VA Health Care: Actions Needed to Improve Family Caregiver Program
Fast Facts
The Family Caregiver Program has provided financial and other types of assistance to caregivers of veterans seriously injured in the line of duty since 9/11.
VA is still working on implementing a new IT system for the program, which will allow it to expand the program to help all veterans’ caregivers as required by the VA MISSION Act of 2018.
VA doesn’t have the data it needs to determine whether the program is appropriately staffed and participants are monitored. This could make it harder for VA to determine the number and type of staff it will need once the program expands.
We recommended that VA collect reliable staffing and monitoring data.
VA hallway sign directing people to Post 9/11 Transition & Care Management
Highlights
What GAO Found
Within the Department of Veterans Affairs (VA), the Veterans Health Administration (VHA) has established staffing requirements for its Program of Comprehensive Assistance for Family Caregivers (Family Caregiver Program) that allow for variation, but its staffing data are not complete or accurate. VHA requires its local VA medical centers (VAMC) to have at least one Caregiver Support Coordinator to manage the program. Otherwise, VAMCs have flexibility in determining the additional staff needed. VHA's Caregiver Support Program Office funds most Family Caregiver Program staff at VAMCs. VAMCs also may fund additional program staff or have other VAMC staff assist the program as a collateral duty, but GAO found that the program office only tracks the staff it has funded. GAO also identified discrepancies between the number of staff it observed at selected VAMCs and the program office's staffing data. Without complete and accurate staffing data, the program office does not have reliable information about the program's current staffing levels, which could hamper its efforts to project needed staff when the program's eligibility is expanded.
The program office routinely monitors VAMCs' performance in meeting departmental timeliness requirements for reviewing enrollment applications for the Family Caregiver Program. However, it is not able to monitor whether VAMCs are completing required quarterly contacts and annual home visits to enrolled caregivers and veterans. The Family Caregiver Program's current information technology (IT) system—the Caregiver Application Tracker (CAT)—has limited reporting capabilities and cannot provide system-wide data on the completion of these contacts and visits even though this information is documented in CAT. GAO found that some VAMCs and the regional Veterans Integrated Service Networks (VISNs) that oversee them use spreadsheets to track the completion of these requirements, but the program office does not collect these data. Without system-wide data on contacts and visits, the program office is limited in its ability to monitor and identify when VAMCs may need additional staff to meet these requirements, including once the program's eligibility is expanded.
VA has yet to implement a new IT system that fully supports the Family Caregiver Program as required by the VA MISSION Act. VHA and the Office of Information and Technology (OIT) have been working jointly on projects since 2015 to improve and replace CAT. However, two of these projects were terminated without delivering viable software improvements or a replacement system. According to two independent assessments, these prior efforts lacked both effective leadership and implementation of the processes needed for requirements management. VA has asserted that its third project, in which OIT and VHA have begun to acquire and implement a commercial product to replace CAT, will take steps to avoid the issues that have impacted its past efforts. However, the initial replacement for CAT is not expected until late October 2019. Further, despite this initial deployment and additional releases expected through the summer of 2020, the department has not yet fully committed to a date by which it will certify that the new IT system fully supports the program. Until the system is implemented and certified, the expansion of eligibility for the Family Caregiver Program will be delayed.
Why GAO Did This Study
Since 2011, the VA Family Caregiver Program has provided assistance to caregivers of seriously injured post-9/11 veterans at VAMCs nationwide. However, GAO previously reported that some VAMCs have struggled to manage the program's workload. The VA MISSION Act of 2018 requires the expansion of program eligibility to veterans of all eras contingent upon implementation and certification of a new IT system.
The VA MISSION Act included a provision for GAO to review VA's efforts to implement a new IT system. GAO was also asked to examine staffing for the program. This report examines the extent to which VA 1) has established staffing requirements and has data to track program staffing; 2) monitors whether VAMCs are meeting departmental requirements for application review timeliness and required contacts; and 3) has implemented an IT system that fully supports the program. GAO reviewed program documentation and data. GAO also interviewed VHA officials and officials from four VAMCs and their VISNs that varied in their numbers of applications and approved caregivers. GAO also interviewed OIT officials and reviewed documentation related to their efforts to acquire and develop an IT system for the program.
Recommendations
GAO is making three recommendations to VA to collect complete staffing data, establish a process to ensure the data are accurate, and establish an interim method for collecting system-wide data on required contacts and visits. VA concurred with all three recommendations.
Recommendations for Executive Action
| Agency Affected | Recommendation | Status |
|---|---|---|
| Department of Veterans Affairs | The Secretary of the VA should direct the Under Secretary for Health to collect complete staffing data for the Family Caregiver Program that includes Caregiver Support Program Office funded staff, VAMC funded staff, and staff that assist the program as a collateral duty at each VAMC. (Recommendation 1) |
Closed – Implemented
The Department of Veterans Affairs (VA) concurred with this recommendation. In September 2020, the Veterans Health Administration (VHA) reported that it had provided guidance to VA Medical Center (VAMC) officials in August 2020 detailing how to assign Caregiver Support Program office-funded staff a Family Caregiver Program-specific code in the Human Resource (HR) Smart system. VHA documentation shows that HR-Smart reports on Family Caregiver Program staff assigned this code have become more complete over time, and as of April 2022, VHA was able to pull reports showing the staff assigned the program's code, their position title, and location, among other data. According to VHA officials, the number of staff assigned the code as of April 2022 was approaching 1,900 staff nation-wide. In addition, the Caregiver Support Program Office continues to have Veterans Integrated Service Network (VISN) officials also report Family Caregiver Program staffing data on a weekly basis, including any VAMC-funded staff within the VISN. The VISN-reported data is reconciled against the HR Smart data and used to verify the completeness of the HR Smart data. VHA officials report that the need for and use of collateral duty staff has been greatly reduced since the introduction of Centralized Eligibility and Appeals Teams (CEAT) to determine eligibility and review appeals for the Family Caregiver Program in fiscal year 2021. CEAT staff are tracked in HR Smart and VHA reported that there were 195 CEAT staff at the end of fiscal year 2021. The Caregiver Support Program Office's use of the HR Smart Family Caregiver Program-specific code to track full-time staff in conjunction with continued VISN-reporting helps ensure that VHA has complete staffing data for the program.
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| Department of Veterans Affairs | The Secretary of the VA should direct the Under Secretary for Health to establish a process to ensure that the Family Caregiver Program staffing data that are collected and reported to the Caregiver Support Program Office are accurate. (Recommendation 2) |
Closed – Implemented
The Department of Veterans Affairs (VA) concurred with this recommendation. In April 2022, the Veterans Health Administration (VHA) reported that the Caregiver Support Program Office has a process in place to help ensure the accuracy of staffing data for the Family Caregiver Program. On a weekly basis, the caregiver support lead in each Veterans Integrated Service Network, (VISN) compiles staffing data in a spreadsheet and submits it to the program office. The program office uses a computer program to reconcile the VISN-provided data against a weekly report from the Human Resource (HR) Smart system that includes all staff who are assigned the HR Smart code that is associated with the Family Caregiver program. The output from this program annotates any discrepancies between the two datasets and recommends corrections to reconcile these discrepancies. This output is available to VISN leads and the program office in a dashboard format. According to VHA officials, the program office works with the VISN leads to resolve the identified discrepancies in real-time each week. The process that VHA has put in place will help to ensure the accuracy of staffing data for the Family Caregiver Program.
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| Department of Veterans Affairs | The Secretary of the VA should direct the Under Secretary for Health to identify and use an interim method to collect data from VAMCs on their completion of required quarterly contacts and annual home visits with caregivers and veterans that can be used until a new IT system is implemented. (Recommendation 3) |
Closed – Implemented
VHA concurred with the recommendation. In late-October 2019, the Caregiver Support Program Office began entering data on veterans and their caregivers who were new to the Caregiver Support Program, including the Program of Comprehensive Assistance for Family Caregivers (Family Caregiver Program), into a new information technology (IT) system-the Caregiver Record Management Application (CARMA). On December 2, 2019, the Caregiver Support Program Office fully transitioned to CARMA from its previous IT system-the Caregiver Application Tracker (CAT)-and began using CARMA to support the administrative needs of both new and existing caregivers and veterans in the Family Caregiver Program. This transition included migrating existing data on caregivers and veterans that was in CAT to CARMA. Since the transition in early December 2019, program staff have been able to use CARMA to review and filter data to generate lists of all required monitoring-quarterly contacts and annual home visits-that have been completed, are upcoming, or are overdue. CARMA users can create customized lists that allow them to view the status of required monitoring by individual VA medical center (VAMC) or regionally by Veterans Integrated Service Network (VISN). Users can also customize the view by period of time (e.g., last 30 days, next 30 days, etc.). The implementation of the capability within CARMA to view and generate data on required monitoring would allow the Caregiver Support Program Office to obtain the data needed to monitor the completion of required quarterly contacts and annual home visits with caregivers and veterans in the Family Caregiver Program.
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