THE SECRETARY OF VETERANS AFFAIRS WASHINGTON May 16, 2018 The Honorable Robert P. Casey, Jr. United States Senate Washington, DC 20510 Dear Senator Casey: Thank you for your April 24, 2018, co-signed letter to the Department of Veterans Affairs (VA) requesting VA conduct a retrospective review of the eligibility determinations of caregivers who were discharged from the VA Program of Comprehensive Assistance for Family Caregivers (PCAFC) on the basis of Veteran clinical eligibility prior to April 17, 2017, as well as how VA is tracking the implementation of PCAFC improvements initiated in 2017. VA shares your concerns about rectifying inconsistent or inaccurate assessments and is therefore strengthening the Veterans Health Administration Clinical Appeals process in order to ensure that if an inaccurate or inconsistent decision was made, it will be rectified through a Clinical Appeal. We would be happy to brief you on the work we are doing in this area. VA initiated a strategic review of the PCAFC in April 2017, which resulted in several key improvements, as noted in your letter, including significant advancements in communication about eligibility determinations, revocations and the appeals process, internal processes and procedures, and staff training. In addition to these key areas of improvement, the Caregiver Support Program engages in ongoing process improvement efforts including routine monitoring of key data points within the administration of PCAFC, including approvals, revocations, and application processing times across VA medical centers. When data points for a specific site demonstrate disparity from the group, such data points are considered ?outliers,? which may lead to additional review and/or intervention to ensure adherence to policy and/or to provide corrective education as needed. Such interventions may include internal audits (national or local) and/or site visits. Site visits are conducted throughout the year by members of the National Caregiver Support Program Office. These consultative visits serve to ensure adherence to statute, regulation, and national policy governing the Caregiver Support Program. Factors influencing the identification of sites include Veterans Integrated Service Network/facility requests, key performance indicators (rates of approval, denial, revocation, timeliness), and additional clinical indicators such as case consultation requests. Following site visits, the National Caregiver Support Program Office requires action plans be developed by the site to address corrective actions needed, which may include internal record reviews. We continue to monitor the progress sites have made as part of continuous improvement. Page .2. The Honorable Robert P. Casey, Jr. VA recognizes the importance of clear and direct communication of eligibility decisions with Veterans and caregivers. When communicating PCAFC eligibility and revocation decisions, Caregiver Support Coordinators (080) are required to make every effort to meet in person with the Veteran and caregiver. If barriers or safety concerns prohibit such a face-to-face meeting, the local clinical staff have the authority to determine the most appropriate way to communicate these decisions. This communication is followed by the issuance of the standardized revocation letter, which includes guidance on the process to appeal such a decision. VA offers an array of supports and services that support Veterans and caregivers in addition to PCAFC. Upon revocation, 0803 are able to offer information and referrals to many valuable resources to meet the specific needs of individual caregivers. 0803 are located at every VA medical center and serve essential roles in supporting caregivers of Veterans. The Caregiver Support Program does not have an ideal CSC-to-Veterans ratio for participation in PCAFC due to the complexity of defining the workload equitably. Current policy focuses on adherence to the governing statute, section 1720G of title 38, United States Code, and its implementing regulations. The number of 0803 required to meet the requirements of these authorities is left to the discretion of the local site. In January 2018, VA published a notice in the Federal Register seeking public comment on eight specific questions regarding the administration of PCAFC and will use this feedback to inform any updates to the program and its implementing regulations that will continue to improve transparency and consistent decision making. VA appreciates interest by members of Congress on additional ways to improve PCAFC through statutory change and looks fon/vard to continued opportunities to work together to ensure Veterans and caregivers receive the support and services they deserve. Should you have further questions, please have a member of your staff contact Ms. Ashley Tomaselli, Congressional Relations Officer, at (202) 461 -031 7 or by email at A similar response was sent to Senator Heller. Thank you for your continued support of our mission. Sincerely, Robert L. Wilkie Acting THE SECRETARY OF VETERANS AFFAIRS WASHINGTON May 16, 2018 The Honorable Dean Heller United States Senate Washington, DC 20510 Dear Senator Heller: Thank you for your April 24, 2018, co-signed letter to the Department of Veterans Affairs (VA) requesting VA conduct a retrospective review of the eligibility determinations of caregivers who were discharged from the VA Program of Comprehensive Assistance for Family Caregivers (PCAFC) on the basis of Veteran clinical eligibility prior to April 17, 2017, as well as how VA is tracking the implementation of PCAFC improvements initiated in 2017. VA shares your concerns about rectifying inconsistent or inaccurate assessments and is therefore strengthening the Veterans Health Administration Clinical Appeals process in order to ensure that if an inaccurate or inconsistent decision was made, it will be rectified through a Clinical Appeal. We would be happy to brief you on the work we are doing in this area. VA initiated a strategic review of the PCAFC in April 2017, which resulted in several key improvements, as noted in your letter, including significant advancements in communication about eligibility determinations, revocations and the appeals process, internal processes and procedures, and staff training. In addition to these key areas of improvement, the Caregiver Support Program engages in ongoing process improvement efforts including routine monitoring of key data points within the administration of PCAFC, including approvals, revocations, and application processing times across VA medical centers. When data points for a specific site demonstrate disparity from the group, such data points are considered ?outliers,? which may lead to additional review and/or intervention to ensure adherence to policy and/or to provide corrective education as needed. Such interventions may include internal audits (national or local) and/or site visits. Site visits are conducted throughout the year by members of the National Caregiver Support Program Office. These consultative visits serve to ensure adherence to statute, regulation, and national policy governing the Caregiver Support Program. Factors influencing the identification of sites include Veterans Integrated Service Network/facility requests, key performance indicators (rates of approval, denial, revocation, timeliness), and additional clinical indicators such as case consultation requests. Following site visits, the National Caregiver Support Program Office requires action plans be developed by the site to address corrective actions needed, which may include internal record reviews. We continue to monitor the progress sites have made as part of continuous improvement. Page 2. The Honorable Dean Heller VA recognizes the importance of clear and direct communication of eligibility decisions with Veterans and caregivers. When communicating PCAFC eligibility and revocation decisions, Caregiver Support Coordinators (CSC) are required to make every effort to meet in person with the Veteran and caregiver. If barriers or safety concerns prohibit such a face-to-face meeting, the local clinical staff have the authority to determine the most appropriate way to communicate these decisions. This communication is followed by the issuance of the standardized revocation letter, which includes guidance on the process to appeal such a decision. VA offers an array of supports and services that support Veterans and caregivers in addition to PCAFC. Upon revocation, CSCs are able to offer information and referrals to many valuable resources to meet the specific needs of individual caregivers. CSCs are located at every VA medical center and serve essential roles in supporting caregivers of Veterans. The Caregiver Support Program does not have an ideal CSC-to-Veterans ratio for participation in PCAFC due to the complexity of defining the workload equitably. Current policy focuses on adherence to the governing statute, section 1720G of title 38, United States Code, and its implementing regulations. The number of 0803 required to meet the requirements of these authorities is left to the discretion of the local site. In January 2018, VA published a notice in the Federal Register seeking public comment on eight specific questions regarding the administration of PCAFC and will use this feedback to inform any updates to the program and its implementing regulations that will continue to improve transparency and consistent decision making. VA appreciates interest by members of Congress on additional ways to improve PCAFC through statutory change and looks forward to continued opportunities to work together to ensure Veterans and caregivers receive the support and sen/ices they deserve. Should you have further questions, please have a member of your staff contact Ms. Ashley Tomaselli, Congressional Relations Officer, at (202) 461-0317 or by email at Ashley.Tomaselli@va.gov. A similar response was sent to Senator Casey. Thank you for your continued support of our mission. Sincerely, Wm Robert L. Wilkie Acting