Nine Ways to Improve the Health and Well-Being of America's Military and Veteran Caregivers

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There are 105.6 million caregivers in the United States today, of whom 14.3 million (14 percent) are caring for wounded, ill, or injured service members or veterans. These military and veteran caregivers bear tremendous responsibility: They help those they care for with eating, bathing, memory, mood management, medication administration, and other tasks. If the time they spent caregiving commanded a wage, it would total well over $100 billion.

Since RAND's original research on military and veteran caregivers was released in 2014, much has changed. Policies were enacted to better support military and veteran caregivers, new caregiver programs and activities were launched or strengthened, and necessary research and evaluation studies provided insights into this community and the programs designed to support them. Other changes, such as those listed in Figure 1, also may have altered military and veteran caregivers’ experiences.

These changes called for a new, national examination of military and veteran caregivers. With support from the Elizabeth Dole Foundation, RAND researchers undertook such an examination. Their analysis suggested nine ways to better support America's military and veteran caregivers—our hidden heroes—in emerging from the shadows.

• Aging of the veteran population
• Troop withdrawal from Afghanistan
• Awareness about service member exposure to environmental toxins
• Legal advances for lesbian, gay, bisexual, transgender, queer, and other sexual and gender minority veterans and service members
• Coronavirus pandemic and associated lockdowns

1. Increase access to mental health and substance use treatment for caregivers and their children.

Military and veteran caregivers have unmet mental health needs (Figure 2). Thirty-six percent of military/veteran caregivers to those 60 or under wanted mental health treatment in the past year but did not receive it. Some were concerned about cost, but most reported that they "didn’t have time for treatment" or were "concerned about hospitalization or taking medications."

Twenty-seven percent of military and veteran caregivers were also raising a child. Of these children, 39 percent helped with at least one caregiving task. These caregiving children had higher levels of emotional and conduct problems than non-caregiving youth; 24 percent of parents with caregiving youth reported that they wanted mental health care for their kids, but their kids did not receive it.

Those seeking to support the mental health needs of military/veteran caregivers should explore novel mental health care delivery models, such as delivering services during nontraditional hours, telehealth, asynchronous counseling, mobile health apps, task shifting, and Collaborative Care (which integrates evidence-based mental health care into primary care), to help fulfill the unmet mental health needs of caregivers and their children.

2. Increase opportunities for caregivers to access available financial support, and offer additional financial compensation to caregivers for the work they perform.

Military and veteran caregivers annually incur an average of $8,583 in out-of-pocket costs and forgo an average of $4,522 in household income. This disproportionately affects military/veteran caregivers with incomes near or below the federal poverty level (see Figure 3). Forty-four percent of military and veteran caregivers to those 60 or under are food insecure (Figure 4).

Organizations that serve caregivers should inform them about programs that provide financial assistance and help them apply for those programs. Policymakers should continue to explore tax credit options for caregivers akin to the 2021 expansion of the Child Tax Credit. This tax credit is estimated to have raised millions of Americans out of poverty.

• Military/veteran caregiver households with incomes at or above 130 percent of the federal poverty level: 65 percent
• Military/veteran caregiver households with incomes below 130 percent of the federal poverty level: 35 percent

• 40 percent of military and veteran caregivers to those 60 and under are food-insecure
• 25 percent of these food-insecure caregivers participate in the Supplemental Nutrition Assistance Program

3. Tailor caregiver support programs to reflect caregivers' diverse preferences and needs.

Military and veteran caregivers are a diverse group. One way to see that diversity is to compare those who are caring for someone 60 or younger with those caring for someone over 60. A greater proportion of those caring for service members and veterans 60 and under are men (47 percent versus 42 percent), under age 35 (49 percent versus 28 percent), and in the workforce (58 percent versus 46 percent). Those for whom they are caring also differ: More care recipients 60 or under are women (42 percent versus 18 percent), served in the post-9/11 era (41 percent versus 2 percent), and have been diagnosed with a substance use disorder or mental health condition (62 percent versus 40 percent). Figure 5 brings together these two groups to underscore the importance of diversity in developing support programs.

To better serve all military and veteran caregivers, policies and programs should tailor outreach, program offerings, and the ways in which they deliver services. Suggestions include the following:

• Use inclusive language to attract all caregivers, including those who may currently be underserved (male caregivers, other relatives) and those who do not identify as caregivers.
• Provide activities that caregivers can do with the care recipient, particularly those caring for individuals 60 or under, and provide activities to help keep care recipients over 60 safe at home.
• Offer a mix of online and in-person support. More military/veteran caregivers to those 60 or under participated in in-person support groups (30 percent) than online groups (15 percent).

4. Expand and promote home health care considering how caregivers will be affected.

Fifty-three percent of military/veteran caregivers told the RAND team that they had relied on home health care in the past two years to help care for the service member or veteran. Those who used this assistance were less likely to meet criteria for excessive caregiver burden. While these results are promising, using home health care may create additional tasks, such as coordinating and training health care workers.

Caregivers can also incur out-of-pocket costs associated with providing care in the home, and managing home health care staff can create new work disruptions for caregivers.

Expansion of home health care should be done while considering caregivers' needs. Residential options should be available to those care recipients for whom such placement is safer.

5. Focus programmatic and social support within the context of local conditions in which military/veteran caregivers live.

The locations where caregivers live affect the resources and supports available to them. On average, military and veteran caregivers live in communities in which 11 percent of households have incomes below the federal poverty level (versus 9 percent among non-caregivers) and 4 percent of adults are unemployed (versus 3 percent among non-caregivers). Military and veteran caregivers are also more likely to live in neighborhoods with fewer resources than non-caregivers, as measured by the Child Opportunity Index.

Policies and interventions that target local resources, such as housing, food access, or economic conditions, for low-resourced communities generally hold promise to ultimately improve military and veteran caregivers’ health and well-being.

6. Encourage health care systems to better integrate caregivers into health care teams.

Most military and veteran caregivers do not feel integrated into health care teams (see Figure 6). Thirty-nine percent of military and veteran caregivers reported having experienced a hassle in health care, such as needing to remind staff to do things for the care recipient (18 percent), delays in paperwork (17 percent), or feeling that health care staff treated them rudely (14 percent). Among military and veteran caregivers who experienced any hassles, 20 percent reported that it was due to their age; this was more commonly felt among younger caregivers than older caregivers.

Researchers should document the value (i.e., improved patient outcomes, cost savings) of integrating caregivers into health care environments and teams. Policymakers should continue to explore mechanisms—such as creating new Medicare Current Procedural Terminology codes for caregivers—to incentivize providers to integrate caregivers into the care they provide.

7. Promote work environments that are supportive of caregivers.

Around one-half of military and veteran caregivers are working. Many who work experience significant work disruptions (Figure 7). RAND researchers found that caregivers who experience a work disruption forgo about $11,168 in household income per year. Working caregivers who do not experience work disruptions forgo much less income, though still a significant amount ($2,016 per year). Workplace accommodations could help working caregivers avoid these disruptions, but, unfortunately, many military and veteran caregivers do not benefit from them. While many can take paid sick days (69 percent) and unpaid family leave (58 percent), one-half or fewer are afforded flexible work schedules, telecommuting options, paid family leave, a compressed work week, or an employee assistance program.

Such accommodations could keep caregivers employed, minimize work disruptions, and ultimately keep money in caregivers' pockets.

8. Continue to conduct rigorous evaluations of those initiatives designed to support military and veteran caregivers.

Many military and veteran caregivers are using support services (see Figure 8). However, between one-third and one-half of those who participate in these programs still meet criteria for excessive caregiver burden. Evaluation is key to ensuring that programs are achieving their intended outcomes and are worth the resources and time that caregivers devote to participating in them.

9. Continue to conduct research that fully captures the breadth of caregiving and those who serve as caregivers.

There are multiple avenues for future in-depth research on military and veteran caregivers. Two are priorities. First, the RAND team employed a task-oriented approach for identifying caregivers, rather than relying on them to self-identify as caregivers (see the box). This approach identified many more people as caregivers than in previous research, and future research should continue to explore what constitutes caregiving and who is a caregiver. The second research priority, which builds on the first, is the need for research to fully capture the experiences of caregivers to individuals with substance use disorders, mental health conditions, neurological conditions, and traumatic brain injuries. Caregiving to individuals with these conditions may require caregivers to perform tasks that are not fully captured in the activities of daily living and the instrumental activities of daily living (the measures most used to measure caregiving duties). Fully capturing these tasks will better position efforts to support these caregivers through program development and public policy.

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Topics

• Long-Term Care
• Military Caregivers
• Military Families
• Posttraumatic Stress Disorder
• Traumatic Brain Injury