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Witness Testimony of Hon. Robert A. Petzel, M.D., Under Secretary for Health, 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 Department of Veterans Affairs (VA) Implementation Plan (the Plan) for the provisions of title I of Public Law 111-163, the Caregivers and Veterans Omnibus Health Services Act of 2010 (the Act). I am accompanied today by Mr. Walt Hall, Assistant General Counsel, and Ms. Deborah Amdur, Chief Consultant for Care Management and Social Work, VHA.

VA has provided support to caregivers of Veterans for almost eight decades. We understand how critical family caregivers are for the Veterans they support with such dedication. Veterans are best served when they can live their lives as independently as possible and when surrounded by their loved ones. VA remains committed to ensuring Veterans receive the care they need in the least restrictive environment possible. The Act enhances VA’s existing authority to provide services for caregivers of Veterans and will allow VA to provide groundbreaking new benefits and services to certain caregivers of eligible Veterans whose serious injuries were incurred or aggravated in the line of duty on or after September 11, 2001.

This is an historic law that provides unprecedented benefits to caregivers of certain seriously injured Veterans and Servicemembers. Many Veterans and caregivers, Veterans Service Organizations, and community partners have worked to enact this legislation and have provided input into VA’s Implementation Plan. VA is working as quickly and responsibly as possible to deliver the enhanced benefits authorized by the Act to eligible Veterans and their caregivers and will keep the Committee closely apprised of its progress.

Servicemembers injured in Afghanistan and Iraq are surviving injuries that would have been fatal in past conflicts, due in part to advanced protective equipment and medical treatment. VA and the Department of Defense see the full range—and countless combinations—of injuries suffered by these returning Veterans and Servicemembers.

My testimony today discusses what VA is doing to support Veterans and Servicemembers and their caregivers, and what assistance and support services VA will provide under the new law. I will begin by briefly summarizing the law; describing VA’s comprehensive efforts to develop the programs required by this law and draft the Plan; detailing VA’s existing programs for supporting caregivers; providing VA’s recommendation for benefits and enhancements to these programs; and then present a path forward for full implementation.

About the Law

The Caregivers and Veterans Omnibus Health Services Act of 2010 (the Act) was signed into law by President Obama on May 5, 2010. Title I of the Act authorizes VA to provide specified new benefits to the approved primary and family caregivers of eligible Veterans who incurred or aggravated a serious injury in the line of duty on or after September 11, 2001. VA distinguishes between three categories of caregivers who may receive assistance and support under the new law:

  1. General Caregiver:  Any person who provides personal care services to an enrolled Veteran, regardless of era or injury, under the program of support services for caregivers of covered Veterans.
  2. Family Caregiver:  A person designated by the eligible Veteran who is approved as a provider of personal care services for an eligible Veteran who supports the primary family caregiver in meeting the Veteran’s daily needs, under the program of comprehensive assistance for family caregivers. This person can be a family member or someone who lives with the eligible Veteran full time.
  3. Primary Family Caregiver: This person is designated by the eligible Veteran and is designated by VA as the primary provider of personal care services for an eligible Veteran. This will be the person primarily responsible for the Veteran’s daily care and assistance, under the program of comprehensive assistance for family caregivers. This person can be a family member or someone who lives with the eligible Veteran full time.

Caregivers of qualifying Veterans will receive educational sessions made available in person and online; access to telehealth services and other available technologies; techniques, strategies and skills for caring for a disabled Veteran; counseling, training and other services necessary for the Veteran’s treatment; respite care that is medically and age appropriate for the Veteran; and referral services to community and other support programs. It is important to emphasize that these are programs and services currently available within VA, but these are being expanded as a result of the Act.

Approved family caregivers of eligible Veterans may receive tailored instruction and training for the Veteran’s care; travel, lodging and per diem while undergoing training; respite care for the Veteran while the caregiver receives training; lodging and subsistence during travel to and from, and for the duration of medical examinations, treatments or care for the Veteran; ongoing technical support; and counseling.

Designated primary family caregivers may receive a monthly stipend paid directly to the caregiver; health care coverage under the Civilian Health and Medical Program of VA (CHAMPVA), if the caregiver is not already entitled to care or services under a health plan contract; mental health services; and at least 30 days of respite care per year, which can include in-home care. Stipend amounts will be based on the amount and degree of personal care services provided. Under the Implementation Plan submitted to the Committee in February, VA would ensure that stipend amounts are comparable to the earnings of a Home Health Aide in the Veteran’s local community. The actual amounts and other details of the stipend will be defined through regulations and are still in development.

Primary and family caregivers will be chosen by the Veteran through a joint application process with the assistance of a local VA caregiver support coordinator. VA will assess the eligibility of the Veteran for the family caregiver program and the capacity for the Veteran’s selected caregiver(s) to provide the personal care services required by the Veteran.

Implementation Plan

Even before the Act was signed by the President, VA had begun work to identify resources and develop plans to put these enhancements and new benefits in place. VA established a Steering Committee to oversee the implementation process. The Committee reviewed the law, recommended staff resources necessary for full implementation, and established four Workgroups that analyzed and developed recommendations for different aspects of the Caregiver Support Program: benefits, clinical issues, eligibility and information technology. The Committee consisted of more than 50 subject matter experts from across the country with expertise in polytrauma care, care management, mental health, administration, law, business processes, information technology, contracts, and other specialties. The Department of Defense also participated in these sessions. The Workgroups conducted face-to-face meetings and held regular conference calls to address issues associated with implementation, answer questions critical for VA’s Implementation Plan and develop effective processes that could be put in place across the system.

VA held a Caregiver Conference in Washington, D.C. in July 2010 and conducted a series of meetings and round table discussions with Veterans, caregivers, national non­governmental organizations (NGO) with expertise in caregiving, and Veterans Service Organizations (VSO) to solicit their input and identify concerns. VA staff met with VSOs on October 5, 2010 and October 13, 2010. These meetings included representatives from the American Legion, AMVETS, Blinded Veterans Association, Disabled American Veterans, Iraq and Afghanistan Veterans of America, Military Officers Association of America, National Military Family Association, Paralyzed Veterans of America, Veterans of Foreign Wars, Veterans of Modern Warfare, and Wounded Warrior Project. On October 7, 2010, VA met with NGOs possessing expertise in caregiving, including American Red Cross, Easter Seals, National Alliance for Caregiving, National Family Caregivers Association, Family Caregiver Alliance, Rosalynn Carter Institute for Caregiving, National Association of Area Agencies on Aging, National Council on Independent Living, and ARCH National Respite Network and Resource Center.

The Implementation Plan was delivered and briefed to staff of the House and Senate Veterans’ Affairs Committees on February 9, 2011. This Plan can be accessed electronically on VA’s Caregiver Web site at: http://www.caregiver.va.gov/docs/Caregivers_part1.pdf. It is important to note that the Plan comprises VA’s recommendations; the final word on eligibility criteria, as well as the other details of implementation, will come only after completion of the rulemaking process, which includes Office of Management and Budget (OMB) review and a period for public comment, which can also result in adjustments to the rules governing the program.

Existing Services Available to Caregivers and Veterans through VA

As noted earlier, VA has offered support and benefits to the caregivers of Veterans since before World War II. VA has provided aid and attendance benefits for decades as part of certain Veterans’ direct benefits, and depending upon the nature of disability. VA can provide up to $4,977 per month in special monthly compensation (in addition to the $2,673 in disability compensation for 100 percent service-connected condition) for eligible Veterans in need of aid and attendance to allow them to pay caregivers. The amount varies depending on the level of aid and attendance needed.

For example, 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. This includes instruction and specialized training in specialty areas such as traumatic brain injury (TBI), spinal cord injury/disorders, and blind rehabilitation. VA has a caregiver assistance healthy living center on My HealtheVet (www.myhealth.va.gov) and hosts a caregiver website (www.caregiver.va.gov). Both of these sites include information on VA and community resources and caregiver health and wellness.

VA offers a number of programs and services to support Veteran care at home. VA purchases personal care services to assist Veterans in their homes with activities of daily living. These benefits are available to Veterans who, without these services, would require nursing home or other institutional placement and are provided using public and private agencies. VA also offers purchased skilled home care through contract agencies for Veterans who are homebound and in need of skilled services such as nursing, social services, or physical, occupational or speech therapy. 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.

The Veteran-Directed Home and Community-Based Care program 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. In-home hospice care is also available for Veterans who are in the advanced stages of incurable disease. Care includes comfort-oriented and supportive services that are provided by an interdisciplinary team of providers and volunteers. Community Home Hospice services are available 24 hours a day, 7 days a week. 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.

Specialty care services, such as for blind rehabilitation, polytrauma, spinal cord injury, and a range of modifications or adaptations are also provided to Veterans and caregivers in need. Family training programs at Blind Rehabilitation Centers provide family members and caregivers with education about blindness in general, and specific information about their family member’s vision loss. In VA’s Polytrauma System of Care, caregiver and family education and training are provided as part of the rehabilitation process through meetings with the care team, written and web-based information, and other forums. This education includes rehabilitation techniques to facilitate adaptation, safe and effective use of prosthetic or other devices, skill development to meet the needs of the Veteran, behavioral management training, and information on how to access community resources. Specialized information on TBI is also available if the Veteran has this condition. During initial rehabilitation of a Veteran with a new spinal cord injury, VA trains the Veteran to guide a caregiver in meeting the Veteran’s personal care needs. Caregiver support is also provided directly by VA staff and through referral to community support services where needed. Home care services for bowel and bladder care are also available, and VA can pay for these services through a professional home health agency. VA provides patient lifts to help caregivers move Veterans with limited mobility, ramps to facilitate ingress and egress from a home, vehicular and home modifications and adaptations, attendant controls on any power wheelchair, and specially adaptive housing modifications to provide a barrier-free, wheelchair accessible living environment for the Veteran and the caregiver.

VA offers a range of family support initiatives. Family counseling, spiritual and pastoral care, and temporary lodging at Fisher Houses are all currently available. Counseling for family members under 38 United States Code (U.S.C.) 1782 may also be available. Respite care, either at home or in an institutional setting, 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. Adult Day Health Care Centers also provides respite care in a safe environment with constant supervision.

VA launched a Caregiver Support Line (1-855-260-3274) that is providing counsel on issues related to non-institutional care, benefits, the law, and other questions. Since its activation on February 1, 2011, the line received more than 3,000 calls. This Support Line, staffed by clinical social workers, provides immediate and highly responsive access to information for caregivers. Each VA medical center has designated a Caregiver Support Point of Contact to coordinate caregiver activities and serve as a resource expert for Veterans, their families and VA providers to assist them in locating and accessing non-VA resources.

VA’s Plan for Benefits and Enhancements to Caregivers—The Plan outlines VA’s proposal for providing enhanced benefits for family caregivers of eligible Veterans and Servicemembers. The Plan includes recommendations concerning eligibility, application, training, monitoring and implementation, stipend amounts, health care benefit coverage, mental health services, and travel, lodging and per diem. As noted above, the recommendations that comprise the plan are just that – recommendations – and there are steps remaining in the rulemaking review process (including a period for public comment) that provide an opportunity for adjustments in the rules and processes that will be followed by VA in carrying out the provisions of the Act.

Following are some of the areas that received concentrated attention and discussion in the Implementation Plan. They are treated in full detail in the Plan, but we would like to highlight some of the prominent areas here.

Eligibility for Family Caregiver Program

VA’s Implementation Plan outlines proposed clinical eligibility criteria that would be used by VA clinical providers to determine a Veteran’s eligibility to participate in the family caregiver program (i.e. whether family caregiver(s) of the Veteran may be approved and/or designated to receive support under the family caregiver program), and to help determine the amount and level of the stipend the primary family caregiver would receive. These clinical eligibility criteria would be applied, along with other eligibly criteria (such as whether the Servicemember is “undergoing medical discharge,” and whether the serious injury was incurred or aggravated on or after September 11, 2001) to determine which Veterans and Servicemembers are eligible to participate in the family caregiver program.

The clinical eligibility assessment would consist of two parts. The first part would include evaluation based on clear clinical criteria to determine the appropriateness of the Veteran for the program, and VA’s proposal for those standards can be found at pages 13 and 14 of the Plan. This has proven to be the most challenging aspect of VA’s implementation planning – to ensure that VA can put forward eligibility standards that fulfill the aims of the law, while setting out criteria that can be applied consistently by clinicians and understood by Veterans and their families.

The second part of the proposed assessment would determine the base level of the stipend to be provided to the primary family caregiver, based upon the complexity of the Veteran’s functional limitations and the assistance required, as defined by activities of daily living (ADL) and required hours of care. Pages 16 and 17 of the Plan provide greater detail of how this assessment would be conducted.

The Act defines “family member” as a member of the family of the Veteran (parent, spouse, child, step-family member, or extended family member) or someone who lives with the Veteran but is not a family member. The definition establishes eligibility requirements for family caregivers seeking to participate in the program. In the Plan at page 18, VA proposes standards aimed at ensuring the caregiver meets minimum competency requirements, and that VA performs its due diligence to prevent, whenever possible, potentially abusive situations.

The Application for Family Caregivers

The Act provides that Veterans and caregivers seeking participation in the program will submit a joint application to VA. VA proposes an application process that would be managed nationally to take advantage of VA’s existing infrastructure and ensure a quick and accurate review. The application would be based on existing elements of the CHAMPVA application, VA’s Geriatric and Extended Care Referral Form, and newly developed portions in response to the Act.

VA clinicians will be trained in the specific program eligibly criteria to assess the needs of the Veteran and confirm his or her need for caregiver support. VA clinical providers will determine whether the care the Veteran needs can be provided at home and whether a family member(s) on the application will be capable of providing such care. VA will evaluate the family member(s) to determine the amount of instruction, preparation and training the family member requires to provide the personal care service the Veteran needs.

VA aimed in the Plan to design the application process to be as simple as possible for the Veteran, the proposed family caregivers, and VA staff. VA will also incorporate the application into the Veteran’s electronic health record. We will offer a paper application and an online version of the application as well. The Caregiver Support Coordinator or designated case manager at each VA medical center will work with the Veteran and the proposed family caregiver to determine the appropriateness of each caregiver and the educational needs of each participating family member.

Education and Training

Education and training for family caregivers would include two parts under VA’s Plan: first, a basic caregiver curriculum that will be available in standard classrooms or self study through books, DVD, or online media. It will include training on the standard information applicable to all caregivers and Veterans and will allow the family caregivers to choose the mode of training that is most convenient for them. It will cover material every family caregiver must understand and will include ten core competencies: medication management, vital signs and pain control, infection control, nutrition, functional activities, activities of daily living, communication and cognition skills, behavior management skills, skin care, and caregiver self-care.

The second part of the training will be specific to the individual Veteran’s care needs. It will emphasize care related to the Veteran’s condition, such as traumatic brain injury (TBI), post-traumatic stress disorder (PTSD), impulse control, suicide risk and prevention, substance use disorders, dementia, depression and anger.

Both parts of the training would require that the caregiver demonstrate their competence to provide personal care services to the Veteran in the home. This is an important factor because VA has heard from caregivers about the difficulty they have experienced in transferring skills learned in a clinical setting to the home environment. VA proposes to conduct home visits in a supportive manner to provide additional onsite training, to facilitate successful completion of the training, to validate the family caregivers’ competence, and to provide additional support or problem solving as necessary. Appendix B of the Implementation Plan includes a standard assessment tool VA proposes to use during the home visit to ensure a consistent approach across the country.

Under VA’s Plan, within 10 business days of the family caregivers’ completion of education and training, VA would conduct a home visit to assess the family caregivers’ understanding and competence in providing the care needed by the Veteran. During the initial visit, VA will review core competencies and the family caregiver will be required to demonstrate their understanding of these competencies and those related to the Veteran’s specific care needs. Our goal is to support and provide additional training as necessary to ensure the caregiver and Veteran have what they need.

VA heard from NGOs and others regarding the training and education requirements established in the Act. The NGOs recommended that VA use training materials based on a nationally recognized program that could be modified slightly to address the needs of Veterans and Servicemembers eligible to participate in the family caregiver program. We support this concept and are looking for partners to develop this material. Some VSOs and caregivers recommended that family members with experience in caregiving should be exempt from the required training, but VA in its Plan recognized the importance of establishing clinically demonstrated competency to provide care, which is a requirement of the Act.

Training would extend beyond just care delivery for the Veteran to include segments on self-care and stress management, important skills which caregivers may not have learned before. Moreover, training sessions provide opportunities for caregivers to connect with one another, to develop peer support networks and to exchange ideas that can benefit caregivers and Veterans alike.

Monitoring and Implementation

The Act is very clear that VA “…shall monitor the well-being of each eligible Veteran receiving personal care services under the program…” (38 U.S.C. 1720G(a)(9)(A)). VA monitoring as outlined in the Plan would include evaluation of the Veteran and caregiver’s physical and emotional state, including any signs of abuse and neglect, the adequacy of care and supervision being provided by the family caregivers, the Veteran and family caregivers overall adjustment to care at home, and signs of caregiver stress. Home visits would be completed with a supportive and educational approach to ensure the caregiver is equipped to succeed in their role. VA would focus on the Veteran or legal guardian and caregiver’s perception of the optimal social, emotional, and physical state of welfare in a safe and nurturing environment.

In addition to the in-home competence review after the caregiver has completed training, VA in its Plan proposes follow up well-being checks at least once each quarter, and more often if there are significant changes in the Veteran’s condition or in home dynamics as noted by the Patient Aligned Care Team (PACT) or primary care team. VA saw annual in-home full reassessment of the primary family caregiver’s competence as necessary for continued receipt of the stipend and other benefits. The initial assessment and the quarterly follow up checks would be conducted by a member of the interdisciplinary health team, such as a registered nurse, social worker, physical therapist, or others. Ongoing monitoring would be provided by VA staff through programs such as Home-Based Primary Care, Community Health, Spinal Cord Injury and Disorders Home Care, or Mental Health Intensive Case Management. The Caregiver Support Coordinator or designated case manager would be responsible for ensuring the ongoing monitoring of primary and family caregiver competencies.

Changes in the level of care noted during home evaluation visits would be reported back to the facility Caregiver Support Coordinator or designated case manager and the PACT or primary care team. If there are concerns about caregiver competence that do not pose an immediate safety concern for the Veteran, VA would conduct an assessment to determine what additional training the caregiver requires, and VA would make the necessary arrangements for the caregiver to receive this training in a timely manner. If, during the initial assessment or follow-up home visits, there is evidence of abuse or neglect (or other immediate concerns for the safety of the Veteran), VA will make immediate arrangements for alternate care. Suspected abuse or neglect must be reported in compliance with law and VA policy.

VA has heard the concerns raised by VSOs, NGOs, Veterans and caregivers alike that, while monitoring is essential to ensuring the well-being of the Veteran, it must be done in a supportive manner. VA agrees with this principle entirely and in its Plan noted it would train those conducting in-home visits and assessments to provide support compassionately to the Veteran and caregiver’s specific situation and needs.

The Veteran or legal guardian or the primary family caregiver can request that the designation of primary family caregiver be revoked. VA can initiate revocation for cause or due to the permanent institutionalization or death of the Veteran. Further information about VA’s proposed revocation process can be found on pages 29-31 of VA’s Implementation Plan.

Stipend

VA will issue stipends directly to the designated primary family caregiver under this program. The stipend is made in recognition of the sacrifices that families make when caring for a seriously injured eligible Veteran, and is based on the amount and degree of personal care services provided. As specifically provided in the Act, this stipend is not an entitlement. The stipend is not intended to replace career earnings, and a primary family caregiver does not become a VA employee based on receipt of the monthly caregiver stipend. Details of VA’s proposal for implementing the stipend payments can be found at page 23 of the Plan.

The stipend payments to primary family caregivers constitute “payments [of benefits] made to, or on account of, a beneficiary” that are exempt from taxation under 38 U.S.C. 5301(a)(1).

Health Care Benefit Coverage Primary family caregivers of eligible Veterans may receive medical care under the Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA) if they are not entitled to care or services under a health plan contract (including Medicare, Medicaid, worker’s compensation, insurance policies or contracts, etc.). CHAMPVA is a comprehensive health care benefit program in which VA shares the cost of certain health care services with eligible beneficiaries.

Mental Health Services

VA recognizes that caregivers can experience stress that may result in depression, anger, interpersonal conflict, anxiety, substance use, sleep disturbance, social isolation, or other conditions. Caregiving can also place stress upon the marital or family relationship as well. VA has heard from caregivers that they need and want access to mental health services. As a result, VA’s Plan would include mental health and counseling services to ensure that the primary family caregiver can access support and services to alleviate stress, burnout, and other complications.

In accordance with 38 U.S.C. 1782, general caregivers, as well as family caregivers, would have access to consultation, professional counseling, marriage and family counseling, training and mental health services as necessary in connection with the treatment of the Veteran.

VA would offer mental health and counseling services needed by family caregivers but unrelated to the treatment of the Veteran by providing individual and group therapy and counseling and peer support groups. Under the proposal outlined in the Plan, VA would not provide medication or other medical procedures related to mental health treatment or inpatient psychiatric care. If a primary family caregiver has CHAMPVA or other coverage, such care could be provided by those plans, subject to the health plan’s particular terms.

Travel, Lodging and Per Diem

Travel, lodging and per diem expenses would be provided to family caregivers when family caregivers are undergoing needed training. In addition, family caregivers may be provided the expenses of travel, including lodging and subsistence, when the eligible Veteran is traveling to and from, and throughout the duration of, a medical examination, treatment or care episode.

Respite Care

Caregiving, as noted earlier, places significant demands on those who provide personal care services for a seriously injured eligible Veteran. Respite care is designed to offer family caregivers temporary relief from the demands of daily care, thereby supporting the Veteran’s desire to remain in his or her home. VA may provide respite care for the Veteran during the family caregivers’ training if needed. Respite care for the primary family caregiver will be available for at least 30 days annually under the Act, and VA proposes including 24 hour care commensurate with the care provided by the family caregiver. The VA Caregiver Support Coordinator or designated case manager, in collaboration with the Patient Aligned Care Team (PACT) or primary care team would assess the Veteran and caregiver for appropriate respite services. VA is committed to delivering clinically and age appropriate respite care services through VA and non-VA programs.

VA’s Path Forward for Implementation

The Act is a tremendous step forward for this country in supporting those who have made significant sacrifices on its behalf. It represents the hard work and efforts of Congress, Veterans Service Organizations, VA, and most importantly, our seriously injured Veterans and their caregivers. We understand the frustration many have experienced with the pace of implementation, and we share that frustration. We regret the delay in transmitting the Implementation Plan to the Committee. The Act also identified January 30, 2011 as the date on which caregiver benefits would commence. Given the complexity of these programs, the need for stakeholder input, and the need for regulations, VA was not able to meet that date.

But let me assure our Veterans, their families, and the Committee that we have been working tirelessly to implement this program and begin delivering the benefits established in law. On February 28, 2011, VA transmitted a draft Interim Final Rule to the Office of Management and Budget. We believe this measure will expedite the rulemaking process and set the path to begin delivering caregiver benefits as early as this summer.

VA has been active on myriad other fronts that do not require the publication of regulations to accomplish other implementation milestones. We released a request for proposals in January to assist the Department in creating a national program of caregiver training. This curriculum will serve as the basis for establishing the competencies of family caregivers participating in the program and will promote effective care for our seriously injured Veterans. We launched a new Caregiver Support Line on February 1, 2011 out of awareness of the urgent need to provide information and additional support to caregivers. We are planning to hire at least one full time Caregiver Support Coordinator at every VA medical center by the end of April 2011. We are working now on a new, state-of-the-art Web site that will be launched in May 2011. We are already planning to add additional staff on a temporary basis to manage the creation of these programs and to handle the initial wave of applications from Veterans and caregivers.

VA will also employ a comprehensive outreach program so that Veterans and their caregivers are aware of these services and can easily apply. Our Caregiver Support Coordinators will assist them in this process and will make every effort to expedite our review and the delivery of benefits.

VA understands the concerns that have been expressed on the scope of the benefit, as outlined in our Plan. The Secretary appreciates that VA has an important obligation to get this benefit right. That means making sure those clinicians can consistently apply – and Veterans and their families can understand – our eligibility criteria, as we evaluate the myriad types and combinations of circumstances that injured Veterans and their families face.

Conclusion

There is no higher priority than delivering world class health care services and benefits to our seriously injured Veterans and Servicemembers and their caregivers. We again appreciate the efforts of Congress, the Veterans Service Organizations, and all of our stakeholders in making this Act a reality. It is important for VA as it moves ahead in implementing all parts of the caregiver provisions of the Act to keep the Committee apprised and to hear and respond to your concerns. Thank you for inviting me here to testify today to do that. My colleagues and I are prepared to answer your questions at this time.