Program of Comprehensive Assistance for Family Caregivers
The VA MISSION Act of 2018 created a new standard for the VA’s Caregiver Support Program’s (CSP) Program of Comprehensive Assistance for Family Caregivers (PCAFC). It also expanded eligibility beyond Post 9/11 caregivers. These changes prompted a revision in the evaluation process which VA established in CFR RIN 2900-AQ48 issued October 1, 2020. The new standards are defined in VHA Directive 1152(1) issued October 1, 2020. Two significant changes are: (1) the Activities of Daily Living (ADL) standard requires care to be provided “each and every time” an ADL is performed and (2) the standard for Supervision, Protection, and Instruction (SPI) now requires “substantial daily care”.
Application and Evaluation Process
The following outlines the steps of the evaluation process that the Caregiver Support Program uses to determine if a veteran qualifies for the Program of Comprehensive Assistance for Family Caregivers. The process utilizes standardized forms available through VHA and posted in medical records. The forms cannot be altered.
For new applicants (including non-Post 9/11 veterans), the evaluation process for PCAFC begins with the submission of your VA Form 10-10 CG, Step 1 below. The local Caregiver Support Program handles the review process for both new and Legacy applicant.
Click on the steps below for a more detailed description.
This form gathers basic information such as dates of service of the veteran, rated disabilities, and other biographical and logistical information about the veteran and caregiver. It includes basic information about age, address, etc.
This is an interview in which both the veteran and caregiver are asked a set of questions. The interviewer may ask what the veteran is rated for, what diagnoses they have, and what medications they are on. Even if they do not ask these questions, you should check with the interviewer to make sure all of this information is complete and correct because it is an important evaluation requirement. The VA CSP interviewer usually just copies and pastes this information out of the record. Again, you should carefully review this information once it is placed into MyHealtheVet because it is not uncommon to have errors that are best corrected at this time. Do not trust that the VA has the ratings, diagnoses, or medications correct.
This is also the time to tell the VA CSP if the veteran sees outside doctors. If the veteran sees outside doctors, then please gather those records from those doctors, including community care doctors.Do NOT assume that VA has them.
There will be a standard set of questions that the interviewer, usually a social worker, will ask both the veteran and the caregiver about what the veteran’s employment, educational, substance abuse/mental health history, etc. are.The interview will move on to history of pain, dietary concerns, daily diet, exercise routine, etc. The interview will also include other topics such as treatment goals and changes in health. The interviewer will ask the veteran if (s)he feels that the caregiver is supporting their treatment goals. The last question for the veteran will be about home services the VA provides.
In the caregiver portion of the interview, there are specific questions about how the caregiver provides assistance with each ADL. If you have been at this for a long time, it is helpful to write down what you do each day to make sure that you capture all of the assistance you are providing and how you do so. (Some of it becomes so rote that you forget that it actually is a caregiver duty.)
They will also ask if the caregiver has concerns about the veteran’s sleeping habits, memory, treatment goals, concerns for the veteran’s safety, preparations the caregiver has in place if they are going to be away from the veteran, and if there are any concerns that the caregiver has about the veteran. This is your chance to list all the extra concerns about the veteran’s care that you have or duties which you perform that you have not been able to fit in one of the above answers.
This functional assessment/interview is done by a different person than the Veteran Assessment.They will NOT have read your answers to the Veteran assessment, so give complete answers to questions they may ask and provide information you feel is relevant to the assessments they are doing.
The Veteran Functional Assessment is required to be performed by a health professional, most likely the nurse assigned to the Caregiver Support Program.VA has very specific definitions of each ADL and Supervision, Protection, and Instruction criteria. (See the sheets on the ADL assessment and the SPI assessment.) The CSP staff will request the caregiver describe what they do for the veteran for each ADL. Be as specific and as expansive as possible. Describe what makes it necessary for you to do each thing for the veteran—for example in toileting, if you say I must clean the veteran’s bottom after defecating each time, say why—such as he is missing both arms. Always say what you do, why you do it, and how often you do it (each time, daily, weekly, monthly, etc.)
For the safety and supervision portion of the assessment, they will ask a set of specific questions. Expound on each and every question that is relevant. Answer with what you do, why you do it, and how often you do it. Never just say, “I help with medication management.” Instead say, ““I help with medication management of ___# of medications because the veteran cannot manage them due to _____________, and I must do this (each time, daily, weekly, monthly - however often you have to do it)." If meds are given, once a day say that. If you monitor medication the veteran is taking, explain why you have to do that. If you have to monitor the friends and family of the veteran because she/he is easily exploitable due to judgement issues, say so, and explain what disability causes that to be so, and how often/in what situations it happens.
There will be a series of questions about self-direction, exploitation, self-neglect, memory, etc. Once again, be very specific. State what diagnosis requires you to do each thing and how often. The Caregiver Support Personnel will write down your answers, but then they are required to assign the veteran/caregiver a functional level based on each ADL or SPI (See the sheet on the ADL assessment and the SPI assessment). At the end, it is important that you add whatever concerns you have or duties you perform that have not yet been covered. Make sure you read over the information recorded during this assessment and correct any misinformation as soon as this information is uploaded to MyHealtheVet.
The Caregiver Support Program team is required to contact the Primary Care Manager (PCM) in order to ask a few questions. The question that appears to be weighted most heavily is, “Without a caregiver, would the veteran require institutionalization?” Another key question is, “Does the caregiver understand the treatment plan?”
Normally, this questionnaire is only sent to the PCM. HOWEVER, it is strongly suggested that you urge the CSP to ask questions of the veteran’s other specialized doctors. For example, if your caregiving centers on Alzheimer’s, urge the CSP to talk to the neurologist who manages the condition. If the caregiving needs revolve around a spinal cord injury, then the person who manages the chronic pain, the doctor who orders PT, the physical therapist, etc. should also be contacted.
For mental health disorders, ask them to reference the last neuropsych examination, talk to the treating psychiatrist and psychologist/LCSW (licensed clinical social worker). Note that the standardized evaluation form only requires the CSP team and PCM to go back 12 months from the date of the start of the Legacy review. Therefore, you need to tell the assessor specific concerns that may not have been addressed in the past 12 months, but lend credence to the need for a caregiver—things such as a neuropsych assessment, loss of part of the brain or the body, or the extent of a spinal cord injury. Do NOT depend on your doctors to do this paperwork. Read it over when it is entered in MyHealthEVet to make sure that it is accurate and get it corrected immediately, if necessary.
Once all these pieces are completed, the assessment is sent off to the Centralized Eligibility Assessment Team (CEAT). The decision is made at that level by a team of medical staff that is separate from your local Caregiver Support Program team. The CEAT notifies your team of their decision, and your local team will notify you of the CEAT decision. The target timeline from application submission to initial approval/denial determination is 90 days.
If the veteran and caregiver are approved for the program, several more steps must be completed before the veteran and caregiver are able to receive pay. These include: (1) caregiver training and (2) an in home assessment of health of both the veteran and caregiver. This in home assessment is to ensure the caregiver is able to provide care safely (both mentally and physically). After these steps, the application returns to the CEAT for final approval. Pay is backdated to the date of the application to the program.
If the veteran and caregiver are denied, the veteran and caregiver will be referred to the Program of General Caregiver Support Services.