[Congressional Bills 118th Congress]
[From the U.S. Government Publishing Office]
[S. 141 Introduced in Senate (IS)]
<DOC>
118th CONGRESS
1st Session
S. 141
To amend title 38, United States Code, to improve certain programs of
the Department of Veterans Affairs for home and community based
services for veterans, and for other purposes.
_______________________________________________________________________
IN THE SENATE OF THE UNITED STATES
January 30, 2023
Mr. Moran (for himself, Mr. Tester, and Ms. Hassan) introduced the
following bill; which was read twice and referred to the Committee on
Veterans' Affairs
_______________________________________________________________________
A BILL
To amend title 38, United States Code, to improve certain programs of
the Department of Veterans Affairs for home and community based
services for veterans, and for other purposes.
Be it enacted by the Senate and House of Representatives of the
United States of America in Congress assembled,
SECTION 1. SHORT TITLE; TABLE OF CONTENTS.
(a) Short Title.--This Act may be cited as the ``Elizabeth Dole
Home and Community Based Services for Veterans and Caregivers Act of
2023'' or the ``Elizabeth Dole Home Care Act''.
(b) Table of Contents.--The table of contents for this Act is as
follows:
Sec. 1. Short title; table of contents.
Sec. 2. Definitions.
Sec. 3. Increase of expenditure cap for noninstitutional care
alternatives to nursing home care.
Sec. 4. Coordination with Program of All-Inclusive Care for the
Elderly.
Sec. 5. Home and community based services: programs.
Sec. 6. Coordination with assistance and support services for
caregivers.
Sec. 7. Development of centralized website for program information.
Sec. 8. Improvements relating to Home Maker and Home Health Aide
program.
Sec. 9. Reviews and other improvements relating to home and community
based services.
SEC. 2. DEFINITIONS.
In this Act:
(1) Caregiver; family caregiver.--The terms ``caregiver''
and ``family caregiver'' have the meanings given those terms
under section 1720K(g) of title 38, United States Code (as
added by section 5(a)(1)).
(2) Covered program.--The term ``covered program''--
(A) means any program of the Department for home
and community based services; and
(B) includes the programs specified in section
1720K of title 38, United States Code (as added by
section 5(a)(1)).
(3) Department.--The term ``Department'' means the
Department of Veterans Affairs.
(4) Home and community based services.--The term ``home and
community based services''--
(A) means the services referred to in section
1701(6)(E) of title 38, United States Code; and
(B) includes services furnished under a program
specified in section 1720K of such title (as added by
section 5(a)(1)).
(5) Home based primary care program; home maker and home
health aide program; veteran directed care program.--The terms
``Home Based Primary Care program'', ``Home Maker and Home
Health Aide program'', and ``Veteran Directed Care program''
mean the programs of the Department specified in subsections
(d), (c), and (b) of such section 1720K, respectively.
(6) Home health agency; home health aide; native american
veteran, tribal health program; urban indian organization.--The
terms ``home health agency'', ``home health aide'', ``Native
American veteran'', ``tribal health program'', and ``Urban
Indian organization'' have the meanings given those terms in
subsection (g) of such section 1720K.
(7) Secretary.--The term ``Secretary'' means the Secretary
of Veterans Affairs.
(8) Veterans service organization.--The term ``veterans
service organization'' means any organization recognized by the
Secretary under section 5902 of title 38, United States Code.
SEC. 3. INCREASE OF EXPENDITURE CAP FOR NONINSTITUTIONAL CARE
ALTERNATIVES TO NURSING HOME CARE.
(a) Increase of Expenditure Cap.--Section 1720C(d) of title 38,
United States Code, is amended--
(1) by striking ``The total cost'' and inserting ``(1)
Except as provided in paragraph (2), the total cost'';
(2) in paragraph (1), as designated by paragraph (1), by
striking ``65 percent of''; and
(3) by adding at the end the following new paragraph:
``(2) The total cost of providing services or in-kind assistance in
the case of any veteran for any fiscal year under the program may
exceed the cost that would otherwise have been incurred as specified in
paragraph (1) if the Secretary determines such higher total cost is in
the best interest of the veteran.''.
(b) Applicability.--The amendments made by subsection (a) shall
apply with respect to any fiscal year beginning on or after the date of
the enactment of this Act.
SEC. 4. COORDINATION WITH PROGRAM OF ALL-INCLUSIVE CARE FOR THE
ELDERLY.
Section 1720C of title 38, United States Code, as amended by
section 3, is further amended by adding at the end the following new
subsection:
``(f) In furnishing services to a veteran under the program
conducted pursuant to subsection (a), if a medical center of the
Department through which such program is administered is located in a
geographic area in which services are available to the veteran under a
PACE program (as such term is defined in sections 1894(a)(2) and
1934(a)(2) of the Social Security Act (42 U.S.C. 1395eee(a)(2); 1396u-
4(a)(2))), the Secretary shall establish a partnership with the PACE
program operating in that area for the furnishing of such services.''.
SEC. 5. HOME AND COMMUNITY BASED SERVICES: PROGRAMS.
(a) Programs.--
(1) In general.--Subchapter II of chapter 17 of title 38,
United States Code, is amended by inserting after section 1720J
the following new section:
``Sec. 1720K. Home and community based services: programs
``(a) In General.--In furnishing noninstitutional alternatives to
nursing home care under the authority of section 1720C of this title
(or any other authority under this chapter or other provision of law
administered by the Secretary of Veterans Affairs), the Secretary shall
carry out each of the programs specified in this section in accordance
with such relevant authorities except as otherwise provided in this
section.
``(b) Veteran Directed Care Program.--(1) The Secretary of Veterans
Affairs, in collaboration with the Secretary of Health and Human
Services, shall carry out a program to be known as the `Veteran
Directed Care program' under which the Secretary of Veterans Affairs
may enter into agreements with the providers described in paragraph (2)
to provide to eligible veterans funds to obtain such in-home care
services and related items as may be determined appropriate by the
Secretary of Veterans Affairs and selected by the veteran, including
through the veteran hiring individuals to provide such services and
items or directly purchasing such services and items.
``(2) The providers described in this paragraph are the following:
``(A) An Aging and Disability Resource Center, an area
agency on aging, or a State agency.
``(B) A center for independent living.
``(3) In carrying out the Veteran Directed Care program, the
Secretary of Veterans Affairs shall--
``(A) administer such program through each medical center
of the Department of Veterans Affairs;
``(B) ensure the availability of such program in American
Samoa, Guam, the Commonwealth of the Northern Mariana Islands,
the Commonwealth of Puerto Rico, the Virgin Islands of the
United States, and any other territory or possession of the
United States; and
``(C) ensure the availability of such program for eligible
veterans who are Native American veterans receiving care and
services furnished by the Indian Health Service, a tribal
health program, an Urban Indian organization, or (in the case
of a Native Hawaiian veteran) a Native Hawaiian health care
system.
``(4) If a veteran participating in the Veteran Directed Care
program is catastrophically disabled, the veteran may continue to use
funds under the program during a period of hospitalization in the same
manner that the veteran would be authorized to use such funds under the
program if the veteran were not hospitalized.
``(c) Home Maker and Home Health Aide Program.--(1) The Secretary
shall carry out a program to be known as the `Home Maker and Home
Health Aide program' under which the Secretary may enter into
agreements with home health agencies to provide to eligible veterans
such home health aide services as may be determined appropriate by the
Secretary.
``(2) In carrying out the Home Maker and Home Health Aide program,
the Secretary shall ensure the availability of such program--
``(A) in the locations specified in subparagraph (B) of
subsection (b)(3); and
``(B) for the veteran populations specified in subparagraph
(C) of such subsection.
``(d) Home Based Primary Care Program.--The Secretary shall carry
out a program to be known as the `Home Based Primary Care program'
under which the Secretary may furnish to eligible veterans in-home
health care, the provision of which is overseen by a physician of the
Department.
``(e) Purchased Skilled Home Care Program.--The Secretary shall
carry out a program to be known as the `Purchased Skilled Home Care
program' under which the Secretary may furnish to eligible veterans
such in-home care services as may be determined appropriate and
selected by the Secretary for the veteran.
``(f) Caregiver Support.--(1) With respect to a resident caregiver
of a veteran participating in a program under this section who is a
family caregiver, the Secretary shall--
``(A) if the veteran meets the requirements of a covered
veteran under section 1720G(b) of this title, provide to such
caregiver the option of enrolling in the program of general
caregiver support services under such section;
``(B) subject to paragraph (2), provide to such caregiver
not fewer than 14 days of covered respite care each year; and
``(C) conduct on an annual basis (and, to the extent
practicable, in connection with in-person services provided
under the program in which the veteran is participating), a
wellness check of such caregiver.
``(2) The Secretary shall provide not fewer than 30 days of covered
respite care each year to any resident caregiver who provides services
funded under the Veteran Directed Care program under subsection (b).
``(3) Covered respite care provided to a resident caregiver of a
veteran under paragraph (1) or (2), as the case may be, may exceed 14
days annually or 30 days annually, respectively, if an extension is
requested by the resident caregiver or veteran and determined medically
appropriate by the Secretary.
``(g) Definitions.--In this section:
``(1) The terms `Aging and Disability Resource Center',
`area agency on aging', and `State agency' have the meanings
given those terms in section 102 of the Older Americans Act of
1965 (42 U.S.C. 3002).
``(2) The terms `caregiver' and `family caregiver', with
respect to a veteran, have the meanings given those terms,
respectively, under subsection (d) of section 1720G of this
title with respect to an eligible veteran under subsection (a)
of such section or a covered veteran under subsection (b) of
such section, as the case may be.
``(3) The term `center for independent living' has the
meaning given that term in section 702 of the Rehabilitation
Act of 1973 (29 U.S.C. 796a).
``(4) The term `covered respite care' means, with respect
to a caregiver of a veteran, respite care that--
``(A) includes 24-hour per day care of the veteran
commensurate with the care provided by the caregiver;
``(B) is medically and age-appropriate; and
``(C) includes in-home care services.
``(5) The term `eligible veteran' means any veteran--
``(A) for whom the Secretary determines
participation in a specific program under this section
is medically necessary to promote, preserve, or restore
the health of the veteran; and
``(B) who absent such participation would be at
increased risk for hospitalization, placement in a
nursing home, or emergency room care.
``(6) The term `home health agency' has the meaning given
that term in section 1861(o) of the Social Security Act (42
U.S.C. 1395x(o)).
``(7) The term `home health aide' means an individual
employed by a home health agency to provide in-home care
services.
``(8) The term `in-home care service' means any service,
including a personal care service, provided to enable the
recipient of such service to live at home.
``(9) The term `Native American veteran' has the meaning
given that term in section 3765 of this title.
``(10) The terms `Native Hawaiian' and `Native Hawaiian
health care system' have the meanings given those terms in
section 12 of the Native Hawaiian Health Care Improvement Act
(42 U.S.C. 11711).
``(11) The term `resident caregiver' means a caregiver or a
family caregiver of a veteran who resides with the veteran.
``(12) The terms `tribal health program' and `Urban Indian
organization' have the meanings given those terms in section 4
of the Indian Health Care Improvement Act (25 U.S.C. 1603).''.
(2) Clerical amendment.--The table of sections at the
beginning of such subchapter is amended by inserting after the
item relating to section 1720J the following new item:
``1720K. Home and community based services: programs.''.
(b) Deadline for Improved Administration.--The Secretary shall
ensure that the Veteran Directed Care program and the Home Maker and
Home Health Aide program are administered through each medical center
of the Department in accordance with section 1720K of title 38, United
States Code (as added by subsection (a)(1)), by not later than two
years after the date of the enactment of this Act.
(c) Administration of Veteran Directed Care Program.--
(1) Procedures.--The Secretary shall establish procedures
to identify staffing needs for the Program and define the roles
and responsibilities of personnel of the Program at the
national, Veterans Integrated Service Network, and facility
levels, including responsibilities for engagement with veterans
participating in the Program, veterans interested in the
Program, and providers described in section 1720K(b)(2), as
added by subsection (a)(1).
(2) Staffing model.--
(A) In general.--The Secretary shall establish a
staffing model for the administration of the Program at
each medical center of the Department.
(B) Staffing ratio.--The Secretary shall establish
a staffing ratio for administration of the Program at
each facility of the Department at which the Program is
carried out, which shall include a specified number of
full-time equivalent employees, with no collateral
duties, per number of veterans served by the Program.
(3) Funding for program.--
(A) In general.--The Secretary shall develop
methods for tracking and reporting demand by veterans
for and use by veterans of services under the Program
to inform yearly cost estimates for the Program.
(B) Dedicated funding.--The Secretary shall ensure
each medical center of the Department receives
dedicated funding for administration and staffing of
the Program, tailored to demand for and use of the
Program at such medical center.
(C) Separate funding.--Funding provided to carry
out the Program shall be separate from any other
funding for the purchased long term services and
supports programs of the Department.
(4) Program defined.--In this subsection, the term
``Program'' means the Veteran Directed Care program.
SEC. 6. COORDINATION WITH ASSISTANCE AND SUPPORT SERVICES FOR
CAREGIVERS.
(a) Coordination With Program of Comprehensive Assistance for
Family Caregivers.--
(1) Coordination.--Section 1720G(a) of title 38, United
States Code, is amended by adding at the end the following new
paragraph:
``(14)(A) In the case of a veteran or caregiver who seeks services
under this subsection and is denied such services, or a veteran or the
family caregiver of a veteran who is discharged from the program under
this subsection, the Secretary shall--
``(i) if the veteran meets the requirements of a covered
veteran under subsection (b), provide to such caregiver the
option of enrolling in the program of general caregiver support
services under such subsection;
``(ii) assess the veteran or caregiver for participation in
any other available program of the Department for home and
community based services (including the programs specified in
section 1720K of this title) for which the veteran or caregiver
may be eligible and, with respect to the veteran, store (and
make accessible to the veteran) the results of such assessment
in the electronic medical record of the veteran; and
``(iii) provide to the veteran or caregiver written
information on any such program identified pursuant to the
assessment under clause (ii), including information about
facilities, eligibility requirements, and relevant contact
information for each such program.
``(B) For each veteran or family caregiver who is discharged from
the program under this subsection, a caregiver support coordinator
shall provide for a smooth and personalized transition from such
program to an appropriate program of the Department for home and
community based services (including the programs specified in section
1720K of this title), including by integrating caregiver support across
programs.''.
(2) Applicability.--The amendment made by paragraph (1)
shall apply with respect to denials and discharges described in
paragraph (14) of such section, as added by paragraph (1),
occurring on or after the date of the enactment of this Act.
(b) Technical and Conforming Amendments.--Section 1720G(d) of such
title is amended--
(1) by striking ``or a covered veteran'' each place it
appears and inserting ``, a veteran denied or discharged as
specified in paragraph (14) of such subsection, or a covered
veteran''; and
(2) by striking ``under subsection (a), means'' each place
it appears and inserting ``under subsection (a) or a veteran
denied or discharged as specified in paragraph (14) of such
subsection, means''.
(c) Review Relating to Caregiver Contact.--The Secretary shall
conduct a review of the capacity of the Department to establish a
streamlined system for contacting all caregivers enrolled in the
program of general caregiver support services under section 1720G(b) of
title 38, United States Code, to provide to such caregivers program
updates and alerts relating to emerging services for which such
caregivers may be eligible.
SEC. 7. DEVELOPMENT OF CENTRALIZED WEBSITE FOR PROGRAM INFORMATION.
(a) Centralized Website.--The Secretary shall develop and maintain
a centralized and publicly accessible internet website of the
Department as a clearinghouse for information and resources relating to
covered programs.
(b) Contents.--The website under subsection (a) shall contain the
following:
(1) A description of each covered program.
(2) An informational assessment tool that enables users
to--
(A) assess the eligibility of a veteran, or a
caregiver of a veteran, for any covered program; and
(B) receive information, as a result of such
assessment, on any covered program for which the
veteran or caregiver (as the case may be) may be
eligible.
(3) A list of required procedures for the directors of
medical facilities of the Department to follow in determining
the eligibility and suitability of veterans for participation
in a covered program, including procedures applicable to
instances in which the resource constraints of a facility (or
of a community in which a facility is located) may result in
the inability to address the health needs of a veteran under a
covered program in a timely manner.
(c) Updates.--The Secretary shall ensure the website under
subsection (a) is updated on a periodic basis.
SEC. 8. IMPROVEMENTS RELATING TO HOME MAKER AND HOME HEALTH AIDE
PROGRAM.
(a) Pilot Program for Communities With Shortage of Home Health
Aides.--
(1) Program.--The Secretary shall carry out a pilot program
under which the Secretary shall provide home maker and home
health aide services to veterans who reside in communities with
a shortage of home health aides.
(2) Locations.--The Secretary shall select 10 geographic
locations in which the Secretary determines there is a shortage
of home health aides at which to carry out the pilot program
under paragraph (1).
(3) Nursing assistants.--
(A) In general.--In carrying out the pilot program
under paragraph (1), the Secretary may hire nursing
assistants as new employees of the Department, or
reassign nursing assistants who are existing employees
of the Department, to provide to veterans in-home care
services (including basic tasks authorized by the State
certification of the nursing assistant) under the pilot
program, in lieu of or in addition to the provision of
such services through non-Department home health aides.
(B) Relationship to home based primary care
program.--Nursing assistants hired or reassigned under
subparagraph (A) may provide services to a veteran
under the pilot program under paragraph (1) while
serving as part of a health care team for the veteran
under the Home Based Primary Care program.
(4) Duration.--The pilot program under paragraph (1) shall
be for a duration of three years.
(5) Report to congress.--Not later than one year after the
date on which the Secretary determines the pilot program under
paragraph (1) has terminated, the Secretary shall submit to the
Committee on Veterans' Affairs of the Senate and the Committee
on Veterans' Affairs of the House of Representatives a report
on the result of the pilot program.
(b) Report on Use of Funds.--Not later than one year after the date
of the enactment of this Act, the Secretary shall submit to the
Committee on Veterans' Affairs of the Senate and the Committee on
Veterans' Affairs of the House of Representatives a report containing,
with respect to the period beginning in fiscal year 2011 and ending in
fiscal year 2022, the following:
(1) An identification of the amount of funds that were
included in a budget of the Department during such period for
the provision of in-home care to veterans under the Home Maker
and Home Health Aide program in effect during such period but
were not expended for the provision of such care, disaggregated
by medical center of the Department for which such unexpended
funds were budgeted.
(2) An identification of the number of veterans for whom,
during such period, the hours during which a home health aide
was authorized to provide services to the veteran under such
program were reduced for a reason other than a change in the
health care needs of the veteran, and a detailed description of
the reasons why any such reductions may have occurred.
(c) Updated Guidance on Program.--
(1) In general.--Not later than one year after the date of
the enactment of this Act, the Secretary shall issue updated
guidance for the Home Maker and Home Health Aide program.
(2) Matters to include.--Guidance updated under paragraph
(1) shall include the following:
(A) A process for the transition of veterans from
the Home Maker and Home Health Aide program to other
covered programs.
(B) A requirement for the directors of the medical
facilities of the Department to complete such process
whenever a veteran with care needs has been denied
services from home health agencies under the Home Maker
and Home Health Aide program as a result of the
clinical needs or behavioral issues of the veteran.
SEC. 9. REVIEWS AND OTHER IMPROVEMENTS RELATING TO HOME AND COMMUNITY
BASED SERVICES.
(a) Office of Geriatric and Extended Care.--
(1) Review of programs.--The Under Secretary for Health of
the Department shall conduct a review of each program
administered through the Office of Geriatric and Extended Care
of the Department, or successor office, to--
(A) ensure consistency in program management;
(B) eliminate service gaps at the medical center
level; and
(C) ensure the availability of, and the access by
veterans to, home and community based services.
(2) Assessment of staffing needs.--The Secretary shall
conduct an assessment of the staffing needs of the Office of
Geriatric and Extended Care of the Department, or successor
office.
(3) Goals for geographic alignment of care.--
(A) Establishment of goals.--The Director of the
Office of Geriatric and Extended Care, or successor
office, shall establish quantitative goals to enable
aging or disabled veterans who are not located near
medical centers of the Department to access extended
care services (including by improving access to home
and community based services for such veterans).
(B) Implementation timeline.--Each goal established
under subparagraph (A) shall include a timeline for the
implementation of the goal at each medical center of
the Department.
(4) Goals for in-home specialty care.--The Director of the
Office of Geriatric and Extended Care, or successor office,
shall establish quantitative goals to address the specialty
care needs of veterans through in-home care, including by
ensuring the education of home health aides and caregivers of
veterans in the following areas:
(A) Dementia care.
(B) Care for spinal cord injuries and diseases.
(C) Ventilator care.
(D) Other speciality care areas as determined by
the Secretary.
(5) Report to congress.--Not later than one year after the
date of the enactment of this Act, the Secretary shall submit
to the Committee on Veterans' Affairs of the Senate and the
Committee on Veterans' Affairs of the House of Representatives
a report containing the findings of the review under paragraph
(1), the results of the assessment under paragraph (2), and the
goals established under paragraphs (3) and (4).
(b) Review of Incentives and Efforts Relating to Home and Community
Based Services.--
(1) Review.--The Secretary shall conduct a review of the
following:
(A) The financial and organizational incentives for
the directors of medical centers of the Department to
establish or expand covered programs at such medical
centers.
(B) Any incentives for such directors to provide to
veterans home and community based services in lieu of
institutional care.
(C) The efforts taken by the Secretary to enhance
spending of the Department for extended care by
shifting the balance of such spending from
institutional care to home and community based
services.
(D) The plan of the Under Secretary for Health of
the Department to accelerate efforts to enhance
spending as specified in subparagraph (C), to match the
progress of similar efforts taken by the Administrator
of the Centers for Medicare & Medicaid Services with
respect to spending of the Centers for Medicare &
Medicaid Services for extended care.
(2) Report to congress.--Not later than one year after the
date of the enactment of this Act, the Secretary shall submit
to the Committee on Veterans' Affairs of the Senate and the
Committee on Veterans' Affairs of the House of Representatives
a report on the findings of the review under paragraph (1).
(c) Review of Respite Care Services.--Not later than two years
after the date of the enactment of this Act, the Secretary shall
conduct a review of the use, availability, and effectiveness of the
respite care services furnished by the Secretary under chapter 17 of
title 38, United States Code.
(d) Collaboration To Improve Home and Community Based Services.--
(1) Feedback and recommendations on caregiver support.--
(A) Feedback and recommendations.--The Secretary
shall solicit from the entities described in
subparagraph (B) feedback and recommendations regarding
opportunities for the Secretary to enhance home and
community based services for veterans and caregivers of
veterans, including through the potential provision by
the entity of care and respite services to veterans and
caregivers who may not be eligible for any program
under section 1720G of title 38, United States Code, or
section 1720K of such title (as added by section
5(a)(1)), but have a need for assistance.
(B) Covered entities.--The entities described in
this subparagraph are veterans service organizations
and nonprofit organizations with a focus on caregiver
support (as determined by the Secretary).
(2) Collaboration for native american veterans.--The
Secretary shall collaborate with the Director of the Indian
Health Service and representatives from tribal health programs
and Urban Indian organizations to ensure the availability of
home and community based services for Native American veterans,
including Native American veterans receiving health care and
medical services under multiple health care systems.
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