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United States Government Accountability Office: 
GAO: 

Report to Congressional Requesters: 

September 2014: 

VA Health Care: 

Actions Needed to Address Higher-Than-Expected Demand for the Family 
Caregiver Program: 

GAO-14-675: 

GAO Highlights: 

Highlights of GAO-14-675, a report to congressional requesters. 

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. 

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. 

What GAO Recommends: 

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. 

View [hyperlink, http://www.gao.gov/products/GAO-14-675]. For more 
information, contact Randall B. Williamson at (202) 512-7114 or 
williamsonr@gao.gov. 

[End of section] 

Contents: 

Letter: 

Background: 

Some VAMCs Had Difficulty Meeting Higher-Than-Expected Demand and Data 
System Limitations Have Impeded VHA's Ability to Monitor Workload: 

Conclusions: 

Recommendations for Executive Action: 

Agency Comments and Our Evaluation: 

Appendix I: Veterans Affairs Medical Centers by CSC-to-Approved 
Caregiver Workload Ratio, as of May 2014: 

Appendix II: Comments from the Department of Veterans Affairs: 

Appendix III: GAO Contact and Staff Acknowledgments: 

Figures: 

Figure 1: Actual and Estimated Obligations for the Family Caregiver 
Program, Fiscal Years 2011 through 2015: 

Figure 2: Number of Actual Applications and Approvals Compared to 
VHA's Projected Number of Approvals for Family Caregiver Program, 
Fiscal Years 2011-2014: 

Figure 3: VA Medical Centers (VAMCs) Grouped by Number of Approved 
Family Caregivers, as of May 2014: 

Figure 4: VA Medical Centers (VAMCs) Grouped by CSC-to-Caregiver 
Workload Ratios, as of May 2014: 

Abbreviations: 

CHAMPVA: Civilian Health and Medical Program of the Department of 
Veterans Affairs: 

CSC: caregiver support coordinator: 

DOD: Department of Defense: 

IT: information technology: 

PTSD: post-traumatic stress disorder: 

TBI: traumatic brain injury: 

VA: Department of Veterans Affairs: 

VAMC: VA medical center: 

VHA: Veterans Health Administration: 

VISN: Veterans Integrated Service Network: 

[End of section] 

United States Government Accountability Office: 
GAO:
441 G St. N.W. 
Washington, DC 20548: 

September 18, 2014: 

The Honorable Richard M. Burr: 
Ranking Member: 
Committee on Veterans' Affairs: 
United States Senate: 

The Honorable Jeff Miller: 
Chairman: 
Committee on Veterans' Affairs: 
House of Representatives: 

Since the beginning of the Iraq and Afghanistan conflicts in 2001, 
advancements in medical care and body armor have reduced fatality 
rates, allowing more servicemembers to recover from catastrophic 
physical and psychological injuries, including multiple limb loss, 
traumatic brain injury (TBI), and post-traumatic stress disorder 
(PTSD). The cumulative number of post-9/11 veterans who were wounded 
in action was 1.3 million in 2012--nearly triple the 482,000 post-9/11 
veterans who were wounded in action in 2001.[Footnote 1] Given the 
increased number of recovering veterans, the need for caregivers has 
grown substantially. Family members most often serve in this role and 
are referred to as "family caregivers." A RAND study estimated that 
there are 1.1 million family caregivers of post-9/11 veterans and that 
each year they provide personal care services valued at $3 billion, 
enabling seriously injured veterans to live at home rather than in 
institutions.[Footnote 2] These caregivers assist with the tasks of 
everyday living--as well as making and keeping appointments, helping 
navigate the Department of Defense's (DOD) and the Department of 
Veterans Affairs' (VA) complex health care systems, serving as 
advocates, and making decisions on medical, legal, financial, and 
benefit issues. 

Caregivers enable those for whom they are caring to live better 
quality lives and can contribute to faster rehabilitation and 
recovery; however, time spent caregiving can lead to the loss of 
income, jobs, or health care and can exact a substantial physical, 
emotional, and financial toll, according to RAND and others. In 
addition to assisting veterans with activities of daily living, family 
caregivers may have other concurrent responsibilities, such as raising 
children or caring for aging parents. Some veterans will need 
caregiver assistance for many years or throughout their lifetimes. To 
the extent that family caregivers' well-being is compromised, they may 
become unable or unwilling to fulfill their caregiving role, leaving 
the responsibilities to be borne by other social institutions. 
According to RAND, improving family caregivers' well-being and 
ensuring their continued ability to provide care requires a 
multifaceted approach--including training, health care coverage, and 
support services--to reduce the burdens caregiving may create and to 
bolster their ability to serve as caregivers more effectively. 

To provide greater support for caregivers of post-9/11 veterans, 
Congress passed legislation requiring VA to establish a program to 
assist caregivers with the rigors of caring for seriously injured 
veterans.[Footnote 3] In May 2011, the Veterans Health Administration 
(VHA)--which operates VA's health care system--established the Program 
of Comprehensive Assistance for Family Caregivers (Family Caregiver 
Program) at each of its VA medical centers (VAMC) across the United 
States.[Footnote 4] In accordance with applicable requirements, the 
program provides approved primary family caregivers with a monthly 
financial stipend, the amount of which is based on the amount and 
degree of personal care services--such as assisting with bathing and 
eating--provided to the veteran, and geographic location. The program 
also provides caregivers with other types of assistance, including 
training, referral services, counseling, some mental health services, 
and respite care.[Footnote 5] Additionally, primary family caregivers 
approved for the Family Caregiver Program may be eligible for coverage 
through the Civilian Health and Medical Program of the Department of 
Veterans Affairs (CHAMPVA) if they have no other coverage. As of May 
2014, about 15,600 caregivers were approved for the Family Caregiver 
Program, and the estimated obligations for fiscal year 2014 are over 
$263 million. 

You asked us to review VA's efforts to support the family caregivers 
of seriously injured veterans through its implementation of this 
program. This report examines how VHA is implementing its Family 
Caregiver Program, including the types of issues that have been 
identified during initial implementation. 

To examine how VHA is implementing the Family Caregiver Program and to 
identify the types of issues that transpired during initial 
implementation, we met with officials from VHA's Caregiver Support 
Program office--the office responsible for managing and overseeing the 
Family Caregiver Program. We obtained and reviewed the program's 
authorizing legislation and implementing regulations as well as 
relevant policy and management documents, including the program's 
implementation plan, policy guidebook, and the orientation manual for 
caregiver support coordinators (CSC), who administer the program at 
the medical facility level.[Footnote 6] In addition, we obtained and 
reviewed information on the numbers of CSCs and approved caregivers 
for each VAMC, and other program statistics from the Caregiver Support 
Program office, including aggregate data from weekly reports on the 
numbers of applications and caregiver approvals. We spoke with 
Caregiver Support Program officials about these data, and they 
explained that data from their information technology (IT) system is 
not reliable unless additional steps have been taken to verify them. 
We confirmed that the data we obtained from program officials had been 
verified, and therefore, we determined that these data were 
sufficiently reliable for the purposes of our report. Additionally, we 
applied federal standards for internal control related to capturing 
information and monitoring performance to assess the ability of the 
Caregiver Support Program office to oversee the program as well as 
standards for efficiency and effectiveness of operations.[Footnote 7] 

To understand how the Family Caregiver Program was being implemented 
at the medical facility level, we interviewed officials at five VAMCs, 
including the directors, selected staff such as departmental leaders, 
clinicians, and CSCs. We also interviewed program officials from the 
five Veterans Integrated Service Networks (VISN) who oversee the 
program at these facilities to obtain their perspective on the 
implementation of the program.[Footnote 8] However, the information we 
obtained from interviews with VAMC and VISN officials cannot be 
generalized. We selected a nonprobability sample of VAMCs based on 
geographic dispersion and a range of CSC-to-approved caregiver ratios--
from 1: 34 to 1: 167. The VAMCs we selected were Washington, D.C. 
(VISN 5); Fayetteville, North Carolina (VISN 6); Temple, Texas (VISN 
17); Fort Harrison, Montana (VISN 19); and Palo Alto, California (VISN 
21). We also met with organizations that represent veterans to obtain 
their views on the program and its implementation. Finally, we 
interviewed a non-generalizable sample of 11 caregivers of veterans 
who are approved for VHA's Family Caregiver Program at some of the 
VAMCs we contacted to obtain their experiences and perspectives on 
this program. 

We conducted this performance audit from June 2013 to September 2014 
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. 

Background: 

VHA's Family Caregiver Program is designed to provide support and 
services to family caregivers of post-9/11 veterans who have a serious 
injury incurred or aggravated in the line of duty. The program 
provides approved primary family caregivers with a monthly financial 
stipend as well as training and other support services, such as 
counseling and respite care.[Footnote 9] 

Family Caregiver Program Eligibility Requirements: 

The Family Caregiver Program has a series of eligibility requirements 
that must be satisfied in order for family caregivers to be approved. 

* To meet the program's initial eligibility criteria the veteran 
seeking caregiver assistance must have a serious injury that was 
incurred or aggravated in the line of duty on or after September 11, 
2001.[Footnote 10] According to the program's regulations, a serious 
injury is any injury, including TBI, psychological trauma, or other 
mental disorder, that has been incurred or aggravated in the line of 
duty and renders the veteran or servicemember in need of personal care 
services. 

* The veteran must be in need of personal care services for a minimum 
of 6 continuous months based on any one of the following clinical 
eligibility criteria: (a) an inability to perform one or more 
activities of daily living, such as bathing, dressing, or eating; 
[Footnote 11] (b) a need for supervision or protection based on 
symptoms or residuals of neurological or other impairment or injury 
such as TBI, PTSD, or other mental health disorders; (c) the existence 
of a psychological trauma or a mental disorder that has been scored by 
a licensed mental health professional, with a Global Assessment of 
Functioning score of 30 or less,[Footnote 12] continuously during the 
90-day period immediately preceding the date on which VHA initially 
received the application; or (d) the veteran has been rated 100 
percent service connected disabled for the veteran's qualifying 
serious injury and has been awarded special monthly compensation that 
includes an aid and attendance allowance.[Footnote 13] 

* To be considered competent to care for the veteran, family 
caregivers must meet certain requirements including (1) having the 
ability to communicate and follow details of the treatment plan and 
instructions related to the care of the veteran; (2) not determined by 
VA to have abused or neglected the veteran; (3) being at least 18 
years of age; and (4) either being a family member--such as a spouse, 
son or daughter, parent, step-family member, or extended family 
member--or an unrelated person who lives or will live full-time with 
the veteran. 

* Family caregivers must also complete required training before being 
approved for the program. 

Family Caregiver Program Organizational Structure: 

VHA's Caregiver Support Program office is responsible for developing 
policy and providing guidance and oversight for the Family Caregiver 
Program. It also directly administers the program's stipend, provides 
support services such as a telephone hotline and website, and arranges 
CHAMPVA coverage for eligible caregivers.[Footnote 14] Furthermore, 
the office provides funding to VAMCs to cover certain program costs, 
such as the salaries of the CSCs, who implement and administer the 
Family Caregiver Program at the local VAMC level, as well as the costs 
VAMCs incur for having their clinical staff, such as nurses, conduct 
the program's required in-home visits to approved caregivers and their 
veterans. 

CSCs are generally licensed social workers, clinical psychologists, or 
registered nurses, and they have both clinical and administrative 
responsibilities. Their clinical responsibilities 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. Their 
administrative responsibilities may include responding to inquiries 
about the program, overseeing the application process, entering 
information about applications and approved caregivers into IT 
systems, and facilitating the processing of appeals. As of May 2014, 
there were 233 CSCs assigned to 140 VAMCs or healthcare systems across 
the country.[Footnote 15] Additionally, each of the 21 regional VISN 
offices also has a VISN CSC lead for the program, who provides 
guidance to CSCs and helps address their questions or concerns. 

Family Caregiver Program Funding: 

Congress authorized over $1.5 billion for the Family Caregiver Program 
and other caregiver services for fiscal years 2011 through 2015. VHA's 
actual and estimated obligations for the program for fiscal years 2011 
through 2015 have increased at a steady rate. (See figure 1.) 

Figure 1: Actual and Estimated Obligations for the Family Caregiver 
Program, Fiscal Years 2011 through 2015: 

[Refer to PDF for image: vertical bar graph] 

Fiscal year: 2011; 
Expenditures[A]: $30.8 million. 

Fiscal year: 2012; 
Expenditures[A]: $115 million. 

Fiscal year: 2013; 
Expenditures[A]: $225.8 million. 

Fiscal year: 2014[B]; 
Expenditures[A]: $263.8 million. 

Fiscal year: 2015[C]; 
Expenditures[A]: $305.7 million. 

Source: GAO analysis of VHA information. GAO-14-675. 

[A] Obligations for fiscal year 2011 cover a partial year since the 
program was implemented in Spring 2011. 

[B] Most current estimated obligations according to VHA's Office of 
Finance. 

[C] Estimated obligations published in the President's Budget for 
fiscal year 2015. 

[End of figure] 

The Caregiver Support Program office uses this funding to cover costs 
such as program staffing, general caregiver education and training, 
caregiver stipends, CHAMPVA costs for primary family caregivers, the 
Caregiver Support Line, the Caregiver website, and outreach materials. 
It also provides funding to VAMCs to cover certain program costs 
rather than requiring the VAMCs to pay for them directly from their 
medical facilities' budgets. These costs include CSC salaries, 
reimbursement for home visits, respite care, and mental health 
services as well as assistance with travel expenses for eligible 
caregivers when accompanying the veteran to an appointment. 

Family Caregiver Program Application Adjudication Process: 

The Family Caregiver Program application has a sequential, multistep 
adjudication process. CSCs are responsible for overseeing this process 
and for ensuring that all steps of the application process are 
completed within 45 days, as outlined in the program's guidance. CSCs 
are expected to cultivate relationships with VAMC medical staff to 
request their assistance in performing medical eligibility assessments 
and completing the home visits--2 key steps in the process. For 
applications that cannot be fully adjudicated within the program's 45-
day goal, the CSC may request additional time to process the 
application from the Caregiver Support Program office.[Footnote 16] 
The steps of the application process are as follows: 

Step 1: Application Review. After the caregiver and veteran submit an 
application for the program, the CSC reviews the application and 
determines the caregiver's potential eligibility.[Footnote 17] 

Step 2: Initial Eligibility Determination for the Veteran. The CSC 
then determines whether the veteran is a post-9/11 veteran enrolled in 
VHA (or servicemember undergoing medical discharge) and has a 
documented line-of-duty injury. 

Step 3: Final Eligibility Determination for the Veteran. After initial 
eligibility has been determined, a VHA medical provider is to complete 
a medical assessment to determine the medical condition of the 
veteran, their need for a caregiver, and all other program eligibility 
criteria. The provider then determines the veteran's rating for the 
stipend amount the primary family caregiver is eligible to receive. 
The stipend amounts are organized into three tiers. The stipend amount 
that the caregiver could receive is based on the assigned tier level 
and the geographic location of the veteran's residence. Tier 3 
indicates the highest level of injury and need for a caregiver and has 
the highest level of payment, while Tiers 2 and 1 indicate the lower 
levels of injury and correspondingly lower levels of payment.[Footnote 
18] 

Step 4: Eligibility Determination for the Caregiver. While the 
veteran's eligibility is being verified, the CSC determines the 
caregiver's eligibility for the program by conducting an assessment of 
the caregiver's ability to serve in that role, either through a phone 
call or in-person meeting. 

Step 5: Review of Program Services. Once the veteran and caregiver 
have been determined eligible for the program, the CSC schedules a 
joint meeting to discuss the types of Family Caregiver Program 
services for which they may be eligible once they complete the 
application process and are approved for participation in the program. 
This would include a discussion of the stipend payment as well as 
potential coverage through CHAMPVA. 

Step 6: Caregiver Training. The caregiver must complete the program's 
training class, which is offered online, through self-instruction with 
a workbook and a CD or DVD, or where available, through 2 days of 
facilitated classroom instruction. The training covers 10 
competencies, including self-care, nutrition, and medication 
management. 

Step 7: Home Visit. Within 10 days after the caregiver completes the 
training, an initial home visit is conducted to determine if the 
caregiver has the physical capacity and skills necessary to provide 
medical care to the veteran, and if the home is safe and adequately 
equipped. Since the initial home visit includes physical assessment 
and medical components, it must be completed by a medical professional 
such as a registered nurse, nurse practitioner, clinical nurse 
specialist, physician assistant or physician. When a veteran requires 
a caregiver due to a mental health diagnosis, the home visit is to be 
completed by or in collaboration with a mental health provider. 

Step 8: Notification of Program Eligibility. Once the home visit 
assessment has been completed and the results confirm that the 
caregiver is prepared to provide satisfactory care of the veteran, the 
CSC completes the final approval of the caregiver. This entails 
sending approval paperwork to the caregiver, including the direct 
deposit form for the stipend, and updating the relevant VHA systems, 
including the program's IT system and the veteran's medical record. 

Caregivers who are denied eligibility for the program, or who believe 
that the veteran's condition is more severe than the rating indicates, 
may appeal the decision. CSCs coordinate with VAMC patient advocates 
and other VHA staff to process these appeals--requests for review and 
reconsideration--first with the VAMC director and subsequently at the 
VISN level, if necessary.[Footnote 19] 

As of May 2014, approximately 15,600 caregivers had been approved for 
the program. About 6,000 of these caregivers were assigned to Tier 3 
(highest level) for their stipend payments, about 6,000 to Tier 2 
(middle level), and 3,600 to Tier 1 (lowest level). The average 
monthly payments per tier were approximately $2,320 for Tier 3, $1,470 
for Tier 2, and $600 for Tier 1. At this time, almost 8 out of 10 of 
the caregivers approved for the Family Caregiver Program were spouses, 
while other approved caregivers were parents, relatives, and friends. 
Most of these caregivers were assisting veterans with mental health 
diagnoses or brain injuries who may also have had other physical 
injuries or disabilities. Specifically, 92 percent of these veterans 
have a service-connected mental health condition, 63 percent have 
PTSD, and 26 percent have a TBI. 

The program requires interim quarterly home visits for its approved 
caregivers, unless otherwise clinically indicated. These visits are to 
be conducted by clinical staff, but CSCs may also conduct them if they 
have a clinical background, such as being a registered nurse or a 
clinical psychologist.[Footnote 20] The home visits serve multiple 
purposes and are intended to monitor the well-being of the veteran. 
They are also used to determine whether the caregiver continues to 
have the physical capacity and skills necessary to provide medical 
care to the veteran, and whether the home remains safe and adequately 
equipped. The Caregiver Support Program office also permits home 
visits to be conducted by telephone after 1 year of satisfactory home 
visits has been completed for cases that do not pose exceptional 
medical risk. 

Some VAMCs Had Difficulty Meeting Higher-Than-Expected Demand and Data 
System Limitations Have Impeded VHA's Ability to Monitor Workload: 

VHA officials significantly underestimated the demand for the Family 
Caregiver Program. As a result, the program did not have sufficient 
support for the ensuing workload at some VAMCs, and the resulting 
staffing shortages impeded the timeliness of key functions and 
negatively impacted services to caregivers. Furthermore, VHA's 
Caregiver Support Program office does not have ready access to the 
type of data that would allow it to monitor and manage the program's 
workload due to the limited capabilities of its data system, which was 
designed to manage a much smaller program. 

Program's Staffing Not Adequate to Handle Higher-Than-Expected Demand 
at Some VAMCs: 

VISN and VAMC officials told us that the program's initial staffing 
did not provide sufficient resources to support the unexpectedly high 
and increasing workload since the program began in 2011. VHA officials 
originally estimated that approximately 4,000 caregivers would be 
approved for the program by the end of fiscal year 2014. This estimate 
was based on the number of expected post-9/11 veterans and 
servicemembers who have serious medical or behavioral conditions 
involving impairment in at least one activity of daily living or who 
require supervision or protection, using available data from the 
Veterans Benefits Administration and DOD.[Footnote 21] However, the 
number of individuals approved for the Family Caregiver Program far 
exceeded the original estimate: by May 2014, almost 30,400 caregivers 
had applied and about 15,600 had been approved. (See figure 2.) 

Figure 2: Number of Actual Applications and Approvals Compared to 
VHA's Projected Number of Approvals for Family Caregiver Program, 
Fiscal Years 2011-2014: 

[Refer to PDF for image: multiple line graph] 

Fiscal year: 2011; 
Applications: 1,476; 
Enrollment: 1,314; 
Projected Enrollment: 3,596. 

Fiscal year: 2012; 
Applications: 10,641; 
Enrollment: 6,606; 
Projected Enrollment: 3,740. 

Fiscal year: 2013; 
Applications: 21,737; 
Enrollment: 12,710; 
Projected Enrollment: 3,890. 

Fiscal year: 2014; 
Applications: 35,333; 
Enrollment: 17,172; 
Projected Enrollment: 4,046. 

Source: GAO analysis of VHA information. GAO-14-675. 

[End of figure] 

Caregiver Support Program officials told us that after 3 years of 
operation, demand for the Family Caregiver Program remains high: 
system-wide, there has been no appreciable decrease in the number of 
caregivers submitting applications for the program. In fact, the 
number of "in-process" applications for the Family Caregiver Program 
more than doubled from 1,966 in April 2013 to 4,318 in May 2014. As of 
May 2014, 98 VAMCs had more than 50 approved caregivers. (See figure 
3.) 

Figure 3: VA Medical Centers (VAMCs) Grouped by Number of Approved 
Family Caregivers, as of May 2014: 

[Refer to PDF for image: vertical bar graph] 

Number of approved caregivers: 25 or less; 
Number of VAMCs: 11. 

Number of approved caregivers: 26 to 50; 
Number of VAMCs: 31. 

Number of approved caregivers: 51 to 100; 
Number of VAMCs: 44. 

Number of approved caregivers: More than 100; 
Number of VAMCs: 54. 

Source: GAO analysis of VHA information. GAO-14-675. 

Note: While caregiver support coordinators (CSC) administer the Family 
Caregiver Program at all 151 VA facilities, they are assigned to 140 
VAMCs or healthcare systems, which may include more than one VA 
facility. We present program statistics based on CSC assignments 
because that is how they are tracked by the Caregiver Support Program 
office. 

[End of figure] 

The initial arrangement for CSCs and VAMC staff that VHA established 
for this program proved inadequate in the face of such high demand. 
The program initially placed a single CSC at each VAMC largely to 
perform administrative and caregiver support functions, with the 
expectation that each VAMC would provide the program with physician, 
nursing, and administrative staff as needed to perform specific 
program functions. However, VISN officials and VAMC officials we spoke 
with said that there are too few CSCs to handle the program's workload 
effectively. Specifically, at some VAMCs, CSCs have been unable to 
perform all of the routine administrative tasks associated with their 
approved caregivers, as initially expected.[Footnote 22] For example, 
some VISN and VAMC officials told us that the number of appeals filed 
by veterans and caregivers has become an unexpectedly large component 
of CSCs' workload, making it difficult to fulfill the full range of 
their responsibilities. A Caregiver Support Program official clarified 
that while CSCs typically work with the VAMC patient advocates to 
handle appeals, they may be taking on greater responsibility for the 
appeals process at VAMCs with large numbers of appeals for the program. 

Caregiver Support Program officials acknowledged that the workload for 
the Family Caregiver Program has been burdensome for some CSCs, 
depending on the number of their approved caregivers and the amount of 
assistance they have at the local level. As of May 2014, the number of 
approved caregivers per CSC varied widely across VAMCs, ranging from 6 
to 251. (See figure 4.) Caregiver Support Program officials stated 
that their office does not use a formal CSC-to-caregiver target ratio 
because staffing decisions are largely the domain of local managers 
and the use of a specific workload ratio by the Caregiver Support 
Program could limit VAMCs' discretion in determining when to request 
additional CSCs. (See appendix I for a list of VAMCs' CSC-to-caregiver 
workload ratio.) 

Figure 4: VA Medical Centers (VAMCs) Grouped by CSC-to-Caregiver 
Workload Ratios, as of May 2014: 

[Refer to PDF for image: vertical bar graph] 

CSC-to-approved caregiver ratio: 1:1 to 1:25; 
Number of VAMCs: 16. 

CSC-to-approved caregiver ratio: 1:26 to 1:50; 
Number of VAMCs: 50. 

CSC-to-approved caregiver ratio: 1:51 to 1:100; 
Number of VAMCs: 52. 

CSC-to-approved caregiver ratio: More than 1:100; 
Number of VAMCs: 22. 

Source: GAO analysis of VHA information. GAO-14-675. 

Note: While caregiver support coordinators (CSC) administer the Family 
Caregiver Program at all 151 VA facilities, they are assigned to 140 
VAMCs or healthcare systems, which may include more than one VA 
facility. We present program statistics based on CSC assignments 
because that is how they are tracked by the Caregiver Support Program 
office. 

[End of figure] 

Furthermore, Caregiver Support Program officials had expected VAMC 
officials to direct their clinical staff to perform the medical 
assessments and home visits needed by the Family Caregiver Program as 
part of their ongoing care to veterans. However, VISN and VAMC 
officials we contacted told us that their facilities do not have 
sufficient medical staff to effectively manage the additional workload 
generated by the Family Caregiver Program, which they view as a 
collateral duty. According to most VISN and VAMC officials, obtaining 
clinical staff for the program can be difficult at VAMCs where 
directors may not consider the Family Caregiver Program to be a high 
priority. For example, officials at one VAMC told us that lack of 
support from the VAMC director led to a situation in which the 
director refused to have nurses conduct home visits for the Family 
Caregiver Program. At another facility, a VAMC director told us that 
lack of support by her predecessor led to large backlogs of 
unprocessed applications and incomplete home visits for the Family 
Caregiver Program, which she discovered following her recent transfer 
to that facility. According to some VISN officials, this dynamic 
sometimes placed CSCs, as the administrators of the local Family 
Caregiver Program, in the position of pleading for support from VAMC 
physicians and nurses. In May 2014, a Caregiver Support Program 
official explained that although the office has issued program policy 
and guidance to medical facilities, it also plans to issue a directive 
that outlines organizational responsibilities for the Family Caregiver 
Program, including those at the VAMC level. This official did not 
provide a specific timeframe for the issuance of the directive but 
stated that it would occur following the issuance of final program 
regulations. 

VISN and VAMC officials we spoke with noted that the Family Caregiver 
Program's approach of having VAMC physicians conduct medical 
assessments for program eligibility has been a challenge. Physicians 
at the VAMCs we contacted were already experiencing heavy workloads 
prior to the implementation of the Family Caregiver Program, and some 
physicians were not able to take on additional tasks that they viewed 
as collateral duties, according to VISN and VAMC officials. Some 
physicians who were initially willing to conduct medical assessments 
could not continue doing so when the number of applications for the 
program increased. VISN and VAMC officials also stated that some 
physicians do not want to perform medical assessments because they are 
concerned that having a role in determining eligibility for a program 
that includes a financial stipend could compromise their clinical 
relationship with the patient. As a result of these factors, the 
number of physicians willing to conduct medical assessments for the 
program is limited at some VAMCs. CSCs at some VAMCs told us that the 
typical wait time for a medical assessment can be a month or longer. 

VISN and VAMC officials also agreed that providing nurses for the home 
visits needed by the Family Caregiver Program has posed problems and 
remains an ongoing challenge. These officials explained that most 
clinic nurses are already too busy to assume an additional workload. 
Officials at one VISN told us that some nurses who originally agreed 
to conduct quarterly home visits for the Family Caregiver Program 
stopped doing so after home visits became a burden, due to the 
increasing number of approved caregivers. In addition, VAMC and VISN 
officials at every location we contacted told us that home visits to 
remote areas require long driving times, which are challenging to 
accommodate. Staff at one VAMC we contacted pointed out that their 
catchment area covers 147,000 square miles, and some of their 
caregivers live over 8 hours away, requiring nurses to contend with 
multiple overnight stays per month and dangerous travel conditions in 
the winter. 

Staffing Shortages Impeded Timeliness of Key Functions and Negatively 
Affected Services to Caregivers Despite Actions Taken to Address Them: 

Timelines for key functions of the caregiver program, such as those 
for adjudicating applications within 45 days or making quarterly home 
visits to family caregivers, are not being met because CSCs at some 
VAMCs were not able to obtain sufficient support from medical facility 
staff. As a result, some caregivers have had to wait longer for an 
eligibility determination and to receive program benefits. Staff at 
many of the VAMCs we contacted told us that delays exist at some or 
every step of the application process for the Family Caregiver 
Program, including determining caregiver eligibility, administering 
medical assessments, and conducting initial home visits. Officials at 
all of the VAMCs we contacted stated that there were applications at 
that facility that had been open for longer than 45 days, and one VAMC 
had over 400 open applications, some going back to June 2013. 
According to the Caregiver Support Program office, in June 2014, 111 
VAMCs had applications that had been in process for 45 to 90 days; 
most of these facilities (95 percent) had 20 or fewer applications in 
this category. Additionally, the office reported that 65 VAMCs had 
applications that had been open 91 days or more; most of these VAMCs 
(85 percent) had 25 or fewer applications in this category. 

Furthermore, home visits are not always being made on a timely basis. 
At one VAMC, initial home visits to assess caregivers' skills, which 
are supposed to take place within 10 days of the caregiver's 
completion of core training, took from one to two months to complete, 
which delayed eligibility determinations. Staff at some of the VAMCs 
we contacted were also struggling to maintain the quarterly schedule 
for follow-up home visits due to the larger-than-expected number of 
approved caregivers. At one VAMC, CSCs told us that follow-up home 
visits occur every 6 to 9 months, in contrast to the program's 
standard of every 90 days. Delays in home visits could be problematic 
because these visits provide medical staff with an opportunity to 
assess the welfare and environment of the caregiver and veteran--
issues that may not be evident during clinic visits, such as whether 
special dietary needs are being met and whether medications are being 
properly administered. 

At some VAMCs, the volume of administrative and procedural activities 
performed by CSCs has curtailed or even displaced their ability to 
provide services to caregivers and veterans. VISN staff we spoke with 
told us that as a result of the high workload burden, CSCs who are 
overwhelmed do not have the ability to perform some caregiver support 
functions offered by the Family Caregiver Program, such as support 
groups and counseling. Caregivers and officials from non-VA 
organizations told us that some CSCs do not return caregivers' phone 
calls. One caregiver recounted that when she became desperate to learn 
how to manage a veteran with increasingly severe symptoms from a TBI, 
her CSC told her that hers was one of many requests and that the 
program could not provide counseling for caregivers. This caregiver 
subsequently received services from a non-profit organization. 

Officials from the Caregiver Support Program and the VAMCs we 
contacted also told us that they have taken steps to address staffing 
shortages for the Family Caregiver Program, although some of the steps 
have had limited success. For example, 

* In recognition that some VAMCs had more approved caregivers than 
originally anticipated, the Caregiver Support Program office began to 
allow VAMCs to request additional CSCs in August 2011. By May 2014, 
VAMCs had submitted 99 requests for salary funding to the Caregiver 
Support Program office for adding one to five more CSCs to their 
facility. Specifically, the requests from VAMCs totaled 112 additional 
CSCs, of which the Caregiver Support Program office approved about 94 
additional positions. 

* In March 2014, the Caregiver Support Program also began funding 
temporary CSCs, who were hired for terms of 120 days. As of May 2014, 
the office has funded 10 CSCs on a temporary basis. According to a 
Caregiver Support Program official, these CSCs must meet the same 
qualifications as a full-time CSC, and their duties are to be 
established at the local level. In addition, some VAMCs have provided 
their own clerical support to CSCs for routine administrative tasks. 

* In August 2012, the Caregiver Support Program office also began 
allowing VAMCs to conduct home visits by telephone after 1 year of 
satisfactory home visits had been completed for cases that do not pose 
exceptional medical risk. Some of the VAMCs we contacted are planning 
to expand their use of follow-up telephone contact with caregivers in 
lieu of in-person home visits. However, officials at one VAMC told us 
that they did this with only three to four families because they 
considered almost all families approved for the Family Caregiver 
Program to be at risk because of the high proportion of caregivers who 
were caring for veterans with PTSD who were not clinically stable. 

* VAMCs have also tried various approaches for improving physicians' 
willingness and ability to participate in the Family Caregiver 
Program. For example, officials from the Caregiver Support Program 
office told us that some VAMCs use a multidisciplinary team--instead 
of individual physicians--to make determinations for eligibility and 
for the level of financial stipend, enabling the workload to be shared 
by multiple clinicians. Another VAMC hired a physician on a part-time 
basis just to perform eligibility examinations for the program. One 
VAMC with serious workload backlogs is examining the option of using 
physicians who are already under contract for conducting medical 
assessments for determining disability benefits, instead of using VAMC 
treatment physicians. The VAMC director who is exploring this option 
mentioned that this approach could also resolve physicians' concerns 
about compromising the physician/patient relationship posed by 
determining eligibility for a program that includes a financial 
stipend. However, Caregiver Support Program officials stated that 
regardless of the approaches VAMCs may take to conduct the medical 
assessments, the program's regulation requires that the physician 
making eligibility determinations for the Family Caregiver Program be 
a member of the veteran's treatment team.[Footnote 23] 

* To increase nurses' willingness to provide assistance to the 
program, some VAMCs offered their nurses overtime pay to conduct home 
visits, and other VAMCs made temporary work-sharing arrangements with 
nearby VAMCs for nursing coverage. Officials in the VISNs we contacted 
told us that some VAMCs have used the funding they received for 
additional CSC positions to hire nurses for the sole purpose of 
conducting home visits for the program because of the heavy workload. 
Some officials also told us that they consider the home visit 
reimbursement amounts to be insufficient to cover their expenses, such 
as for GPS units, other electronic devices, and time needed for 
associated administrative activities. However, an official with the 
Caregiver Support Program office stated that this should not be 
necessary because the program's reimbursement for home visits covers 
salary expenses, travel costs, and time for administrative activities. 

* Some VAMCs have also hired contractors to conduct home visits, 
although contractors may not be available in some locations. 

A Caregiver Support Program official stated that the budget for the 
Family Caregiver Program has been adequate to meet operating costs as 
of March 2014. Nonetheless, VHA officials at all levels told us that 
VAMC directors were cautious about requesting additional CSCs or 
hiring additional nurses for making home visits. These officials 
explained that VAMC directors are concerned that when the Family 
Caregiver Program's initial 5-year budget authorization expires, the 
cost of the additional nurses and CSCs could shift from the Caregiver 
Support Program office to the VAMCs. VAMC directors stated that their 
caution is based on experience, in that this shift has occurred in the 
past with other new VHA programs that had initially received funding 
support from their program offices. Caregiver Support Program 
officials acknowledged VAMC officials' concerns about the program's 
funding and added that they are aware of some VAMCs--even facilities 
with growing numbers of approvals--that are cautious about requesting 
additional CSCs. Nonetheless, a Caregiver Support Program official 
stated that VHA continues to request funding for the Family Caregiver 
Program, including a funding request for fiscal year 2015 that was 
submitted with the budget request. 

Notwithstanding incremental efforts to improve staffing levels for the 
program at some VAMCs, CSCs and VAMC staff predict that staffing 
shortages and the ensuing workload problems are likely to recur 
because VHA's current staffing of the program is not sufficient and 
overall approvals continue to increase at a steady rate--about 500 
approvals per month. As a result, according to VAMC officials, some 
facilities have not been able to overcome the workload problems that 
developed upon program implementation. A Caregiver Support Program 
official stated that program officials recognize the need to formally 
re-evaluate key aspects of the Family Caregiver Program, including 
program staffing and the processes for eligibility assessments and 
home visits, in light of the fact that the program was designed to 
manage a much smaller caregiver population. This is consistent with 
federal internal control standards, which emphasize the need for 
effective and efficient operations, including the use of agency 
resources such as human capital.[Footnote 24] 

VHA's Oversight of the Family Caregiver Program Is Impeded by IT 
System Limitations: 

The Caregiver Support Program office does not have ready access to the 
workload data that would allow it to monitor the effect of the Family 
Caregiver Program on VAMCs' resources due to limitations with the 
Caregiver Application Tracker--the IT system that was established for 
the program. According to federal standards for internal control, 
agencies should identify, capture, and distribute pertinent 
information in a form and time frame that permits officials to perform 
their duties efficiently.[Footnote 25] However, the Caregiver Support 
Program office is not able to easily retrieve data that would allow it 
to better assess workload trends at individual VAMCs--such as the 
length of time applications are delayed or the timeliness of home 
visits--even though these data are already captured in the Caregiver 
Application Tracker. Consequently, Caregiver Support Program officials 
only retrieve these data on an ad hoc, as-needed basis, which limits 
their ability to assess the scope and extent of workload problems 
comprehensively at individual VAMCs and on a system-wide basis. 

A Caregiver Support Program official told us that the office becomes 
aware of workload problems at some VAMCs through various informal 
information channels, such as CSCs' requests for application 
extensions and communication with the CSCs and VISN CSC 
leads.[Footnote 26] However, relying on informal information channels 
does not provide the office with a comprehensive picture of the 
program's workload across all VAMCs, and this puts it in a reactive 
position of addressing workload issues after problems have already 
developed. Having a system that allows for easy retrieval of data 
would better position the office to proactively identify both existing 
and potential workload problems at VAMCs and work with their CSCs to 
identify solutions before problems develop or worsen. It would also 
facilitate access to data needed for pinpointing where certain 
processes may be getting stalled. For example, a Caregiver Support 
Program official told us that it would be helpful to be able to track 
the status of the various phases of the application process to 
identify the phases that are taking too long, which would help the 
office to better determine how to improve the overall timeliness of 
application adjudication. 

A Caregiver Support Program official explained that the Caregiver 
Application Tracker had to be developed quickly due to time 
constraints and was designed to manage a relatively low volume of 
information for what was conceived to be a much smaller program. It is 
a web-based system designed to facilitate the exchange of information 
about approved caregivers between VAMCs and other VHA entities, 
including the Health Administration Center, which processes the 
caregiver stipend payments and administers CHAMPVA. CSCs are 
responsible for entering nonclinical data into the system, which 
includes information related to the application process and the status 
of home visits. The Caregiver Support Program office manages the 
system and uses its data to monitor certain aspects of the program. 
Specifically, a program official explained that the system can 
generate a few basic reports that have been preprogrammed, including a 
weekly report with aggregate data on the status of applications and 
stipend payments. The Caregiver Support Program office uses these data 
to monitor the program as well as data from other sources, including 
data on the number of approved caregivers who have completed training 
and the number of telephone calls to the Caregiver Support 
Line.[Footnote 27] However, data that are not contained in the 
preprogrammed reports must be extracted from the system on an ad hoc 
basis. 

Caregiver Support Program officials told us that they take steps to 
validate the data they obtain from the system because they have 
observed some inconsistencies--particularly with ad hoc data--and as a 
result, they have concerns about its reliability. These officials told 
us that each time they extract ad hoc data from the system, they 
validate the data through additional sources to ensure its accuracy. 
Caregiver Support Program officials explained that they have already 
taken steps to verify the sources of the data that are used for the 
system's reports and do not need to verify these data every time a 
report is generated. Nonetheless, these officials noted that they will 
periodically compare the current weekly data that is reported by the 
system with data from the prior week to ensure that there are no 
drastic changes which would indicate a need for additional 
verification. 

Program officials explained that the system has no agility or 
flexibility to perform additional tasks beyond its basic tracking 
functions, and retrieving data from the system on an ad hoc basis 
often requires time-consuming manual procedures. These officials 
explained that the system's data files are organized by veteran, and 
all of the veterans who apply for the program are captured in the 
system whether or not their caregivers were approved. As a result, the 
system that was designed to manage 5,000 records by the end of 2015 
had over 30,000 records as of May 2014. Officials said that the 
system's limited capabilities became more apparent as the number of 
records in the system increased, which made retrieving data on an ad 
hoc basis more difficult and time consuming. For example, according to 
program officials, in response to our request for the number of VAMCs 
with applications over 45 days old, they had to download all of their 
relevant data into a spreadsheet, review the data for accuracy, make 
the necessary corrections, and then manually count the number of 
applications over 45 days old. A Caregiver Support Program official 
told us that it took three people about 8 to 10 hours in total to pull 
this information together. 

Officials further explained that the Caregiver Application Tracker is 
a stand-alone system that is not integrated with other VHA systems, 
and as a result, it cannot perform sophisticated functions or searches 
that would require pulling information from these other systems. 
Officials told us that this hinders their ability to monitor certain 
aspects of the program and results in time-consuming efforts to 
compile program-related data.[Footnote 28] For example, the use of 
respite care--one of the benefits of the Family Caregiver Program--is 
tracked by a different VHA system. To determine how many veterans in 
the Family Caregiver Program are using respite care, program officials 
told us that they must download their data into a spreadsheet and then 
upload this information to the IT system for respite care use in order 
to crosswalk the information. Furthermore, data on Family Caregiver 
Program appeals are maintained in the Patient Advocate Program's 
tracking system, which is also managed by a different VHA office. 
Caregiver Support Program officials told us that they have to request 
appeals data from this office, and to date, there have been a few 
requests for caregiver appeals data in response to congressional 
inquiries. However, because the Patient Advocate Program's tracking 
system was not designed in a way that allows them to easily retrieve 
information that is specific to the Family Caregiver Program, the 
Caregiver Support Program office had received a report for only one of 
the inquiries as of May 2014. A Caregiver Support Program official 
told us that they are working with the Patient Advocate Program to 
identify methods to obtain the appeals data they need, such as by 
capturing whether an appeal is related to the Family Caregiver Program. 

As a result of these system limitations, the Caregiver Support Program 
office does not have the capability to routinely track and analyze the 
type of workload data it needs to produce a meaningful assessment of 
the program's impact on VAMCs. According to federal standards for 
internal control, agencies should conduct monitoring activities to 
assess the quality of performance over time and should use the results 
to correct identified deficiencies and make improvements.[Footnote 29] 
However, the lack of ready access to comprehensive workload data 
impedes the program office's ability to proactively identify and 
correct workload problems as they manifest or to identify and make 
modifications as necessary to ensure that the program is appropriately 
structured to meet caregivers' demand for its services. Consequently, 
a Caregiver Support Program official told us that the program office 
has only been able to assess workload problems and make interim 
adjustments, such as allowing VAMCs to request additional CSC 
positions, based on informal feedback and has not been able to conduct 
a formal re-assessment of the program that is based on comprehensive 
program data. 

A Caregiver Support Program official acknowledged that they recognize 
the need for a more capable, flexible system that can interface with 
other departmental systems. This official also told us that program 
office officials are working with their information technology office 
to develop the requirements for a comprehensive system and that they 
are exploring the possibility of whether an existing VHA system could 
be adapted to meet their needs. However, this official was not sure 
how long it would take to obtain another IT system and whether this 
effort would be displaced by higher priorities. As a result, it is not 
clear when program officials will have access to comprehensive 
workload data for the Family Caregiver Program to better assess how it 
is functioning. Although it will be difficult to identify changes 
needed to improve the program's efficiency and effectiveness without 
these data, VAMCs' workload problems will persist--and caregivers will 
not get the services they need--unless the program office begins 
taking steps towards identifying solutions. 

Conclusions: 

Family caregivers play a crucial role in caring for seriously injured 
post-9/11 veterans by taking on critically important and often 
stressful responsibilities for their well-being and potentially 
keeping them out of costly institutions. The Family Caregiver Program 
was intended to provide supportive services to this caregiver 
population, but VHA significantly underestimated program demand. The 
subsequent stress on resources at some VAMCs resulted in delayed 
application decisions and home visits--ultimately limiting services to 
caregivers. Incremental steps to alleviate staffing shortfalls have 
benefited the program in some locations, but these efforts will not 
likely be sufficient in light of the steady growth of approved 
caregivers in the program. After 3 years of operation, it is clear 
that VHA needs to formally reassess and restructure key aspects of the 
Family Caregiver Program, which was designed to meet the needs of a 
much smaller population. This would include determining how best to 
ensure that staffing levels are sufficient to manage the local 
workload as well as determining whether the timelines and procedures 
for application processing and home visits are reasonable given the 
number of approved caregivers. 

To accomplish this, the Caregiver Support Program office will need to 
take a strategic, data-driven approach that would include an analysis 
of the program's workload data at both the aggregate and VAMC levels. 
It will therefore be necessary for VHA's Caregiver Support Program 
office to obtain an IT system that will facilitate access to the types 
of data--including interfacing with other VHA systems, such as systems 
for clinical patient records and respite care--that would allow it to 
more fully understand the program's workload and its effect on VAMCs, 
CSCs, and caregivers. The current approach of relying on informal 
information channels limits the program office's ability to comprehend 
the scope and magnitude of workload problems system-wide and leaves it 
in a reactive position of adding staff to the program only after 
significant workload problems have developed. A more capable IT system 
would enable the Caregiver Support Program to comprehensively monitor 
the program and proactively identify both actual and potential VAMC 
workload problems and target areas where improvements could be made. 
However, without a clear time frame for obtaining another IT system, 
workload issues will persist unless the Caregiver Support Program 
office starts to identify solutions to help alleviate VAMCs' workload 
burdens, such as modifications to the timelines and procedures for 
application processing and home visits, and the identification of 
additional ways to provide staffing support. If the program's workload 
problems are not addressed, the quality and scope of caregiver 
services, and ultimately the services that veterans receive, will 
continue to be compromised. 

Recommendations for Executive Action: 

To ensure that the Family Caregiver Program is able to meet 
caregivers' demand for its services, we recommend that the Secretary 
of the Department of Veterans Affairs 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. 

We also recommend that the Secretary of the Department of Veterans 
Affairs 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, and: 

* 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. 

Agency Comments and Our Evaluation: 

We provided a draft of this report to VA for review and comment. While 
the draft was at VA for comment, officials from VHA's Management 
Review Service expressed concerns with two of the three 
recommendations in the draft report. 

* Officials expressed concern that our recommendation to expedite the 
process for identifying and implementing an IT system for the Family 
Caregiver Program was directed to the Undersecretary for Health. They 
explained that obtaining a new IT system would require the involvement 
of multiple offices within VA, including central offices that are 
under the Secretary of VA. Based on this information, we revised our 
recommendation and have redirected it to the Secretary to ensure that 
it is inclusive of all necessary offices within the department. 

* Officials also commented on our recommendation about using data from 
the new IT system to formally reassess key aspects of the program and 
make modifications as needed. They suggested broadening the 
recommendation to include data from other sources, such as any data 
they may obtain through the solutions they implement in advance of 
obtaining a new IT system. In consideration of this information and 
the fact that we refer to relevant data from other IT systems in our 
report, we modified our recommendation to state that the 
Undersecretary for Health should 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. 

As a result of these revisions, VA concurred with all three of our 
recommendations in its letter, which is reprinted in appendix II. VA 
also provided technical comments, which we incorporated as 
appropriate. In concurring with our third recommendation to use data 
from the IT system as well as other relevant data to reassess the 
program, VA did not mention using data from the new IT system as part 
of its evaluation. As a result, we are concerned that VA's proposed 
actions only partially address this recommendation. Specifically, VA's 
response focused on using relevant information from solutions 
developed in response to our second recommendation as well as other 
relevant data to formally reassess key aspects of the program. A VHA 
official explained that no one knows how long it will take to develop 
the new IT system, or how long it will be before data from the system 
are available, and as a result, VHA developed their response based on 
actions they knew they could accomplish. However, the substance of our 
recommendation is focused on using comprehensive workload data from 
the new IT system as the foundation of a data-driven program analysis. 
Without such data, VHA will not be positioned to make sound, well-
informed decisions about the program, potentially allowing it to 
continue to struggle to meet the needs of the caregivers of seriously 
wounded and injured veterans. 

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

If you or your staff have any questions about this report, please 
contact me at (202) 512-7114 or williamsonr@gao.gov. Contact points 
for our Offices of Congressional Relations and Public Affairs may be 
found on the last page of the report. GAO staff who made major 
contributions to this report are listed in appendix III. 

Signed by: 

Randall B. Williamson: 
Director, Health Care: 

[End of section] 

Appendix I: Veterans Affairs Medical Centers by CSC-to-Approved 
Caregiver Workload Ratio, as of May 2014: 

VAMCS with CSC-to-approved caregiver ratio of 25 or less: 

Veterans Integrated Service Networks (VISN): 16; 
Veterans Affairs Medical Center (VAMC): Veterans Healthcare System 
(HCS) of the Ozarks; 
Location: Fayetteville, AR; 
No. CSCs: 1; 
Approved Caregivers: 6; 
Caregiver Support Coordinator (CSC) to Approved Caregiver Ratio: 1:6. 

Veterans Integrated Service Networks (VISN): 4; 
Veterans Affairs Medical Center (VAMC): Coatesville VAMC; 
Location: Coatesville, PA; 
No. CSCs: 1; 
Approved Caregivers: 7; 
Caregiver Support Coordinator (CSC) to Approved Caregiver Ratio: 1:7. 

Veterans Integrated Service Networks (VISN): 19; 
Veterans Affairs Medical Center (VAMC): Grand Junction VAMC; 
Location: Grand Junction, CO; 
No. CSCs: 1; 
Approved Caregivers: 8; 
Caregiver Support Coordinator (CSC) to Approved Caregiver Ratio: 1:8. 

Veterans Integrated Service Networks (VISN): 20; 
Veterans Affairs Medical Center (VAMC): Alaska HCS; 
Location: Anchorage, AK; 
No. CSCs: 1; 
Approved Caregivers: 10; 
Caregiver Support Coordinator (CSC) to Approved Caregiver Ratio: 1:10. 

Veterans Integrated Service Networks (VISN): 4; 
Veterans Affairs Medical Center (VAMC): Lebanon VAMC; 
Location: Lebanon, PA; 
No. CSCs: 1; 
Approved Caregivers: 11; 
Caregiver Support Coordinator (CSC) to Approved Caregiver Ratio: 1:11. 

Veterans Integrated Service Networks (VISN): 23; 
Veterans Affairs Medical Center (VAMC): VA Black Hills HCS; 
Location: Fort Meade and Hot Springs, SD; 
No. CSCs: 1; 
Approved Caregivers: 12; 
Caregiver Support Coordinator (CSC) to Approved Caregiver Ratio: 1:12. 

Veterans Integrated Service Networks (VISN): 19; 
Veterans Affairs Medical Center (VAMC): Sheridan VAMC; 
Location: Sheridan, WY; 
No. CSCs: 1; 
Approved Caregivers: 15; 
Caregiver Support Coordinator (CSC) to Approved Caregiver Ratio: 1:15. 

Veterans Integrated Service Networks (VISN): 15; 
Veterans Affairs Medical Center (VAMC): John J. Pershing VAMC; 
Location: Poplar Bluff, MO; 
No. CSCs: 1; 
Approved Caregivers: 16; 
Caregiver Support Coordinator (CSC) to Approved Caregiver Ratio: 1:16. 

Veterans Integrated Service Networks (VISN): 2; 
Veterans Affairs Medical Center (VAMC): Bath VAMC; 
Location: Bath, NY; 
No. CSCs: 1; 
Approved Caregivers: 18; 
Caregiver Support Coordinator (CSC) to Approved Caregiver Ratio: 1:18. 

Veterans Integrated Service Networks (VISN): 18; 
Veterans Affairs Medical Center (VAMC): West Texas VA HCS; 
Location: Big Spring, TX; 
No. CSCs: 1; 
Approved Caregivers: 19; 
Caregiver Support Coordinator (CSC) to Approved Caregiver Ratio: 1:19. 

Veterans Integrated Service Networks (VISN): 15; 
Veterans Affairs Medical Center (VAMC): VA St. Louis HCS; 
Location: St. Louis, MO; 
No. CSCs: 2; 
Approved Caregivers: 40; 
Caregiver Support Coordinator (CSC) to Approved Caregiver Ratio: 1:20. 

Veterans Integrated Service Networks (VISN): 10; 
Veterans Affairs Medical Center (VAMC): Chillicothe VAMC; 
Location: Chillicothe, OH; 
No. CSCs: 1; 
Approved Caregivers: 23; 
Caregiver Support Coordinator (CSC) to Approved Caregiver Ratio: 1:23. 

Veterans Integrated Service Networks (VISN): 11; 
Veterans Affairs Medical Center (VAMC): VA Illiana HCS; 
Location: Danville, IL; 
No. CSCs: 2; 
Approved Caregivers: 47; 
Caregiver Support Coordinator (CSC) to Approved Caregiver Ratio: 1:24. 

Veterans Integrated Service Networks (VISN): 23; 
Veterans Integrated Service Networks (VISN): Iowa City HCS; 
Location: Iowa City, IA; 
No. CSCs: 2; 
Approved Caregivers: 48; 
Caregiver Support Coordinator (CSC) to Approved Caregiver Ratio: 1: 24. 

Veterans Integrated Service Networks (VISN): 2; 
Veterans Affairs Medical Center (VAMC): Albany VAMC - Samuel S. 
Stratton; 
Location: Albany, NY; 
No. CSCs: 2; 
Approved Caregivers: 48; 
Caregiver Support Coordinator (CSC) to Approved Caregiver Ratio: 1:24. 

Veterans Integrated Service Networks (VISN): 1; 
Veterans Affairs Medical Center (VAMC): Manchester VAMC; 
Location: Manchester, NH; 
No. CSCs: 2; 
Approved Caregivers: 50; 
Caregiver Support Coordinator (CSC) to Approved Caregiver Ratio: 1:25. 

VAMCS with CSC-to-approved caregiver ratio of 26 to 50: 

Veterans Integrated Service Networks (VISN): 9; 
Veterans Affairs Medical Center (VAMC): Huntington VAMC; 
Location: Huntington, WV; 
No. CSCs: 2; 
Approved Caregivers: 52; 
Caregiver Support Coordinator (CSC) to Approved Caregiver Ratio: 1:26. 

Veterans Integrated Service Networks (VISN): 16; 
Veterans Affairs Medical Center (VAMC): Michael E. DeBakey VAMC; 
Location: Houston, TX; 
No. CSCs: 2; 
Approved Caregivers: 51; 
Caregiver Support Coordinator (CSC) to Approved Caregiver Ratio: 1:26. 

Veterans Integrated Service Networks (VISN): 21; 
Veterans Affairs Medical Center (VAMC): VA Sierra Nevada HCS; 
Location: Reno, CA; 
No. CSCs: 2; 
Approved Caregivers: 53; 
Caregiver Support Coordinator (CSC) to Approved Caregiver Ratio: 1:27. 

Veterans Integrated Service Networks (VISN): 23; 
Veterans Affairs Medical Center (VAMC): Sioux Falls VA HCS; 
Location: Sioux Falls, SD; 
No. CSCs: 1; 
Approved Caregivers: 27; 
Caregiver Support Coordinator (CSC) to Approved Caregiver Ratio: 1:27. 

Veterans Integrated Service Networks (VISN): 4; 
Veterans Affairs Medical Center (VAMC): Wilmington VAMC; 
Location: Wilmington, DE; 
No. CSCs: 2; 
Approved Caregivers: 58; 
Caregiver Support Coordinator (CSC) to Approved Caregiver Ratio: 1:29. 

Veterans Integrated Service Networks (VISN): 23; 
Veterans Affairs Medical Center (VAMC): Fargo VA HCS; 
Location: Fargo, ND; 
No. CSCs: 1; 
Approved Caregivers: 29; 
Caregiver Support Coordinator (CSC) to Approved Caregiver Ratio: 1:29. 

Veterans Integrated Service Networks (VISN): 7; 
Veterans Affairs Medical Center (VAMC): Birmingham VAMC; 
Location: Birmingham, AL; 
No. CSCs: 2; 
Approved Caregivers: 59; 
Caregiver Support Coordinator (CSC) to Approved Caregiver Ratio: 1:30. 

Veterans Integrated Service Networks (VISN): 2; 
Veterans Affairs Medical Center (VAMC): Canandaigua VAMC; 
Location: Canandaigua, NY; 
No. CSCs: 1; 
Approved Caregivers: 30; 
Caregiver Support Coordinator (CSC) to Approved Caregiver Ratio: 1:30. 

Veterans Integrated Service Networks (VISN): 4; 
Veterans Affairs Medical Center (VAMC): VA Butler HCS; 
Location: Butler, PA; 
No. CSCs: 1; 
Approved Caregivers: 31; 
Caregiver Support Coordinator (CSC) to Approved Caregiver Ratio: 1:31. 

Veterans Integrated Service Networks (VISN): 16; 
Veterans Affairs Medical Center (VAMC): Alexandria HCS; 
Location: Alexandria, LA; 
No. CSCs: 2; 
Approved Caregivers: 62; 
Caregiver Support Coordinator (CSC) to Approved Caregiver Ratio: 1:31. 

Veterans Integrated Service Networks (VISN): 16; 
Veterans Affairs Medical Center (VAMC): Gulf Coast Veterans HCS; 
Location: Biloxi/Gulfport, MS; Mobile, AL; Pensacola & Panama City, FL; 
No. CSCs: 4; 
Approved Caregivers: 126; 
Caregiver Support Coordinator (CSC) to Approved Caregiver Ratio: 1:32. 

Veterans Integrated Service Networks (VISN): 4; 
Veterans Affairs Medical Center (VAMC): Clarksburg - Louis A. Johnson 
VAMC; 
Location: Clarksburg, WV; 
No. CSCs: 2; 
Approved Caregivers: 64; 
Caregiver Support Coordinator (CSC) to Approved Caregiver Ratio: 1:32. 

Veterans Integrated Service Networks (VISN): 23; 
Veterans Affairs Medical Center (VAMC): St. Cloud VA HCS; 
Location: St. Cloud, MN; 
No. CSCs: 1; 
Approved Caregivers: 32; 
Caregiver Support Coordinator (CSC) to Approved Caregiver Ratio: 1:32. 

Veterans Integrated Service Networks (VISN): 15; 
Robert J. Dole VAMC; 
Location: Wichita, KS; 
No. CSCs: 1; 
Approved Caregivers: 34; 
Caregiver Support Coordinator (CSC) to Approved Caregiver Ratio: 1:34. 

Veterans Integrated Service Networks (VISN): 16; 
Veterans Affairs Medical Center (VAMC): Jack C. Montgomery HCS; 
Location: Muskogee, OK; 
No. CSCs: 2; 
Approved Caregivers: 67; 
Caregiver Support Coordinator (CSC) to Approved Caregiver Ratio: 1:34. 

Veterans Integrated Service Networks (VISN): 3; 
Veterans Affairs Medical Center (VAMC): VA Hudson Valley HCS; 
Location: Castle Point and Montrose, NY; 
No. CSCs: 2; 
Approved Caregivers: 68; 
Caregiver Support Coordinator (CSC) to Approved Caregiver Ratio: 1:34. 

Veterans Integrated Service Networks (VISN): 3; 
Veterans Affairs Medical Center (VAMC): Northport VAMC; 
Location: Northport, NY; 
No. CSCs: 2; 
Approved Caregivers: 68; 
Caregiver Support Coordinator (CSC) to Approved Caregiver Ratio: 1:34. 

Veterans Integrated Service Networks (VISN): 1; 
Veterans Affairs Medical Center (VAMC): VA Boston HCS; 
Location: Boston, MA; 
No. CSCs: 2; 
Approved Caregivers: 69; 
Caregiver Support Coordinator (CSC) to Approved Caregiver Ratio: 1:35. 

Veterans Integrated Service Networks (VISN): 19; 
Veterans Affairs Medical Center (VAMC): VA Salt Lake City HCS; 
Location: Salt Lake City, UT; 
No. CSCs: 2; 
Approved Caregivers: 70; 
Caregiver Support Coordinator (CSC) to Approved Caregiver Ratio: 1:35. 

Veterans Integrated Service Networks (VISN): 7; 
Veterans Affairs Medical Center (VAMC): Tuscaloosa VAMC; 
Location: Tuscaloosa, AL; 
No. CSCs: 1; 
Approved Caregivers: 35; 
Caregiver Support Coordinator (CSC) to Approved Caregiver Ratio: 1:35. 

Veterans Integrated Service Networks (VISN): 10; 
Veterans Affairs Medical Center (VAMC): Cincinnati VAMC; 
Location: Cincinnati, OH; 
No. CSCs: 1; 
Approved Caregivers: 36; 
Caregiver Support Coordinator (CSC) to Approved Caregiver Ratio: 1:36. 

Veterans Integrated Service Networks (VISN): 1; 
Veterans Affairs Medical Center (VAMC): VA Maine HCS - Togus; 
Location: Augusta, ME; 
No. CSCs: 1; 
Approved Caregivers: 36; 
Caregiver Support Coordinator (CSC) to Approved Caregiver Ratio: 1:36. 

Veterans Integrated Service Networks (VISN): 1; 
Veterans Affairs Medical Center (VAMC): White River Junction VAMC; 
Location: White River Junction, VT; 
No. CSCs: 1; 
Approved Caregivers: 36; 
Caregiver Support Coordinator (CSC) to Approved Caregiver Ratio: 1:36. 

Veterans Integrated Service Networks (VISN): 19; 
Veterans Affairs Medical Center (VAMC): Cheyenne VAMC; 
Location: Cheyenne, WY; 
No. CSCs: 1; 
Approved Caregivers: 36; 
Caregiver Support Coordinator (CSC) to Approved Caregiver Ratio: 1:36. 

Veterans Integrated Service Networks (VISN): 16; 
Veterans Affairs Medical Center (VAMC): Overton Brooks VAMC; 
Location: Shreveport, LA; 
No. CSCs: 1; 
Approved Caregivers: 36; 
Caregiver Support Coordinator (CSC) to Approved Caregiver Ratio: 1:36. 

Veterans Integrated Service Networks (VISN): 12; 
Veterans Affairs Medical Center (VAMC): William S. Middleton Memorial 
Veterans Hospital; 
Location: Madison, WI; 
No. CSCs: 1; 
Approved Caregivers: 37; 
Caregiver Support Coordinator (CSC) to Approved Caregiver Ratio: 1:37. 

Veterans Integrated Service Networks (VISN): 1; 
Veterans Affairs Medical Center (VAMC): Providence VAMC; 
Location: Providence, RI; 
No. CSCs: 1; 
Approved Caregivers: 37; 
Caregiver Support Coordinator (CSC) to Approved Caregiver Ratio: 1:37. 

Veterans Integrated Service Networks (VISN): 11; 
Veterans Affairs Medical Center (VAMC): Battle Creek VAMC; 
Location: Battle Creek, MI; 
No. CSCs: 2; 
Approved Caregivers: 74; 
Caregiver Support Coordinator (CSC) to Approved Caregiver Ratio: 1:37. 

Veterans Integrated Service Networks (VISN): 23; 
Veterans Affairs Medical Center (VAMC): Omaha - VA Nebraska-Western 
Iowa HCS; 
Location: Grand Island, Lincoln, and Omaha, NE; 
No. CSCs: 2; 
Approved Caregivers: 75; 
Caregiver Support Coordinator (CSC) to Approved Caregiver Ratio: 1:38. 

Veterans Integrated Service Networks (VISN): 12; 
Veterans Affairs Medical Center (VAMC): Clement J. Zablocki VAMC; 
Location: Milwaukee, WI; 
No. CSCs: 1; 
Approved Caregivers: 38; 
Caregiver Support Coordinator (CSC) to Approved Caregiver Ratio: 1:38. 

Veterans Integrated Service Networks (VISN): 12; 
Veterans Affairs Medical Center (VAMC): Oscar G. Johnson VAMC; 
Location: Iron Mountain, MI; 
No. CSCs: 1; 
Approved Caregivers: 40; 
Caregiver Support Coordinator (CSC) to Approved Caregiver Ratio: 1:40. 

Veterans Integrated Service Networks (VISN): 7; 
Veterans Affairs Medical Center (VAMC): Carl Vinson VAMC; 
Location: Dublin, GA; 
No. CSCs: 2; 
Approved Caregivers: 79; 
Caregiver Support Coordinator (CSC) to Approved Caregiver Ratio: 1:40. 

Veterans Integrated Service Networks (VISN): 3; 
Veterans Affairs Medical Center (VAMC): James J. Peters VAMC; 
Location: Bronx, NY; 
No. CSCs: 3; 
Approved Caregivers: 123; 
Caregiver Support Coordinator (CSC) to Approved Caregiver Ratio: 1:41. 

Veterans Integrated Service Networks (VISN): 8; 
Veterans Affairs Medical Center (VAMC): West Palm Beach VAMC; 
Location: West Palm Beach, FL; 
No. CSCs: 2; 
Approved Caregivers: 82; 
Caregiver Support Coordinator (CSC) to Approved Caregiver Ratio: 1:41. 

Veterans Integrated Service Networks (VISN): 8; 
Veterans Affairs Medical Center (VAMC): C.W. Bill Young VAMC; 
Location: Bay Pines, FL; 
No. CSCs: 3; 
Approved Caregivers: 127; 
Caregiver Support Coordinator (CSC) to Approved Caregiver Ratio: 1:42. 

Veterans Integrated Service Networks (VISN): 20; 
Veterans Affairs Medical Center (VAMC): Jonathan M. Wainwright 
Memorial VAMC; 
Location: Walla Walla and Yakima, WA; 
No. CSCs: 1; 
Approved Caregivers: 42; 
Caregiver Support Coordinator (CSC) to Approved Caregiver Ratio: 1:42. 

Veterans Integrated Service Networks (VISN): 16; 
Veterans Affairs Medical Center (VAMC): Central Arkansas HCS; 
Location: Little Rock, AR; 
No. CSCs: 1; 
Approved Caregivers: 43; 
Caregiver Support Coordinator (CSC) to Approved Caregiver Ratio: 1:43. 

Veterans Integrated Service Networks (VISN): 6; 
Veterans Affairs Medical Center (VAMC): Durham VAMC; 
Location: Durham, NC; 
No. CSCs: 3; 
Approved Caregivers: 130; 
Caregiver Support Coordinator (CSC) to Approved Caregiver Ratio: 1:43. 

Veterans Integrated Service Networks (VISN): 20; 
Veterans Affairs Medical Center (VAMC): Mann-Grandstaff VAMC; 
Location: Spokane, WA; 
No. CSCs: 2; 
Approved Caregivers: 85; 
Caregiver Support Coordinator (CSC) to Approved Caregiver Ratio: 1:43. 

Veterans Integrated Service Networks (VISN): 7; 
Veterans Affairs Medical Center (VAMC): Wm. Jennings Bryan Dorn VAMC; 
Location: -Columbia, SC; 
No. CSCs: 2; 
Approved Caregivers: 87; 
Caregiver Support Coordinator (CSC) to Approved Caregiver Ratio: 1:44. 

Veterans Integrated Service Networks (VISN): 5; 
Veterans Affairs Medical Center (VAMC): Martinsburg VAMC; 
Location: Martinsburg, WV; 
No. CSCs: 1; 
Approved Caregivers: 45; 
Caregiver Support Coordinator (CSC) to Approved Caregiver Ratio: 1:45. 

Veterans Integrated Service Networks (VISN): 6; 
Veterans Affairs Medical Center (VAMC): Beckley VAMC; 
Location: Beckley, VA; 
No. CSCs: 1; 
Approved Caregivers: 45; 
Caregiver Support Coordinator (CSC) to Approved Caregiver Ratio: 1:45. 

Veterans Integrated Service Networks (VISN): 4; 
Veterans Affairs Medical Center (VAMC): Pittsburgh HCS; 
Location: Pittsburgh, PA; 
No. CSCs: 1; 
Approved Caregivers: 45; 
Caregiver Support Coordinator (CSC) to Approved Caregiver Ratio: 1:45. 

Veterans Integrated Service Networks (VISN): 1; 
Veterans Affairs Medical Center (VAMC): Edith Nourse Rogers Memorial 
Veterans Hospital; 
Location: Bedford, MA; 
No. CSCs: 1; 
Approved Caregivers: 45; 
Caregiver Support Coordinator (CSC) to Approved Caregiver Ratio: 1:45. 

Veterans Integrated Service Networks (VISN): 10; 
Veterans Affairs Medical Center (VAMC): Chalmers P. Wylie Ambulatory 
Care Center; 
Location: Columbus, OH; 
No. CSCs: 1; 
Approved Caregivers: 48; 
Caregiver Support Coordinator (CSC) to Approved Caregiver Ratio: 1:48. 

Veterans Integrated Service Networks (VISN): 6; 
Veterans Affairs Medical Center (VAMC): Salem VAMC; 
Location: Salem, VA; 
No. CSCs: 1; 
Approved Caregivers: 48; 
Caregiver Support Coordinator (CSC) to Approved Caregiver Ratio: 1:48. 

Veterans Integrated Service Networks (VISN): 4; 
Veterans Affairs Medical Center (VAMC): Erie VAMC; 
Location: Erie, PA; 
No. CSCs: 1; 
Approved Caregivers: 48; 
Caregiver Support Coordinator (CSC) to Approved Caregiver Ratio: 1:48. 

Veterans Integrated Service Networks (VISN): 4; 
Veterans Affairs Medical Center (VAMC): Wilkes-Barre VAMC; 
Location: Wilkes-Barre, PA; 
No. CSCs: 1; 
Approved Caregivers: 48; 
Caregiver Support Coordinator (CSC) to Approved Caregiver Ratio: 1:48. 

Veterans Integrated Service Networks (VISN): 21; 
Veterans Affairs Medical Center (VAMC): VA Palo Alto HCS; 
Location: Livermore, Menlo Park, and Palo Alto, CA; 
No. CSCs: 4; 
Approved Caregivers: 196; 
Caregiver Support Coordinator (CSC) to Approved Caregiver Ratio: 1:49. 

Veterans Integrated Service Networks (VISN): 20; 
Veterans Affairs Medical Center (VAMC): VA Roseburg HCS; 
Location: Roseburg, OR; 
No. CSCs: 2; 
Approved Caregivers: 98; 
Caregiver Support Coordinator (CSC) to Approved Caregiver Ratio: 1:49. 

VAMCS with CSC-to-approved caregiver ratio of 51 to 100: 

Veterans Integrated Service Networks (VISN): 6; 
Veterans Affairs Medical Center (VAMC): Salisbury - W.G. (Bill) Hefner 
VAMC; 
Location: Salisbury, NC; 
No. CSCs: 3; 
Approved Caregivers: 153; 
Caregiver Support Coordinator (CSC) to Approved Caregiver Ratio: 1:51. 

Veterans Integrated Service Networks (VISN): 11; 
Veterans Affairs Medical Center (VAMC): John D. Dingell VAMC; 
Location: Detroit, MI; 
No. CSCs: 1; 
Approved Caregivers: 51; 
Caregiver Support Coordinator (CSC) to Approved Caregiver Ratio: 1:51. 

Veterans Integrated Service Networks (VISN): 21; 
Veterans Affairs Medical Center (VAMC): San Francisco VAMC; 
Location: San Francisco, CA; 
No. CSCs: 1; 
Approved Caregivers: 52; 
Caregiver Support Coordinator (CSC) to Approved Caregiver Ratio: 1:52. 

Veterans Integrated Service Networks (VISN): 4; 
Veterans Affairs Medical Center (VAMC): Altoona - James E. Van Zandt 
VAMC; 
Location: Altoona, PA; 
No. CSCs: 2; 
Approved Caregivers: 103; 
Caregiver Support Coordinator (CSC) to Approved Caregiver Ratio: 1:52. 

Veterans Integrated Service Networks (VISN): 1; 
Veterans Affairs Medical Center (VAMC): VA Connecticut HCS; 
Location: Newington and West Haven, CT; 
No. CSCs: 2; 
Approved Caregivers: 105; 
Caregiver Support Coordinator (CSC) to Approved Caregiver Ratio: 1:53. 

Veterans Integrated Service Networks (VISN): 16; 
Veterans Affairs Medical Center (VAMC): G.V. (Sonny) Montgomery VAMC; 
Location: Jackson, MS; 
No. CSCs: 2; 
Approved Caregivers: 106; 
Caregiver Support Coordinator (CSC) to Approved Caregiver Ratio: 1:53. 

Veterans Integrated Service Networks (VISN): 17; 
Veterans Affairs Medical Center (VAMC): VA Texas Valley Coastal Bend 
HCS; 
Location: Harlingen, TX; 
No. CSCs: 2; 
Approved Caregivers: 108; 
Caregiver Support Coordinator (CSC) to Approved Caregiver Ratio: 1:54. 

Veterans Integrated Service Networks (VISN): 16; 
Veterans Affairs Medical Center (VAMC): Oklahoma City VAMC; 
Location: Oklahoma City, OK; 
No. CSCs: 1; 
Approved Caregivers: 54; 
Caregiver Support Coordinator (CSC) to Approved Caregiver Ratio: 1:54. 

Veterans Integrated Service Networks (VISN): 15; 
Veterans Affairs Medical Center (VAMC): Marion VAMC; 
Location: Marion, IL; 
No. CSCs: 1; 
Approved Caregivers: 54; 
Caregiver Support Coordinator (CSC) to Approved Caregiver Ratio: 1:54. 

Veterans Integrated Service Networks (VISN): 22; 
Veterans Affairs Medical Center (VAMC): VA Southern Nevada HCS; 
Location: North Las Vegas, NV; 
No. CSCs: 3; 
Approved Caregivers: 166; 
Caregiver Support Coordinator (CSC) to Approved Caregiver Ratio: 1:55. 

Veterans Integrated Service Networks (VISN): 11; 
Veterans Affairs Medical Center (VAMC): Richard L. Roudebush VAMC; 
Location: Indianapolis, IN; 
No. CSCs: 2; 
Approved Caregivers: 111; 
Caregiver Support Coordinator (CSC) to Approved Caregiver Ratio: 1:56. 

Veterans Integrated Service Networks (VISN): 11; 
Veterans Affairs Medical Center (VAMC): VA Northern Indiana HCS; 
Location: Marion and Fort Wayne, IN; 
No. CSCs: 2; 
Approved Caregivers: 112; 
Caregiver Support Coordinator (CSC) to Approved Caregiver Ratio: 1:56. 

Veterans Integrated Service Networks (VISN): 16; 
Veterans Affairs Medical Center (VAMC): Southeast Louisiana VA HCS; 
Location: New Orleans, LA; 
No. CSCs: 1; 
Approved Caregivers: 56; 
Caregiver Support Coordinator (CSC) to Approved Caregiver Ratio: 1:56. 

Veterans Integrated Service Networks (VISN): 18; 
Veterans Affairs Medical Center (VAMC): Amarillo VA HCS; 
Location: Amarillo, TX; 
No. CSCs: 1; 
Approved Caregivers: 56; 
Caregiver Support Coordinator (CSC) to Approved Caregiver Ratio: 1:56. 

Veterans Integrated Service Networks (VISN): 12; 
Veterans Affairs Medical Center (VAMC): Jesse Brown VAMC; 
Location: Chicago, IL; 
No. CSCs: 1; 
Approved Caregivers: 56; 
Caregiver Support Coordinator (CSC) to Approved Caregiver Ratio: 1:56. 

Veterans Integrated Service Networks (VISN): 20; 
Veterans Affairs Medical Center (VAMC): Portland VAMC; 
Location: Portland, OR and Vancouver, WA; 
No. CSCs: 3; 
Approved Caregivers: 172; 
Caregiver Support Coordinator (CSC) to Approved Caregiver Ratio: 1:57. 

Veterans Integrated Service Networks (VISN): 10; 
Veterans Affairs Medical Center (VAMC): Louis Stokes Cleveland VAMC; 
Location: -Cleveland, OH; 
No. CSCs: 2; 
Approved Caregivers: 114; 
Caregiver Support Coordinator (CSC) to Approved Caregiver Ratio: 1:57. 

Veterans Integrated Service Networks (VISN): 23; 
Veterans Affairs Medical Center (VAMC): VA Central Iowa HCS; 
Location: Des Moines and Knoxville, IA; 
No. CSCs: 1; 
Approved Caregivers: 59; 
Caregiver Support Coordinator (CSC) to Approved Caregiver Ratio: 1:59. 

Veterans Integrated Service Networks (VISN): 19; 
Veterans Affairs Medical Center (VAMC): VA Montana HCS; 
Location: Fort Harrison, MT; 
No. CSCs: 2; 
Approved Caregivers: 122; 
Caregiver Support Coordinator (CSC) to Approved Caregiver Ratio: 1:61. 

Veterans Integrated Service Networks (VISN): 9; 
Veterans Affairs Medical Center (VAMC): Lexington VAMC; 
Location: Lexington, KY; 
No. CSCs: 1; 
Approved Caregivers: 61; 
Caregiver Support Coordinator (CSC) to Approved Caregiver Ratio: 1:61. 

Veterans Integrated Service Networks (VISN): 23; 
Veterans Affairs Medical Center (VAMC): Minneapolis VA HCS; 
Location: Minneapolis, MN; 
No. CSCs: 1; 
Approved Caregivers: 62; 
Caregiver Support Coordinator (CSC) to Approved Caregiver Ratio: 1:62. 

Veterans Integrated Service Networks (VISN): 11; 
Veterans Affairs Medical Center (VAMC): Aleda E. Lutz VAMC; 
Location: Saginaw, MI; 
No. CSCs: 1; 
Approved Caregivers: 62; 
Caregiver Support Coordinator (CSC) to Approved Caregiver Ratio: 1:62. 

Veterans Integrated Service Networks (VISN): 1; 
Veterans Affairs Medical Center (VAMC): VA Central Western 
Massachusetts HCS; 
Location: Northampton and Leeds, MA; 
No. CSCs: 1; 
Approved Caregivers: 62; 
Caregiver Support Coordinator (CSC) to Approved Caregiver Ratio: 1:62. 

Veterans Integrated Service Networks (VISN): 12; 
Veterans Affairs Medical Center (VAMC): Captain James A. Lovell 
Federal Health Care Center; 
Location: North Chicago, IL; 
No. CSCs: 1; 
Approved Caregivers: 63; 
Caregiver Support Coordinator (CSC) to Approved Caregiver Ratio: 1:63. 

Veterans Integrated Service Networks (VISN): 10; 
Veterans Affairs Medical Center (VAMC): Dayton VAMC; 
Location: Dayton, OH; 
No. CSCs: 1; 
Approved Caregivers: 64; 
Caregiver Support Coordinator (CSC) to Approved Caregiver Ratio: 1:64. 

Veterans Integrated Service Networks (VISN): 3; 
Veterans Affairs Medical Center (VAMC): New York Harbor HCS; 
Location: New York City, Manhattan and Brooklyn, NY; 
No. CSCs: 1; 
Approved Caregivers: 64; 
Caregiver Support Coordinator (CSC) to Approved Caregiver Ratio: 1:64. 

Veterans Integrated Service Networks (VISN): 2; 
Veterans Affairs Medical Center (VAMC): VA Western New York HCS; 
Location: Batavia and Buffalo, NY; 
No. CSCs: 1; 
Approved Caregivers: 65; 
Caregiver Support Coordinator (CSC) to Approved Caregiver Ratio: 1:65. 

Veterans Integrated Service Networks (VISN): 21; 
Veterans Affairs Medical Center (VAMC): VA Pacific Islands HCS; 
Location: Honolulu, HI; 
No. CSCs: 3; 
Approved Caregivers: 197; 
Caregiver Support Coordinator (CSC) to Approved Caregiver Ratio: 1:66. 

Veterans Integrated Service Networks (VISN): 6; 
Veterans Affairs Medical Center (VAMC): Asheville VAMC; 
Location: Asheville, NC; 
No. CSCs: 1; 
Approved Caregivers: 67; 
Caregiver Support Coordinator (CSC) to Approved Caregiver Ratio: 1:67. 

Veterans Integrated Service Networks (VISN): 6; 
Veterans Affairs Medical Center (VAMC): Hunter Holmes McGuire VAMC; 
Location: Richmond, VA; 
No. CSCs: 2; 
Approved Caregivers: 136; 
Caregiver Support Coordinator (CSC) to Approved Caregiver Ratio: 1:68. 

Veterans Integrated Service Networks (VISN): 9; 
Veterans Affairs Medical Center (VAMC): Mountain Home VAMC; 
Location: Mountain Home, TN; 
No. CSCs: 2; 
Approved Caregivers: 136; 
Caregiver Support Coordinator (CSC) to Approved Caregiver Ratio: 1:68. 

Veterans Integrated Service Networks (VISN): 8; 
Veterans Affairs Medical Center (VAMC): Miami VA HCS; 
Location: Miami, FL; 
No. CSCs: 2; 
Approved Caregivers: 137; 
Caregiver Support Coordinator (CSC) to Approved Caregiver Ratio: 1:69. 

Veterans Integrated Service Networks (VISN): 20; 
Veterans Affairs Medical Center (VAMC): White City or VA Southern 
Oregon Rehabilitation Center; 
Location: White City, OR; 
No. CSCs: 2; 
Approved Caregivers: 144; 
Caregiver Support Coordinator (CSC) to Approved Caregiver Ratio: 1:72. 

Veterans Integrated Service Networks (VISN): 20; 
Veterans Affairs Medical Center (VAMC): Boise VAMC; 
Location: Boise, ID; 
No. CSCs: 1; 
Approved Caregivers: 72; 
Caregiver Support Coordinator (CSC) to Approved Caregiver Ratio: 1:72. 

Veterans Integrated Service Networks (VISN): 15; 
Veterans Affairs Medical Center (VAMC): Kansas City VAMC; 
Location: Kansas City, MO; 
No. CSCs: 1; 
Approved Caregivers: 72; 
Caregiver Support Coordinator (CSC) to Approved Caregiver Ratio: 1:72. 

Veterans Integrated Service Networks (VISN): 19; 
Veterans Affairs Medical Center (VAMC): VA Eastern Colorado HCS; 
Location: Denver, CO; 
No. CSCs: 3; 
Approved Caregivers: 232; 
Caregiver Support Coordinator (CSC) to Approved Caregiver Ratio: 1:77. 

Veterans Integrated Service Networks (VISN): 22; 
Veterans Affairs Medical Center (VAMC): VA Greater Los Angeles HCS; 
Location: Los Angeles, CA; 
No. CSCs: 2; 
Approved Caregivers: 155; 
Caregiver Support Coordinator (CSC) to Approved Caregiver Ratio: 1:78. 

Veterans Integrated Service Networks (VISN): 8; 
Veterans Affairs Medical Center (VAMC): North Florida/South Georgia VA 
HCS; 
Location: Gainesville and Lake City, FL; 
No. CSCs: 2; 
Approved Caregivers: 162; 
Caregiver Support Coordinator (CSC) to Approved Caregiver Ratio: 1:81. 

Veterans Integrated Service Networks (VISN): 3; 
Veterans Affairs Medical Center (VAMC): VA New Jersey HCS; 
Location: East Orange and Lyons, NJ; 
No. CSCs: 2; 
Approved Caregivers: 162; 
Caregiver Support Coordinator (CSC) to Approved Caregiver Ratio: 1:81. 

Veterans Integrated Service Networks (VISN): 8; 
Veterans Affairs Medical Center (VAMC): James A. Haley VA Hospital; 
Location: Tampa, FL; 
No. CSCs: 2; 
Approved Caregivers: 164; 
Caregiver Support Coordinator (CSC) to Approved Caregiver Ratio: 1:82. 

Veterans Integrated Service Networks (VISN): 5; 
Veterans Affairs Medical Center (VAMC): Maryland HCS; 
Location: Baltimore and Perry Point, MD; 
No. CSCs: 1; 
Approved Caregivers: 83; 
Caregiver Support Coordinator (CSC) to Approved Caregiver Ratio: 1:83. 

Veterans Integrated Service Networks (VISN): 17; 
Veterans Affairs Medical Center (VAMC): Central Texas Veterans HCS; 
Location: Marline, Temple and Waco, TX; 
No. CSCs: 3; 
Approved Caregivers: 256; 
Caregiver Support Coordinator (CSC) to Approved Caregiver Ratio: 1:85. 

Veterans Integrated Service Networks (VISN): 18; 
Veterans Affairs Medical Center (VAMC): Southern Arizona VA HCS; 
Location: Tucson, AZ; 
No. CSCs: 1; 
Approved Caregivers: 86; 
Caregiver Support Coordinator (CSC) to Approved Caregiver Ratio: 1:86. 

Veterans Integrated Service Networks (VISN): 22; 
Veterans Affairs Medical Center (VAMC): VA San Diego HCS; 
Location: San Diego, CA; 
No. CSCs: 3; 
Approved Caregivers: 271; 
Caregiver Support Coordinator (CSC) to Approved Caregiver Ratio: 1:90. 

Veterans Integrated Service Networks (VISN): 12; 
Veterans Affairs Medical Center (VAMC): Tomah VAMC; 
Location: Tomah, WI; 
No. CSCs: 1; 
Approved Caregivers: 91; 
Caregiver Support Coordinator (CSC) to Approved Caregiver Ratio: 1:91. 

Veterans Integrated Service Networks (VISN): 18; 
Veterans Affairs Medical Center (VAMC): Phoenix VA HCS; 
Location: Phoenix, AZ; 
No. CSCs: 3; 
Approved Caregivers: 282; 
Caregiver Support Coordinator (CSC) to Approved Caregiver Ratio: 1:94. 

Veterans Integrated Service Networks (VISN): 11; 
Veterans Affairs Medical Center (VAMC): VA Ann Arbor HCS; 
Location: Ann Arbor, MI; 
No. CSCs: 1; 
Approved Caregivers: 95; 
Caregiver Support Coordinator (CSC) to Approved Caregiver Ratio: 1:95. 

Veterans Integrated Service Networks (VISN): 18; 
Veterans Affairs Medical Center (VAMC): El Paso VA HCS; 
Location: El Paso, TX; 
No. CSCs: 1; 
Approved Caregivers: 96; 
Caregiver Support Coordinator (CSC) to Approved Caregiver Ratio: 1:96. 

Veterans Integrated Service Networks (VISN): 17; 
Veterans Affairs Medical Center (VAMC): VA North Texas HCS; 
Location: Bonham and Dallas, TX; 
No. CSCs: 3; 
Approved Caregivers: 287; 
Caregiver Support Coordinator (CSC) to Approved Caregiver Ratio: 1:96. 

Veterans Integrated Service Networks (VISN): 21; 
Veterans Affairs Medical Center (VAMC): VA Northern California HCS; 
Location: Mather and Martinez, CA; 
No. CSCs: 3; 
Approved Caregivers: 291; 
Caregiver Support Coordinator (CSC) to Approved Caregiver Ratio: 1:97. 

Veterans Integrated Service Networks (VISN): 4; 
Veterans Affairs Medical Center (VAMC): Philadelphia VAMC; 
Location: Philadelphia, PA; 
No. CSCs: 1; 
Approved Caregivers: 99; 
Caregiver Support Coordinator (CSC) to Approved Caregiver Ratio: 1:99. 

Veterans Integrated Service Networks (VISN): 7; 
Veterans Affairs Medical Center (VAMC): Ralph H. Johnson VAMC; 
Location: Charleston, SC; 
No. CSCs: 2; 
Approved Caregivers: 197; 
Caregiver Support Coordinator (CSC) to Approved Caregiver Ratio: 1:99. 

VAMCS with CSC-to-approved caregiver ratio of 101 to 150: 

Veterans Integrated Service Networks (VISN): 9; 
Veterans Affairs Medical Center (VAMC): Robley Rex VAMC (Ft. Knox); 
Location: Louisville, KY; 
No. CSCs: 2; 
Approved Caregivers: 204; 
Caregiver Support Coordinator (CSC) to Approved Caregiver Ratio: 1:102. 

Veterans Integrated Service Networks (VISN): 7; 
Veterans Affairs Medical Center (VAMC): Charlie Norwood VAMC; 
Location: Augusta, GA; 
No. CSCs: 1; 
Approved Caregivers: 106; 
Caregiver Support Coordinator (CSC) to Approved Caregiver Ratio: 1:106. 

Veterans Integrated Service Networks (VISN): 2; 
Veterans Affairs Medical Center (VAMC): Syracuse VAMC; 
Location: Syracuse, NY; 
No. CSCs: 1; 
Approved Caregivers: 107; 
Caregiver Support Coordinator (CSC) to Approved Caregiver Ratio: 1:107. 

Veterans Integrated Service Networks (VISN): 6; 
Veterans Affairs Medical Center (VAMC): Hampton VAMC; 
Location: Hampton, VA; 
No. CSCs: 2; 
Approved Caregivers: 220; 
Caregiver Support Coordinator (CSC) to Approved Caregiver Ratio: 1:110. 

Veterans Integrated Service Networks (VISN): 21; 
Veterans Affairs Medical Center (VAMC): VA Central California HCS; 
Location: Fresno, CA; 
No. CSCs: 1; 
Approved Caregivers: 111; 
Caregiver Support Coordinator (CSC) to Approved Caregiver Ratio: 1:111. 

Veterans Integrated Service Networks (VISN): 18; 
Veterans Affairs Medical Center (VAMC): Northern Arizona VA HCS; 
Location: Prescott, AZ; 
No. CSCs: 2; 
Approved Caregivers: 224; 
Caregiver Support Coordinator (CSC) to Approved Caregiver Ratio: 1:112. 

Veterans Integrated Service Networks (VISN): 15; 
Veterans Affairs Medical Center (VAMC): VA Eastern Kansas HCS; 
Location: Leavenworth and Topeka, KS; 
No. CSCs: 2; 
Approved Caregivers: 225; 
Caregiver Support Coordinator (CSC) to Approved Caregiver Ratio: 1:113. 

Veterans Integrated Service Networks (VISN): 7; 
Veterans Affairs Medical Center (VAMC): Central Alabama VA HCS; 
Location: Montgomery and Tuskegee, AL; 
No. CSCs: 2; 
Approved Caregivers: 241; 
Caregiver Support Coordinator (CSC) to Approved Caregiver Ratio: 1:121. 

Veterans Integrated Service Networks (VISN): 22; 
Veterans Affairs Medical Center (VAMC): VA Long Beach HCS; 
Location: Long Beach, CA; 
No. CSCs: 2; 
Approved Caregivers: 245; 
Caregiver Support Coordinator (CSC) to Approved Caregiver Ratio: 1:123. 

Veterans Integrated Service Networks (VISN): 22; 
Veterans Affairs Medical Center (VAMC): VA Loma Linda HCS; 
Location: Loma Linda, CA; 
No. CSCs: 3; 
Approved Caregivers: 375; 
Caregiver Support Coordinator (CSC) to Approved Caregiver Ratio: 1:125. 

Veterans Integrated Service Networks (VISN): 18; 
Veterans Affairs Medical Center (VAMC): New Mexico VA HCS; 
Location: Albuquerque, NM; 
No. CSCs: 2; 
Approved Caregivers: 251; 
Caregiver Support Coordinator (CSC) to Approved Caregiver Ratio: 1:126. 

Veterans Integrated Service Networks (VISN): 15; 
Veterans Affairs Medical Center (VAMC): Harry S. Truman Memorial; 
Location: Columbia, MO; 
No. CSCs: 1; 
Approved Caregivers: 133; 
Caregiver Support Coordinator (CSC) to Approved Caregiver Ratio: 1:133. 

Veterans Integrated Service Networks (VISN): 12; 
Veterans Affairs Medical Center (VAMC): Edward Hines, Jr. VA Hospital; 
Location: Hines, IL; 
No. CSCs: 1; 
Approved Caregivers: 134; 
Caregiver Support Coordinator (CSC) to Approved Caregiver Ratio: 1:134. 

Veterans Integrated Service Networks (VISN): 8; 
Veterans Affairs Medical Center (VAMC): VA Caribbean HCS; 
Location: San Juan, PR; 
No. CSCs: 3; 
Approved Caregivers: 429; 
Caregiver Support Coordinator (CSC) to Approved Caregiver Ratio: 1:143. 

Veterans Integrated Service Networks (VISN): 9; 
Veterans Affairs Medical Center (VAMC): Tennessee Valley HCS; 
Location: Nashville and Murfreesboro, TN; 
No. CSCs: 3; 
Approved Caregivers: 451; 
Caregiver Support Coordinator (CSC) to Approved Caregiver Ratio: 1:150. 

VAMCS with CSC-to-approved caregiver ratio of 151 or more: 

Veterans Integrated Service Networks (VISN): 8; 
Veterans Affairs Medical Center (VAMC): Orlando VAMC; 
Location: Orlando, FL; 
No. CSCs: 3; 
Approved Caregivers: 472; 
Caregiver Support Coordinator (CSC) to Approved Caregiver Ratio: 1:157. 

Veterans Integrated Service Networks (VISN): 20; 
Veterans Affairs Medical Center (VAMC): VA Puget Sound HCS; 
Location: Lakewood and Seattle, WA; 
No. CSCs: 2; 
Approved Caregivers: 331; 
Caregiver Support Coordinator (CSC) to Approved Caregiver Ratio: 1:166. 

Veterans Integrated Service Networks (VISN): 17; 
Veterans Affairs Medical Center (VAMC): South Texas Veterans HCS; 
Location: Kerrville and San Antonio, TX; 
No. CSCs: 2; 
Approved Caregivers: 342; 
Caregiver Support Coordinator (CSC) to Approved Caregiver Ratio: 1:171. 

Veterans Integrated Service Networks (VISN): 5; 
Veterans Affairs Medical Center (VAMC): Washington D.C. VAMC; 
Location: Washington, DC; 
No. CSCs: 1; 
Approved Caregivers: 181; 
Caregiver Support Coordinator (CSC) to Approved Caregiver Ratio: 1:181. 

Veterans Integrated Service Networks (VISN): 9; 
Veterans Affairs Medical Center (VAMC): Memphis VAMC; 
Location: Memphis, TN; 
No. CSCs: 2; 
Approved Caregivers: 367; 
Caregiver Support Coordinator (CSC) to Approved Caregiver Ratio: 1:184. 

Veterans Integrated Service Networks (VISN): 6; 
Veterans Affairs Medical Center (VAMC): Fayetteville VAMC; 
Location: Fayetteville, NC; 
No. CSCs: 3; 
Approved Caregivers: 570; 
Caregiver Support Coordinator (CSC) to Approved Caregiver Ratio: 1:190. 

Veterans Integrated Service Networks (VISN): 7; 
Veterans Affairs Medical Center (VAMC): Atlanta VAMC; 
Location: Decatur, GA; 
No. CSCs: 1; 
Approved Caregivers: 251; 
Caregiver Support Coordinator (CSC) to Approved Caregiver Ratio: 1:251. 

Veterans Affairs Medical Center (VAMC): Total (140 VAMCs); 
No. CSCs: 233; 
Approved Caregivers: 15,661. 

Source: GAO analysis of Veterans Health Administration documents. 
GAO-14-675. 

Note: While caregiver support coordinators (CSC) administer the Family 
Caregiver Program at all 151 VA facilities, they are assigned to 140 
VAMCs or healthcare systems, which may include more than one VA 
facility. We present program statistics based on CSC assignments 
because that is how they are tracked by the Caregiver Support Program 
office. 

[End of table] 

[End of section] 

Appendix II: Comments from the Department of Veterans Affairs: 

Department of Veterans Affairs: 
Washington, DC 20420: 

August 8, 2014: 

Mr. Randall Williamson: 
Director, Health Care: 
U.S. Government Accountability Office: 
441 G Street, NW: 
Washington, DC 20548: 

Dear Mr. Williamson: 

The Department of Veterans Affairs (VA) has reviewed the Government
Accountability Office's (GAO) draft report, "VA Health Care: Actions 
Needed to Address Higher-Than-Expected Demand for the Family Caregiver 
Program" (GAO-14-675). VA generally agrees with GAO's conclusions and 
concurs with GAO's recommendations to the Department. 

The enclosure specifically addresses GAO's recommendations and 
provides technical comments to the draft report. VA appreciates the 
opportunity to comment on your draft report. 

Sincerely, 

Signed by: 

Joe D. Riojas: 
Chief of Staff: 

Enclosure: 

Department of Veterans Affairs (VA) Response to Government 
Accountability Office (GAO) Draft Report "VA Health Care: Actions 
Needed to Address Higher-Than-Expected Demand for the Family Caregiver 
Program" (GAO-14-675): 

Recommendation 1: To ensure that the Family Caregiver Program is able 
to meet caregivers' demand for its services, we recommend that the 
Secretary of the Department of Veterans Affairs 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 Comment: Concur. To ensure that all caregivers' requirements are 
identified and addressed expeditiously, the Veterans Health 
Administration (VHA) will work through the Information Technology (IT) 
governance boards to prioritize this new IT system requirement into 
the fiscal year 2015 budget operating plan. Once appropriately 
prioritized, VHA will ensure their business requirements for the 
caregivers' system are identified such that cost estimates can be 
developed, project timelines for development and implementation can be 
established, and funding can be identified in the budget operating 
plan. Once the plan is approved, the Office of Information and 
Technology will ensure this project is managed through the Project 
Accountability Management System for rigorous oversight through 
milestone and techstat reviews, thereby ensuring systematic management 
of all phases of IT system development and implementation. The target 
implementation date will be driven by the scope and complexities of 
these requirements. 

GAO Recommendation: GAO also recommends that the Secretary of the 
Department of Veterans Affairs direct the Undersecretary for Health to: 

Recommendation 2: 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. 

VA Comment: Concur. VHA will identify solutions to alleviate VA 
medical centers' workload burden by exploring options such as 
modifications to procedures and timelines for the Program of 
ComprehensiVe Assistance for Family Caregivers. Target Completion 
Date: April 15, 2015. 

VHA will identify additional ways to provide staffing support through 
engaging VA medical center and Veterans Integrated Service Network-
level leadership as well as VHA Central Office Program Office 
leadership, including Primary Care and Mental Health, to increase 
support of staffing at the medical center level. Target Completion 
Date: January 15, 2015. 

Recommendation 3: 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 Comment: Concur. Using relevant information from solutions 
developed in response to Recommendation 2 and other relevant data, VHA 
will formally reassess how key aspects of the Program of Comprehensive 
Assistance for Family Caregivers are structured. Target Completion 
Date: June 30, 2015. 

VHA will identify and implement modifications to policies and 
procedures, consistent with effective solutions developed in response 
to Recommendation 2, within the Program of Comprehensive Assistance 
for Family Caregivers, as needed, to ensure that the program is 
functioning as envisioned so that caregivers may receive the services 
they need in a timely manner. Target Completion Date: April 15, 2015. 

[End of section] 

Appendix III: GAO Contact and Staff Acknowledgments: 

GAO Contact: 

Randall B. Williamson, Director, (202) 512-7114 or williamsonr@gao.gov: 

Staff Acknowledgments: 

In addition to the contact above, Bonnie Anderson, Assistant Director; 
Frederick Caison; Christine Davis; Cathy Hamann; Jacquelyn Hamilton; 
Giao N. Nguyen; and Chan-My J. Sondhelm made key contributions to this 
report. 

[End of section] 

Footnotes: 

[1] Defense Manpower Data Center, cited in Family and Medical Leave 
Act is Essential for Military Caregivers, U.S. Congress Joint Economic 
Committee (February 2013). 

[2] RAND, Hidden Heroes: America's Military Caregivers (RR-499-TEDF. 
Santa Monica, Calif., April 2014). 

[3] See Caregivers and Veterans Omnibus Health Services Act of 2010, 
Pub. L. No. 111-163, 124 Stat. 1130 (May 5, 2010) (codified at 38 
U.S.C. § 1720G). References to a "caregiver" in this report mean the 
individual approved by VA to serve as the veteran's primary caregiver. 
While a veteran may have up to three approved caregivers at a time 
under the program, see 38 C.F.R. § 71.25(a)(1), only the primary 
caregiver is eligible for the full range of services authorized by the 
statute. 38 U.S.C. §§ 1720G(a)(3)(A), (a)(7)(B). 

[4] VA implemented the Family Caregiver Program concurrently with the 
Program of General Caregiver Support Services at each of its VA 
medical centers. Unlike the Family Caregiver Program, which is 
available to veterans who incurred or aggravated a serious injury in 
the line of duty on or after September 11, 2001, the Program of 
General Caregiver Support Services is available to veterans of all 
eras. Both programs are administered by the National Caregiver Support 
Program Office in VA's national headquarters and are collectively 
called the Caregiver Support Program. 

[5] Respite care is offered for veterans to help alleviate caregiver 
burden and may include in-home care by VA staff, short-term 
institutional stays such as at a nursing home, or adult day health 
care. The program also includes a peer support mentoring program and a 
toll-free National Caregiver Support Line staffed by licensed clinical 
social workers who answer questions from caregivers, veterans, and 
members of the public. 

[6] VA issued the Family Caregiver Program regulations in an interim 
final rule on May 5, 2011. See 76 Fed. Reg. 26148, adding Part 71, 
Caregivers Benefits and Certain Medical Benefits Offered to Family 
Members of Veterans, to Title 38 of the Code of Federal Regulations. 
Although VA established a 60-day public comment period, it stated that 
the regulations set forth in the interim final rule were effective 
immediately in order to ensure timely implementation of the program. 
VA stated that it would announce a final rule, incorporating any 
changes made in response to public comments, in a subsequent Federal 
Register notice, which had not occurred during the period of our 
review. See 76 Fed. Reg. 26158. 

[7] GAO, Standards for Internal Control in the Federal Government, 
[hyperlink, http://www.gao.gov/products/GAO-AIMD-00-21.3.1] 
(Washington, D.C.: November 1999). 

[8] VA's health care system is divided into 21 regions called VISNs. 
Each of VA's 21 VISNs is responsible for managing and overseeing 
medical facilities within a defined geographic region. 

[9] Other approved caregivers--referred to as secondary family 
caregivers--are eligible for training, counseling, and certain lodging 
and subsistence, for example, but not the stipend or CHAMPVA coverage. 

[10] The applicant could also be a servicemember who is undergoing 
medical discharge from the military. 

[11] The activities of daily living that veterans may need assistance 
with to qualify for the program include dressing or undressing; 
bathing; grooming; toileting; eating; mobility such as from the bed to 
a chair; and frequently adjusting a prosthetic or orthopedic device 
that cannot be done without assistance. 

[12] The Global Assessment of Functioning assessment is a well-
established mental health examination that uses a score of zero to 100 
to determine an individual's ability to function psychologically and 
socially. An individual who has been assessed as having a 
psychological trauma or mental disorder and has been scored at 30 or 
less generally requires a higher level of care that would include 
constant supervision. 

[13] VA's Aid & Attendance is a financial benefit for veterans who 
require assistance from a caregiver. It can be added to a veteran's 
existing pension if the veteran requires assistance with activities of 
daily living or for safety. Veterans who are bedridden, severely 
visually impaired, or reside in a nursing home due to mental or 
physical incapacity also may qualify. 

[14] Primary family caregivers approved for the Family Caregiver 
Program qualify for CHAMPVA if they are not eligible for TRICARE and 
are not entitled to care or services under a health plan contract (as 
defined in 38 U.S.C. § 1725(f)), including Medicare or employer 
provided health insurance. Caregivers covered by CHAMPVA can receive 
medical services from community providers or, when available, from 
VAMCs. 

[15] While CSCs administer the Family Caregiver Program at 151 VA 
facilities, they are assigned to 140 VAMCs or healthcare systems, 
which may include more than one VA facility. We present program 
statistics based on CSC assignments because that is how they are 
tracked by the Caregiver Support Program office. 

[16] The stipend for primary family caregivers is paid retroactive to 
the date that the joint application is received by VHA or the date on 
which the eligible veteran begins receiving care at home, whichever is 
later. Similarly, caregiver benefits are effective as of the date that 
the joint application is received by VHA or the date on which the 
eligible veteran begins receiving care at home, whichever is later. 
Benefits are provided once the individual is designated as a family 
caregiver. 

[17] Caregivers apply for the program using the 10-10CG form, 
Application for Comprehensive Assistance for Family Caregivers 
Program, and it may be submitted online, by mail, by phone, in person, 
or by fax. 

[18] A caregiver whose veteran is rated tier 3 receives a stipend that 
is the equivalent of 40 hours per week of the wage for a private 
sector home health aide in the veteran's geographical area. A 
caregiver whose veteran is rated tier 2 receives the equivalent of 25 
hours per week of the wage for a home health aide, and a caregiver 
whose veteran is rated tier 1 receives an amount equivalent to 10 
hours per week. Although a set quantity of hours is used to determine 
the stipend amount, the hours are not meant to equal the actual number 
of hours that a family caregiver may provide to the veteran. 

[19] A Patient Advocate Program is stationed at every VAMC to address 
patient inquiries and complaints as well as to provide assistance with 
filing clinical appeals. 

[20] The CSCs who conduct the quarterly home visits are generally 
precluded from conducting the initial home visit assessment due to 
potential conflict of interest. 

[21] VA's interim final rule explains the basis for this estimate. See 
76 Federal Register 26148, at 26160. 

[22] CSCs' administrative tasks include entering data on the number of 
applications, approvals, appeals, and other information about the 
local program into the Caregiver Application Tracker system, as well 
as entering clinical notes into the veteran's medical record and 
caregiver's file. 

[23] The regulation provides that the "approval and designation will 
be a clinical determination authorized by the eligible veteran's 
primary care team." 38 C.F.R. § 71.25(f). 

[24] See [hyperlink, http://www.gao.gov/products/GAO/AIMD-00-21.3.1]. 

[25] See [hyperlink, http://www.gao.gov/products/GAO/AIMD-00-21.3.1]. 

[26] According to this official, in these instances, they provide 
coaching and support to the CSC and VISN CSC lead and may work with 
them on identifying solutions, which may include the development of an 
action plan with the support of VAMC leadership. 

[27] A Caregiver Support Program official told us that additional 
oversight efforts have included an annual quality assurance audit on 
specific outcome measures, periodic caregiver surveys about the 
national caregiver training program, and an analysis of the program's 
impact on the health and well-being of approved caregivers and their 
veterans that was completed by VA's Office of the Actuary in January 
2014. 

[28] Officials also told us that because of this limitation, 
administrative tasks for the Family Caregiver Program require entering 
or retrieving data from multiple information systems, such as clinical 
patient records and benefit records. 

[29] See [hyperlink, http://www.gao.gov/products/GAO/AIMD-00-21.3.1]. 

[End of section] 

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