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. 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   However, the number of individuals approved  Administration and DOD.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. As of May 2014,  98 VAMCs had more than 50 approved caregivers. 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. As a result, according to VAMC officials, some facilities have not  been able to overcome the workload problems that developed upon  program implementation. 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. 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.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. 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. 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. 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. 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. 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.
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.