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Witness Testimony of Barbara Cohoon, Ph.D., R.N., Government Relations Deputy Director, National Military Family Association

Chairwoman Buerkle and Distinguished Members of this Subcommittee, the National Military Family Association would like to thank you for the opportunity to present testimony on “Implementation of Caregiver Assistance: Are we getting it right?” The National Military Family Association will take the opportunity to discuss our concerns regarding the Department of Veterans Affairs’ Caregiver Implementation Plan and several issues of importance to family caregivers of the wounded, ill, and injured service members, veterans, their families, and caregivers in the following subject areas:

  1. Wounded Service Members Have Wounded Families
  2. Caregivers
  3. VA Caregiver Implementation Plan
  4. Budget
  5. Additional Caregiver Compensation
  6. Senior Oversight Committee

Wounded Service Members Have Wounded Families

The National Military Family Association asserts that behind every wounded service member and veteran is a wounded family. Spouses, children, parents, and siblings of service members injured defending our country experience many uncertainties. Fear of the unknown and what lies ahead in future weeks, months, and even years, weighs heavily on their minds.

Transitions can be especially problematic for wounded, ill, and injured service members, veterans, and their families. The Department of Veterans Affairs (VA) and the Department of Defense (DoD) health care systems, along with State agency involvement, should alleviate, not heighten these concerns. Our Association believes the government must take a more inclusive view of military and veterans’ families. Those who have the responsibility to care for the wounded service member and veteran must also consider the needs of the spouse, children, parents of single service members, siblings, and especially the caregivers.

Who are the families of Wounded Service members?

In the past, the VA and DoD have generally focused their benefit packages for a service member’s family on his/her spouse and children. Now, however, it is not unusual to see the parents and siblings of a single service member presented as part of the service member’s family unit since they offer primary support. Almost 50 percent of the members are single in the active duty, National Guard, and Reserve. Having a wounded service member is new territory for family units. Whether the service member is married or single, their families will be affected in some way by the injury. As more single service members are wounded, more parents and siblings must take on the role as caregiver helping their son, daughter, or sibling through the recovery process. Family members are an integral part of the health care team. Their presence has been shown to improve the service member and veteran’s quality of life and aid in a speedy recovery.

Our Association gathered information about issues affecting our wounded service members, veterans, and their families through numerous encounters with families, including a focus group held 2008 at Camp Lejeune and our Operation Purple® Healing Adventures Family Retreats in 2008, 2009, and 2010. Families said they find themselves having to redefine their roles following the injury. They must learn how to parent and become a spouse/lover with an injury. Spouses talked about the stress their new role as caregiver has placed on them and their families. Often overwhelmed, they feel as if they have no place to turn to for help. We found many have put their own lives on hold while caring 24/7 for their loved one. Even with all of the additional support by the individual Services and corrective legislative action by Members of Congress, caregivers of the wounded, ill, and injured still find their responsibilities to be overwhelming.

Caregivers

Caregivers need to be recognized for the important role they play in the care of their loved one. Without them, the quality of life of the wounded, ill, and injured service members and veterans, such as physical, psycho-social, and mental health, would be significantly compromised. They are viewed as an invaluable resource to VA and DoD health care providers because they tend to the needs of the service members and the veterans on a regular basis. Their daily involvement saves VA, DoD, and State agency health care dollars in the long run.

Caregivers of the severely wounded, ill, and injured service members and veterans have a long road ahead of them. In order to perform their job well, they must be given the skills to be successful. The National Military Family Association is pleased with the passage of the Caregivers and Veterans Omnibus Health Services Act of 2010 (P.L. 111-163) that will provide for the training and compensation for caregivers of wounded,  ill, and injured, service members undergoing medical separation and veterans. This law places the VA in an active role in recognizing caregivers’ important contributions and enabling them to become better caregivers to their loved ones. It is a “win-win” for everyone involved.

VA Caregiver Implementation Plan

While our Association is extremely appreciative of Members of Congress for the passage of this landmark legislation, we have some concerns regarding the VA’s implementation plan. These concerns include a delay in implementation and the interpretation of the law’s intent by the VA regarding veteran and caregiver eligibility requirements and available benefits.

Delay

The VA has not met the implementation timeline for the caregiver portion of P.L. 111-163. The bill was signed into law by President Barack Obama on May 5, 2010 with an implementation plan date no longer than 180 days and the commencement of programs no longer than 270 days after enactment of the Act. This required the VA to provide a caregiver implementation plan no later than November 2010 and begin providing the benefit by January 31, 2011. The VA just submitted an Interim Final Rule to the Office of Management and Budget on March 1, 2011 and has posted information about its caregiver implementation plan. The VA is now late in implementing the law. Every day the VA waits to implement the caregiver provision means those who care for our wounded, ill, and injured are going without valuable resources that were intended to improve the quality of the caregiver’s life and of the life of those they care for. Our Association acknowledges the VA has not implemented other provisions provided in the law as well. These include: women veteran’s health care; rural health improvements; mental health services for veterans; and other health care matters. These provisions must also be implemented as quickly as possible.

Our Association, along with other Veteran and Military Service Organizations, frequently states how important this piece of legislation is for our Nation’s caregivers. Every day the VA delays its implementation only places additional stress on an already strained population. We really cannot afford to put this off even one more day. The least the VA could do in order to compensate for its delay is to provide retroactive stipend payments to caregivers from the original date of implementation required by law.  

Congressional Intent

Our Association, along with several others, was involved with the careful drafting of the caregiver legislation. We all worked hard ensuring the language included important provisions to provide valuable support to the caregivers of our wounded, ill, and injured service members and veterans. We feel very fortunate to have played such an important role in the development of the legislation. We are also thankful to the VA for inviting us to participate in the VA’s roundtable discussion and provide our input on the caregiver program’s implementation. However, we have concerns with the VA’s interpretation of the caregiver provision in P.L. 111-163 in two areas: veteran and caregiver eligibility and available benefits. We feel the VA is not meeting the intent of Congress or the needs of caregivers the law was intended to help.

Eligibility

The VA’s eligibility establishes a much more stringent criteria then the law dictates. According to the VA’s caregiver implementation plan, the veteran’s eligibility is tied to:

  • the veteran’s inability to live independently in their community without the support from a caregiver;
  • the caregiver providing personal care services at home continuously; and
  • the veteran being hospitalized, placed in a nursing home, or in other institutional care settings without the support of the caregiver.

It appears the VA chose not to incorporate the law and the intent of Congress and to capture a larger less medically disabled population. The inclusion of language, “has a serious injury (including traumatic brain injury, psychological trauma, or other mental disorder)” and “a need for supervision” was intended to allow for wounded, ill, and injured service members and veterans to be included without the requirement of a catastrophic medical condition or the need for institutional level of care. Many of our wounded, ill, and injured service members and veterans have mild to moderate cognitive impairment that require caregiver support, but they certainly do not need hospitalization or to be institutionalized. The law’s language was intended to capture this population and allow their caregivers to be eligible to receive benefits. However, the VA’s interpretation will exclude this population. More importantly, the VA’s interpretation will now cause a much smaller number of caregivers to qualify. Original estimates stated the law would have assisted 3,500 caregivers; however, during recent testimony the VA stated only 840 caregivers would qualify under these criteria.

The application process cannot begin until after the service member has completed the DoD disability evaluation process, has been found unfit for duty due to their medical condition, and received a date of separation. According to the Army’s MILPER Message #09-067 regarding the Army Transition Center Policy and Procedures for Disability Evaluation System (DES) Separation Processing, a soldier found unfit for duty by the physical evaluation board will be assigned a separation date not later than 90 days. The VA’s implementation plan state the service member and the caregiver cannot begin the application process until they receive a date of separation. Our Association believes this may not provide enough time for the completion of all of the VA’s eligibility criteria before the service member and their caregiver enter veteran status. Our Association is concerned this may impact the seamless transition of programs and services for the service member, but more importantly for the caregiver.      

Currently, the DoD is providing a caregiver compensation benefit to the service member for services provided by their caregiver. The law states DoD’s compensation stops three months (90-days) after the service member has been medically retired.  However, the VA’s caregiver benefits do not begin until training and pre-defined competencies have been successfully completed by the caregiver, in the home, and validated by the VA.  Ninety days until the service member medically retires, along with DoD’s additional 90-days following medical retirement to receive caregiver compensation, may not provide enough time for:

  • the VA’s caregiver application process to be completed;
  • the VA to determine the service member and caregiver are eligible; and
  • the caregiver to successfully complete the required caregiver training. 

This scenario has the potential to create a gap in monetary compensation and impact the family’s financial stability because the DoD’s caregiver compensation benefit has stopped and the VA caregiver stipend benefit has not started.

Eligibility dictates that the service member and veteran will receive care at home once caregiver training is complete. This means that even if a service member has a date of medical separation the caregiver will still not qualify if the service member/veteran is still receiving care from a hospital. Therefore, the service member would need to be finished with all treatment and ready to be cared for solely at home in order to qualify for this program. This would also delay the service member’s ability to submit the application and for the VA to begin caregiver benefits.

There is a strong possibility given the eligibility criteria that some service members with multiple injuries, such as a mild or moderate TBI, a loss of an extremity, PTS or PTSD, and 10% burn, may not qualify for this program. Multiple injuries are commonly seen in our returning service members from war. The potential disqualifying criteria states, “incapacity, physical or mental which requires care or assistance on a regular basis to protect the veteran from hazards or dangers incident to his or her daily environment.”  It is the word “incapacity” that will most likely disqualify them and subsequently the caregiver from receiving any benefits. Again, this was not the intent of the law. Co-morbid injuries may require the service member and veteran to need the assistance and support of a caregiver; therefore, they should be included in these benefits.  

The inclusion of the language “has a serious injury (including traumatic brain injury, psychological trauma, or other mental disorder)” and “a need for supervision” was intended to allow for wounded, ill, and injured service members and veterans to be eligible. Illness was one condition that was intended to be included. It is unclear whether or not illness is considered an eligible medical condition for the VA caregiver benefit. If illness is not included, then there is the potential for DoD’s caregiver compensation benefit and the VA’s caregiver benefit to apply to different sets of service members and veterans. DoD’s would include illness and the VA’s would not. This could potentially create a disparity in benefits and a lack of a seamless transition regarding compensation. Therefore, our Association recommends that illness be included as an eligibility requirement by the VA.  Maintaining financial compensation will be key in ensuring these families’ financial situations stay stable during transition from active duty to veteran status.

The time to acknowledge the caregiver’s important role and to implement a standardized, certified program, and begin compensation is while the wounded, ill, and injured service member is still on active duty status. The self-selection process of a caregiver occurs during the early phase of the recovery process. All branches of the Services are holding onto their wounded, ill, and injured service members much longer than previous wars. Years may have passed before the caregiver and the wounded, ill, and injured service member reach eligibility and can benefit from the VA’s important programs and services. Therefore, we recommend that the designation and education of caregivers be established while they are still upstream on active-duty, rather than wait until they have transitioned to veteran status.

Benefits

Waiting until after the receipt of a medical separation date will prevent caregivers from being able to receive training and obtain benefits early enough in the recovery phase to make a difference in their quality of life and in the quality of care they provide. Service members often receive care in a military hospital and/or VA Polytrauma Center and then recover at home, and then return to the hospital for follow on care/surgeries. This training requirement will prevent eligible caregivers from receiving any advance training for in-home care until the service member is being medically retired from the military. Our Association finds this troubling because a recent survey by the National Alliance for Caregiving, “Caregivers of Veterans – Serving on the Homefront,” found a top challenge faced by veteran caregivers was not knowing what to expect medically with the veteran’s condition and not knowing how to address Post Traumatic Stress Disorder (PTSD) or mental illness. Caregivers have frequently stated they did not know how to care for a service member and veteran when they were discharged from the hospital and went home during their recovery phase. This can cause increased stress on an already anxious caregiver. Our Association believes the sooner you provide caregivers with the skills they need to perform their duties, the sooner they will be able to provide a higher quality of care to the wounded, ill, and injured service member and veteran. The VA’s decision to wait until the service member is medically retired from the military and getting care only at home before beginning the application process will certainly prevent this valuable training opportunity from occurring at the appropriate time to make a difference in the quality of care of the wounded, ill, and injured service member.   

The delay in eligibility also impacts the ability to obtain time sensitive needed benefits, such as access to mental health counseling, health care benefits, and financial compensation. This especially impacts non-spouse caregivers who would greatly benefit from these services. According to the recent survey, “Caregivers of Veterans – Serving on the Homefront” one in four respondents were parents caring for Operation Enduring Freedom and Operation Iraqi Freedom veterans. Also, a larger proportion of veteran caregivers compared to their National (civilian) counterparts reported mental illness, such as depression or anxiety (70%) or PTSD (60%) compared to their National counterparts (28%). Veteran caregivers also reported their situation to be highly stressful (68% versus 31% Nationally) and 75 percent stated it placed a stress on their marriage (74%).

According to this recent survey, there are widespread impacts on the caregiver’s health, such as increased levels of stress and anxiety (77%) and not sleeping (77%), and a decrease in the utilization of healthy behaviors, such as seeing their medical provider. Our Association is hearing that caregivers are reaching the stage of burnout and many are deciding to walk away from their roles as caregivers. The longer the VA waits to begin benefits, the more opportunity there is for the caregiver’s quality of life to worsen and for the caregiver to reach the stage of burnout. The caregiver survey highlighted the increased stress our veteran caregivers are under compared to their National counterparts. The law and Congressional intent were to allow the VA to provide assistance through value-added benefits to the caregiver early enough in the process to make a difference and prevent the development of physical health, mental health, and/or financial problems. Caregivers of our wounded, ill, and injured need these services now, and sooner in the recovery process than later.

The VA has decided to begin all of the benefits at the same time. They could very easily make training information and access to valuable VA and DoD resources available much earlier in the process than their proposed timeline. Again, the earlier access to pertinent resources and information related to VA and DoD benefits for the service member, veteran, and themselves, will only be a win-win for everyone involved. Allowing early access to information validates the important role caregivers provide. Plus, an educated caregiver will only provide better care in the long run. Our Association recommends the VA begin caregiver benefits as early as possible while the service member is still on active duty status and not wait until they have received a final determination.

We acknowledge and applaud VA’s recent launch of a caregiver section on their website. However, the outreach to potential recipients was not included in their caregiver implementation plan. How will caregivers of our wounded, ill, and injured service members and veterans of all eras be made aware of this valuable resource?

Training

The VA’s decision to delay access to valuable training may force each Service to begin their own training program in order to compensate for this delay. Most likely, this may cause each Service’s training program to vary in its scope and practice; therefore, it may not meet VA’s training objectives. This could force the caregiver to undergo two different training programs in order to provide care and receive needed benefits.

Stipend

Many caregivers have given up their jobs. Therefore, the family has less money to make ends meet. The caregiver stipend will most likely not equal the caregiver’s lost wages, but it will be better than not having any additional income. Our Association appreciates VA’s acknowledging the need to compensate caregivers for providing direct hands-on medical care. We support the VA’s decision to use a stipend matrix applying the U.S. Department of Labor’s Bureau of Labor Statistics (BLS) hourly wage index in the geographic market times the number of hours/Full Time Equivalent (FTE) required to perform a determined number(s) of Activities of Daily Living in determining the caregiver’s stipend. However, we notice that the VA did not include a provision to pay caregivers for performing non-medical care services.

Our Association has always proposed that financial compensation should recognize the types of medical and non-medical care services provided by the caregiver. We have also advocated for this compensation to begin while the hospitalized service member is still on active duty, continue throughout transition, and into veteran status.

Our Association’s proposal for a non-medical compensation for caregivers would be on a sliding scale with a minimum and maximum amount allowed under this provision. The payment would reflect the amount of services the caregiver was providing, such as traveling to appointments or making appointments. The amount would increase as the demand for services increased, such as following a surgery, and decrease as the need dissipated after recovery. This need would have to be assessed quickly without delay in order to provide the correct amount of compensation. The compensation could begin with the level determined during the initial evaluation and could increase, but not decrease, until the service member enters veteran status and establishes a permanent residence. The amount should remain the same regardless of where the caregiver resides from the time of eligibility until they reach veteran status and establish a permanent residence.

The reason for wanting to include a non-medical compensation benefit is because there are many hours in a day spent performing these activities that play an integral part in maintaining the service member and veteran’s quality of life yet are not captured by the VA’s BLS stipend matrix. Plus, Section 1115 of title 38 of the United States Code provides compensation to the veteran only when the spouse cannot perform the duties of a caregiver. This same level of stipend should be applied to non-medical care services provided by caregivers to service members and veterans.  

The VA’s stipend is paid directly to the caregiver for their services, which we appreciate. We are concerned over the VA’s statement that the caregiver stipend may be considered taxable income. This was certainly not an intended consequence. Our Association looks forward to working with the VA and Members of Congress on addressing this potential issue.    

CHAMPVA

Our Association is pleased caregivers will have the opportunity to benefit from the Civilian Health and Medical Program of the Department of Veterans Affairs, known as CHAMPVA. We appreciate caregivers being allowed to access health care through community based CHAMPVA providers or on a space available basis at VA Medical Centers. The population most likely to use this benefit will be the veteran’s parent. They will at some point become eligible for Medicare. Therefore, we would recommend the VA include a provision to help guide them during this transition process to ensure continuity of health care services.

Mental Health Services

The VA caregiver implementation plan states, “Primary family caregivers will be covered … for mental health services in connection with the treatment of the Veteran” and “mental health services needed by the primary family caregiver but not related to the treatment of the Veteran.” The implementation plan states further, “but not medication.” We wonder if medication will be provided by the caregiver’s medical provider. If so, how will the coordination between the caregiver’s medical provider and the person/entity providing mental health services be accomplished? We recommend VA provide coordination of mental health services and appropriate medication when indicated by the caregiver’s primary health care provider to ensure the caregiver is receiving a holistic approach to mental health care. Also, the caregiver implementation plan does not explain what the VA means by expanded “counseling” services under the law. We would appreciate it if the VA would clarify what these counseling services for family caregivers will include.

Travel, Lodging, and Per Diem

Our Association is concerned over the reimbursement process. Being paid after the event may cause an unwarranted financial burden on the family. We would recommend the VA evaluate the financial impact on the caregiver before granting travel and offer advance travel compensation if warranted. What does the VA mean they will provide reimbursement “when appropriate” and determine costs based on “any other extenuating circumstance?” These are vague and open-ended statements that need further clarification. The implementation plan is not clear on who submits the request for travel authorization, the caregiver, veteran, or the case manager? Our Association would recommend the case manager or a VA employee be assigned to provide this service. Caregivers have enough on their plate without the added burden of submitting forms.

Respite Care

The VA currently has authority to provide respite care and says it does not require additional authority to expand respite care services under the new law. The VA policy currently allows up to thirty days annually and states additional days may be offered due to unforeseen circumstances. And, they say they will assess the Veteran and caregiver for appropriate respite care services. The VA is not meeting the intent of the law regarding this benefit. The intent was to add more respite care hours to the current VA policy, not keep the status quo. Caregivers of our wounded, ill, and injured veterans are experiencing tremendous stress and strain. This fact has been validated in the recent caregiver survey where veteran caregivers experienced higher burden of care (65%) compared to National caregivers (31%).  We recommend caregivers have immediate access to these additional hours on top of the hours already provided in VA’s current policy without the need to be “assessed” by the VA to determine if they are eligible for additional hours.

Monitoring

The intent of the law is for the VA to be as unobtrusive as possible when monitoring the caregiver’s performance. The plan’s statement that “on-going monitoring will include home visits … at least every ninety days,” means to us that this could occur more frequently. If so, how frequent and what would trigger the visit? It appears the VA is constantly monitoring and will collect data during three separate occasions: in-home visits, ongoing visits, and well-being visits. Where is this information going and who is coordinating all of the data? How often will the veteran’s activities of daily living and the caregiver’s hours be re-evaluated? What does the VA mean by “the initial validation of caregiver competence will be done in a timely manner?” What does the VA consider timely?

It appears the VA is focused exclusively on the care and well-being of the veteran rather than making sure the caregiver is also physically, mentally, and financially stable. We recommend the VA take a holistic approach to care and include the caregiver and the family when assessing the veteran. Everyone’s health and well-being is linked together, especially when caring for the wounded, ill, and injured service member and veteran. This would require the VA to assess the primary caregiver and their family’s well-being during each of their visits and make appropriate referrals for care and/or services to address the issue(s). Timely intervention is key in making sure caregivers get the right care at the right time and the issue is quickly resolved. The VA must also look for abuse of the caregiver by the veteran and provide appropriate mediation when necessary.

Revocation of Primary Family Caregiver

Our Association is pleased the VA provided an implementation plan if the primary caregiver decides to no longer provide the required personal care services. The VA states all benefits for the primary caregiver will end once their role ends. We appreciate the VA offering to work with the primary caregiver during transition; however, we would request the VA provide a definite timeline and criteria required to be met prior to the stopping of the stipend. We hope the potential financial impact on the caregiver and family is also taken into consideration before discontinuing the stipend and the impact of ending any benefits on the veteran, caregiver, and their family.

The VA needs to clarify additional revocation concerns. What if the veteran is mentally unable to make the decision to revoke the caregiver’s benefit? How does the legal guardian fit into this scenario? What if the primary caregiver is also the veteran’s legal guardian and/or medical power of attorney? What if the veteran has difficulty controlling their anger related to their medical condition and this is the underlying reason for the revocation request(s)? The caregiver implementation plan does not provide any insight on how these matters will be dealt with by the VA.

 Budget

The VA budget will provide $208 million for the implementation of the Caregivers and Veterans Omnibus Health Service Act of 2010 (P.L. 111-163) for Fiscal Year 2012 (FY2012). The money will be used to provide: specialized caregiver training for individualized veteran health care needs; a stipend payment paid directly to caregivers for care provided; and health care and mental health care services for caregivers. The Independent Budget for the Department of Veterans Affairs Fiscal Year 2012 recommended the VA will need approximately $385 million to fund the provisions in P.L. 111-163 in FY2012. They further state the advance appropriations for FY2011 will be insufficient to meet the increased workload placed on the VA by the P.L. 111-163, which may require supplemental funding. We encourage Members of Congress to make sure the law is sufficiently funded to meet all of its requirements.

Additional Compensation for the Caregiver

Our Association is appreciative of the generous benefits included in the Caregivers and Veterans Omnibus Health Service Act of 2010. However, there were some areas not addressed. Our Association would like to take the opportunity to present recommendations.

A report by the Center for Naval Analysis determined 85 percent of caregivers left employment or took a leave of absence from work or school while performing their caregiver duties. They found that the average loss of earnings per caregiver was approximately $3,200 per month. The financial strain placed on the family of our wounded, ill, and injured service member and veteran by the caregiver leaving outside employment has a trickle down affect. Caregivers who have been saving for retirement now find they are ineligible for their employers’ 401(k)s. We believe a mechanism should be established to assist caregivers to save for their retirements, for example, through the federal Thrift Savings Plan.

Once the recovery process is finished and the veteran’s care has stabilized, the caregiver may decide to work outside the home in order to help make financial ends meet. These caregivers may need the ability to learn new skills in order to compete in today’s workforce. We recommend VA offer these caregivers the opportunity to participate in VA’s vocational rehabilitation programs and help retool the caregiver’s resume. We must also find innovative ways to encourage civilian and government employers to hire these caregivers, especially when the veteran is unable to work.

According to the Center of Naval Analysis, wounded, ill, and injured service members and veterans, their families, and caregivers are assisted by many non-governmental organizations (NGOs) and charities. This assistance is important with the overall financial stability of these families during the recovery phase. Our Association’s concern, as we continue into another year of economic downturn, is that we may find many of these NGOs and charities no longer able to assist in the manner they have previously. We believe the availability of outside assistance by others will need to be monitored closely by both the VA and DoD to make sure these families are still being helped. If they are no longer being assisted, we believe the VA and DoD may need to begin providing assistance in those areas previously done by NGOs and charities.

Relocation Allowance

Active duty service members and their spouses qualify through the DoD for military orders to move their household goods (known as a Permanent Change of Station (PCS)) when they leave the military service. Medically retired service members are given a final PCS move. Medically retired married service members are allowed to move their family; however, medically retired single service members only qualify for moving their own personal goods. 

The National Military Family Association suggests medically retired single service members be allowed the opportunity to have their caregiver’s household goods moved as a part of the medically retired single service member’s PCS move. This should be allowed for the eligible primary caregiver and their family. The reason for the move is to allow the medically retired single service member the opportunity to relocate with their caregiver to an area offering the best medical care, rather than the current option that only allows for the medically retired single service member to move their belongings to where the caregiver currently resides. The current option may not be ideal because the area in which the caregiver lives may not be able to provide all the health care services required for treating and caring for the medically retired service member. Instead of trying to create the services in the area, a better solution may be to allow the medically retired service member, their caregiver, and the caregiver’s family to relocate to an area where services already exist, such as a VA Polytrauma Center.

The decision on where to relocate for optimum care should be made with the help of the Federal Recovery Coordinator (case manager), the service member’s physician, the service member, and the caregiver. All aspects of care for the medically retired service member and their caregiver shall be considered. These include a holistic examination of the medically retired service member, the caregiver, and the caregiver’s family for, but not limited to, their needs and opportunities for health care, employment, transportation, and education. The priority for the relocation should be where the best quality of services is readily available for the medically retired service member and his/her caregiver.

Veteran Housing

Many of our wounded, ill, and injured service members and veterans from this current conflict are being cared for by their parents. Also, many adult children of our senior veterans are experiencing first hand trying to juggle the needs of the parents along with the needs of their children, and are referred to as the “sandwich” generation. Parent caregivers worry about who will care for their wounded son or daughter as they age and are unable to fulfill the role of caregiver. Caregivers may reach burnout and will need alternative solutions for providing care. The VA needs to be cognizant of the ever changing landscape and needs of their veteran population and those who care for them. The VA needs to offer alternative housing arrangements, such as assisted living facilities and family/retirement villages, which allow a diversified population to live together in harmony. This will go a long way in allowing for family units to stay together, foster independent living, and maintain dignity for the veteran.

Brooke Army Medical Center (BAMC) has recognized a need to support our wounded, ill, and injured families by expanding the number of guesthouses co-located within the hospital grounds and providing a family reintegration program for their Warrior Transition Unit. The on-base school system is also sensitive to issues surrounding these children. A warm, welcoming family support center located in guest housing serves as a sanctuary for family members. VA medical facilities could benefit from looking at successful programs like BAMC’s that embrace the family unit and commit to building family friendly environments of care for our wounded, ill, and injured service members, veterans, and their families. We recommend the development of alternative housing and living arrangements for veterans, their families, and those who care for them.

Mental Health

The need for mental health services will remain high for some time even after military operations scale down and service members and their families transition to veteran status. Veterans’ families and caregiver requirements for a full spectrum of mental health services — from preventative care and stress reduction techniques, to individual or family counseling, to medical mental health services—will continue to grow. It is also important to note if DoD has not been effective in the prevention and treatment of mental health issues, the residual will spill over into the VA health care system. The VA must be ready. They must partner with DoD and State agencies in order to address mental health issues early on in the process and provide transitional mental health programs. They must maintain robust rehabilitation and reintegration programs for veterans, their families, and caregivers that will require VA’s attention over the long-term.

The National Military Family Association is especially concerned with the scarcity of services available to the veterans’ families and caregivers as they leave the military following the end of their activation or enlistment. Military families will no longer qualify for many of the Services’ family support programs and DoD’s Military OneSource. Our Association recommends the VA increase outreach to veterans, their families and caregivers, and the communities they live in about available mental health resources to help them deal with the residual effects of long frequent deployments.

Children of the Veteran and Caregiver

The impact of the wounded, ill, and injured veteran on their children is often overlooked and underestimated. These children experience a metaphorical death of the parent they once knew and must make many adjustments as their parent recovers. Many families relocate to be near the treating Military Treatment Facility (MTF) or the VA Polytrauma Center in order to make the rehabilitation process more successful. As the spouse focuses on the rehabilitation and recovery, older children take on new roles. They may become the caregivers for other siblings, as well as for the wounded parent. Many spouses send their children to stay with neighbors or extended family members, as they tend to their wounded, ill, and injured spouse. Children get shuffled from place to place until they can be reunited with their parents. Once reunited, they must adapt to the parent’s new injury and living with the “new normal.” We must remember the caregiver may not be the veteran’s spouse. They may be the wounded veteran’s parent, sibling, or friend. These children are also affected and Congress and the VA must be cognizant of their potential psychological needs as well.

We encourage partnerships between government agencies, VA, DoD, and State agencies and recommend they reach out to those private and non-governmental organizations who are experts on children and adolescents. They could identify and incorporate best practices in the prevention and treatment of mental health issues affecting these children. We must remember to focus on preventative care upstream, while still in the active duty phase, in order to have a solid family unit as they head into the veteran phase of their lives. VA, DoD, State, and our local communities must become more involved in establishing and providing supportive services for our nation’s children.

Expansion of Caregiver Pilot Programs

The VA currently has eight caregiver assistance pilot programs to expand and improve health care education and provide needed training and resources for caregivers who assist disabled and aging veterans in their homes. These pilot programs are important; however, there is a strong need for 24-hour in-home respite care, 24-hour supervision, emotional support for caregivers living in rural areas, and coping skills to manage both the veteran’s and caregiver’s stress. We are appreciative that P.L. 111-163 will provide for increased respite care hours, along with counseling and mental health services for caregivers, but neither addresses the 24-hour supervision. We recommend if these pilot programs are found successful, they should be implemented by the VA as soon as possible and fully funded by Congress. Another program not addressed is the need for adequate child care. The caregiver may have non-school aged children of their own or the wounded, ill, and injured veteran may be a single parent. The availability of child care is needed in order to attend their medical appointments, especially mental health appointments. Our Association encourages the VA to create a drop-in child care program for medical appointments on their premises or partner with other organizations to provide this valuable service.

Senior Oversight Committee

Our Association is appreciative of the provision in the National Defense Authorization Act for Fiscal Year 2009 (NDAA FY09) continuing the DoD and VA Senior Oversight Committee (SOC) until December 2010. The DoD established the Office of Wounded Warrior Care and Transition Policy to take over the SOC responsibilities. The office has seen frequent leadership and staff changes and a narrowing of their mission. We urge Congress to put a mechanism in place to continue to monitor this Office for its responsibilities in maintaining VA and DoD’s partnership and making sure joint initiatives create a seamless transition of services and benefits for our wounded, ill, and injured service members, veterans, their families, and caregivers. 

Recommendations

  • Broaden eligibility criteria to meet Congressional intent;
  • Clarify eligibility requirements and benefits provided by the VA;
  • Provide retroactive stipend payments to the original date of implementation required by law;
  • Begin caregiver benefits as early as possible while the service member is still on active duty status and not wait until  they have received a final determination;
  • Provide extra respite care as required by law;
  • Provide adequate funding to implement caregiver benefits;
  • Maintain seamless transition of benefits and programs;
  • Coordinate and collaborate health care and behavioral health care services between the VA, DoD, and State and governmental agencies in sharing of resources;
  • Approve relocation allowances and provide alternative housing and living arrangements;
  • Increase outreach to veterans, their families, and the communities they live in about available benefits;
  • Provide opportunities for the entire family to reconnect and bond as a family again;
  • Provide a holistic approach to care that incorporates the impact of the wound, illness, or injury on the family unit;
  • Expand all of the VA’s caregiver pilot programs; and
  • Continue oversight of the SOC by Members of Congress.

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