Within VHA, the Caregiver Support Program Office, VISNs, and VAMCs all have a role in administering and overseeing the Family Caregiver Program. Caregiver Support Program Office. The Caregiver Support Program Office administers the Caregiver Support Program, which has two main components— 1. the Family Caregiver Program, which is available to eligible post-9/11 veterans, and their qualified caregivers, and 2. the Program of General Caregiver Support Services, which is available to covered veterans from any service era and their qualified caregivers. The Caregiver Support Program Office develops policy and procedures and provides guidance, oversight, and support for both components of the Caregiver Support Program. As of April 2019, this office had 11 full-time staff, with authorization to hire eight additional staff. VISNs. Each of VHA’s 18 VISNs has a lead official for the Family Caregiver Program—either a VAMC CSC who serves in the VISN lead role for at least 25 percent of the CSC’s time or a VISN employee who is responsible for the Family Caregiver Program as one of their VISN duties. The VISN lead official’s role is to provide guidance to CSCs within the VISN and to help address their questions or concerns. VISN lead officials are also responsible for disseminating information, collecting data when needed, conducting quality assurance audits, assisting and coordinating responses to inquiries from the Caregiver Support Program Office, and monitoring the Family Caregiver Program workload across the VISN. VAMCs. The program is administered at the local level at 140 VAMCs. Each VAMC has staff that are assigned to the program on either a full- time or part-time basis, as well as other VAMC staff that may assist with specific Family Caregiver Program-related activities as a collateral duty. VAMC staff assigned to the Family Caregiver Program may include the following: CSCs. CSCs are the primary program staff administering the program at VAMCs. They are generally licensed clinical social workers or registered nurses. CSCs have clinical responsibilities that 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. CSCs also have administrative responsibilities that may include responding to inquiries about the program, overseeing the application process, and entering information about applications and approved caregivers into IT systems. During the first quarter of fiscal year 2019, there were approximately 436 CSCs assigned to 140 VAMCs. Administrative staff. Administrative staff are typically responsible for activities such as mailing communications to program applicants and participants, scheduling appointments, entering data into CAT, and otherwise supporting the administrative needs of the program. During the first quarter of fiscal year 2019, 24 of the 140 VAMCs or health care systems had administrative staff members assigned to the program. Clinical staff. Some VAMCs have clinical staff assigned to the program, which can include registered nurses, doctors, nurse practitioners, occupational therapists, or psychologists. These staff typically conduct in-home monitoring and may help with clinical eligibility determinations of veterans during the application process. During the first quarter of fiscal year 2019, 17 VAMCs had approximately 12 full-time-equivalent doctors, nurse practitioners, occupational therapists, and psychologists assigned to the program. Other VAMC clinical staff who are not assigned to the Family Caregiver Program may assist the program as a collateral duty. For example, they may serve as members of the clinical eligibility team or assist with program monitoring—including quarterly contacts and annual home visits—or program appeals (see fig. 1). The Caregiver Support Program Office directly funds the salaries for staff assigned to the Family Caregiver Program at VAMCs. Specifically, it funds the salaries of the CSCs, as well as some other staff who are assigned to the program, such as administrative staff or clinical staff. However, some VAMCs may also choose to fund additional staff for the program, if they identify a need. Additionally, the portion of time spent by VAMC staff assisting the program as a collateral duty may be reimbursed by the Caregiver Support Program Office. To participate in the program, caregivers and veterans must submit applications to their local VAMC or to VHA’s Health Eligibility Center. CSCs manage the multi-step application process, which includes administrative and clinical eligibility determinations, among other requirements (see fig. 2). According to VHA policy, VAMCs should review applications for the program within 45 days. However, this review can be extended up to 90 days if the veteran’s caregiver has not completed required training, or the veteran is hospitalized during the application process. Once caregivers and veterans are enrolled in the Family Caregiver Program, VHA policy requires CSCs or other VAMC clinical staff to periodically monitor the veteran’s overall health and well-being and the adequacy of the care and supervision being provided by the caregiver. This monitoring is to be documented in CAT as well as in the Computerized Patient Record System because it is a clinical encounter. The monitoring includes quarterly contacts. These contacts are supposed to occur every 90 calendar days, unless otherwise clinically indicated. They may be conducted as home visits, or if approved by the veteran’s primary care team, the contacts can be completed via telephone, a face-to-face visit at a VHA medical facility, or using clinical video telehealth. annual home visits. Caregivers and veterans must receive at least one home visit each year. According to Caregiver Support Program Office officials, the annual home visit counts as one of the quarterly contacts. If a veteran demonstrates an improvement or decline in their functioning while in the program, VAMC staff are supposed to reassess the veteran to determine whether they remain clinically eligible for the program or whether a change in the stipend tier level (increase or decrease) may be appropriate. A reassessment may result in a discharge from the program, a tier level change, or no change. However, the VA Secretary announced a moratorium on discharges and tier level decreases on December 21, 2018 due to continued concerns from veterans, caregivers, and others about VAMCs’ inconsistent application of eligibility requirements. According to Caregiver Support Program Office officials, there is no current timeline for when the moratorium will be lifted. In August 2018, the VA Office of Inspector General (VA OIG) issued a report on its review of the Family Caregiver Program, which focused on whether the program effectively provided services and support to qualified veterans and their caregivers. The VA OIG found that program applications were not reviewed in a timely manner, eligibility criteria were not consistently applied, caregivers and veterans were not routinely monitored, and that VHA had failed to effectively establish a governance structure that promoted program management accountability. The VA OIG made six recommendations to improve the program, including recommendations to establish a governance structure and to assess the adequacy of the program’s staffing levels at VAMCs. In May 2019, the VA OIG reported that the program had implemented the two recommendations related to establishing a governance environment and designating VISN lead officials for the program. Specifically, the Family Caregiver Program issued an updated directive for the program and additional standard operating procedures in October 2018 to address the governance environment recommendation and issued a memorandum regarding VISN lead officials in January 2019 to address the VISN lead official recommendation. According to the VA OIG, the remaining recommendations have not yet been implemented. The VA MISSION Act, which was enacted in June 2018, included provisions directing VA to implement an IT system to support the Family Caregiver Program and the incremental expansion of program eligibility. Specifically, the Act required VA to implement an IT system by October 1, 2018. According to the Act, the IT system is to allow for data assessment and comprehensive monitoring of the program. The VA MISSION Act also required VA to submit an initial report to Congress regarding the status of the planning, development, and deployment of this system within 90 days of enactment of the Act and a final report by October 1, 2019. The final report is to include a certification by the VA Secretary that the system has been implemented, along with a description of how the Secretary is using the system to monitor the workload of the program. In addition, the VA MISSION Act requires an incremental expansion of eligibility for the Family Caregiver Program. Specifically, within 2 years of the VA Secretary certifying the IT system for the Family Caregiver Program, VHA is to expand program eligibility to caregivers of veterans with a serious injury incurred or aggravated in the line of duty on or before May 7, 1975 or on or after September 11, 2001. Two years after this initial expansion of eligibility, VHA is to further expand program eligibility to include any veteran with a serious injury incurred or aggravated in the line of duty and in need of personal care services as specified in the statute. The Caregiver Support Program Office policy requires every VAMC to have at least one full-time CSC to administer the program. The policy also requires VAMCs to have an eligibility determination process, but does not specify staffing requirements for that process beyond stating that “appropriate” providers should be involved. This broad guidance provides VAMCs with flexibility in determining which providers to include in the eligibility determination process. We found that each of the four VAMCs we visited staff their Family Caregiver Program differently, including both the staff assigned to the program as well as other VAMC staff assisting the program as a collateral duty. While all four VAMCs had at least one CSC on staff, as required, other staff assigned to the program varied and included administrative staff, a non-CSC social worker, and non-CSC registered nurses. Furthermore, the differences we identified with VAMC staff assisting the program as a collateral duty included staff that assist with clinical eligibility determinations as well as staff that assist with other program requirements. Specifically, each of the four VAMCs had assembled their own clinical eligibility teams, which varied in composition and could include physicians, therapists, or mental health professionals. Other variations with staff assisting the program included three VAMCs that utilized members of the Home Based Primary Care team to assist with initial home visits, quarterly contacts, and annual home visits, and a VAMC that used physicians to assist the program with assigning stipend tier levels (see table 1). We found that VHA’s Caregiver Support Program Office does not have complete and accurate staffing information for the Family Caregiver Program. First, the Caregiver Support Program Office does not have complete information on all staff supporting the program. The office only tracks staff funded by the Caregiver Support Program Office, but does not track program staff that are VAMC-funded or other VAMC staff that assist the program as a collateral duty. For example, one site we visited had a VAMC-funded nurse that conducted quarterly contacts and home visits, but this nurse was not being tracked by the program office. Similarly, the program office was not tracking the time and resources related to VAMCs’ clinical eligibility team members. At each of the four VAMCs we visited, members of the clinical eligibility teams dedicated between 3 and 12 hours a month preparing for and attending the eligibility meetings. Furthermore, although the program’s VISN lead officials collect data on the Caregiver Support Program Office funded positions at each VAMC annually at a minimum and submit these data to the Caregiver Support Program Office, there is no documented process to validate the data’s accuracy. VHA employs a process that relies on VISN lead officials collecting data from facilities, and as a result, the overall accuracy of the data depends on the accuracy of the data VAMCs report. Based on our review of the staffing data, we identified discrepancies between the Caregiver Support Program Office’s staffing data for the first quarter of fiscal year 2019 and the number of staff we observed at all four VAMCs we visited. At two VAMCs, the number of CSCs that the Caregiver Support Program Office reported was higher than what we found. Caregiver Support Program Office officials said that these staffing discrepancies could be due to vacant positions. However, officials at the two VAMCs did not indicate that they had vacant positions at the time of our site visits. The third VAMC had a part-time registered nurse staffed to the program that was not included in the Caregiver Support Program Office’s staffing data even though this position was funded by VHA. Caregiver Support Program Office officials could not provide a reason for this discrepancy. The fourth VAMC had an administrative staff member funded by the Caregiver Support Program Office that was not included in the staffing data. Additionally, the Caregiver Support Program Office does not know the exact number of CSCs assigned to the program. The program office funds CSC positions, which can be filled by registered nurses or social workers. The program office also funds registered nurses who are not CSCs. However, the program office’s staffing data does not distinguish between the two types of registered nurse positions because they do not currently have the capability to collect such staffing details. As a result, Caregiver Support Program Office officials told us they could not identify registered nurses who are CSCs from other registered nurses assigned to the program. Officials reported that they are working on finding a way to collect details on the types of registered nurse positions. Although Caregiver Support Program Office officials said that they are taking steps to collect more information about the staff involved in supporting the Family Caregiver Program to prepare for the MISSION Act expansion, these efforts do not fully address the problems with data completeness and accuracy that we identified. Officials said that they are starting to collect data on the Family Caregiver Program staff more frequently. Specifically, the program plans to collect information on Caregiver Support Program Office funded staff at each VAMC from the VISN lead officials quarterly instead of annually, to align with how other national programs collect such data. During the course of this review officials said they had begun working on updating the method they use to collect staffing data. Caregiver Support Program Office officials said that this revised data collection instrument will include mandatory fields and data entry rules to ensure that the data reported are more consistent. However, officials did not provide any timelines for when they will begin using the updated method. Program officials have begun to develop a staffing model in anticipation of future program growth when eligibility expands to include pre-9/11 veterans. To create the staffing model, officials are identifying current program staff at the VHA, VISN, and VAMC levels and the tasks these staff perform. However, officials indicated that the model will use Caregiver Support Program Office staffing data because those are the only staffing data available for the program. As a result, VAMC-funded staff and collateral staff will not be included. Consequently, the completeness of the staffing model will be compromised and the current and future staffing resources identified by the model may not accurately estimate the program’s needs. The lack of complete and accurate staffing data for the Family Caregiver Program is inconsistent with federal internal control standards that require management to use quality information to achieve its objectives. Without complete and accurate information about the total number and types of staff that support the program, VHA does not know whether the program’s staffing approach and available resources are sufficient to meet the program’s requirements as well as the needs of participating caregivers and veterans. Furthermore, without complete and accurate staffing data, it is unclear how the Caregiver Support Program Office will develop projections of the staff that will be needed to enroll and support additional caregivers and veterans when the Family Caregiver Program’s eligibility is expanded as required by the MISSION Act. Within VHA, the Caregiver Support Program Office monitors the timeliness of VAMCs’ processing of applications for the Family Caregiver Program. Specifically, Caregiver Support Program Office officials told us that they review a monthly report from CAT. These reports show the number of applications in process at each VAMC and how long they have been in process. Officials also said that they share this information with VISN lead officials each month. However, since the inception of the program, VAMCs have had difficulty meeting VHA’s requirement to review applications within 90 days. Our analysis of CAT data found that about 68 percent of the 17,576 applications submitted from October 2017 through September 2018 were reviewed within 90 days. In January 2019, a memorandum was issued that required all VAMCs to develop action plans to address application processing delays beyond 90 days. Further, any VAMCs with more than 10 applications beyond 120 days or any exceeding 365 days were required to submit their action plans to the Caregiver Support Program Office. As a result of this memo, 11 VAMCs have submitted action plans. Caregiver Support Program Office officials said that they have assigned staff to monitor the action plans and have discussed the plans with the leadership of the VISNs that oversee these VAMCs. Additionally, in February 2019, VHA established a national level performance metric to measure application processing timeliness for the program that will be updated on a monthly basis, according to Caregiver Support Program Office officials. VHA’s goal is for 90 percent of Family Caregiver Program applications submitted in fiscal year 2019 to be processed within 90 days. The May 2019 report from CAT shows that 94 percent of the 1,246 current applications have been in process 90 days or less. VHA’s Caregiver Support Program Office lacks system-wide data from CAT or other sources on the completion of VAMCs’ required quarterly contacts and annual home visits conducted with caregivers and veterans in the Family Caregiver Program. Although these contacts and visits are supposed to be documented in CAT, the system has limited reporting capabilities. As a result, Caregiver Support Program Office officials are unable to obtain system-wide data that would allow them to monitor VAMCs’ completion of these requirements. Furthermore, officials could not readily provide these data for the four VAMCs we visited because doing so would have required them to manually review each veteran’s record (921 records across the four VAMCs). Given CAT’s reporting limitations, some VAMC and VISN lead officials we spoke with indicated that they have developed their own methods for tracking contacts and visits at the facility or regional levels. For example, officials at one VAMC told us they had developed a spreadsheet for the purpose of tracking quarterly contacts and annual home visits. Further, the VISN lead officials from one VISN told us that their VAMCs report information on their ability to schedule and complete contacts and visits on a monthly basis. The program office does not collect these data from the VAMCs or VISNs. The Caregiver Support Program Office has been able to collect limited information on the extent to which quarterly contacts and annual home visits are completed through 1) bi-annual audits of a sample of Family Caregiver Program participant records that are rolled into in an annual report and 2) site visits to select VAMCs. Caregiver Support Program Office officials told us that the audits of program participants’ records serve as their main source of information on the completion of required contacts and visits. However, the focus of the audits vary each year, which means that officials cannot monitor trends in performance over time because the information is not comparable year-to-year. For example, in fiscal years 2017 and 2018, the focus was on the records of caregivers and veterans who had been discharged from the program, and in fiscal year 2016, the focus was on newly approved caregivers and veterans. In addition, because the audits are focused on a random sample of individual participants’ records, they do not provide the Caregiver Support Program Office with information to determine whether individual VAMCs are meeting these requirements. Program office officials also told us that their site visits to VAMCs include a review of the processes for required quarterly contacts and annual home visits. As of January 2019, program office officials had conducted 16 site visits since fiscal year 2016— representing about 11 percent of VAMCs. Caregiver Support Program Office officials also report that they intend to develop a site visit plan as part of MISSION Act implementation planning. Without system-wide data on VAMCs’ monitoring efforts, the program office does not know whether contacts and visits are being completed as required or whether VAMCs may need more staff to conduct them. The VAMC officials we spoke with acknowledged that their ability to complete quarterly contacts and annual home visits was dependent upon having enough staff. For example, one VAMC official reported that its facility did not complete an entire quarter of contacts and visits to caregivers and veterans because they did not have sufficient staffing resources. Similarly, a VISN lead official said that the VAMCs in its network also have had trouble meeting monitoring requirements due to insufficient staff. The lack of system-wide data on VAMCs’ completion of required contacts and visits is inconsistent with federal internal control standards that require management to use quality information to achieve their objectives. Furthermore, without these data, the Caregiver Support Program Office is also limited in its ability to estimate the additional staff that will be needed to conduct these contacts and visits once the program’s eligibility expands. VHA and OIT have worked jointly over the last four years to both fix and replace the existing Family Caregiver Program IT system, CAT, but these efforts have not led to the implementation of an IT system that fully supports the needs of the program. The VA MISSION Act included provisions that directed the department to implement an IT system for the Family Caregiver Program by October 1, 2018 and required certification of the system from the VA Secretary by October 1, 2019. However, the department reported to congressional committees in October 2018 that meeting the system implementation deadline of the VA MISSION Act was not feasible. Consequently, that deadline has not yet been met. Specifically, VHA and OIT undertook two related efforts beginning in 2015: CAT Rescue was initiated in July 2015 as a short-term project intended to improve both the quality of CAT’s data and the system’s reliability and security. However, schedule delays and significant defects identified during system testing contributed to CAT Rescue’s termination in April 2018. According to OIT officials, the department spent about $2.86 million on CAT Rescue. However, the project did not deliver viable software improvements. Caregivers Tool (CareT), a companion project to CAT Rescue, was initiated in September 2015 and was intended to produce a replacement for CAT. The project was to develop and deliver a replacement system with expanded capabilities, such as easier caregiver application submission and enhanced caregiver program analysis capabilities. However, the CareT acquisition depended on CAT Rescue, which did not deliver the needed data improvements. When CAT Rescue was terminated, data improvement and migration activities that were previously part of CAT Rescue were moved to the CareT project and contract extensions were necessary to allow more time for system development and testing in relation to these expanded requirements. Subsequently, OIT and VHA Caregiver Support Program Office officials acknowledged that development delays and the number and critical nature of system defects identified during user acceptance testing had led to the VHA Caregiver Support Program Office’s loss of confidence in CareT as a viable replacement for CAT. As a result, VA suspended the CareT acquisition in January 2019 to assess the way forward. Ultimately, work on CareT ended in late February 2019. According to OIT officials, the department spent about $8.11 million on CareT between 2015 and 2019. However, no fully functioning system replacement was delivered as intended. VA commissioned two independent assessments that examined issues impacting the CAT Rescue and CareT projects. These assessments, completed by Digital Service at VA and the MITRE Corporation in early 2019, cited a number of deficiencies that likely contributed to the termination of CAT Rescue and impacted the ability of CareT to successfully deliver new system capabilities. For example, the assessments identified deficiencies in the following areas: Requirements management: The department did not effectively implement a process for requirements development and prioritization. As a result, OIT, program office staff, and the development contractors did not have a shared understanding of how the system was to perform. In addition, the requirements identified may have been overly complex and insufficient to facilitate IT development. Efforts to elaborate on the requirements over the course of the projects were not consistent and led to delays. Further, significant defects identified during testing were not effectively prioritized and requirements remained unmet. Leadership: CAT Rescue and CareT did not have stable leadership and experienced staff throughout the department’s efforts to address issues with the program. Specifically, there was a lack of sustained leadership or a product owner needed to create and enforce a technical vision across contractors and the department. Without such leadership, there was a lack of effective governance and shared accountability across VHA, OIT, and the development contractor. According to the assessments, these deficiencies, among others, have resulted in VA’s inability to successfully deliver IT improvements as planned. We have previously reported that successfully overcoming challenges in areas such as those identified in the independent assessments of CAT Rescue and CareT is critical to increasing an agency’s odds for delivering an IT system acquisition. With the loss of confidence in CareT as a viable solution and the subsequent results of the independent assessments, VA has redirected its efforts for a third time and initiated a new project, referred to as the Caregiver Record Management Application (CARMA), in March 2019. Specifically, CARMA is focused on acquiring a solution to CAT using a commercial product that is to be configured to fit the needs of the Family Caregiver Program and support the program’s expansion. The first CARMA release, planned for late October 2019, is intended to replace CAT and improve program reporting. According to program officials, this release is expected to include expanded capabilities needed to develop system-wide reports on the completion of the required quarterly contacts and annual home visits. The second release, planned for January 2020, is intended to refine initial functionality and improve stipend processing capabilities. Additional product releases are expected at least through the summer of 2020 to incorporate new capabilities, such as online application submissions for veterans and the ability to connect to existing VA systems that manage veteran and caregiver identity and relationship management. However, it is unclear what additional work may be necessary to accommodate the expansion of the Family Caregiver Program given that the department is only in the early stages of planning. Further, the department has not yet established a target date for certifying CARMA. According to OIT officials, the cost for CARMA is estimated to be between $5.7 million and $6.3 million, but additional costs for licensing and modifications to legacy systems are also expected. As of June 2019, OIT and VHA with assistance from the Digital Service at VA had taken steps to identify key project stakeholders, estimate costs, establish a timeline, and compile the initial set of requirements for implementing the first release. The department had also identified a Product Manager, who is to be responsible for coordinating efforts between OIT and VHA. According to officials from the Digital Service at VA, the CARMA project plans to use a better, more agile approach for managing requirements. In addition, the staff asserted that the department has established and filled the new Product Manager position, which is intended to improve project leadership. Despite these actions, VA has not yet demonstrated results to show whether these changes will be sufficiently effective to overcome the issues that contributed to the failure of both CAT Rescue and CareT. It is also not yet certain when VA will successfully implement and certify its IT system as required by the VA MISSION Act. Further, because the expansion of the program is contingent on the certification by the VA Secretary that the IT system fully supports the program, continued delays with the IT system will postpone needed assistance for caregivers and veterans who may qualify for these benefits when eligibility requirements are expanded. Thus, it will be important that VA ensure that the actions taken to improve requirements management and leadership of the CARMA project are effectively implemented in order to improve the likelihood that the project will deliver an IT system that fully supports the Family Caregiver Program. As VA prepares for the expansion of the Family Caregiver Program to include caregivers of veterans who served prior to September 11, 2001, it will be important that VA have an informed understanding of the staffing resources needed to support the program. However, we found that VA continues to struggle to have the information and tools needed to effectively monitor the Family Caregiver Program. Since the Family Caregiver Program was implemented in 2011, it has experienced difficulties in meeting program requirements, such as for monitoring program enrollees, potentially impacting the caregivers and veterans it is intended to support. As both we and the VA OIG have reported, determining and ensuring there are sufficient program staff to support the program is one of VHA’s greatest obstacles in meeting program requirements. In particular, VHA’s Caregiver Support Program Office does not have complete and accurate staffing data with which to assess current and future staffing levels because it is not collecting data on all VAMC staff who support the program, and the data that are collected are not validated. The Caregiver Support Program Office is further impeded in its ability to assess whether VAMCs’ staffing levels for the program are adequate because it lacks system-wide data on the completion of periodic contacts and visits with caregivers and veterans. While the new IT system should address this issue, the program office would benefit from having an interim method to collect this information as VA’s previous efforts to fix and replace CAT have not been successful. Until the program office has reliable data for oversight and planning, the difficulties VA has experienced since the Family Caregiver Program was implemented could be further exacerbated when the program’s eligibility expands to include the caregivers of veterans of all eras. We recommend that the Secretary of the VA direct the Under Secretary for Health to take the following actions: Collect complete staffing data for the Family Caregiver Program that includes Caregiver Support Program Office funded staff, VAMC funded staff, and staff that assist the program as a collateral duty at each VAMC. (Recommendation 1) Establish a process to ensure that the Family Caregiver Program staffing data that are collected and reported to the Caregiver Support Program Office are accurate. (Recommendation 2) Identify and use an interim method to collect data from VAMCs on their completion of required quarterly contacts and annual home visits with caregivers and veterans that can be used until a new IT system is implemented. (Recommendation 3) VA provided written comments on a draft of this report, which are reprinted in appendix I. In its written comments, VA concurred with all three recommendations. VA also provided technical comments, which we incorporated as appropriate. With respect to our recommendation on collecting complete staffing data, VA concurred and stated it is in the process of developing a data collection mechanism that will allow for the capture of more specific data about staffing roles and disciplines of Family Caregiver Program staff. VA also concurred with our recommendation to establish a process that ensures that the staffing data collected and reported to the Caregiver Support Program Office are accurate. VA stated that the VISN lead officials will be responsible for reviewing and validating the staffing data submitted and that the data collection mechanism under development for this purpose will have data validation processes in place for its data fields to ensure that the data entered by VISN leads are accurate. VA also concurred with our recommendation that it needs to identify and use an interim method to collect data on the completion of required quarterly contacts and annual home visits that can be used until a new IT system is implemented. In its technical comments, VA noted that data on quarterly contacts and annual home visits with caregivers and veterans are also captured in the Computerized Patient Record System because these visits are considered clinical encounters, which we note in our report. VA further stated that staff should be able to track the workload entered into the Computerized Patient Record System if VAMCs have appropriately set up their IT systems with the designated code for this program. VA asserted that in response to our recommendation it is exploring the feasibility of using data from the Computerized Patient Record System as an interim solution for monitoring the completion of quarterly contacts and annual home visits system-wide. Additionally, VA reiterated that the first release of CARMA, which it plans to release in October 2019, should include the capabilities necessary to develop system-wide reports on the completion of required quarterly contacts and annual home visits. We are sending copies of this report to the Secretary of Veterans Affairs, the appropriate congressional committees, and other interested parties. In addition, the report is available at no charge on the GAO website at http://www.gao.gov. If you or your staff have any questions about this report, please contact Sharon M. Silas at (202) 512-7114 or silass@gao.gov or Carol C. Harris at (202) 512-4456 or harriscc@gao.gov. Contact points for our Offices of Congressional Relations and Public Affairs are on the last page of this report. GAO staff who made major contributions to this report are listed in appendix II. In addition to the contacts named above, Bonnie Anderson (Assistant Director), Mark Bird (Assistant Director), Alison Goetsch (Analyst-in- Charge), Emily Loriso, and Jennifer Stavros-Turner made key contributions to this report. Also contributing were Jennie F. Apter, Chris Businsky, Krister Friday, Monica Perez-Nelson, and Ethiene Salgado- Rodriguez. VA Health IT: Use of Acquisition Best Practices Can Improve Efforts to Implement a System to Support the Family Caregiver Program. GAO-19- 581T. Washington, D.C.: May 22, 2019. Veterans Affairs: Addressing IT Management Challenges Is Essential to Effectively Supporting the Department’s Mission. GAO-19-476T. Washington, D.C.: April 2, 2019. VA Health Care: Improvements Needed to Manage Higher-Than- Expected Demand for the Family Caregiver Program. GAO-15-245T. Washington, D.C.: December 3, 2014. VA Health Care: Actions Needed to Address Higher-Than-Expected Demand for the Family Caregiver Program. GAO-14-675. Washington, D.C.: September 18, 2014. Information Technology: Critical Factors Underlying Successful Major Acquisitions. GAO-12-7. Washington, D.C.: October 21, 2011.
Since 2011, the VA Family Caregiver Program has provided assistance to caregivers of seriously injured post-9/11 veterans at VAMCs nationwide. However, GAO previously reported that some VAMCs have struggled to manage the program's workload. The VA MISSION Act of 2018 requires the expansion of program eligibility to veterans of all eras contingent upon implementation and certification of a new IT system. The VA MISSION Act included a provision for GAO to review VA's efforts to implement a new IT system. GAO was also asked to examine staffing for the program. This report examines the extent to which VA 1) has established staffing requirements and has data to track program staffing; 2) monitors whether VAMCs are meeting departmental requirements for application review timeliness and required contacts; and 3) has implemented an IT system that fully supports the program. GAO reviewed program documentation and data. GAO also interviewed VHA officials and officials from four VAMCs and their VISNs that varied in their numbers of applications and approved caregivers. GAO also interviewed OIT officials and reviewed documentation related to their efforts to acquire and develop an IT system for the program. Within the Department of Veterans Affairs (VA), the Veterans Health Administration (VHA) has established staffing requirements for its Program of Comprehensive Assistance for Family Caregivers (Family Caregiver Program) that allow for variation, but its staffing data are not complete or accurate. VHA requires its local VA medical centers (VAMC) to have at least one Caregiver Support Coordinator to manage the program. Otherwise, VAMCs have flexibility in determining the additional staff needed. VHA's Caregiver Support Program Office funds most Family Caregiver Program staff at VAMCs. VAMCs also may fund additional program staff or have other VAMC staff assist the program as a collateral duty, but GAO found that the program office only tracks the staff it has funded. GAO also identified discrepancies between the number of staff it observed at selected VAMCs and the program office's staffing data. Without complete and accurate staffing data, the program office does not have reliable information about the program's current staffing levels, which could hamper its efforts to project needed staff when the program's eligibility is expanded. The program office routinely monitors VAMCs' performance in meeting departmental timeliness requirements for reviewing enrollment applications for the Family Caregiver Program. However, it is not able to monitor whether VAMCs are completing required quarterly contacts and annual home visits to enrolled caregivers and veterans. The Family Caregiver Program's current information technology (IT) system—the Caregiver Application Tracker (CAT)—has limited reporting capabilities and cannot provide system-wide data on the completion of these contacts and visits even though this information is documented in CAT. GAO found that some VAMCs and the regional Veterans Integrated Service Networks (VISNs) that oversee them use spreadsheets to track the completion of these requirements, but the program office does not collect these data. Without system-wide data on contacts and visits, the program office is limited in its ability to monitor and identify when VAMCs may need additional staff to meet these requirements, including once the program's eligibility is expanded. VA has yet to implement a new IT system that fully supports the Family Caregiver Program as required by the VA MISSION Act. VHA and the Office of Information and Technology (OIT) have been working jointly on projects since 2015 to improve and replace CAT. However, two of these projects were terminated without delivering viable software improvements or a replacement system. According to two independent assessments, these prior efforts lacked both effective leadership and implementation of the processes needed for requirements management. VA has asserted that its third project, in which OIT and VHA have begun to acquire and implement a commercial product to replace CAT, will take steps to avoid the issues that have impacted its past efforts. However, the initial replacement for CAT is not expected until late October 2019. Further, despite this initial deployment and additional releases expected through the summer of 2020, the department has not yet fully committed to a date by which it will certify that the new IT system fully supports the program. Until the system is implemented and certified, the expansion of eligibility for the Family Caregiver Program will be delayed. GAO is making three recommendations to VA to collect complete staffing data, establish a process to ensure the data are accurate, and establish an interim method for collecting system-wide data on required contacts and visits. VA concurred with all three recommendations.