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Submission For The Record of Veterans Health Administration Central Office

The Department of Veterans Affairs (VA) is providing, for the record, the following statement on implementation of Sections 304 and 401 of Public Law (P.L.) 111-163, the Caregivers and Veterans Omnibus Health Services Act of 2010.

Section 304

The key provisions in Section 304 of P.L. 111-163 relate to providing family counseling services for immediate family members of eligible Operation Enduring Freedom/Operation Iraqi Freedom/Operation New Dawn (OEF/OIF/OND) Veterans and for the provision and training of Veteran Peer Counselors to support this cadre of Veterans.

Section 304 has many provisions in common with Section 107 of P.L. 110-387, which required VA to establish a pilot program to assess the feasibility and advisability of providing peer outreach services, peer support services by licensed providers, readjustment counseling services, and other mental health services to OEF/OIF/OND Veterans.  In January 2011, VA began the pilot program required by Section 107 of P.L. 110-387.  Given the similarity of these requirements to certain requirements in Section 304 of P.L. 111-163, VA wanted to ensure that new programs developed to comply with Section 304 did not unnecessarily duplicate or overlap programs required by Section 107.  Now that the pilot is underway, VA is able to review and evaluate those elements of Section 304 that may require further enhancement.

Many of the requirements in Section 304 were in place or underway when implementation of P.L. 111-163 began.  This statement will mention those briefly and then highlight actions VA has taken to enhance and expand the program since the passage of P.L. 111-163.

Vet Centers have been authorized to provide the full range of readjustment counseling services, including working with families, to eligible OEF/OIF/OND Veterans and their families since 2003.  In conjunction with Vet Center services, mental health clinicians at other VHA facilities provide a full range of general and specialty mental health services to eligible Veterans of all eras including evidence-based psychotherapy, residential treatment programs, and crisis intervention services.

The Vet Center Program continues to provide peer, or Veteran to Veteran, outreach services to OEF/OIF/OND Veterans and their families since the Secretary of Veterans Affairs authorized the program to do so in 2003.  Currently, Veteran Outreach Specialists within the Vet Center Program proactively contact their fellow returning Veterans at military demobilization sites, including National Guard and Reserve locations, and in their communities.  These individuals, all of whom served in recent combat zones, provide information and referral to Vet Center services as well as connection to other VA services.

Vet Centers provide a full range of psychosocial services under the umbrella of readjustment counseling and are able to facilitate the Veteran-to-Veteran connection due to the high percentage of Veterans employed by the program. This has been a tenet of the Vet Center program since its inception over 30 years ago.

Since the passage of P.L. 111-163, VA has continued improving and expanding its program to provide services to eligible OEF/OIF/OND Veterans and their families.  Section 304 of the law includes a requirement that VA provide services to certain immediate family members to assist in the recovery of eligible Veterans who have incurred injury or illness during deployment. 

VA has a robust system in place to provide transition assistance and care management for wounded, ill and injured OEF/OIF/OND Veterans.  Each VA medical center has an OEF/OIF/OND Care Management team that is highly experienced and specially trained in the needs of returning combat Servicemembers.  These teams coordinate patient care activities and ensure that eligible Servicemembers and Veterans are receiving patient-centered, integrated care and benefits.  OEF/OIF/OND clinical case managers screen all returning combat Veterans to identify Veterans who may be in need of case management services so VA can intervene early and provide assistance before the Veteran is in crisis.  In addition to identifying prevalent medical and mental health issues related to deployment, this screening identifies known risk factors for psychosocial issues such as homelessness, unemployment, family problems, and substance abuse.  Severely ill or injured Servicemembers and Veterans are provided a case manager and other OEF/OIF/OND Servicemembers and Veterans are assigned a case manager as indicated by a positive screening assessment, or upon request.  Case management needs are identified early, a plan of care is developed, and follow-up is provided as long as needed.  OEF/OIF/OND case managers are experts at identifying and accessing resources within the VA health care system and the local community to help Veterans recover from their injuries and readjust to civilian life.  The OEF/OIF/OND case managers are well positioned to offer support and assistance to eligible families in need of mental health services as well.

VA is striving to improve these services.  Additional training was provided in January, February, and March 2012 for case managers to improve screening.  The goal is that while screening Veterans for psychosocial risk factors, the OEF/OIF/OND case management team will ask the Veteran questions regarding mental health, substance abuse or other psychosocial issues the Veteran is experiencing associated with immediate family members.

VA is also working with the Department of Health and Human Services, Substance Abuse and Mental Health Services Administration (SAMHSA) to develop training for use of their mental health provider locator, available on the SAMHSA Web site.  Training is available for OEF/OIF/OND case managers who work with family members to assist them in identifying and accessing mental health and community resources for families and children.  VA staff will receive training on SAMHSA’s substance use provider locator no later than June 30, 2012.

A Caregiver Peer Mentoring Support program in which new caregivers are matched with experienced peers for support, guidance, and the sharing of experiences following similar paths in their caregiving journey was launched in January of 2012.  Caregivers interested in being mentors are registered as volunteers at their local VA medical center and complete an orientation program with the Caregiver Support Program.  After orientation, caregiver mentors are matched with an appropriate caregiver with the expectation that they will contact each other regularly to discuss issues, provide support, and solve problems together.  Mentors will receive ongoing support from the Caregiver Support Program, including monthly calls with all of the mentors participating in the program.  The first three peer mentors have been trained and are in the process of being matched.

Caregiver training and education are important components of VA’s Caregiver Support Program.  Family caregivers of eligible seriously injured Veterans are required to complete a Core Curriculum training program prior to approval for the Program of Comprehensive Assistance for Family Caregivers, which provides additional services and benefits to those eligible, including, for designated and approved Primary Family Caregivers, a stipend and CHAMPVA coverage (if the Primary Family Caregiver is not entitled to care or services under a health-plan contract (as defined)).  The Core Curriculum is designed not only to ensure the proper care of the Veteran, but also to support and minimize the physical and mental health consequences of long-term care giving on the caregiver and other family members.  VA has contracted with Easter Seals to develop a comprehensive caregiver training curriculum to address these needs.  The curriculum is offered in three formats:  self-instruction with a workbook and CD/DVD, Web-based online course, or a classroom setting.  The caregiver may choose the option which best meets their needs and learning style.  As of

March 21, 2012, a total of 4,096 family caregivers have completed the training.

In addition to the services provided by the OEF/OIF/OND care management teams as discussed earlier, there were a variety of family programs authorized before the passage of P.L. 111-163 and available through VHA’s Mental Health Services.  For eligible family members these include:

  • Family consultation, family education and family psycho education for Veterans with serious mental illness;
  • Family education and training, brief problem-focused consultations, more intensive family psycho education, and marriage and family counseling;
  • The Support and Family Education Program (SAFE), which is an 18 session workshop for families of Veterans living with PTSD or serious mental illness;
  • The National Alliance on Mental Illness (NAMI) Family-to-Family Education Program (FFEP), a 12-week program developed by NAMI and taught by trained family members (peers);
  • Talk, Listen, Connect:  Deployment, Homecoming, Changes, which is a joint VA-Department of Defense (DoD) and Sesame Street Workshop bilingual educational outreach initiative; and
  • Integrative Behavioral Couples Therapy (IBCT) for returning Servicemembers and their partners.

Although all of these services are currently being provided, availability varies across the VA health care system.  In December, 2011, VA sent a memorandum to the field reminding facilities that these services had been authorized and should be provided on an ongoing basis.  Since sending the memorandum to the field, VA has provided information on Veterans Integrated Service Networks (VISN) Mental Health Lead calls and All Staff Mental Health calls.  Individual facility and VISN consultation has been provided for several sites.  VA will continue to provide assistance until these services are fully available at all locations. 

VA has authority to enter into contracts to provide mental health services to Veterans who are remote from VA services.  In the absence of accessible peer outreach services, peer support services, and readjustment counseling services, VISNs will utilize these contracting options and explore alternative opportunities in surrounding communities, utilize telehealth options, or encourage the use of online applications and options.  Beginning with the memorandum to the field cited above, VA has continued to send reminders to VISN leadership about the need to identify and utilize these options on an ongoing basis.  VA will also add this item to the Mental Health Operations Check List by the end of April 2012.  VA will assess the local need for these contracts in light of the plans that are in place, and will identify any additional needs through site visits this year.  All sites will be visited by the end of fiscal year (FY) 2012.  Technical assistance will be provided to those sites needing to develop contracts.

VA is working with SAMHSA to identify community-based referrals, resources, and options for Veterans and family members to access these referral services.  Developing system-wide solutions to this issue has been difficult, but SAMHSA is building a Web-based resource directory populated with available options for use by OEF/OIF/OND coordinators, social work staff, and other VA providers to ensure that appropriate referrals for care are made.  VA will receive a progress report on this project by June 30, 2012.

VA has solicited for a national contract with a not-for-profit mental health organization to train Veterans to provide peer outreach and peer support services.  VA-contracted community mental health providers that employ Veterans providing peer outreach and peer support services will also require training of those peer Veterans.  Vet Centers provide their own staff training on peer-related issues and will not be included in this contract.  The completion of the bidding and award process is expected by May 30, 2012.

For contracted community mental health care providers, Web-based training (such as the Post-Traumatic Stress Disorder 101 series) currently exists and will be augmented by training on best mental health care practices developed by the Department of Defense (DoD) Center for Deployment Psychology.  In addition, training on military culture is being developed as part of a joint effort between the DoD Center for Deployment Psychology and VHA.  Training in best mental health care practices will be provided as developed throughout FY 2012, with completion anticipated by the end of the fiscal year.

As part of the implementation plan of Section 304, VA’s Planning and System Support Group has created VISN-level maps that identify the location of enrolled and non-enrolled OEF/OIF/OND Veterans and their travel distance to existing VA medical centers, Community Based Outpatient Clinics, and Vet Centers.  These maps can be used by VISNs for planning purposes.  Maps and directions for their use have been disseminated to the field and are currently available for use.

The DoD Office of Reserve Affairs is also creating a list of current National Guard/Reserve members who are nearing the end of an active duty phase to provide outreach to them and their families about services.  This is a collaborative effort with the VA as part of the Section 304 implementation work group.  Information is still being collected by the National Guard and Reserve Offices for this task.  VA is continuing to discuss and refine the details of this item with the Office of Reserve Affairs during regular meetings in which VA and DoD work on implementation of Section 304.

Section 401

Section 401 of Public Law 111-163 authorizes Readjustment Counseling Service (RCS) to expand Vet Center eligibility to include members of the armed forces, including members of the National Guard or Reserve Forces, who served in OEF/OIF/OND.  This authority provides eligible Servicemembers and their families access to safe and confidential readjustment counseling services at any of the 300 Vet Centers and 70 Mobile Vet Centers located in all 50 states, the District of Columbia, Puerto Rico, Guam, and American Samoa.  VA supports this expansion of Vet Center Services.

Section 401 requires that this be a joint rulemaking between VA and DoD. VA worked with DoD to draft the proposed rule, which was published in the Federal Register on March 13, 2012.  The public comment period will end on May 14, 2012.  After the comment period closes, VA and DoD will promptly draft a final rule, to include responses to all comments and revisions as appropriate.  The final rule will be effective 30 days after it has been published in the Federal Register.

VA is ready to implement the program as soon as the final rule is published.  At that time, VA will launch an extensive outreach program to inform eligible Servicemembers about the expansion of Vet Center services.  VA will monitor personnel and resources requirements for the program over time, and will adjust support accordingly once the level of Servicemember participation is determined.