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Witness Testimony of Deborah Amdur, LCSW, ACSW, Chief Consultant, Care Management and Social Work Service, Veterans Health Administration, U.S. Department of Veterans Affairs

Chairwoman Buerkle, Ranking Member Michaud, and distinguished members of the Committee, thank you for the opportunity to discuss the progress the Department of Veterans Affairs (VA) has made in implementing the provisions of title I of Public Law 111-163, the Caregivers and Veterans Omnibus Health Services Act of 2010 (the Act).

When we appeared before you in March, we provided an update on VA’s Implementation Plan for this program and our expected way ahead. We heard the concerns you and the Veterans Service Organizations raised about the eligibility criteria we were considering, and we worked to revise the criteria to include a broader population of Veterans.

We are pleased to report that the Family Caregiver program is fully operational and that primary Family Caregivers have begun receiving stipend payments for the support they are providing to Veterans. On May 5, 2011, VA published an Interim Final Rule (IFR), which implemented the Family Caregiver Program of the Caregivers and Veterans Omnibus Health Services Act of 2010. The public comment period for the IFR closed on July 5, 2011, and we are reviewing the comments we received to determine if any changes to the IFR are necessary. Our final rule will either continue the program as implemented in the IFR or revise it based upon our consideration of the comments.

My testimony today will discuss the eligibility criteria VA is using for this program under the IFR; the training and application process, as well as an update on our progress in these areas to date; and other benefits and programs VA is offering and will be offering to Caregivers of Veterans.

Eligibility Criteria

Under the statutory and regulatory program now in effect, to be eligible for benefits under the Family Caregiver program, Veterans must have incurred or aggravated a serious injury (including traumatic brain injury, psychological trauma, or other mental disorder) in the line of duty on or after September 11, 2001. These Veterans must also be in need of personal care services because of an inability to perform one or more activities of daily living (i.e., bathing, eating, dressing, toileting), or require supervision or protection based on symptoms or residuals of neurological impairment or injury. Servicemembers who are undergoing medical discharge with an identified date of discharge are also eligible for support under this program. Servicemembers and Veterans must require the assistance of a caregiver for a period of at least 6 months to qualify. Veterans cannot receive simultaneous personal care services from another party; for example, a Veteran could not receive home-health-aide services 24 hours a day, 7 days a week and receive support through the Family Caregiver program. Veterans must agree to receive care from a VA-designated primary care team so that VA can appropriately support these Veterans and Family Caregivers. After conducting a thorough analysis of VA’s records and assessing the current Veteran population, VA estimates that approximately 3,600 Veterans and Servicemembers may be eligible for benefits under the Family Caregiver program.

VA also included specific criteria in the IFR to ensure Veterans with a traumatic brain injury or neurological impairment would be eligible to receive benefits. These criteria include a need of supervision or assistance because of seizures, difficulty planning or organizing information, deficits in sleep regulation, delusions or hallucinations, memory deficits, or problems with mood regulation, such as agitation or aggression.

Processing Applications and Training Caregivers

VA began accepting applications for the new Family Caregiver program on May 9, 2011.  During the first week, we assisted more than 625 Veterans, Servicemembers and family members in applying for new benefits under the program. Through June 29, 2011, VA has 1,259 applications in process and had approved stipends for 182 Veterans. As of July 8, VA had processed 176 stipend payments totaling over $430,000 for primary Family Caregivers; this includes stipend payments for the support these Caregivers have provided since May 9, 2011.  The tracking device VA developed to monitor pending applications allows us to pinpoint where any application is in the process and to identify geographic or demographic trends. Based on the limited data available, Family Caregivers are overwhelmingly women (92 percent), spouses (67 percent), and between 26 and 64 years old (45 percent between 26-40, and 43 percent between 41-64). The 10 facilities with the highest number of applications in process are Fayetteville, NC; Dallas, TX; Jackson, MS; Durham, NC; Puget Sound, WA; Augusta, GA; Orlando, FL; Houston, TX; San Antonio, TX; and Washington, DC.

We have been working through the local Caregiver Support Coordinators to reach out to eligible Veterans and Servicemembers in the community to encourage them to apply. Post 9-11 Veterans currently receiving VA’s Aid and Attendance benefit due to injury in the line of duty have been contacted and encouraged to apply for the new Caregiver program. Veterans and family members must submit a joint application, which can be accomplished in person, by mail, by phone (1-877-222-VETS [8387]) or online (www.caregiver.va.gov). Additional support and information is also available through the National Caregiver Support Line (1-855-260-3274).  Within three business days of having received an initial application, the Caregiver Support Coordinator, at the Veteran’s preferred VA medical center, will contact the Veteran and the primary Family Caregiver to assist with completing the application process and schedule required training. This training is necessary before any additional benefits can be provided to the primary Family Caregiver.  VA has partnered with Easter Seals to provide comprehensive Caregiver Training to Family Caregivers of eligible post-9/11 Veterans as authorized by the law.  Easter Seals brings more than 90 years of experience in helping people with disabilities and special needs, and we are very pleased to partner with such a renowned organization.

Training may be completed in any of three ways:  by attending a Family Caregiver training session conducted at a local VA medical center or community location; by self-study using a workbook and DVD that is mailed to the Family Caregiver(s); or by completing the training online; the online training will be available by July 15, 2011. 

More than 450 Family Caregivers have completed their training since the beginning of June, and we continue to train more Caregivers every day so they can better support their loved one and begin receiving the benefits included in the law.

Once the Family Caregiver training is complete, a VA clinician will visit the Veteran’s home. This visit is designed to ensure that the primary Family Caregiver and Veteran have everything they need to be successful in the home setting.  Our clinicians are trained to do this in a supportive and encouraging manner. One Family Caregiver described this home visit as follows:  “All in all, the home visit was as painless as the rest of the process, and in fact it was comforting to have someone in my home to see what else I could do to help my husband….”

Once the home visit is complete, the primary Family Caregiver will begin receiving a monthly stipend based on the Veteran’s level of need. The primary Family Caregiver may also be eligible for health insurance through the Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA), provided that the primary Family Caregiver is not already entitled to care or services under a health plan contract. VA is making the stipend and health insurance benefits retroactive to the date of initial application. Our expectation is that the entire process, from initial application to the delivery of benefits, will be complete within 30 days.

We will continue to conduct well-being visits every 90 days or as clinically indicated. These visits, like the initial home visit, will be performed in a supportive manner. The visits are designed to evaluate the Veteran’s and the primary Family Caregiver’s physical and emotional state.  VA clinicians conducting these visits may make recommendations for additional training, support, equipment or other services in the best interest of the Veteran.

Other Benefits and Programs

In addition to the benefits specific to the primary Family Caregiver of Veterans (the stipend, health care coverage through CHAMPVA, mental health services, and at least 30 days of respite care), VA offers a number of benefits and services to all Caregivers of Veterans. VA’s National Caregiver Support Line, mentioned briefly above, has responded to more than 9,000 calls from Veterans and family members since it was activated in February 2011.  This Support Line, staffed by clinical social workers, provides immediate and highly responsive access to information for Caregivers, and can help coordinate local support through the Caregiver Support Coordinator at each VA medical center. These Coordinators are able to offer additional assistance by connecting Veterans and family members with both VA and non-VA resources. Since April 1, 2011, every VA medical center has had a full time dedicated Caregiver Support Coordinator in place.

VA’s home-based care programs are well-established and have been supporting Veterans in the community for many years. Home-based primary care is a unique program that provides comprehensive long-term primary care through an interdisciplinary team that visits the homes of Veterans with complex, chronic disabling diseases or injuries for which routine clinic-based care is ineffective. Another recent initiative is the Veteran-Directed Home and Community-Based Care program, which provides Veterans of all eras the opportunity to receive services in a Veteran-centered manner that allows them to avoid institutional placement while continuing to live in their homes and communities.  VA operates this program in collaboration with the Administration on Aging under the Department of Health and Human Services.

Veterans and their Caregivers who are in need of close monitoring of vital signs or frequent communication with a health care team can benefit from home telehealth services.  Telehealth offers the possibility of treating chronic conditions cost effectively while contributing to patient satisfaction.

General education and training are also available to all Caregivers. VA routinely offers in-person educational support for Caregivers of Veterans undergoing discharge from an inpatient stay at a VA facility and teaches techniques, strategies, and skills for caring for a disabled Veteran. We offer instruction and specialized training in several specialty areas, such as traumatic brain injury, spinal cord injuries or disorders, and blind rehabilitation. The Caregiver Support Program has provided multiple national education and training to VA staff throughout the country and to a wide range of Federal, state and local organizations.

Our respite care programs are available to any Caregiver of a Veteran.  All Veterans are eligible for 30 days of respite care per year, and this respite care can be provided at home or in an institution. Respite care provides the Caregivers of Veterans with a needed break to relieve the demands of caring for a chronically ill, injured, or disabled family member, and to prevent Caregiver burnout. In fiscal year  2010, more than 12,000 Veterans and Caregivers received respite care through VA. More than 7,500 of these Veterans received respite care in home, and more than 4,700 received care in a nursing home at VA expense. Adult Day Health Care Centers also provide respite care in a safe environment with constant supervision.

VA launched a new Web site on May 31, 2011, www.caregiver.va.gov, which provides a wealth of information and resources for Veterans, families and the general public. The Web site has had over 63,000 hits, totaling over 400,000 pages viewed since its launch. This site provides information on local and national resources, common Veteran conditions, caregiver self-care, and other topics identified as important by caregivers.

Evidence-based support programs and a peer-support mentoring program are in development and will be rolled out over the next 12 months to provide further assistance to the Family Caregivers of Veterans.

Conclusion

Although we have only recently initiated this program, we have received a great deal of positive feedback from Veterans and their Caregivers on the services we are delivering and the support VA professionals in the field are providing.  For example, one Caregiver described the application and evaluation part of the program by saying, “The process has been incredibly painless and very quick, which has been a huge breath of fresh air….”  We know there is room for continued improvement, and we appreciate the opportunity to hear from you and the other witnesses at today’s hearing to determine how we can make this program even better. Thank you for inviting me here to testify today to do that.  I am prepared to answer your questions at this time.