VA Caregiver Support Regulation Overview

The Department of Veteran Affairs (VA) published the Caregiver Support (CS) regulation, 38 CFR 71, to establish how it intends to carry out the guidance of the law and statue to only provide support to caregivers of both caregiver support programs.

The regulation’s latest final rule and amendments, 80 FR 1357 was published on January 09, 2015, and most regulations found online do not include the 80 FR 1357 amendments.  You can find the amendments on the last three (3) pages. (These documents are posted under the documents tab.)

I will only cover what is in the regulation and in a later post I’ll tell you the issues with the it, the program and its operation.

First, there are two (2) independent and separate roles and responsibilities: 1) clinical = primary care team for Veteran and VA clinicians for caregivers upon eligibility and 2) support = Caregiver Support Coordinator (CSC) for caregivers of both caregiver support programs.

The regulation, 38 CFR 71 (80 FR 1357 final rule and amendments), only list the role and responsibilities of the primary care team and other applicable clinicians for eligible caregivers. It doesn’t mention the role and responsibilities of the CSC. But, if we go back to what the law and statue state … The Secretary shall only provide support to eligible caregivers of both caregiver support programs.  The VA (Secretary) has hired licensed clinical social workers (LCSW) for the CSC position which is an administrative position, and itsn’t authorized to perform clinical duties of a LCSW. (Example, my patient advocate at the VA is in an administrative position but she is a nurse by profession. Even though she is a trained nurse she cannot perform clinical duties/responsibilities of a nurse in her current position.)

Note: … means more information prior or follows but was omitted for this post. Please reference the regulation to read the entire document which is 7 pages.

You can click on the following link to take you to an online version of the regulation with the amendments: https://www.govregs.com/regulations/title38_chapterI_part71

Let’s highlight some things in the regulation which includes the amendments. Note: The VA CS (CS), Program of Comprehensive Assistance for Family Members Program (PCAFC) is for family members (applicant) of Servicemembers and Veterans.

Excerpts from 38 CFR 71:

§ 71.15 – Definitions:

Eligible veteran means a veteran, or a servicemember, who is found eligible for a Family Caregiver under § 71.20.

Family Caregiver means both a Primary and Secondary Family Caregiver.

General Caregiver means an individual who meets the requirements of § 71.30.

Primary care team means a group of medical professionals who care for a patient and who are selected by VA based on the clinical needs of the patient. The team must include a primary care provider who coordinates the care, and may include clinical specialists (e.g., a neurologist, psychiatrist, etc.), resident physicians, nurses, physicians’ assistants, nurse practitioners, occupational or rehabilitation therapists, social workers, etc., as indicated by the needs of the particular patient.

Inability to perform an activity of daily living (ADL) means any one of the following:
(1) Inability to dress or undress oneself;
(2) Inability to bathe;
(3) Inability to groom oneself in order to keep oneself clean and presentable;
(4) Frequent need of adjustment of any special prosthetic or orthopedic appliance that, by reason of the particular disability, cannot be done without assistance (this does not include the adjustment of appliances that nondisabled persons would be unable to adjust without aid, such as supports, belts, lacing at the back, etc.);
(5) Inability to toilet or attend to toileting without assistance;
(6) Inability to feed oneself due to loss of coordination of upper extremities, extreme weakness, inability to swallow, or the need for a non-oral means of nutrition; or
(7) Difficulty with mobility (walking, going up stairs, transferring from bed to chair, etc.).

Need for supervision or protection based on symptoms or residuals of neurological or other impairment or injury means requiring supervision or assistance for any of the following reasons:
(1) Seizures (blackouts or lapses in mental awareness, etc.);
(2) Difficulty with planning and organizing (such as the ability to adhere to medication regimen);
(3) Safety risks (wandering outside the home, danger of falling, using electrical appliances, etc.);
(4) Difficulty with sleep regulation;
(5) Delusions or hallucinations;
(6) Difficulty with recent memory; or
(7) Self regulation (being able to moderate moods, agitation or aggression, etc.).

Undergoing medical discharge means that the servicemember has been found unfit for duty due to a medical condition by their Service’s Physical Evaluation Board, and a date of medical discharge has been issued.

§ 71.20 – Eligible veterans and servicemembers:

(b) 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.

(c) Such serious injury renders the individual in need of personal care services for a minimum of 6 continuous months (based on a clinical determination authorized by the individual’s primary care team), based on any one of the following clinical criteria:

(1) An inability to perform an activity of daily living.
(2) A need for supervision or protection based on symptoms or residuals of neurological or other impairment or injury, including traumatic brain injury.
(3) Psychological trauma or a mental disorder that has been scored, by a licensed mental health professional, with Global Assessment of Functioning (GAF) test scores of 30 or less, ….
(4) The veteran is service connected for a serious 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 has been rated 100 percent disabled for that serious injury, and has been awarded special monthly compensation that includes an aid and attendance allowance.

(d) 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.

§ 71.25 – Approval and designation of Primary and Secondary Family Caregivers:

(2) Upon receiving such application, VA will perform the clinical evaluations required by this section; determine whether the application should be granted; and, if so, whether each applicant should be designated as identified in the application.

(c) Assessment, education, and training of applicants. Before VA approves an applicant to serve as a Primary or Secondary Family Caregiver, the applicant must:
(1) Be initially assessed by a VA primary care team as being able to complete caregiver education and training. Such assessment will consider any relevant information specific to the needs of the eligible veteran, as well as:
(i) Whether the applicant can communicate and understand details of the treatment plan and any specific instructions related to the care of the eligible veteran (accommodation for language or hearing impairment will be made to the extent possible and as appropriate); and
(ii) Whether the applicant will be capable of following without supervision a treatment plan listing the specific care needs of the eligible veteran.
(2) 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 eligible veteran’s primary care team.

(e) Initial home-care assessment. No later than 10 business days after VA certifies completion of caregiver education and training, or should an eligible veteran be hospitalized during this process, no later than 10 days from the date the eligible veteran returns home, a VA clinician or a clinical team will visit the eligible veteran’s home to assess the caregiver’s completion of training and competence to provide personal care services at the eligible veteran’s home, and to measure the eligible veteran’s well being.

(f) Approval and designation. If the eligible veteran and at least one applicant meet the requirements of this part, VA will approve the application and designate Primary and/or Secondary Family Caregivers, as appropriate. This approval and designation will be a clinical determination authorized by the eligible veteran’s primary care team. Approval and designation is conditioned on the eligible veteran and designated Family Caregivers remaining eligible for caregiver benefits under this part.

§ 71.30 – General Caregivers:

(a) A General Caregiver is a person who:
(1) Is not a Primary or Secondary Family Caregiver; and
(2) Provides personal care services to a covered veteran under this section, even if the individual does not reside with the veteran.
(b) A covered veteran, for purposes of this section, is a veteran who is enrolled in the VA health care system and needs personal care services because the veteran either:
(1) Is unable to perform an activity of daily living; or
(2) Needs supervision or protection based on symptoms or residuals of neurological or other impairment or injury.
(c) No application or clinical evaluation is required to obtain benefits as a General Caregiver. Veterans or General Caregivers may request any of the benefits listed in § 71.40(a) as needed, from the appropriate VA clinicians and staff at their local VA facilities.
(d) A veteran is not required to meet the eligibility requirements in § 71.20 to be considered a covered veteran.

§ 71.40 – Caregiver benefits:

(b) (2) The primary care team will maintain the eligible veteran’s treatment plan and collaborate with clinical staff making home visits to monitor the eligible veteran’s well-being, adequacy of care and supervision being provided. This monitoring will occur no less often than every 90 days, unless otherwise clinically indicated, and will include an evaluation of the overall health and well-being of the eligible veteran.

(c) (4) (i) VA will clinically rate the eligible veteran’s inability to perform each of the seven ADLs listed in the definition of that term in § 71.15.
(ii) VA will clinically rate the eligible veteran’s need for supervision or protection based on symptoms or residuals of neurological or other impairment or injury using the seven impairments listed in the definition of that term in § 71.15.
(iii) Clinical ratings under paragraphs (c)(4)(i) and (ii) of this section will be scored as follows: …

§ 71.45 – Revocation:

(a) Revocation by the Family Caregiver. ….  VA will, if requested and applicable, assist the Family Caregiver in transitioning to alternative health care coverage and mental health services. VA will notify the eligible veteran verbally and in writing of the request for revocation.

(b) Revocation by the eligible veteran or surrogate. ….

(3) VA will review the request for revocation and determine whether there is a possibility for remediation. This review will take no longer than 30 days. During such review, the eligible veteran or surrogate may rescind the request for revocation. If VA suspects that the safety of the eligible veteran is at risk, then VA may suspend the caregiver’s responsibilities, and remove the eligible veteran from the home if requested by the eligible veteran, or take other appropriate action to ensure the welfare of the eligible veteran, prior to making a formal revocation.
(4) Caregiver benefits will continue for 30 days after the date of revocation, and VA will, if requested by the Family Caregiver, assist the individual with transitioning to alternative health care coverage and mental health services, unless one of the following is true:
(i) VA determines that the Family Caregiver committed fraud or abused or neglected the eligible veteran, in which case benefits will terminate immediately.
(ii) If the revoked individual was the Primary Family Caregiver, and another Primary Family Caregiver is designated within 30 days after the date of revocation, in which case benefits for the revoked Primary Family Caregiver will terminate the day before the date the new Primary Family Caregiver is designated.
(iii) If another individual is designated to be a Family Caregiver within 30 days after the date of revocation, such that there are three Family Caregivers assigned to the eligible veteran, in which case benefits for the revoked Family Caregiver will terminate the day before the date the new Family Caregiver is designated.
(iv) The revoked individual had been living with the eligible veteran and moves out, or the revoked individual abandons or terminates his or her relationship with the eligible veteran, in which case benefits will terminate immediately.

(c) Revocation by VA. VA may immediately revoke the designation of a Family Caregiver if the eligible veteran or individual designated as a Family Caregiver no longer meets the requirements of this part, or if VA makes the clinical determination that having the Family Caregiver is no longer in the best interest of the eligible veteran. VA will, if requested by the Family Caregiver, assist him or her in transitioning to alternative health care coverage and mental health services. If revocation is due to improvement in the eligible veteran’s condition, death, or permanent institutionalization, the Family Caregiver will continue to receive caregiver benefits for 90 days, unless any of the conditions described in paragraphs (b)(4)(i) through (iv) of this section apply, in which case benefits will terminate as specified. ….

I hope I’ve enlightened you on what the regulation states so you can make informed decisions and later understand the issues I describe in the PCAFC. I don’t have any information on the Program of General Caregiver Support Services (PGCSS) because I’m not involved in this program, it doesn’t require an application, clinical assessments, monitoring and the caregiver can go directly to VA clinicians. For those readers who can enlighten me with any issues, I’ll gladly share them.

In my next post I will discuss some details from the regulation’s final rule and amendments, 80 FR 1357 January 09, 2015, as it further details the two (2) caregiver support programs. Information and knowledge is essential.

 

 

 

 

 

 

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