The VA’s Program of Comprehensive Assistance for Family Caregivers, known simply as the Caregivers Program, is back in action. In mid-April (2017), responding to reports that some VA Medical Centers were revoking caregivers at alarmingly high rates, Secretary of Veterans Affairs David Shulkin suspended revocations of caregiver benefits until the program could be fully reviewed. Now that the review is complete and new program policies have been established, the Caregivers Program will resume full operations – including revocations.
So, what came of the review? What did the VA change about the way revocations are handled? Can unfair revocation decisions be appealed?
Reviewing the Caregivers Program
In early April, NPR published a story revealing that while some VA medical centers were adding participants to the Caregivers Program, others were cutting off benefits for hundreds of veterans and their caregivers:
The Portland, Ore., VA cut 66 percent of its caregivers in three years. Seattle cut 49 percent; the South Texas VA cut 48 percent; and Charleston, S.C., went from 197 caregivers in 2014 to just 11 in February of 2017 — a 94 percent reduction. The Charleston VA told NPR some of those vets improved and didn’t need the program, and said that others probably never should have qualified at the start. [Source: NPR]
Twelve days after NPR published the report, the VA suspended revocations and ordered a full review of the Caregivers Program. The three-month review indicated a need for “better communication about clinical revocations, improved internal processes and procedures, and additional staff training.”
The New Caregivers Program Directive
To address the issues raised by the review, the VA issued a new policy directive outlining
- the program responsibilities of all levels of VA staff (ranging from Caregiver Support Coordinators to accountants and IT personnel to VA Medical Center Directors),
- veteran and caregiver eligibility requirements,
- benefits available to caregivers through the program, and
- standardized procedures for revocations from the program.
VA also held mandatory staff trainings on the new directive and created standardized communications and outreach materials to educate veterans and caregivers about the program. If everything goes as planned, agency-wide trainings and outreach materials will prevent different VA facilities from spreading different information about how the Caregivers Program works and stop them from using different standards for revoking caregivers at different locations around the country.
The Rules for Revocations
Now that the procedures for when the VA can or cannot revoke caregiver benefits are established nationwide (through Secretary Shulkin’s directive), participating veterans and their caregivers will ideally be able to hold VA staff more accountable and push back if their benefits are unfairly revoked.
The basic rules for revocations (those ordered by the VA, not by the veteran or caregiver) laid out in the directive can be summarized* as follows:
- If the caregiver or veteran no longer meet the eligibility requirements for the program, caregiver benefits may be revoked.
- If VA makes a “clinical determination” (see “Clinical” Appeals section below) that having the family caregiver is no longer in the best interest of the veteran, caregiver benefits may be revoked.
- If VA revokes your caregiver benefits due to improvement in the Veteran’s condition, death, or permanent institutionalization, the family caregiver will continue to receive caregiver benefits for 90 days.
- If caregiver benefits have been revoked and the family caregiver requests help in transitioning to other health care coverage and/or mental health services, VA is required to help them do so.
- If VA suspects that the safety of the veteran is at risk, they are legally allowed to suspend the caregiver’s responsibilities and help the veteran find new housing arrangements if he/she requests them (or take other “appropriate action” to ensure the veteran’s well-being) before making a formal revocation.
- The veteran and/or family caregiver have the right to file a “clinical” appeal of the VA’s decision to revoke the designation of a caregiver (more on this later).
*The exact language of these rules can be found in the VHA directive mentioned above.
You may be wondering how VA would actually know whether the veteran was meeting the eligibility requirements. To participate in the Caregivers Program, veterans and their caregivers must agree to an initial home visit and ongoing ‘monitoring’ every 90 calendar days. This monitoring can take the form of face-to-face visits at a VA medical facility, a Clinical Video Telehealth (CVT) appointment, or by telephone, depending on the veterans’ condition. Additionally, VA staff must conduct a yearly in-home visit to assess the veteran’s health and abilities as well as the quality of care and supervision provided by the caregiver.
Communicating Revocations to Veterans
If VA staff follow the guidelines in the directive, veterans and their caregivers should have ample opportunity to find out why their caregiver benefits were revoked. When communicating revocation decisions to veterans, VA requires its staff to
- Communicate clearly and directly with the veteran and the family caregiver throughout the revocation process, regardless of the reason for revocation;
- Make every effort to meet in person about the revocation; otherwise “a telephone call is an acceptable alternative;” and,
- Notify the veteran and caregiver in writing and include information on how to appeal the revocation.
“Clinical” Appeals: How to disagree with a revocation decision
We have blogged before about the problem with the appeal process for the caregivers program. While the VA staff that reviewed the program made some suggestions for standardizing the clinical appeals process, the review did little to address the underlying problem: a veteran’s eligibility for the program is considered a “clinical determination.”
Why is this such a problem? Labeling a veteran’s need for a caregiver as a “clinical determination” means that revocation decisions cannot be appealed through the same system as other VA disability benefits (the Veterans Benefits Administration or VBA). Instead, clinical determinations must be appealed through the vet’s VA medical center system, which varies hospital-by-hospital.
The Caregivers Program directive provides each medical center with suggested procedures for clinical appeals but does not standardize these processes across the country. This leaves veterans and caregivers vulnerable to unfair policies at their VA medical centers.
Clinical appeals also limit a veteran’s options for having their case reviewed by independent adjudicators. The only external review option (i.e. the only option for clinical appeal that doesn’t happen within the vet’s VA medical center) is to request a review by the Office for Quality, Safety and Value. The Office then arranges an interview with a reviewer who is not a VA employee. However, the Office for Quality, Safety and Value (a part of the VA), still decides how to interpret that non-VA reviewer’s report and makes the final decision on the appeal.