Summary & Response to Comments

VA Form 21-2680 – Exam for Housebound Status or Permanent Need for Regular Aid and Attendance

Comments on Information Collection Extension

June 21, 2018

VA-2017-VACO-0001-0148 (Academy of Nutrition and Dietetics)

• Alignment with other federal program criteria for homebound status.

  • The commenter noted the underlying criteria for receipt of Aid and Attendance benefits are defined in regulations that have not been updated since 1979.

    • VBA Response: Checked the history of the regulation. However, the issue of amending the regulation is not within the scope of this information collection; no changes to the amendment are proposed, this is merely an extension of an existing information collection. VA makes no changes to the form based on this comment.

  • The commenter stated the statutory definition for whether a non-institutionalized veteran is homebound requires the veteran to be “substantially confined to his or her dwelling and the immediate premises.” The commenter stated that there is significant variation amongst government programs used to determine whether a beneficiary is homebound. The commenter questioned whether VA has considered altering this regulatory criteria for “permanently housebound” determinations to align with recent clarifications put forth for Medicare programming (76 FR 68599-68600).Furthermore, the commenter inquired as to whether VA determined whether an alignment with this definition would be undesirable or impracticable and, if so, the rationale used to make this determination.

    • VBA Response: As the definition is set by statute at 38 U.S.C. 1502(c), any changes would require legislative action by Congress. VA does not have authority to amend a definition set by statute. VA makes no changes to the form based on this comment.

• Use of validated, standardized assessment tools to improve care and lower costs

  • The commenter noted that the form relies on the documentation, diagnosis, and evaluation of the physician, provider, and other caregivers who have provided services to the Veteran. The commenter suggested that the quality of information collected would be improved by incorporating validated nutrition risk screening tools, which would allow caregivers to assess needs and define the necessary services to address those needs. Inclusion of these tools would also require clear instructions to the practitioner completing the form. The commenter felt the form should include more assessment of nutritional needs, noting that factors such as Body Mass Index (BMI), diet order, history of weight loss, and other factors were not included. According to the commenter, inclusion of these and other items is critical as up to 15 percent of community-dwelling and homebound elderly suffer from malnutrition. The commenter stated that VA should align the form with bot the monetary award and “Best Practice” tools to capture nutrition risks and services needed to treat an individual. Additionally, the commenter stated that different methods of data collection could be employed to match with outcomes for treatment and improvement in health.

    • VBA Response: VA notes that the purpose of VA Form 21-2680 is to gather sufficient evidence to determine eligibility for the aid and attendance and/or housebound benefit. The examination records questions pertinent to the question of whether the claimant is housebound or in need of the regular aid and attendance of another person, as defined by statute and/or regulation. The stated purpose of the commenter’s suggestions is to gather evidence aimed at capturing information pertaining to nutritional deficiencies and treatment of said deficiencies, which is beyond the purpose of the aid and attendance or housebound benefit. These benefits are monetary in nature and are not intended to capture or produce information pertaining to specific treatment requirements for individual Veterans. VA has no authority to direct the use of funds once awarded for any specific purpose, to include the furtherance of medical treatment. VA makes no changes to the form based on this comment.

• Estimate of Burden

  • The commenter stated that the estimated respondent burden may be understated.

    • VBA Response: Respondent burden is estimated to be 30-minutes. It is estimated that it takes the respondent 5 minutes per page. As this form is medical in nature, extra time has been granted. As such, VA makes no changes to the form based on this comment.

• Limitations of the Form

  • The commenter stated that the form does not include a mechanism for updating the form as an individual’s condition or status changes.

    • VBA Response: VA Form 21-2680 is designed to collect evidence to determine eligibility for the aid and attendance and/or housebound benefit. This benefit is a one-time award that does not require periodic recertification or re-evaluation, as the criteria include permanence of the condition to establish entitlement. VA also notes that there is no limitation on a claimant/beneficiary from submitting an additional form, should he or she feel the need to document changes in status or condition. If entitlement to the benefit was not previously established, VA will review all additional submissions to determine if a change in eligibility is established. VA makes no changes to the form based on this comment.

  • The commenter also stated that VA should work with professional societies to update the language used related to functional status.

    • VBA Response: VA Form 21-2680 is a tool designed to collect evidence to determine eligibility for aid and attendance and/or housebound benefits. Aid and attendance and housebound benefits are established by statute at section 1114 of title 38, United States Code, and defined in section 1502 of the same title. VA does not have the authority to amend standards set by statute. The current language contained on the form is designed to collect pertinent information regarding the claimant’s eligibility for benefits with the largest amount of flexibility, given the wide range and combination of disabilities which may establish entitlement to aid and attendance and/or housebound benefits. The commenter’s suggestion in updating language regarding measure of functional status is pertinent to the evaluation of an individual for treatment purposes; this is beyond the purpose of the aid and attendance or housebound benefit and VA Form 21-2680. These benefits and this form are intended to capture information pertaining to eligibility and entitlement to monetary benefits under Title 38; they do not pertain to specific treatment requirements for individual claimants. Accordingly, while VA makes no changes based upon this comment at this time, VA invites the Academy of Nutrition and Dietetics to submit additional comments should substantive changes be made in the future.

  • The commenter stated that Section 26 needs more detail for various medications, including the administration of said medication.

    • VBA Response: Section 26 requires the examiner completing the form to state if the claimant requires medication management and, if so, to provide an explanation. Any specific needs regarding medication management, to include, but not limited to, administration of medication, are explained in this portion of the form in accordance to the circumstances facing each individual claimant. VA makes no changes to the form based on this comment.

  • The commenter stated that Section 12, regarding weight, is a standalone measurement and provides no context with regard to weight change over various time periods.

    • VBA Response: While Section 12 only provides for a measurement of actual or estimated weight, VA notes that Section 32 provides an opportunity for the examiner to describe any pathology that affects the claimant’s ability to perform self-care, ambulate, or travel beyond the premises of the home. Section 32 allows the examiner to record not only historical weight changes, but also provides space to describe the functional impact of such measurements and trends. VA makes no changes to the form based on this comment.

  • The commenter stated that Section 14, pertaining to nutrition, is vague as to what is assessed, how, and by what tools. However, the commenter did not provide specific input regarding how the question was vague, nor did they provide suggested improvements for Section 14.

    • VBA Response: Section 14 requests that the examiner provide commentary on the claimant’s nutrition, but does not set the parameters for how this is to be measured. VA notes that VA Form 21-2680 is used to assessed the eligibility of a claimant based on his or her specific disabilities; entitlement to this award is not due solely to nutritional deficiencies caused by disability itself. As written, Section 14 allows an examiner to provide an assessment of an individual’s nutrition on a case-by-case basis, rather than requiring a specific assessment method that may or may not adequately capture the needs of an individual claimant. VA makes no changes to the form based on this comment.

  • The commenter stated that Sections 21 and 22, regarding preparing and eating food, may benefit from more clear standards or definitions. However, the commenter did not provide suggested standards or definitions.

    • VBA Response: Sections 21 and 22 request the examiner to provide information regarding the claimant’s ability to feed him/herself and prepare his/ her own meals. Each question requires the examiner to provide a narrative explanation if the claimant is unable to prepare meals or self-feed. VA has not set a standard definition for these questions to allow for greater flexibility in analyzing the impact various disabilities may have on an individual claimant. VA makes no changes to the form based on this comment.

  • The commenter stated that Section 33, regarding out-of-home activity, is appropriate but lacks specificity in terms of classifying activities. The commenter stated these activities cannot be measured without additional specificity, but did not offer suggestions for providing said specificity.

    • VBA Response: Section 33 allows the examiner to describe how often and under what circumstances the claimant is able to leave the home or immediate premises. VA has not set a standard for measuring these occasions to allow for greater flexibility in analyzing the impact various disabilities may have on an individual claimant, allowing determinations of eligibility for aid and attendance and/or housebound benefits to be made on a case-by-case basis. VA makes no changes to the form based on this comment.

  • The commenter noted that the form does not refer to community resources for out of home care, such as home-delivered meals, which can be effective tools in reducing nutritional risk.

    • VBA Response: VA notes that the purpose of VA Form 21-2680 is to gather sufficient evidence to determine eligibility for the aid and attendance and/or housebound benefit. These benefits are monetary in nature and are not intended to capture or produce information pertaining to specific treatment programs or the efficacy thereof. VA makes no changes to the form based on this comment.

VA-2017-VACO-0001-0149 (Legal Aid Foundation of Los Angeles)

• VA Form 21-2680 creates unnecessary barriers to the receipt of benefits.

  • The commenter stated that the form should expressly delineate which sections must be completed by the claimant and which must be completed by the examiner.

    • VBA Response: VA Form 21-2680, Examination for Housebound Status or Permanent Need for Regular Aid and Attendance, is an examination designed to collect sufficient information to render a decision on eligibility to aid and attendance and/or housebound benefits. As an examination, this information collection should be completed by a licensed health care professional, as non-medical personnel are not competent to render the medical evaluations required by this form. In addition to the title of the form itself, this requirement is further reiterated by Sections 35A, 35B, 35C, 36A, and 36B, all of which require information regarding the medical professional who conducted the examination. VA also notes that this form does not require a claimant’s signature. VA makes no changes to the form based on this comment.

  • The commenter also stated that the form should more clearly demarcate the instructions to the examiner. The commenter further stated that the instructions should be simplified and expanded to include the full definition and examples of aid and attendance and housebound. Similarly, the commenter stated that examiners should directly answer whether a claimant needs aid and attendance or is entitled to higher level aid and attendance.

    • VBA Response: Following Section 9, the form includes a note to the examiner informing him/her of the purpose of the form, the level of detail required in each answer, how to record certain findings, and what information the final examination report should reflect. Where a section may require further information, the form indicates to the examiner to provide an explanation and to attach a separate sheet of paper if additional space is needed to sufficiently document the response. VA notes that while the instructions immediately following Section 9 do reference the definition of housebound and aid and attendance, any determination as to whether these definitions are met are legal, not medical, in nature. The purpose of the examination is to gather sufficient medical evidence to make such a legal determination. Inclusion of examples of scenarios which meet these definitions would not only risk inappropriate delegation of a legal determination, but would also prove irrelevant as eligibility determinations are made on a case-by-case basis in accordance with the entire evidentiary record. VA makes no changes to the form based on this comment.

  • The commenter suggested moving Section 19, What Disabilities Restrict the Listed Activities/Functions, to Section 11, Age and/or Sex. Alternatively, the commenter suggests eliminating Section 19, stating Section 10, Complete Diagnosis, seeks the same information.

    • VBA Response: VA notes that Section 10, Complete Diagnosis, represents a listing of all medical diagnoses experienced by the claimant. In some cases, a diagnosis listed in this section may not have a functional impact that leads to a restriction of activities. Section 19, in contrast, represents a smaller group of these diagnoses that the examiner has determined has a direct impact on functional ability. It making determinations for eligibility, VA must determine which disabilities a claimant suffers from and which ones lead to a functional impairment which may rise to the level of housebound and/or aid and attendance. Additionally, VA notes that housebound and aid and attendance are separate levels of benefits with distinct evidentiary and legal requirements; this form is designed to capture as much information as possible to make a determination for eligibility for both of these benefits while minimizing the burden to the respondent, where possible. Accordingly, VA makes no change to the form based on this comment.

  • The commenter also suggested asking the examiner if the claimant requires supervision to protect him/herself from harm and if the claimant needs frequent assistance adjusting a special prosthetic or orthopedic appliance.

    • VBA Response: VA notes that Sections 29 and 30 require an examiner to describe the restrictions of the upper and lower extremities, while Section 31 pertains to restrictions of the spine, trunk, and neck. Any requirements pertaining to prosthetic or orthopedic appliances, to include their use and adjustment, would be documented in these sections. Additionally, any impairment of the extremities, spine/trunk/neck, or other pathology which directly impacts a claimant’s ability to protect him/herself from harm should be documented in Sections 29 through 32. VA makes no change to the form based on this comment.

  • The commenter suggested elimination of Sections 28, 29, 30, 31, 32, 33, and 34, stating they are not required by statute or by policy.

    • VBA Response: As previously stated, the purpose of VA Form 21-2680 is to collect medical evidence when making a determination for eligibility to aid and attendance and/or housebound criteria. While the commenter is correct that there is no statutory requirement to specifically ask the questions contained in the enumerated sections, VA does have a statutory duty to assist claimants in developing sufficient evidence to make a determination on a claim. See 38 U.S.C. 5103A. Accordingly, VA has exercised its discretion in creating this form and the content therein as the most efficient means of obtaining evidence to make a determination, should such evidence been necessary. VA notes that while the use of VA Form 21-2680 is not required to establish entitlement to aid and attendance and/or housebound benefits, the form is designed to solicit information in a standardized format, which assists in making eligibility determinations. VA makes no change based upon this comment.

  • The commenter suggested including a section on how to submit the form to the Veterans Benefits Administration (VBA).

    • VBA Response: An additional notice with the provided addresses for where to send the form will be added once the form is released to our public website.