This is the accessible text file for GAO report number GAO-09-22R entitled 'VA National Initiatives and Local Programs that Address Education and Support for Families of Returning Veterans' which was released on October 23, 2008. This text file was formatted by the U.S. Government Accountability Office (GAO) to be accessible to users with visual impairments, as part of a longer term project to improve GAO products' accessibility. Every attempt has been made to maintain the structural and data integrity of the original printed product. Accessibility features, such as text descriptions of tables, consecutively numbered footnotes placed at the end of the file, and the text of agency comment letters, are provided but may not exactly duplicate the presentation or format of the printed version. The portable document format (PDF) file is an exact electronic replica of the printed version. We welcome your feedback. Please E-mail your comments regarding the contents or accessibility features of this document to Webmaster@gao.gov. This is a work of the U.S. government and is not subject to copyright protection in the United States. It may be reproduced and distributed in its entirety without further permission from GAO. Because this work may contain copyrighted images or other material, permission from the copyright holder may be necessary if you wish to reproduce this material separately. October 22, 2008: The Honorable Daniel K. Akaka: Chairman: Committee on Veterans' Affairs: United States Senate: The Honorable Michael H. Michaud: Chairman: Subcommittee on Health Committee on Veterans' Affairs: House of Representatives: Subject: VA National Initiatives and Local Programs that Address Education and Support for Families of Returning Veterans: As the military operations in Afghanistan and Iraq--known as Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF), respectively- -have progressed, increasing numbers of OEF/OIF servicemembers have transitioned to veteran status and have begun receiving care from the Department of Veterans Affairs (VA). VA data show that as of March 2008, over 868,000 OEF/OIF servicemembers, including National Guard and Reserve members, had left active duty and become eligible for VA health care, and over 340,000--about 40 percent--had accessed VA health care services. Returning OEF/OIF veterans may have a range of health care needs, such as treatment for mental health conditions like post- traumatic stress disorder (PTSD), treatment for traumatic brain injury (TBI) or other injuries, or counseling to address difficulties readjusting from wartime military service to civilian life. Family members can play an important role in helping and supporting OEF/OIF veterans. For example, family members may notice symptoms the veteran has, such as anxiety or difficulty sleeping, and encourage the veteran to seek care. They may also help the veteran identify health care services and ensure that the veteran receives needed services. Family members may also provide emotional support--such as encouragement and reassurance--to the veteran. For example, they can support the veteran's efforts to reach rehabilitation goals by providing encouragement and helping the veteran stay motivated to participate in rehabilitation therapy. To help the veteran, family members may need a range of education and support from VA. They may need information about symptoms of mental or physical conditions, how those conditions can affect the veteran and the veteran's family, and the health care resources and treatment options that are available. They may also need information on potential readjustment difficulties that the returning veteran may face, as well as ways in which family members can help and support the veteran. At the same time, family members may experience difficulties--such as stress, uncertainty, or strained relationships--due to the veteran's medical conditions or readjustment difficulties. According to VA officials, educated and supportive family members can help facilitate a veteran's readjustment and recovery. You asked us to provide information on the education and support available from VA for families of OEF/OIF veterans. In this report, we describe selected national initiatives and local programs VA has in place that address education and support for families of OEF/OIF veterans who are receiving VA health care. To address this objective, we interviewed VA headquarters officials with responsibilities related to mental health, social work, physical medicine and rehabilitation, primary care, health education, and readjustment counseling about VA initiatives regarding education and support for families of OEF/OIF veterans. In addition, we reviewed documents provided by headquarters officials. To identify local VA programs that provide education and support for families of OEF/OIF veterans, we conducted site visits or phone interviews with staff from two VA regional health care networks (based in Durham, North Carolina, and Long Beach, California); five medical centers (located in Baltimore, Maryland; Durham, North Carolina; Oklahoma City, Oklahoma; San Francisco, California; and the District of Columbia); and four Vet Centers[Footnote 1] (located in Baltimore, Maryland; Raleigh, North Carolina; Silver Spring, Maryland; and the District of Columbia). This selective sample was chosen in order to include (1) varying geographic areas, (2) pilot programs geared toward families of veterans with serious mental illness or TBI, and (3) medical centers with varying levels of specialty services. We also reviewed relevant documents provided by VA staff at these locations. The findings from our site visits and phone interviews cannot be generalized to other locations. We reviewed laws and regulations governing VA's provision of services to families of veterans. We reviewed family education and support initiatives and programs at select locations and did not conduct a comprehensive review of all types of VA initiatives, programs, or other activities that may assist families. We conducted the majority of our work prior to the passage of the Veterans' Mental Health and Other Care Improvements Act of 2008, which was signed into law on October 10, 2008, and amended VA's authority to provide certain services to veterans' family members.[Footnote 2] We have included a discussion of these changes in this report. We conducted this performance audit from March 2008 through October 2008 in accordance with generally accepted government auditing standards. Those standards require that we plan and perform the audit to obtain sufficient, appropriate evidence to provide a reasonable basis for our findings and conclusions based on our audit objectives. We believe that the evidence obtained provides a reasonable basis for our findings and conclusions based on our audit objectives. We briefed your staff on the information contained in this report on August 1, 2008. As discussed with your staff at that time, we agreed to issue this report, which formally transmits the briefing slides and updates the information provided at the briefing. (See encl. I.) The slides included in enclosure I reflect VA's authority to provide services to veterans' family members at the time of our briefing, and do not reflect the amendments to VA's authority that were subsequently made by the Veterans' Mental Health and Other Care Improvements Act of 2008. Background: VA's health care system is organized into 21 regional health care networks that include VA medical centers and community-based outpatient clinics (CBOC). VA medical centers offer services that range from primary care to complex specialty care, such as cardiac or spinal cord injury care. VA's CBOCs are an extension of VA medical centers and mainly provide primary care services. In general, any veteran who has served in a combat theater after November 11, 1998, including OEF/OIF veterans, and who was discharged or released from active service on or after January 28, 2003, has up to 5 years from the date of the veteran's most recent discharge or release from active duty service to enroll in VA's health care system and receive VA health care services without charge for any condition that may be associated with the veteran's combat service.[Footnote 3] Enrolled veterans may have to make copayments for conditions found to have resulted from a cause other than the veteran's combat service. At the end of the 5-year period, veterans who had enrolled in VA's health care system during that period remain enrolled but will be placed in the appropriate enrollment priority group based on the veteran's income and other information.[Footnote 4] Combat-theater veterans who do not enroll during this 5-year period will be subject to the same eligibility and enrollment requirements as other veterans.[Footnote 5] VA also operates Vet Centers, which offer readjustment and family counseling, employment services, bereavement counseling, and a range of social services to assist combat veterans in readjusting from wartime military service to civilian life. All veterans who have served in a combat theater, including OEF/OIF veterans, are eligible for Vet Center services.[Footnote 6] Certain laws require or permit VA to provide education and support to veterans' family members. There are three categories of family members for which VA has authority to provide these services: (1) family members of veterans receiving treatment for service-connected disabilities, (2) family members of veterans receiving treatment for non-service-connected disabilities, and (3) family members of combat veterans receiving readjustment counseling services.[Footnote 7] For a veteran receiving treatment for a service-connected disability, VA is required to provide "consultation, professional counseling, marriage and family counseling,[Footnote 8] training, and mental health services" to eligible individuals, if such services are necessary in connection with the veteran's treatment. For a veteran receiving treatment for a non-service-connected disability, VA is permitted--at the discretion of the Secretary of Veterans Affairs--to provide "consultation, professional counseling, marriage and family counseling,[Footnote 9] training, and mental health services" to eligible individuals, if such services are necessary in connection with the veteran's treatment. (Prior to October 10, 2008, VA was permitted to provide services to family members of veterans receiving treatment for non-service-connected disabilities under such circumstances only if those services were initiated during the veteran's hospitalization and continuing to provide those services on an outpatient basis was essential to discharge the veteran from the hospital.)[Footnote 10] Individuals are eligible to receive these services if they are members of the immediate family or the legal guardian of a veteran or the individual in whose household the veteran intends to live. By regulation, the medical benefits package for veterans includes the family support services that are necessary in connection with the veteran's treatment of a service-connected or non-service-connected disability.[Footnote 11] Family members of combat veterans, including all OEF/OIF veterans, are eligible for Vet Center readjustment counseling services and related mental health services to help the combat veteran readjust to civilian life.[Footnote 12] Summary of Findings: In summary, VA has national initiatives and a range of local programs that address education and support for families of OEF/OIF veterans with post-deployment readjustment, mental health, and other health care needs. Enclosure I provides a more detailed description of these initiatives and programs. VA has two national initiatives that address education and support for families of OEF/OIF veterans, but it is too early to tell what impact these initiatives will have on VA's provision of education and support for families of OEF/OIF veterans. * In June 2008, VA established an interdisciplinary Caregiver Advisory Board that is to develop a caregiver assistance program that addresses caregiver issues across VA's various health care disciplines and programs. The board's activities are to include the identification of core caregiver needs systemwide, the development of initial recommendations for VA caregiver support services, and the oversight of eight caregiver assistance pilot programs to assess the feasibility and advisability of various mechanisms to expand and improve VA caregiver assistance services. * In April 2007, VA established the VA Advisory Committee on OIF/OEF Veterans and Families, which is responsible for reviewing VA services and benefits; providing advice to the Secretary of Veterans Affairs on health care, benefits, and family support issues; and making recommendations for tailoring VA services and benefits to meet the needs of OEF/OIF veterans and their families. Issues affecting families, including dependents and survivors, is one of nine priorities the committee is expected to address. VA expects to publicly issue the committee's interim report with recommendations to the Secretary of Veterans Affairs in fall 2008. The VA medical centers we reviewed offered a range of local programs for families of OEF/OIF veterans.[Footnote 13] We identified examples of medical center programs that addressed the following five issues: post-deployment counseling, PTSD, serious mental illness, caregiver assistance, and serious injuries. * Post-deployment counseling programs included an education and support program for veterans who have recently returned from a combat theater and their families. The program's goals included providing education on post-deployment issues such as the common experiences of veterans returning from combat, coping with PTSD and other reactions to trauma, and reducing family stress; providing a venue for mutual support and encouragement; and linking families with VA and non-VA resources. * The PTSD programs we identified at VA medical centers included marriage and couples therapy on an individual basis or in a group setting, as well as other types of group-oriented programs.[Footnote 14] For example, one program offered 18 educational sessions for groups of family and friends of veterans with PTSD or other mental illnesses. The goals of this program included teaching participants about the symptoms and course of mental illness, giving participants the opportunity to ask questions about psychiatric disorders and treatment options, providing a forum for discussing concerns and obtaining support from peers, and linking families with VA and non-VA resources. * Programs to address serious mental illness included family psychoeducation pilot programs for families of veterans with illnesses such as schizophrenia, bipolar disorder, and major depression.[Footnote 15] These programs use family intervention to help prevent relapse in- -and improve the quality of life and family functioning for--veterans with serious mental illness. * With regard to caregiver assistance, VA announced in December 2007 that it would establish eight caregiver assistance pilot programs at selected VA medical centers nationwide, to examine ways to improve education and provide training and resources for caregivers assisting veterans.[Footnote 16] One of these eight pilot programs focuses on providing education, skills training, and resources to caregivers of veterans with TBI, including both OEF/OIF and non-OEF/OIF veterans. * Among the VA medical center programs focusing on serious injuries was the Family Care Map pilot program at VA's four Polytrauma Rehabilitation Centers (PRC)--regional centers that provide acute comprehensive medical and rehabilitative care for the severely injured.[Footnote 17] This pilot program is an effort to standardize support for families when a veteran is receiving inpatient rehabilitation at a PRC. The Vet Centers we reviewed offered a range of programs for families of OEF/OIF veterans, including group-oriented programs and programs offered on an individual basis, such as couples and family counseling.[Footnote 18] Group-oriented programs addressing issues related to veterans' military service included a relationship enrichment group to provide education and skills to couples to address the impact of PTSD on interpersonal relationships; a parenting class to help veterans and their partners learn effective strategies for successfully raising their children; and a spousal support group providing education about PTSD, TBI, or other deployment-related issues affecting spouses of veterans. Agency Comments: We provided a draft of this report to VA for comment. VA provided technical comments, which we incorporated as appropriate. VA did not provide other comments. We are sending copies of this report to the Secretary of Veterans Affairs and appropriate congressional committees. We will also provide copies to others upon request. In addition, the report is available at no charge on GAO's Web site at [hyperlink, http://www.gao.gov]. If you or your staff have any questions or need additional information, please contact me at (202) 512-7114 or WilliamsonR@gao.gov. Contact points for our Offices of Congressional Relations and Public Affairs may be found on the last page of this report. GAO staff members who made key contributions to this report are listed in enclosure II. Signed by: Randall B. Williamson: Director, Health Care: [End of section] [Enclosure I] VA National Initiatives and Local Programs that Address Education and Support for Families of Returning Veterans: Briefing for the Staff of The Honorable Daniel K. Akaka Chairman, Senate Committee on Veterans’ Affairs: The Honorable Michael H. Michaud Chairman, House Committee on Veterans’ Affairs, Subcommittee on Health: Briefing Overview: Introduction: Objective: Scope and Methodology: Background: Findings: Introduction: As the military operations in Afghanistan and Iraq—known as Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF), respectively—have progressed, increasing numbers of OEF/OIF servicemembers have transitioned to veteran status and have begun receiving care from the Department of Veterans Affairs (VA). Returning OEF/OIF veterans may have a range of health care needs, such as treatment for mental health conditions like post-traumatic stress disorder (PTSD), treatment for traumatic brain injury (TBI) or other injuries, or counseling to address difficulties readjusting to civilian life. Family members can play an important role in helping and supporting OEF/OIF veterans. For example, they may help the veteran identify and obtain health care services or support the veteran’s efforts to reach rehabilitation goals. To help the veteran, family members may need a range of education and support from VA providers, such as information on symptoms of and treatment options for mental or physical conditions, as well as on potential readjustment difficulties. At the same time, family members may experience difficulties, such as stress or uncertainty, due to the veteran’s medical conditions or readjustment difficulties. According to VA officials, educated and supportive family members can help facilitate a veteran’s readjustment and recovery. Objective: Describe selected national initiatives and local programs VA has in place that address education and support for families of OEF/OIF veterans who are receiving VA health care. Scope and Methodology: Reviewed documents from and interviewed VA headquarters officials about VA initiatives regarding education and support for families of OEF/OIF veterans. These officials have responsibilities related to mental health, social work, physical medicine and rehabilitation, primary care, health education, and readjustment counseling. Conducted site visits or phone interviews with staff from two VA regional health care networks, five medical centers, and four Vet Centers to identify local VA programs that provide education and support for families of OEF/OIF veterans.[Footnote 19] This selective sample was chosen in order to include 1) varying geographic areas, 2) pilot programs geared toward families of veterans with serious mental illness or TBI, and 3) medical centers with varying levels of specialty services. We also reviewed relevant documents provided by VA staff at these locations. The findings from our site visits and phone interviews cannot be generalized to other locations. Reviewed laws and regulations governing VA’s provision of services to families of veterans. We reviewed family education and support initiatives and programs at select locations and did not conduct a comprehensive review of all types of VA initiatives, programs, or other activities that may assist families. We conducted this performance audit from March 2008 through October 2008 in accordance with generally accepted government auditing standards. Those standards require that we plan and perform the audit to obtain sufficient, appropriate evidence to provide a reasonable basis for our findings and conclusions based on our audit objectives. We believe that the evidence obtained provides a reasonable basis for our findings and conclusions based on our audit objectives. Background: VA’s health care system is organized into 21 regional health care networks that comprise VA medical centers and community-based outpatient clinics (CBOC). * VA medical centers offer services that range from primary care to complex specialty care, such as cardiac or spinal cord injury care. * VA’s CBOCs are an extension of VA medical centers and mainly provide primary care services. In general, any veteran who has served in a combat theater after November 11, 1998, including OEF/OIF veterans, and who was discharged or released from active service on or after January 28, 2003, has up to 5 years from the date of the veteran’s most recent discharge or release from active duty service to enroll in VA’s health care system and receive VA health care services without charge for any condition that may be associated with the veteran’s combat service. Enrolled veterans may have to make copayments for conditions found to have resulted from a cause other than the veteran’s combat service. At the end of the 5- year period, veterans who had enrolled in VA’s health care system during that period remain enrolled but will be placed in the appropriate enrollment priority group based on the veteran’s income and other information. Combat-theater veterans who do not enroll during this 5-year period will be subject to the same eligibility and enrollment requirements as other veterans. VA data show that as of March 2008, over 340,000—about 40 percent of—veterans who had returned from service in OEF or OIF, including National Guard and Reserve members, had accessed VA health care through VA medical centers and CBOCs. VA also operates Vet Centers, which offer readjustment and family counseling, employment services, bereavement counseling, and a range of social services to assist combat veterans in readjusting from wartime military service to civilian life. * All veterans who have served in a combat theater, including OEF/OIF veterans, are eligible for Vet Center services. Certain laws require or permit VA to provide education and support to veterans’ family members. For example, according to statute:[Footnote 20] * For veterans receiving treatment for a service-connected disability, VA is required to provide “consultation, professional counseling, training, and mental health services” for eligible family members, if such services are necessary in connection with the veteran’s treatment. * For veterans receiving treatment for a non-service-connected disability, VA is permitted—at the discretion of the Secretary of Veterans Affairs—to provide “consultation, professional counseling, training, and mental health services” to eligible family members, but only if those services were initiated during the veteran’s hospitalization, the continued provision of those services on an outpatient basis is essential to permit the discharge of the veteran from the hospital, and the services are necessary in connection with the veteran’s treatment. * Family members of combat veterans—including all OEF/OIF veterans—may be eligible for Vet Center readjustment counseling services for issues related to the veteran’s military service. By regulation, the medical benefits package for veterans includes the family support services that are necessary in connection with the veteran’s treatment of a service- connected or non-service-connected disability.[Footnote 21] Overview of Findings: VA has national initiatives and a range of local programs that address education and support for families of OEF/OIF veterans with mental health, post- deployment readjustment, and other health care needs. National Initiatives: VA’s Caregiver Advisory Board: * Established in June 2008, the board is to develop a caregiver assistance program that addresses caregiver issues across VA’s various health care disciplines and programs. * Members include officials from multiple disciplines, such as primary care, mental health, social work, rehabilitation, and readjustment counseling. * The board is led by VA’s Caregiver Support National Program Manager, who began serving in this position in March 2008. Specific activities are to include: - identification of core caregiver needs systemwide; - determination of staff training needs; - development of policy and tools for staff; - development of initial recommendations for VA caregiver support services; - oversight of eight caregiver assistance pilot programs to assess the feasibility and advisability of various mechanisms to expand and improve VA caregiver assistance services; * It is too early to tell what impact the board will have on VA’s provision of education and support for caregivers, including family members caring for OEF/OIF veterans. VA Advisory Committee on OIF/OEF Veterans and Families: * Established in April 2007, the committee’s focus includes all OEF/OIF veterans and families, with particular attention paid to severely disabled veterans and their families. * Members include OEF/OIF veterans and caregivers, subject matter experts, and reservists. * The committee is responsible for: – reviewing VA services and benefits; – providing advice to the Secretary of Veterans Affairs on health care, benefits, and family support issue; – making recommendations for tailoring VA services and benefits to meet the needs of OEF/OIF veterans and their families; * Issues affecting families, including dependents and survivors, is one of nine priorities the committee is to address. ¾ VA expects to publicly issue the committee’s interim report with recommendations to the Secretary of Veterans Affairs in fall 2008. Examples of VA Medical Center Programs: The following slides provide examples of programs available for family members of OEF/OIF veterans that we identified at the VA medical centers we reviewed. These programs fall into the following categories: Mental health/post-deployment programs * post-deployment counseling; * PTSD; * serious mental illness Other programs: * caregiver assistance pilot programs; * serious ¾ injuries/polytrauma (traumatic injuries to more than one part of the body or organ system); Note: These are selected programs we identified at one or more VA medical centers we reviewed, and are 13 not necessarily available at all VA medical centers. Examples of VA Medical Center Programs: Post-Deployment Counseling: Family education and support program for veterans who have recently returned from a combat theater and their families. * Program goals include: - providing education on post-deployment issues such as the common experiences of veterans returning from combat, improving family relationships, facilitating communication and intimacy, dealing with anger, coping with PTSD and other reactions to trauma, and reducing family stress; – providing a venue for mutual support and encouragement; – linking families with VA and non-VA resources; * Parenting support workshop for veterans, spouses, and others who cared for children during deployment. * Topics covered include the impact of deployment and post-deployment readjustment on children and the family, the effects of parental stress and the need for self-care, and strategies to enhance the parent/child bond. Note: These programs are available for family members of OEF/OIF veterans. They are selected programs we identified at one or more VA medical centers we reviewed, and are not necessarily available at all VA medical centers. Monthly support group for returning veterans and their families. * Includes workshops on issues such as health and wellness, parenting, anger, and sleep difficulties, as well as open-ended sessions to address other topics of interest to participants. Educational sessions at Welcome Home events for returning veterans and their families. * Topics include OEF/OIF veteran mental health issues, reconnecting with significant others and children, and post-deployment family challenges. Presentations for families of OEF/OIF veterans at post-deployment National Guard events on topics such as marriage issues and coping with stress. Note: These programs are available for family members of OEF/OIF veterans. They are selected programs we identified at one or more VA medical centers we reviewed, and are not necessarily available at all VA medical centers. Examples of VA Medical Center Programs: PTSD: Group sessions, examples of which include: * Program offering 18 educational sessions for family and friends of veterans with PTSD or other mental illnesses. Program goals include teaching participants about the symptoms and course of mental illness, giving participants the opportunity to ask questions about psychiatric disorders and treatment options, providing a forum for discussing concerns and obtaining support from peers, and linking families with VA and non-VA resources. Participants can attend one or more sessions. * Family therapy sessions for families and veterans that address issues such as the reasons for veterans’ behavior, experiences when one lives with a veteran with PTSD, problem solving, communication between family members, communication with clinicians, and strategies for coping with veterans’ issues. * “Significant Others” group that provides information on the causes, symptoms, and treatments for PTSD; self-care for trauma survivors and family members; awareness of 'warning sign' symptoms that suggest mental health care should be sought; and information about VA and community resources. Additionally, it provides a venue for participants to receive support from others with similar concerns about a loved one. * Group sessions for family members and friends of veterans with PTSD to increase their understanding of common symptoms and issues related to PTSD. The sessions also provide a venue for veterans, family members, and friends to discuss how PTSD affects their relationships. Marriage and couples therapy, on an individual basis or in a group setting. Note: These programs are available for family members of both OEF/OIF and non-OEF/OIF veterans. They are selected programs we identified at one or more VA medical centers we reviewed, and are not necessarily available at all VA medical centers. Examples of VA Medical Center Programs: Serious Mental Illness: Family psychoeducation pilot programs for families of veterans with serious mental illness, such as schizophrenia, bipolar disorder, and major depression. * During fiscal years 2005 through 2007, VA allocated funding to establish 19 family psychoeducation pilot programs. These programs use family intervention to help prevent relapse in—and improve quality of life and family functioning for—veterans with serious mental illness. Some programs work with families on an individual basis while others work with multiple families in group settings. VA expects to implement family psychoeducation at additional medical centers in fiscal year 2009. – One pilot program, for example, works with multiple families in group settings during weekly and monthly sessions led by psychologists. It is open to veterans with PTSD, major depression, bipolar disorder, or schizophrenia. Topics addressed include the diagnosis and treatment of the condition, communication skills, creating a low stress environment, anger management, and problem solving. Interdisciplinary family intervention team for veterans with serious mental illness and their families. * Services available include family support and education groups; family consultation; family education seminars providing information on mental health recovery and support services; and a more intensive family program that provides education, support, and training on mental illness to help the veteran and improve the functioning of the family as a unit. Note: These programs are available for family members of both OEF/OIF and non-OEF/OIF veterans. They are selected programs we identified at one or more VA medical centers we reviewed, and are not necessarily available at all VA medical centers. Examples of VA Medical Center Programs: Caregiver Assistance Pilot Programs: VA has established eight caregiver assistance pilot programs across the nation to examine ways to improve education and provide training and resources for caregivers assisting veterans.[Footnote 22] * These programs are designed to examine a variety of approaches to caregiver assistance, such as caregiver training, support groups, respite care, and adult day care. * Most of the programs do not focus specifically on caregivers of OEF/OIF veterans, but focus on caregivers of veterans with specific conditions or health care needs, such as caregivers of veterans with stroke-related disabilities or dementia, or caregivers living with veterans age 60 or older who have at least one chronic illness and require assistance with activities of daily living. * The programs are expected to last through fiscal year 2009. VA expects to complete an evaluation of the programs in fiscal year 2009 and assess how they could be expanded to other locations. One of the eight VA caregiver assistance pilot programs focuses on providing education, skills training, and resources to caregivers of veterans with TBI, including both OEF/OIF and non-OEF/OIF veterans. * The program involves staff with two VA regional network offices, multiple VA medical centers, and several community partners. * Services will be available to caregivers in both rural and urban areas. The majority of services are expected to be delivered outside of VA medical centers. * Current and planned activities target more than 500 caregivers and include telephone support groups for caregivers, telephone education group seminars, Web-based training on caregiver self-management, and the use of caregiver resource center specialists to provide one-on-one caregiver support. Examples of VA Medical Center Programs: Serious Injuries/Polytrauma: Polytrauma caregiver support group: * Provides education and support for caregivers, spouses, and other family members of veterans with polytraumatic injuries—injuries to more than one part of the body or organ system, one of which may be life threatening, resulting in physical, cognitive, psychological, or psychosocial impairments and functional disability. * According to staff at the VA medical center that offers this support group, because most of the veterans seen in their polytrauma program have TBI, TBI issues are often discussed during this support group. Family Care Map pilot program at VA’s four Polytrauma Rehabilitation Centers (PRC)[Footnote 23]: * This program is an effort to standardize support for families of veterans receiving inpatient rehabilitation at one of VA’s four PRCs—regional centers that provide acute comprehensive medical and rehabilitative care for the severely injured. * The Family Care Map is a Web-based guide for families that provides information on key steps that will take place at the PRC and the role of family at various points in the rehabilitation process, such as participating in patient and family assessments, participating in the rehabilitation process, focusing on family wellness, and communicating with the PRC team. * The pilot program will run from April 1, 2008 to October 1, 2008, and VA plans to evaluate the pilot program and make any needed changes before implementing the Family Care Map in its final form. Examples of Vet Center Programs: Group sessions on issues related to veterans’ military service, examples of which include: * Relationship enrichment group to provide education and skills to couples to address the impact of PTSD on interpersonal relationships. * Conflict resolution group to help couples develop effective conflict resolution skills, such as communication and negotiation. * “8 Habits of Highly Effective Couples” group focusing on learning habits aimed at improving veterans’ relationships with their partners. * Parenting class to help veterans and their partners learn effective strategies for successfully raising their children. * Session for teenage children of veterans—“The 7 Habits of Highly Effective Teens”— offered in partnership with a local university, focusing on habits that can help veterans’ teenage children succeed academically and socially. * Spousal support group providing education about PTSD, TBI, or other deployment- related issues affecting spouses of veterans. Couples and family counseling on an individual basis. As of July 2008, one Vet Center we reviewed was seeking a family therapist to provide additional family services, such as family and couples counseling, to meet the needs of its OEF/OIF population. Note: These programs are available for family members of combat veterans, including both OEF/OIF and non-OEF/OIF veterans. They are selected programs we identified at one or more Vet Centers we reviewed, and are not necessarily available at all Vet Centers. [End of section] Enclosure II: GAO Contact and Staff Acknowledgments: GAO Contact: Randall B. Williamson at (202) 512-7114 or WilliamsonR@gao.gov: Acknowledgments: In addition to the contact named above, Marcia Mann, Assistant Director; Susannah Bloch; Robin Burke; Lisa Motley; and Giao N. Nguyen made key contributions to this report. [End of section] Footnotes: [1] Vet Centers offer readjustment counseling and other services for combat veterans. [2] Pub. L. No. 110-387, 122 Stat. 4110. [3] 38 U.S.C. § 1710(e)(1)(D), (e)(3)(C). Veterans who were discharged or released before January 28, 2003, and who did not enroll in VA's health care system are eligible for these VA health care services for 3 years after January 28, 2008. [4] VA has established a system of enrollment in accordance with eight enrollment priority categories established by Congress to manage access to services in relation to available resources. The order of priority for the categories is generally based on service-connected disability rating, low income, and other recognized statuses such as former prisoners of war. 38 U.S.C. § 1705; 38 C.F.R. § 17.36 (2008). [5] See 38 U.S.C. §§ 1705, 1710; 38 C.F.R. § 17.36 (2008). [6] 38 U.S.C. § 1712A(a). [7] 38 U.S.C. §§ 1782(a), 1782(b), 1712A(b). [8] On October 10, 2008, the President signed into law the Veterans' Mental Health and Other Care Improvements Act of 2008, which added marriage and family counseling to this list of services. Pub. L. No. 110-387, § 301(a)(2)(A), 122 Stat. 4110, 4120. [9] The Veterans' Mental Health and Other Care Improvements Act of 2008 added marriage and family counseling to this list of services. Pub. L. No. 110-387, § 301(a)(2)(B)(i), 122 Stat. 4110, 4120. [10] See 38 U.S.C. § 1782(b) (added by Pub. L. No. 107-135, § 208(b), 115 Stat. 2446, 2462 (2002)). [11] 38 C.F.R. § 17.38 (2008). [12] If a physician or psychologist determines that providing mental health services to a veteran is necessary to help the veteran readjust to civilian life, VA is required to furnish such services on an outpatient basis within the limits of department facilities. These mental health services may, if determined to be essential to the effective treatment and readjustment of the veteran, include such "consultation, counseling, training, services, and expenses" for family members as are provided for family members of veterans receiving treatment for service-connected and non-service-connected disabilities. [13] The programs we describe are selected programs we identified at one or more VA medical centers we reviewed, and are not necessarily available at all VA medical centers. [14] The VA medical center PTSD programs we identified were available for family members of both OEF/OIF and non-OEF/OIF veterans. [15] The VA medical center serious mental illness programs we identified were available for family members of both OEF/OIF and non- OEF/OIF veterans. [16] These programs were established in response to the Veterans Benefits, Health Care, and Information Technology Act of 2006, which required VA to establish a pilot program to assess the feasibility and advisability of various mechanisms to expand and improve caregiver assistance services. Pub. L. No. 109-461, § 214, 120 Stat. 3403, 3423. [17] The four PRCs are located in Minneapolis, Minnesota; Richmond, Virginia; Palo Alto, California; and Tampa, Florida. VA plans to begin construction on a fifth PRC in San Antonio, Texas, in 2009, and open the PRC in early 2011. [18] These programs were available for family members of combat veterans, including both OEF/OIF and non-OEF/OIF veterans. They are selected programs we identified at one or more Vet Centers we reviewed, and are not necessarily available at all Vet Centers. [19] This includes regional health care networks based in Durham, NC; and Long Beach, CA; medical centers in Baltimore, MD; Durham, NC; Oklahoma City, OK; San Francisco, CA; and Washington, DC; and Vet Centers in Baltimore, MD; Raleigh, NC; Silver Spring, MD; and Washington, DC. [20] 38 U.S.C. §§ 1782(a), 1782(b), 1712A(b). [21] 38 C.F.R. § 17.38 (2008). [22] These programs were established in response to the Veterans Benefits, Health Care, and Information Technology Act of 2006, which required VA to establish a pilot program to assess the feasibility and advisability of various mechanisms to expand and improve caregiver assistance services. See Pub. L. No. 109-461, § 214, 120 Stat. 3403, 3423. [23] The four PRCs are located in Minneapolis, MN; Richmond, VA; Palo Alto, CA; and Tampa, FL. VA plans to begin construction on a fifth PRC in San Antonio, TX in 2009, and open the PRC in early 2011.