VA Health IT: Use of Acquisition Best Practices Can Improve Efforts to Implement a System to Support the Family Caregiver Program
Released: 2019-05-22T00:00:00

Letter

Background

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 that was 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.

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 traumatic brain injury (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: (1) an inability to perform one or more activities of daily living, such as bathing, dressing, or eating; (2) a need for supervision or protection based on symptoms or residuals of neurological or other impairment or injury such as TBI, post-traumatic stress disorder, or other mental health disorders; (3) 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 (4) the veteran has been rated 100 percent service connected disabled for a 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.

Family Caregiver Program Organizational Structure

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 coverage through the Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA) for eligible caregivers if they have no other coverage.

Further, the office provides funding to VAMCs to cover certain program costs. These costs may include the salaries of the caregiver support coordinators (CSC), who implement and administer the Family Caregiver Program at the local VAMC level, and 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 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 health care systems across the country. Additionally, each regional VISN office has a VISN CSC lead for the program, who provides guidance to CSCs and helps address their questions or concerns.

GAO Has Previously Reported on the Family Caregiver Program IT System Limitations

CAT, which was deployed in May 2011, is a web-based system that was designed to facilitate the exchange of information about approved caregivers between VAMCs and other VHA entities. Such entities include the Health Administration Center, which processes the caregiver stipend payments and administers CHAMPVA.

In 2014, we reported that the Caregiver Support Program office was not able to easily retrieve data from CAT that would allow officials 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 were already captured in the system. Caregiver Support Program officials only retrieved workload data on an ad hoc, as-needed basis, which limited their ability to assess the scope and extent of workload problems comprehensively at individual VAMCs and on a system-wide basis. Program officials also expressed concern about the reliability of the system’s data.

As we noted in our report, program officials also identified the need for a more capable and flexible system that could interface with other departmental systems. The officials told us that they had taken initial steps to obtain another IT system to support the Family Caregiver Program; however, the officials were not sure how long it would take to implement the system. Accordingly, we recommended that VA expedite the process for identifying and implementing a system that would fully support the Family Caregiver Program.

VA concurred with our recommendation and subsequently began taking actions in 2015 to implement a replacement system. These actions included taking steps toward implementing short-term improvements to CAT that were to be followed by the implementation of a long-term replacement system. The recommendation continues to remain open.

Statute Directs VA to Implement an IT System to Support the Family Caregiver Program

The John S. McCain III, Daniel K. Akaka, and Samuel R. Johnson VA Maintaining Internal Systems and Strengthening Integrated Outside Networks Act of 2018 (VA MISSION Act), which was enacted in June 2018, included provisions directing VA to implement an IT system to support the Family Caregiver Program and the incremental expansion of program eligibility. Specifically, the act required VA to implement an IT system to fully support the Family Caregiver Program by October 1, 2018. According to the act, the system is to allow for data assessment and comprehensive monitoring of the program. In particular, the system is to have, among other things, the ability to (1) retrieve data to monitor workload trends at the medical center and aggregate levels; (2) manage an increased number of caregivers as the program expands; and (3) integrate with other relevant IT systems at VHA.

The act also stated that VA was to submit an initial report to Congress regarding the status of the planning, development, and deployment of this system within 90 days of enactment of the VA MISSION Act, and that the department is to submit a final report to Congress by October 1, 2019. The final report is to include a certification by the VA Secretary that the system has been implemented, along with a description of how the Secretary is using the system to monitor the workload of the program.

VA Has Not Yet Implemented an IT System That Effectively Supports the Family Caregiver Program

Although we previously recommended that VA expedite implementation of a replacement for CAT, and the MISSION Act directed the department to implement an IT system to support the Family Caregiver Program, VA has not yet been successful in its multiple efforts to implement such a system. Specifically, VA has faced a number of difficulties in developing and implementing short-term improvements as well as a long-term replacement system for CAT.

In July 2015, VHA and the Office of Information and Technology (OIT) initiated a joint acquisition project, called CAT Rescue, to update CAT and improve the system’s data reliability. However, the department reported in January 2017 that this project had experienced delays and identified a large number of defects during system testing. VA terminated the project in April 2018 before any new system capabilities were implemented.

A companion project to CAT Rescue that VA initiated in September 2015 was to develop the Caregivers Tool (CareT), a new system intended to be a long-term replacement for CAT. As envisioned, this system was to use the improved data from CAT Rescue while also adding new system capabilities. However, the user acceptance testing of CareT identified the need for the department to develop more system capabilities than originally planned. Further, the department determined that the time period needed to perform additional system development would have extended beyond the term of the development contract, which ended in April 2017.

VA subsequently awarded a new CareT development contract in July 2017. However, after additional system development, the department determined during user acceptance testing that the system was not performing as expected and implementation of CareT was further delayed. In October 2018, the department reported to congressional committees that implementing a system to fully support the Family Caregiver Program by the VA MISSION Act deadline was not feasible. Subsequently, the department determined that CareT was not a viable solution and VHA and OIT terminated work on the system in February 2019.

VHA and OIT began a third effort in March 2019 to acquire a replacement system that is to be based on an existing commercial product. According to OIT officials, the new IT solution, referred to as the Caregiver Record Management Application (CARMA), is intended to replace CAT. However, the department has not yet established a date for completing CARMA.

Thus, VA’s efforts to implement an IT system that supports the Family Caregiver Program have been continuing with no end in sight. We have ongoing work to further evaluate the status and progress of the department’s efforts to implement a system to support the Family Caregiver Program consistent with the VA MISSION Act requirements. Figure 1 provides a timeline of the various IT projects that VA has undertaken to support the program.

Critical Factors Underlying Successful IT Acquisitions

Our prior work has determined that successfully overcoming IT acquisition challenges can best be achieved when critical success factors are applied. Specifically, we reported in 2011 on common factors critical to the success of IT acquisitions, based on seven agencies having each identified the acquisition that best achieved the agency’s respective cost, schedule, scope, and performance goals. These factors remain relevant today and can serve as a model of best practices that agencies can apply to enhance the likelihood that the acquisition of an IT system such as CARMA will be successfully achieved.

Among the agencies’ seven IT investments, agency officials identified nine factors as having been critical to the success of three or more of the seven investments. These nine critical success factors are consistent with leading industry practices for IT acquisition. The factors are:

Active engagement of program officials with stakeholders.

Qualified and experienced program staff.

Support of senior department and agency executives.

Involvement of end users and stakeholders in the development of requirements.

Participation of end users in testing system functionality prior to formal end user acceptance testing.

Consistency and stability of government and contractor staff.

Prioritization of requirements by program staff.

Regular communication maintained between program officials and the prime contractor.

Sufficient funding.

Officials for all seven selected investments cited active engagement with program stakeholders—individuals or groups (including, in some cases, end users) with an interest in the success of the acquisition—as a critical factor to the success of those investments. Agency officials stated that stakeholders, among other things, reviewed contractor proposals during the procurement process, regularly attended program management office sponsored meetings, were working members of integrated project teams, and were notified of problems and concerns as soon as possible. Further, officials from two investments noted that actively engaging with stakeholders created transparency and trust, and increased the support from the stakeholders.

Additionally, officials for six of the seven selected investments indicated that the knowledge and skills of the program staff were critical to the success of the program. This included knowledge of acquisitions and procurement processes, monitoring of contracts, large-scale organizational transformation, Agile software development concepts, and areas of program management such as earned value management and technical monitoring.

Finally, officials for five of the seven selected investments identified having the end users test and validate the system components prior to formal end user acceptance testing for deployment as critical to the success of their program. Similar to this factor, leading guidance recommends testing selected products and product components throughout the program life cycle. Testing of functionality by end users prior to acceptance demonstrates, earlier rather than later in the program life cycle, that the functionality will fulfill its intended use. If problems are found during this testing, programs are typically positioned to make changes that would be less costly and disruptive than ones made later in the life cycle.

In conclusion, VA has invested considerable time in multiple efforts toward improving and replacing its IT system to better serve the Family Caregiver Program. However, even with these efforts, the department has not yet implemented a system and the program is not prepared for expansion. Going forward, it is important that VA take steps to improve its efforts to implement a replacement IT system for the Family Caregiver Program. In this regard, the department could benefit from applying critical success factors we previously reported as leading to successful federal IT acquisitions. These factors can serve as a model of best practices that the department can apply to enhance the likelihood that its effort to replace the IT system for the Family Caregiver Program will be successful.

Chairs Lee and Brownley, Ranking Members Banks and Dunn, and Members of the Subcommittees, this completes my prepared statement. I would be pleased to respond to any questions that you may have.

GAO Contact and Staff Acknowledgments

If you or your staffs have any questions about this testimony, please contact Carol C. Harris, Director, Information Technology Management Issues, at (202) 512-4456 or harriscc@gao.gov. Contact points for our Offices of Congressional Relations and Public Affairs may be found on the last page of this testimony statement. GAO staff who made key contributions to this testimony are Mark Bird (Assistant Director), Rebecca Eyler, Jacqueline Mai, Monica Perez-Nelson, Scott Pettis, and Jennifer Stavros-Turner (Analyst in Charge).

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