Implementation of the PAWS for Veterans Therapy Act, 18481-18484 [2022-06735]

Agencies

• DEPARTMENT OF VETERANS AFFAIRS

[Federal Register Volume 87, Number 61 (Wednesday, March 30, 2022)]
[Notices]
[Pages 18481-18484]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2022-06735]


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DEPARTMENT OF VETERANS AFFAIRS


Implementation of the PAWS for Veterans Therapy Act

AGENCY: Department of Veterans Affairs.

ACTION: Notice.

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SUMMARY: The Department of Veterans Affairs (VA) is publishing this 
notice to inform the public about how it is implementing the Puppies 
Assisting Wounded Servicemembers for Veterans Therapy Act.

DATES: This notice is effective on March 30, 2022.

FOR FURTHER INFORMATION CONTACT: Stacey Pollack, 810 Vermont Avenue NW, 
Washington, DC 20420; 202-461-4174. This is not a toll-free telephone 
number.

SUPPLEMENTARY INFORMATION: The Puppies Assisting Wounded Servicemembers 
for Veterans Therapy Act (hereinafter referred to as ``the Act'') was 
signed into law by the President on August 25, 2021, (Pub. L. 117-37, 
135 stat. 329). Section 2 of the Act requires VA to conduct a pilot 
program to provide canine training to eligible veterans diagnosed with 
posttraumatic stress disorder (PTSD) as an element of a complementary 
and integrative health program for such veterans. This notice provides 
information on how VA will implement the requirements of section 2 of 
the Act and is not a solicitation for public comment or request for 
information regarding VA's implementation of section 2 of the Act, as 
outlined below. Therefore, responses to this notice may not be used to 
inform VA's implementation of section 2 of the Act, and VA will not 
address such responses. A brief summary of the provisions in section 2 
of the Act follows.

Summary of Provisions in Section 2 of the Act

     Section 2(a) requires that VA, not later than February 21, 
2022, commence the conduct of a pilot program to provide canine 
training to eligible veterans diagnosed with PTSD as an element of a 
complementary and integrative health program for such veterans.
     Section 2(b) requires that the pilot program conducted 
under subsection (a) be carried out for a 5-year period beginning on 
the date of the commencement of the pilot program, by not fewer than 5 
VA medical centers (VAMC) located in geographically diverse areas.
     Section 2(c) requires that, in carrying out the pilot 
program required under subsection (a), VA must seek to enter into 
agreements with nongovernmental entities that VA determines have the 
demonstrated ability to provide the canine training specified in 
subsection (a).
     Section 2(d) establishes certain conditions for inclusion 
in any agreements under subsection (c).
     Section 2(e) establishes that a veteran who has 
participated in the pilot program under subsection (a) may adopt a dog 
that the veteran assisted in training during the pilot program if the 
veteran and the veteran's health provider, in consultation with the 
entity that provided the canine training with respect to that dog under 
the pilot program, determine that it is in the best interest of the 
veteran. This section also includes language regarding the 
responsibility of the entity that provided the canine training under 
the pilot program to provide follow-up training support for the life of 
the dog, if the veteran who participated in the pilot program adopts 
the dog under this subsection.
     Section 2(f) establishes that participation in the pilot 
program under subsection (a) may not preclude a veteran from receiving 
any other medical care or treatment for PTSD furnished by VA for which 
the veteran is otherwise eligible.
     Section 2(g) establishes data collection requirements 
based on veterans' participation in the pilot program and such other 
factors as VA determines appropriate.
     Section 2(h) establishes VA's reporting requirements 
associated with the pilot program.
     Section 2(i) requires the Comptroller General to brief and 
report to Congress on the methodology of the pilot program.
     Section 2(j) establishes definitions, for purposes of 
section 2, for the following terms: Accredited service dog organization 
(SDO), eligible veteran and service dog training instructor.

Implementation of the Pilot Program

    VA's implementation of the pilot program will reflect the following 
considerations:

Canine Training

    Section 2(a) provides that VA must conduct a pilot program to 
provide canine training to eligible veterans diagnosed with PTSD as an 
element of a complementary and integrative health program for such 
veterans. The term canine training is not defined in the Act, and VA 
has not otherwise defined this term. However, the term canine training 
is characterized in the Act as ``an element of a complementary and 
integrative health program'' for veterans participating in the pilot 
program. The Act similarly does not contain a definition of the term 
complementary and integrative health (CIH); however, VA's internal 
policy defines CIH as a group of diverse medical and health care 
approaches and practices that are not considered to be part of 
conventional or allopathic medicine. See Veterans Health Administration 
(VHA) Directive 1137(2), Provision of Complementary and Integrative 
Health (May 18, 2017; amended July 2, 2021).
    Based on its experience, VA has distinguished the following two 
types of CIH: Treatment services and well-being services. Unlike 
treatment services, well-being services are often practices offered 
outside of a clinical setting and involve a practitioner or instructor 
teaching veterans to advance their sense of well-being and improve 
their quality of life.
    VA is implementing the canine training under the pilot program as 
an element of CIH well-being services. CIH well-being services are 
those activities that a veteran may complete without the need for 
assistance from a health care

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professional or in a clinical setting and that may advance the 
veteran's sense of well-being and improve the veteran's quality of 
life. Because the canine training will be considered CIH well-being 
services, it is not a direct clinical intervention, and the training 
does not involve the provision of health care. This will allow more 
veterans to participate in canine training; thereby, affording more 
veterans potential well-being benefits.

Commencement and Duration of the Pilot Program

    Section 2(a) requires that, not later than 180 days after the date 
of the enactment of the Act, VA must commence the conduct of a pilot 
program. As the Act was signed into law on August 25, 2021, VA was 
required to commence the conduct of a pilot program by February 21, 
2022. By this date, VA selected the pilot program sites and initiated 
efforts at the sites to begin implementing the pilot program and to 
ensure VA staff are aware of the canine training to be conducted under 
the pilot program. However, the actual canine training did not begin by 
that date. VA is still working to form agreements with nongovernmental 
entities that will furnish the canine training. For purposes of section 
2(b)(1), VA considers the date the pilot program commenced as February 
21, 2022.

Veteran Participation in the Pilot Program

    Section 2(j)(2) defines the term eligible veteran to mean a veteran 
who is enrolled in VA's patient enrollment system under 38 U.S.C. 1705 
(regulated under 38 CFR 17.36), and who has been recommended for 
participation in the pilot program by a qualified mental health care 
provider or clinical team based on medical judgment that the veteran 
may benefit from such participation with respect to the PTSD symptoms 
of the veteran. In other words, to participate in the pilot, a veteran 
must meet three threshold conditions for eligibility; namely, the 
veteran must be (1) enrolled in the VA health care system; (2) 
diagnosed with PTSD; and (3) recommended by a VA mental health care 
provider or VA clinical team.
    Section 2 does not define or characterize the phrase ``qualified 
mental health care provider or clinical team.'' Rather than define 
qualifications, VA interprets this phrase to mean that a VA mental 
health care provider or VA clinical team must recommend a veteran for 
participation in the pilot program. Limiting the recommendation to VA 
providers will allow VA to assess more consistently each veteran that 
may want to participate under the same criteria and will allow for more 
consistent collection of data, as required under section 2(g)(1)(B)-
(D). Veterans, who receive care from non-VA providers under the 
Veterans Community Care Program and who wish to participate in the 
pilot program, can discuss the program with their non-VA provider but 
will need to obtain a recommendation from a VA mental health care 
provider or VA clinical team. Veterans interested in participating in 
the pilot program, who are receiving care from non-VA providers, should 
contact the participating VAMC where they receive care or authorization 
for non-VA care, for more information on how to participate in the 
pilot program.
    Before a VA mental health care provider or VA clinical team can 
recommend the veteran for participation in the program, the veteran 
must have had an appointment with a primary care, mental health, whole 
health, recreation therapy or social work provider within the previous 
3 months. VA will also require veterans participating in the program to 
remain engaged with one or more of these clinical areas; to remain 
engaged, a veteran must have an appointment at least once every 3 
months until they have completed the pilot program. Section 2(j)(2)(B) 
requires a qualified mental health care provider or clinical team to 
form a medical judgment that participation in the pilot program may 
benefit the veteran with respect to the veteran's PTSD. Having regular 
appointments (at least 1 every 3 months) is essential to ensure that 
this judgment is still accurate. If a veteran who is interested in 
participating in the pilot program has not been seen for an appointment 
within the last 3 months, the veteran can schedule an appointment with 
a VA provider to begin the recommendation and screening process.
    Once the veteran has had this appointment, the veteran can then be 
screened for participation. This screening will be performed by a 
licensed independent VA mental health care provider to confirm the 
diagnosis of PTSD through a clinical assessment and determine 
suitability for participation in the pilot program. This screening must 
occur within 3 months prior to the first canine training session. This 
may require subsequent screening in some cases; for example, if a 
veteran was screened and recommended for participation in the pilot 
program on January 1, but the veteran is unable to participate in the 
program until July 31, due to limited space or other issues, the 
veteran may need to be screened again prior to participation. This 
screening would not necessarily require the veteran to schedule another 
appointment with the licensed independent VA mental health care 
provider; although, a review of the veteran's medical chart may be 
sufficient. The licensed independent VA mental health care provider 
will make a clinical determination as to which, if any, reassessments 
are necessary for participation, and whether such reassessments require 
a direct interaction (either in person, by phone or by telehealth) with 
the veteran. VA will make every effort to ensure that all screening is 
completed in a timely manner and as conveniently as possible for the 
veteran. As noted above, screening must be performed by VA mental 
health care providers and recommendations must be from VA providers or 
clinical teams; meaning, that if VA were unable to offer a screening 
within the designated access standards under 38 CFR 17.4040, that would 
not authorize the veteran to elect to receive care in the community. 
These screenings would not constitute the delivery of medical services 
under such access standards. This also means that the screening will 
impose no copayment obligation on the veteran. The screenings entail 
clinical decision making and the exercise of medical judgment, as may 
occur in a research study or other clinical programs. We note; however, 
that the pilot program is not a research study.
    In the screening, VA providers will assess veterans for criteria 
that would suggest that participation in the pilot program may not be 
appropriate, including, but not limited to frequent aggressive 
behaviors or homicidal ideation that may make it unsafe for the veteran 
to be with a dog or co-morbid diagnoses that would make training with a 
dog difficult or not feasible (e.g., psychosis, delusions, certain 
cognitive impairment). We are stating these additional elements to 
explain to the public how qualified VA mental health care providers or 
clinical teams will make recommendations for participation in the pilot 
program. Once the veteran has been screened, VA will refer eligible 
veterans to the accredited SDO, as described below, for canine 
training. Given these organizations' limited capacity, not all veterans 
who meet eligibility criteria may be able to participate in the 
program. There will be a ``pilot champion'' at each of the five pilot 
sites; the pilot champion will be a VA staff member serving as a 
liaison between the VAMC and the SDO

[[Page 18483]]

furnishing canine training, pursuant to an agreement described in 
section 2(c).
    The canine training model will have veterans engage in both basic 
obedience and other training of a dog, so that the dog may eventually 
become, in most cases, a service dog for another individual. 
Participating in the canine training may improve veterans' self-
efficacy and increase their sense of purpose and self-worth. For 
example, participating veterans may work to train a dog to establish 
trust, build a relationship and practice socializing, and through that 
process, those veterans may better recognize and learn to optimally 
regulate their own emotional arousal to train the dog. These sessions 
are typically conducted in small group classes and will be overseen by 
a certified service dog training instructor. VA clinical staff will not 
accompany a veteran to attend canine training under the pilot program. 
The canine training sessions under the pilot program will typically 
meet once a week for 8 weeks, and participating veterans may work with 
multiple dogs and other veterans within their small group as a form of 
social engagement.

Selection of VA Sites

    Section 2(b)(2) requires VA to ensure that the pilot program is 
carried out by not fewer than five VAMCs located in geographically 
diverse areas. In selecting the five pilot program sites, VA first 
considered the geographic proximity of VAMCs to accredited SDOs, 
because the nongovernmental entities that would provide the canine 
training under section 2(c) are further required to be an accredited 
SDO under section 2(d)(1). Section 2(j)(1) of the Act defines 
accredited SDO as an organization described in section 501(c)(3) of the 
Internal Revenue Code of 1986 that: (1) Provides service dogs to 
veterans with PTSD and (2) is accredited by an accrediting organization 
with demonstrated experience, national scope and recognized leadership 
and expertise in the training of service dogs and education in the use 
of service dogs (as determined by VA). VA recognizes the expertise and 
national scope of the following two organizations that accredit SDOs 
under its regulations in 38 CFR 17.148(c)(1): Assistance Dogs 
International (ADI) and International Guide Dog Federation (IGDF). 
Between ADI-accredited and IGDF-accredited SDOs, only ADI-accredited 
SDOs provide the type of instruction discussed earlier. Therefore, VA 
considered the proximity of VAMCs to ADI-accredited SDOs, for purposes 
of identifying potential pilot program sites.
    VA next considered VAMCs near ADI-accredited SDOs that expressed 
interest in participating in the pilot program for 5 years and would be 
able to conduct assessments and recommend veterans to the pilot 
program, as well as conduct other programmatic aspects of the pilot 
(such as data collection required under section 2(g)). Of the VAMCs 
that met the criteria above, VA then considered five sites that would 
be in geographically diverse areas, as required by section 2(b)(2). VA 
attempted to consider VAMCs that were in different Veterans Integrated 
Service Networks (VISN), which are VA's designated regional systems of 
care in the country. Given these factors, VA identified the following 
five VAMCs as the required pilot program sites under section 2(b)(2): 
Palo Alto, California; Anchorage, Alaska; Asheville, North Carolina; 
West Palm Beach, Florida; and San Antonio, Texas.

Agreements With Entities To Furnish Canine Training

    Section 2(c) requires VA to seek to enter into agreements with 
nongovernmental entities that VA determines can provide canine training 
under the pilot program, and section 2(d) establishes minimum required 
conditions to be included in any such agreements. Section 2(d)(1) 
further establishes that any agreements formed between VA and a 
nongovernmental entity will include a certification from the entity 
that it is an accredited SDO. We reiterate from the discussion earlier 
in this notice, in accordance with section 2(j)(1), as well as VA's 
knowledge and recognition of ADI-accredited SDOs providing service dogs 
to veterans with PTSD, that VA will seek to enter into agreements under 
section 2(c) with ADI-accredited SDOs. Because section 2 does not 
confer any grant or cooperative agreement authority under which VA may 
conduct the pilot program, VA has engaged directly with ADI-accredited 
entities that are located near the five VA pilot sites, to gauge 
interest and determine their ability to furnish canine training under 
the pilot, to include Dogs for Life; Paws for Purple Hearts; and 
Warrior Canine Connection. VA anticipates the agreements formed with 
these entities will establish that SDOs will furnish canine training as 
in-kind services. The agreements further will include all conditions as 
required under section 2(d) and additional terms necessary. VA is 
entering into this agreement with SDOs that have the experience 
necessary to provide this model of training. In this manner, the 
agreements would reflect VA's understanding that these SDOs provide 
canine training to veterans at no cost to veterans. VA does not 
envision forming agreements under section 2(c) that would create any 
additional cost for VA or the veteran in terms of payment for the 
canine training.

Adoption of a Dog

    Section 2(e) establishes that a veteran who has participated in the 
pilot may adopt a dog that the veteran assisted in training as part of 
the pilot program, if the veteran and veteran's provider (in 
consultation with the SDO that provided the canine training under the 
pilot program) determine that it is in the best interest of the 
veteran. The language in section 2(e) establishes a permissive 
authority related to adoption of a dog and does not compel the 
provision of a dog to a veteran. ADI-accredited organizations that will 
be furnishing the canine training under the pilot program train and 
pair qualified service dogs with individuals with disabilities and do 
not necessarily participate in the adoption of dogs.
    Because the adoption provision in section 2(e) is permissive, and 
because the ADI-accredited organizations that will furnish canine 
training under the pilot program may not necessarily participate in the 
adoption of dogs, VA will not implement the adoption provisions under 
section 2(e). Determinations about whether it is in the best interest 
of a veteran to adopt a dog extends beyond VA providers' scope of 
licensure, the VA Scope of Practice and their sphere of clinical 
expertise. This does not prevent any veteran from independently seeking 
to adopt a dog; however, such adoption would not be an adoption under 
section 2(e)(1). Any veteran seeking to be prescribed a service dog and 
subsequent service dog benefits, instead of merely adopting a dog, 
would have to be separately evaluated by VA under the criteria in 
section 17.148 and prescribed a service dog, prior to owning the dog, 
to be considered for service dog benefits.

Beneficiary Travel

    The canine training under the pilot is not considered examination, 
treatment or care for purposes of qualifying for reimbursement or 
payment of beneficiary travel (BT) expenses, should a veteran eligible 
for BT benefits need to travel to receive the canine training. Although 
BT benefits will not be available for any travel that may be associated 
with the canine training under the pilot, we believe in many cases that 
veterans who would participate in the pilot will be able to transport 
themselves. Other

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transportation options, such as the Volunteer Transportation Network, 
may also be available.

Appeals

    During the course of the pilot program, disagreements may arise 
regarding veteran participation. We anticipate that the vast majority 
of these disagreements will be subject to VA's clinical appeals 
process, as set forth currently in VHA Directive 1041, Appeal of 
Veterans Health Administration Clinical Decisions (September 28, 2020). 
The clinical appeals process applies to a written request for higher 
review of one or more medical determinations. Medical determinations 
usually concern the need for and appropriateness of specific types of 
medical care and treatment for an individual and generally include 
decisions by an appropriate health care professional based on their 
medical judgment.
    Eligibility to participate in the pilot program is limited, by 
section 2(j)(2), to veterans who are: (1) Enrolled in the VA health 
care system; (2) diagnosed with PTSD; and (3) recommended for 
participation in the pilot program by a qualified mental health care 
provider or clinical team, based on medical judgment that the veteran 
may benefit from such participation with respect to the diagnosed PTSD 
of the veteran. While determinations of whether a veteran is enrolled 
in the VA health care system are administrative and not clinical, such 
matters are typically easily discernable and do not entail much 
dispute. Disagreements with administrative decisions are appealable to 
the Board of Veterans' Appeals. However, diagnosis of PTSD and a 
recommendation concerning the need for, and the appropriateness of, 
specific types of medical care and treatment, based on medical 
judgment, are decisions that are clinical in nature and therefore 
subject to the clinical appeals process in VHA Directive 1041.
    Throughout the course of the pilot program, SDOs providing the 
canine training will have the discretion and authority to determine 
whether they will provide training to a veteran at a particular time. A 
veteran who is disruptive; incapable of or unwilling to follow 
directions; or presents a danger to themselves or others (including the 
dogs being trained) could be denied the ability to participate in the 
program on at least a temporary basis. In any of these situations, such 
information will be relayed to the pilot champion, who will coordinate 
with the provider or clinical team responsible for the initial 
recommendation for participation to determine if that recommendation is 
still applicable. If the provider's or team's medical judgment changes, 
based on this or any other information, such that they no longer 
recommend the veteran's participation, that decision would be a 
clinical decision appealable under VHA Directive 1041. If the SDO 
determines it will not or cannot provide the canine training for other 
reasons, such as limited resources or other constraints, the SDO and VA 
will attempt to ensure that eligible veterans who have been recommended 
for participation are able to do so at a later time. Participation will 
generally be granted on a first-come, first-served basis.

Signing Authority

    Denis McDonough, Secretary of Veterans Affairs, approved this 
document on March 23, 2022 and authorized the undersigned to sign and 
submit the document to the Office of the Federal Register for 
publication electronically as an official document of the Department of 
Veterans Affairs.

Luvenia Potts,
Regulation Development Coordinator, Office of Regulation Policy & 
Management, Office of General Counsel, Department of Veterans Affairs.
[FR Doc. 2022-06735 Filed 3-29-22; 8:45 am]
BILLING CODE 8320-01-P