VA Caregiver Support Directive Overview

The Caregiver Support (CS) is managed by the VA Social Worker Department (SWD). In June 2017 the CS published VHA Directive 1152. It was written by the SWD without inclusion of the VA medical department for the clinical responsibilities. Remember from the regulation review, there are two (2) independent and separate roles and responsibilities: 1) clinical = primary care team for Veteran and VA clinicians for eligible caregivers of both caregiver support programs, and 2) support = Caregiver Support Coordinators (CSC) for caregivers of both caregiver support programs.

The directive doesn’t include the definition, role and responsibilities of the Veteran’s primary care team among other violations, alterations and omissions to the law, statue and regulation I will discuss in a future post. It is 24 pages if you wish to read it. This post is highlighting some key items.

Excerpts from VHA Directive 1152 June 14, 2017:

RESPONSIBLE OFFICE: The Office of Care Management Social Work Services, Caregiver Support Program, is responsible for the contents of this VHA directive. Questions may be referred to the Director, Caregiver Support Program at 202-461-6780.

1. PURPOSE. This Veterans Health Administration (VHA) directive establishes policy for the Caregiver Support Program. AUTHORITY: Title 38 United States Code (U.S.C.) 1720G; Title 38 Code of Federal Regulations (CFR) Part 71.

2. BACKGROUND

Public Law 111-163, the Caregivers and Veterans Omnibus Health Services Act of 2010, established 38 U.S.C. 1720G, directing VA to establish a Program of Comprehensive Assistance for Family Caregivers and a Program of General Caregiver Support Services.

3. DEFINITIONS

4. POLICY

5. RESPONSIBILITIES

a. Caregiver Support Program Office.

b. Health Eligibility Center (HEC).

c. VHA Office of Community Care (OCC), Caregiver Support Program Division.

d. Member Services, Veterans Transportation Program.

e. Health Resource Center (HRC).

f. Veterans Integrated Service Network (VISN) Director.

(1) Ensuring that each VA medical center within the VISN employs at least one full-time equivalent employee in the role of Caregiver Support Coordinator.

(3) Ensuring that the Caregiver Support Program is operated consistently across the VISN.

g. VISN Lead for the Caregiver Support Program.

h. VA Medical Center Director.

(1) Ensuring a minimum of one full-time equivalent employee Caregiver Support Coordinator position is filled without collateral responsibilities.

(5) Ensuring that applications for the Program of Comprehensive Assistance for Family Caregivers are processed within 45 calendar days after the application was submitted unless a caregiver has not completed the required training or the Veteran is hospitalized during the application process in which case the 45-day period can be extended for up to 90 days after the application was submitted.

i. VA Medical Center Chief of Staff.

(1) Developing processes and procedures to facilitate eligibility determinations for the Program of Comprehensive Assistance for Family Caregivers. Such determinations may be made by the Veteran’s VA primary care team. Alternatively, a VA Caregiver Support Program multidisciplinary Clinical Eligibility Team or an individual VA provider may be designated to complete eligibility determinations with input from the Veteran’s primary care team. An eligibility determination shall consider input from the caregiver and Veteran or Veteran’s representative, as applicable. If the Veteran receives treatment from community providers, clinical documentation from the community providers should also be considered to the extent possible. This assessment will consider whether or not participation in the Program of Comprehensive Assistance for Family Caregivers is in the best interest of the Veteran. The assessment will also identify the Veteran’s level of dependency based on the degree to which the Veteran is unable to perform one or more activities of daily living and/or needs supervision or protection based on symptoms or residuals of neurological or other impairment or injury for purposes of determining the applicable stipend.

(3) Ensuring that initial in-home assessments and ongoing program monitoring (conducted every 90 days, unless otherwise clinically indicated) provide education and support to caregivers, and evaluate the well-being of the Veteran.

(6) Ensuring that all appropriate providers (e.g., primary care, specialty care, and mental health providers) participate in clinical determinations concerning the Veteran’s eligibility for and participation in the Program of Comprehensive Assistance for Family Caregivers and that the timelines set forth in 38 CFR 71.25 and 71.40 are met.

(7) Encouraging discussions of caregiver support at town hall meetings and Community Veterans Engagement Boards (CVEB) as appropriate.

j. Caregiver Support Coordinator.

(1) Managing and coordinating the application process for the Program of Comprehensive Assistance for Family Caregivers, including assisting Veterans and caregivers to complete VA Form 10-10CG, or successor form, and documenting the application approvals and denials, and participant status changes in the designated Caregiver Support Program data system and electronic health record as appropriate. Caregiver Support Coordinators are responsible for ensuring that caregiver training is made available to caregivers (whether in-person, online, or through other available format) and coordinating with the clinical support staff assigned to the Program of Comprehensive Assistance for Family Caregivers to ensure completion of clinical assessments, required home visits and monitoring every 90 calendar days (unless otherwise clinically indicated).

(2) Ensuring an initial home visit is conducted no later than 10 business days after certification by VA that the caregiver completed the required core curriculum training, or if the Veteran is hospitalized, no later than 10 days after the Veteran returns home.

(8) Educating Primary Care and Mental Health Services staff on the Caregiver
Support Program and encouraging all Patient Aligned Care Teams (PACTs) and
Behavioral Health Interdisciplinary Program (BHIP) teams to engage the caregiver as
part of the Veteran’s health care team.

k. Managerial Cost Accounting Office (MCAO) VA Medical Center Manager/Liaison.

l. Health Informatics Specialists (HIS)/Clinical Application Coordinators (CACs).

6. THE PROGRAM OF COMPREHENSIVE ASSISTANCE FOR FAMILY CAREGIVERS

(2) The individual has a serious injury (including traumatic brain injury, psychological trauma, or other mental disorder) incurred or aggravated in the line of duty in the active military, naval, or air service on or after September 11, 2001.

(3) Such serious injury renders the individual in need of personal care services from another individual (a caregiver) for a minimum of 6 continuous months based on any one of the following clinical criteria: …

(4) A clinical determination (authorized by the individual’s primary care team) has been made that it is in the best interest of the individual to participate in the program.

b. Approval and Designation of Primary and Secondary Family Caregivers. A Veteran’s eligibility for the Program of Comprehensive Assistance for Family Caregivers may be determined by the VA Caregiver Support Coordinator who receives the application (as provided in paragraph 6.b.(1)(b)) or the Caregiver Support Coordinator will refer the application to the Veteran’s VA primary care team to complete eligibility determinations. Alternatively, a VA Caregiver Support Program multidisciplinary Clinical Eligibility Team or an individual VA provider may be designated to complete eligibility determinations with input from the Veteran’s primary care team. An eligibility determination shall consider input from the caregiver and Veteran or Veteran’s representative, as applicable. If the Veteran receives treatment from community providers, clinical documentation from the community providers should also be considered to the extent possible. Determining and establishing eligibility is a multi-step process. The entire process should be completed within 45 days after the application was submitted unless a caregiver has not completed the required training or the Veteran is hospitalized during the application process in which case the 45-day period can be extended for up to 90 days after the application was submitted. See 38 CFR 71.40(d)(1). Eligibility determinations include the following steps: …

(b) Upon receiving the application, a VA Caregiver Support Coordinator will evaluate eligibility by identifying a potentially qualifying injury that was incurred or aggravated in the line of duty in the active military, naval, or air service on or after September 11, 2001, and assessing whether the potentially qualifying injury may render the Veteran in need of personal care services from a caregiver. In performing this initial eligibility evaluation, the Caregiver Support Coordinator will consider input from the caregiver and the Veteran or Veterans’ representative, as applicable. If the Caregiver Support Coordinator determines that the Veteran does not have a potentially qualifying injury that was incurred or aggravated in the line of duty in the active military, naval, or air service on or after September 11, 2001, or the potentially qualifying injury does not render the Veteran in need of personal care services from a caregiver, the Caregiver Support Coordinator will issue the applicant a determination that the applicant is not eligible for the Program of Comprehensive Assistance for Family Caregivers. If the Coordinator does not issue such a determination, the Caregiver Support Coordinator will refer the application to the Veteran’s VA primary care team, a VA Caregiver Support Program multidisciplinary Clinical Eligibility Team or an individual VA provider to perform the required clinical evaluations, including evaluating the Veteran’s level of dependency for purposes of determining the applicable stipend.

(3) Assessment, Training, and Education of Applicants. Before VA approves an application for an applicant to serve as a primary or secondary family caregiver, all of the following requirements must be satisfied:
(a) The applicant must be initially assessed by a VA primary care team as being able to complete caregiver education and training. NOTE: The Veterans Transportation Service may be available for purposes of this assessment in accordance with 38 CFR Part 70, Subpart B. This assessment must consider any relevant information specific to the needs of the Veteran, as well as:
1. Whether the applicant can communicate and understand details of the treatment plan and any specific instructions related to the care of the Veteran. NOTE: Accommodation for language or hearing impairment will be made to the extent possible and as appropriate.

2. Whether the applicant will be capable of following, without supervision, a treatment plan listing the specific care needs of the Veteran.
(b) Complete caregiver training and demonstrate the ability to carry out the specific personal care services, core competencies, and other additional care requirements prescribed by the Veteran’s primary care team.

(5) Initial Home Care Assessment. No later than 10 business days after VA certifies completion of caregiver education and training, or should a Veteran be hospitalized during this process, no later than 10 days from the date the Veteran returns home, a VA clinician or a clinical team will visit the Veteran’s home to assess the caregiver’s completion of training and competence to provide personal care services at the home, and to measure the Veteran’s well-being. The initial in-home visit must be completed by a VA clinician or clinical team, not through a contract with a non-VA provider.

(6) Approval and Designation. If VA determines that the Veteran and at least one family caregiver applicant meet the applicable eligibility requirements, VA will approve the application and designate primary and/or secondary family caregivers, as appropriate. This approval and designation is a clinical determination. Approval and designation is conditioned on the Veteran and designated family caregivers remaining eligible for caregiver benefits under this directive. Veterans and family caregivers who are determined ineligible, will be informed that they have the right to file a clinical appeal using the VHA clinical appeals process identified in VHA Directive 1041, Appeal of VHA Clinical Decisions, or subsequent policy issue.

c. (5) Monitoring. As discussed above, an initial home visit is required as part of the application process; ongoing interim monitoring is required every 90 calendar days after approval and designation, unless otherwise clinically indicated, to monitor the Veteran’s overall health and well-being and adequacy of care and supervision being provided. Based upon the clinical determination of the Veteran’s primary care team, interim monitoring can be completed through face-to-face visits at a VA medical facility, through Clinical Video Telehealth (CVT), or by telephone; otherwise interim face-to-face in-home visits are required. When a home visit is required for the 90-day (or otherwise) interim monitoring, the home visit may be completed by VA staff or through a contract with a non-VA provider with the use of Purpose of Visit (POV) code 25 for Caregiver Oversight Visits. An annual in-home visit must be conducted, even in cases where the Veteran’s primary care team determines that 90-day (or otherwise) interim monitoring can be accomplished without an in-home visit. The annual in-home visit must be conducted by VA staff and not through a contract with a non-VA provider.

7. REVOCATION FROM THE PROGRAM OF COMPREHENSIVE ASSISTANCE FOR FAMILY CAREGIVERS

8. THE PROGRAM OF GENERAL CAREGIVER SUPPORT SERVICES

In my next post I’ll discuss the various forms, handouts and literature.

 

 

 

 

 

 

 

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