
decisions can be reviewed and reversed. We commend VA for the 
substantial improvements they have made since releasing the initial 
implementation plan, but also urge the Department to carefully consider 
the issues we have raised today as well as the much more detailed 
comments WWP submitted to the Federal Register. VA must still correct 
serious flaws in its interim regulation in order to ensure that this 
program fulfills the intent of the Congress and the promise of the law.
    In closing, WWP looks forward to working with VA and with this 
Committee in bridging these gaps.
                                 
   Prepared Statement of Deborah Amdur, LCSW, ACSW, Chief Consultant,
                Care Management and Social Work Service
  Veterans Health Administration, U.S. Department of Veterans Affairs
    Chairwoman Buerkle, Ranking Member Michaud, and distinguished 
Members of the Committee, thank you for the opportunity to discuss the 
progress the Department of Veterans Affairs (VA) has made in 
implementing the provisions of title I of Public Law 111-163, the 
Caregivers and Veterans Omnibus Health Services Act of 2010 (the Act).
    When we appeared before you in March, we provided an update on VA's 
Implementation Plan for this program and our expected way ahead. We 
heard the concerns you and the Veterans Service Organizations raised 
about the eligibility criteria we were considering, and we worked to 
revise the criteria to include a broader population of veterans.
    We are pleased to report that the Family Caregiver program is fully 
operational and that primary family caregivers have begun receiving 
stipend payments for the support they are providing to veterans. On May 
5, 2011, VA published an Interim Final Rule (IFR), which implemented 
the Family Caregiver Program of the Caregivers and Veterans Omnibus 
Health Services Act of 2010. The public comment period for the IFR 
closed on July 5, 2011, and we are reviewing the comments we received 
to determine if any changes to the IFR are necessary. Our final rule 
will either continue the program as implemented in the IFR or revise it 
based upon our consideration of the comments.
    My testimony today will discuss the eligibility criteria VA is 
using for this program under the IFR; the training and application 
process, as well as an update on our progress in these areas to date; 
and other benefits and programs VA is offering and will be offering to 
caregivers of veterans.
Eligibility Criteria
    Under the statutory and regulatory program now in effect, to be 
eligible for benefits under the Family Caregiver program, Veterans must 
have incurred or aggravated a serious injury (including traumatic brain 
injury, psychological trauma, or other mental disorder) in the line of 
duty on or after September 11, 2001. These veterans must also be in 
need of personal care services because of an inability to perform one 
or more activities of daily living (i.e., bathing, eating, dressing, 
toileting), or require supervision or protection based on symptoms or 
residuals of neurological impairment or injury. Servicemembers who are 
undergoing medical discharge with an identified date of discharge are 
also eligible for support under this program. Servicemembers and 
veterans must require the assistance of a caregiver for a period of at 
least 6 months to qualify. Veterans cannot receive simultaneous 
personal care services from another party; for example, a veteran could 
not receive home-health-aide services 24 hours a day, 7 days a week and 
receive support through the Family Caregiver program. Veterans must 
agree to receive care from a VA-designated primary care team so that 
the VA can appropriately support these veterans and family caregivers. 
After conducting a thorough analysis of VA's records and assessing the 
current veteran population, VA estimates that approximately 3,600 
veterans and servicemembers may be eligible for benefits under the 
Family Caregiver program.
    VA also included specific criteria in the IFR to ensure veterans 
with a traumatic brain injury or neurological impairment would be 
eligible to receive benefits. These criteria include a need of 
supervision or assistance because of seizures, difficulty planning or 
organizing information, deficits in sleep regulation, delusions or 
hallucinations, memory deficits, or problems with mood regulation, such 
as agitation or aggression.
Processing Applications and Training Caregivers
    VA began accepting applications for the new Family Caregiver 
program on May 9, 2011. During the first week, we assisted more than 
625 veterans, servicemembers and family members in applying for new 
benefits under the program. Through June 29, 2011, VA has 1,259 
applications in process and had approved stipends for 182 veterans. As 
of July 8, VA had processed 176 stipend payments totaling over $430,000 
for primary family caregivers; this includes stipend payments for the 
support these caregivers have provided since May 9, 2011. The tracking 
device VA developed to monitor pending applications allows us to 
pinpoint where any application is in the process and to identify 
geographic or demographic trends. Based on the limited data available, 
Family caregivers are overwhelmingly women (92 percent), spouses (67 
percent), and between 26 and 64 years old (45 percent between 26-40, 
and 43 percent between 41-64). The 10 facilities with the highest 
number of applications in process are Fayetteville, NC; Dallas, TX; 
Jackson, MS; Durham, NC; Puget Sound, WA; Augusta, GA; Orlando, FL; 
Houston, TX; San Antonio, TX; and Washington, DC.
    We have been working through the local Caregiver Support 
Coordinators to reach out to eligible veterans and servicemembers in 
the community to encourage them to apply. Post 9-11 veterans currently 
receiving VA's Aid and Attendance benefit due to injury in the line of 
duty have been contacted and encouraged to apply for the new caregiver 
program. Veterans and family members must submit a joint application, 
which can be accomplished in person, by mail, by phone (1-877-222-VETS 
[8387]) or online (www.caregiver.va.gov). Additional support and 
information is also available through the National Caregiver Support 
Line (1-855-260-3274). Within three business days of having received an 
initial application, the Caregiver Support Coordinator, at the 
veteran's preferred VA medical center, will contact the veteran and the 
primary family caregiver to assist with completing the application 
process and schedule required training. This training is necessary 
before any additional benefits can be provided to the primary family 
caregiver. VA has partnered with Easter Seals to provide comprehensive 
Caregiver Training to family caregivers of eligible post-9/11 veterans 
as authorized by the law. Easter Seals brings more than 90 years of 
experience in helping people with disabilities and special needs, and 
we are very pleased to partner with such a renowned organization.
    Training may be completed in any of three ways: by attending a 
family caregiver training session conducted at a local VA medical 
center or community location; by self-study using a workbook and DVD 
that is mailed to the family caregiver(s); or by completing the 
training online; the online training will be available by July 15, 
2011.
    More than 450 family caregivers have completed their training since 
the beginning of June, and we continue to train more caregivers every 
day so they can better support their loved one and begin receiving the 
benefits included in the law.
    Once the family caregiver training is complete, a VA clinician will 
visit the veteran's home. This visit is designed to ensure that the 
primary family caregiver and veteran have everything they need to be 
successful in the home setting. Our clinicians are trained to do this 
in a supportive and encouraging manner. One family caregiver described 
this home visit as follows: ``All in all, the home visit was as 
painless as the rest of the process, and in fact it was comforting to 
have someone in my home to see what else I could do to help my husband 
. . . ''
    Once the home visit is complete, the primary family caregiver will 
begin receiving a monthly stipend based on the veteran's level of need. 
The primary family caregiver may also be eligible for health insurance 
through the Civilian Health and Medical Program of the Department of 
Veterans Affairs (CHAMPVA), provided that the primary family caregiver 
is not already entitled to care or services under a health plan 
contract. VA is making the stipend and health insurance benefits 
retroactive to the date of initial application. Our expectation is that 
the entire process, from initial application to the delivery of 
benefits, will be complete within 30 days.
    We will continue to conduct well-being visits every 90 days or as 
clinically indicated. These visits, like the initial home visit, will 
be performed in a supportive manner. The visits are designed to 
evaluate the veteran's and the primary family caregiver's physical and 
emotional state. VA clinicians conducting these visits may make 
recommendations for additional training, support, equipment or other 
services in the best interest of the veteran.
Other Benefits and Programs
    In addition to the benefits specific to the primary family 
caregiver of veterans (the stipend, health care coverage through 
CHAMPVA, mental health services, and at least 30 days of respite care), 
VA offers a number of benefits and services to all caregivers of 
veterans. VA's National Caregiver Support Line, mentioned briefly 
above, has responded to more than 9,000 calls from veterans and family 
members since it was activated in February 2011. This Support Line, 
staffed by clinical social workers, provides immediate and highly 
responsive access to information for caregivers, and can help 
coordinate local support through the Caregiver Support Coordinator at 
each VA medical center. These Coordinators are able to offer additional 
assistance by connecting veterans and family members with both VA and 
non-VA resources. Since April 1, 2011, every VA medical center has had 
a full time dedicated Caregiver Support Coordinator in place.
    VA's home-based care programs are well-established and have been 
supporting veterans in the community for many years. Home-based primary 
care is a unique program that provides comprehensive long-term primary 
care through an interdisciplinary team that visits the homes of 
veterans with complex, chronic disabling diseases or injuries for which 
routine clinic-based care is ineffective. Another recent initiative is 
the Veteran-Directed Home and Community-Based Care program, which 
provides veterans of all eras the opportunity to receive services in a 
veteran-centered manner that allows them to avoid institutional 
placement while continuing to live in their homes and communities. VA 
operates this program in collaboration with the Administration on Aging 
under the Department of Health and Human Services.
    Veterans and their caregivers who are in need of close monitoring 
of vital signs or frequent communication with a health care team can 
benefit from home telehealth services. Telehealth offers the 
possibility of treating chronic conditions cost effectively while 
contributing to patient satisfaction.
    General education and training are also available to all 
caregivers. VA routinely offers in-person educational support for 
caregivers of veterans undergoing discharge from an inpatient stay at a 
VA facility and teaches techniques, strategies, and skills for caring 
for a disabled veteran. We offer instruction and specialized training 
in several specialty areas, such as traumatic brain injury, spinal cord 
injuries or disorders, and blind rehabilitation. The Caregiver Support 
Program has provided multiple national education and training to VA 
staff throughout the country and to a wide range of Federal, State and 
local organizations.
    Our respite care programs are available to any caregiver of a 
veteran. All veterans are eligible for 30 days of respite care per 
year, and this respite care can be provided at home or in an 
institution. Respite care provides the caregivers of veterans with a 
needed break to relieve the demands of caring for a chronically ill, 
injured, or disabled family member, and to prevent caregiver burnout. 
In fiscal year 2010, more than 12,000 veterans and caregivers received 
respite care through VA. More than 7,500 of these veterans received 
respite care in home, and more than 4,700 received care in a nursing 
home at VA expense. Adult Day Health Care Centers also provide respite 
care in a safe environment with constant supervision.
    VA launched a new Web site on May 31, 2011, www.caregiver.va.gov, 
which provides a wealth of information and resources for veterans, 
families and the general public. The Web site has had over 63,000 hits, 
totaling over 400,000 pages viewed since its launch. This site provides 
information on local and national resources, common veteran conditions, 
caregiver self-care, and other topics identified as important by 
caregivers.
    Evidence-based support programs and a peer-support mentoring 
program are in development and will be rolled out over the next 12 
months to provide further assistance to the family caregivers of 
veterans.
Conclusion
    Although we have only recently initiated this program, we have 
received a great deal of positive feedback from veterans and their 
caregivers on the services we are delivering and the support VA 
professionals in the field are providing. For example, one caregiver 
described the application and evaluation part of the program by saying, 
``The process has been incredibly painless and very quick, which has 
been a huge breath of fresh air . . . .'' We know there is room for 
continued improvement, and we appreciate the opportunity to hear from 
you and the other witnesses at today's hearing to determine how we can 
make this program even better. Thank you for inviting me here to 
testify today to do that. I am prepared to answer your questions at 
this time.
                                 
 Prepared Statement of Adrian Atizado, Assistant National Legislative 
                  Director, Disabled American Veterans
    Madame Chairwoman and Members of the Subcommittee:
    On behalf of the more than 1.2 million members of the Disabled 
American Veterans (DAV) and its Auxiliary, thank you for inviting our 
organization to submit testimony for this important oversight hearing 
on the Department of Veterans Affairs (VA) proposed interim final rule 
(IFR) to implement title I of the Caregivers and Veterans Omnibus 
Health Services Act of 2010, Public Law (P.L.) 111-163.
    As you may be aware, DAV submitted comments to the IFR and it is 
with sincere appreciation that we have this opportunity to share our 
comments, concerns, and recommendations. We believe VA's effort in 
proposing rules to implement a national caregiver support program is 
commendable. Nonetheless, we believe the program as proposed will fall 
short of its Congressional mandate without a number of significant 
changes.
    Based on VA's advances in medicine, health technology, expansion of 
home care and the Department's push to provide the highest quality of 
care to veterans in the least restrictive setting to achieve 
rehabilitation, recovery, and community reintegration, today's VA 
health care and the delivery of such care have shifted the burden, 
cost, and responsibility for some levels and types of care onto sick 
and disabled veterans, their families and other loved ones.
    Without proper training and support, family caregivers and veterans 
receiving care from family caregivers can incur greater emotional, 
physical, and financial strain. Families have been brought to the verge 
of bankruptcy and ruin. Such adverse impacts would affect the quality 
of care and quality of life of caregivers and care recipients, as well 
as other family members and loved ones. We believe a strong and 
flexible VA family caregiver program can provide caregivers the support 
they need and allow veterans to remain in their own homes--a much 
healthier outcome for the victims of war, their families, and for VA as 
well.
    We urge this Subcommittee to continue its strong oversight of this 
critical program and to ensure VA meets two required reports to be 
submitted to the House and Senate Veterans' Affairs Committees not 
later than 2 years after the effective date (January 30, 2013) on a 
comprehensive annual evaluation on implementation and on the 
feasibility and advisability of expanding caregiver assistance under 
title 38, United States Code (U.S.C.), Sec. 1720G(a) to caregivers of 
veterans seriously injured in the line of duty prior to September 11, 
2001. In addition, we urge Congress to provide sufficient program 
funding to help make this program a success.
Effective date of benefits provided under 38 U.S.C. Sec. 1720G
    We note that public comments have been submitted to VA on the issue 
of effective date for benefits provided under 38 U.S.C. Sec. 1720G. We 
believe Section 101(a)(3) of P.L. 111-163 is pertinent and provides 
that the amendments made by this subsection shall take effect on the 
date that is 270 days after the date of the enactment of this Act 
(January 30, 2011).
    VA proposes the effective date of its rule is May 5, 2011. (76 Fed. 
Reg. at 26148). The Department provides further clarification under 38 
Sec. CFR 17.40(d), ``[C]aregiver benefits are effective as of the date 
that the signed joint application is received by VA or the date on 
which the eligible veteran begins receiving care at home, whichever is 
later. However, benefits will not be provided until the individual is 
designated as a family caregiver.'' Additionally, ``[T]he stipend . . . 
due prior to such designation, based on the date of application, will 
be paid retroactive to the date that the joint application is received 
by VA or the date on which the eligible veteran begins receiving care 
at home, whichever is later.''
    In statutory interpretation, if ``the plain meaning of a statute is 
discernable, that `plain meaning must be given effect.' '' Johnson v. 
Brown, 9 Vet.App. 369, 371 (1996) (quoting Tallman v. Brown, 7 Vet.App. 
453, 460 (1995)); see also Brown v. Gardner, 513 U.S. 115, 119 (1994). 
``Determining a statute's plain meaning requires examining the specific 
language at issue and the overall structure of the statute.'' Gardner 
v. Derwinski, 1 Vet.App. 584, 586 (1991) (citing Bethesda Hosp. Ass'n 
v. Bowen, 485 U.S. 399, 403-05 (1988)), aff'd sub nom. Gardner v. 
Brown, 5 F.3d 1456 (Fed.Cir. 1993), aff'd, 513 U.S. 115 (1994). Because 
the plain reading of the P.L. 111-163 is unambiguous, we believe the 
effective date of benefits provided under 38 U.S.C. Sec. 1720G should 
be January 30, 2011.
Eligibility requirements for the family caregiver program
    VA proposes a veteran or servicemember be eligible for benefits and 
services provided under 38 U.S.C. Sec. 1720G(a) if the individual meets 
requirements under 38 U.S.C. Sec. 1720G(a)(2)(A) and (B), and all three 
elements under (C). However, the law clearly defines an eligible 
individual as one that meets requirements under 38 U.S.C. 
Sec. 1720G(a)(2)(A) and (B), and only one of the three elements under 
(C).
    Under 38 U.S.C. Sec. 1720G(a)(2), to be eligible for a program of 
comprehensive assistance for their family caregivers, an individual 
must: (A) Be a veteran or member of the Armed Forces undergoing medical 
discharge from the Armed Forces, and; (B) have a serious injury 
(including traumatic brain injury, psychological trauma, or other 
mental disorder) incurred or aggravated in the line of duty in the 
active military, naval, or air service on or after September 11, 2001. 
In addition, the individual must be in need of personal care services 
because of one of the following: (i) An inability to perform one or 
more activities of daily living; (ii) A need for supervision or 
protection based on symptoms or residuals of neurological or other 
impairment or injury; or (iii) Such other matters as the Secretary 
considers appropriate.
    VA on the other hand, proposes to define an eligible veteran for 
the family caregiver program under 38 U.S.C. Sec. 1720G(a)(1), to mean 
a veteran or servicemember who is determined to be eligible for a 
Primary and Secondary family caregiver. VA provides further 
clarification that to be eligible for a Primary and Secondary family 
caregiver under this rule, VA proposes the veteran or servicemember 
meet all requirements under 38 CFR Sec. 71.20 (a) through (g).
    DAV disagrees strongly with this proposal. In requiring a veteran 
or servicemember to meet all of the conditions under 38 CFR Sec. 71.20, 
VA's proposal goes beyond the plain reading of the law and imposes a 
more restrictive criteria that will result in fewer veterans in urgent 
need being deemed eligible for the benefits of the law. This proposed 
stricture will serve to deny benefits to deserving veterans.
    We strongly recommend VA revise its proposed definition of an 
``eligible veteran'' for the purposes of this benefit, and accordingly 
to revise its proposed eligibility criteria.
    In addition, we voiced our concern that VA's interpretation of the 
proposed definition in individual cases may mean a veteran with a 
serious illness other than those specifically listed may be excluded 
from eligibility for family caregiver benefits, even if he or she meets 
all other requirements as proposed in the IFR. Such an outcome would be 
inequitable and not in keeping with the intent of Congress in enacting 
this benefit for those who nearly gave the ultimate sacrifice in combat 
deployments, training accidents and in contracting serious diseases in 
the line of duty or while performing military duty.
    Veterans and servicemembers this program was intended to benefit 
have been and continue to be described as those who are, ``wounded, 
ill, and injured.'' From the recently established programs within the 
Department of Defense (DoD), such as the Recovery Coordination Program 
(RCP), established by Section 1611 of the fiscal year 2008 National 
Defense Authorization Act, to the VA Federal Recovery Coordination 
Program (FRCP), wounded, ill or injured servicemembers, and their 
families have been the target population to provide comprehensive 
assistance.
    We also believe Congress intended this program for those veterans 
and servicemembers who are ``seriously ill.'' The Joint Explanatory 
Statement of P.L. 111-163 states, ``[T]he Compromise Agreement also 
includes an authorization for appropriations that is below the estimate 
furnished by the Congressional Budget Office. The lower authorization 
level is based on information contained in a publication (Economic 
Impact on Caregivers of the Seriously Wounded, Ill, and Injured, April 
2009) of the Center for Naval Analyses (CNA).'' This report was written 
``[t]o estimate the economic impact on caregivers of the seriously 
wounded, ill, and injured (WII),'' at the request of the Principal 
Deputy Assistant Secretary of the Air Force for Manpower and Reserve 
Affairs who was tasked by the Joint DoD/VA Wounded, Ill, and Injured 
Senior Oversight Committee.
    Subsequent to the passing of P.L. 111-163, VA's press release dated 
February 9, 2011, (New and Enhanced VA Benefits Provided to Caregivers 
of Veterans), which quotes Secretary of Veterans Affairs Eric K. 
Shinseki declaring, ``[c]aregivers make tremendous sacrifices every day 
to help veterans of all eras who served this Nation . . . They are 
critical partners with VA in the recovery and comfort of ill and 
injured veterans, and they deserve our continued training, support and 
gratitude.'' (Emphasis added.)
    Furthermore, VA's June 4, 2009, testimony before the House 
Veterans' Affairs Subcommittee on Health, discussing the Department's 
programs and support of family caregivers states, ``[c]aregivers 
deliver essential services to seriously injured veterans and 
servicemembers and VA continues to support these compassionate 
providers as they help our wounded, ill and injured heroes regain and 
maintain health.''
    Accordingly, we recommend VA adding the term ``seriously ill'' as 
considered under 38 U.S.C. Sec. 1720G(a)(2)(B) and accordingly to 
revise its proposed eligibility criteria.
Definition of ``in the best interest'' of the veteran or servicemember
    In citing 38 U.S.C. Sec. 7120G(a)(1)(B), (``[T]he Secretary shall 
only provide support under the program required by subparagraph (A) to 
a family caregiver of an eligible veteran if the Secretary determines 
it is in the best interest of the eligible veteran to do so.''), VA 
proposes the following:

        [I]n the best interest means, for the purpose of determining 
        whether it is in the best interest of the eligible veteran to 
        participate in the Family Caregiver program under 38 U.S.C. 
        1720G(a), a clinical determination that participation in such 
        program is likely to be beneficial to the eligible veteran. 
        Such determination will include consideration, by a clinician, 
        of whether participation in the program significantly enhances 
        the eligible veteran's ability to live safely in a home 
        setting, supports the eligible veteran's potential progress in 
        rehabilitation, if such potential exists, and creates an 
        environment that supports the health and well-being of the 
        eligible veteran.

    38 CFR Sec. 71.15. We read this proposal to mean the ``in the best 
interest'' test includes that the following criteria must be met: (1) 
Participation in the program significantly enhances the eligible 
veteran's ability to live safely in a home setting; (2) Participation 
in the program supports the eligible veteran's potential progress in 
rehabilitation, if such potential exists; and (3) Participation in the 
program creates an environment that supports the health and well-being 
of the eligible veteran.'' (Emphasis added.) (38 CFR Sec. 71.15)
    DAV takes no issue with the proposed criteria 2 and 3. However, we 
take issue with the proposed criteria. 1. First, the ``significantly 
enhances'' criterion is ill-defined. The discussion on this criterion 
in the IFR and the proposed regulation does not provide for, or define, 
a measurement system or scale to express the degree to which the 
``significantly enhances'' standard is or is not met.
    Second, the goal of this program is, ``[t]o ensure the veteran is 
able to live in a residential setting without unnecessary deterioration 
of his or her disability, and safe from potential abuse or neglect.'' 
76 Fed. Reg. at 26148. (See also the Joint Explanatory Statement of 
P.L. 111-163, ``[T]he overall caregiver support program for caregivers 
of eligible [Operation Enduring Freedom] or [Operation Iraqi Freedom] 
veterans would authorize VA to provide training and supportive services 
to family members and certain others who wish to care for a disabled 
veteran in the home and to allow veterans to receive the most 
appropriate level of care.'')
    We believe criteria 2 and 3 subscribe to the aforementioned goal as 
described in the IFR based on certain terms such as ``[s]upports the 
eligible veteran's potential progress . . . if such potential exists,'' 
and ``creates an environment that supports . . .''
    However, we believe criterion 1 proposes an unreasonable standard 
beyond the goal of the program. For example, comparing criterion 1, 
``[p]articipation in the program significantly enhances the eligible 
veteran's ability to live safely in a home setting,'' to the program's 
goal ``[t]o ensure that the situation [occurs in which a] veteran is 
able to live in a residential setting without unnecessary deterioration 
of his or her disability, and safe from potential abuse or neglect.'' 
Criterion 1 is clearly a higher standard.
    In addition, when determining whether benefits and services from 
VA's medical benefits package will be provided to an eligible veteran, 
38 CFR Sec. 17.38(b) states:

        ``[C]are referred to in the `medical benefits package' will be 
        provided to individuals only if it is determined by appropriate 
        health care professionals that the care is needed to promote, 
        preserve, or restore the health of the individual and is in 
        accord with generally accepted standards of medical practice.

    (1)  Promote health. Care is deemed to promote health if the care 
will enhance the quality of life or daily functional level of the 
veteran, identify a predisposition for development of a condition or 
early onset of disease which can be partly or totally ameliorated by 
monitoring or early diagnosis and treatment, and prevent future 
disease.
    (2)  Preserve health. Care is deemed to preserve health if the care 
will maintain the current quality of life or daily functional level of 
the veteran, prevent the progression of disease, cure disease, or 
extend life span.
    (3)  Restoring health. Care is deemed to restore health if the care 
will restore the quality of life or daily functional level that has 
been lost due to illness or injury.''
    We note VA does not impose any form of the ``significantly 
enhances'' criterion to provide care, yet it is a requisite 
consideration veterans and their family caregivers must meet in order 
to participate in these benefits. DAV believes this imposes an 
unnecessarily high standard and undue burden on the veteran, 
servicemember, and family caregivers of these individuals.
    We recommend VA revise its proposed regulation to include a 
measurement system or scale to express the degree to which the 
``significantly enhances'' standard is or is not met, or else remove 
the pertinent phrase entirely.
``In the best interest'' as a requirement for eligibility of a veteran 
        or servicemember
    As previously mentioned, VA proposes that to be eligible for 
benefits under 38 U.S.C. Sec. 1720G(a), a veteran or servicemember must 
meet all requirements under 38 CFR Sec. 71.20, including subsection 
(d). (``[A] clinical determination has been made that it is in the best 
interest of the individual to participate in the program'') (Emphasis 
added). VA further clarifies and designates the ``in the best 
interest'' determination as a medical determination in citing 38 U.S.C. 
1720G(a)(1)(B). (76 Fed. Reg. at 26149). (``[V]A concludes that 
determinations of `in the best interest' must be clinical 
determinations.'').
    DAV is concerned with VA's proposed use of the ``in the best 
interest'' determination as an eligibility requirement and its 
designation as a clinical determination.
    According to the language of the law, we believe the ``in the best 
interest'' determination is to be performed on an eligible veteran. 
(``[I]f the Secretary determines it is in the best interest of the 
eligible veteran. . .'') (Emphasis added). Furthermore, the purpose of 
using the ``in the best interest'' determination is to satisfy a 
condition that would require VA to provide support under 38 U.S.C. 
Sec. 1720G(a) to a family caregiver of a veteran or servicemember, and 
not for the purposes of determining eligibility of the veteran himself 
or herself for the benefit.
    Regarding the designation of ``in the best interest'' 
determinations as clinical determinations, DAV notes the proposed 
regulation does not explicitly characterize the ``in the best 
interest'' determination to be a ``medical determination.'' However, we 
believe VA is at least strongly implying the phrase ``clinical 
determination'' as analogous to ``medical determination,'' according to 
38 CFR Sec. 20.101(b), which in turn may import implications for a 
veteran's procedural and appellate rights in the case of an adverse 
decision.
    Current regulations stipulate the Board of Veterans' Appeals (BVA) 
jurisdiction over eligibility issues outlined under 38 CFR 
Sec. 20.101(b):

        [T]he Board's appellate jurisdiction extends to questions of 
        eligibility for hospitalization, outpatient treatment, and 
        nursing home and domiciliary care; for devices such as 
        prostheses, canes, wheelchairs, back braces, orthopedic shoes, 
        and similar appliances; and for other benefits administered by 
        the Veterans Health Administration.

    However, because VA's proposal makes eligibility determinations 
contingent upon a medical determination (presumably to be made by a 
Veterans Health Administration clinician), it is in conflict with 38 
CFR Sec. 20.101(b), which also states:

        [M]edical determinations, such as determinations of the need 
        for and appropriateness of specific types of medical care and 
        treatment for an individual, are not adjudicative matters and 
        are beyond the Board's jurisdiction. Typical examples of these 
        issues are whether a particular drug should be prescribed, 
        whether a specific type of physiotherapy should be ordered, and 
        similar judgmental treatment decisions with which an attending 
        physician may be faced.

    Congress broadly divested all Federal courts but the United States 
Court of Appeals for Veterans Claims (CAVC) and the United States Court 
of Appeals for the Federal Circuit of jurisdiction to review any 
``questions of law and fact necessary to a decision by the Secretary 
under a law that affects the provision of benefits by the Secretary to 
veterans.'' 38 U.S.C. 511(a).
    The question of a veteran's eligibility for benefits administered 
by the VA is subject to a question of law and fact necessary to a 
decision by the Secretary and is therefore subject to one review on 
appeal to the Secretary, where final decisions on such appeals shall be 
made by the BVA. (38 U.S.C. Sec. Sec. 7104, 7105, 7108)
    Based on VA's proposed regulation, however, should an appeal be 
perfected based on a denial of eligibility due to a ``medical 
determination,'' it may preclude review by the BVA and thus obviate 
appellate review by CAVC. (38 CFR 20.101(b)). We believe such an 
outcome would be antithetical to the purposes of the act, and indeed, 
would not be in the best interest of the severely disabled veterans 
this law aims to serve.
 Proposed definition of ``personal care services'' and their use in 
        calculating the amount of monthly stipend
    The law defines ``personal care services'' to mean, ``[s]ervices 
that provide the veteran the . . . [a]ssistance with one or more 
independent activities of daily living [and] [a]ny other non-
institutional extended care (as such term is used in section 1701(6)(E) 
of this title). 38 U.S.C. Sec. 1720G(d)(4). 38 U.S.C. Sec. 1701(6)(E) 
further provides, ``[N]oninstitutional extended care services, 
including alternatives to institutional extended care that the 
Secretary may furnish directly, by contract, or through provision of 
case management by another provider or payer.'' (Emphasis added).
    VA proposes to define personal care services as, ``[C]are or 
assistance of another person necessary in order to support the eligible 
veteran's health and well-being, and perform personal functions 
required in everyday living ensuring the eligible veteran remains safe 
from hazards or dangers incident to his or her daily environment.'' (38 
CFR Sec. 71.15).
    DAV believes VA's proposed definition is inadequate. In its 
discussion, VA limited the scope used to define the term ``personal 
care services,'' thus limiting its definition and other elements of the 
family caregiver program that are contingent upon its definition. These 
elements include identifying the personal care services required by the 
eligible veteran, education and training of family caregivers to meet 
those needs, and calculation of the monthly stipend.
    VA indicates the statutory term ``independent activity of daily 
living,'' [d]oes not have a commonly understood usage or meaning,'' and 
interprets the phrase to mean, ``[p]ersonal functions required in 
everyday living to sustain health and well-being and keep oneself safe 
from hazards or dangers incident to one's daily environment. (76 Fed. 
Reg. at 26149).
    DAV agrees that ``independent activity of daily living'' is not a 
commonly used phrase; however, based on the context of the statute, the 
goal of this program, and VA health care programs and services that 
allow disabled veterans to remain in the community, we believe it is 
reasonable for VA to include in its proposed definition, services that 
provide the veteran assistance with Activities of Daily Living and 
Instrumental Activities of Daily Living.
    ``Activities of daily living'' are defined as, ``[e]veryday 
routines generally involving functional mobility and personal care, 
such as bathing, dressing, toileting, and meal preparation.'' Stedman's 
Medical Dictionary 30, 22 (28th ed. 2006). Instrumental Activities of 
Daily Living are defined as: ``more complex and demanding activities of 
daily living required for more independent living[,] . . . includ [ing] 
using the telephone, traveling, shopping, preparing meals, doing 
housework, taking medications properly, and managing money.'' Stedman's 
Medical Dictionary 942, 1724 (28th ed. 2006).
    Furthermore, to define ``other non-institutional extended care (as 
such term is used in section 1701(6)(E) of this title),'' VA cites 38 
U.S.C. Sec. 1701(6)(E) as the statutory authority for the Department to 
provide non-institutional extended care and states that it provides 
non-institutional care services to enrolled veterans (and as provided 
in 38 CFR 17.36(a)) through VA's medical benefits package, which 
include but are not limited to ``noninstitutional geriatric evaluation, 
noninstitutional adult day health care, and noninstitutional respite 
care.'' 38 CFR Sec. 17.38(a)(1)(xi)(B).
    By using the phrase ``[a]s such term is used in section . . . ,'' 
DAV believes that the law is merely citing 38 U.S.C. Sec. 1701(6)(E) to 
help define the term ``non-institutional extended care'' and that it 
does not preclude other statutory authority that allows the Department 
to provide non-institutional extended care and alternatives to 
institutional extended care.
    Consider for example, 38 U.S.C. Sec. 1710B(a)(5), which discusses 
other, ``[n]oninstitutional alternatives to nursing home care as the 
Secretary may furnish as medical services under section 1701(10) of 
this title.'' In addition, 38 U.S.C. Sec. 1720C provides VA authority 
to provide ``[N]oninstitutional alternatives to nursing home care.'' 
(``[T]he Secretary may furnish medical, rehabilitative, and health- 
related services in noninstitutional settings for veterans who are 
eligible under this chapter for, and are in need of, nursing home 
care.'').
    Other statutory authorities that allow VA to provide home-based 
health care services include 38 U.S.C. Sec. 1717. This section provides 
the authority for VA to provide home health services to an eligible 
veteran in any residential setting. (``[A]s part of medical services 
furnished to a veteran under section 1710(a) of this title, the 
Secretary may furnish such home health services as the Secretary finds 
to be necessary or appropriate for the effective and economical 
treatment of the veteran . . . The Secretary may furnish home health 
services to a veteran in any setting in which the veteran is 
residing'').
    While section 1717 does not specifically state the authority 
provided is for noninstitutional or alternatives to institutional 
extended care, VA has used this authority to provide home health 
services under HBPC (See VHA Handbook 1141.01, Home-Based Primary Care, 
at 1). HBPC is an interdisciplinary home health care program delivering 
primary care provided by an interdisciplinary health care team in the 
homes of veterans. The goals of this program include ``[P]romoting the 
veteran's maximum level of health and independence by providing 
comprehensive care and optimizing physical, cognitive, and psychosocial 
function,'' and ``[R]educing the need for, and providing an acceptable 
alternative to, hospitalization, nursing home care, emergency 
department and outpatient clinic visits, through longitudinal care that 
provides close monitoring, early intervention, and a therapeutic safe 
home environment.'' (Emphasis added.)
    Based on these laws and regulations, we look finally at VA's fiscal 
year 2012 budget request, for which Congress has provided 
appropriations and which lists those extended care programs it has 
categorized as ``non-institutional.'' These services include VA, State, 
and Contract Adult Day Health Care, Home-Based Primary Care, Homemaker/
Home Health Aide Programs, Spinal Cord Injury Home Care, Telehome 
Health, and ``Other Home Based Programs.''
    In its proposed definition for ``personal care services,'' VA does 
not mention consideration of services beyond those under 38 CFR 
Sec. Sec. 17.36(a) and 17.38(a)(1)(xi)(B). Instead, VA proposes to 
``[c]linically rate the eligible veteran's inability to perform each of 
the seven [Activities of Daily Living] . . . [and] . . . the eligible 
veteran's need for supervision or protection based on symptoms or 
residuals of neurological or other impairment or injury using the seven 
impairments listed in the definition of that term in [38 CFR] 
Sec. 71.15.''
    While we understand the assessment of need is required clinically 
and by law (to provide caregiver training and ongoing support in 
providing personal care services to the eligible veteran under 38 
U.S.C. 1720G(a)(3)(A)(i)(I) and (II)), we believe it reasonable to 
infer Congress intended the personal care services reflect skilled and 
unskilled home care services VA currently provides. Neither VA's 
proposed definition of personal care services nor the 14 categories of 
its assessment instrument reflect the plain reading of the law, which 
specifically ``[m]eans services provide[d] [to] the veteran.'' 
(Emphasis added).
    In addition, DAV's concern with VA's proposal is four-fold. One, VA 
proposes to use a new 14-item instrument based on ``[t]hree widely 
accepted clinical tools for measuring Activities of Daily Living and 
functional dependence . . . The Katz Basic Activities of Daily Living 
Scale (Katz ADL); the UK Functional Independence Measure and Functional 
Assessment Measure (FIM + FAM); and the Neuropsychiatric Inventory 
(NPI).'' However, unlike VA's 14-item assessment instrument, the Katz 
ADL, UK FIM + FAM, and the NPI have proven reliability (internal 
consistency/reproducibility), validity (construct and criterion 
validity), responsiveness as an outcome measure, interpretability 
(provides clinically relevant event), and burden (cost and time to 
administer).
    Two, VA proposes to evaluate the level of dependency with ``[T]he 
sum of the zero-to-four scores assigned to each of the 14 categories . 
. . is then applied to a presumptive level of need: Eligible veterans 
who score 21 or higher . . . are presumed to need . . . 40 hours of 
care per week . . . an eligible veteran who scores 13 to 20 total . . . 
will be presumed to require 25 hours per week of caregiver assistance . 
. . [and] . . . an eligible veteran who scores 1 to 12 will be presumed 
to require 10 hours per week.'' (76 Fed. Reg. at 26155). We note the 
validity and reliability of the Katz ADL instrument has been proven 
using a 2-, 3-, or 4-level scale, the UK FIM + FAM with a 7-level scale 
and the NPI uses a 6-level scale to measure ``frequency'' and a 3-point 
scale to measure ``severity.'' However, VA provides no discussion that 
using the Department's proposed 5-level scale (0-4) for its new 
instrument will provide equivalent inter-rater reliability and validity 
as the three assessment instruments on which it is based.
    Three, VA proposes to give equal weight to all scores and/or items 
when clinically evaluating the level of a veteran's dependency based on 
its 14-item instrument. It is particularly conspicuous that VA provided 
no discussion or evidence this particular proposal is clinically or 
scientifically valid especially when all 14 items are derived from 
three distinct assessment instruments that measure different domains.
    Four, VA proposes to use, ``[t]he sum of the zero-to-four scores 
assigned to each of the 14 categories . . . to assign a presumed number 
of hours required of the caregiver,'' ostensibly, to meet the law's 
requirement that VA determine, ``[t]he amount and degree of personal 
care services,'' the family caregiver provides the veteran. DAV is 
concerned that VA's proposed presumptions eliminate the flexibility 
afforded to the clinical team assigned to perform these assessments to 
determine how long and how often any one type of assistance or personal 
care service a patient would require, which can vary from one patient 
to another, to remain in their community of choice. This variability 
can be of such value as to change the level of benefits the caregiver 
may receive.
    With the time burden of performing the Katz ADL instrument 
consisting of a short six-item rating scale, the time required to 
administer the FIM+FAM is approximately 35 minutes, and the NPI 
interview can be completed in 7 to 10 minutes. However, according to a 
1994 article in Neurology titled, ``The Neuropsychiatric Inventory: 
Comprehensive assessment of psychopathology in dementia,'' a caregiver 
of a patient with more psychopathology will require longer interviews 
than the presumed 7 to 10 minutes.
    Because it is not only the level of caregiver benefit affected by 
the final definition of personal care services as well as the 
determination of the amount and degree of such services, but also the 
family caregiver's responsibility to the veteran, we recommend VA use 
these three instruments and determine the actual personal care services 
the eligible veteran needs and those personal care services the family 
caregiver will be required to provide (VA proposes in 38 CFR 
Sec. 17.25(c), an assessment of specific personal care services and a 
``[t]reatment plan listing the specific care needs of the eligible 
veteran''). We also recommend VA determine the frequency and hours 
required to perform such personal care services. Such assessments are 
currently performed outside VA as well as the determination of 
frequency and hours of home care services a patient needs to remain in 
their community. We believe this is a more reasonable and accurate 
approach to meet the law's requirement for VA to determine the amount 
and degree of personal care services each eligible veteran needs.
Beneficiary travel limitations
    VA's family caregiver beneficiary travel proposal, based on 38 
U.S.C. Sec. 1720G(a)(6)(C), would be subject to any limitations or 
exclusions under Part 70 or title 38. VA indicated there is no reason 
to believe that section 1720G extends beneficiary travel benefits to 
family caregivers but does not also require the equal application of 
the limitations that apply to all individuals eligible for benefits 
under part 70.
    DAV recommended VA take the opportunity to revise its regulations 
to meet the travel and transportation policies contained in its own 
2009 Geriatric and Extended Care Strategic Plan.
    This strategic plan, which has been submitted to Congress, notes, 
``[t]he major goal of community-based extended care is to reduce or 
eliminate the need for veterans to travel to access care. Nonetheless, 
assistance in transportation options is a consistently cited top need 
for informal caregivers. VA does allow caregivers to travel with 
veterans who themselves have a travel benefit, if their presence is 
necessary to the well-being of the veteran. But this does nothing for 
veterans lacking the benefit, or for assisting caregivers to 
participate in support groups.''
    Significant barriers identified by VA in the strategic plan 
include, ``[A]vailability of transportation services for disabled 
individuals is variable, insufficient, requires effort to access, and 
is often costly. Likewise, transportation is often provided only for 
care recipients and not for caregivers. Eligibility requirements are 
strict and round-trip duration times are excessive for many patients.'' 
Moreover, ``[f]indings from a 2006 survey of VA health care staff 
(primarily social work, nursing, and physicians working in CLCs and 
HBPC programs) rating the perceived importance and availability of a 
range of caregiver support services. Inadequate transportation was 
cited most frequently by VA staff as a barrier to accessing [Adult Day 
Health Care] and caregiver support groups.''
    Notably, issues with the eligibility requirements were specifically 
discussed in the strategic plan. ADHC has strong appeal for veterans 
whose family caregivers must be absent (e.g., for work or other 
commitments) during workdays. ADHC may be provided for a specific 
number of days outside the number of routinely scheduled visits. These 
days would be counted as respite care under 38 U.S.C. 1720B since these 
ADHC visits are temporary additions to the routine services the veteran 
already receives.
    ``[V]eterans with an indication for medical transport and meeting 
eligibility criteria, (outlined in Beneficiary Travel Handbook 1601B.05 
July 29, 2008), may be eligible for special mode transportation to and 
from medical appointments. Caregivers may ride with the veteran if 
there is a determined need for an attendant. Although this benefit is 
available at all VA medical centers, the extent of its use can vary 
considerably based on the definition of ``medically indicated.'' In 
general, this refers to veterans requiring air or ground ambulance, 
wheel chair transportation, or transportation specially designed to 
transport disabled persons. ''
    The Beneficiary Travel Handbook 1601B.05 was recently revised but 
such revisions did not address the issues surrounding the eligibility 
criteria. The strategic plan recommendations regarding beneficiary 
travel include (#26) a, ``[n]eeds based (not eligibility based) 
beneficiary travel for frail/disabled veterans.''
    We urge VA to reconsider its proposal to provide to family 
caregivers beneficiary travel benefits, ``[s]ubject to any limitations 
or exclusions under part 70 as well.'' (76 Fed. Reg. at 26153). Doing 
so would include family caregivers of those veterans who already face 
barriers to use this critical and needed benefit to access support and 
services.
    Madam Chairwoman, DAV believes VA has a unique opportunity to 
address within its health care system, a national health care challenge 
with regard to informal caregivers. This new VA program could be a 
blessing to caregivers of severely disabled veterans and a benevolent 
response to those grievously injured in war and in military duties. We 
believe the comments, concerns, and recommendations we submitted will 
make the caregiver support program more effective, more humane, and one 
that will reach more veterans as intended by Congress and the American 
people.
    Again, we thank you for the opportunity to present our views on 
VA's IFR for title I of P.L. 111-163. The DAV is committed to working 
constructively with Congress, VA, and the Administration to ensure 
family caregivers do not remain undertrained, underpaid, 
underappreciated, undervalued, and exhausted by their duties.

                                 
       Statement of Tom Tarantino, Senior Legislative Associate,
                Iraq and Afghanistan Veterans of America
    Madam Chairwoman, Ranking Member, and Members of the Committee, on 
behalf of Iraq and Afghanistan Veterans of America's 200,000 member 
veterans and supporters, I thank you for inviting me to testify at this 
hearing to share our members' views on this important issue.
    My name is Tom Tarantino and I am the Senior Legislative Associate 
with IAVA. I proudly served 10 years in the Army beginning my career as 
an enlisted Reservist and leaving service as an Active Duty Cavalry 
Officer. Throughout those 10 years, my single most important duty was 
to take care of other soldiers. In the military, they teach us to have 
each other's backs. Although my uniform is now a suit and tie, I am 
proud to work with this Congress to ensure the entire country has the 
backs of America's servicemembers and veterans.
    The fight is not over when our warriors leave the combat zone. They 
have made a commitment: we have asked them to sacrifice their time and 
families, to risk their lives and limbs, to protect us. It is only 
right that we as a people, as a Nation, make good on our commitment to 
take care of our warriors, especially when they leave pieces of 
themselves on the battlefield. Taking care of our veterans often means 
taking care of their families.
    IAVA strongly supports the Caregivers Assistance Program. We 
recognize that wounded warriors deserve the chance to live the fullest 
life possible. Whether their wounds are physical, mental, or some 
combination of the two, veterans heal better and faster when they are 
comfortable and happy with access to the support of family and friends. 
If the choice is between being warehoused in a VA or DoD facility or 
recovering at home surrounded by family and friends, IAVA believes that 
the compassionate choice and the logical choice are one and the same. 
As one spouse of a wounded warrior put it, ``[We] just want to be 
included in our society rather than being segregated.''
    It is our duty to ensure that the any assistance program fully 
meets the needs of those it is designed to help. To that end, IAVA 
would like to make some suggestions about modifications to the Interim 
Final Rule for the Caregivers Assistance Program.
1.  The GAF score required to enter the program is too restrictive. In 
        addition, the requirement to have a continuously low GAF score 
        is restrictive and self-defeating.
    The Interim Final Rule sets several criteria for entry into the 
program; one of these is evaluation using the General Assessment of 
Functioning (GAF). To be eligible for the program, a veteran must have 
a GAF score of 30 or below at the beginning and end of a 90 day period 
and the score cannot rise above 30 in the interim. In other words, 3 
continuous months of a 30 or below GAF score.
    The first problem we see is that a GAF score of 30 corresponds to 
such severe impairment that a veteran would need treatment that is 
beyond the scope of a family caregiver. Higher GAF scores still present 
serious problems: a GAF score of 31-40 denotes ``some impairment in 
reality testing and communication or major impairment in several 
areas'' including being unable to work. A GAF score of 41-50 denotes 
``Serious symptoms (e.g., suicidal ideation, severe obsessional 
rituals, frequent shoplifting) OR any serious impairment in social, 
occupational, or school functioning'' including the inability to keep a 
job or maintain friendships.
    The point of any rehabilitation is to help veterans get better. 
Under the VA rule, however, if a veteran shows improvement by receiving 
a single GAF score above 30, he or she becomes ineligible to receive 
Caregivers Assistance. The VA rule appears to force a choice: get 
treated, get better and be ineligible or remain non-functional with a 
poor quality of life and be eligible.
    IAVA believes that relaxing the GAF criteria would be in the best 
interests of veterans. Raising the GAF score required to participate in 
the program to as high as 50 would still mean that veterans with 
profound mental health issues would be eligible for the program and not 
be penalized for improving.
2.  Stronger coordination with DoD programs and third-party providers 
        is necessary.
    The VA definition of primary care team on 26149 of Vol. 76 No. 87 
of the Federal Register does not make it clear who composes that team. 
Because a significant population eligible for this program are retired 
medically from service or covered by insurers outside the VA, many 
receive treatment outside the VA system, for example from TRICARE 
providers and third-party providers under fee-for-service programs. 
Veterans who are diagnosed with mental or physical disabilities that 
make them eligible for the Caregivers Assistance Program after 
separation from service may also have been treated by physicians and 
clinicians outside the VA system, i.e. through private insurance. With 
pending legislation that is likely to expand fee-for-service programs 
and third-party providers, situations where a veteran is under the care 
of a doctor outside the VA system will only increase. It is imperative 
that VA primary care teams consult these doctors and utilize their 
assessments and that this requirement is explicitly stated.
    IAVA has spoken with veterans or family members being treated 
outside of the VA system whose treating physicians have never been 
consulted by VA clinicians making eligibility determinations or 
treatment recommendations. In one case, a clinical psychiatrist who for 
over 5\1/2\ years has treated a veteran with traumatic brain injury 
(TBI) and mental health issues stemming from his war injuries has never 
spoken to or been contacted by VA personnel in any capacity. If such a 
long-standing relationship does not qualify for the ``primary care 
team'' then what will?
    IAVA does not support the contention that clinicians outside the VA 
should make the call on who is eligible for the program. It is a VA 
program and the VA should administer it. However, IAVA believes that 
review of existing patient records and consultations with non-VA 
clinicians who are treating a particular veteran should form at least 
part of the basis for decisions. Clinicians who determine entry into 
the program and progress in the program must consult with clinicians 
who are actually treating the veteran. There is no need to reinvent the 
wheel and delay veterans and their families' entry into the Caregivers 
Assistance Program.
3.  Differentiation between Primary Family Caregivers (PFC) and 
        Secondary Family Caregivers (SFC) needs to be lessened. 
        Qualifications for SFC, particularly the requirements reside 
        with the veteran, need to be relaxed.
    IAVA understands the levels of caregiver differentiation and agrees 
that different levels of commitment should receive different levels of 
benefits. The structure that the VA has proposed for the levels of 
responsibility and the number of Family Caregivers (FC), however, will 
negatively impact family caregivers, particularly during periods of 
respite care. Accommodation in the VA's interpretation of 38 CFR 71 
should be made for exceptional circumstances and the authority to 
accommodate should be made clear as well.
    VA has established that there can only be one PFC, although there 
does not need to be one at all. VA has also established that there can 
be a maximum of only two SFC, even if there is no PFC. A veteran, 
therefore, could have between 1 and 3 family caregivers. A veteran may 
have an unlimited number of General Caregivers (GC). VA describes GC as 
``Good Samaritans'' [Federal Register Vol 76 No 87 26152] and that 
corresponds to the level of benefits they receive: just enough to make 
them helpful with ``less critical personal care.'' This means that the 
bulk of care rests on the shoulders of PFC and SFC. The difference 
between PFC and SFC are that PFC receive all the benefits of SFC and a 
monthly stipend, respite care for at least 30 days per year and health 
care coverage through CHAMPVA. Any FC must be ``(i) The eligible 
veteran's spouse, son, daughter, parent, step-family member, or 
extended family member; or (ii) Someone who lives with the eligible 
veteran full-time or will do so if designated as a family caregiver.''
    Keeping in mind the above restrictions and benefits, let us 
consider the following scenario: a wounded veteran without a large 
family who has no PFC. Essentially, with the requirements for entry 
into the Caregivers Assistance Program, that veteran will rely on 1 to 
3 SFC for assistance with the vast majority of their specialized needs. 
The veteran may not have a PFC for a variety of reasons: inability of 
family or friends to commit as the primary source of care, desire of 
the veteran not to be a burden on family, or a small family or no 
family, i.e. an orphan. Whatever the reason, if there is no PFC then 
the SFC should be pro-rated a monthly stipend based upon their level of 
care. This will help defray the costs of care for the SFC, who receive 
the same training and are expected by the VA to perform the same tasks 
at the same level of competency as the PFC. One can easily imagine a 
scenario with a rotation of SFC who share the responsibilities of care 
on a rotating basis and they should be eligible for benefits 
commensurate with their level of responsibility.
    In addition, the restriction on FC to live with the veteran should 
be relaxed. For example, if a spouse of a wounded veteran is the PFC 
then a sibling or parent might be willing to be a SFC. However, under 
the current interpretation, a best friend or a cousin would not be 
eligible to be a SFC unless that person lives with the veteran ``full-
time.'' This distinction does not recognize that in some cases 
immediate family members may not have as close a relationship with a 
veteran as the veteran's best friend, for example. If the SFC 
``generally serves as a back up to the Primary Family Caregiver'' 
[Federal Register Vol. 76 No. 87 26148] then anyone with (1) a close 
relationship that mirrors that of a family member and (2) who is 
willing to accept the responsibility of an SFC should be classified as 
an ``extended family member'' and allowed to function as an SFC if the 
veteran and/or PFC approve regardless of whether or not they are 
domiciled with the veteran. In addition, the definition of ``Someone 
who lives with the designated veteran full-time'' should be interpreted 
to recognize that ``full-time'' living might occur on a part-time basis 
as in the next suggestion.
4.  The provision of ``respite care'' needs to be clearly defined
    What respite care consists of or entails is not clearly defined but 
in practice has been either placing a veteran into a VA hospital or 
placing a home health care aide in the veteran's home. While these are 
acceptable alternatives, with the availability of SFC and GC creating 
an unfamiliar environment should be the last resort rather than the 
first option. The practice of the provision of respite care is too 
rigid and, as one caregiver put it, ``People won't use it because it 
doesn't meet their needs'' nor does it meet the intent of the 
Caregivers Assistance Program.
    Another scenario similar to the ones given above might entail the 
respite of a PFC. During this period, VA will provide ``respite care.'' 
In conjunction with the suggestion above, relaxing the definition of 
extended family would allow the option of a SFC to move in with a 
veteran full-time for a short period of time, enough to allow respite 
for a FC while still giving the veteran the continuity of care and home 
life the program is intended to provide.
    In addition, pro-rating a stipend for SFC would allow them to 
defray part of the costs associated with providing respite for another 
FC. Covering travel for the respite caregiver would also be beneficial. 
The current interpretation appears to assume that all who take on the 
role of a FC reside in geographic proximity. This is often not the case 
and accommodation should be made. Provision should be made for covering 
the actual costs of travel, as is done under TRICARE.
    While some might contend that these measures will add costs to the 
program, the associated benefits of meeting the intent of the program 
(allowing a veteran to remain in a home environment while recovering) 
and the cost of removing a veteran to a VA hospital or providing in-
home care through an unfamiliar home health care aide are likely 
greater.
    IAVA understands the need establish solid criteria to receive 
caregivers assistance. With budgets coming under tremendous scrutiny, 
government agencies must do their utmost to make certain that there is 
not even the perception of fraud, waste or abuse. However, the 
Caregivers Assistance Program is not a boondoggle or a giveaway. It is 
not a program designed to make anyone wealthy. It is not even designed 
to make anyone, veteran or family member, whole again. The Caregivers 
Assistance Program merely provides the ability to exist at an extremely 
modest level while helping a loved one.
    The story of Sarah Wade, who has been instrumental in getting this 
program instituted, is a great example. When her husband, Ted, was 
injured, she was enrolled in college with the hope of becoming a 
Foreign Service officer; Ted was going to become a commissioned officer 
through the Army's Green to Gold program. Our country lost the future 
contributions of a fantastic couple dedicated to public service; the 
Wade's lost their plans for the future. Now, Sarah cares for Ted and 
his very modest benefits from medical retirement and SSI, as well as 
her part--time work, sustains them. Had life continued for them as 
planned, they would have made very comfortable salaries. Now though, as 
Sarah succinctly puts it ``Ted was capped at an E-5 for the rest of his 
life. Our standard of living was frozen.''
    While the ``VA does not intend that the stipend replace career 
earnings'' [p. 26155, Federal Register Vol. 76, No. 87], caring for a 
veteran who qualifies for the Caregivers Assistance Program is a full-
time job in itself. The income from the Caregivers Assistance Program 
will not make anyone rich nor will it place veterans and their families 
remotely close to where they would have been financially before their 
injuries. But it will give them, and thousands of other veterans and 
their families, a small cushion and a little peace of mind while their 
(and our) heroes recover.
    IAVA believes that the Congress, the VA and the American people 
have recognized how important this issue is. We support the efforts of 
all those who are dedicated to taking care of our warriors when they 
return home, especially those wounded warriors who need our help the 
most. We hope that our comments help make that goal a reality.
                                 
     Statement of Barbara Cohoon, Ph.D., R.N., Government Relations
         Deputy Director, National Military Family Association
    Chairwoman Buerkle and Distinguished Members of this Subcommittee, 
the National Military Family Association would like to thank you for 
the opportunity to present testimony on ``Implementation of Caregiver 
Assistance: Moving Forward.'' The National Military Family Association 
will take the opportunity to discuss our concerns regarding the 
Department of Veterans Affairs' Caregiver Implementation Plan and 
several issues of importance to family caregivers of the wounded, ill, 
and injured servicemembers, veterans, their families, and caregivers in 
the following subject areas:

      I. VA Caregiver Implementation Plan
     II. Additional Caregiver Compensation
     III. Senior Oversight Committee
VA Caregiver Implementation Plan
    While our Association is extremely appreciative of Members of 
Congress for the passage of this landmark legislation, we have some 
concerns regarding the Department of Veterans' Affairs' (VA's) 
implementation plan. These concerns include the need for these 
important caregiver benefits to start earlier in the servicemember's 
recovery process, retroactive stipend to the implementation of the law 
on January 31, 2011, and the establishment of a Department of Defense 
(DoD) and VA seamless transition of caregiver benefit.
Illness
    Illness was one condition that was intended to be included in the 
caregiver provision in Caregivers and Veterans Omnibus Health Services 
Act of 2010--Public Law 111-163. Congressman Michael Michaud (D-2nd/ME) 
introduced the Caregiver Assistance and Resource Enhancement Act (CARE 
Act, H.R. 3155). According to his press release on July 29, 2009, 
``[t]he bill would establish a caregiver program to help family and 
non-family members who provide care for disabled, ill, or injured 
veterans.'' This bill passed the full House of Representatives. As the 
new caregiver program was launched, Secretary of Veterans Affairs Eric 
K. Shinseki commented on February 12, 2011, ``They [caregivers] are 
critical partners with VA in the recovery and comfort of ill and 
injured veterans. The law states, ``[n]eed for supervision or 
protection based on symptoms or residuals of neurological or other 
impairment or injury.'' The inclusion of the words ``or other 
impairment'' could include illness related conditions. However, illness 
was not included in the VA's interpretation of the law. This creates 
the potential for DoD's caregiver compensation benefit and the VA's 
caregiver benefit to apply to different sets of servicemembers and 
veterans. DoD's includes illness and the VA's would not. This could 
potentially create a disparity in benefits and a lack of a seamless 
transition regarding compensation. Maintaining financial compensation 
will be key in ensuring these families' financial situations stay 
stable during transition from active duty to veteran status. The 
frequent mention of our Armed Forces members' exposure to toxic 
chemicals from burn pits may have a long-lasting effect. Therefore, 
service-connected illnesses need to be included as a qualifying 
condition. Our Association recommends that illness be included as an 
eligibility requirement by the VA.
Starting Time of the Benefit
    The time to acknowledge the caregiver's important role and to 
implement the caregiver benefit is while the wounded, ill, and injured 
servicemember is still on active duty status. The self-selection 
process of a caregiver occurs during the early phase of the recovery 
process. All Service branches are holding onto their wounded, ill, and 
injured servicemembers much longer than previous wars. Years may have 
passed before the caregiver and the wounded, ill, and injured 
servicemember reach eligibility and can benefit from the VA's important 
programs and services. Therefore, we recommend that the designation of 
caregiver benefits be established while they are still upstream on 
active-duty beginning with the start of the Medical Evaluation Board 
(MEB) process, rather than wait until they have transitioned to veteran 
status.
    Waiting until after the receipt of a medical separation date to 
start the caregiver benefit application process will prevent caregivers 
from being able to receive training and obtain benefits early enough in 
the recovery phase to make a difference in their quality of life and in 
the quality of care they provide. Servicemembers often receive care in 
a military hospital and/or VA Polytrauma Center, recover at home, and 
then return to the hospital for follow-on care and subsequent 
surgeries. The VA's training requirement will prevent eligible 
caregivers from receiving any advance training for in-home care until 
the servicemember is being medically discharged from the military. Our 
Association finds this troubling because a recent survey by the 
National Alliance for Caregiving, ``Caregivers of Veterans--Serving on 
the Homefront,'' found a top challenge faced by veteran caregivers was 
not knowing what to expect medically with the veteran's condition and 
not knowing how to address Post-Traumatic Stress Disorder (PTSD) or 
mental illness. Caregivers have frequently stated they did not know how 
to care for a servicemember or veteran when they were discharged from 
the hospital and went home during their recovery phase. This can cause 
increased stress on an already anxious caregiver. Our Association 
believes the sooner you provide caregivers with the skills they need to 
perform their duties, the sooner they will be able to provide a higher 
quality of care to the wounded, ill, and injured servicemember and 
veteran. The VA's decision to wait until the servicemember is medically 
discharged from the military before beginning the training program will 
certainly prevent this valuable training opportunity from occurring at 
the appropriate time to make a difference in the quality of care of the 
wounded, ill, and injured servicemember.
    The delay in eligibility also impacts the ability to obtain time 
sensitive needed benefits, such as access to mental health counseling, 
health care benefits, and financial compensation. This especially 
impacts non-spouse caregivers who would greatly benefit from these 
services. A recent VA press release stated 17 percent of caregiver 
applicants were from mothers. According to the ``Caregivers of 
Veterans--Serving on the Homefront'' survey, one in four respondents 
were parents caring for Operation Enduring Freedom and Operation Iraqi 
Freedom veterans.
    Our Association is hearing that caregivers are reaching the stage 
of burnout and many are deciding to walk away from their roles as 
caregivers. According to ``Caregivers of Veterans--Serving on the 
Homefront'' survey, there are widespread impacts on the caregiver's 
health, such as increased levels of stress and anxiety (77 percent), 
and not sleeping (77 percent), and a decrease in the utilization of 
healthy behaviors, such as seeing their medical provider. The caregiver 
survey highlighted the increased stress our veteran caregivers are 
under compared to their National counterparts. The law and 
Congressional intent were to allow the VA to provide assistance through 
value-added benefits to the caregiver early enough in the process to 
make a difference and prevent the development of physical health, 
mental health, and/or financial problems. The longer the VA waits to 
begin benefits, the more opportunity there is for the caregiver's 
quality of life to worsen and for the caregiver to reach the stage of 
burnout. Caregivers of our wounded, ill, and injured need these 
services sooner in the recovery process than later.
    The interim final rule states, ``we do not believe that Congress 
intended to authorize prolonged caregiver benefits for active duty 
servicemembers, particularly because they have authorized Department of 
Defense to provide similar benefits to active duty servicemembers.'' 
Our Association would disagree with this statement. They are two 
separate benefits with significant differences. The DoD's benefit does 
NOT include training, health care, counseling, or respite care, which 
are only included in the VA's caregiver benefit. Reliance on the DoD 
program only further delays caregivers from receiving health care, 
counseling, respite, and training benefits as it was intended to have 
been received. Also, DoD's benefit only provides compensation in the 
form of a payment to the servicemember who meets certain eligibility 
criteria and has a caregiver. The benefit is geared more towards the 
VA's aid and attendance benefit in regards to establishing the level of 
compensation received by the servicemember rather than the VA's new 
caregiver benefit. It would be better if these two benefits married up 
with a seamless transition of the aid and attendance benefit. The DoD 
benefit should not be considered a ``caregiver benefit.''
Starting all Programs at the Same Time
    The VA has decided to begin all of the benefits at the same time. 
They could very easily make training information and access to valuable 
VA and DoD resources available much earlier in the process than their 
proposed timeline. Again, the earlier access to pertinent resources and 
information related to VA and DoD benefits for the servicemember, 
veteran, and caregivers, will only be a win-win for everyone involved. 
Allowing early access to information validates the important role 
caregivers provide. Plus, an educated caregiver will only provide 
better care in the long run. Our Association recommends the VA begin 
caregiver benefits as early as possible while the servicemember is 
still on active duty status and not wait until they have received a 
final determination.
Stipend
    Our Association, along with other Veteran and Military Service 
Organizations, frequently state how important this piece of legislation 
is for our Nation's caregivers. Every day the VA delays its 
implementation only places additional stress on an already strained 
population. We really cannot afford to put this off even one more day. 
The least the VA could do in order to compensate for its delay is to 
provide retroactive stipend payments to caregivers from the original 
date of implementation required by law.
    Our Association appreciates the VA acknowledging the need to 
compensate caregivers for providing direct hands-on medical care. 
However, we notice that the VA did not include a provision to pay 
caregivers for performing non-medical care services. Our Association 
has always proposed that financial compensation should recognize the 
types of medical and non-medical care services provided by the 
caregiver. The law states ``the amount of the monthly personal 
caregiver stipend provided under subparagraph (A)(ii)(V) shall be 
determined in accordance with a schedule established by the Secretary 
that specifies stipends based upon the amount and degree of personal 
care services provided.'' The law allows the Secretary of the VA the 
flexibility to include non-medical care services to be captured. The 
law also states ``stipends,'' not stipend, can be provided.
    The reason for wanting to include a non-medical compensation 
benefit is because there are many hours in a day spent performing these 
activities that play an integral part in maintaining the servicemember 
and veteran's quality of life yet are not captured by the VA's U.S. 
Department of Labor's Bureau of Labor Statistics (BLS) stipend matrix. 
Plus, Section 1115 of title 38 of the United States Code provides 
compensation to the veteran only when the spouse cannot perform the 
duties of a caregiver. This same level of stipend should be applied to 
non-medical care services provided by caregivers to servicemembers and 
veterans.
CHAMPVA
    Our Association is pleased caregivers will have the opportunity to 
benefit from the Civilian Health and Medical Program of the Department 
of Veterans Affairs, known as CHAMPVA. The population most likely to 
use this benefit will be the veteran's parent. However, there may be 
spouses who will qualify for this benefit. If the veterans were 
medically separated and were not medically retired, their spouses and 
children do not qualify for TRICARE (Department of Defense's health 
care benefit) following separation from the Service. Under this 
circumstance, veteran spouses and their children qualify for CHAMPVA 
once the veteran obtains a 100 percent disability rating from the VA. 
The veteran spouse, who qualified under the ``Caregiver'' benefit, 
should retain CHAMPVA coverage following revocation of the caregiver 
benefit because the veteran had received a 100 percent disability 
rating by the VA. We want to ensure spouses of 100 percent disabled 
veterans, no matter how they initially qualified for the CHAMPVA health 
care benefit, retain this benefit.
    CHAMPVA coverage should be a retroactive benefit. Caregivers that 
are currently submitting applications should be told to keep all of 
their health care receipts from the time the caregiver law should have 
been implemented, January 31, 2011. The eligible caregiver would submit 
their receipts once they meet the VA caregiver requirement. The VA 
should then provide CHAMPVA coverage for eligible caregivers back to 
this date. Future caregivers should be told to keep all of their health 
care receipts from the time the application was submitted. The VA 
should then cover all future eligible caregivers for CHAMPVA back to 
when the application process was submitted. They should be encouraged 
to seek care from CHAMPVA providers in the interim period. The 
Department of Defense did this exact same procedure for the new TRICARE 
Young Adult benefit. Eligible young adults were told to keep all of 
their medical receipts and submit them once the law was implemented.
Mental Health Services
    The interim final rule states, ``[t]he counseling provided to 
family caregivers is intended to treat those family caregivers, 
independent of whether that treatment is likely to support the clinical 
objectives of the eligible veteran's treatment plan.'' The interim 
final rule further states the VA will provide these same mental health 
services to Secondary family caregivers as well as Primary family 
caregivers. The interim final rule discusses this information under the 
``Supplementary Information'' section. However, when the counseling 
benefit is discussed in Sec. 71.40 Caregiver benefits, it states all 
counseling services are described under Sec. 71.50. This section states 
``VA will provide . . . in connection with the treatment of a 
disability for which the veteran is receiving treatment through VA.'' 
It appears to contradict what was stated earlier. Our Association would 
like to make sure that this is clearly stated in both Sections that 
Primary and Secondary family caregivers will receive counseling 
services independent of whether that treatment is likely to support the 
clinical objective of the eligible veteran's treatment plan as intended 
by the VA's interim final rule.
Aggravated While in the Line of Duty
    According to the interim final rule, the words ``incurred or 
aggravated a serious injury'' must have occurred while in the line of 
duty. It is unclear if a veteran's caregiver would qualify for this 
benefit if the injury, obtained while on active duty but was now 
aggravated to the point of needing caregiver assistance, occurred on 
veteran status. An example would be a veteran who has an embedded piece 
of IED shrapnel in the brain that began to leak toxins or needed to be 
surgically removed resulting in a worsening medical condition and the 
requirement of a caregiver. The veteran would still benefit from other 
VA programs, such as aid and attendance, but his/her caregiver could no 
longer qualify for this important benefit. Our Association would like 
to ensure caregivers are still eligible for the VA's caregiver benefit 
even if the serious injury was aggravated after the servicemember 
became a veteran.
Report on Expansion of Family Caregiver Assistance
    Our Association is concerned that the VA did not reference a report 
on the feasibility and advisability of expanding the caregiver benefit 
to family caregivers of veterans who have a serious injury incurred or 
aggravated in the line of duty while on active duty before September 
11, 2001. We want to make sure the VA fulfills this reporting 
responsibility because it is an integral part of the implementation of 
the caregiver program.
Additional Compensation for the Caregiver
    Our Association is appreciative of the generous benefits included 
in the Caregivers and Veterans Omnibus Health Service Act of 2010. 
However, there were some areas not addressed. Our Association would 
like to take the opportunity to present recommendations.
    A report by the Center for Naval Analysis determined 85 percent of 
caregivers left employment or took a leave of absence from work or 
school while performing their caregiver duties. They found that the 
average loss of earnings per caregiver was approximately $3,200 per 
month. The financial strain placed on the family of our wounded, ill, 
and injured servicemember and veteran by the caregiver leaving outside 
employment has a trickle down affect. Caregivers who have been saving 
for retirement now find they are ineligible for their employers' 
401(k)s. We believe a mechanism should be established to assist 
caregivers to save for their retirements, for example, through the 
Federal Thrift Savings Plan.
    Once the recovery process is finished and the veteran's care has 
stabilized, the caregiver may decide to work outside the home in order 
to help make financial ends meet. These caregivers may need the ability 
to learn new skills in order to compete in today's workforce. We 
recommend VA offer these caregivers the opportunity to participate in 
VA's vocational rehabilitation programs and help retool the caregiver's 
resume. We must also find innovative ways to encourage civilian and 
government employers to hire these caregivers, especially when the 
veteran is unable to work.
    According to the Center of Naval Analysis, wounded, ill, and 
injured servicemembers and veterans, their families, and caregivers are 
assisted by many non-governmental organizations (NGOs) and charities. 
This assistance is important with the overall financial stability of 
these families during the recovery phase. Our Association's concern, as 
we continue into another year of economic downturn, is that we may find 
many of these NGOs and charities no longer able to assist in the manner 
they have previously. We believe the availability of outside assistance 
by others will need to be monitored closely by both the VA and DoD to 
make sure these families are still being helped. If they are no longer 
being assisted, we believe the VA and DoD may need to begin providing 
assistance in those areas previously covered by NGOs and charities.
Relocation Allowance for Caregivers
    Active duty servicemembers and their spouses qualify through the 
DoD for military orders to move their household goods (known as a 
Permanent Change of Station (PCS)) when they leave the military 
service. Medically retired servicemembers are given a final PCS move. 
Medically retired married servicemembers are allowed to move their 
family; however, medically retired single servicemembers only qualify 
for moving their own personal goods.
    The National Military Family Association suggests the VA should pay 
for the caregivers move as part of the VA caregiver law. We recommend 
that impending medically retired single servicemembers who are eligible 
for the VA's caregiver benefit be allowed the opportunity to have their 
caregiver's household goods moved, too. This should be allowed for the 
eligible primary caregiver and their family. The reason for the move is 
to allow the impending medically retired single servicemember the 
opportunity to relocate with their caregiver to an area offering the 
best medical care, rather than the current option that only allows for 
the impending medically retired single servicemember to move their 
belongings to where the caregiver currently resides. The current option 
may not be ideal because the area in which the caregiver lives may not 
have all the health care services required for treating and caring for 
the impending medically retired servicemember. Instead of trying to 
create the services in the area, a better solution may be to allow the 
impending medically retired servicemember, their caregiver, and the 
caregiver's family to relocate to an area where services already exist, 
such as a VA Polytrauma Center.
    The decision on where to relocate for optimum care should be made 
with the help of the VA caregiver team: Federal Recovery Coordinator 
(case manager); the servicemember's physician; the servicemember, and 
the caregiver. All aspects of care for the impending medically retired 
servicemember and their caregiver shall be considered. These include a 
holistic examination of the impending medically retired servicemember, 
the caregiver, and the caregiver's family for, but not limited to, 
their needs and opportunities for health care, employment, 
transportation, and education. The priority for the relocation should 
be where the best quality of services is readily available for the 
impending medically retired servicemember and eligible for the VA's 
caregiver benefit along with his/her caregiver.
Veteran Housing
    Many of our wounded, ill, and injured servicemembers and veterans 
from this current conflict are being cared for by their parents. Also, 
many adult children of our senior veterans are experiencing first-hand 
the challenge of trying to juggle the needs of the parents along with 
the needs of their children, and are referred to as the ``sandwich'' 
generation. Parent caregivers worry about who will care for their 
wounded son or daughter as they age and are unable to fulfill the role 
of caregiver. Caregivers may reach burnout and will need alternative 
solutions for providing care. The VA needs to be cognizant of the ever 
changing landscape and needs of their veteran population and those who 
care for them. The VA needs to offer alternative housing arrangements, 
such as assisted living facilities and family/retirement villages, 
which allow a diversified population to live together in harmony. This 
will go a long way in allowing for family units to stay together, 
foster independent living, and maintain dignity for the veteran.
    Brooke Army Medical Center (BAMC) has recognized a need to support 
our wounded, ill, and injured families by expanding the number of 
guesthouses co-located within the hospital grounds and providing a 
family reintegration program for their Warrior Transition Unit. The on-
base school system is also sensitive to issues surrounding these 
children. A warm, welcoming family support center located in guest 
housing serves as a sanctuary for family members. VA medical facilities 
could benefit from looking at successful programs like BAMC's that 
embrace the family unit and commit to building family friendly 
environments of care for our wounded, ill, and injured servicemembers, 
veterans, and their families. We recommend the development of 
alternative housing and living arrangements for veterans, their 
families, and those who care for them.
Mental Health
    The need for mental health services will remain high for some time 
even after military operations scale down and servicemembers and their 
families transition to veteran status. Veterans' families and caregiver 
requirements for a full spectrum of mental health services--from 
preventative care and stress reduction techniques, to individual or 
family counseling, to medical mental health services--will continue to 
grow. It is also important to note if DoD has not been effective in the 
prevention and treatment of mental health issues, the residual will 
spill over into the VA health care system. The VA must be ready. They 
must partner with DoD and State agencies in order to address mental 
health issues early on in the process and provide transitional mental 
health programs. They must maintain robust rehabilitation and 
reintegration programs for veterans, their families, and caregivers 
that will require VA's attention over the long-term.
    The National Military Family Association is especially concerned 
with the scarcity of services available to the veterans' families and 
caregivers as they leave the military following the end of their 
activation or enlistment. Military families will no longer qualify for 
many of the Services' family support programs and DoD's Military 
OneSource. Our Association recommends the VA increase outreach to 
veterans, their families and caregivers, and the communities they live 
in about available mental health resources to help them deal with the 
residual effects of long frequent deployments.
Children of the Veteran and Caregiver
    The impact of the wounded, ill, and injured veteran on their 
children is often overlooked and underestimated. These children 
experience a metaphorical death of the parent they once knew and must 
make many adjustments as their parent recovers. Many families relocate 
to be near the treating Military Treatment Facility (MTF) or the VA 
Polytrauma Center in order to make the rehabilitation process more 
successful. As the spouse focuses on the rehabilitation and recovery, 
older children take on new roles. They may become the caregivers for 
other siblings, as well as for the wounded parent. Many spouses send 
their children to stay with neighbors or extended family members, as 
they tend to their wounded, ill, and injured spouse. Children get 
shuffled from place to place until they can be reunited with their 
parents. Once reunited, they must adapt to the parent's new injury and 
living with the ``new normal.'' We must remember the caregiver may not 
be the veteran's spouse. They may be the wounded veteran's parent, 
sibling, or friend. These children are also affected and Congress and 
the VA must be cognizant of their potential psychological needs as 
well.
    We encourage partnerships between government agencies, VA, DoD, and 
State agencies and recommend they reach out to those private and non-
governmental organizations who are experts on children and adolescents. 
They could identify and incorporate best practices in the prevention 
and treatment of mental health issues affecting these children. We must 
remember to focus on preventative care upstream, while still in the 
active duty phase, in order to have a solid family unit as they head 
into the veteran phase of their lives. VA, DoD, State, and our local 
communities must become more involved in establishing and providing 
supportive services for our Nation's children.
Expansion of Caregiver Pilot Programs
    The VA currently has eight caregiver assistance pilot programs to 
expand and improve health care education and provide needed training 
and resources for caregivers who assist disabled and aging veterans in 
their homes. These pilot programs are important; however, there is a 
strong need for 24-hour in-home respite care, 24-hour supervision, 
emotional support for caregivers living in rural areas, and coping 
skills to manage both the veteran's and caregiver's stress. We are 
appreciative that P.L. 111-163 will provide for increased respite care 
hours, along with counseling and mental health services for caregivers, 
but neither addresses the 24-hour supervision. We recommend if these 
pilot programs are found successful, they should be implemented by the 
VA as soon as possible and fully funded by Congress. Another program 
not addressed is the need for adequate child care. The caregiver may 
have non-school aged children of their own or the wounded, ill, and 
injured veteran may be a single parent. The availability of child care 
is needed in order to attend their medical appointments, especially 
mental health appointments. Our Association encourages the VA to create 
a drop-in child are program for medical appointments on
their premises or partner with other organizations to provide this 
valuable service.
Senior Oversight Committee
    The National Military Family Association is appreciative of the 
provision in the National Defense Authorization Act for Fiscal Year 
2009 (NDAA FY09) continuing the DoD and VA Senior Oversight Committee 
(SOC) until December 2010. The DoD established the Office of Wounded 
Warrior Care and Transition Policy to take over the SOC 
responsibilities. The office has seen frequent leadership and staff 
changes and a narrowing of their mission. We urge Congress to put a 
mechanism in place to continue to monitor this Office for its 
responsibilities in maintaining VA and DoD's partnership and making 
sure joint initiatives create a seamless transition of services and 
benefits for wounded, ill, and injured servicemembers, veterans, their 
families, and caregivers.
Recommendations
      Broaden eligibility criteria to meet Congressional 
intent;
      Establish a DoD and VA seamless transitional caregiver 
benefit;
      Provide retroactive stipend payments to the original date 
of implementation required by law;
      Begin caregiver benefits as early as possible while the 
servicemember is still on active duty status and not wait until they 
have received a final determination;
      Coordinate and collaborate health care and behavioral 
health care services between the VA, DoD, and State and governmental 
agencies in sharing of resources;
      Approve relocation allowances and provide alternative 
housing and living arrangements;
      Increase outreach to veterans, their families, and the 
communities they live in about available benefits;
      Provide opportunities for the entire family to reconnect 
and bond as a family again;
      Provide a holistic approach to care that incorporates the 
impact of the wound, illness, or injury on the family unit;
      Expand all of the VA's caregiver pilot programs; and
      Continue oversight of the SOC/Office of Wounded Warrior 
Care and Transition Policy by Members of Congress.

    The National Military Family Association would like to thank you 
again for the opportunity to provide testimony on the VA's caregiver 
implementation plan for P.L. 111-163. Military families support the 
Nation's military missions. The least their country can do is make sure 
servicemembers, veterans, their families, and caregivers have 
consistent access to high quality health and behavioral care. Wounded 
servicemembers and veterans have wounded families. The system should 
provide coordination of care, and VA and DoD need to work together to 
create a seamless transition. We ask this Subcommittee to assist in 
meeting that responsibility. We look forward to working with you to 
improve the quality of life for servicemembers, veterans, their 
families and caregivers, and survivors.

                                 
               Statement of Paralyzed Veterans of America
    Chairwoman Buerkle, Ranking Member Michaud, and Members of the 
Subcommittee, Paralyzed Veterans of America (PVA) would like to thank 
you for the opportunity to submit our views on the ongoing 
implementation of the caregiver provisions of P.L. 111-163, the 
``Caregivers and Veterans Omnibus Health Services Act.'' Additionally, 
we appreciate the opportunity to outline the concerns that we raised in 
our comments on the Interim Final Rule that the Department of Veterans 
Affairs (VA) published on May 5, 2011, on the final implementation of 
the caregiver program. We urge Congress to continue to conduct 
oversight of the VA's implementation plan to ensure that its full 
intent is being met. Moreover, we encourage the Subcommittee to 
continue to follow-up with the VA on the reporting requirements for the 
next 2 years.
    PVA has 65 years of experience understanding the complex needs of 
spouses, family members, friends, and personal care attendants that 
love and care for veterans with life-long medical conditions. As a 
result of today's technological and medical advances, veterans are 
withstanding combat injuries and returning home in need of medical care 
on a consistent basis. Such advances are also prolonging and enhancing 
the lives and physical capabilities of injured veterans from previous 
conflicts. No matter the progress of modern science, these veterans 
need the health-care expertise and care from a health team comprised of 
medical professionals, mental health professionals, and caregivers. As 
a part of the health care team, caregivers must receive ongoing support 
to provide quality care to the veteran.
    PVA and its partners worked extremely hard to get comprehensive 
caregiver legislation enacted during the 111th Congress. Fortunately, 
on May 5, 2010, the President signed into law P.L. 111-163, the 
``Caregivers and Veterans Omnibus Health Services Act.'' This 
legislation created an innovative new caregiver program to be 
administered by the Department of Veterans Affairs (VA). The law called 
for the VA to begin implementation of this important new program within 
270 days of enactment of the bill. This placed the deadline for 
implementation of this legislation in February of this year. 
Unfortunately, the VA was very slow to accomplish that task.
    As you know, the VA republished its Interim Final Rule on May 5, 
2011, regarding the implementation of the caregiver provisions of P.L. 
111-163. PVA expressed concerns with four areas of the caregiver 
program as outlined by the VA's rules. They include: veterans' with 
severe illnesses excluded from eligibility; the caregiver stipend; the 
revocation of primary family caregiver status; and, the report on 
expansion of family caregiver assistance. Additionally, we have 
expressed concern in previous comments for the record with the 
projected funding needs to implement the caregiver program and continue 
to maintain it through at least FY 2015, as originally envisioned by 
the legislation. We will explain each of these issues individually.

Veterans' With Severe Illnesses Not Considered Eligible
    PVA has serious concerns that veterans who have incurred a severe 
illness as a result of their service are excluded from consideration as 
eligible for this program. This is the number one complaint that we 
have received from our members who are eligible under the Post-9/11 
criteria for this program. PVA's membership includes veterans with 
spinal cord injury or dysfunction (disease). A spinal cord disease is 
no less catastrophic than a spinal cord injury. It is a fact that 
veterans who have been diagnosed with Amyotrophic Lateral Sclerosis 
(ALS) and Multiple Sclerosis (MS) will eventually experience a 
catastrophic impact on their activities of daily living. And yet, these 
individuals who may be in greater need of caregiver services than any 
other population of injured veterans have no avenue for support through 
the new caregiver program.
    Unfortunately, the VA's interpretation of the law excludes 
consideration of veterans with severe illness. However, the legislation 
was clearly intended to support populations of veterans that have 
experienced a catastrophic injury or illness. In fact, Congressman 
Michael Michaud (D-ME), then Chairman of the House Veterans' Affairs 
Subcommittee on Health, commented when introducing similar caregiver 
legislation, ``the bill would establish a caregiver program to help 
family and non-family members who provide care for disabled, ill, or 
injured veterans.'' Additionally, the Secretary of Veterans Affairs, 
Eric Shinseki, emphasized during the roll-out of the new caregiver 
program that ``caregivers are critical partners with VA in the recovery 
and comfort of ill and injured veterans.'' Meanwhile, the VA has 
interpreted the language of the law very narrowly ensuring that 
veterans dealing with catastrophic illnesses will be unable to 
participate in the program. This is simply unacceptable.
    We have been told that the VA believes it needs clarifying 
legislation in order to make this change to the program. If this is in 
fact true, then the Subcommittee must move immediately to consider 
legislation to correct this inconsistency in the implementation of the 
program in order to ensure that caregiver assistance is available for 
veterans who have experienced either injury or illness.
Caregiver Stipend
    With regards to the caregiver stipend, the interim final rule 
states that the caregiver stipend amount will be determined by the 
eligible veteran's level of dependency based on the degree to which the 
eligible veteran is unable to perform one or more activities of daily 
living (ADL), or the degree to which the veteran is in need of 
supervision or protection based on symptoms of residuals of 
neurological or other impairment or injury.
    The rule also states that the 14 ADLs and needs that are listed in 
the Eligible Veterans and Servicemembers section will each be given a 
clinical rating from zero to four, with zero representing no caregiver 
assistance needed in that area by the veteran, and four meaning the 
veteran is in need of total assistance with regard to that specific ADL 
or need.
    PVA is concerned that in the current calculation for caregiver 
stipends, personal care services are not taken into consideration. It 
is often the case that the very injuries that necessitate a caregiver 
also result in the veteran not being able to perform personal functions 
that are also necessary to ensure his or her health and safety, but are 
not direct medical activities. As a result, the caregiver provides 
``personal care services'' such as financial management or weekly 
shopping that occupies a significant amount of his or her time and 
energy.
    In the rule, VA defines personal care services as ``care or 
assistance of another person necessary in order to support the eligible 
veterans health and well-being, and perform personal functions required 
in everyday living ensuring the eligible veteran remains safe from 
hazards or dangers incident to his or her daily environment.'' While 
this definition may capture some of the caregiver services outlined in 
the definition for ADLs, there are many daily responsibilities 
involving personal care that are not included, and will therefore not 
be included in the Primary family caregiver stipend. If the stipend is 
to be an accurate reflection of the eligible veteran's level of 
dependency and an acknowledgement of the sacrifices that Primary family 
caregiver make to care for seriously injured veterans, personal care 
services must be taken into consideration in the stipend calculation.
Revocation of Primary Family Caregiver Status
    The interim final rule allows for up to 30 days of continuing 
caregiver benefits after a veteran revokes the status of a Primary 
family caregiver. PVA understands that the purpose of this safeguard is 
to determine if remediation is possible, and to allow time for the 
revoked caregiver to find additional health care coverage if necessary. 
It is for similar reasons that PVA believes that guidelines should also 
be put in place that requires the caregiver to provide the veteran with 
notice should he or she choose to revoke their caregiver status. By 
designating a specific amount of time that is required for caregivers 
to continue their responsibilities after notice of revocation, with the 
exception of caregiver abuse or negligence, the VA gives the veteran 
time to arrange for replacement care as the veteran will need time to 
identify a new primary caregiver, make arrangements with the secondary 
caregiver if necessary, and complete a new VA caregiver application.
Report on Expansion of Family Caregiver Assistance
    Perhaps the most important provision in P.L. 111-163 for PVA is the 
reporting requirements outlined in Sec. 1720G(d). PVA cannot 
overemphasize the importance of this provision. Specifically, the law 
states,

        ``Not later than 2 years after the date described in subsection 
        (a)(3)(A), the Secretary shall submit to the Committee on 
        Veterans' Affairs of the Senate and the Committee on Veterans' 
        Affairs of the House of Representatives a report on the 
        feasibility and advisability of expanding the provision of 
        assistance under section 1720G(a) of title 38, United States 
        Code, as added by subsection (a)(1), to family caregivers of 
        veterans who have a serious injury incurred or aggravated in 
        the line of duty in the active military, naval, or air service 
        before September 11, 2001.''

    PVA was disappointed that veterans who became injured or ill prior 
to September 11, 2001, were excluded from the comprehensive caregiver 
support programs. The fact is, PVA's members--veterans with spinal cord 
injury or dysfunction--would benefit from this program more than any 
other population of veterans. And yet, the majority of those veterans 
are excluded by the arbitrary date of September 11, 2001, from the 
comprehensive caregiver program. No reasonable justification (other 
than cost considerations) can be provided for why pre-9/11 veterans 
with a service-connected injury or illness should be excluded from the 
comprehensive caregiver program. Catastrophically disabled veterans 
needs are not different simply because they may have been injured prior 
to the selected date.
    With regards to the interim final rule, PVA is particularly 
concerned that the VA offered no reference to this reporting 
requirement in its proposed rules. We believe that given the 
opportunity, the VA may simply choose to ignore this requirement so as 
not to draw attention to an obvious deficiency in the caregiver program 
that it cannot or will not be able to implement. The VA must ensure 
that it fulfills this reporting requirement as it is an integral part 
of the implementation of the caregiver program. This critical report 
will pave the way to access to much-needed caregiver assistance for 
many more catastrophically disabled veterans who are currently being 
denied eligibility simply because of the arbitrary date assigned to 
this benefit by Congress.
    Lastly, PVA remains concerned about the VA's lack of commitment in 
its FY 2012 budget request and FY 2013 advance appropriation estimate 
for the funding necessary to fully implement this program. While the 
Administration claims to have provided an additional $208 million for 
implementation of P.L. 111-163, it is not clear where that additional 
funding is included in the FY 2012 Medical Care budget request. Our 
analysis suggests that for FY 2012, the VA actually requested 
approximately $65.9 million for the implementation of the caregiver 
provisions of P.L. 111-163 and an additional $70.6 million for FY 2013. 
While we appreciate the fact that the Military Construction and 
Veterans' Affairs appropriations bills approved by the full House and 
currently being considered in the Senate purportedly address this 
funding need, we believe insufficient funding has been provided to 
fully implement this program. With this in mind, PVA, along with the 
co-authors of The Independent Budget--AMVETS, Disabled American 
Veterans, and Veterans of Foreign Wars--recommended approximately $385 
million to fund the provisions of P.L. 111-163 in FY 2012.
    PVA would like to thank this Subcommittee for the opportunity to 
express our views relating to the implementation of the VA's new 
caregiver program. We hope that the Subcommittee and Congress will take 
an active role to ensure that the VA is actually implementing the 
provisions of P.L. 111-163 as intended. Failure to comply with the 
intent of Congress is simply not an option in this case. The most 
severely disabled veterans and their families are depending on the VA 
to get it right. We look forward to working with the Subcommittee as it 
continues addressing these issues. We will gladly respond to any 
questions. Thank you.

                                 
                 Statement for Wounded Warrior Project
    Chairman Buerkle, Ranking Member Michaud, and Members of the 
Subcommittee,
    Wounded Warrior Project (WWP) applauds this Committee's ongoing 
oversight of the Department of Veterans Affairs' (VA) implementation of 
the comprehensive caregiver assistance program. This Committee's 
vigilance and leadership have been critical to the important progress 
made in moving the program from what was, initially, a flawed 
implementation plan to a reality that is already making a difference in 
the lives of families who have endured so much.
    We trust this hearing will underscore that--even as VA has made 
significant improvement to the implementation plan and great strides in 
rolling out the program--more work must be done, particularly in 
refining the Interim Final Regulation (IFR) published on May 5, 2011. 
VA's adoption of WWP recommendations, submitted as comments on that 
regulation, would help bridge remaining gaps between the law's promise 
and regulatory-barriers many families still face.
    In our view, the following comments offer the Department a road map 
for achieving in full the goal Congress set in enacting a historic 
caregiver-assistance law. WWP is pleased to provide this Committee with 
these comments as part of our statement for the record:
1.  Eligibility issues:
     a.   Under the IFR, warriors with certain serious mental health 
        conditions would likely be deemed ``ineligible'' for caregiver-
        assistance. Accordingly, new Section 71.15, which identifies 
        reasons that might create a need for supervision or protection, 
        should be expanded to include pertinent symptoms of PTSD, 
        anxiety and depression.
    The caregiver law provides that an eligible veteran is one who has 
a serious injury, and it specifies that that term includes 
``psychological trauma, or other mental disorder.'' The IFR identifies 
possible bases for establishing a need for caregiver assistance. Among 
those is that a wounded warrior requires supervision and protection 
based on symptoms or residuals of neurological or other impairment or 
injury. The IFR identifies seven different circumstances that might 
require supervision or protection, but the Department specifically 
welcomes additional suggestions on these circumstances. WWP agrees that 
additional criteria are needed. The seven factors identified in the IFR 
do address very relevant considerations. Nevertheless, we do not 
believe the factors are sufficiently comprehensive, particularly with 
respect to widely prevalent mental health conditions that in some 
circumstances dictate a need for caregiving assistance.
    For example, in the case of a veteran with PTSD, ``need for 
supervision or protection'' could conceivably be established under the 
IFR based on its inclusion of such symptoms as difficulty with sleep 
regulation and inability to moderate agitation. However, a veteran with 
PTSD marked by other severe symptoms (such as significant avoidant 
behaviors) may need a caregiver's supervision and protection, but would 
likely not qualify under these IFR criteria. In addition, a veteran 
with significant anxiety and related fearfulness (such as fear of 
leaving the home) could also require some degree of caregiver 
assistance. As currently drafted, there is no single criterion or group 
of criteria under Section 71.15 related to supervision or protection 
that would address such anxiety symptoms. Similarly, it is not clear 
that symptoms of depression are necessarily covered under that Section. 
(The reference to ``self regulation'' is at best ambiguous because it 
is described in terms that suggest it applies only to being able to 
regulate an agitated or aggressive state. And while very severe 
depression could involve suicidality and thus be covered under the 
``safety risk'' criterion, an individual with depression may pose no 
safety risk and still need considerable assistance. PTSD, anxiety and 
depression are not only widely prevalent among OEF/OIF veterans, but 
can certainly dictate a need for caregiving assistance in the nature of 
supervision and protection. Given that PTSD and other mental disorders 
are signature wounds of this war, and specifically included in the 
statute, it would be unreasonable to fail to take account of common, 
severe symptoms of those conditions. Accordingly, the criteria in 
Section 71.15 should be revised and expanded.
    WWP recognizes that the IFR establishes a criterion under which a 
need for caregiving can be based on a mental disorder that has been 
scored under a Global Assessment Functioning (GAF) test at 30 or less 
continuously during a 90-day period. A GAF score of 21-30 is defined as 
``behavior is considerably influenced by delusions or hallucinations OR 
serious impairment, in communication or judgment (e.g., sometimes 
incoherent, acts grossly inappropriately, suicidal preoccupation) OR 
inability to function in almost all areas (e.g., stays in bed all day, 
no job, home, or friends).'' Requiring a GAF score of 30 or less sets 
an unreasonably restrictive eligibility bar, particularly given the 
observations set forth above regarding situations in which individuals 
with PTSD, anxiety and depression likely would not be deemed to need 
caregiver assistance under the Section 71.15 criteria on supervision or 
protection.
    In setting a GAF ``line'' that is too restrictive and omitting 
pertinent behavioral health criteria in Section 71.15 relating to 
supervision or protection, the IFR will fail to cover veterans who 
should be deemed eligible based on a real need for caregiver 
assistance. As such, the IFR creates what amounts to serious disparity. 
Consider that the IFR, on the one hand, implicitly recognizes that a 
veteran with a physical injury may be ``eligible'' based on a 
relatively limited need for assistance with activities of daily living. 
(For example, a veteran may need relatively limited assistance daily 
based on an inability to dress himself; yet the IFR would appropriately 
provide for caregiver-support to the veteran's caregiver. Similarly, a 
veteran who experienced moderate traumatic brain injury, manifested 
only in limited difficulty with planning and organization, might need 
only limited assistance such as with maintaining a medication regimen, 
but caregiver support could again be authorized under the IFR.) But a 
veteran with anxiety, for example, would have to be almost totally 
disabled under the GAF-criterion--and likely need full-time 
assistance--to be deemed eligible. This surely unintended disparity 
between IFR eligibility standards applicable to a physical injury and 
those applicable to a common mental health condition is fundamentally 
inconsistent with a law that clearly recognized that both mental 
disorders and physical injuries can render veterans in need of 
caregiver assistance. It is also inconsistent with the principle of 
``mental health parity'' which is firmly embedded in Federal law. \1\ 
Such disparity should be excised from the regulation.
---------------------------------------------------------------------------
     \1\ See, e.g., Paul Wellstone and Pete Domenici Mental Health 
Parity and Addiction Equity Act of 2008, Public Law 110-343.
---------------------------------------------------------------------------
     b.   The ``GAF eligibility provision'' is not only unduly 
        restrictive, it is an arbitrary standard that, contrary to law, 
        has become the exclusive criterion under the IFR for 
        determining eligibility in the case of a mental health 
        condition.
    As discussed above, the ``GAF eligibility provision'' is unduly 
restrictive. Implicitly, the Department's position is that the only 
circumstances under which a mental health condition would require 
another's assistance is where mental impairment is so profound as to 
manifest in (1) delusions or hallucinations; (2) suicidal 
preoccupation; (3) gross inappropriateness; or (4) bedridden status. 
Given how disabling mental illness can be, such a view fails to account 
for the fact that individuals with less severe symptoms may also need 
another's daily assistance, albeit not necessarily round-the-clock or 
full time care. In attempting to explain this provision, the Department 
states that a ``GAF scores in the 21-30 range is the minimum impairment 
standard that VA will require to consider a mental health diagnosis a 
serious injury.'' \2\ It states further that:
---------------------------------------------------------------------------
     \2\ Federal Register, 76, no. 87 (May 5, 2011): 26150.

          ``At this assessed level of impairment, the supervision or 
        protection of a caregiver is essential to the individual. An 
        individual who has been assessed as having a psychological 
        trauma or mental disorder scored at 30 GAF or less generally 
        requires a higher level of care that would provide constant 
        supervision.'' \3\
---------------------------------------------------------------------------
     \3\ Id. (emphasis added).

    The underscored language above surely makes the point. Nothing in 
the law suggests that a need for caregiver-assistance must be constant. 
To the contrary, Congress made it clear that the extent of personal 
care services needed by eligible veterans would vary substantially and 
directed the Secretary to provide Primary caregivers a stipend that 
``shall be determined . . . based upon the amount and degree of 
personal care services provided.'' \4\ The IFR provisions addressing 
the stipend clearly provide that a Primary caregiver of a veteran who 
is determined to need as little as 10 hours of caregiver assistance 
weekly would still be entitled to receive comprehensive caregiver 
supports. Setting a GAF score at a level that requires ``constant 
supervision of the veteran'' is contrary to the law that directs the 
Secretary to provide caregivers support tied to the duration of needed 
caregiving. In short, this standard is contrary to law.
---------------------------------------------------------------------------
     \4\ 38 U.S.C. Sec. 1720G(a)(3)(C)(i).
---------------------------------------------------------------------------
    Beyond the question whether it is lawful to set a GAF-score ``bar'' 
at 21-30 rather than a higher level, the IFR raises the more basic 
question: what is the foundation for establishing any GAF score 
criterion? The VA states that the GAF-eligibility provision, Section 
71.20(c)(3), is authorized by 38 U.S.C. Sec. 1720G(a)(2)(C)(iii), under 
which the Secretary may establish additional circumstances that create 
a need of personal care services other than the specific criteria 
identified in the law. In WWP's view, relying on a tool used to 
subjectively rate social, occupational, and psychological functioning 
is an extraordinarily poor proxy for assessing a need for caregiver 
assistance. However, the GAF provision is not simply a too-restrictive, 
arbitrary standard. Given that the VA has established with the GAF 
provision a separate eligibility criterion applicable only to 
``psychological trauma or a mental disorder,'' Section 71.20(c)(3) 
provides the exclusive eligibility criterion for a veteran needing 
personal care services because of a mental health condition. As such, 
Section 71.20(c)(3) has not only established a much higher eligibility 
threshold for a mental health condition than for any other disorder, it 
effectively renders meaningless the law's ``need for supervision or 
protection'' language in the case of a veteran with PTSD or other 
mental health condition. Instead, the regulation sets a very specific 
test applicable to veterans with a mental disorder, such that--even if 
that veteran's condition is so severe that it creates a need for 
supervision or protection--one must assume that the veteran would be 
deemed not to meet the IFR's eligibility requirements.
    The VA's explanation of this provision belies the notion that GAF-
criterion is simply ``an alternative'' avenue of eligibility. As the VA 
clearly explains ``GAF scores in the 21-30 range is the minimum 
impairment standard that VA will require to consider a mental health 
diagnosis a serious injury.'' \5\ The VA has established a double 
standard here. In interpreting the statutory language ``an eligible 
veteran is any individual who . . . has a serious injury (including 
traumatic brain injury, psychological trauma, or other mental 
disorder),'' \6\ the VA explains that a mental health condition is not 
``serious'' unless it results in functional impairment that requires 
``constant supervision.'' Yet for ANY other injury, including traumatic 
brain injury (which may manifest itself exclusively in behavioral 
manifestations little different from certain mental health conditions), 
the IFR defines ``serious injury'' differently: ``any injury . . . that 
renders the veteran or servicemember in need of personal care 
services.'' \7\ Under this definition, a veteran suffering from 
traumatic brain injury could receive as little as 10 hours per week of 
caregiver assistance. Setting disparate standards based solely on 
diagnosis for determining whether an individual is in need of 
supervision or protection because impaired behavioral-health 
functioning cannot be squared with a law that draws no distinction 
among types of injury, and provides a specific, clearly-applicable 
criterion in law for determining need for personal care services. WWP 
submits that including Section 71.20(c)(3) in a final regulation would 
be contrary to law, and strongly urges that it be deleted in its 
entirety.
---------------------------------------------------------------------------
     \5\ Federal Register (May 5, 2011): 26150
     \6\ 38 U.S.C. Sec. 1720G(a)(2)(B) (2010).
     \7\ 38 CFR Sec. 71.15 (2011).
---------------------------------------------------------------------------
     c.   Contrary to law, the IFR draws so tight a link between injury 
        and need for personal care services that veterans whose 
        injuries (only) ``lead to'' the need for caregiver support will 
        be rendered ineligible.
    The VA explains that it interprets the caregiver law to require ``a 
causal relationship'' between a veteran's serious injury and a need for 
personal care services. While WWP does not suggest that the VA's 
interpretation of the statute is unreasonable in principle, the IFR 
draws too fine a line -- particularly in the absence of specific 
statutory language requiring any causal connection\8\--in defining 
serious injury to mean an injury that ``renders'' the individual in 
need of personal care services.\9\
---------------------------------------------------------------------------
     \8\ The Department acknowledges that the law imposes no such test. 
See Federal Register (May 5, 2011): 26150.
     \9\ 38 CFR Sec. 71.15 (2011).
---------------------------------------------------------------------------
    To say, in effect, that the injury must have caused the need for 
caregiver-assistance is at best to create ambiguity, and potentially to 
render ineligible a veteran under circumstances where a condition 
secondary to his or her injury causes the need for personal care 
services. Consider the case of a veteran who sustained multiple shell 
fragment wounds in Iraq. While those injuries were not severely 
disabling and did not create a need for sustained caregiver assistance, 
the veteran after separation from service underwent further surgery for 
removal of shell fragments, and as a result of a mishap in surgery 
suffered loss of oxygen and now requires extensive personal care 
services. One can also readily imagine the instance of a warrior who 
lost a leg in Afghanistan, and subsequently (after separation from 
service) sustains a severe traumatic brain injury in a bad fall due to 
loss of balance.
    To focus narrowly and exclusively on whether the initial injury 
``renders'' the veteran in need of personal care services is to misread 
both the language and the purpose of the caregiver law. If it is to 
conform to law, the final regulation must clarify that a secondary 
condition resulting from that initial injury can provide an equally 
sound basis for establishing a causal link to the need for caregiver-
assistance. WWP urges that the final rule make clear that eligibility 
extends to any serious condition that is ``related to, caused by, or 
derived from'' an injury incurred or aggravated during service.
     d.   The IFR fails to articulate clearly the manner in which 
        ``clinical eligibility'' will be determined and does not ensure 
        that the caregiver's perspective is taken into account.
    As drafted, the IFR is singularly vague regarding how the VA is to 
arrive at a judgment that a particular wounded veteran requires 
caregiver-assistance. The VA should remedy this ambiguity.
    The IFR states that ``need of personal care services [will be] . . 
. based on . . . [specified] clinical criteria.'' \10\ It provides that 
``upon receiving [the required application for caregiver assistance] VA 
will perform the clinical evaluations required by this section.'' \11\ 
The IFR further states that ``VA will clinically rate the eligible 
veteran's need for supervision or protection . . . using the seven 
impairments listed in . . . sec. 71.15.'' \12\ New Section 71.25(f)--
relating to approval and designation of primary and secondary family 
caregivers is the only provision of the regulation that speaks to the 
process by which at least certain clinical judgments are to be made. 
The provision is vague, at best:
---------------------------------------------------------------------------
    \10\ 38 CFR Sec. 71.20(c) (2011).
    \11\ 38 CFR Sec. 71.25(a)(2) (2011).
    \12\ 38 CFR Sec. 71.40(c)(4)(ii) (2011).

        If the eligible veteran and at least one applicant meet the 
        requirements of this part, VA will approve the application and 
        designate Primary and/or Secondary family caregivers, as 
        appropriate. This approval and designation will be a clinical 
        determination authorized by the eligible veteran's primary care 
        team.\13\
---------------------------------------------------------------------------
    \13\ 38 CFR Sec. 17.25(f) (2011).

    One infers that this language means that the primary care team (as 
opposed to a single non-physician, for example) is to perform the 
clinical evaluation. An interdisciplinary evaluation is critically 
important, but the IFR is certainly not clear on that point.
    WWP recently conducted a survey of caregivers to understand the 
experience of families who had applied for comprehensive-assistance 
under the caregiver law during the 7-week period following the initial-
application date. Among the findings, the survey responses suggest that 
there is variability from facility to facility as to who determines a 
veteran's need for caregiver assistance, as well as an apparent failure 
to communicate to caregivers how that determination is made. Asked 
their understanding of who determines a veteran's need for caregiver-
assistance, more than one in five respondents expressed the 
understanding that it was the primary care physician; one in four 
responded that it was the clinical team; while more than four in ten 
expressed uncertainty. Clarifying who makes the determination that a 
veteran needs caregiver-assistance is only a first step, however. The 
regulation states that VA is to ``clinically rate'' the veteran, but 
does not define that term or specify how such clinical rating is to be 
conducted. In considering the determinations that must be made 
regarding whether, and the extent to which, impairments result in a 
need for supervision or protection, clinical judgment must take account 
of how the veteran functions in his or her home and community, not 
simply how the veteran appears in a medical facility's examination 
room. Such judgment cannot, for example, be reliably based on prior VA 
medical records, and must necessarily rely heavily on interviewing the 
caregiver and the veteran. But as one caregiver's experience (reported 
to WWP through our recent survey) indicates, the VA's lack of guidance 
on the importance of obtaining a full understanding of the veteran's 
limitations and needs (to include obtaining the caregiver's 
perspective) can result in an inaccurate assessment:

        ``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. His physician had only seen him a couple of times, we 
        were told this was the reason he was going in for an interview/
        assessment. The assessment was supposed to provide the 
        understanding of my warrior's needs. Since I was not there, and 
        my warrior does not recall the entire interview, I do not know 
        if the doctor really got a good understanding of the 
        situation.''

    WWP urges that the regulation make clear that the various clinical 
determinations implicit in the IFR are to be made by an 
interdisciplinary clinical team, and that the team must interview both 
the caregiver and veteran to gain an understanding of the extent and 
nature of the veteran's need for personal care services. In those 
instances in which a need for caregiving is based on a need for 
supervision and protection, VA should require use of the 
Neuropsychiatric Inventory (NPI) (or similar tool). The NPI, which VA 
cited as a source for its scoring methodology, would be an apt tool for 
interviewing a caregiver because it is structured to gain information 
on the frequency and severity of impairment across ten behavioral 
areas, as well as to assess caregiver distress. (Insight on the degree 
of caregiver distress would also be a useful tool in determining 
caregiver's need for education and training, supportive services, and 
respite care.)
    WWP recommends that the term ``clinical rating'' be defined to 
address the above described concerns, to include identifying who makes 
such determinations, the manner in which such determinations are made 
(that is, that they are not to be based on inferences drawn from prior 
medical or compensation records, must take account of extensive 
interview with the caregiver, etc.), and the nature of the examinations 
and home assessments that must be conducted.
 The final regulation should clarify that a veteran with any service-
        connected condition incurred or aggravated on or after 9/11 may 
        be an ``eligible veteran'' under the caregiver law.
    The IFR essentially restates the statutory language in providing an 
eligible veteran is ``an individual [who] . . . has a serious injury, 
including traumatic brain injury, psychological trauma, or other mental 
disorder[.]'' \14\ That phrasing leaves an important issue unresolved. 
The final rule should clarify that caregivers of veterans who incurred 
a serious illness or disease in service on or after 9/11 will not be 
excluded from the comprehensive assistance program.
---------------------------------------------------------------------------
    \14\ 38 CFR Sec. 71.20(b) (2011)
---------------------------------------------------------------------------
    While the statute does not define the term ``serious injury'', the 
statutory language is instructive. Its key provision is ``serious 
injury (including traumatic brain injury, psychological trauma, or 
other mental disorder).'' \15\ The dictionary definition of ``injury'' 
encompasses any kind of suffering, which would include diseases. See 
Webster's third new international dictionary 1164 (3d ed. 1976) 
(defining ``injury'' to mean ``hurt, damage, or loss sustained.''); 
random house unabridged dictionary 983 (2d ed. 1993) (defining 
``injury'' as ``a particular form or instance of harm.''); Merriam 
Webster collegiate dictionary (10th ed. 1996) (defining ``injury'' as 
``hurt, damage, or loss sustained.''). Moreover, the use of the word 
``including'' in Section 1720G(a)(2)(B) is not to be construed 
narrowly, as providing an all inclusive list of qualifying 
disabilities, but rather sets forth examples of the types of disabling 
conditions that would constitute a ``serious injury'' under the 
statute. See Federal Land Bank of St. Paul v. Bismarck Lumber Co., 314 
U.S. 95, 100 (1941) (``the term `including' is not one of all-embracing 
definition, but connotes simply an illustrative application of the 
general principle.''). By including ``other mental disorder'' in 
addition to those caused by ``psychological trauma,'' the statute 
strongly suggests an intention to include not only disabling conditions 
caused by external trauma, but also conditions that may have been 
caused by an illness or disease process.\16\ While it seems clear that 
the phrase ``serious injury'' cannot be read to mean only ``traumatic 
injury,'' the inquiry does not end there.
---------------------------------------------------------------------------
    \15\ 38 U.S.C. Sec. 1720G(a)(2)(B) (2010).
    \16\ Psychological trauma'' is not itself a psychiatric diagnosis. 
See Diagnostic and Statistical Manual of Mental Disorders, 4th. 
Edition, American Psychiatric Association.
---------------------------------------------------------------------------
    While the statute itself does not provide a more concrete 
definition of the phrase ``seriously injured,'' that term has been 
widely used by the Department of Defense (DoD) and Department of 
Veterans Affairs (VA) in relation to benefits, care and services 
provided to servicemembers and veterans of Operation Enduring Freedom 
(OEF) and Operation Iraqi Freedom (OIF). DoD classifies casualties for 
reporting purposes into one of the following seven casualty statuses: 
Deceased, DUSTWUN (a temporary status), Missing, Very Seriously Ill or 
Injured (VSI), Seriously Ill or Injured (SI), Incapacitating Illness or 
Injury (III), and Not Seriously Injured (NSI).\17\ This DoD 
classification system is used by both DoD and VA to provide and 
coordinate care to servicemembers of OEF and OIF. For example, DoD uses 
these classifications to determine eligibility for a servicemembers' 
next of kin (NOK) to receive travel at government expense to aid the 
servicemember's recovery through presence at their hospital 
bedside.\18\ Both VA and DoD use this classification to qualify a 
servicemember for the assignment of a Federal Recovery Care 
Coordinator, the individuals tasked with ensuring seamless transition 
from DoD to VA care.\19\ As a further example, VA uses this 
classification to assign case managers to veterans of OEF and OIF in 
order to ensure that their care is well coordinated.\20\
---------------------------------------------------------------------------
    \17\ ``Military Personnel Casualty Matters, Policies, and 
Procedures,'' Department of Defense Instructions 1300.18, September 18, 
2000, p. 19, http://biotech.law.lsu.edu/blaw/dodd/corres/pdf2/
i130018p.pdf.
    \18\ ``Military Personnel Casualty Matters, Policies, and 
Procedures,'' Department of Defense Instructions 1300.18, September 18, 
2000, p. 7, http://biotech.law.lsu.edu/blaw/dodd/corres/pdf2/
i130018p.pdf.
    \19\ Memorandum from the Under Secretary of Defense for Personnel 
and Readiness, June 10, 2009, http://www.health.mil/libraries/
HA_Policies_and_Guidelines/09-021.pdf.
    \20\ VHA Handbook 1010.01, ``Transition Assistance and Case 
Management of Operation Iraqi Freedom (OIF) and Operation Enduring 
Freedom (OEF) veterans,'' May 31, 2007.
---------------------------------------------------------------------------
    The legislative history of the Veterans and Caregivers Omnibus 
Health Services Act, P.L. 111-163, makes clear that Congress intended 
for caregiver benefits under the act to extend to those servicemembers 
of OEF and OIF who are classified as ``seriously ill or injured'' or 
``very seriously ill or injured.'' The Joint Explanatory Statement that 
accompanied the legislation expressly states:

          The Compromise Agreement also includes an authorization for 
        appropriations that is below the estimate furnished by the 
        Congressional Budget Office. The lower authorization level is 
        based on information contained in a publication (Economic 
        Impact on Caregivers of the Seriously Wounded, Ill, and 
        Injured, April 2009) of the Center for Naval Analyses (CNA). 
        This study estimated that, annually, 720 post-September 11, 
        2001 veterans require comprehensive caregiver services. The 
        Compromise Agreement limits the caregiver program only to 
        ``seriously injured or very seriously injured'' veterans who 
        were injured or aggravated an injury in the line of duty on or 
        after September 11, 2001.\21\

    \21\ Joint Explanatory Statement Submitted by Senator Akaka, 
Chairman of the Senate Committee on Veterans' Affairs, Congressional 
Record, April 22, 2010, S2567, http://www.gpo.gov/fdsys/pkg/CREC-2010-
04-22/pdf/CREC-2010-04-22-pt1-PgS2566.pdf#page=1.

    The referenced study conducted by the Center for Naval Analyses 
(CAN), entitled ``Economic Impact on Caregivers of the Seriously 
Wounded, Ill, and Injured,'' expressly based its estimates of the need 
for caregiver services on the DoD classifications of ``Very Seriously 
Injured and Ill'' and ``Seriously Injured and Ill.'' Thus the study 
---------------------------------------------------------------------------
states:

        We estimate that the average annual incidence of seriously WII 
        servicemembers needing a caregiver is about 720. This estimate 
        is based on the number of ``very seriously ill or injured'' or 
        'seriously ill or injured' (VSI/SI) servicemembers. If we 
        restrict this to just VSI cases, the average annual number is 
        170.\22\
---------------------------------------------------------------------------
    \22\ ``Economic Impact on Caregivers of the Seriously Wounded, Ill, 
and Injured,'' CNA Analysis and Solutions, April 2009, p. 3, http://
www.cna.org/documents/D0019966.A2.pdf (emphasis added).

    While the statute uses a truncated reference to the DoD 
classification system, ``seriously injured,'' rather than the full 
reference to ``seriously injured and ill,'' this should not be 
interpreted as an intent to further limit eligibility by excluding 
servicemembers whose need for caregiver services is based on illness. 
It is common for the DoD classifications of ``Very Seriously Injured 
and Ill'' and 'Seriously Injured and Ill'' to be truncated when 
referenced to ``very seriously injured'' and ``seriously injured.'' For 
example, in a 2005 memorandum between the Department of Defense and 
Department of Veterans Affairs with the express subject of ``Expediting 
Veterans Benefits to Members with Serious Injuries and Illnesses,'' the 
body of the memo truncates the reference by deleting the word ``ill'' 
---------------------------------------------------------------------------
as follows:

          The Department of Veterans Affairs (VA) and the Department of 
        Defense (DoD) identified an initiative to expedite data 
        exchange between the DoD and the VA for 'seriously injured' 
        members, and those members entering the Physical Evaluation 
        Board Process.\23\
---------------------------------------------------------------------------
    \23\ Memorandum from the Under Secretary of Defense for Personnel 
and Readiness, September 27, 2005, http://www.health.mil/libraries/
HA_Policies_and_Guidelines/05-018.pdf.

    Similarly, in a 2008 report the Department of Veterans Affairs 
Office of the Inspector General noted that the truncated reference to 
``seriously injured'' or ``seriously disabled'' was meant to refer to 
---------------------------------------------------------------------------
the traditional DoD classification codes that include illness, stating:

          VBA defines seriously disabled veterans as servicemembers who 
        definitely or possibly will be discharged from military service 
        because of an injury or illness and all veterans with DoD 
        classification codes of very seriously injured, seriously 
        injured, or a special category involving an amputation.\24\
---------------------------------------------------------------------------
    \24\ ``Audit of Veterans Benefits Administration Transition 
Assistance for Operations Enduring and Iraqi Freedom Servicemembers and 
Veterans,'' Department of Veterans Affairs Office of Inspector General, 
July 17, 2008, pg. i, http://www.va.gov/oig/52/reports/2008/VAOIG-06-
03552-169.pdf (emphasis added).

    Despite the use of the common, truncated reference to DoD's 
classification of ``Seriously Injured and Ill, Congress clearly 
intended the legislation to cover those individuals identified in the 
(CNA) study as in need of caregiver services, estimated to be 720 
families annually, and appropriated funding to cover the costs of 
providing caregiver benefits to those families.
    Finally, the caregiver law cannot be read in isolation and without 
regard to the carefully woven system of benefits codified in title 38 
of the U.S. Code, which it amends. Importantly, with a single readily 
distinguishable exception,\25\ the entire VA benefit system is 
structured so as not to differentiate between injury and illness as a 
basis for eligibility. Thus, veterans are equally eligible for monetary 
compensation for any injury or illness that is incurred coincident with 
service or is aggravated by service,\26\ entitlement to higher levels 
of ``special monthly compensation'' may be awarded based on 
disabilities resulting from either an injury or disease process,\27\ 
and veterans who are determined catastrophically disabled due to an 
injury or disease receive a higher priority access to VA health 
care.\28\ The caregiver provisions should be interpreted in harmony 
with the general principle established in the statutory scheme, that 
veterans with a qualifying disability are entitled to benefits whether 
such disability resulted from an injury or an illness. See Exxon Mobil 
Corp. v. Allapattah Services, Inc., 545 U.S. 546, 559 (2005) (``In 
order to determine the scope of [a statutory provision] . . . then, we 
must examine the statute's text in light of context, structure, and 
related statutory provisions''); United States v. Gomez, 490 U.S. 858, 
864 (1989) (``We interpret the Federal Magistrates Act in light of its 
structure and purpose.'').
---------------------------------------------------------------------------
    \25\ 38 U.S.C. Sec. 1980A (2010).
    \26\ 38 CFR Sec. 3.303(a) (2011).
    \27\ 38 CFR Sec. 3.350(a)(3),(f)(4)(i) (2011).
    \28\ 38 C.F.R Sec. 17.36(e) (2011).
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2. The Stipend

        a.  In establishing a schedule for caregiver stipends, the IFR 
        unreasonably applies an untested, flawed ``scoring'' 
        methodology that dramatically underestimates the number of 
        hours of caregiving needed by an individual who requires 
        supervision or protection and is inconsistent with law.

    The caregiver law directs that the amount of the monthly personal 
caregiver stipend is to be determined in accordance with a VA-
established schedule that is based on the amount and degree of personal 
care services provided. The VA explains that in arriving at a stipend 
amount it will determine the veteran's level of dependency by reference 
to the degree to which the veteran in unable to perform activities of 
daily living or the degree to which the veteran is in need of 
supervision of protection based on symptoms or residuals of 
neurological or other impairment or injury. The IFR methodology with 
reference to the criterion, need for supervision and protection, fails 
even to approximate the amount and degree of personal care services 
many wounded warriors with traumatic brain injury and other behavioral 
impairments need. In describing that methodology, the VA explains that 
its ``scoring criteria'' are ``based on three widely accepted clinical 
tools for measuring ADLs and functional dependence: The Katz Basic 
Activities of Daily Living Scale, the UK Functional Independence 
Measure and Functional Assessment Measure; and the Neuropsychiatric 
Inventory.'' \29\ We note, in that regard, that at least one of those 
tools, the Neuropsychiatric Inventory, is not, by its own description, 
a tool for measuring functional dependence, but instead an assessment 
tool to monitor change. The following case profiles demonstrate that, 
regardless of the utility of those tools in other settings, the scoring 
methodology itself has not been adequately tested, and must be revised.
---------------------------------------------------------------------------
    \29\ Federal Register (May 5, 2011): 26150.

    1.  Veteran A returned from Iraq in 2008 and has been clinically 
diagnosed with severe depression which began in service. He is able to 
perform all activities of daily living, but is unable to work or 
perform much in the way of gainful activity because of symptoms of 
depression which include utter lack of energy, difficulty in even 
getting out of bed or concentrating on tasks, and feelings of 
hopelessness. Medications have not alleviated his now-chronic symptoms, 
and his family members have maintained virtually full-time watch to 
ensure that he does not attempt to harm himself. Under the current 
scale, since a need for total assistance in any one domain is assigned 
a rating of only ``4'', Veteran A is rated as a ``4'' for safety risk, 
``4'' for self-regulation, and ``4'' for difficulty with planning and 
organizing, for a total score of 12. Because the scoring criteria under 
the IFR creates an irrebuttable presumption that a veteran with a score 
of 12 or less requires 10 hours per week of caregiver assistance, this 
veteran's primary caregiver, his wife, would receive a stipend for 10 
hours of caregiving per week--or about $15 day--even though she is 
effectively a full-time caregiver and thus unable to pursue employment 
and earn any additional income.
    2.  Veteran B returned from Afghanistan where he sustained a severe 
traumatic brain injury and other wounds as a result of an IED blast. 
After a lengthy post-operative course during which he underwent 
extensive rehabilitation, he walks with a limp but is able to perform 
all activities of daily living. Despite his head injuries, he has no 
cognitive deficit, seizures, memory problems, or difficulty with 
planning and organizing. In fact, the single manifestation of his 
injuries is that he experiences severe, erratic mood swings, and 
unpredictably and often exhibits aggressive and even violent outbursts. 
He is unable to control these behaviors, even with medication, and as a 
result is unable to work. His wife accompanies him everywhere--serving 
as a buffer to avoid incidents, driving him to frequent medical 
appointments, and keeping him out of trouble. Under the IFR rating 
scale, veteran B is rated as a 4 based on total inability to self-
regulate; as a result, his wife would receive the minimum stipend, 
based on the methodology that ``the eligible veteran is presumed to 
require 10 hours per week of caregiver assistance.'' Notwithstanding 
that regulatory presumption, the fact is that his wife is his full-time 
caregiver.
    3.  Veteran C sustained a moderate to severe traumatic brain injury 
during his third tour in Iraq and suffers from severe chronic short-
term memory loss. While he is able to carry out all activities of daily 
living, he is both very forgetful and easily distracted. As a result, 
he is unable to work and spends much of his time at home. Even after a 
lengthy period of rehabilitation, he manifests behaviors such as 
forgetting to turn off appliances or the stove that have frightened his 
family. His mother felt the need to quit her job and stay home with him 
to prevent any mishap. Under the current scale, Veteran C is rated as 4 
for difficulty with planning and organizing, a 4 for safety risks, and 
a 4 for difficulty with recent memory, for a score of 12. Under the IFR 
rating criteria, Veteran C's mother, his primary caregiver, would 
receive a stipend that is based on the assumption that she provides 
only 10 hours of caregiving assistance per week; in fact she spends 
approximately that much time in a caregiving capacity daily.

    These hypotheticals underscore the fundamental flaw in the IFR 
scoring methodology applicable to caregivers who provide protection or 
supervision. If an aggregated scoring methodology is to be employed, it 
must recognize that deficits in a single domain--such as being a safety 
risk or being unable to regulate severe mood swings, for example--may 
create a need for total assistance and should be sufficient to result 
in a determination that the veteran requires full-time caregiving. Yet 
this model fails to recognize that, unlike a methodology that gauges 
caregiving need of an individual with limitations in activities of 
daily living, a need for full-time caregiving cannot necessarily be 
determined by an aggregated-scoring tool.
    WWP's recent survey of caregivers demonstrates the above-cited 
concerns, as illustrated by a respondent's comments:

        I was told that my husband scored in the low Tier level I, with 
        an `11.' This only allows 10 hrs a week, approximately $426 a 
        month. I don't agree with this because my husband needs 
        continuous supervision due to his TBI, PTSD, Mental Health and 
        also sometimes 2-3 days a week requires bed rest due to 
        physical pain. So 10 hrs a week is like about 1.42 hrs a day. I 
        have to help him remember to take meds 3 x times daily, assist 
        with cooking, driving, medical appointment; and just overall 
        supervision for his safety. Ten hours a week is nowhere near 
        the time I spend caring for him.

    Clearly, as the above examples illustrate, the scoring methodology 
is flawed as it relates to assessing the extent and degree of personal 
services required by veterans for whom caregiving-assistance is based 
on a need for supervision or protection. But the criteria suffer from a 
more fundamental flaw. Under the law, ``the amount of the . . . stipend 
. . . shall be determined in accordance with a schedule established by 
the Secretary that specifies stipends based upon the amount and degree 
of personal care services provided.'' \30\ The law defines the phrase 
``personal care services'' in pertinent part to mean ``services that 
provide the veteran . . . [a]ssistance with one or more independent 
activities of daily living.'' \31\ Those IADL's assess the relative 
ability of an individual to carry out specified activities 
independently, to include use the telephone, shop, prepare meals, keep 
house, do laundry, travel, take medications correctly, and handle 
finances.\32\ The law clearly requires the VA at least to include these 
criteria in determining the amount and degree of personal care services 
a caregiver is providing, as it relates to determining a stipend 
amount. The IFR does not do so, and, accordingly, is not consistent 
with law.
---------------------------------------------------------------------------
    \30\ 38 U.S.C. Sec. 1720G(a)(3)(C)(i) (2010).
    \31\ 38 U.S.C. Sec. 1720G(d)(4) (2010).
    \32\ Lawton MP, Brody EM. Assessment of older people: self-
maintaining and instrumental activities of daily living. Gerontologist 
1969; 9(3):179-186; http://www.unmc.edu/media/intmed/geriatrics/nebgec/
pdf/frailelderlyjuly09/toolkits/timmactivitiesdailyliving.pdf.
---------------------------------------------------------------------------
    For the reasons set forth above, Section 71.40(c)(4) must be 
revised.
b.  While establishing a cap of 40 hours/week for a caregiver stipend, 
        the IFR does not address how caregiving-needs exceeding 40 
        hours would be
        covered.
    The IFR states that an eligible veteran with a score of ``21 or 
higher . . . is presumed to require 40 hours per week of Caregiver 
assistance.'' \33\ But it fails to address circumstances under which 
caregiving-needs exceed that limit. WWP understands that the intent of 
this provision is to cap stipend amounts at that level. The underlying 
rationale, as WWP understands it, is laudatory--to avoid having 
caregivers work unreasonably long, strenuous hours and to give them 
respite by meeting those additional needed caregiving hours through 
home health agency services. That important policy should be 
specifically articulated in the regulation. However, the policy must 
also take account of the circumstances facing caregivers in rural and 
other areas where home health services are not available (as well as 
those instances in which agencies are not capable of providing the 
required specialized care a wounded warrior needs). Given those 
relatively frequent situations, WWP believes it would be unreasonable 
to fail to address this situation. We urge that the VA revise the 
regulation to afford caregivers a reasonable opportunity to rebut the 
presumption that a veteran requires only 40 hours of caregiver 
assistance a week, and, accordingly to enable a caregiver to receive a 
stipend amount that encompasses and reasonably approximates the 
additional number of caregiving hours that circumstances may require.
---------------------------------------------------------------------------
    \33\ 38 CFR Sec. 71.40(c)(6)(4)(iv)(a) (2011).
---------------------------------------------------------------------------
c.  Setting the stipend rate based only on the amount of services 
        provided is inconsistent with law.
    In directing the Secretary to establish a schedule for determining 
the amount of the monthly caregiver stipend, the statute provides the 
VA must, to the extent practicable, ensure that the stipend amount ``is 
not less than the monthly amount a commercial home health care entity 
would pay an individual in the geographic area of the eligible veteran 
to provide equivalent personal care services to the eligible veteran.'' 
\34\ Importantly, two different considerations must be built into the 
development of that stipend schedule: ``the amount and degree of 
personal care services provided.'' \35\ The VA's formulation, however, 
interprets the statute in a manner that effectively ignores the term 
``degree.'' This interpretation cannot stand.
---------------------------------------------------------------------------
    \34\ 38 U.S.C. Sec. 1720G(a)(3)(C)(ii) (2010).
    \35\ Id. at Sec. 1720G(a)(3)(C)(i) (emphasis added).
---------------------------------------------------------------------------
    The VA explains that ``the direct stipend payment is calculated 
based on the BLS wage rate for a Home Health Aide using the 75th 
percentile of the hourly wage rate in the geographic area of residence 
of the eligible veteran.'' \36\ The Bureau of Labor Statistics 
describes a home health aide as one who provides ``routine 
individualized health care such as changing bandages and dressing 
wounds, and applying topical medications to the elderly, convalescents, 
or persons with disabilities at the patient's home or in a care 
facility. Monitor or report changes in health status. May also provide 
personal care such as bathing, dressing, and grooming of patient.'' 
\37\ WWP submits the caregiving needs of many within the population of 
young severely wounded veterans are far more extensive than the kind of 
routine care described by BLS, and often cannot be met by a home health 
aide. In describing her role as a caregiver, one explained, ``I am my 
husband's accountant; occupational therapist; physical therapist; 
driver; mental health counselor; and life coach.'' \38\ Further, during 
its consideration of caregiver legislation, Congress heard testimony 
indicating that home health aides often lack the specialized training 
or capability to meet the needs of profoundly disabled veterans.\39\
---------------------------------------------------------------------------
    \36\ Federal Register (May 5, 2011): 26154.
    \37\ U.S. Department of Labor, Bureau of Labor Statistics, 
Occupational Employment and Wages, May 2010, 31-1011, Home Health 
Aides, http://www.bls.gov/oes/current/oes311011.htm.
    \38\ Wounded Warrior Project Statement for the Record, ``Oversight 
Hearing: TBI--Progress in Treating the Signature Wound of the Current 
Conflicts,'' Committee on Veterans Affairs, U.S. Senate, May 5, 2010.
    \39\ See testimony of Anna Frese, ``Meeting the Needs of Family 
Caregivers of Veterans,'' Committee on Veterans Affairs, U.S. House of 
Representatives, Hrg. No. 111-26, 111th Cong. 1st Sess., June 4, 2009.
---------------------------------------------------------------------------
    The VA states that ``[w]e determined that the 75th percentile most 
accurately reflects the national hourly wage rate for the competencies 
to be performed.'' \40\ WWP questions the basis for that determination. 
Family caregivers of more severely wounded veterans seldom provide 
simply home-health care, but typically assist (and often substitute 
for) the veteran in carrying out a range of other demanding 
responsibilities, to include financial management and running a 
household. The VA states that ``[t]here is a large standard deviation 
on wage rates for home health aides depending on their experience and 
education as well as the economic factors in the geographic area 
(mainly supply and demand).'' \41\ Given the higher level of functions 
provided by many caregivers, and the VA's own acknowledgement that wage 
rates vary depending on the complexity of duties performed, the seventy 
fifth percentile fails to address adequately the degree of personal 
care services provided.
---------------------------------------------------------------------------
    \40\ Federal Register (May 5, 2011): 26154.
    \41\ Id.
---------------------------------------------------------------------------
    Finally, setting the stipend at the 75th percentile fails to take 
account of the purpose of the stipend, which is to provide a level of 
financial support to ensure that the economic strains on family 
caregivers do not result in or contribute to families no longer being 
able to sustain their caregiving.\42\ The Secretary cannot ignore the 
reality that setting the stipend level too low will directly result in 
continued economic strain for caregivers. As scholars have observed, 
caregiver pay provides a low living standard and ``caregiver'' is 
included in the class of low-wage jobs that leave workers 
struggling.\43\ Caregivers and other direct-service workers often do 
not receive livable wages, and a high proportion of these workers rely 
on some form of public assistance in order to make ends meet.\44\ 
Considered in terms of Bureau of Labor Statistics' national estimates, 
a uniform per-hour stipend rate at the 75th percentile is only $11.55/
hour, more than $2.50/hour, or 18 percent, below the national estimate 
at the 90th percentile.\45\
---------------------------------------------------------------------------
    \42\ See Sen. Rep. No. 111-080, Caregiver and Veterans Health 
Services Act of 2009 (September 25, 2009), http://thomas.loc.gov/
cgibin/cpquery/?&dbname=cp111&sid=cp111sBb3W&refer
=&r_n=sr080.111&item=&&&sel=TOC_0& ``Hearing on Pending Health Care 
Legislation,'' Committee on Veterans Affairs, U.S. Senate (April 22, 
2009); http://veterans.senate.gov/
hearings.cfm?action=release.display&release_id=55fa0387-887a-479f-
b97618c26056444e
    \43\ See Beth Shulman, The Betrayal of Work: How Low-Wage Jobs Fail 
30 Million Americans, The New Press (2003).
    \44\ Hewitt et al., ``A synthesis of direct service workforce 
demographics and challenges access intellectual/developmental 
disabilities, aging, physical disabilities, and behavioral health,'' 
National Direct Service Workforce Center (Nov. 2008).
    \45\ Bureau of Labor Statistics, Id.
---------------------------------------------------------------------------
    Given that the stipend was designed to both reflect the degree of 
services provided by family caregivers and afford caregivers financial 
support to ease their economic strain, WWP urges that the caregiver 
stipend be appropriately set at the 90th percentile of the hourly wage 
rate in the geographic area of residence of the eligible veteran rather 
than the 75th.
3.  The IFR fails to address the processes for appealing adverse 
        decisions.
    The IFR is silent with respect to both a right to appeal adverse 
decisions under the program and with respect to the processes for 
exercising that right. The omission is glaring and must be remedied. An 
application for caregiver assistance may call upon VA personnel to make 
a wide-ranging number of decisions any one of which holds the potential 
for damaging error.
    To illustrate, the law contemplates the potential for numerous 
clinical determinations under the law, with clinical judgment 
potentially involved in such determinations as whether there is a need 
for personal care services; whether provision of caregiver-assistance 
``is in the best interest of the veteran;'' the extent of caregiver-
assistance the veteran requires; and the quality of the personal care 
services provided to the veteran. Any one of those decisions has far-
reaching ramifications. Yet VA claimants are barred from obtaining 
judicial or even administrative review (through the Board of Veterans 
Appeals) of ``medical determinations.'' It is critical, therefore, that 
with respect to those decisions that are truly medical determinations, 
the final regulation should, at a minimum, (a) specify the mechanism or 
mechanisms through which a caregiver or veteran may appeal such a 
decision, (b) require that caregivers and veterans be provided a 
written explanation of the basis of any clinical determination they 
question, (c) be afforded the right to provide independent medical 
evidence in support of any appeal, and (d) be afforded a reasonably 
prompt, independent review of such appeal.
    The caregiver law, of course, states that ``[a] decision by the 
Secretary under this section affecting the furnishing of assistance or 
support shall be considered a medical determination.'' \46\ In our 
view, therefore, a final regulation must provide claimants and 
Department personnel clear direction as to precisely which issues under 
this program are actually medical determinations and which are not. We 
believe that the proper definition of ``medical determinations'' is the 
one provided in 38 CFR Sec. 20.101(b): ``Medical determinations, such 
as determinations of the need for and appropriateness of specific types 
of medical care and treatment for an individual, are not adjudicative 
matters and are beyond the Board's jurisdiction. Typical examples of 
these issues are whether a particular drug should be prescribed, 
whether a specific type of physiotherapy should be ordered, and similar 
judgmental treatment decisions with which an attending physician may be 
faced.'' Clearly establishing the applicability of this definition is 
essential to making sure that veterans do not lose their due process 
rights to challenge any adverse eligibility determination, as they have 
such rights as to other services and benefits provided by the Veterans 
Health Administration. See, e.g., 38 CFR Sec. 20.101(b) (``The Board's 
appellate jurisdiction extends to questions of eligibility [.]''). 
Providing a cross-reference to that regulation would limit unappealable 
decisions under the statute to the kinds of clinical determinations 
addressed in regulation. Compare Zimick v. West, 11 Vet. App. 45, 48 
(1998) (``[S]pecific medical determinations as to the appropriate 
medical treatment are not adjudicative matters over which the Board has 
jurisdiction.''), with Meakin v. West, 11 Vet. App. 183, 187 (1998) 
(``determinations as to whether the applicant is a veteran, whether he 
seeks treatment for a service-connected disability, and whether VA 
facilities are geographically inaccessible are on their face obviously 
not medical determinations.''). Any broader limitation of appealability 
would raise serious due process concerns by precluding veterans from 
challenging eligibility and other similar determinations, to which they 
have property rights under law. See Mathews v. Eldridge, 424 U.S. 319, 
332 (1976); Nat'l Ass'n of Radiation Survivors v. Derwinski, 994 F.2d 
583, 588 n.7 (9th Cir. 1992).
---------------------------------------------------------------------------
    \46\ 38 U.S.C. Sec. 1720G(c)(1) (2010).
---------------------------------------------------------------------------
    Certainly Congress cannot be deemed to have intended to abrogate a 
claimant's right to due process. Additionally, Section 1720G(c)(1) must 
be read to harmonize with an existing body of law, and longstanding 
precedent, governing appellate and judicial review. Congress cannot 
have intended that claimants would be denied the opportunity to pursue 
appellate remedies on issues that would otherwise be subject to such 
review. By way of illustration, Congress could not have intended to 
deny claimants a right to administratively appeal a decision that a 
veteran's injury was not (a) incurred in line of duty; (b) incurred on 
or after September 11, 2001, or (c) incurred in service. Congress could 
not have intended to deny a veteran the right to appeal a VA 
determination that denies his or her application for comprehensive 
caregiver assistance on the basis that the caregiver is not a member of 
the veteran's family under 38 U.S.C. Sec. 1720G(d)(A). A VA denial of a 
veteran's application based on a decision under 38 U.S.C. 
Sec. 1720G(d)(B) that the veteran's caregiver (who is not a member of 
the veteran's family) does not live with the veteran surely cannot be 
beyond review on the ground that it is a ``medical determination.'' A 
decision to deny a designated Primary caregiver travel benefits or a 
monthly stipend to which she or he is specifically entitled by law 
cannot be beyond the range of administrative and judicial review. Even 
decisions made by clinicians cannot be shielded from administrative 
review as an exercise of medical judgment when they are mistakenly 
based on the wrong legal standard. It is not inconceivable, for 
example, that a clinician or clinicians might determine that a veteran 
not in need of personal care services based on their employing a ``need 
for nursing home care'' criterion, contrary to law.
    While Section 1720(c)(1) is apt recognition that implementing 
Section 1720G(a) would entail a series of determinations requiring the 
exercise of medical judgment, the legislative history provides not a 
scintilla of evidence to suggest that Congress had any intention of 
taking the unprecedented step of depriving veterans of longstanding 
appellate rights. The final regulation must make that clear.
4.  The IFR provisions regarding respite care fail to address specific 
        requirements of the caregiver law.
    Respite is one of the most important needs caregivers face, and the 
caregiver law provides important direction regarding this vital 
support. But the IFR omits reference to a key provision of the law. 
While the IFR states that respite care is to include ``24-hour-per day 
care . . . commensurate with the care provided the Family caregiver to 
permit extended respite,'' the IFR is silent regarding the critically 
important statutory direction that ``respite care . . . shall be 
medically and age-appropriate and include in-home care.'' Department 
officials have advised that this omission was unintentional. WWP 
appreciates programmatic efforts to stress the importance of making 
such respite available, and certainly looks forward to having this 
requirement clearly articulated in the final regulation. Of course, 
absent language that at least restates that requirement, there is 
concern that VA facility personnel might at some point erroneously 
advise caregivers that their only extended-respite option is to place 
their warriors in VA nursing home units-- precisely the concern that 
prompted the age-appropriate, in-home provisions of the law.
5.  The final regulation should clarify CHAMPVA eligibility where a 
        caregiver loses prior coverage.
    Section 71.40(c) aptly states that ``VA will provide to Primary 
family caregivers all of the benefits listed in paragraphs (c)(1) 
through (4).'' But the IFR goes on to state at Section 71.40(c)(3) that 
``primary family caregivers are to be considered eligible for 
enrollment in the Civilian Health and Medical Program of the Department 
of Veterans Affairs (CHAMPVA), unless they are entitled to care or 
services under a health-plan contract''.\47\ Stating that ``caregivers 
are to be considered eligible'' undercuts that directive language--
diluting an expression of entitlement into a vague instruction. In 
short, the phrase ``to be considered'' is ambiguous surplusage, and 
should be deleted from the final regulation.
---------------------------------------------------------------------------
    \47\ 38 CFR Sec. 71.40(c)(3) (2011).
---------------------------------------------------------------------------
    The IFR phrasing has significance, however, because it highlights 
the fact that unidentified VA personnel will make determinations under 
this section as to whether caregivers ``are entitled to care or 
services under a health-plan contract.'' That raises the question, what 
further guidance will those personnel be given in making such 
determinations? It would not be extraordinary, for example, 
particularly under current economic conditions, for a caregiver to lose 
health insurance coverage benefits after having begun to receive VA 
caregiver-assistance. (One can readily imagine, for example, the plight 
of a middle-aged mother who, as her warrior-son's full-time caregiver, 
suddenly loses health benefits when her husband loses his job. Consider 
also that the same caregiver, living on a fixed, limited income and 
facing growing expenses might lose health coverage because of being 
unable to afford to pay health-care premiums.) It should be made clear 
that entitlement to CHAMPVA coverage is not simply a one-point-in-time 
determination, but that this support must be provided when needed 
throughout the period of caregiving.
    The law itself makes this clear, stating without qualification as 
to any point in time, ``the Secretary shall provide to family 
caregivers . . . medical care under Section 1781 of this title.'' 
Importantly, too, the purpose of the law is ``to provide assistance to 
caregivers of veterans'' in recognition of their inherent 
vulnerabilities.\48\ As WWP testified in support of the S. 801 (later 
incorporated into S. 1963), ``studies have shown that family caregivers 
experience an increased likelihood of stress, depression, and mortality 
as compared to their non-caregiving peers'' and ``caregivers report 
poorer levels of perceived health, more chronic illnesses, and poorer 
immune responses to viral challenges.'' \49\ Senator Daniel Akaka, the 
lead sponsor of S. 801 and then-Chairman of the Senate Veterans' 
Affairs Committee, acknowledged these vulnerabilities and stated that 
the purpose of S. 801 was to ``help alleviate those problems [such as 
decreased household income and potential loss of health insurance] so 
as to allow the caregiver to focus entirely on caring for the 
veteran.'' \50\ A caregiver's losing health coverage certainly creates 
additional vulnerability for both the caregiver and the veteran. We 
urge that the provision be clarified to ensure that caregivers who at 
any point in time lose prior health benefits can enroll in CHAMPVA.
---------------------------------------------------------------------------
    \48\ Explanatory Statement: Amendment of the House of 
Representatives to S.1963 Caregivers and Veterans Omnibus Health 
Services Act of 2010. Submitted by Senator Akaka, Congressional Record 
156:58 S2566 (April 22, 2010) Available from: U.S. Government Printing 
Office; accessed June 20, 2011.
    \49\ Hearing on Pending Health-Related Legislation, Committee on 
Veterans Affairs, U.S. Senate (April 22, 2009)
    \50\ Senator Akaka (HI). Congressional Record 155:56 (April 2, 
2009) p. S4350 Available from: U.S. Government Printing Office; 
accessed June 20, 2011.
---------------------------------------------------------------------------
6.  The final regulation should clarify eligibility for reimbursement 
        of travel expenses.
    In comments supplementing publication of the IFR, the VA 
acknowledges that ``VA must provide Primary and Secondary family 
caregivers with 'lodging and subsistence under [38 U.S.C.] 111(e),' '' 
\51\ as amended by the caregiver law. The VA states that it has 
implemented that requirement by including in the IFR a provision 
stating that family caregivers ``are to be considered eligible for 
beneficiary travel under 38 CFR part 70.'' This phrasing suffers from 
the same flaw as the ``are to be considered eligible'' phrasing 
employed with respect to CHAMPVA (discussed above). Moreover, the IFR 
fails to amend the beneficiary travel regulations at 38 CFR part 70 or 
to include any language addressing the scope of the travel benefit 
established in Section 104 of the caregiver law. However, that 
provision of the caregiver law makes it clear that a family caregiver 
is eligible for the expenses of travel in connection with (and for the 
duration of) a veteran's examination, treatment, or care 
notwithstanding that the veteran may not need an attendant to perform 
such travel.
---------------------------------------------------------------------------
    \51\ Federal Register (May 5, 2011): 26153.
---------------------------------------------------------------------------
    WWP has received reports from caregivers indicating apparent 
misunderstanding on the part of VA personnel regarding caregivers' 
eligibility for beneficiary-travel reimbursement. In our view, failing 
to include in regulations the substantive changes in beneficiary-travel 
eligibility established in the caregiver law (beyond the vague 
statement that caregivers are to be considered eligible for beneficiary 
travel) can only compound the risk of error.
 Wounded Warrior Project have not received any Federal grants or 
        contracts, during this year or in the last two fiscal years, 
        from any agency or program relevant to the subject of the July 
        11, 2010 Subcommittee on Health Oversight Hearing on the 
        Caregiver Assistance Program implementation.
                                 
                   MATERIAL SUBMITTED FOR THE RECORD

                                     Committee on Veterans' Affairs
                                             Subcommittee on Health
                                                    Washington, DC.
                                                      July 13, 2011

Ms. Deborah Amdur, LCSW
Chief Consultant, Care Management and Social Work
Veterans Health Administration
U.S. Department of Veterans Affairs
810 Vermont Avenue, NW
Washington, DC 20420

Dear Ms. Amdur:

    In reference to our Subcommittee on Health Committee hearing 
entitled ``Implementation of Caregiver Assistance: Moving Forward?'' 
that took place on July 11, 2011. I would appreciate it if you could 
answer the enclosed hearing questions by the close of business on 
August 13, 2011.
    In an effort to reduce printing costs, the Committee on Veterans' 
Affairs, in cooperation with the Joint Committee on Printing, is 
implementing some formatting changes for materials for all full 
Committee and Subcommittee hearings. Therefore, it would be appreciated 
if you could provide your answers consecutively and single-spaced. In 
addition, please restate the question in its entirety before the 
answer.
    Due to the delay in receiving mail, please provide your response to 
Jian Zapata and fax your responses to Jian at 202-225-2034. If you have 
any questions, please call 202-225-9756.

            Sincerely,

                                                 Michael H. Michaud
                                          Ranking Democratic Member
Enclosure
CW:jz

                                 

                        Questions for the Record

                  House Committee on Veterans' Affairs

                         Subcommittee on Health

                   Ranking Member Michael H. Michaud

           Hearing on Implementation of Caregiver Assistance:

                        Are We Getting It Right?

                             July 11, 2011

Budget
    Question 1: Are there any updates in the projected funding needs to 
implement the caregiver program and to continue to maintain through at 
least FY 2015?

    Response: Updated funding needs were provided in the preamble of 
VA's Caregivers Program Interim Final Rule published on May 5, 2011. 
The updated estimates are displayed in the chart below:

                                              Cost of Projections for Caregiver Program--(FY 2011-FY 2015)
--------------------------------------------------------------------------------------------------------------------------------------------------------
            Description of Costs                   FY 2011           FY 2012           FY 2013           FY 2014           FY 2015        5 Year Total
--------------------------------------------------------------------------------------------------------------------------------------------------------
Caregiver Program Staff                          $8,083,644.80    $19,400,747.43    $20,176,777.32    $20,983,848.42    $21,823,202.37    $90,468,220.34
--------------------------------------------------------------------------------------------------------------------------------------------------------
Caregiver Program Stipend                       $27,617,530.00    $77,658,984.00    $83,992,329.20    $90,834,536.00    $96,215,650.00   $378,319,029.20
--------------------------------------------------------------------------------------------------------------------------------------------------------
Respite Care                                    $13,815,832.00    $35,156,000.00    $37,966,400.00    $41,107,360.00    $44,436,480.00   $172,482,072.00
--------------------------------------------------------------------------------------------------------------------------------------------------------
Mental Health Services                             $305,660.00       $992,970.00     $1,073,088.00     $1,158,606.00     $1,254,894.00     $4,785,218.00
--------------------------------------------------------------------------------------------------------------------------------------------------------
General Care Educ. & Trng.                       $6,057,760.00       $190,185.60       $205,852.80       $222,682.50       $240,683.40     $6,917,164.30
--------------------------------------------------------------------------------------------------------------------------------------------------------
Lodging/Mileage/Meal Per Diem (Veteran             $466,975.52     $1,211,092.78     $1,308,547.76     $1,413,433.83     $1,528,241.79     $5,928,291.68
 Inpatient/Outpatient Visits)
--------------------------------------------------------------------------------------------------------------------------------------------------------
Mileage for Caregiver Training                     $373,085.00        $35,856.00        $37,350.00        $38,844.00        $40,338.00       $525,473.00
--------------------------------------------------------------------------------------------------------------------------------------------------------
Health care Coverage (CHAMPVA)                   $2,752,390.92     $6,765,401.32     $6,943,472.78     $7,505,688.62     $8,205,989.03    $32,172,942.66
--------------------------------------------------------------------------------------------------------------------------------------------------------
Caregiver Oversight (Contract)                           $0.00     $1,448,846.08     $1,567,203.20     $1,694,887.36     $1,833,527.52     $6,544,464.16
--------------------------------------------------------------------------------------------------------------------------------------------------------
Caregiver Oversight (VA)                         $4,014,070.96    $10,420,334.14    $11,271,763.58    $12,189,701.34    $13,184,910.50    $51,080,780.52
--------------------------------------------------------------------------------------------------------------------------------------------------------
Caregiver Support Line                           $1,500,000.00     $2,500,000.00     $2,599,999.58     $2,703,999.11     $2,812,159.03    $12,116,157.72
--------------------------------------------------------------------------------------------------------------------------------------------------------
Study and Survey                                   $245,959.20       $238,359.20       $225,859.20             $0.00             $0.00       $710,177.60
--------------------------------------------------------------------------------------------------------------------------------------------------------
Outreach & Additional Supt. Programs             $3,811,561.00     $2,673,358.00     $2,772,356.00     $2,830,224.00     $2,923,433.00    $15,010,932.00
--------------------------------------------------------------------------------------------------------------------------------------------------------
TOTAL                                           $69,044,469.40   $158,692,134.55   $170,140,999.42   $182,683,811.18   $196,499,508.63   $777,060,923.18
--------------------------------------------------------------------------------------------------------------------------------------------------------

    Question 2: I understand that the Administration has provided an 
additional $208 million for implementation of P.L. 111-163.

    Question 2(a): Is that funding included in the FY 2012 Medical Care 
budget request?

    Response: Yes. Of the $208 million, over $158 million is for the 
Caregiver Program and $49 million is for the remaining requirements in 
the law.

    Question 3: Would you be able to provide the Committee the number 
of requests that you receive for services when you have the final 
number?

    Response: Yes. The Department of Veterans Affairs (VA) has 
developed a comprehensive tracking tool, the Caregiver Application 
Tracker, which enables us to track the number and status of 
applications received. As of August 5, 2011, VA has received over 1,729 
applications for the Program of Comprehensive Assistance for Family 
Caregivers. VA made 528 stipend payments in the month of August. At 
present, 120 primary family caregivers are eligible for Civilian Health 
and Medical Program for the Department of Veterans Affairs (CHAMPVA) 
benefits, out of which 83 are eligible for CHAMPVA benefits based on 
the Program of Comprehensive Assistance for Family Caregivers.
    Requests for Caregiver services can include those of both family 
and general caregivers. Under the new Program of Comprehensive 
Assistance for Family Caregivers, Family caregiver service requests 
include applications for stipend and CHAMPVA benefits, as well as 
requests for training (which is part of the required application 
process), requests for respite care, and requests for mental health 
services. All of these requests and related data are being recorded in 
our newly developed Caregiver Application Tracker and in our existing 
computerized patient medical record system.
    In addition, requests for general caregiver services can include 
any of the more than two dozen existing VA services that were available 
to all era veterans and their caregivers prior to the enactment of P.L. 
111-163. We have recently developed new funding codes to track the use 
of general caregiver services and their related costs along with family 
caregiver services and costs. Tracking and analyzing the data on both 
family and general caregivers will provide VA with valuable information 
in planning for the future needs of veterans and their caregivers.
    VA will provide regular reporting to Congress on this and other 
caregiver-related data and information.
Eligibility
    Question 1: What other information aside from interviews, medical 
records, consultations with medical staff, compensation and pension 
examinations, etc. is assessed in determining eligibility for this 
benefit?

    Response: Primarily, a determination of eligibility for the Program 
of Comprehensive Support for Family Caregivers is a clinical 
assessment. First, eligibility is determined by reviewing the veteran's 
demographic data to ensure the veteran incurred or aggravated a serious 
injury in the line of duty on or after September 11, 2001. If this 
information is missing, incomplete, or in question, further review may 
be conducted by VA's Health Eligibility Center to obtain required 
information from Department of Defense (DoD) records.
    However, in determining an applicant's clinical eligibility for 
family caregiver benefits, VA takes a whole-person approach. To that 
extent, not only do we review records and conduct interviews with the 
veteran and their caregiver, but the local Caregiver Support 
Coordinator (CSC) also works with all the members of the Veteran's 
Patient Aligned Care Team, which may include the veteran's caregiver, 
the Federal Recovery Coordinator, the Operation Enduring Freedom/
Operation Iraqi Freedom/Operation New Dawn (OEF/OIF/OND) Case Manager, 
service liaisons, occupational or physical therapists, mental health 
clinicians, and any other medical specialty provider that may be 
assigned to the team. If there is a question about a particular item on 
the assessment, the veteran can be seen by a specialist, such as an 
occupational therapist, to determine the level of personal assistance 
that the veteran requires in a specific area. VA does require that a 
veteran be receiving on-going care from a VA-designated clinical team 
to participate in the Family Caregiver program.
    Primary family caregivers who are entitled to care or services 
under a health plan contract, including TRICARE, Medicare, Medicaid, or 
a commercial health insurance plan, are not eligible for CHAMPVA as a 
primary family caregiver.

    Question 2: Are there any provisions in place requiring that 
caregivers be informed of how their eligibility for the stipend is 
calculated in the event that they would like to appeal the decision?

    Response: Caregivers are provided with information about filing an 
appeal when the CSC contacts them regarding a denial. This guide 
details the clinical appeals process, as well as the requisite steps. 
CSCs also will help direct caregivers to their facility's patient 
advocate, who will help the veteran and caregiver through the appeals 
process.
    Based on the feedback received at the July 11, 2011 hearing, and in 
response to feedback from several caregivers, we are establishing a 
procedure where family caregivers will be mailed a stipend 
determination letter that will list their stipend tier (determined by 
the clinical assessment), their stipend amount (determined by the tier 
and a formula published in the Interim Final Rule), information on how 
the stipend was calculated, and the appeals process. The format and 
content of this letter will be fully developed by September 2011. VA 
will provide individual letters to each primary family caregiver who 
has received a stipend to-date, and all new primary family caregiver 
stipend recipients thereafter. CSCs will then follow up with each 
stipend recipient to explain the tier amount. During this follow-up, 
the clinical assessment form will be reviewed with the caregiver and 
veteran as a quality check and to further explain the tier calculation 
determination.

    Question 3: How can a veteran or caregiver appeal an adverse 
medical or legal decision?

    Response: A veteran can appeal an adverse decision through VA's 
clinical appeals process. 38 U.S.C. 1720G(c)(1) specifies that, ``[a] 
decision by the Secretary under this section affecting the furnishing 
of assistance or support shall be considered a medical determination.'' 
Consequently, all decisions regarding eligibility for, and the 
provision of benefits under, the Caregiver program will be considered 
medical determinations, appealable through the clinical appeals 
process, as defined by the Veterans Health Administration (VHA) 
Directive 2006-057.
    In the context of the Program of Comprehensive Assistance for 
Family Caregivers, the veteran (or designated representative) can 
appeal a medical decision by requesting a facility-level document 
review. If the veteran is not satisfied with the decision, he or she 
may appeal to the Veterans Integrated Service Network (VISN).
    The VISN's clinical panel will review the veteran's record along 
with other documentation and make a recommendation to the VISN 
Director. The VISN panel can also request an independent external 
review at any time during the process. A final written report with the 
findings and recommendations, from the external review, will be 
provided to the VISN Director within 10 days of the full documentation 
request. A decision will be made within 30 days for internal reviews, 
and for external reviews, within 45 days.
    In accordance with 38 CFR Sec. 20.101(b), which discusses the Board 
of Veterans' Appeals as they relate to determinations made by VHA, 
clinical decisions concerning a veteran's need for medical care or the 
type of medical treatment needed in a particular patient case are not 
within the Board's jurisdiction; as a result, such clinical decisions 
may not be appealed to the Board of Veterans' Appeals.

    Question 4: Has there been discussion about beginning the 
application for caregiver benefits while a veteran is they are still on 
active-duty beginning with the start of the Medical Evaluation Board 
(MEB) process, rather than waiting until they have transitioned to 
veteran status?

    Response: Members of the Armed Forces ``undergoing medical 
discharge'' are eligible for the Family Caregiver program under the 
law. However, in response to the Interim Final Rule, we have received a 
number of public comments regarding the application process and its 
initiation for current servicemembers. We are currently reviewing these 
comments and will respond to them pursuant to the regulatory comments 
process.

    Question 5: Concerns have been raised that veterans who have 
incurred a severe illness as a result of their service are excluded 
from consideration for this program. Is this true?

    Question 5(a): PVA testified that VA believes that they need 
clarifying legislation in order to include severe illnesses to be 
considered for eligibility to the program. Can you please comment on 
this?

    Response: The law prescribes eligibility criteria that the veteran 
or servicemember must meet in order to participate in the Program of 
Comprehensive Assistance for Family Caregivers including that the 
veteran or servicemember has a ``serious injury (including traumatic 
brain injury, psychological trauma, or other mental disorder) incurred 
or aggravated in the line of duty . . . on or after September 11, 
2001.'' 38 U.S.C. 1720G(a)(2)(B).
    While ``psychological trauma[s]'' or ``other mental disorder[s]'' 
may be considered illnesses, the statutory eligibility criteria does 
not account for other conditions that are considered to be illnesses, 
but only those conditions that are considered to be serious injuries. 
Legislation would be required to authorize VA to include illnesses in 
the Program of Comprehensive Assistance for Family Caregivers 
eligibility criteria. Therefore veterans and servicemembers with a 
serious or severe illness, who do not have a qualifying serious injury, 
do not meet the statutory eligibility criteria for the Family Caregiver 
program.
Mental Health
    Question 1: I appreciate that the Interim Final Rule includes 
criteria for veterans with traumatic brain injury.

    Question 1(a): In the case of a veteran who has PTSD, depression or 
anxiety, has VA explored ways to assist family members who must provide 
care for these veterans?

    Response: Psychological trauma or other mental disorders are 
specifically considered to be serious injuries under 38 U.S.C. 
1720G(a)(2)(B), and veterans with these conditions may be eligible for 
the Program of Comprehensive Assistance for Family Caregivers if all 
other eligibility criteria are met, including that the veteran's 
serious injury renders him or her in need of personal care services (as 
defined) for at least 6 continuous months based on any one of the 
following clinical criteria: (1) inability to perform an activity of 
daily living (as defined); (2) need for supervision or protection based 
on symptoms or residuals of neurological or other impairment or injury 
(as defined), including traumatic brain injury; (3) psychological 
trauma or mental disorder that has been scored, by a licensed mental 
health professional, with a Global Assessment of Functioning (GAF) test 
scores of 30 or less, continuously for the requisite time period; or 
(4) service-connection for qualifying serious injury, has been rated 
100 percent disabled for that serious injury, and has been awarded 
Special Monthly Compensation that includes an Aide and Attendance 
allowance.
    Family members of persons with PTSD, depression, or anxiety, as 
well as family members of veterans with psychosis or bipolar disorder, 
often need assistance understanding how to support the veteran's 
independence and strategies to support his or her reaching their 
specified goals. Family members and loved ones also need support and 
guidance for their own health. Their needs often are distinct from 
those of caregivers for veterans with chronic, debilitating physical 
disorders such as Alzheimer's, dementia, severe cardiovascular illness, 
or end stage lung disease, which also typically worsen over time 
despite effective health care. For caregivers of this second group of 
veterans, obtaining assistance helping the veteran meet basic 
activities of daily living and instrumental activities of daily living 
often becomes the paramount issue.
    While both groups of family members may clearly benefit from VA 
assistance, their individual requests usually differ. Families of 
persons with PTSD, depression, or anxiety, as well as family members of 
those with psychosis or bipolar disorder, often desire assistance in 
communicating better with their veteran loved one, learning how to de-
escalate conflicts, and developing strategies for supporting the 
veteran's independence rather than strategies for directly handling the 
veteran's needs themselves.
    Family caregivers of those with chronic physical health conditions 
may, in contrast, want to know about respite care, protecting the 
veteran's physical safety, or assuring the veteran does not wander off 
and become lost. Consistent with this observation, surveyed spouses of 
veterans with PTSD requested such services as an educational program 
about PTSD and couples therapy to ``better support their loved ones.'' 
\1\ In contrast, Caregivers of veterans who had had cerebral strokes 
reported the most unmet needs around managing behavior at home (e.g., 
falling), managing emotional ups and downs, and assuring the physical 
safety of the veteran.\2\
---------------------------------------------------------------------------
    \1\ Sherman, M. D, et al. (2005). Mental health needs of cohabiting 
partners of Vietnam veterans with combat-related PTSD. Psychiatric 
Services 56(9): 1150-2.
    \2\ Hinojosa, M. S. and M. R. Rittman (2007). Stroke caregiver 
information needs: comparison of Mainland and Puerto Rican caregivers. 
Journal of Rehabilitation Research and Development 44(5): 649-58.
---------------------------------------------------------------------------
    In this context of evidence-based, recovery-oriented mental health 
care, a basic tenet is that many individuals with mental illness are 
capable of living independently, setting and striving to meet their own 
personal goals, and handling personal challenges. In most cases, they 
do not need a ``caregiver,'' as that role is defined in the context of 
dementia, severe traumatic brain injury, and other chronic, 
debilitating physical problems. Certainly, research suggests that 
positive family support can be a critical aspect of recovery from 
mental illnesses such as PTSD, depression, and anxiety. For example, 
positive family attitudes are associated with successful outcomes in 
PTSD treatment,\3\ as well as reduced rates of relapse in depression 
and schizophrenia.\4\ Data such as these serve as the foundation for 
the development of VA's continuum of family services, which support 
family members who are assisting with the veteran's mental health 
recovery. VA has made a commitment to implementing evidence-based 
practices, Veteran- and family-driven care, and a recovery-oriented 
mental health system, where those with mental illnesses have the 
essential services and supports necessary to live, work, learn, and 
participate fully in the community.
---------------------------------------------------------------------------
    \3\ Tarrier, N., C., et al. (1999). Relatives' expressed emotion 
(EE) and PTSD treatment outcome. Psychol Med 29(4): 801-11.
    \4\ Wearden, A. J., et al. (2000). A review of expressed emotion 
research in health care. Clinical Psychology Review 20(5): 633-66.
---------------------------------------------------------------------------
    VA also recognizes that a subset of those with mental illness do 
have more serious, debilitating, and treatment-resistant symptoms, that 
are reflected in low scores on the GAF scale. Veterans who do 
demonstrate sustained low GAF scores (30 or less), pose significant 
safety risks, or are in need of ongoing supervision, and meet the other 
program eligibility criteria are eligible for the full range of 
caregiver benefits. However, VA also is committed to meeting the array 
of family members' needs that emerge as they provide care and support 
for any veteran with mental illness, and VA has embarked on a number of 
family services initiatives that complement the specific provisions of 
the Program of Comprehensive Assistance for Family Caregivers. These 
include discussing family involvement with the patient on a regular 
basis, offering marriage and family counseling (as provided for under 
38 U.S.C. Sec. 1782), family education, veteran-centered family 
consultation, family psychoeducation (an evidence-based model of family 
counseling and therapy), and integrative behavioral couples therapy.
Home Visits
    Question 1: In our March hearing, it was recommended that the 
quarterly home visitations be reduced over time to be less intrusive 
for families. Has this been explored further since?

    Response: Current guidance to the field is to complete the 
supportive in-home assessment at least quarterly, or as clinically 
indicated. In other words, if the veteran has a Home-Based Primary Care 
Team already providing regular home services, and if the team can also 
complete the in-home assessment as part of a scheduled service, a 
separate visit may not be necessary. In addition, if during an initial 
home visit, no follow-up needs or concerns were identified, the 
veteran's clinical team could decide to lengthen the time between home 
visits. The time span between home visits will remain a clinical 
decision.
    Although we appreciated the individual concerns reported at the 
hearing and we are reviewing the issues reported, the vast majority of 
the reports we have received concerning the home visits, have been 
consistently positive. In most cases, these reports have been 
unsolicited and support the theory of a helpful and informational home 
visit. One recent example of these reports includes a caregiver 
stating, ``This was the most extensive evaluation my son has had since 
he was first injured almost 7 years ago.'' We would not want to 
decrease the frequency of the visits for those who are receiving the 
support and benefit intended by that process.
    Many of the supportive home visits have also enabled VA to identify 
additional resources and services that can benefit the caregiver and 
veteran. In several cases, additional care needs for the veteran have 
been identified and appointments have been scheduled in specialty 
clinics. Home visits have also resulted in additional equipment being 
provided in collaboration with the CSC and Patient Aligned Care Team. 
In one case, the veteran's young children had few age-appropriate toys 
to play with because of competing financial decisions the family was 
forced to make. The nurse who completed the home visit and the CSC were 
able to identify community resources that provided additional toys to 
the veteran's children, and this family was most appreciative. We 
believe these examples are in keeping with the caring intent and 
supportive purpose of the home visit requirement.
Monthly Stipend
    Question 1: DAV recommends that VA determine the frequency and 
hours required to perform personal care services.

    Question 1(a): Can you expand on why this assessment is not used to 
determine the amount and degree of personal care services each veteran 
needs?

    Response: VA determines the frequency and hours required to perform 
personal care services through a standardized review of the type and 
intensity of caregiver assistance required to provide a safe and 
supportive home environment for the veteran. The level of care required 
is bracketed into tiered categories that can be equated to minimum, 
medium, or maximum hours (maximum hours would be considered up to 40 
hours per week). The amount of the stipend provided to the primary 
family caregiver will represent the maximum amount available for the 
tier to which the veteran is assigned. The standardized review is 
facilitated through an assessment template that includes the major 
components of three evaluation instruments that are widely accepted in 
the health care field and that have been refined and consistently 
validated in research. The assessment template reviews both activities 
and instrumental activities of daily living; functional capacity 
specific to mental and cognitive impairment that may be present in 
traumatic brain injury, post-traumatic stress disorder, or other mental 
disorders; the veteran's ability to live and function independently; 
and any need for supervision or protection that may be required to 
support the veteran's living at home.
    The three evaluation instruments that were used to develop VA's 
Caregiver clinical eligibility assessment template are the Katz Basic 
Activities of Daily Living Scale, the UK Functional Independence 
Measure (FIM) and Functional Assessment Measure (FAM), and the 
Neuropsychiatric Inventory (NPI).
Katz Index of Independence in Activities of Daily Living
    The Katz Index of Independence in Activities of Daily Living, 
commonly referred to as the Katz ADL, is the most appropriate 
instrument to assess functional status as a measurement of the client's 
ability to perform activities of daily living independently. Clinicians 
typically use the tool to detect problems in performing activities of 
daily living and to plan care accordingly. The index ranks adequacy of 
performance in the six functions of bathing, dressing, toileting, 
transferring, continence, and feeding. In the 35 years since the 
instrument has been developed, it has been modified and simplified and 
different approaches to scoring have been used. In that time, the Katz 
ADL has gained increased acceptance as an accurate measure of physical 
functioning. National databases, state long-term care programs, 
insurers who offer private long-term care insurance policies, Federal 
legislation, and a body of research literature routinely use 
limitations in the ADLs identified by Katz as appropriate proxies for 
an individual's level of physical impairment.
UK Functional Independence Measure (FIM)
    The FIM is the product of an effort to resolve the long standing 
problem of lack of uniform measurement and data on disability and 
rehabilitation outcomes. It was designed to assess areas of dysfunction 
in activities which commonly occur in individuals with any progressive, 
reversible or fixed neurologic, musculoskeletal and other disorders. 
The Functional Assessment Measure (FAM) was developed by clinicians 
representing each of the disciplines in an inpatient rehabilitation 
program. The FAM was developed as an adjunct to the FIM to specifically 
address the major functional areas that are relatively less emphasized 
in the FIM, including cognitive, behavioral, communication, and 
community functioning measures. In clinical research studies, the 
FIM+FAM scales have demonstrated high internal reliability and prove 
adequate for most clinical and research purposes in comparable samples 
of patients with head injury.
Neuropsychiatric Inventory
    The Neuropsychiatric Inventory (NPI) is a tool for assessment of 
psychopathology in patients with dementia and other neuropsychiatric 
disorders. The NPI is based on a structured interview with a caregiver 
who is familiar with the patient. The following neuropsychiatric 
domains are evaluated: delusions, hallucinations, dysphoria, anxiety, 
agitation/aggression, euphoria, disinhibition, irritability, apathy, 
aberrant motor activity, and night-time behavior disturbances.
    Content validity, concurrent validity, inter-rater reliability, and 
test-retest reliability of the NPI are established in research. The NPI 
is a useful instrument for characterizing the psychopathology of 
dementia syndromes, investigating the neurobiology of brain disorders 
with neuropsychiatric manifestations, distinguishing among different 
dementia syndromes, and assessing the efficacy of treatment.
Training
    Question 1: In regard to training, I understand there is a basic 
self-guided workbook.

    Question 1(a): Will there be efforts to provide workbooks for more 
specialized instruction?

    Question 1(b): Will there be efforts to help tailor training to 
individual veterans' needs?

    Response: The workbook is one modality of the comprehensive 
curriculum that was designed in partnership with Easter Seals to 
provide family caregivers with the basic information necessary to be 
successful in their responsibilities. Additional curriculum modalities 
include the supportive CD that accompanies the home study workbook, 
traditional classrooms which are scheduled nationwide and are available 
for scheduling per caregiver request, and a soon-to-be-launched online 
version of the comprehensive training. The core caregiver training is 
designed to supplement individual and general training information and 
services VA has continued to offer.
    Training on the individual veteran's needs is a separate process 
that remains the responsibility of the Patient Aligned Care Team or 
other assigned provider at the local VA medical center (VAMC). This 
specific training on individual medical or mental health conditions and 
needs is presented to the veteran and caregiver at ongoing 
appointments, in the home, or may have taken place prior to discharge 
from a VAMC facility or Polytrauma Center. For example, prior to 
discharge from an inpatient unit, a family caregiver may be taught to 
change a dressing or assist with intravenous (IV) antibiotics that the 
veteran will need when they return home. On rehabilitation units, such 
as spinal cord injuries and disabilities centers, there are apartments 
available where veterans and caregivers may stay prior to discharge to 
``test'' their new skills before the veteran is discharged.
    Additionally, VA has an extensive array of condition-specific 
training and resources, including classroom and small group training, 
pamphlets, guidebooks and coordination with local resources, for 
specific medical or mental health conditions in general. All of this 
information and these resources are available to any veteran or 
caregiver as requested or appropriate.

    Question 2: We heard from one caregiver with 6 plus years of care 
giving, that she was insulted by the workbook.

    Question 2(a): Is there a plan to expedite training for those 
caregivers who already have significant experience?

    Response: VA understands the frustration experienced by this 
caregiver and has been mindful of these sensitivities in developing the 
Easter Seals Caregiver training curriculum. VA believes the training 
material accurately acknowledges and respects the time and sacrifice of 
both new and experienced caregivers. Beyond a very small number of 
similar reports on the workbook, VA has received an unprecedented 
number of unsolicited reports from caregivers that have been most 
appreciative and complimentary of the training material.
    A recent example of such reports is from a father of a post-9/11 
veteran who wrote: ``Eight years after embarking on the toughest role 
of my life, and the most rewarding, I am grateful to see such a user 
friendly, thorough, simple, encouraging, uplifting, Caregiver training 
tool. In the span of an hour, I reviewed lessons I was forced to learn 
on my own (but was grateful for the validation), I was reminded of 
skills/tips I learned along the way (and sometimes forget to practice) 
but, most importantly, was provided with an easy-to-navigate workbook 
that can sit on my kitchen desk as a reminder to our entire family that 
all of the information necessary to care for [our veteran] (and 
ourselves) is easily accessible.''
    While VA recognizes that many caregivers may have already received 
skills and knowledge through training or experience, it is important to 
establish a standard baseline of understanding for all family 
caregivers. We believe this is facilitated through the various training 
modalities so caregivers can decide independently if they would like to 
spend 10 to 15 hours in a traditional classroom, or navigate training 
online or through a self-paced workbook. Since the training includes a 
brief self-assessment with answers that validates the completion of 
required training, we believe caregivers can use their own discretion 
in how much time they spend on the training, and in doing so, they 
confirm they have received the basic or core training required.
    VA and Easter Seals continue to evaluate the caregiver training and 
will make modifications, as appropriate.

    Question 3: How many hours long is the training?

    Response: Current family caregiver classroom training lasts 
approximately 10 to 15 hours spread over 2 days. The time it takes to 
complete the workbook will vary significantly from caregiver to 
caregiver, depending on their existing knowledge and experience. Again, 
Family caregivers determine which mode of training they prefer, and 
many family caregivers have stated they prefer completing the home 
workbook at their own pace while others have opted for the workbook and 
plan to attend the classroom training at a later date. An online 
version of the curriculum will be available shortly.
    Family caregivers who have completed the classroom training have 
reported exponential benefit beyond the training material in being able 
to meet and network with other caregivers or to learn more about 
existing VA services and benefits of which they were not previously 
aware. It should also be noted that the training content and course 
length was designed with input from caregivers beforehand, and we have 
actively sought input and feedback from all caregivers completing the 
training so we can continue to refine the process to best meet the 
needs of caregivers while also completing the baseline training 
objective for all caregivers.
CHAMPVA
    Question 1: What guidance is given to personnel making 
determinations regarding CHAMPVA?

    Response: The CSC at the VAMC receives guidance through training, 
fact sheets, and procedures to advise the primary family caregiver that 
eligibility for CHAMPVA health care benefits is limited to those 
primary family caregivers who are not entitled to care or services 
under a health plan contract such as TRICARE, Medicare, Medicaid, or 
other health insurance. The CSC asks the caregiver if he/she has other 
such coverage, and this information is entered into a database for use 
by the CHAMPVA program staff. The staff at CHAMPVA, utilizing detailed 
desk procedures for guidance, verifies that the primary family 
caregiver is not entitled to care or services under a health plan 
contract and also reviews the veterans' record to determine if the 
caregiver may qualify for CHAMPVA based on other eligibility category 
(other than the individual serving as a designated primary family 
caregiver).

    Question 2: Of this first pool of recipients, approximately how 
many will be receiving CHAMPVA benefits?

    Response: The first pool of stipend recipients contained 215 
primary family caregivers, out of which 80 primary family caregivers 
were enrolled in CHAMPVA. 65 primary Family caregivers, out of the 80, 
were eligible for CHAMPVA benefits based on the Program of 
Comprehensive Assistance for Family Caregivers. At present, 120 primary 
family caregivers are eligible for CHAMPVA benefits, out of which 83 
are eligible for CHAMPVA benefits based on the Program of Comprehensive 
Assistance for Family Caregivers.
Implementation
    Question 1: What training materials are available for secondary 
caregivers?

    Response: Currently all the training material available to primary 
family caregivers is also available to secondary family caregivers. 
This includes the home-based workbook for the core family caregiver 
curriculum, the traditional classroom instruction, and the online 
course. To date, the workbook has been the most requested mode of 
training, and additional copies of the workbook can be made available 
upon request. We continue to encourage family caregivers (which can 
include the primary or secondary caregiver) to attend the classroom 
instruction when possible because VA has observed additional benefits 
to caregivers in peer networking and raised awareness of VA services 
and benefits.

    Question 2: I commend your partnership with Easter Seals to provide 
the comprehensive Caregiver Training. How long is this partnership 
expected to last or will the VA eventually be able to provide this 
training in house?

    Response: VA's comprehensive family caregiver training was 
developed through a contract with Easter Seals, which ends around May 
2012. The current partnership has been very beneficial for caregivers, 
since both VA and Easter Seals have combined efforts and resources to 
make classrooms, trainers, and networked resources available to 
caregivers nationwide. VA will review the quality and progress of the 
Easter Seals training as we move forward and will use that information 
in determining whether or not to renew the contract or to consider 
other options in the future.

    Question 2(a): Are there other organizations also assisting in this 
training?

    Response: Yes, several other organizations worked in collaboration 
with VA and Easter Seals in developing the core caregiver training 
which included research, design, development, revision, and now 
includes ongoing review and quality assurance. These additional 
organizations include: Atlas Research, the National Alliance for 
Caregiving, the Family Caregiver Alliance, the National Alliance for 
Hispanic Health, and the National Family Caregivers Association.

    Question 3: Would you comment on the variability at the local level 
that we have heard about in rolling out the program?

    Question 3(a): How are you monitoring implementation at the VA 
medical centers?

    Response: VA researched the issue of variability that was reported 
in the recent hearing and has continued to review the issue on a 
broader scale.
    As part of our broader review on quality, validity, and inter-rater 
reliability, VA randomly sampled various caregiver clinical assessments 
completed at 21 different VAMCs representing each national region, and 
found that there was a variance of less than 16 percent between similar 
decisions made by facilities. Of that 16 percent variance, more than 
half of those would have been rated at a lower stipend tier by the 
quality reviewer, so the variance that existed was in the veteran's 
favor. There were three cases identified that the quality reviewer 
would have rated higher, and each of those cases has been reviewed and 
adjusted, as necessary, by the Patient Aligned Care Team.
    VA will continue to monitor the consistency of implementation of 
the program across VAMCs. We will also continue to train all staff 
involved in the assessment and application process to maintain accurate 
and consistently high quality assessment.
Miscellaneous
    Question 1: The National Military Families Association recommends 
that VA offer these caregivers the opportunity to participate in VA's 
vocational rehabilitation programs and to help retool the caregiver's 
resume.

    Question 1(a): Has this idea been explored?

    Response: Currently, VA's Vocational Rehabilitation and Employment 
(VR&E) program may only provide educational and vocational counseling 
to a family caregiver if the caregiver is eligible for education 
benefits under Title 38 of the United States Code, Chapter 35, 
Survivors' and Dependents' Educational Assistance, or is eligible as a 
veteran for Chapter 31 or education benefits. The President's 
Commission on Care of America's Returning Wounded Warriors recommended 
strengthening family support systems and improving the quality of life 
for families. The availability of educational and vocational 
counseling, coupled with the supportive counseling provided by VHA, can 
help caregivers cope with the changes caused by an injury to a family 
member. These resources facilitate career and life planning by helping 
caregivers understand available options and explore potential resources 
for their families.
    While VA supports the idea of helping caregivers prepare for and 
obtain suitable employment, their participation in a VA program of 
vocational rehabilitation cannot be implemented without the enactment 
of new legislation.
    Question (2): Because 17 percent of applicants for these benefits 
are parents of veterans, what is VA's long term plan in regards to 
ensuring that veterans are cared for as they age and no longer can be 
cared for by their families?

    Response: VA works with the Department of Health and Human 
Services' Administration on Aging on many initiatives, including 
Veteran Directed Community Based Care, which allows aging and disabled 
veterans to remain at home with assistance. In addition, VA has pilot 
programs such as the Assisted Living Pilot, which allows eligible 
veterans to be placed in Assisted Living settings that can provide a 
level of care that is needed well before a veteran requires placement 
in a skilled nursing facility.
    VA will provide ongoing assistance and evaluation of caregivers as 
they age to ensure appropriate assistance for the veteran as part of 
the ongoing supportive home visit process.

    Question 3: Can you provide us with an update on the eight 
caregiver assistance pilot programs?

    Response: VA concluded the eight Caregiver Assistance Pilot 
Programs on August 31, 2009. The outcomes of the pilot programs have 
guided our development of evidenced-based support programs and services 
for family caregivers.
    The outcome or current status of the eight Caregiver assistance 
pilot programs includes:

    1.  REACH VA--Resources for Enhancing Alzheimer's Caregiver Health: 
The REACH VA pilot was able to demonstrate a significant decrease in 
caregiver burden, depressive symptoms, and impact of depressive 
symptoms on daily life. Improved outcomes for veterans included a 
decrease in reported troubling dementia related behaviors, and in the 
potential for abuse as measured by caregiver frustration. There was 
also a 2-hour decrease in the amount of time the caregiver spent on 
duty, which represented a trend toward significance. The pilot 
demonstrated improvement of veteran and caregiver quality of life.

          VA is funding the ongoing implementation of REACH VA. Sixteen 
        (16) sites are currently trained in and are using REACH VA as 
        an intervention. VA is planning to expand REACH VA to all VAMCs 
        within the next 5 years. REACH VA is also currently being 
        adapted for use with caregivers of veterans with spinal cord 
        injuries and disabilities, and will be piloted with this 
        population later in 2011. A plan to adapt the program for use 
        with caregivers of veterans with traumatic brain injury is also 
        under review.

    2.  Transition Assistance Program (TAP): Findings indicate that as 
caregiver satisfaction with TAP increased, self-efficacy increased and 
caregiver burden and depression decreased. When coupled with the very 
high rate of program satisfaction, this pattern suggests TAP 
participation increased caregivers' ability to cope with the demands of 
their roles. Veteran motor function was significantly linked to 
caregiver satisfaction suggesting that as satisfaction with TAP 
increased, so did veteran functional ability. These associations 
occurred across TAP participants and non-participants alike. The pilot 
did not demonstrate significant differences in resource utilization 
linked to participation in TAP.

    3.  VA California Office on Caregiving:

            a.  VA Cares Caregiver Centers of Expertise
            b.  California Caregiver Resource Center
            c.  Powerful Tools' Caregiver Training Program
            d.  Building Better Caregivers

          The pilot identified several new, potentially effective and 
        efficient approaches to providing support to caregivers. 
        General results of the pilot revealed good satisfaction with 
        the Powerful Tools Training (PTC) Course, the Building Better 
        Caregivers (BBC) Workshop, and the Tele-Educational 
        Conferences. Results continue to be collected for the PTC and 
        BBC Internet workshop. Use of the BBC Workshop demonstrated 
        significant improvement in stress, strain, depression, sense of 
        self-efficacy, and reduction of caregiver burden. Although 
        there was no demonstrated impact on health care utilization, it 
        is felt that additional data is required to demonstrate a 
        linkage and a longer period of follow-up beyond the 3-month 
        assessments (originally planned for 6 months) performed in 
        these studies would be needed to properly assess the effects on 
        health services utilization by the caregiver and the veteran.

          Both the Building Better Caregivers Workshop and Powerful 
        Tools Training Course are under consideration for national 
        implementation.

    4.  Tampa and Miami VA Medical Centers Respite and Caregiver 
Support Program Service: Veterans and caregivers using the pilot 
respite programs at both Tampa and Miami VAMCs reported high levels of 
satisfaction with services. Caregiver burden was significantly lower 
after participation in the pilot respite programs than at baseline. The 
caregivers at both Miami and Tampa reported significant improvements in 
mental health and decreased caregiver burden. Decreased use of 
inpatient services and shorter lengths of stays were both positive 
outcomes at both Tampa and Miami after the respite program than at 
baseline.

    5.  Communicating Effectively with Health Care Professionals: The 
pilot did not demonstrate any significant impact on the caregiver as a 
result of the workshop or written materials provided. In addition, the 
pilot did not demonstrate an impact on veteran health outcomes, provide 
measurable improvement in health care communication between the 
caregiver or veteran and VA, or demonstrate a cost savings to VA as a 
result of the intervention.

    6.  Telehealth Technology to Support Family Caregivers: The 
participants (other than the wait list control group) all rated 
``satisfied'' or ``very satisfied'' with the Health Buddy. However, the 
pilot failed to demonstrate any impact on health care utilization and 
caregiver depression and burden measures. This could be due to the low 
number of participants or the inability of some participants to 
complete post-baseline data.

    7.  Use of Caregiver Advocates: The pilot showed a positive impact 
on the health care of the caregiver, the caregiver's ability to accept 
assistance, and a decrease in overall stress or burden experienced by 
the caregiver. This pilot provided one impetus for the creation of the 
CSC positions at VAMCs.

    8.  Heroes of the Heart: The pilot's post-intervention scores seem 
to suggest that caregiver burden was lowered 2 weeks following the 
respite intervention, but the overall findings are not significant 
enough to generalize for all respite interventions. The pilot also 
found that geographic barriers present many challenges to providing 
respite care and alternative respite options available in rural areas 
are limited. VA is currently exploring alternate options for respite 
care in rural areas.

    Question 4: To what extent has the U.S. Department of Defense been 
consulted to ensure seamless transitional caregiver benefits?

    Response: VA has worked actively with DoD in developing VA's 
Program of Comprehensive Assistance for Family Caregivers. VA maintains 
a mutually beneficial working relationship with DoD and is assisting 
DoD in its development of a similar program. Currently, VA is assisting 
DoD in discussions with Easter Seals to establish a caregiver training 
program for active duty servicemembers and their caregivers.
    Additionally, VA maintains multiple programs that communicate and 
liaise with DoD in the seamless transition process for veterans and 
their caregivers. Federal Recovery Coordinators work actively with 
servicemembers and their families as they transition from active duty, 
while VA Liaisons work from Military Treatment Facilities to coordinate 
transition to VAMCs where they are then assisted by OEF/OIF/OND Program 
Managers and Social Work Case Managers, as appropriate.

    Question 5: What sort of outreach has been conducted over the past 
few months to spread the word about this program?

    Response: VA is committed to ensuring that stakeholders are 
informed of the benefits and services available to support family 
caregivers and the veterans they care for at home. Veterans Service 
Organizations and caregiver-focused non-governmental organizations have 
been partners in outreach efforts on the expanded VA services including 
family caregiver benefits, respite, and other new or existing benefits 
and services. Many of these organizations have actively hosted 
information related to the Caregiver program authority in P.L. 111-163 
in their publications and on their Web sites. In collaboration with VA, 
these organizations have also included direct online links to the new 
Comprehensive Assistance for Family Caregiver program application. 
Multiple national press releases and media interviews have resulted in 
the posting of information about VA caregiver benefits and services and 
the application process in multiple venues. VA's caregiver information 
is also posted on the main VA Web site.
    The Caregiver Support Program established a toll-free National 
Caregiver Support Line (1-855-260-3274), which opened February 1, 2011, 
at the Canandaigua VAMC campus. This Support Line is available to 
respond to inquiries about the new caregiver services associated with 
P.L. 111-163 and to serve as a resource and referral center for Family 
Caregivers. The Caregiver Support Line provides referrals to local VAMC 
CSCs, VA, and community-based resources. The Support line also provides 
emotional support to family and general caregivers. The Support Line is 
staffed by licensed social workers and has received more than 12,000 
calls since it was established.
    In addition to the Caregiver Support Line, the Caregiver Support 
Program launched a new Web site on May 31, 2011, www.caregiver.va.gov, 
which provides a wealth of information and resources for veterans, 
families and the general public. The Web site receives more than 1,000 
visits daily with each visitor reviewing more than six separate pages 
on the Web site per visit.
    The Caregiver Support Program has provided multiple national 
education and training events to VA staff throughout the country and to 
a wide range of Federal, State, and local organizations. Within each 
medical center, CSCs have contacted veterans known to their medical 
center who may be eligible for the Program of Comprehensive Assistance 
for Family Caregivers. In addition, CSCs have contacted veterans who 
receive VA's Aide and Attendance benefit who may be eligible for the 
Program of Comprehensive Assistance for Family Caregivers to provide 
information on applying for the Comprehensive Program and its benefits, 
and also to provide support and assistance with other benefits and 
services.

    Question 6: Can you provide more information regarding the Peer-
Support Mentoring Program?

    Question 6(a): Is this the same program as the Caregiver Support 
Advisory Board that is being implemented at the Syracuse, NY, 
Department of Veterans Affairs (VA) Medical Center, as indicated by Ms. 
Cheryl Cox?

    Question 6(b): Will this program be required at all VA Medical 
Centers?

    Question 6(c): What would this Board do?

    Response: VA strongly endorses peer-support mentoring and is 
facilitating the creation of such programs at its facilities. According 
to the National Alliance for Caregiving's 2010 survey of caregivers, 
more than 45 percent of caregivers reported seeking most of their 
information and support from other caregivers, peers, and online 
resources. VA is in the process of developing a Peer Support Mentoring 
Program to harness the power of these relationships and provide a forum 
and a network of peers who can support and learn from one another. More 
experienced caregivers will be matched with newer, less experienced 
caregivers. Peer mentors will be provided with training and ongoing 
support as they work with caregivers of veterans. Peer mentors can also 
be bridge builders for caregivers by empowering them to form new 
supportive relationships and linking them to resources available within 
VA and the community. We have researched many peer programs both within 
VA and in the community, allowing us to identify best practices. We 
will work with caregivers to develop this program and integrate these 
best practices in the final design of the Peer Mentoring Program. The 
Caregiver Support Program plans to train the first group of peer 
mentors by the end of 2011.
    A separate initiative is the creation of local Caregiver Advisory 
Boards, which VA anticipates will support education of and 
collaboration with veterans, caregivers and VA staff; support the 
National Caregiver Support Program's mission and goals; and recognize 
National Family Caregiver Month by providing assistance with an annual 
event each year. The successful implementation and ongoing support of 
caregiver services mandated in P.L. 111-163 will be supported by these 
Boards. In addition, the Boards will support VA in its recognition of 
the significant contributions caregivers make in caring for veterans, 
which allows them to safely remain in their homes. VA is working to 
establish a Caregiver Advisory Board at each VAMC through the CSCs, to 
ensure compliance with the Federal Advisory Committee Act and any other 
applicable policies and laws.
Moving Forward
    Question 1: Obviously VA did not meet the timelines set forth in 
P.L. 111-163 concerning the submission of the implementation plan or 
the actual implementation of the law.

    Question 1(a): Moving forward, would you tell the Committee what 
your next steps are?

    Response: VA's next steps are to continue refining the current 
processes recently developed under the new law and the Interim Final 
Rule. Part of the refinement process involves reviewing the public 
comments submitted in response to VA's Interim Final Rule published in 
the Federal Register on May 5, 2011. VA will determine an appropriate 
response and related actions to these comments while also moving 
forward with planned expansions to VA's existing caregiver services and 
identified best practices. VA will host focus groups with caregivers, 
professionals, and stakeholders to review current services and 
resources and to plan for future services and resources. VA is 
currently reviewing the workload and performance of the CSC at each 
VAMC to determine if a second full-time CSC is required.

                                 
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