Various disabilities prevent many veterans from independently performing everyday living activities (see fig. 1). VA offers enhanced monthly benefits that help such individuals obtain needed services. These services can be provided at home, in an assisted living facility, or a nursing home and can be provided by private providers, family and friends, and VHA. VA is required to ensure that potential recipients are informed about available benefits and to the maximum extent possible are offered assistance applying for them. VBA administers enhanced monthly benefits as well as other monetary and nonmonetary benefits, and conducts outreach through its 57 regional offices and Benefits Assistance Service and other VA offices. Veterans may be eligible for A&A benefits if they establish a factual need for A&A, when considering many factors, including an ability to perform everyday personal functions such as bathing, dressing, eating, adjusting prosthetic devices, and protecting themselves from hazards or dangers in their daily environment; are a patient in a nursing home; are bedridden; or are blind or nearly blind. Veterans may be eligible for Housebound benefits if they have a disability rated at 100 percent and, as a result, are permanently or substantially confined to their homes, or a disability rated at 100 percent, and at least one other disability rated at 60 percent or more—although these individuals are legally classified as Housebound, they may be able to leave their homes. A&A and Housebound benefits both offer assistance that helps veterans function more independently, but A&A benefits are only for those who are in need of regular aid and attendance of another person, whereas Housebound benefits are for those who may be substantially confined to their homes. In addition to individual requirements specific to A&A and Housebound benefits, individuals have to meet the eligibility requirements for basic disability compensation or pension benefits. When A&A or Housebound benefits are received as part of disability compensation benefits, the combined payment is called enhanced disability compensation. To qualify for disability compensation benefits, veterans must have disabling injuries or illnesses that occurred or were made worse by their active military service. Such veterans must also have received a discharge or release under conditions other than dishonorable. Per VA’s policy manual, VA is supposed to automatically consider the need for the A&A or Housebound benefit when awarding veterans a disability rating of 100 percent and may grant the benefit when there is sufficient medical evidence to support the individual’s need for aid and attendance. The total monthly enhanced disability compensation benefit amount for A&A varies based on the veteran’s level of disability and family composition, whereas the amount of the Housebound benefit varies based only on the veteran’s family composition. For example, depending upon a veteran’s level of disability, the total monthly enhanced disability compensation payment for a single veteran receiving A&A benefits can range from approximately $3,300 to approximately $7,700 while the monthly payment for a veteran with a spouse and one child can range from approximately $3,600 to approximately $7,900. In contrast, the total monthly payment with Housebound benefits is approximately $3,000 for a single veteran and approximately $3,300 for a veteran with a spouse and child. For veterans receiving either A&A or Housebound benefits, the monthly amount is increased by $136 if the spouse requires A&A, by $75 for each child in excess of one, and by $240 for each school child over the age of 18. When veterans receive A&A or Housebound benefits as part of a VA pension, the combined payment is called an enhanced pension. Veterans who served during a period of war and meet other service requirements may receive a VA pension if they are 65 or older, or at any age if they have disabilities unrelated to their military service that render them permanently and totally disabled, among other requirements. Because VA pension benefits are offered to help veterans or their surviving spouses of limited means, potential recipients must not exceed certain income and asset thresholds. Table 1 shows the differences in the maximum annual pension benefit limits for 2010 based on family composition for a VA pension recipient without enhanced benefits, with the A&A benefit, and with the Housebound benefit. Veterans may have other sources of income, such as Social Security disability and retirement benefits, Medicaid, and private insurance, some of which may be counted in determining whether a veteran meets income eligibility requirements for a pension. For example, Social Security retirement benefits are counted as part of a veteran’s income, whereas public assistance benefits such as Social Security’s Supplemental Security Income is not. In addition to income, VA considers the net worth of individuals, excluding the value of the person’s home and vehicle. The standard that VA uses to determine eligibility for these benefits is whether the individuals’ resources are sufficient to meet their basic needs without assistance from VA. While there is no specified limit on the amount of resources individuals may have, if they have assets of $80,000 or more, per VA’s policy manual, VA is supposed to conduct an assessment to determine if their assets are sufficient to meet their basic needs. Assets counted toward the “sufficient means” figure of $80,000 include bank accounts, certificates of deposit, money market accounts, investment accounts, annuities, retirement accounts, and life insurance cash surrender values. To assess ongoing eligibility and benefit levels, VA requires pensioners who have income other than Social Security to file an annual income report. In addition to enhanced monthly benefits, VA provides other benefits to help veterans perform daily living activities. For example, VBA provides benefits to help veterans purchase or convert an automobile to accommodate their disability. VHA offers other services, including the Home-Based Primary Care program, adult medical foster care, and adult day health care. VA data at the end of fiscal year 2010 showed that for the overall enhanced monthly benefit population (including veterans and survivors), most recipients were veterans, over age 65, receiving the benefit as part of their monthly pension benefit, and receiving the A&A supplement, but the composition and characteristics of the recipient population is changing (see fig. 2). According to VA’s data, more than 271,000 veterans and survivors received enhanced monthly benefits at the end of fiscal year 2010—a 52 percent increase since the end of fiscal year 2000. While veterans over age 65 comprised the majority of the overall enhanced monthly benefit population from fiscal years 2000 to 2010, there was an increased share of survivors, recipients age 65 or younger, those receiving the benefits under the disability compensation program, and those receiving the Housebound benefit enhancement. These changes were primarily driven by veterans age 65 or younger receiving these benefits—particularly those ages 46 to 65—-as well as younger veterans receiving enhanced compensation benefits that included the Housebound enhancement. Changes in the characteristics of the overall population of veterans and survivors who received enhanced monthly benefits were also mirrored in the population of veteran recipients. For example, the data showed that younger veterans are an increasing share of the veteran enhanced monthly benefit population. Although veterans over age 65 continued to comprise the majority of enhanced monthly benefit recipients at the end of fiscal year 2010, their share of the veteran enhanced monthly benefit population has decreased steadily. Specifically, at the end of fiscal year 2010, veterans over age 65 who received enhanced monthly benefits accounted for a 64 percent share of all veterans receiving these benefits compared with a 76 percent share in fiscal year 2000. Meanwhile the share of veteran enhanced monthly benefit recipients age 65 or younger increased from 24 percent to 36 percent over this time period (see fig. 3). While this increase was primarily driven by veterans ages 46 to 65, there was also a substantial increase in the percentage of veterans ages 18 to 45. Also for veterans who received enhanced monthly benefits, VA data showed that most received enhanced pension benefits that included the A&A benefit. This was particularly true for veteran recipients over age 65, although their share of these benefits declined from 62 percent in fiscal year 2000 to 50 percent in fiscal year 2010. For veterans age 65 and under receiving enhanced pension benefits with the A&A benefit, their share remained about the same—14 percent in fiscal year 2000 compared with 13 percent in fiscal year 2010 (see fig. 4). By the end of fiscal year 2010, the percentage of veteran recipients age 65 or younger who received enhanced disability compensation benefits that included the Housebound benefit almost tripled from 6 percent in fiscal year 2000 to 17 percent in fiscal year 2010. VA’s data also showed that most veterans receiving enhanced monthly benefits served during earlier war periods, but the number of recipients from more recent war periods is growing. The majority of recipients served during World War II, the Korean Conflict, and the Vietnam War (see fig. 5). Although Persian Gulf War (Gulf War) veterans comprised a relatively small proportion of veteran recipients, their numbers increased at a greater rate during fiscal years 2000 to 2010 (from less than 1,300 to nearly 11,000—more than a sevenfold increase) than veterans from any other period of service. Appendix II provides more information on the periods of service that qualify veterans for enhanced monthly pension benefits. In addition to analyzing the overall characteristics of veterans who received enhanced monthly benefits, we specifically analyzed the disabling conditions of Gulf War veterans. Consistently, the most common categories of disabling conditions during that time period were skeletal conditions, neurological conditions and convulsive disorders, and mental and eating disorders. However, there were significant changes among other disabling conditions and categories of disabling conditions. For example, ear conditions increased from ninth most common in 2000 to fourth most common in fiscal year 2010, while cardiovascular conditions went from sixth most common in fiscal year 2000 to eighth most common in fiscal year 2010. In addition, the proportion of Gulf War veteran enhanced monthly benefit recipients reporting diagnoses of Post Traumatic Stress Disorder grew dramatically from 8 percent at the end of fiscal year 2000 to 28 percent at the end of fiscal year 2010. Additionally, 7 percent of veteran enhanced monthly benefit recipients from the Gulf War reported diagnoses of traumatic brain injuries at the end of fiscal year 2010. Similar to the veteran population who received enhanced monthly benefits, the characteristics of survivors who received these benefits have also changed between the end of fiscal years 2000 and 2010. Over this period, most survivor recipients of enhanced monthly benefits were over age 65, and there was a slight decrease—from 6 percent to 3 percent—in the share of survivors age 65 or younger. Survivors primarily received enhanced pension benefits, and the share of such recipients increased from 77 percent in fiscal year 2000 to 84 percent in fiscal year 2010. Also, the percentage of survivor recipients of enhanced monthly benefits that included A&A benefits increased from 91 percent to 96 percent from fiscal years 2000 to 2010. Figure 6 shows the characteristics of survivor recipients at the end of each fiscal year from 2000 to 2010. For fiscal years 2000 to 2010, the total VA paid for enhanced benefits increased from approximately $124 million to $409 million; however, VA does not know the portion of enhanced benefit costs paid specifically for A&A and Housebound benefits. VA stated that it does not separately compile and monitor costs specifically attributable to A&A and Housebound benefits because they are not “stand-alone” benefits. The agency also stated that it would be complicated and difficult to track these costs separately in the agency’s current system and that it would take a considerable amount of resources to determine the costs and benefits of tracking this type of data. Veterans and family members who participated in our focus groups and one-on-one interviews said that enhanced monthly benefits help them obtain needed assistance in different ways. For example, these benefits helped them pay for in-home services by private providers, offset lost income of family members who provide care, or defray the costs of an assisted living facility. One veteran told us that enhanced monthly benefits help him afford the home-based care that enables him and his wife to remain in their home. Another veteran told us that these benefits help replace some of the family income that was lost when his wife retired early from her job to care for him, rather than having him stay in a nursing home. Among the veterans we contacted, the activities they most frequently reported needing help with were bathing, dressing, and toileting (see fig. 7). In addition, 12 of the veterans we contacted said that enhanced monthly benefits also help them obtain other services, including transportation, doing laundry, preparing meals, and managing medications. The veterans we spoke with also used their enhanced monthly benefits to obtain services from one or more of three sources—private providers, family members or friends, and VHA. They obtained services from each of these sources with similar frequency (see fig. 8). About half of the veterans we spoke with (16 of 33) obtained home-based services from VHA. VHA offers various home-care services, including its Home-Based Primary Care Program, adult day health care, and adult medical foster care. The Home-Based Primary Care Program provides services such as rehabilitation and coordination of care to veterans who need assistance with daily living activities, among other health-care needs. One veteran we contacted said that the Home-Based Primary Care Program provided all needed services to help him meet his in-home health care needs. However, as we have noted in prior work, these services were not available in certain areas—especially rural locations, where approximately 40 percent of the veteran population enrolled in the VA health care system lives, according to VA. These gaps could make it difficult for some veterans to access VHA home-based care. VHA officials said that as of July 2010, there were still a limited number of home-based care service providers to contract with in some rural areas. However, according to VHA officials, one step the agency has taken to address this problem is to collaborate with local area agencies on aging to help arrange for needed services. Also, VA is planning to expand its Home- Based Primary Care Program, which currently operates in 15 VA medical centers. Some veterans may need to purchase services from private providers to assist them in performing daily living activities, which could make it difficult for veterans living in higher-cost regions of the country to obtain services. Private providers may offer a variety of services, such as housekeeping provided by home care aides and administration of oral medication by home health aides. The cost of these services varies among and within states. Nationally, our analysis of MetLife and Genworth data showed that the hourly cost for obtaining services from home care aides ranges from $9 to $38, and the national median hourly Generally, service costs are lowest in Southern states. cost is $18.25. The median hourly cost of obtaining services from home health aides was less than the national median for all but one Southern state. Figure 9 shows regional and state differences in service costs. The cost of care also varies within states. For example, the median hourly cost of obtaining services from a home care aide in California ranges from $18.86 in Los Angeles to $24.38 in San Francisco, or about a 29 percent cost difference. Also, services are less available in some rural areas, which can limit recipients’ ability to obtain them. In addition, according to a study by the National Association for Home Care and Hospice, providers nationwide are finding it difficult to hire and retain a sufficient number of home health aides and home care aides to provide assistance to individuals needing them. Family members and friends are also called upon to help veterans perform daily activities but can face difficulties in doing so. About half of the veterans we contacted (17 of 33) relied on family members or friends to help them, and in some cases these individuals were their sole source of care. For example, the spouse of one veteran said that she had to attend to him 24 hours a day—including bathing and dressing him, and taking him to dialysis treatment—which prevented her from getting a job. An August 2009 study of veterans who received assistance from family caregivers found that persons with disabilities who had more restrictions in performing daily living activities and more health care needs were less likely than people with fewer restrictions to obtain home-based care, placing additional stress on their caregivers. According to a November 2010 study, some of the major difficulties family members and others face in providing caregiver support for veterans include a lack of knowledge about the veterans’ medical condition as well as a lack of skills to help caregivers perform various activities. Some of the caregivers we contacted said they were unable to provide all of the assistance needed to perform everyday living activities. For example, one veteran relied on his spouse for assistance, but she was not always able to perform certain tasks. The veteran relies on a device to lift him, but when he falls, he told us that his spouse has to call the fire department to lift him. Last year, Congress passed the Caregivers and Veterans Omnibus Health Services Act of 2010 in part to provide assistance to family caregivers of veterans. The legislation directs VA to provide specified benefits and services to the caregivers of certain Post 9/11 veterans who have serious service-connected injuries and are in need of personal care services. As required by the new legislation, VA developed an implementation plan to guide its provision of benefits and services to caregivers of eligible veterans. Additionally, VA has begun to offer additional caregiver services to the families of seriously injured Post 9/11 veterans, such as monthly stipends, training, medical-related travel cost reimbursements, and respite care. The legislation also requires VA to report to Congress on the feasibility of expanding the family caregiver benefits to veterans whose injuries were incurred before 9/11. VA’s data for fiscal years 2000 to 2010 indicate that elderly veterans and their surviving family members are the primary recipients of enhanced monthly benefits, although many other potentially eligible elderly veterans likely are unaware of these benefits. VA has previously acknowledged that enhanced pensions, whose primary recipients are elderly veterans, are underused and that not all potential recipients are aware of these benefits. Also, a 2004 VA study found that while 62 percent of pension recipients might be eligible for these benefits, only about 22 percent received them.925,000 veterans and between 940,000 and 1.38 million surviving family members would be eligible for, but would not be receiving, VA pension benefits. A portion of these veterans and surviving family members were expected to also qualify for enhanced monthly benefits. The study found, however, that the lack of awareness about the VA pension is the primary reason eligible veterans and their surviving family members may not be applying for enhanced monthly benefits. Some VA officials and Veterans Service Organizations (VSO) representatives we spoke with also said that This study estimated that, in 2010, between 565,000 and many elderly veterans are unaware of VA benefits for which they may be eligible, including enhanced monthly benefits. According to one VA official, this lack of awareness exists because many elderly veterans were never informed about VA benefits after they left the service. If elderly veterans do not learn about enhanced monthly benefits from VA or other reliable sources such as VSOs, there is a risk they will be misinformed or become victims of predatory financial practices. According to some VA officials, as well as representatives from an elderly advocacy organization, VSOs, state and local government officials, and elder law attorneys we spoke with, some elderly veterans learn about enhanced monthly benefits from financial planners and attorneys who may charge for services that VA and VSOs provide for free. These officials said that some attorneys and financial planners may convince elderly veterans, who ordinarily would be ineligible for a VA pension because of excess assets, to reduce these assets by transferring them into annuities or irrevocable trusts. We also observed websites where organizations market asset transfer services to help elderly veterans qualify for VA pension and enhanced monthly benefits. Representatives from an elderly advocacy organization noted that financial planners may be charging significant fees for each senior citizen they assist in transferring assets to qualify for a VA pension. Once established, these investments could severely limit veterans’ access to their assets or prevent them from obtaining Medicaid benefits in the future. For example, one elder law attorney told us that some elderly veterans may need nursing home care, but transferring assets to qualify for VA pension benefits may cause them to be ineligible for Medicaid benefits that would pay for this care. VA provides outreach to both the general veteran population and to specific veteran population groups identified as warranting additional attention, such as seriously disabled (Post 9/11), homeless, and elderly veterans. VA’s general outreach activities tend to focus on benefits such as health care, disability compensation, education, and home loans. However, certain benefits like enhanced monthly benefits are more likely to be highlighted during outreach activities for specific veteran population groups based on their potential eligibility. For example, VA officials told us that there is an increased emphasis on enhanced monthly benefits during outreach to seriously disabled Post 9/11 veterans, as well as elderly veterans, who comprise major segments of the eligible population for these benefits. VA provides personalized outreach to seriously injured Post 9/11 veterans, which gives them several opportunities to learn about enhanced monthly benefits. For example, VA assigns staff to military treatment facilities to provide these veterans with tailored benefits information and to initiate the claims process. Also, these veterans are assigned a case manager and have access to VHA social workers who may inform them about enhanced monthly benefits and help them apply for these benefits. In addition, for the disability compensation program, VA requests information on disabling conditions of all applicants. Under VA’s policy manual, the agency is to use this information to consider eligibility for enhanced monthly benefits for veterans with a disability rating of 100 percent, and, seriously injured Post-9/11 veterans may qualify for these benefits as part of their disability compensation. VA’s outreach to elderly veterans provides them with fewer opportunities to learn about enhanced monthly benefits. VA conducts outreach activities in locations where the elderly reside or congregate, such as assisted living facilities and senior centers, and at events sponsored by or in collaboration with organizations that serve the elderly. However, some elderly veterans who may qualify for enhanced monthly benefits may have disabilities that prevent them from attending such events or do not interact with the organizations that VA collaborates with. According to VA officials, the agency does not have outreach designed to specifically target elderly veterans who may be confined to their home. In contrast to the compensation program, for pension applicants age 65 and older, VA only requests information on disabling conditions of those applicants who indicate they are housebound or in need of regular assistance of another person to consider eligibility for enhanced monthly benefits. Therefore, VA would not have information needed to consider eligibility for enhanced monthly benefits for all pension applicants. VA has collaborated on elderly outreach with national organizations that serve the elderly. For example, at the national level, VA has partnered with the Assisted Living Federation of America to develop informational material on enhanced monthly benefits and has staffed benefits booths during conferences held by this and other organizations that serve the elderly. Agency officials told us that such efforts may increase in the future as VBA identifies more organizations to partner with for outreach initiatives. VBA has also participated in an advisory group of the Center for Benefits Outreach and Enrollment to identify best practices for elderly outreach. VA also provides informational material on its benefits, but the content may not provide enough details about eligibility and application requirements for enhanced monthly benefits. For example, VA’s 2011 benefits handbook informs readers that enhanced monthly benefits are available, although it does not elaborate on the specific limitations with everyday living activities or transportation that a veteran must have in order to be eligible for these benefits. VA benefits pamphlets, a handout on pension benefits, as well as presentations used during outreach activities that we assessed also lacked such information. Additionally, enhanced monthly benefits are mentioned in the attachments VA includes with award letters sent to veterans when they are granted pension benefits. However, they do not discuss eligibility requirements. Also, the eligibility verification form that some pension recipients annually complete does not include information about enhanced monthly benefits, although some pension recipients may qualify for these benefits, but are not receiving them. In addition to printed material, VA provides online information about enhanced monthly benefits, but this information may be difficult to find. For example, the home page on VA’s website does not provide direct links to access information on these benefits, which could make it difficult for users to locate information about them. The home page does contain a link for the pension program that provides information on eligibility and application requirements for A&A and Housebound benefits; however, because it is not apparent that this link would provide such information, users may not be inclined to follow it. Also, VA and the Department of Defense recently developed the eBenefits web portal to provide veterans with customized information on, and how to apply for, VA benefits and assistance, but it does not include a direct link to information on enhanced monthly benefits. A few of our focus group participants commented that they had difficulty finding information about enhanced monthly benefits on VA’s website. Website guidelines recommend that navigation procedures to access online information be simple and that links be properly labeled to help users obtain desired results. Finally, VA provides information on enhanced monthly benefits through its nine call centers, including a call center that exclusively responds to inquiries related to the VA pension. These centers handle inquiries from the 800 number that VA directs veterans to call for information about benefits. In response to a VA Office of Inspector General study that found that veterans had difficulty getting through to call agents and obtaining correct information, VBA implemented a new call routing system in March 2011 to improve callers’ access to call agents, and is working to develop national performance standards for call agents to improve the quality of services provided. Most outreach activities for VA’s benefits are conducted at the VBA regional office level, and VBA provides broad guidance on conducting outreach to its regional offices. In its procedures manual, VA requires each VBA regional office to designate an elderly outreach coordinator and provides suggestions on collaborating with agencies or organizations that serve the elderly. However, besides these suggestions, this manual does not define the specific duties of the coordinator or identify other types of elderly outreach activities that should be conducted. We contacted 10 of VBA’s 57 regional offices and of these 10 offices, only 4 collaborated with local agencies that serve the elderly, despite suggestions in the manual to do so. Also, the extent to which VBA regional offices coordinated and collaborated on outreach with local VHA facilities varied among the 10 regional offices we contacted. For example, while staff in all of these offices said that they coordinate with VHA, only six indicated that they provide training to social workers and other VHA employees to enable them to provide information on available VBA benefits to potential recipients. Staff in all of the regional offices we contacted told us they collaborate with VSOs on outreach, but the extent and nature of this collaboration differed. The collaboration included such things as training VSO staff on available benefits and working with VSO staff to conduct outreach in remote areas or to provide application assistance to veterans who are physically unable to visit the regional office. Some offices may have worked with VSOs in one or a combination of these ways. Similarly, the extent to which regional offices identified locations to conduct elderly outreach also varied among the 10 regional offices we contacted. Staff in 5 offices told us they proactively identify locations to disseminate information on VA benefits as well as identify potential recipients. During these elderly outreach activities, regional office staff may have one-on-one conversations with attendees and provide information on enhanced monthly benefits to those who indicate they need assistance to perform everyday living activities. However, staff in the other five offices said that they did not conduct elderly outreach activities at all, or only did so in response to invitations from other organizations. Agencywide, the amount of time VBA regional offices spent conducting elderly outreach activities varied considerably. VA’s fiscal year 2010 data show that the total number of hours regional offices reported spending on elderly outreach ranged from 0 to over 100. For example, 2 regional offices reported spending over 100 hours, 12 reported less than 10 hours, and 9 offices either reported they did not conduct any elderly outreach or did not report this information. There may be several reasons for this wide variance. Although staff in most regional offices we contacted said that limited staff, funding, and other resources minimize their capacity to conduct outreach, some offices had staff with full-time responsibilities for outreach, including elderly outreach. In contrast, other offices conducted outreach as part of ancillary duties or on a voluntary basis. VA is currently prioritizing outreach to the homeless as well as Post 9/11 veterans and staff in some offices we contacted told us they focus their outreach on those veteran groups rather than the elderly. Also, VA has acknowledged that the number of elderly veterans is increasing but has yet to establish detailed plans or performance goals for its elderly outreach efforts. For example, VA’s strategic plan for fiscal years 2011 to 2015 includes outreach initiatives for different veteran population groups but none that specifically target elderly veterans. In addition, for elderly outreach, VA is currently using the total number of hours devoted annually to these types of activities as a performance indicator, but this does not provide the information needed to assess the outcomes and effectiveness of the agency’s efforts. VBA officials told us the agency is in the process of identifying appropriate performance goals and measures for all of its outreach efforts. VA’s broad guidance posed some challenges for regional offices in conducting elderly outreach, and VA has begun to take steps to address this issue. For example, staff in one office said they conducted minimal elderly outreach, in part, due to a lack of guidance from VA’s central office, while staff in another office told us that more specific guidelines on conducting elderly outreach are needed. Recently, VA has taken some steps to enhance guidance to regional offices. For example, in May 2010, VA’s central office reinstituted bimonthly conference calls with regional elderly outreach coordinators to facilitate information sharing among participants. Also, VA’s central office requires regional offices to submit weekly reports on their outreach activities through a web-based reporting tool. The reports include information on the type of outreach activity conducted, the number of hours devoted to each targeted veteran population group, and the number of attendees at an outreach event. According to VBA officials, the reporting tool is currently being enhanced to enable VA’s central office to conduct a more in-depth analysis of the information reported, which may in turn allow for more tailored guidance to each regional office. Many of the staff at regional offices and the veterans we spoke with provided suggestions on how VA might increase awareness about enhanced monthly benefits. Staff at several VBA regional offices suggested VA increase awareness by using local or national media to disseminate information targeted to elderly veterans. Suggestions by veterans included mailing information on eligibility and application requirements to potential recipients. Some of the veterans we spoke with also said that VHA was their first source of information about enhanced monthly benefits and that VHA employees should play a primary role in providing this information. Enhanced monthly benefits can play a critical role in helping aging and disabled veterans obtain the services they need to perform everyday living activities and, in many cases, allow them to stay in their homes or other noninstitutional settings. Demand for these benefits will likely grow as life expectancy increases and more younger service members return home with injuries from global conflicts. Although enhanced monthly benefits have existed for decades, many within certain populations, such as elderly veterans, are unaware of them and are, therefore, forgoing valuable benefits. While VA conducts a number of outreach efforts and provides information to educate veterans and their families about available benefits, there are opportunities for VA to improve its efforts to ensure that potential recipients, particularly the elderly and those who are not connected to VA’s health care system, are aware of all benefits for which they may be eligible. Without specific performance goals and metrics to improve outreach to elderly veterans, more detailed guidance to better instruct regional offices on how to conduct elderly outreach, and improved information on application and eligibility requirements for enhanced monthly benefits that is easy to access, many elderly veterans and their family members may fail to receive assistance that could improve their quality of life. It will be important for VA to address these issues to ensure that veterans are aware of all available benefits for which they may qualify. Taking steps to better inform elderly veterans about enhanced monthly benefits will not only ensure that they receive benefits that could help them obtain needed services to perform daily living activities, but also ensure that younger veterans are aware of the benefits as they age and possibly develop a need to access these benefits. To enable VA to improve its efforts to educate veterans and their family members about enhanced monthly benefits, we recommend that the Secretary of VA direct the Undersecretary for Benefits to take steps to conduct more focused outreach to potential recipients, which could entail the following: Improving communication of and accessibility to information about enhanced monthly benefits. Such efforts could include (1) providing more information in the VA benefits handbook and other informational material on VA benefits, (2) increasing the visibility of links on VA’s website to information about these benefits, and (3) using local or national broadcast and print media to disseminate information about these benefits. Continuing efforts to establish specific performance goals and metrics for increasing outreach to elderly veterans. Providing more detailed guidance to regional offices on how elderly outreach should be conducted and on the specific duties of outreach coordinators. We provided a draft of this report to VA for review and comment. In its written comments (see app. III), VA concurred with our recommendation and provided information on a number of actions the agency planned to take or explore to address it. For example, VA stated that it would include more detailed language about enhanced monthly benefits in its 2012 Federal Benefits for Veterans, Dependents and Survivors handbook as well as post information about these benefits on VA’s website, the joint VA/Department of Defense eBenefits portal, and VA social media directories such as Facebook and Twitter. VA also stated that it would explore the feasibility of targeted direct mailings to veteran and survivor pension recipients to inform them of the eligibility requirements for enhanced benefits and the application process. As part of its efforts to establish specific performance goals and metrics, VA stated that it plans to analyze available data related to its current outreach efforts to clarify expectations and address measures and standards of outreach to elderly veterans and survivors. Additionally, VA stated that VBA would provide guidance to regional offices on how to conduct elderly outreach through such means as regular conference calls and national awareness training for outreach coordinators. As agreed with your office, unless you publicly announce the contents of this report earlier, we plan no further distribution until 30 days from the report date. At that time, we will send copies to relevant congressional committees, the Department of Veterans Affairs, and other interested parties. In addition, the report will be 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) 512-7215 or bertonid@gao.gov. Contact points for our Offices of Congressional Relations and Public Affairs may be found on the last page of this report. GAO staff who made key contributions to this report are listed in appendix IV. The objectives of our review were to determine (1) characteristics of enhanced monthly benefit recipients, (2) how enhanced monthly benefits help veterans obtain needed services, and the associated difficulties they face in obtaining these services, and (3) the Department of Veterans Affairs’ (VA) efforts in educating veterans and their family members about the availability of the benefits. For our first objective, we obtained and analyzed case-level demographic data about individuals who received enhanced monthly benefits at the end of each fiscal year from 2000 to 2010, or whose benefits had been terminated. The data included recipients’ age, disabling conditions, period of service, state of residence, type of benefit received, and where applicable, the reason for termination of benefits. We also obtained information on the total enhanced monthly benefit payment. These data were retrieved from VA’s Benefits Delivery Network and Veterans Services Network. Data obtained included any veterans and qualified surviving spouses or parents who received Aid & Attendance (A&A) or Housebound benefits as an enhancement to monthly compensation or pension benefits during this time period. Since these data are not publicly available, VA compiled data extracts for our use. We reviewed relevant federal laws and regulations. We also reviewed VA policies and other documents, and interviewed officials in the VA’s Veterans Benefits Administration (VBA) Compensation and Pension Services to identify requirements for receiving enhanced monthly benefits, and how benefit amounts are determined. In our analysis of information about periods of service, we excluded veterans who fought in World War I or during the Mexican Border Period because they comprised a very small number of cases at the end of fiscal year 2000 (a total of 123, or less than 0.11 percent of all veteran recipients) and none by the end of fiscal year 2010. Also, we removed duplicate entries in the diagnostic code fields in VA’s data. Our assessment of the reliability of VA’s data is discussed separately in this appendix. For our second objective, we reviewed studies and reports by GAO and others to obtain information on the services that recipients of enhanced monthly benefits may need to perform everyday living activities, the different sources of this help, and difficulties veterans may face in obtaining these services. We also interviewed two national and two local organizations that provide services and support to the elderly, individuals with disabilities, and their caregivers. In addition, we analyzed information on the cost of acquiring these services to show how costs can vary across all 50 states and the District of Columbia. We also examined provisions of the Caregivers and Veterans Omnibus Health Services Act of 2010 to determine how it would help caregivers. A more detailed discussion of our analysis of cost data is provided separately in this appendix. For our third objective, we reviewed relevant federal laws and regulations to identify VA’s outreach responsibilities. To evaluate outreach to potential recipients by VA’s central office, we interviewed officials from central office who were familiar with its efforts. We also identified VA’s past and present outreach activities, as well as its outreach plans. In addition, we reviewed the outreach guidance that VBA central office provides to VBA regional offices. To evaluate VBA regional office outreach efforts targeted to potential recipients, we contacted officials from 10 regional offices. These regional offices were judgmentally selected to represent the different characteristics of VA’s regional offices. In addition, we examined fiscal year 2010 data on regional office elderly outreach activities. We assessed VA’s print and online informational materials for clarity and the extent to which they provide complete information on eligibility and application requirements for enhanced monthly benefits. We also analyzed VA’s website and eBenefits portal for ease of accessing information about eligibility and application requirements. In addition, we reviewed studies about Internet usage among elderly and disabled populations. To enhance our evaluation of VA’s outreach efforts, we interviewed representatives of veterans service organizations (VSO) to obtain their views on VA’s outreach efforts. We also interviewed representatives of organizations that represent and interact with elderly populations and individuals with disabilities, some of whom have collaborated with VA on outreach. In addition, we used key outreach best practices identified in GAO and other reports as criteria to assess VA’s outreach efforts. The criteria included outlining of strategic goals for the campaign and determination of a identification and researching of the target audience to understand some of its key characteristics, such as size of population; establishment of strategic partnerships with other entities that are stakeholders in the issue to get help with planning and implementing the outreach campaign; targeting of the outreach message with audience specific, culturally sensitive content and use of media and languages that are the most appropriate for the audience; reinforcement of the message with repetition and different media, especially when targeting people who may be challenging to serve; and development and implementation of performance measures for evaluating the effectiveness of the outreach campaign. As part of our audit work for objectives two and three, we conducted a series of focus groups and one-on-one interviews with veterans who receive enhanced monthly benefits or a family member they chose to represent their views. A detailed discussion of the methodology used to plan, conduct, and analyze the results of these focus groups, and one-on- one interviews, is provided separately in this appendix. We conducted this performance audit from December 2009 through December 2011 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. To assess the reliability of these data, we (1) reviewed documentation for data extracts, (2) conducted electronic testing for obvious errors in accuracy and completeness, and (3) worked closely with agency officials to identify any data problems. When we found discrepancies (such as missing or invalid values), we brought them to VBA’s attention and worked with agency program and data specialists to correct the discrepancies before conducting our analyses. In some cases, we opted to limit our analysis to avoid using unreliable information. For example, because of persistent problems with data on terminated cases, we narrowed our scope to include only cases that were active as of the end of each fiscal year. In addition, because the data for fiscal years 2007 to 2010 lacked information on the disabling conditions for a large number of veterans from earlier periods of service, we limited our analysis of this information to veterans from the Gulf War period. Based on our assessment and steps taken to limit our use of problematic information, we determined the data were sufficiently reliable for the purposes of our report. We obtained summary-level data on the cost of noninstitutional care in all 50 states and the District of Columbia from the MetLife Mature Market Institute’s 2010 Market Survey of Long-Term Care Costs and Genworth Financial’s 2010 Cost of Care Survey. Both studies report costs for each type of service provider at the state level and for some localities within each state. We limited our analysis to the three types of noninstitutional care reported in these studies: home care aides (or homemaker services), home health aides, and assisted living facilities. For home care aides and home health aides, we reported hourly rates. For assisted living facilities, we reported monthly rates. To assess the reliability of the data reported in these studies, we reviewed methodological documentation for both studies. We also interviewed knowledgeable individuals from each organization who were involved in the design and execution of the survey and analysis of the survey data. As a result of our work, we determined that the data were sufficiently reliable for our purposes. To demonstrate how costs of obtaining services vary across the county, we reported the median cost for the three types of service providers in all 50 states and the District of Columbia. While the Cost of Care Survey reported median costs for each type of service, we calculated the median costs using record-level data from the Market Survey of Long-Term Care Costs. We report the midpoint between the two median costs from each study. There was a small and methodologically immaterial difference in data we reported about the median hourly cost of home care aides in Los Angeles; the MetLife data represented Los Angeles and the Genworth data represented Los Angeles County. To help assess the role played by enhanced monthly benefits in helping veterans obtain needed services and the impact of VA outreach activities, we obtained views from veteran recipients or their designated family representatives through a series of six focus groups we conducted in September 2010. We conducted two focus groups in each of three locations—San Antonio, Texas; Saint Petersburg, Florida; and Norfolk, Virginia. These locations were selected because each provided a large pool of veterans who likely were receiving enhanced monthly benefits as part of their compensation or pension payments from which to draw focus group volunteers. To obtain information from focus group participants, we established a standard protocol to facilitate the discussions. We pretested the protocol to identify any needed changes before conducting the focus groups and one-on-one interviews. We randomly selected enhanced monthly benefit recipients to participate in our focus groups using VA fiscal year 2009 data on recipients who lived in or around our three focus group locations. We obtained information from 33 veterans or their designated family representatives. To increase the number of responses from veterans or their representatives, we conducted phone interviews with veterans who could not attend a focus group. During these interviews, we covered the same topics discussed during our focus groups. In addition to the focus groups and one-on-one interviews, one veteran chose to provide written responses. The characteristics of focus group participants varied widely. The age of participants ranged from 39 to 96 years of age, with an average age of 73 years. Also, the veterans we contacted served in various war periods, including World War II, the Korean Conflict, Vietnam War, and the Gulf War. In addition, participants reported a variety of disabling conditions. Some focus group participants received enhanced monthly benefits as part of their pension and others as part of their compensation benefit payment. Table 2 summarizes characteristics of veterans we contacted. Each focus group covered several major topics, including VA outreach activities, processes for filing a claim for enhanced monthly benefits, services obtained as a benefit recipient, and recommendations for improving VA outreach practices, as well as veteran experiences in obtaining these benefits. A GAO facilitator led each discussion to keep participants focused on the specified issues within discussion time frames. With the consent of all focus group participants, we recorded each discussion and had each recording professionally transcribed.focus group discussion protocol was also used to guide one-on-one interviews. We summarized the information collected and identified common themes. While we identified a number of common themes across the six focus groups, our results cannot be generalized to the universe of veterans receiving enhanced monthly benefits. Indian wars. January 1, 1817, through December 31, 1898. Service must have been rendered with the United States military forces against Indian tribes or nations. Spanish-American War. April 21, 1898, through July 4, 1902. If veterans served with the United States military forces engaged in hostilities in the Moro Province, the ending date is July 15, 1903. The Philippine Insurrection and the Boxer Rebellion are included. Mexican border period. May 9, 1916, through April 5, 1917, in the case of veterans who served in Mexico, on the borders thereof, or in the waters adjacent thereto. World War I. April 6, 1917, through November 11, 1918. If veterans served with the United States military forces in Russia, the ending date is April 1, 1920. Service after November 11, 1918, and before July 2, 1921, is considered World War I service if the veterans served in the active military, naval, or air service after April 5, 1917, and before November 12, 1918. World War II. December 7, 1941, through December 31, 1946. If the veterans were in service on December 31, 1946, continuous service before July 26, 1947, is considered World War II service. Korean Conflict. June 27, 1950, through January 31, 1955. Vietnam Era. The period beginning on February 28, 1961, and ending on May 7, 1975, in the case of veterans who served in the Republic of Vietnam during that period. The period beginning on August 5, 1964, and ending on May 7, 1975, in all other cases. Persian Gulf War. August 2, 1990, through date to be prescribed by Presidential proclamation or law. Future dates. The period beginning on the date of any future declaration of war by Congress and ending on a date prescribed by Presidential proclamation or concurrent resolution of Congress. Daniel Bertoni, (202) 512-7215 or bertonid@gao.gov. In addition to the contact named above, individuals making key contributions to this report were Shelia Drake, Assistant Director; James Bennett; Melinda Cordero; Mary Crenshaw; Alex Galuten; Isabella Johnson; Nelson Olhero; Kate Van Gelder; Walter Vance; and Mark Ward. VA’s Fiduciary Program: VA Plans to Improve Program Compliance and Policies, but Sustained Management Attention is Needed. GAO-10-635T. Washington, D.C.: April 22, 2010. VA’s Fiduciary Program: Improved Compliance and Policies Could Better Safeguard Veterans’ Benefits. GAO-10-241. Washington, D.C.: February 26, 2010. VA Health Care: Long-Term Care Strategic Planning and Budgeting Need Improvement. GAO-09-145. Washington, D.C.: January 23, 2009. Veterans’ Benefits: Improved Management Would Enhance VA’s Pension Program. GAO-08-112. Washington, D.C.: February 14, 2008. VA Long-Term Care: Service Gaps and Facility Restrictions Limit Veterans’ Access to Noninstitutional Care. GAO-03-487. Washington, D.C.: May 9, 2003. The Government Accountability Office, the audit, evaluation, and investigative arm of Congress, exists to support Congress in meeting its constitutional responsibilities and to help improve the performance and accountability of the federal government for the American people. GAO examines the use of public funds; evaluates federal programs and policies; and provides analyses, recommendations, and other assistance to help Congress make informed oversight, policy, and funding decisions. GAO’s commitment to good government is reflected in its core values of accountability, integrity, and reliability. The fastest and easiest way to obtain copies of GAO documents at no cost is through GAO’s website (www.gao.gov). 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Summary: The Department of Veterans Affairs (VA) offers Aid and Attendance (A&A) benefits to individuals who need regular assistance and the attendance of another person or Housebound benefits to individuals who are substantially confined to their homes. These benefits, which increase recipients monthly disability compensation or pension payments, are called enhanced compensation or enhanced pension, respectivelycollectively referred to as enhanced monthly benefits. This report describes (1) characteristics of enhanced monthly benefit recipients; (2) how the benefits help veterans obtain needed services, and the associated difficulties they face in obtaining these services; and (3) VAs efforts to educate veterans and their family members about the availability of the benefits. GAOs work included analyzing VA case-level demographic data from fiscal years 2000 to 2010 on enhanced monthly benefit recipients, conducting facilitated focus groups with veterans and their family representatives, and interviewing VA headquarters and regional officials on VAs outreach efforts for enhanced monthly benefits, as well as reviewing relevant federal laws and regulations. According to VA data during fiscal years 2000 to 2010, most enhanced monthly benefit recipients were veterans, over age 65, and receiving the A&A enhancement as part of their pension benefit. The recipient population is changing, however. In particular, the percentage of enhanced monthly benefit recipients age 65 or younger increased from 18 percent to 24 percent over the decade. Also, the percentage of recipients paid benefits under the disability compensation program increased from 15 percent to 26 percent. The cost of enhanced monthly benefits has increased from $124 million in fiscal year 2000 to $409 million in fiscal year 2010; however, VA does not know what portion of these costs was paid specifically for A&A and Housebound benefits. VA maintains data on enhanced monthly benefit recipients total payments but does not separately identify the amount awarded as an A&A or Housebound benefit. VA officials stated that under its current system, separately tracking the costs of these benefits would be complicated and difficult. Enhanced monthly benefits helped veterans obtain services to perform everyday living activities in different ways, but high service costs and limited service availability in some areas can make it difficult to acquire the services. Benefit recipients GAO spoke with said that they used their benefits to pay for in-home services by private providers, offset lost income from family members who provided care for them, or defray the costs of an assisted living facility. However, obtaining services from private providers can still pose difficulties for some recipients because of the generally higher cost of services in large urban areas or the limited availability of services in rural areas. VA conducts a number of outreach activities to educate veterans and their family members about available benefits; however, a large number of elderly veterans may not be aware of their potential eligibility for enhanced monthly benefits. A VA study found that of pension recipientswho are mainly elderly veterans62 percent might be eligible for enhanced monthly benefits but only 22 percent received them, which the study primarily attributed to lack of awareness about the benefits. VAs outreach efforts may not be sufficient to inform elderly veterans about enhanced monthly benefits because outreach activities do not typically focus on these benefits, some printed material lacks information on eligibility and application requirements for these benefits, and the extent to which regional offices conduct elderly outreach varies, among other reasons. GAO recommends that VA conduct more focused outreach to better educate potential recipients about enhanced monthly benefits. VA agreed with the recommendation and described a number of actions it would take or explore to address it, such as including more detailed information in its printed material on enhanced monthly benefits.