Determining Eligibility

While Schultz was able to get Steven’s VA care providers to sign off on her application for caregiver benefits, she knows of fellow caregivers who have had extreme difficulty. “One veteran’s wife applied, and the VA social worker couldn’t get his primary-care provider to sign off on it. This was a veteran who has a TBI, as well as a spinal cord injury, and she has been his caregiver for several years,” Schultz said. “That’s the type of disparity that worries me and other caregivers.”

It also worries veterans service organization. Anna Freese, director of the warrior-support program at the Wounded Warrior Project (WWP), testifying at the same hearing, described similar disparities in approving applications. A WWP survey of caregivers applying for assistance revealed wide variability from facility to facility in VA regarding who makes the determination of whether a veteran and their caregiver are eligible and how that decision is made.

“For example, one caregiver has provided almost constant care and supervision for her husband who has suffered TBI,” Freese said. “Eleven days after applying for assistance, a VA nurse practitioner contacted her to advise her that the application had been denied. This decision was made without reviewing the veteran’s medical records or consulting with his care team. The nurse concluded on the basis of his compensation and pension-exam records that he did not need assistance in performing the activities in daily living.”

That situation ended favorably, but only because another VA employee took the initiative and intervened, Freese said. “The rule is altogether vague in how clinical eligibility determinations should be made and who should make them.”

Caregiver coordinators — those who oversee the program at individual facilities — testified at the hearing that those examples do not describe the process at their facilities and that they have tried to create a team approach that includes the caregiver in the process.

“In Syracuse, all veterans that have applied have been closely case-managed by our OEF/OIF team,” explained Cheryl Cox, caregiver support coordinator for the Syracuse VAMC. “It’s not required, but once we receive the initial application, the coordinator contacts the caregiver to set up the initial assessment within two days. When I do that, I talk with the caregiver about what they’re dealing with and bring that back to the team to help assess clinical eligibility.”

Mary Fullerton, caregiver support coordinator for the North Florida/South Georgia VA Healthcare System described a similar approach. “Most of the providers know the caregivers, and they’re very open to them being a part of the decision-making process.”

The program does have some significant gaps, however, both Cox and Fullerton said.

“The biggest challenge for me, because I want to support all caregivers, is the illness versus injury question. Right now, the program excludes illness and so it excludes caregivers that provide significant amounts of care to our veterans,” Cox said.”

For Fullerton, the gap involves VA’s older population, who are not eligible for the OEF/OIF-specific caregiver support program. “I have worked with this geriatric population of veterans, and these families have been providing the same levels of caregiving. It’s very frustrating that this program is not open to them,” she said.

According to VA officials, they are aware that there are disparities in how the program is being handled facility-to-facility, and they are taking steps to rectify them. “We did provide and do provide extensive training to those in the field who are implementing the actual program, explained Deborah Amdur, VA’s care management chief consultant. “And we have heard the concerns and take them very seriously that we need more transparency as to how decisions are made. We are reminding our support coordinators that they are sharing very openly with families and veterans the basis on which decisions are made.”

VA will also begin sending a letter to caregivers when they are notified of their eligibility, explaining how that determination is made. VA is also trying to make caregivers aware that there is an appeals process and that they are supportive of individuals appealing decisions, Amdur said.

In response to concerns about reliability among eligibility determination, a quality-assessment team looked at 50 records of veterans who applied for caregiver benefits, essentially putting them through a second eligibility process to determine consistency. Of those, 84% were consistent with the previous determination and 16% were inconsistent. But all but three of those were inconsistent in favor of the caregiver.

Of the three that were scored lower during the initial eligibility determination, there was one that assessors had serious concerns with and asked for a reevaluation.

It might be too early in the rollout process to determine whether inconsistencies are due to the speed of the implementation, or of changes that need to be made in the regulation. The public comment period on the interim rule closed on July 5. VA will examine the comments before determining whether to keep the regulations as they are or adjust them.

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