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What GAO Found

The Veterans Health Administration (VHA)—within the Department of Veterans Affairs (VA)—significantly underestimated caregivers' demand for services when it implemented the Program of Comprehensive Assistance for Family Caregivers (Family Caregiver Program). As a result, some VA medical centers (VAMCs) had difficulties managing the larger-than-expected workload, and some caregivers experienced delays in approval determinations and in receiving program benefits. VHA officials originally estimated that about 4,000 caregivers would be approved for the program by September 30, 2014. However, by May 2014 about 15,600 caregivers had been approved—more than triple the original estimate. The program's staffing was based on VA's initial assumptions about the potential size of the program and consisted of placing a single caregiver support coordinator at each VAMC to administer the program. In addition, each VAMC was to provide clinical staff to carry out essential functions of the program, such as conducting medical assessments for eligibility and making home visits. This led to implementation problems at busy VAMCs that did not have sufficient staff to conduct these program functions in addition to their other duties. As a result, timelines for key program functions, such as those for completing applications within 45 days and making quarterly home visits to caregivers, are not being met. VHA has taken some steps to address staffing shortages; however, some VAMCs have not been able to overcome their workload problems because the program continues to grow at a steady rate—about 500 approved caregivers are being added to the program each month. Federal internal control standards emphasize the need for effective and efficient operations, including the use of agency resources.

The Caregiver Support Program office, which manages the program, does not have ready access to the type of workload data that would allow it to routinely monitor the effects of the Family Caregiver Program on VAMCs' resources due to limitations with the program's information technology (IT) system—the Caregiver Application Tracker. Program officials explained that this system was designed to manage a much smaller program, and as a result, the system has limited capabilities. According to federal standards for internal control, agencies should identify, capture, and distribute information that permits officials to perform their duties efficiently. However, outside of obtaining basic aggregate program statistics, the program office is not able to readily retrieve data from the system that would allow it to better assess the scope and extent of workload problems at VAMCs. Program officials also expressed concern about the reliability of the system's data, which they must take steps to validate. The lack of ready access to comprehensive workload data impedes the program office's ability to monitor the program and identify workload problems or make modifications as needed. This runs counter to federal standards for internal control which state that agencies should monitor their performance over time and use the results to correct identified deficiencies and make improvements. Program officials told GAO that they have taken initial steps to obtain another IT system, but they are not sure how long it will take. However, unless the program office begins taking steps towards identifying solutions prior to obtaining a new system, VAMCs' workload problems will persist and caregivers will not be able to get the services they need.

Why GAO Did This Study

In May 2010, Congress required VA to establish a program to support family caregivers of seriously injured post-9/11 veterans. In May 2011, VHA implemented its Family Caregiver Program at all VAMCs across the country, offering caregivers an array of services, including a monthly stipend, training, counseling, referral services, and expanded access to mental health and respite care. In fiscal year 2014, VHA obligated over $263 million for the program.

GAO was asked to examine VA's implementation of the Family Caregiver Program. This report examines how VHA is implementing the program, including the types of issues that have been identified during initial implementation. GAO obtained and reviewed relevant policy documents and program data and interviewed officials from VHA's Caregiver Support Program office. GAO also met with officials from five VAMCs and their corresponding Veterans Integrated Service Networks to obtain information on program implementation at the medical facility level.

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GAO recommends that VA (1) expedite the process for implementing a new IT system that will enable officials to obtain workload data; and that VHA (2) identify solutions to alleviate VAMCs' workload burden in advance of obtaining a new IT system, and (3) use data from the new IT system, once implemented, and other relevant data, to re-assess the program and implement changes as needed. VA agreed with GAO's recommendations.

Recommendations for Executive Action

Agency Affected Recommendation Status
Department of Veterans Affairs 1. To ensure that the Family Caregiver Program is able to meet caregivers' demand for its services, the Secretary of the Department of Veterans Affairs should expedite the process for identifying and implementing an IT system that fully supports the program and will enable VHA program officials to comprehensively monitor the program's workload, including data on the status of applications, appeals, home visits, and the use of other support services, such as respite care.
VA concurred with our recommendation and the Veterans Health Administration (VHA) and the Office of Information and Technology (OIT) have been working jointly on projects since 2015 to improve and replace the IT system for the Family Caregiver Program. 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. In March 2019, VA began a third project, the Caregiver Record Management Application (CARMA), in which OIT and VHA began to acquire and implement a commercial product to replace the program's existing IT system. In February 2020, VA reported that to support the administrative needs of the Family Caregiver Program it had transitioned from its previous IT system to CARMA, its new IT system, in two stages: 1) In October 2019, VA deployed an initial release of CARMA for data entry of veterans and caregivers newly participating in the program, and 2) On December 2, 2019 the transition of existing veterans and caregivers to CARMA occurred. VA also reported in February 2020 that further enhancements and improvements to CARMA would be released over the coming months. However, the department has not yet fully committed to a date by which it will certify that CARMA fully supports the program. As of July 2020, this recommendation remains open pending further updates.
Department of Veterans Affairs 2. The Secretary of the Department of Veterans Affairs should direct the Undersecretary for Health to identify solutions in advance of obtaining a replacement IT system to help alleviate VAMCs' workload burden, such as modifications to the program's procedures and timelines, including those for application processing and home visits, as well as the identification of additional ways to provide staffing support.
Closed - Implemented
In June 2015, VA stated that it had introduced initiatives in response to GAO's recommendation to reduce workload burden on VA medical centers (VAMC) caused by the Family Caregiver Program's application and home visit requirements. VA's initiatives included Funding 42 additional Caregiver Support Coordinators (CSC), who are the program's VAMC-level clinicians and daily managers; Permitting VAMC administrative staff access to the program's information system to enable them to input data, thereby reducing administrative burden on CSCs; Providing a national training event on the program's application process for VAMC clinical staff to encourage their support of the caregiver program; Intensified training for CSCs on the determination of administrative eligibility for the program; Allowing CSCs, in consultation with the veteran's treatment team, the option to utilize methods other than home visits for performing follow-up monitoring assessments, such as face-to-face meetings during a veteran's clinic visit, contact by telephone, or through telehealth technology; Providing orientation training to new CSCs through telephone calls from national Caregiver Support Program managers; Conducting visits to several VAMCs by national Caregiver Support Program managers for consultative, supportive, and training purposes; In addition to initiatives introduced by national Caregiver Support Program officials, some individual VAMCs took steps to address excessive workload burden by using temporary detailees to augment Caregiver Support Coordinators; Utilizing VA benefits program physicians to eliminate long waiting times for physical assessments, and by paying RNs overtime to reduce the number of delayed home visits; and Modifying local Family Caregiver eligibility procedures by having an interdisciplinary team prescreen veterans, followed by a physical assessment conducted by a single physician to determine eligibility and stipend amount. According to a CSC, these procedures reduced workload, avoided lengthy waits for physical assessments, and by having an interdisciplinary team and a single physician perform all of the physical assessments, decisions regarding eligibility and stipend were more consistent. This improved consistency in decisions led to further decreases in workload burden due to the fewer number of appeals filed by veterans. As result of VA's national and local efforts, workload burden on VAMCs generated by the Family Caregiver Program's application and home visit procedures has moderated. Although VA continues to receive applications at approximately the same rate as in FY 2014, from January through June 2015, the number of applications completed within program guidelines rose from 57% to 62% and the percentage of applications in process for more than 90 days declined from 43% to 38%. By June 2015, only 8 VAMCs accounted for 80% of the applications that were older than 120 days. Although workload burden remains a serious challenge for VA's Family Caregiver Program, these results demonstrate that initiatives taken by VA have resulted in positive trends in application completion times.
Department of Veterans Affairs 3. The Secretary of the Department of Veterans Affairs should direct the Undersecretary for Health to use data from the IT system, once implemented, as well as other relevant data to formally reassess how key aspects of the program are structured and to identify and implement modifications as needed to ensure that the program is functioning as envisioned so that caregivers can receive the services they need in a timely manner.
VA concurred with this recommendation. VA transitioned in late 2019 to a new IT system, the Caregiver Record Management Application (CARMA). However, the Department has not yet certified the readiness of CARMA to fully support the needs of the Program of Comprehensive Assistance for Family Caregivers (Family Caregiver Program). Prior to the transition to CARMA, VA had developed manual processes to obtain and monitor key data points, allowing it to reassess policies and procedures for the Family Caregiver Program. In its September 2019 update, VA reported that it anticipates being able to certify the IT system when proposed regulatory changes to enable the expansion of the Family Caregiver Program are finalized and the necessary changes which have an impact on IT are implemented. VA also reported that following certification, IT development will continue on IT requirements that do not directly impact VA's ability to expand the program, such as improving the program's ability to track and report on clinical appeals. As of July 2020, this recommendation remains open pending further updates on how VA plans to use data from the IT system to monitor and assess the program's performance.

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