VA Health Care: Actions Needed to Address Higher-Than-Expected Demand for the Family Caregiver Program
Published: 2014-09-18T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: In May 2010, Congress required VA to establish a program to support family caregivers of seriously injured post-9/11 veterans. In May 2011, VHA implemented its Family Caregiver Program at all VAMCs across the country, offering caregivers an array of services, including a monthly stipend, training, counseling, referral services, and expanded access to mental health and respite care. In fiscal year 2014, VHA obligated over $263 million for the program.
GAO was asked to examine VA's implementation of the Family Caregiver Program. This report examines how VHA is implementing the program, including the types of issues that have been identified during initial implementation. GAO obtained and reviewed relevant policy documents and program data and interviewed officials from VHA's Caregiver Support Program office. GAO also met with officials from five VAMCs and their corresponding Veterans Integrated Service Networks to obtain information on program implementation at the medical facility level.
section_title: What GAO Found
paragraphs: The Veterans Health Administration (VHA)—within the Department of Veterans Affairs (VA)—significantly underestimated caregivers' demand for services when it implemented the Program of Comprehensive Assistance for Family Caregivers (Family Caregiver Program). As a result, some VA medical centers (VAMCs) had difficulties managing the larger-than-expected workload, and some caregivers experienced delays in approval determinations and in receiving program benefits. VHA officials originally estimated that about 4,000 caregivers would be approved for the program by September 30, 2014. However, by May 2014 about 15,600 caregivers had been approved—more than triple the original estimate. The program's staffing was based on VA's initial assumptions about the potential size of the program and consisted of placing a single caregiver support coordinator at each VAMC to administer the program. In addition, each VAMC was to provide clinical staff to carry out essential functions of the program, such as conducting medical assessments for eligibility and making home visits. This led to implementation problems at busy VAMCs that did not have sufficient staff to conduct these program functions in addition to their other duties. As a result, timelines for key program functions, such as those for completing applications within 45 days and making quarterly home visits to caregivers, are not being met. VHA has taken some steps to address staffing shortages; however, some VAMCs have not been able to overcome their workload problems because the program continues to grow at a steady rate—about 500 approved caregivers are being added to the program each month. Federal internal control standards emphasize the need for effective and efficient operations, including the use of agency resources.
The Caregiver Support Program office, which manages the program, does not have ready access to the type of workload data that would allow it to routinely monitor the effects of the Family Caregiver Program on VAMCs' resources due to limitations with the program's information technology (IT) system—the Caregiver Application Tracker. Program officials explained that this system was designed to manage a much smaller program, and as a result, the system has limited capabilities. According to federal standards for internal control, agencies should identify, capture, and distribute information that permits officials to perform their duties efficiently. However, outside of obtaining basic aggregate program statistics, the program office is not able to readily retrieve data from the system that would allow it to better assess the scope and extent of workload problems at VAMCs. Program officials also expressed concern about the reliability of the system's data, which they must take steps to validate. The lack of ready access to comprehensive workload data impedes the program office's ability to monitor the program and identify workload problems or make modifications as needed. This runs counter to federal standards for internal control which state that agencies should monitor their performance over time and use the results to correct identified deficiencies and make improvements. Program officials told GAO that they have taken initial steps to obtain another IT system, but they are not sure how long it will take. However, unless the program office begins taking steps towards identifying solutions prior to obtaining a new system, VAMCs' workload problems will persist and caregivers will not be able to get the services they need.
section_title: What GAO Recommends
paragraphs: GAO recommends that VA (1) expedite the process for implementing a new IT system that will enable officials to obtain workload data; and that VHA (2) identify solutions to alleviate VAMCs' workload burden in advance of obtaining a new IT system, and (3) use data from the new IT system, once implemented, and other relevant data, to re-assess the program and implement changes as needed. VA agreed with GAO's recommendations.

section_title: Letter
paragraphs: Since the beginning of the Iraq and Afghanistan conflicts in 2001,  advancements in medical care and body armor have reduced fatality  rates, allowing more servicemembers to recover from catastrophic  physical and psychological injuries, including multiple limb loss, traumatic  brain injury (TBI), and post-traumatic stress disorder (PTSD). The  cumulative number of post-9/11 veterans who were wounded in action  was 1.3 million in 2012—nearly triple the 482,000 post-9/11 veterans who  were wounded in action in 2001. Given the increased number of  recovering veterans, the need for caregivers has grown substantially.  Family members most often serve in this role and are referred to as  “family caregivers.” A RAND study estimated that there are 1.1 million  family caregivers of post-9/11 veterans and that each year they provide  personal care services valued at $3 billion, enabling seriously injured   These caregivers  veterans to live at home rather than in institutions.assist with the tasks of everyday living—as well as making and keeping  appointments, helping navigate the Department of Defense’s (DOD) and  the Department of Veterans Affairs’ (VA) complex health care systems,  serving as advocates, and making decisions on medical, legal, financial,  and benefit issues.
Caregivers enable those for whom they are caring to live better quality  lives and can contribute to faster rehabilitation and recovery; however,  time spent caregiving can lead to the loss of income, jobs, or health care  and can exact a substantial physical, emotional, and financial toll,  according to RAND and others. In addition to assisting veterans with  activities of daily living, family caregivers may have other concurrent  responsibilities, such as raising children or caring for aging parents. Some  veterans will need caregiver assistance for many years or throughout  their lifetimes. To the extent that family caregivers’ well-being is  compromised, they may become unable or unwilling to fulfill their  caregiving role, leaving the responsibilities to be borne by other social  institutions. According to RAND, improving family caregivers’ well-being  and ensuring their continued ability to provide care requires a  multifaceted approach—including training, health care coverage, and  support services—to reduce the burdens caregiving may create and to  bolster their ability to serve as caregivers more effectively.
To provide greater support for caregivers of post-9/11 veterans, Congress  passed legislation requiring VA to establish a program to assist  caregivers with the rigors of caring for seriously injured veterans. In May  2011, the Veterans Health Administration (VHA)—which operates VA’s  health care system—established the Program of Comprehensive  Assistance for Family Caregivers (Family Caregiver Program) at each of   In accordance  its VA medical centers (VAMC) across the United States.with applicable requirements, the program provides approved primary  family caregivers with a monthly financial stipend, the amount of which is  based on the amount and degree of personal care services—such as  assisting with bathing and eating—provided to the veteran, and  geographic location. The program also provides caregivers with other  types of assistance, including training, referral services, counseling, some  mental health services, and respite care.caregivers approved for the Family Caregiver Program may be eligible for  coverage through the Civilian Health and Medical Program of the  Department of Veterans Affairs (CHAMPVA) if they have no other  coverage. As of May 2014, about 15,600 caregivers were approved for  the Family Caregiver Program, and the estimated obligations for fiscal  year 2014 are over $263 million.
You asked us to review VA’s efforts to support the family caregivers of  seriously injured veterans through its implementation of this program.  This report examines how VHA is implementing its Family Caregiver  Program, including the types of issues that have been identified during  initial implementation.
To examine how VHA is implementing the Family Caregiver Program and  to identify the types of issues that transpired during initial implementation,  we met with officials from VHA’s Caregiver Support Program office—the  office responsible for managing and overseeing the Family Caregiver  Program. We obtained and reviewed the program’s authorizing legislation  and implementing regulations as well as relevant policy and management  documents, including the program’s implementation plan, policy  guidebook, and the orientation manual for caregiver support coordinators  (CSC), who administer the program at the medical facility level.addition, we obtained and reviewed information on the numbers of CSCs  and approved caregivers for each VAMC, and other program statistics  from the Caregiver Support Program office, including aggregate data from  weekly reports on the numbers of applications and caregiver approvals.  We spoke with Caregiver Support Program officials about these data, and   In  they explained that data from their information technology (IT) system is  not reliable unless additional steps have been taken to verify them. We  confirmed that the data we obtained from program officials had been  verified, and therefore, we determined that these data were sufficiently  reliable for the purposes of our report. Additionally, we applied federal  standards for internal control related to capturing information and  monitoring performance to assess the ability of the Caregiver Support  Program office to oversee the program as well as standards for efficiency  and effectiveness of operations.
To understand how the Family Caregiver Program was being  implemented at the medical facility level, we interviewed officials at five  VAMCs, including the directors, selected staff such as departmental  leaders, clinicians, and CSCs. We also interviewed program officials from  the five Veterans Integrated Service Networks (VISN) who oversee the  program at these facilities to obtain their perspective on the  implementation of the program.from interviews with VAMC and VISN officials cannot be generalized. We  selected a nonprobability sample of VAMCs based on geographic  dispersion and a range of CSC-to-approved caregiver ratios—from 1:34  to 1:167. The VAMCs we selected were Washington, D.C. (VISN 5);  Fayetteville, North Carolina (VISN 6); Temple, Texas (VISN 17); Fort  Harrison, Montana (VISN 19); and Palo Alto, California (VISN 21). We  also met with organizations that represent veterans to obtain their views  on the program and its implementation. Finally, we interviewed a non- generalizable sample of 11 caregivers of veterans who are approved for  VHA’s Family Caregiver Program at some of the VAMCs we contacted to  obtain their experiences and perspectives on this program.
However, the information we obtained  We conducted this performance audit from June 2013 to September 2014  in accordance with generally accepted government auditing standards.  Those standards require that we plan and perform the audit to obtain  sufficient, appropriate evidence to provide a reasonable basis for our  findings and conclusions based on our audit objectives. We believe that  the evidence obtained provides a reasonable basis for our findings and  conclusions based on our audit objectives.
subsections: section_title: Background
paragraphs: VHA’s Family Caregiver Program is designed to provide support and  services to family caregivers of post-9/11 veterans who have a serious  injury incurred or aggravated in the line of duty. The program provides  approved primary family caregivers with a monthly financial stipend as  well as training and other support services, such as counseling and  respite care.
subsections: section_title: Family Caregiver Program Eligibility Requirements
paragraphs: The Family Caregiver Program has a series of eligibility requirements that  must be satisfied in order for family caregivers to be approved.
To meet the program’s initial eligibility criteria the veteran seeking  caregiver assistance must have a serious injury that was incurred or  aggravated in the line of duty on or after September 11, 2001.  According to the program’s regulations, a serious injury is any injury,  including TBI, psychological trauma, or other mental disorder, that has  been incurred or aggravated in the line of duty and renders the  veteran or servicemember in need of personal care services.
The veteran must be in need of personal care services for a minimum  of 6 continuous months based on any one of the following clinical  eligibility criteria: (a) an inability to perform one or more activities of  daily living, such as bathing, dressing, or eating; (b) a need for supervision or protection based on symptoms or residuals of  neurological or other impairment or injury such as TBI, PTSD, or other  mental health disorders; (c) the existence of a psychological trauma or  a mental disorder that has been scored by a licensed mental health  professional, with a Global Assessment of Functioning score of 30 or  less, continuously during the 90-day period immediately preceding  the date on which VHA initially received the application; or (d) the  veteran has been rated 100 percent service connected disabled for  the veteran’s qualifying serious injury and has been awarded special  monthly compensation that includes an aid and attendance  allowance.
To be considered competent to care for the veteran, family caregivers  must meet certain requirements including (1) having the ability to  communicate and follow details of the treatment plan and instructions  related to the care of the veteran; (2) not determined by VA to have  abused or neglected the veteran; (3) being at least 18 years of age;  and (4) either being a family member—such as a spouse, son or  daughter, parent, step-family member, or extended family member— or an unrelated person who lives or will live full-time with the veteran.
Family caregivers must also complete required training before being  approved for the program.
section_title: Family Caregiver Program Organizational Structure
paragraphs: VHA’s Caregiver Support Program office is responsible for developing  policy and providing guidance and oversight for the Family Caregiver  Program. It also directly administers the program’s stipend, provides  support services such as a telephone hotline and website, and arranges  CHAMPVA coverage for eligible caregivers. Furthermore, the office  provides funding to VAMCs to cover certain program costs, such as the  salaries of the CSCs, who implement and administer the Family  Caregiver Program at the local VAMC level, as well as the costs VAMCs  incur for having their clinical staff, such as nurses, conduct the program’s  required in-home visits to approved caregivers and their veterans.
CSCs are generally licensed social workers, clinical psychologists, or  registered nurses, and they have both clinical and administrative  responsibilities. Their clinical responsibilities may include identifying and  coordinating appropriate interventions for caregivers or referrals to other  VA or non-VA programs, such as mental health treatment, respite care, or  additional training and education. Their administrative responsibilities may  include responding to inquiries about the program, overseeing the  application process, entering information about applications and approved  caregivers into IT systems, and facilitating the processing of appeals. As  of May 2014, there were 233 CSCs assigned to 140 VAMCs or  healthcare systems across the country. Additionally, each of the 21  regional VISN offices also has a VISN CSC lead for the program, who  provides guidance to CSCs and helps address their questions or  concerns.
section_title: Family Caregiver Program Funding
paragraphs: Congress authorized over $1.5 billion for the Family Caregiver Program  and other caregiver services for fiscal years 2011 through 2015. VHA’s  actual and estimated obligations for the program for fiscal years 2011  through 2015 have increased at a steady rate. (See fig.1.)
The Caregiver Support Program office uses this funding to cover costs  such as program staffing, general caregiver education and training,  caregiver stipends, CHAMPVA costs for primary family caregivers, the  Caregiver Support Line, the Caregiver website, and outreach materials. It  also provides funding to VAMCs to cover certain program costs rather  than requiring the VAMCs to pay for them directly from their medical  facilities’ budgets. These costs include CSC salaries, reimbursement for  home visits, respite care, and mental health services as well as  assistance with travel expenses for eligible caregivers when  accompanying the veteran to an appointment.
section_title: Family Caregiver Program Application Adjudication Process
paragraphs: The Family Caregiver Program application has a sequential, multistep  adjudication process. CSCs are responsible for overseeing this process  and for ensuring that all steps of the application process are completed  within 45 days, as outlined in the program’s guidance. CSCs are  expected to cultivate relationships with VAMC medical staff to request  their assistance in performing medical eligibility assessments and  completing the home visits—2 key steps in the process. For applications  that cannot be fully adjudicated within the program’s 45-day goal, the  CSC may request additional time to process the application from the  Caregiver Support Program office. The steps of the application process  are as follows:  Step 1: Application Review. After the caregiver and veteran submit an  application for the program, the CSC reviews the application and  determines the caregiver’s potential eligibility.
Step 2: Initial Eligibility Determination for the Veteran. The CSC then  determines whether the veteran is a post-9/11 veteran enrolled in VHA (or  servicemember undergoing medical discharge) and has a documented  line-of-duty injury.
Step 3: Final Eligibility Determination for the Veteran. After initial  eligibility has been determined, a VHA medical provider is to complete a  medical assessment to determine the medical condition of the veteran,  their need for a caregiver, and all other program eligibility criteria. The  provider then determines the veteran’s rating for the stipend amount the  primary family caregiver is eligible to receive. The stipend amounts are  organized into three tiers. The stipend amount that the caregiver could  receive is based on the assigned tier level and the geographic location of  the veteran’s residence. Tier 3 indicates the highest level of injury and  need for a caregiver and has the highest level of payment, while Tiers 2  and 1 indicate the lower levels of injury and correspondingly lower levels  of payment.
Step 4: Eligibility Determination for the Caregiver. While the veteran’s  eligibility is being verified, the CSC determines the caregiver’s eligibility  for the program by conducting an assessment of the caregiver’s ability to  serve in that role, either through a phone call or in-person meeting.
Step 5: Review of Program Services. Once the veteran and caregiver  have been determined eligible for the program, the CSC schedules a joint  meeting to discuss the types of Family Caregiver Program services for  which they may be eligible once they complete the application process  and are approved for participation in the program. This would include a  discussion of the stipend payment as well as potential coverage through  CHAMPVA.
Step 6: Caregiver Training. The caregiver must complete the program’s  training class, which is offered online, through self-instruction with a  workbook and a CD or DVD, or where available, through 2 days of  facilitated classroom instruction. The training covers 10 competencies,  including self-care, nutrition, and medication management.
Step 7: Home Visit. Within 10 days after the caregiver completes the  training, an initial home visit is conducted to determine if the caregiver  has the physical capacity and skills necessary to provide medical care to  the veteran, and if the home is safe and adequately equipped. Since the  initial home visit includes physical assessment and medical components,  it must be completed by a medical professional such as a registered  nurse, nurse practitioner, clinical nurse specialist, physician assistant or  physician. When a veteran requires a caregiver due to a mental health  diagnosis, the home visit is to be completed by or in collaboration with a  mental health provider.
Step 8: Notification of Program Eligibility. Once the home visit  assessment has been completed and the results confirm that the  caregiver is prepared to provide satisfactory care of the veteran, the CSC  completes the final approval of the caregiver. This entails sending  approval paperwork to the caregiver, including the direct deposit form for  the stipend, and updating the relevant VHA systems, including the  program’s IT system and the veteran’s medical record.
Caregivers who are denied eligibility for the program, or who believe that  the veteran’s condition is more severe than the rating indicates, may  appeal the decision. CSCs coordinate with VAMC patient advocates and  other VHA staff to process these appeals—requests for review and  reconsideration—first with the VAMC director and subsequently at the  VISN level, if necessary.
As of May 2014, approximately 15,600 caregivers had been approved for  the program. About 6,000 of these caregivers were assigned to Tier 3  (highest level) for their stipend payments, about 6,000 to Tier 2 (middle  level), and 3,600 to Tier 1 (lowest level). The average monthly payments  per tier were approximately $2,320 for Tier 3, $1,470 for Tier 2, and $600  for Tier 1. At this time, almost 8 out of 10 of the caregivers approved for  the Family Caregiver Program were spouses, while other approved  caregivers were parents, relatives, and friends. Most of these caregivers  were assisting veterans with mental health diagnoses or brain injuries  who may also have had other physical injuries or disabilities. Specifically,  92 percent of these veterans have a service-connected mental health  condition, 63 percent have PTSD, and 26 percent have a TBI.
The program requires interim quarterly home visits for its approved  caregivers, unless otherwise clinically indicated. These visits are to be  conducted by clinical staff, but CSCs may also conduct them if they have  a clinical background, such as being a registered nurse or a clinical   The home visits serve multiple purposes and are intended  psychologist.to monitor the well-being of the veteran. They are also used to determine  whether the caregiver continues to have the physical capacity and skills  necessary to provide medical care to the veteran, and whether the home  remains safe and adequately equipped. The Caregiver Support Program  office also permits home visits to be conducted by telephone after 1 year  of satisfactory home visits has been completed for cases that do not pose  exceptional medical risk.
section_title: Some VAMCs Had Difficulty Meeting Higher-Than- Expected Demand and Data System Limitations Have Impeded VHA’s Ability to Monitor Workload
paragraphs: VHA officials significantly underestimated the demand for the Family  Caregiver Program. As a result, the program did not have sufficient  support for the ensuing workload at some VAMCs, and the resulting  staffing shortages impeded the timeliness of key functions and negatively  impacted services to caregivers. Furthermore, VHA’s Caregiver Support  Program office does not have ready access to the type of data that would  allow it to monitor and manage the program’s workload due to the limited  capabilities of its data system, which was designed to manage a much  smaller program.
subsections: section_title: Program’s Staffing Not Adequate to Handle Higher-Than-Expected Demand at Some VAMCs
paragraphs: VISN and VAMC officials told us that the program’s initial staffing did not  provide sufficient resources to support the unexpectedly high and  increasing workload since the program began in 2011. VHA officials  originally estimated that approximately 4,000 caregivers would be  approved for the program by the end of fiscal year 2014. This estimate  was based on the number of expected post-9/11 veterans and  servicemembers who have serious medical or behavioral conditions  involving impairment in at least one activity of daily living or who require  supervision or protection, using available data from the Veterans Benefits   However, the number of individuals approved  Administration and DOD.for the Family Caregiver Program far exceeded the original estimate: by  May 2014, almost 30,400 caregivers had applied and about 15,600 had  been approved. (See fig. 2.)
Caregiver Support Program officials told us that after 3 years of operation,  demand for the Family Caregiver Program remains high: system-wide,  there has been no appreciable decrease in the number of caregivers  submitting applications for the program. In fact, the number of “in- process” applications for the Family Caregiver Program more than  doubled from 1,966 in April 2013 to 4,318 in May 2014. As of May 2014,  98 VAMCs had more than 50 approved caregivers. (See fig. 3.)
The initial arrangement for CSCs and VAMC staff that VHA established  for this program proved inadequate in the face of such high demand. The  program initially placed a single CSC at each VAMC largely to perform  administrative and caregiver support functions, with the expectation that  each VAMC would provide the program with physician, nursing, and  administrative staff as needed to perform specific program functions.  However, VISN officials and VAMC officials we spoke with said that there  are too few CSCs to handle the program’s workload effectively.  Specifically, at some VAMCs, CSCs have been unable to perform all of  the routine administrative tasks associated with their approved  caregivers, as initially expected. For example, some VISN and VAMC  officials told us that the number of appeals filed by veterans and  caregivers has become an unexpectedly large component of CSCs’  workload, making it difficult to fulfill the full range of their responsibilities.  A Caregiver Support Program official clarified that while CSCs typically  work with the VAMC patient advocates to handle appeals, they may be  taking on greater responsibility for the appeals process at VAMCs with  large numbers of appeals for the program.
Caregiver Support Program officials acknowledged that the workload for  the Family Caregiver Program has been burdensome for some CSCs,  depending on the number of their approved caregivers and the amount of  assistance they have at the local level. As of May 2014, the number of  approved caregivers per CSC varied widely across VAMCs, ranging from  6 to 251. (See fig. 4.) Caregiver Support Program officials stated that their  office does not use a formal CSC-to-caregiver target ratio because  staffing decisions are largely the domain of local managers and the use of  a specific workload ratio by the Caregiver Support Program could limit  VAMCs’ discretion in determining when to request additional CSCs. (See  app. I for a list of VAMCs’ CSC-to-caregiver workload ratio.)
Furthermore, Caregiver Support Program officials had expected VAMC  officials to direct their clinical staff to perform the medical assessments  and home visits needed by the Family Caregiver Program as part of their  ongoing care to veterans. However, VISN and VAMC officials we  contacted told us that their facilities do not have sufficient medical staff to  effectively manage the additional workload generated by the Family  Caregiver Program, which they view as a collateral duty. According to  most VISN and VAMC officials, obtaining clinical staff for the program can  be difficult at VAMCs where directors may not consider the Family  Caregiver Program to be a high priority. For example, officials at one  VAMC told us that lack of support from the VAMC director led to a  situation in which the director refused to have nurses conduct home visits  for the Family Caregiver Program. At another facility, a VAMC director  told us that lack of support by her predecessor led to large backlogs of  unprocessed applications and incomplete home visits for the Family  Caregiver Program, which she discovered following her recent transfer to  that facility. According to some VISN officials, this dynamic sometimes  placed CSCs, as the administrators of the local Family Caregiver  Program, in the position of pleading for support from VAMC physicians  and nurses. In May 2014, a Caregiver Support Program official explained  that although the office has issued program policy and guidance to  medical facilities, it also plans to issue a directive that outlines  organizational responsibilities for the Family Caregiver Program, including  those at the VAMC level. This official did not provide a specific timeframe  for the issuance of the directive but stated that it would occur following the  issuance of final program regulations.
VISN and VAMC officials we spoke with noted that the Family Caregiver  Program’s approach of having VAMC physicians conduct medical  assessments for program eligibility has been a challenge. Physicians at  the VAMCs we contacted were already experiencing heavy workloads  prior to the implementation of the Family Caregiver Program, and some  physicians were not able to take on additional tasks that they viewed as  collateral duties, according to VISN and VAMC officials. Some physicians  who were initially willing to conduct medical assessments could not  continue doing so when the number of applications for the program  increased. VISN and VAMC officials also stated that some physicians do  not want to perform medical assessments because they are concerned  that having a role in determining eligibility for a program that includes a  financial stipend could compromise their clinical relationship with the  patient. As a result of these factors, the number of physicians willing to  conduct medical assessments for the program is limited at some VAMCs.  CSCs at some VAMCs told us that the typical wait time for a medical  assessment can be a month or longer.
VISN and VAMC officials also agreed that providing nurses for the home  visits needed by the Family Caregiver Program has posed problems and  remains an ongoing challenge. These officials explained that most clinic  nurses are already too busy to assume an additional workload. Officials at  one VISN told us that some nurses who originally agreed to conduct  quarterly home visits for the Family Caregiver Program stopped doing so  after home visits became a burden, due to the increasing number of  approved caregivers. In addition, VAMC and VISN officials at every  location we contacted told us that home visits to remote areas require  long driving times, which are challenging to accommodate. Staff at one  VAMC we contacted pointed out that their catchment area covers  147,000 square miles, and some of their caregivers live over 8 hours  away, requiring nurses to contend with multiple overnight stays per month  and dangerous travel conditions in the winter.
section_title: Staffing Shortages Impeded Timeliness of Key Functions and Negatively Affected Services to Caregivers Despite Actions Taken to Address Them
paragraphs: Timelines for key functions of the caregiver program, such as those for  adjudicating applications within 45 days or making quarterly home visits  to family caregivers, are not being met because CSCs at some VAMCs  were not able to obtain sufficient support from medical facility staff. As a  result, some caregivers have had to wait longer for an eligibility  determination and to receive program benefits. Staff at many of the  VAMCs we contacted told us that delays exist at some or every step of  the application process for the Family Caregiver Program, including  determining caregiver eligibility, administering medical assessments, and  conducting initial home visits. Officials at all of the VAMCs we contacted  stated that there were applications at that facility that had been open for  longer than 45 days, and one VAMC had over 400 open applications,  some going back to June 2013. According to the Caregiver Support  Program office, in June 2014, 111 VAMCs had applications that had been  in process for 45 to 90 days; most of these facilities (95 percent) had 20  or fewer applications in this category. Additionally, the office reported that  65 VAMCs had applications that had been open 91 days or more; most of  these VAMCs (85 percent) had 25 or fewer applications in this category.
Furthermore, home visits are not always being made on a timely basis. At  one VAMC, initial home visits to assess caregivers’ skills, which are  supposed to take place within 10 days of the caregiver’s completion of  core training, took from one to two months to complete, which delayed  eligibility determinations. Staff at some of the VAMCs we contacted were  also struggling to maintain the quarterly schedule for follow-up home  visits due to the larger-than-expected number of approved caregivers. At  one VAMC, CSCs told us that follow-up home visits occur every 6 to   9 months, in contrast to the program’s standard of every 90 days. Delays  in home visits could be problematic because these visits provide medical  staff with an opportunity to assess the welfare and environment of the  caregiver and veteran—issues that may not be evident during clinic visits,  such as whether special dietary needs are being met and whether  medications are being properly administered.
At some VAMCs, the volume of administrative and procedural activities  performed by CSCs has curtailed or even displaced their ability to provide  services to caregivers and veterans. VISN staff we spoke with told us that  as a result of the high workload burden, CSCs who are overwhelmed do  not have the ability to perform some caregiver support functions offered  by the Family Caregiver Program, such as support groups and  counseling. Caregivers and officials from non-VA organizations told us  that some CSCs do not return caregivers’ phone calls. One caregiver  recounted that when she became desperate to learn how to manage a  veteran with increasingly severe symptoms from a TBI, her CSC told her  that hers was one of many requests and that the program could not  provide counseling for caregivers. This caregiver subsequently received  services from a non-profit organization.
Officials from the Caregiver Support Program and the VAMCs we  contacted also told us that they have taken steps to address staffing  shortages for the Family Caregiver Program, although some of the steps  have had limited success. For example,  In recognition that some VAMCs had more approved caregivers than  originally anticipated, the Caregiver Support Program office began to  allow VAMCs to request additional CSCs in August 2011. By May  2014, VAMCs had submitted 99 requests for salary funding to the  Caregiver Support Program office for adding one to five more CSCs to  their facility. Specifically, the requests from VAMCs totaled 112  additional CSCs, of which the Caregiver Support Program office  approved about 94 additional positions.
In March 2014, the Caregiver Support Program also began funding  temporary CSCs, who were hired for terms of 120 days. As of May  2014, the office has funded 10 CSCs on a temporary basis. According  to a Caregiver Support Program official, these CSCs must meet the  same qualifications as a full-time CSC, and their duties are to be  established at the local level. In addition, some VAMCs have provided  their own clerical support to CSCs for routine administrative tasks.
In August 2012, the Caregiver Support Program office also began  allowing VAMCs to conduct home visits by telephone after 1 year of  satisfactory home visits had been completed for cases that do not  pose exceptional medical risk. Some of the VAMCs we contacted are  planning to expand their use of follow-up telephone contact with  caregivers in lieu of in-person home visits. However, officials at one  VAMC told us that they did this with only three to four families  because they considered almost all families approved for the Family  Caregiver Program to be at risk because of the high proportion of  caregivers who were caring for veterans with PTSD who were not  clinically stable.
VAMCs have also tried various approaches for improving physicians’  willingness and ability to participate in the Family Caregiver Program.  For example, officials from the Caregiver Support Program office told  us that some VAMCs use a multidisciplinary team—instead of  individual physicians—to make determinations for eligibility and for the  level of financial stipend, enabling the workload to be shared by  multiple clinicians. Another VAMC hired a physician on a part-time  basis just to perform eligibility examinations for the program. One  VAMC with serious workload backlogs is examining the option of  using physicians who are already under contract for conducting  medical assessments for determining disability benefits, instead of  using VAMC treatment physicians. The VAMC director who is  exploring this option mentioned that this approach could also resolve  physicians’ concerns about compromising the physician/patient  relationship posed by determining eligibility for a program that  includes a financial stipend. However, Caregiver Support Program  officials stated that regardless of the approaches VAMCs may take to  conduct the medical assessments, the program’s regulation requires  that the physician making eligibility determinations for the Family  Caregiver Program be a member of the veteran’s treatment team.
To increase nurses’ willingness to provide assistance to the program,  some VAMCs offered their nurses overtime pay to conduct home  visits, and other VAMCs made temporary work-sharing arrangements  with nearby VAMCs for nursing coverage. Officials in the VISNs we  contacted told us that some VAMCs have used the funding they  received for additional CSC positions to hire nurses for the sole  purpose of conducting home visits for the program because of the  heavy workload. Some officials also told us that they consider the  home visit reimbursement amounts to be insufficient to cover their  expenses, such as for GPS units, other electronic devices, and time  needed for associated administrative activities. However, an official  with the Caregiver Support Program office stated that this should not  be necessary because the program’s reimbursement for home visits  covers salary expenses, travel costs, and time for administrative  activities.
Some VAMCs have also hired contractors to conduct home visits,  although contractors may not be available in some locations.
A Caregiver Support Program official stated that the budget for the Family  Caregiver Program has been adequate to meet operating costs as of  March 2014. Nonetheless, VHA officials at all levels told us that VAMC  directors were cautious about requesting additional CSCs or hiring  additional nurses for making home visits. These officials explained that  VAMC directors are concerned that when the Family Caregiver Program’s  initial 5-year budget authorization expires, the cost of the additional  nurses and CSCs could shift from the Caregiver Support Program office  to the VAMCs. VAMC directors stated that their caution is based on  experience, in that this shift has occurred in the past with other new VHA  programs that had initially received funding support from their program  offices. Caregiver Support Program officials acknowledged VAMC  officials’ concerns about the program’s funding and added that they are  aware of some VAMCs—even facilities with growing numbers of  approvals—that are cautious about requesting additional CSCs.  Nonetheless, a Caregiver Support Program official stated that VHA  continues to request funding for the Family Caregiver Program, including  a funding request for fiscal year 2015 that was submitted with the budget  request.
Notwithstanding incremental efforts to improve staffing levels for the  program at some VAMCs, CSCs and VAMC staff predict that staffing  shortages and the ensuing workload problems are likely to recur because  VHA’s current staffing of the program is not sufficient and overall  approvals continue to increase at a steady rate—about 500 approvals per  month. As a result, according to VAMC officials, some facilities have not  been able to overcome the workload problems that developed upon  program implementation. A Caregiver Support Program official stated that  program officials recognize the need to formally re-evaluate key aspects  of the Family Caregiver Program, including program staffing and the  processes for eligibility assessments and home visits, in light of the fact  that the program was designed to manage a much smaller caregiver  population. This is consistent with federal internal control standards,  which emphasize the need for effective and efficient operations, including  the use of agency resources such as human capital.
section_title: VHA’s Oversight of the Family Caregiver Program Is Impeded by IT System Limitations
paragraphs: The Caregiver Support Program office does not have ready access to the  workload data that would allow it to monitor the effect of the Family  Caregiver Program on VAMCs’ resources due to limitations with the  Caregiver Application Tracker—the IT system that was established for the  program. According to federal standards for internal control, agencies  should identify, capture, and distribute pertinent information in a form and  time frame that permits officials to perform their duties efficiently.However, the Caregiver Support Program office is not able to easily  retrieve data that would allow it to better assess workload trends at  individual VAMCs—such as the length of time applications are delayed or  the timeliness of home visits—even though these data are already  captured in the Caregiver Application Tracker. Consequently, Caregiver  Support Program officials only retrieve these data on an ad hoc, as- needed basis, which limits their ability to assess the scope and extent of  workload problems comprehensively at individual VAMCs and on a  system-wide basis.
A Caregiver Support Program official told us that the office becomes  aware of workload problems at some VAMCs through various informal  information channels, such as CSCs’ requests for application extensions  and communication with the CSCs and VISN CSC leads. relying on informal information channels does not provide the office with a  comprehensive picture of the program’s workload across all VAMCs, and  this puts it in a reactive position of addressing workload issues after  problems have already developed. Having a system that allows for easy  retrieval of data would better position the office to proactively identify both  existing and potential workload problems at VAMCs and work with their  CSCs to identify solutions before problems develop or worsen. It would  also facilitate access to data needed for pinpointing where certain  processes may be getting stalled. For example, a Caregiver Support  Program official told us that it would be helpful to be able to track the  status of the various phases of the application process to identify the  phases that are taking too long, which would help the office to better  determine how to improve the overall timeliness of application  adjudication.
According to this official, in these instances, they provide coaching and support to the  CSC and VISN CSC lead and may work with them on identifying solutions, which may  include the development of an action plan with the support of VAMC leadership. caregivers between VAMCs and other VHA entities, including the Health  Administration Center, which processes the caregiver stipend payments  and administers CHAMPVA. CSCs are responsible for entering  nonclinical data into the system, which includes information related to the  application process and the status of home visits. The Caregiver Support  Program office manages the system and uses its data to monitor certain  aspects of the program. Specifically, a program official explained that the  system can generate a few basic reports that have been preprogrammed,  including a weekly report with aggregate data on the status of  applications and stipend payments. The Caregiver Support Program  office uses these data to monitor the program as well as data from other  sources, including data on the number of approved caregivers who have  completed training and the number of telephone calls to the Caregiver  Support Line. However, data that are not contained in the  preprogrammed reports must be extracted from the system on an ad hoc  basis.
Caregiver Support Program officials told us that they take steps to  validate the data they obtain from the system because they have  observed some inconsistencies—particularly with ad hoc data—and as a  result, they have concerns about its reliability. These officials told us that  each time they extract ad hoc data from the system, they validate the  data through additional sources to ensure its accuracy. Caregiver Support  Program officials explained that they have already taken steps to verify  the sources of the data that are used for the system’s reports and do not  need to verify these data every time a report is generated. Nonetheless,  these officials noted that they will periodically compare the current weekly  data that is reported by the system with data from the prior week to  ensure that there are no drastic changes which would indicate a need for  additional verification.
Program officials explained that the system has no agility or flexibility to  perform additional tasks beyond its basic tracking functions, and  retrieving data from the system on an ad hoc basis often requires time- consuming manual procedures. These officials explained that the  system’s data files are organized by veteran, and all of the veterans who  apply for the program are captured in the system whether or not their  caregivers were approved. As a result, the system that was designed to  manage 5,000 records by the end of 2015 had over 30,000 records as of  May 2014. Officials said that the system’s limited capabilities became  more apparent as the number of records in the system increased, which  made retrieving data on an ad hoc basis more difficult and time  consuming. For example, according to program officials, in response to  our request for the number of VAMCs with applications over 45 days old,  they had to download all of their relevant data into a spreadsheet, review  the data for accuracy, make the necessary corrections, and then  manually count the number of applications over 45 days old. A Caregiver  Support Program official told us that it took three people about 8 to   10 hours in total to pull this information together.
Officials further explained that the Caregiver Application Tracker is a  stand-alone system that is not integrated with other VHA systems, and as  a result, it cannot perform sophisticated functions or searches that would  require pulling information from these other systems. Officials told us that  this hinders their ability to monitor certain aspects of the program and  results in time-consuming efforts to compile program-related data. For  example, the use of respite care—one of the benefits of the Family  Caregiver Program—is tracked by a different VHA system. To determine  how many veterans in the Family Caregiver Program are using respite  care, program officials told us that they must download their data into a  spreadsheet and then upload this information to the IT system for respite  care use in order to crosswalk the information. Furthermore, data on  Family Caregiver Program appeals are maintained in the Patient  Advocate Program’s tracking system, which is also managed by a  different VHA office. Caregiver Support Program officials told us that they  have to request appeals data from this office, and to date, there have  been a few requests for caregiver appeals data in response to  congressional inquiries. However, because the Patient Advocate  Program’s tracking system was not designed in a way that allows them to  easily retrieve information that is specific to the Family Caregiver  Program, the Caregiver Support Program office had received a report for  only one of the inquiries as of May 2014. A Caregiver Support Program  official told us that they are working with the Patient Advocate Program to  identify methods to obtain the appeals data they need, such as by  capturing whether an appeal is related to the Family Caregiver Program.
As a result of these system limitations, the Caregiver Support Program  office does not have the capability to routinely track and analyze the type  of workload data it needs to produce a meaningful assessment of the  program’s impact on VAMCs. According to federal standards for internal  control, agencies should conduct monitoring activities to assess the  quality of performance over time and should use the results to correct  identified deficiencies and make improvements. However, the lack of  ready access to comprehensive workload data impedes the program  office’s ability to proactively identify and correct workload problems as  they manifest or to identify and make modifications as necessary to  ensure that the program is appropriately structured to meet caregivers’  demand for its services. Consequently, a Caregiver Support Program  official told us that the program office has only been able to assess  workload problems and make interim adjustments, such as allowing  VAMCs to request additional CSC positions, based on informal feedback  and has not been able to conduct a formal re-assessment of the program  that is based on comprehensive program data.
A Caregiver Support Program official acknowledged that they recognize  the need for a more capable, flexible system that can interface with other  departmental systems. This official also told us that program office  officials are working with their information technology office to develop the  requirements for a comprehensive system and that they are exploring the  possibility of whether an existing VHA system could be adapted to meet  their needs. However, this official was not sure how long it would take to  obtain another IT system and whether this effort would be displaced by  higher priorities. As a result, it is not clear when program officials will have  access to comprehensive workload data for the Family Caregiver  Program to better assess how it is functioning. Although it will be difficult  to identify changes needed to improve the program’s efficiency and  effectiveness without these data, VAMCs’ workload problems will  persist—and caregivers will not get the services they need—unless the  program office begins taking steps towards identifying solutions.
section_title: Conclusions
paragraphs: Family caregivers play a crucial role in caring for seriously injured post- 9/11 veterans by taking on critically important and often stressful  responsibilities for their well-being and potentially keeping them out of  costly institutions. The Family Caregiver Program was intended to provide  supportive services to this caregiver population, but VHA significantly  underestimated program demand. The subsequent stress on resources at  some VAMCs resulted in delayed application decisions and home visits— ultimately limiting services to caregivers. Incremental steps to alleviate  staffing shortfalls have benefited the program in some locations, but these  efforts will not likely be sufficient in light of the steady growth of approved  caregivers in the program. After 3 years of operation, it is clear that VHA  needs to formally reassess and restructure key aspects of the Family  Caregiver Program, which was designed to meet the needs of a much  smaller population. This would include determining how best to ensure  that staffing levels are sufficient to manage the local workload as well as  determining whether the timelines and procedures for application  processing and home visits are reasonable given the number of approved  caregivers.
To accomplish this, the Caregiver Support Program office will need to  take a strategic, data-driven approach that would include an analysis of  the program’s workload data at both the aggregate and VAMC levels. It  will therefore be necessary for VHA’s Caregiver Support Program office to  obtain an IT system that will facilitate access to the types of data— including interfacing with other VHA systems, such as systems for clinical  patient records and respite care—that would allow it to more fully  understand the program’s workload and its effect on VAMCs, CSCs, and  caregivers. The current approach of relying on informal information  channels limits the program office’s ability to comprehend the scope and  magnitude of workload problems system-wide and leaves it in a reactive  position of adding staff to the program only after significant workload  problems have developed. A more capable IT system would enable the  Caregiver Support Program to comprehensively monitor the program and  proactively identify both actual and potential VAMC workload problems  and target areas where improvements could be made. However, without  a clear time frame for obtaining another IT system, workload issues will  persist unless the Caregiver Support Program office starts to identify  solutions to help alleviate VAMCs’ workload burdens, such as  modifications to the timelines and procedures for application processing  and home visits, and the identification of additional ways to provide  staffing support. If the program’s workload problems are not addressed,  the quality and scope of caregiver services, and ultimately the services  that veterans receive, will continue to be compromised.
section_title: Recommendations for Executive Action
paragraphs: To ensure that the Family Caregiver Program is able to meet caregivers’  demand for its services, we recommend that the Secretary of the  Department of Veterans Affairs expedite the process for identifying and  implementing an IT system that fully supports the program and will enable  VHA program officials to comprehensively monitor the program’s  workload, including data on the status of applications, appeals, home  visits, and the use of other support services, such as respite care.
We also recommend that the Secretary of the Department of Veterans  Affairs direct the Undersecretary for Health to  identify solutions in advance of obtaining a replacement IT system to  help alleviate VAMCs’ workload burden, such as modifications to the  program’s procedures and timelines, including those for application  processing and home visits, as well as the identification of additional  ways to provide staffing support, and use data from the IT system, once implemented, as well as other  relevant data to formally reassess how key aspects of the program  are structured and to identify and implement modifications as needed  to ensure that the program is functioning as envisioned so that  caregivers can receive the services they need in a timely manner.
section_title: Agency Comments and Our Evaluation
paragraphs: We provided a draft of this report to VA for review and comment. While  the draft was at VA for comment, officials from VHA’s Management  Review Service expressed concerns with two of the three  recommendations in the draft report.
Officials expressed concern that our recommendation to expedite the  process for identifying and implementing an IT system for the Family  Caregiver Program was directed to the Undersecretary for Health.  They explained that obtaining a new IT system would require the  involvement of multiple offices within VA, including central offices that  are under the Secretary of VA. Based on this information, we revised  our recommendation and have redirected it to the Secretary to ensure  that it is inclusive of all necessary offices within the department.
Officials also commented on our recommendation about using data  from the new IT system to formally reassess key aspects of the  program and make modifications as needed. They suggested  broadening the recommendation to include data from other sources,  such as any data they may obtain through the solutions they  implement in advance of obtaining a new IT system. In consideration  of this information and the fact that we refer to relevant data from  other IT systems in our report, we modified our recommendation to  state that the Undersecretary for Health should use data from the IT  system, once implemented, as well as other relevant data to formally  reassess how key aspects of the program are structured.
As a result of these revisions, VA concurred with all three of our  recommendations in its letter, which is reprinted in appendix II. VA also  provided technical comments, which we incorporated as appropriate. In  concurring with our third recommendation to use data from the IT system  as well as other relevant data to reassess the program, VA did not  mention using data from the new IT system as part of its evaluation. As a  result, we are concerned that VA’s proposed actions only partially  address this recommendation. Specifically, VA’s response focused on  using relevant information from solutions developed in response to our  second recommendation as well as other relevant data to formally  reassess key aspects of the program. A VHA official explained that no  one knows how long it will take to develop the new IT system, or how long  it will be before data from the system are available, and as a result, VHA  developed their response based on actions they knew they could  accomplish. However, the substance of our recommendation is focused  on using comprehensive workload data from the new IT system as the  foundation of a data-driven program analysis. Without such data, VHA will  not be positioned to make sound, well-informed decisions about the  program, potentially allowing it to continue to struggle to meet the needs  of the caregivers of seriously wounded and injured veterans.
We are sending copies of this report to the Secretary of Veterans Affairs,  appropriate congressional committees, and other interested parties. In  addition, the report is available at no charge on the GAO website at  http://www.gao.gov.
If you or your staff have any questions about this report, please contact  me at (202) 512-7114 or williamsonr@gao.gov. Contact points for our  Offices of Congressional Relations and Public Affairs may be found on  the last page of the report. GAO staff who made major contributions to  this report are listed in appendix III.
section_title: Appendix I: Veterans Affairs Medical Centers by CSC-to-Approved Caregiver Workload Ratio, as of May 2014
subsections: section_title: Veterans Integrated Service Networks (VISN) VAMCS with CSC-to-approved caregiver ratio of 25 or less 16
paragraphs: Veterans Affairs Medical Center  (VAMC)
section_title: 1 VAMCS with CSC-to-approved caregiver ratio of 26 to 50 9 Huntington VAMC
section_title: Veterans Integrated Service Networks (VISN) 4
paragraphs: Veterans Affairs Medical Center  (VAMC)
section_title: Veterans Integrated Service Networks (VISN) 6
paragraphs: Veterans Affairs Medical Center  (VAMC)
section_title: Veterans Integrated Service Networks (VISN) 9
paragraphs: Veterans Affairs Medical Center  (VAMC)
section_title: Veterans Integrated Service Networks (VISN) 11
paragraphs: Veterans Affairs Medical Center  (VAMC)
section_title: VAMCS with CSC-to-approved caregiver ratio of 101 to 150 9 Robley Rex VAMC (Ft. Knox)
section_title: VAMCS with CSC-to-approved caregiver ratio of 151 or more 8 Orlando VAMC
section_title: Veterans Integrated Service Networks (VISN) 7
paragraphs: Veterans Affairs Medical Center  (VAMC)
Total (140 VAMCs)
section_title: Appendix II: Comments from the Department of Veterans Affairs
section_title: Appendix III: GAO Contact and Staff Acknowledgments
subsections: section_title: GAO Contact
section_title: Staff Acknowledgments
paragraphs: In addition to the contact above, Bonnie Anderson, Assistant Director;  Frederick Caison; Christine Davis; Cathy Hamann; Jacquelyn Hamilton;  Giao N. Nguyen; and Chan-My J. Sondhelm made key contributions to  this report.