VA Health Care: Actions Needed to Improve Family Caregiver Program

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.

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.

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.

Since September 11, 2001, many veterans have suffered serious physical  or psychological injuries in the line of duty and rely on support and  assistance from caregivers, who are often family members. Family  caregivers typically assist veterans with tasks of everyday living, like  bathing and eating, as well as making and keeping appointments and  making medical, legal, or financial decisions. The assistance that family  caregivers provide can enable veterans to achieve a better quality of life  and contribute to their rehabilitation and recovery. However, while these  caregivers enable seriously injured veterans to continue living in their  homes rather than institutions, caregivers may encounter financial  difficulties due to lost income, and caregiving activities can take a toll on  their physical and emotional health.

To provide greater support for caregivers of post-9/11 veterans, the  Caregivers and Veterans Omnibus Health Services Act of 2010 required  the Department of Veterans Affairs (VA) to establish a program to assist  these caregivers with caring for seriously injured veterans. In May 2011,  the Veterans Health Administration (VHA)—which operates VA’s health  care system—implemented the Caregiver Support Program, which  included the establishment of the Program of Comprehensive Assistance  for Family Caregivers (Family Caregiver Program) at each of its VA  medical centers (VAMC) across the United States. In accordance with  applicable requirements, the program provides approved primary  caregivers with a monthly financial stipend based on the level of caregiver  support that the veteran needs. The program also offers other types of  assistance to caregivers, including training, referral services, counseling,  some mental health services, and respite care, among others. As of  September 30, 2018, an estimated 19,690 caregivers of post-9/11  veterans were enrolled in the Family Caregiver Program.

In 2014, we reported that VHA had experienced difficulties with  implementing the program because it had significantly underestimated the  number of caregivers who would apply for and be eligible to enroll in the  program. Specifically, we found that VAMCs had insufficient staff to  manage the program, and as a result, some VAMCs had difficulty  meeting the department’s timeliness requirements for reviewing  applications and making all required contacts with enrolled veterans and  their caregivers. We also reported that VHA’s ability to use the program’s  information technology (IT) system, the Caregiver Application Tracker  (CAT), for tasks beyond tracking the status of applications was difficult  and time-consuming, limiting VHA’s capability to monitor the program. We  recommended, among other things, that VA implement an IT system that  would support the Family Caregiver Program and enable officials to  comprehensively monitor the program. As of July 2019, this  recommendation had not been implemented. Since 2015, VA’s Office of  Information and Technology (OIT) and VHA’s Caregiver Support Program  Office have jointly worked to acquire new IT system capabilities to replace  CAT.

The population of caregivers enrolled in the Family Caregiver Program is  expected to increase with the future expansion of program eligibility. The  VA MISSION Act of 2018, enacted in June 2018, requires the expansion  of Family Caregiver Program eligibility to include caregivers of veterans  who served prior to September 11, 2001. However, before the expansion  of eligibility can occur, the VA MISSION Act requires VA to implement an  IT system for the program, and the VA Secretary must certify to Congress  that the new system will fully support the Family Caregiver Program by  allowing for data assessment and comprehensive monitoring by October  1, 2019.

We were asked to review issues related to VHA’s staffing of the Family  Caregiver Program. The VA MISSION Act also included a provision for us  to review VA’s efforts to develop and implement an IT system to support  the program. This report examines the extent to which  1.  VHA has established staffing requirements for the Family Caregiver  Program and has data to track program staffing at VAMCs;  2.  VHA monitors whether VAMCs are meeting departmental  requirements for the timeliness of application reviews and for contacts  with caregivers and veterans for the Family Caregiver Program; and  3.  VA has implemented an IT system that fully supports the Family  Caregiver Program.

To examine the extent to which VHA has established staffing  requirements and has data to track Family Caregiver Program staffing at  VAMCs, we reviewed VHA’s 2018 policy directive to identify the  program’s staffing requirements. We interviewed VHA officials from the  Caregiver Support Program Office, which sets policy for the Family Caregiver Program. We also reviewed VHA staffing data for the positions  that the Caregiver Support Program Office funded at all VAMCs for fiscal  years 2016, 2017, 2018, and the first quarter of 2019, the most recent  period for which data were available. We determined that these were the  only staffing data available, and while they were suitable for the purposes  of site selection, they also have limitations, which we discuss in the  report. We visited four selected VAMCs to discuss their staffing and  workload for the Family Caregiver Program. We also interviewed lead  officials for the Family Caregiver Program from each Veterans Integrated  Service Network (VISN) associated with the four selected VAMCs, to  discuss their roles as well as program staffing within the VISNs. We  selected VAMCs with varying program sizes and workloads based on 1)  the number of applications received from fiscal year 2016 through fiscal  year 2018 (as of September 4, 2018); 2) the number of caregivers  enrolled as of June 1, 2018; and 3) the number and types of caregiver  support coordinators (CSCs), who administer the program at VAMCs, as  of fiscal year 2018. The VAMCs we selected were Altoona,  Pennsylvania (VISN 4); Augusta, Georgia (VISN 7); Orlando, Florida  (VISN 8); and Chicago, Illinois (VISN 12). For the four VAMCs we visited,  we identified the program’s staffing levels and compared this information  to the Caregiver Support Program Office’s staffing data for these facilities.  We also interviewed CSCs and other program staff as well as staff who  assist the program as a collateral duty. The information we obtained from  the selected VAMCs and VISNs cannot be generalized. We evaluated  VHA’s staffing requirements and data for the program against federal  internal control standards for information and communication.

To examine the extent to which VHA monitors whether VAMCs are  meeting requirements for the timeliness of application reviews and  making contacts with caregivers and veterans for the Family Caregiver  Program, we reviewed relevant policies and other program documents,  such as VHA’s policy directive for the program and reports on application  review timeliness. We also reviewed Family Caregiver Program data  from fiscal year 2018, to the extent it was available from CAT, on the  timeliness with which VAMCs process applications for the Family  Caregiver program and the extent to which VAMC staff met departmental  requirements for contacting caregivers and veterans on a quarterly basis  and making annual home visits. We reviewed documentation and  interviewed officials about the application processing data from CAT and  determined that it was reliable for the purposes of our engagement.  However, we could not obtain system-wide data on required contacts and  visits with caregivers and veterans from CAT, which we discuss in the  report. We interviewed officials from VHA’s Caregiver Support Program  Office about their monitoring of Family Caregiver Program requirements,  including the types of data they use for this purpose. Further, to  understand how officials at VAMCs are meeting program requirements,  we interviewed leadership and staff associated with the Family Caregiver  Program at the four VAMCs we visited. We also interviewed the officials  who serve as VISN lead officials for the VAMCs we visited. We compared  VHA’s monitoring of Family Caregiver Program application processing  timeliness and the completion of quarterly contacts and annual home  visits with federal internal control standards for information and  communication.

To examine the extent to which the VA has implemented an IT system  that fully supports the Family Caregiver Program consistent with the VA  MISSION Act, we examined program documentation related to VA’s  efforts to update its IT system, including documentation on the project  management plan, schedule, the system design, testing results, and  defect reports. Further, we examined two independent assessments  commissioned by VA that documented the history of VA’s efforts to  develop an IT system replacement and related challenges, findings, and  recommendations. We also examined initial planning documents for the  most recent IT acquisition effort. Finally, we interviewed relevant officials  from the VHA, such as Caregiver Support Program Office officials, and  OIT staff familiar with the various activities undertaken by the department  to develop and implement an IT system to support the Family Caregiver  Program.

We conducted this performance audit from April 2018 to September 2019  in accordance with generally accepted government auditing standards.  Those standards require that we plan and perform the audit to obtain  sufficient, appropriate evidence to provide a reasonable basis for our  findings and conclusions based on our audit objectives. We believe that  the evidence obtained provides a reasonable basis for our findings and  conclusions based on our audit objectives.

Family Caregiver Program Organizational Structure

Within VHA, the Caregiver Support Program Office, VISNs, and VAMCs  all have a role in administering and overseeing the Family Caregiver  Program.

Caregiver Support Program Office. The Caregiver Support Program  Office administers the Caregiver Support Program, which has two main  components—  1.  the Family Caregiver Program, which is available to eligible post-9/11  veterans, and their qualified caregivers, and  2.  the Program of General Caregiver Support Services, which is  available to covered veterans from any service era and their qualified  caregivers.

The Caregiver Support Program Office develops policy and procedures  and provides guidance, oversight, and support for both components of the  Caregiver Support Program. As of April 2019, this office had 11 full-time  staff, with authorization to hire eight additional staff.

VISNs. Each of VHA’s 18 VISNs has a lead official for the Family  Caregiver Program—either a VAMC CSC who serves in the VISN lead  role for at least 25 percent of the CSC’s time or a VISN employee who is  responsible for the Family Caregiver Program as one of their VISN duties.  The VISN lead official’s role is to provide guidance to CSCs within the  VISN and to help address their questions or concerns. VISN lead officials  are also responsible for disseminating information, collecting data when  needed, conducting quality assurance audits, assisting and coordinating  responses to inquiries from the Caregiver Support Program Office, and  monitoring the Family Caregiver Program workload across the VISN.

VAMCs. The program is administered at the local level at 140 VAMCs.  Each VAMC has staff that are assigned to the program on either a full- time or part-time basis, as well as other VAMC staff that may assist with  specific Family Caregiver Program-related activities as a collateral duty.

VAMC staff assigned to the Family Caregiver Program may include the  following:

CSCs. CSCs are the primary program staff administering the program  at VAMCs. They are generally licensed clinical social workers or  registered nurses. CSCs have clinical responsibilities that may include  identifying and coordinating appropriate interventions for caregivers or  referrals to other VA or non-VA programs, such as mental health  treatment, respite care, or additional training and education. CSCs  also have administrative responsibilities that may include responding  to inquiries about the program, overseeing the application process,  and entering information about applications and approved caregivers  into IT systems. During the first quarter of fiscal year 2019, there were  approximately 436 CSCs assigned to 140 VAMCs.

Administrative staff. Administrative staff are typically responsible for  activities such as mailing communications to program applicants and  participants, scheduling appointments, entering data into CAT, and  otherwise supporting the administrative needs of the program. During  the first quarter of fiscal year 2019, 24 of the 140 VAMCs or health  care systems had administrative staff members assigned to the  program.

Clinical staff. Some VAMCs have clinical staff assigned to the  program, which can include registered nurses, doctors, nurse  practitioners, occupational therapists, or psychologists. These staff  typically conduct in-home monitoring and may help with clinical  eligibility determinations of veterans during the application process.  During the first quarter of fiscal year 2019, 17 VAMCs had  approximately 12 full-time-equivalent doctors, nurse practitioners,  occupational therapists, and psychologists assigned to the program.

Other VAMC clinical staff who are not assigned to the Family Caregiver  Program may assist the program as a collateral duty. For example, they  may serve as members of the clinical eligibility team or assist with  program monitoring—including quarterly contacts and annual home  visits—or program appeals (see fig. 1).

Funding for Family Caregiver Program Staff

The Caregiver Support Program Office directly funds the salaries for staff  assigned to the Family Caregiver Program at VAMCs. Specifically, it  funds the salaries of the CSCs, as well as some other staff who are  assigned to the program, such as administrative staff or clinical staff.  However, some VAMCs may also choose to fund additional staff for the  program, if they identify a need. Additionally, the portion of time spent by  VAMC staff assisting the program as a collateral duty may be reimbursed  by the Caregiver Support Program Office.

Family Caregiver Program Application Process

To participate in the program, caregivers and veterans must submit  applications to their local VAMC or to VHA’s Health Eligibility Center.  CSCs manage the multi-step application process, which includes  administrative and clinical eligibility determinations, among other  requirements (see fig. 2). According to VHA policy, VAMCs should review  applications for the program within 45 days. However, this review can be  extended up to 90 days if the veteran’s caregiver has not completed  required training, or the veteran is hospitalized during the application  process.

Once caregivers and veterans are enrolled in the Family Caregiver  Program, VHA policy requires CSCs or other VAMC clinical staff to  periodically monitor the veteran’s overall health and well-being and the  adequacy of the care and supervision being provided by the caregiver.  This monitoring is to be documented in CAT as well as in the  Computerized Patient Record System because it is a clinical encounter.  The monitoring includes quarterly contacts. These contacts are supposed to occur every 90  calendar days, unless otherwise clinically indicated. They may be  conducted as home visits, or if approved by the veteran’s primary care  team, the contacts can be completed via telephone, a face-to-face  visit at a VHA medical facility, or using clinical video telehealth. annual home visits. Caregivers and veterans must receive at least  one home visit each year. According to Caregiver Support Program  Office officials, the annual home visit counts as one of the quarterly  contacts.

If a veteran demonstrates an improvement or decline in their functioning  while in the program, VAMC staff are supposed to reassess the veteran  to determine whether they remain clinically eligible for the program or  whether a change in the stipend tier level (increase or decrease) may be  appropriate. A reassessment may result in a discharge from the program,  a tier level change, or no change. However, the VA Secretary announced  a moratorium on discharges and tier level decreases on December 21,  2018 due to continued concerns from veterans, caregivers, and others  about VAMCs’ inconsistent application of eligibility requirements.

According to Caregiver Support Program Office officials, there is no  current timeline for when the moratorium will be lifted.

VA Office of Inspector General Review of the Family Caregiver Program

In August 2018, the VA Office of Inspector General (VA OIG) issued a  report on its review of the Family Caregiver Program, which focused on  whether the program effectively provided services and support to qualified  veterans and their caregivers. The VA OIG found that program  applications were not reviewed in a timely manner, eligibility criteria were  not consistently applied, caregivers and veterans were not routinely  monitored, and that VHA had failed to effectively establish a governance  structure that promoted program management accountability. The VA  OIG made six recommendations to improve the program, including  recommendations to establish a governance structure and to assess the  adequacy of the program’s staffing levels at VAMCs. In May 2019, the VA  OIG reported that the program had implemented the two  recommendations related to establishing a governance environment and  designating VISN lead officials for the program. Specifically, the Family  Caregiver Program issued an updated directive for the program and  additional standard operating procedures in October 2018 to address the  governance environment recommendation and issued a memorandum  regarding VISN lead officials in January 2019 to address the VISN lead  official recommendation. According to the VA OIG, the remaining  recommendations have not yet been implemented.

The VA MISSION Act, which was enacted in June 2018, included  provisions directing VA to implement an IT system to support the Family  Caregiver Program and the incremental expansion of program eligibility.  Specifically, the Act required VA to implement an IT system by October 1,  2018. According to the Act, the IT system is to allow for data assessment  and comprehensive monitoring of the program. The VA MISSION Act  also required VA to submit an initial report to Congress regarding the  status of the planning, development, and deployment of this system within  90 days of enactment of the Act and a final report by October 1, 2019.  The final report is to include a certification by the VA Secretary that the  system has been implemented, along with a description of how the  Secretary is using the system to monitor the workload of the program.

In addition, the VA MISSION Act requires an incremental expansion of  eligibility for the Family Caregiver Program. Specifically, within 2 years of  the VA Secretary certifying the IT system for the Family Caregiver  Program, VHA is to expand program eligibility to caregivers of veterans  with a serious injury incurred or aggravated in the line of duty on or before  May 7, 1975 or on or after September 11, 2001. Two years after this initial  expansion of eligibility, VHA is to further expand program eligibility to  include any veteran with a serious injury incurred or aggravated in the line  of duty and in need of personal care services as specified in the statute.

Staffing Requirements for the Family Caregiver Program Allow Variation across VAMCs; VHA Lacks Complete and Accurate Staffing Data for the Program

Family Caregiver Program Staffing Varies across VAMCs

The Caregiver Support Program Office policy requires every VAMC to  have at least one full-time CSC to administer the program. The policy  also requires VAMCs to have an eligibility determination process, but  does not specify staffing requirements for that process beyond stating  that “appropriate” providers should be involved. This broad guidance  provides VAMCs with flexibility in determining which providers to include  in the eligibility determination process.

We found that each of the four VAMCs we visited staff their Family  Caregiver Program differently, including both the staff assigned to the  program as well as other VAMC staff assisting the program as a collateral  duty. While all four VAMCs had at least one CSC on staff, as required,  other staff assigned to the program varied and included administrative  staff, a non-CSC social worker, and non-CSC registered nurses.  Furthermore, the differences we identified with VAMC staff assisting the  program as a collateral duty included staff that assist with clinical eligibility  determinations as well as staff that assist with other program  requirements. Specifically, each of the four VAMCs had assembled their  own clinical eligibility teams, which varied in composition and could  include physicians, therapists, or mental health professionals. Other  variations with staff assisting the program included three VAMCs that  utilized members of the Home Based Primary Care team to assist with  initial home visits, quarterly contacts, and annual home visits, and a  VAMC that used physicians to assist the program with assigning stipend  tier levels (see table 1).

VHA Lacks Complete and Accurate Information on Family Caregiver Program Staffing

We found that VHA’s Caregiver Support Program Office does not have  complete and accurate staffing information for the Family Caregiver  Program. First, the Caregiver Support Program Office does not have  complete information on all staff supporting the program. The office only  tracks staff funded by the Caregiver Support Program Office, but does not  track program staff that are VAMC-funded or other VAMC staff that assist  the program as a collateral duty. For example, one site we visited had a  VAMC-funded nurse that conducted quarterly contacts and home visits,  but this nurse was not being tracked by the program office. Similarly, the  program office was not tracking the time and resources related to VAMCs’  clinical eligibility team members. At each of the four VAMCs we visited,  members of the clinical eligibility teams dedicated between 3 and 12  hours a month preparing for and attending the eligibility meetings.

Furthermore, although the program’s VISN lead officials collect data on  the Caregiver Support Program Office funded positions at each VAMC  annually at a minimum and submit these data to the Caregiver Support  Program Office, there is no documented process to validate the data’s  accuracy. VHA employs a process that relies on VISN lead officials  collecting data from facilities, and as a result, the overall accuracy of the  data depends on the accuracy of the data VAMCs report. Based on our  review of the staffing data, we identified discrepancies between the  Caregiver Support Program Office’s staffing data for the first quarter of  fiscal year 2019 and the number of staff we observed at all four VAMCs  we visited.

At two VAMCs, the number of CSCs that the Caregiver Support  Program Office reported was higher than what we found. Caregiver  Support Program Office officials said that these staffing discrepancies  could be due to vacant positions. However, officials at the two VAMCs  did not indicate that they had vacant positions at the time of our site  visits.

The third VAMC had a part-time registered nurse staffed to the  program that was not included in the Caregiver Support Program  Office’s staffing data even though this position was funded by VHA.  Caregiver Support Program Office officials could not provide a reason  for this discrepancy.

The fourth VAMC had an administrative staff member funded by the  Caregiver Support Program Office that was not included in the staffing  data.

Additionally, the Caregiver Support Program Office does not know the  exact number of CSCs assigned to the program. The program office  funds CSC positions, which can be filled by registered nurses or social  workers. The program office also funds registered nurses who are not  CSCs. However, the program office’s staffing data does not distinguish  between the two types of registered nurse positions because they do not  currently have the capability to collect such staffing details. As a result,  Caregiver Support Program Office officials told us they could not identify  registered nurses who are CSCs from other registered nurses assigned to  the program. Officials reported that they are working on finding a way to  collect details on the types of registered nurse positions.

Although Caregiver Support Program Office officials said that they are  taking steps to collect more information about the staff involved in  supporting the Family Caregiver Program to prepare for the MISSION Act  expansion, these efforts do not fully address the problems with data  completeness and accuracy that we identified. Officials said that they are  starting to collect data on the Family Caregiver Program staff more  frequently. Specifically, the program plans to collect information on  Caregiver Support Program Office funded staff at each VAMC from the  VISN lead officials quarterly instead of annually, to align with how other  national programs collect such data. During the course of this review  officials said they had begun working on updating the method they use to  collect staffing data. Caregiver Support Program Office officials said that  this revised data collection instrument will include mandatory fields and  data entry rules to ensure that the data reported are more consistent.  However, officials did not provide any timelines for when they will begin  using the updated method.

Program officials have begun to develop a staffing model in anticipation of  future program growth when eligibility expands to include pre-9/11  veterans. To create the staffing model, officials are identifying current  program staff at the VHA, VISN, and VAMC levels and the tasks these  staff perform. However, officials indicated that the model will use  Caregiver Support Program Office staffing data because those are the  only staffing data available for the program. As a result, VAMC-funded  staff and collateral staff will not be included. Consequently, the  completeness of the staffing model will be compromised and the current  and future staffing resources identified by the model may not accurately  estimate the program’s needs.

The lack of complete and accurate staffing data for the Family Caregiver  Program is inconsistent with federal internal control standards that require  management to use quality information to achieve its objectives. Without  complete and accurate information about the total number and types of  staff that support the program, VHA does not know whether the program’s  staffing approach and available resources are sufficient to meet the  program’s requirements as well as the needs of participating caregivers  and veterans. Furthermore, without complete and accurate staffing data,  it is unclear how the Caregiver Support Program Office will develop  projections of the staff that will be needed to enroll and support additional  caregivers and veterans when the Family Caregiver Program’s eligibility  is expanded as required by the MISSION Act.

VHA Monitors VAMCs’ Performance Processing Applications but Lacks System-Wide Data to Monitor Required Contacts with Caregivers and Veterans

VHA Monitors VAMCs’ Reviews of Family Caregiver Program Applications and Has Taken Steps to Improve Timeliness

Within VHA, the Caregiver Support Program Office monitors the  timeliness of VAMCs’ processing of applications for the Family Caregiver  Program. Specifically, Caregiver Support Program Office officials told us  that they review a monthly report from CAT. These reports show the  number of applications in process at each VAMC and how long they have  been in process. Officials also said that they share this information with  VISN lead officials each month.

However, since the inception of the program, VAMCs have had difficulty  meeting VHA’s requirement to review applications within 90 days. Our  analysis of CAT data found that about 68 percent of the 17,576  applications submitted from October 2017 through September 2018 were  reviewed within 90 days. In January 2019, a memorandum was issued  that required all VAMCs to develop action plans to address application  processing delays beyond 90 days. Further, any VAMCs with more than  10 applications beyond 120 days or any exceeding 365 days were  required to submit their action plans to the Caregiver Support Program  Office. As a result of this memo, 11 VAMCs have submitted action plans.  Caregiver Support Program Office officials said that they have assigned  staff to monitor the action plans and have discussed the plans with the  leadership of the VISNs that oversee these VAMCs.

Additionally, in February 2019, VHA established a national level  performance metric to measure application processing timeliness for the  program that will be updated on a monthly basis, according to Caregiver  Support Program Office officials. VHA’s goal is for 90 percent of Family  Caregiver Program applications submitted in fiscal year 2019 to be  processed within 90 days. The May 2019 report from CAT shows that 94  percent of the 1,246 current applications have been in process 90 days or  less.

VHA Lacks System-Wide Data on the Extent to Which VAMC Staff Have Completed Required Contacts and Visits with Caregivers and Veterans

VHA’s Caregiver Support Program Office lacks system-wide data from  CAT or other sources on the completion of VAMCs’ required quarterly  contacts and annual home visits conducted with caregivers and veterans  in the Family Caregiver Program. Although these contacts and visits are  supposed to be documented in CAT, the system has limited reporting  capabilities. As a result, Caregiver Support Program Office officials are  unable to obtain system-wide data that would allow them to monitor  VAMCs’ completion of these requirements. Furthermore, officials could  not readily provide these data for the four VAMCs we visited because  doing so would have required them to manually review each veteran’s  record (921 records across the four VAMCs).

Given CAT’s reporting limitations, some VAMC and VISN lead officials we  spoke with indicated that they have developed their own methods for  tracking contacts and visits at the facility or regional levels. For example,  officials at one VAMC told us they had developed a spreadsheet for the  purpose of tracking quarterly contacts and annual home visits. Further,  the VISN lead officials from one VISN told us that their VAMCs report  information on their ability to schedule and complete contacts and visits  on a monthly basis. The program office does not collect these data from  the VAMCs or VISNs.

The Caregiver Support Program Office has been able to collect limited  information on the extent to which quarterly contacts and annual home  visits are completed through 1) bi-annual audits of a sample of Family  Caregiver Program participant records that are rolled into in an annual  report and 2) site visits to select VAMCs. Caregiver Support Program  Office officials told us that the audits of program participants’ records  serve as their main source of information on the completion of required  contacts and visits. However, the focus of the audits vary each year,  which means that officials cannot monitor trends in performance over time  because the information is not comparable year-to-year. For example, in  fiscal years 2017 and 2018, the focus was on the records of caregivers  and veterans who had been discharged from the program, and in fiscal  year 2016, the focus was on newly approved caregivers and veterans. In  addition, because the audits are focused on a random sample of  individual participants’ records, they do not provide the Caregiver Support  Program Office with information to determine whether individual VAMCs  are meeting these requirements. Program office officials also told us that  their site visits to VAMCs include a review of the processes for required  quarterly contacts and annual home visits. As of January 2019, program  office officials had conducted 16 site visits since fiscal year 2016— representing about 11 percent of VAMCs. Caregiver Support Program  Office officials also report that they intend to develop a site visit plan as  part of MISSION Act implementation planning.

Without system-wide data on VAMCs’ monitoring efforts, the program  office does not know whether contacts and visits are being completed as  required or whether VAMCs may need more staff to conduct them. The  VAMC officials we spoke with acknowledged that their ability to complete  quarterly contacts and annual home visits was dependent upon having  enough staff. For example, one VAMC official reported that its facility did  not complete an entire quarter of contacts and visits to caregivers and  veterans because they did not have sufficient staffing resources.  Similarly, a VISN lead official said that the VAMCs in its network also  have had trouble meeting monitoring requirements due to insufficient  staff. The lack of system-wide data on VAMCs’ completion of required  contacts and visits is inconsistent with federal internal control standards  that require management to use quality information to achieve their  objectives. Furthermore, without these data, the Caregiver Support  Program Office is also limited in its ability to estimate the additional staff  that will be needed to conduct these contacts and visits once the  program’s eligibility expands.

VA Has Yet to Implement an IT System That Fully Supports the Family Caregiver Program

VHA and OIT have worked jointly over the last four years to both fix and  replace the existing Family Caregiver Program IT system, CAT, but these  efforts have not led to the implementation of an IT system that fully  supports the needs of the program. The VA MISSION Act included  provisions that directed the department to implement an IT system for the  Family Caregiver Program by October 1, 2018 and required certification  of the system from the VA Secretary by October 1, 2019. However, the  department reported to congressional committees in October 2018 that  meeting the system implementation deadline of the VA MISSION Act was  not feasible. Consequently, that deadline has not yet been met.

Specifically, VHA and OIT undertook two related efforts beginning in  2015:

CAT Rescue was initiated in July 2015 as a short-term project  intended to improve both the quality of CAT’s data and the system’s  reliability and security. However, schedule delays and significant  defects identified during system testing contributed to CAT Rescue’s  termination in April 2018. According to OIT officials, the department  spent about $2.86 million on CAT Rescue. However, the project did  not deliver viable software improvements.

Caregivers Tool (CareT), a companion project to CAT Rescue, was  initiated in September 2015 and was intended to produce a  replacement for CAT. The project was to develop and deliver a  replacement system with expanded capabilities, such as easier  caregiver application submission and enhanced caregiver program  analysis capabilities. However, the CareT acquisition depended on  CAT Rescue, which did not deliver the needed data improvements.  When CAT Rescue was terminated, data improvement and migration  activities that were previously part of CAT Rescue were moved to the  CareT project and contract extensions were necessary to allow more  time for system development and testing in relation to these expanded  requirements.

Subsequently, OIT and VHA Caregiver Support Program Office  officials acknowledged that development delays and the number and  critical nature of system defects identified during user acceptance  testing had led to the VHA Caregiver Support Program Office’s loss of  confidence in CareT as a viable replacement for CAT. As a result,  VA suspended the CareT acquisition in January 2019 to assess the  way forward. Ultimately, work on CareT ended in late February 2019.  According to OIT officials, the department spent about $8.11 million  on CareT between 2015 and 2019. However, no fully functioning  system replacement was delivered as intended.

VA commissioned two independent assessments that examined issues  impacting the CAT Rescue and CareT projects. These assessments,  completed by Digital Service at VA and the MITRE Corporation in early  2019, cited a number of deficiencies that likely contributed to the  termination of CAT Rescue and impacted the ability of CareT to  successfully deliver new system capabilities. For example, the  assessments identified deficiencies in the following areas:

Requirements management: The department did not effectively  implement a process for requirements development and prioritization.  As a result, OIT, program office staff, and the development  contractors did not have a shared understanding of how the system  was to perform. In addition, the requirements identified may have  been overly complex and insufficient to facilitate IT development.  Efforts to elaborate on the requirements over the course of the  projects were not consistent and led to delays. Further, significant  defects identified during testing were not effectively prioritized and  requirements remained unmet.

Leadership: CAT Rescue and CareT did not have stable leadership  and experienced staff throughout the department’s efforts to address  issues with the program. Specifically, there was a lack of sustained  leadership or a product owner needed to create and enforce a  technical vision across contractors and the department. Without such  leadership, there was a lack of effective governance and shared  accountability across VHA, OIT, and the development contractor.

According to the assessments, these deficiencies, among others, have  resulted in VA’s inability to successfully deliver IT improvements as  planned. We have previously reported that successfully overcoming  challenges in areas such as those identified in the independent  assessments of CAT Rescue and CareT is critical to increasing an  agency’s odds for delivering an IT system acquisition.

With the loss of confidence in CareT as a viable solution and the  subsequent results of the independent assessments, VA has redirected  its efforts for a third time and initiated a new project, referred to as the  Caregiver Record Management Application (CARMA), in March 2019.  Specifically, CARMA is focused on acquiring a solution to CAT using a  commercial product that is to be configured to fit the needs of the Family  Caregiver Program and support the program’s expansion.

The first CARMA release, planned for late October 2019, is intended to  replace CAT and improve program reporting. According to program  officials, this release is expected to include expanded capabilities needed  to develop system-wide reports on the completion of the required  quarterly contacts and annual home visits. The second release, planned  for January 2020, is intended to refine initial functionality and improve  stipend processing capabilities. Additional product releases are expected  at least through the summer of 2020 to incorporate new capabilities, such  as online application submissions for veterans and the ability to connect  to existing VA systems that manage veteran and caregiver identity and  relationship management.

However, it is unclear what additional work may be necessary to  accommodate the expansion of the Family Caregiver Program given that  the department is only in the early stages of planning. Further, the  department has not yet established a target date for certifying CARMA.  According to OIT officials, the cost for CARMA is estimated to be between  $5.7 million and $6.3 million, but additional costs for licensing and  modifications to legacy systems are also expected.

As of June 2019, OIT and VHA with assistance from the Digital Service at  VA had taken steps to identify key project stakeholders, estimate costs,  establish a timeline, and compile the initial set of requirements for  implementing the first release. The department had also identified a  Product Manager, who is to be responsible for coordinating efforts  between OIT and VHA. According to officials from the Digital Service at  VA, the CARMA project plans to use a better, more agile approach for  managing requirements. In addition, the staff asserted that the  department has established and filled the new Product Manager position,  which is intended to improve project leadership.

Despite these actions, VA has not yet demonstrated results to show  whether these changes will be sufficiently effective to overcome the  issues that contributed to the failure of both CAT Rescue and CareT. It is  also not yet certain when VA will successfully implement and certify its IT  system as required by the VA MISSION Act. Further, because the  expansion of the program is contingent on the certification by the VA  Secretary that the IT system fully supports the program, continued delays  with the IT system will postpone needed assistance for caregivers and  veterans who may qualify for these benefits when eligibility requirements  are expanded. Thus, it will be important that VA ensure that the actions  taken to improve requirements management and leadership of the  CARMA project are effectively implemented in order to improve the  likelihood that the project will deliver an IT system that fully supports the  Family Caregiver Program.

As VA prepares for the expansion of the Family Caregiver Program to  include caregivers of veterans who served prior to September 11, 2001, it  will be important that VA have an informed understanding of the staffing  resources needed to support the program. However, we found that VA  continues to struggle to have the information and tools needed to  effectively monitor the Family Caregiver Program. Since the Family  Caregiver Program was implemented in 2011, it has experienced  difficulties in meeting program requirements, such as for monitoring  program enrollees, potentially impacting the caregivers and veterans it is  intended to support. As both we and the VA OIG have reported,  determining and ensuring there are sufficient program staff to support the  program is one of VHA’s greatest obstacles in meeting program  requirements. In particular, VHA’s Caregiver Support Program Office  does not have complete and accurate staffing data with which to assess  current and future staffing levels because it is not collecting data on all  VAMC staff who support the program, and the data that are collected are  not validated. The Caregiver Support Program Office is further impeded in  its ability to assess whether VAMCs’ staffing levels for the program are  adequate because it lacks system-wide data on the completion of periodic  contacts and visits with caregivers and veterans. While the new IT system  should address this issue, the program office would benefit from having  an interim method to collect this information as VA’s previous efforts to fix  and replace CAT have not been successful. Until the program office has  reliable data for oversight and planning, the difficulties VA has  experienced since the Family Caregiver Program was implemented could  be further exacerbated when the program’s eligibility expands to include  the caregivers of veterans of all eras.

We recommend that the Secretary of the VA direct the Under Secretary  for Health to take the following actions:

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)

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)

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)

VA provided written comments on a draft of this report, which are  reprinted in appendix I. In its written comments, VA concurred with all  three recommendations. VA also provided technical comments, which we  incorporated as appropriate. With respect to our recommendation on  collecting complete staffing data, VA concurred and stated it is in the  process of developing a data collection mechanism that will allow for the  capture of more specific data about staffing roles and disciplines of  Family Caregiver Program staff.

VA also concurred with our recommendation to establish a process that  ensures that the staffing data collected and reported to the Caregiver  Support Program Office are accurate. VA stated that the VISN lead  officials will be responsible for reviewing and validating the staffing data  submitted and that the data collection mechanism under development for  this purpose will have data validation processes in place for its data fields  to ensure that the data entered by VISN leads are accurate.

VA also concurred with our recommendation that it needs to identify and  use an interim method to collect data on the completion of required  quarterly contacts and annual home visits that can be used until a new IT  system is implemented. In its technical comments, VA noted that data on  quarterly contacts and annual home visits with caregivers and veterans  are also captured in the Computerized Patient Record System because  these visits are considered clinical encounters, which we note in our  report. VA further stated that staff should be able to track the workload  entered into the Computerized Patient Record System if VAMCs have  appropriately set up their IT systems with the designated code for this  program. VA asserted that in response to our recommendation it is  exploring the feasibility of using data from the Computerized Patient  Record System as an interim solution for monitoring the completion of  quarterly contacts and annual home visits system-wide. Additionally, VA  reiterated that the first release of CARMA, which it plans to release in  October 2019, should include the capabilities necessary to develop  system-wide reports on the completion of required quarterly contacts and  annual home visits.

We are sending copies of this report to the Secretary of Veterans Affairs,  the appropriate congressional committees, and other interested parties. In  addition, the report is available at no charge on the GAO website at  http://www.gao.gov.

If you or your staff have any questions about this report, please contact  Sharon M. Silas at (202) 512-7114 or silass@gao.gov or Carol C. Harris  at (202) 512-4456 or harriscc@gao.gov. Contact points for our Offices of  Congressional Relations and Public Affairs are on the last page of this  report. GAO staff who made major contributions to this report are listed in  appendix II.

Appendix I: Comments from the Department of Veterans Affairs

Appendix II: GAO Contacts and Staff Acknowledgments

In addition to the contacts named above, Bonnie Anderson (Assistant  Director), Mark Bird (Assistant Director), Alison Goetsch (Analyst-in- Charge), Emily Loriso, and Jennifer Stavros-Turner made key  contributions to this report. Also contributing were Jennie F. Apter, Chris  Businsky, Krister Friday, Monica Perez-Nelson, and Ethiene Salgado- Rodriguez.

VA Health IT: Use of Acquisition Best Practices Can Improve Efforts to  Implement a System to Support the Family Caregiver Program. GAO-19- 581T. Washington, D.C.: May 22, 2019.

Veterans Affairs: Addressing IT Management Challenges Is Essential to  Effectively Supporting the Department’s Mission. GAO-19-476T.  Washington, D.C.: April 2, 2019.

VA Health Care: Improvements Needed to Manage Higher-Than- Expected Demand for the Family Caregiver Program. GAO-15-245T.  Washington, D.C.: December 3, 2014.

VA Health Care: Actions Needed to Address Higher-Than-Expected  Demand for the Family Caregiver Program. GAO-14-675. Washington,  D.C.: September 18, 2014.

Information Technology: Critical Factors Underlying Successful Major  Acquisitions. GAO-12-7. Washington, D.C.: October 21, 2011.

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.