Masthead header

Caregiver setting up weekly medications

Note: the following discussion is in no way related to receiving home health care, unskilled or skilled, by VHA, Veterans Health Administration. This is a discussion on Aid and Attendance as it relates to benefits, VBA, Veterans Benefits Administration.

There is not a VA disability benefit that is specifically aid and attendance. Aid and attendance are part of additional ratings above 100 per cent compensation. Ratings above 100 per cent compensation are known as Special Monthly Compensation, SMC. The amount of aid and attendance awarded in SMC depends on the documented need of the veteran.

The SMC schedule has 11 different levels, all the levels are letters, such as L, L1/2, M, M1/2, N, N1/2, O/P, R.1, R.2, S, and T. The compensation goes up accordingly. The highest compensation rating is R2. To be rated R2 the veteran must be in need of regular aid and attendance and, additionally, in the need of personal health-care services provided on a daily basis in the veteran’s home by a person who is licensed to provide such services or who provides services under the regular supervision of a licensed health-care professional. The difference between R1 and R2: R1 the veteran requires, unskilled, regular aid and attendance. R2 the veteran requires the R1 criteria and skilled care in the home without otherwise the veteran would need to be in a long-term care facility.

Aid and Attendance is a medical rating and additional amounts of money available with all VA disability income benefit levels to help individuals receiving these benefits cope with the added burden of helplessness. The additional amounts of money require a Rating Veterans Service Officer in the Regional Office to establish the need and issue a rating. A Rating Veterans Service Officer is an employee with the Veterans Benefits Administration.

Criteria for the Need for Aid and Attendance

38 CFR 3.352 Criteria for determining need for aid and attendance and “permanently bedridden”.  

(a) Basic criteria for regular aid and attendance and permanently bedridden. The following will be accorded consideration in determining the need for regular aid and attendance, 3.351(c)(3)

  • inability of veteran to dress or undress himself (herself), or to keep himself (herself) ordinarily clean and presentable
  • frequent need of adjustment of any special prosthetic or orthopedic appliances which by reason of the particular disability cannot be done without aid (this will not include the adjustment of appliances which normal persons would be unable to adjust without aid, such as supports, belts, lacing at the back, etc)
  • inability of veteran to feed himself (herself) through loss of coordination of upper extremities or through extreme weakness
  • inability to attend to the wants of nature
  • or incapacity, physical or mental, which requires care and assistance on a regular basis to protect the veteran from hazards or dangers incident to his or her daily environment
  • “Bedridden” will be a proper basis for the determination (need for aid and attendance). For the purpose of this paragraph “bedridden” will be that condition which, through its essential character, actually requires that the claimant remain in bed. The fact that claimant has voluntarily taken to bed or that a physician has prescribed rest in bed for the greater or lesser part of the day to promote convalescence or cure will not suffice.

A veteran does not need to require all of the above for a favorable rating for SMC. The veterans condition, along with the functions the veteran is unable to perform, are all taken in to consideration. The bar to meet is that the veteran is experiencing a level of helplessness to need regular aid and attendance. The need does not have to be a constant one but must need regular assistance.

(c) Attendance by a relative. The performance of the necessary aid and attendance service by a relative of the beneficiary or other member of his or her household will not prevent the granting of the additional allowance.

The following are regulations broken down in common language:

  • Assistance with bathing or showering
  • Assistance with toileting
  • Assistance with feeding (having a need to be fed by someone else)
  • Assistance with dressing or undressing
  • Assistance with transferring in or out of a bed or chair
  • Assistance with incontinence
  • Assistance with walking
  • Assistance with keeping oneself ordinarily clean and presentable, including hygiene issues
  • Assistance with frequent need of adjustment of special prosthetic or orthopedic devices which cannot be done without the aid of another person
  • Having an incapacity (physical or psychological/psychiatric) requiring care or assistance on a regular basis to protect the patient from hazards or dangers to his or her daily environment.

Again, the veteran does not need to meet all of the above criteria to be rated for aid and attendance. For a veteran with ALS meeting any of the above criteria is generally not difficult though it must be documented by a physician.

VA does not require a relative, or caregiver, be paid for services in order to receive aid and attendance compensation in the form of a SMC rating.


To be a caregiver is sometimes a choice, and sometimes not a choice. Sometimes being a caregiver is a gift, and sometimes being a caregiver is a painful experience. Sometimes the caregiver experience is all of this and more: a choice, not a choice, a gift, painful, joyful, heartwarming, satisfying, frustrating, and limiting.

On October 23, 1993, unbeknownst to me I would become a caregiver for the rest of my existence. On that day it never occurred to me that a new role was added to my life. All I knew was that my husband, Tom, was a very sick man on this day, and needed help, quickly. What we did not know but would soon learn is he had encephalitis. The encephalitis damaged his executive functioning ability and other, various parts of his brain.

All the things I knew about our life, our family’s future, and myself was flipped upside down on this day. Tom was 38 years old and I was 33. Our kids were 9 and 10 years old. Tom was our leader, he was the guy who loved us fiercely, protected us always, and worked harder than anyone I had ever known. How were we all going to survive this? It would be a few months before it dawned on me that we were surviving, and we were just surviving, because I was learning how to take the reins.

It would be 20 years before it occurred to me I was a caregiver. I had always thought of caregiving as something older people end up doing for their spouses. The first two decades of being a caregiver I did not have peer support. I did what I did because my family needed me to. Despite the sometimes-extreme difficulties I went back to work to help feed our family, to have healthcare benefits for us, to be on a forward trajectory that gives hope instead of mired in the muck of our lost man. Tom was with us but not with us in the way he was pre-brain infection. I finished my undergraduate degree, and earned two master’s degrees, all on a part-basis while I worked, raised my children, and cared for Tom. Faith and flexibility kept me in the game of our life, however, it was a while before I learned that this was key to success.

For a few months, when Tom was at his sickest, I was so overwhelmed with fear, and isolation that I nearly gave up on life. We had no income, his disability claim was denied, and he could barely get out of bed. It was winter in upstate New York. It snowed, and snowed, and snowed. The kids were out of school more days in January then in school. They were bouncing off the walls with boredom. Tom’s eyes were a mess and he wore sunglasses indoors because the sun reflecting on the snow was more than he could take. I hated it all. There was no relief in sight. I was more alone than I ever thought possible. Everything I had wanted to do for myself as the kids got older was permanently shelved. I was grieving hard and did not know it. I couldn’t see my faith through my tears and hurting heart, it felt gone yet it wasn’t. It was always there, and I know it because I am here today.

June of 2010 Tom was diagnosed with Amyotrophic Lateral Sclerosis, ALS. He is a Marine Corps veteran. ALS is a service connected disease. It is a devastating, fatal diagnosis. Even then, when Tom was diagnosed with ALS, I did not categorize myself as a caregiver. It would be three more years after the diagnosis, 2013, before a few younger caregivers of veterans pointed out that I was a caregiver, either way, with or without the label, Tom is still my husband, still the love of my life, and I would not have cared for him any differently if I had always thought of myself as a caregiver. Spouse first, caregiver second.

If I was sitting in a room with younger caregivers to impart the wisdom I have gained over the years I would say if you are faithful it will not leave you even if you feel you do not tend to it daily and it will carry you in the darkest of times. I would say embrace flexibility as a way of life, you will be less frustrated and stressed, it will carry you through some tough times. I would say to take care of yourself because if you do not chances are you will find later in life that some of your health issues are as a result of neglecting your own care. Self-care is health care. The better we take care of ourselves the more successfully we will care for our loved one.

Every now and then a good day, and some luck, comes our way. It wasn’t too hot or too sunny today. Tom ‘husbands’ his strength well. In preparation for painting en plein air this morning he physically did almost nothing the last two days. Though his muscles are now depleted of energy after the effort he was able to stand while painting this morning.

The last two photographs informed this painting. They could be taped together. The sky was split. The one of Tom while painting I took at the end just before he called it a day. The sky had changed up and the light was filtering down beautifully.

It’s important to add to this little piece that the fact that Tom can still stand is not a measure of God’s love for him or the level of care he receives. ALS is a bastard of a disease. It is a roll of the DNA dice how it manifests itself in someone. Some people have a fast, make your head spin, progression and a few are slower in progression like Tom, most are somewhere in the middle. The fact that Tom can still stand does not in anyway indicate how difficult the wasting is on his body – it’s exhausting. The truth of it is no one can control ALS.

What we can control is how we choose to live with the hand that is dealt to us. In this I follow Tom’s lead. He is the master of courageously facing this enemy day in, and day out. He relies on his faith to get him to get through. Intellectually, emotionally, and spiritually, he doesn’t give in, and he doesn’t give up.



From the day of diagnosis to May 1, 2018, this is how many days Amyotrophic Lateral Sclerosis, ALS, has been in our life. It is a lot of days. It is a long time. It feels like yesterday. It feels like time is on speed.

The journey to a definitive diagnosis was a long time in coming. It took years. It was fear filled. It was words we did not want to hear.

Fasiculations, muscle weakness and atrophy were, and are, daily reminders that this is a disease of epic proportions. Tom’s progression is slower than most accounting for the difficulty in diagnosing it. It was not a surprise that it was ALS. It took our breath away. It made me think of all of the days we had together. It made me scared of our future.

My dad used to say Tom and I were tied to the hip. It’s an old-fashioned kind of saying. It’s a true statement. It’s a poignant reminder of our mad love for each other.

We saw a number of specialists in search of a diagnosis. We traveled up and down the east coast, over a few years, seeking an answer to his ills. It was a mission. It was important to us to know what was wrong. It is a time I miss, a time of not knowing. It is ignorance is bliss.

After going through the tests, and the tests, and the tests, we saw one last neurologist. He kindly sat in front of Tom, making eye contact with just him, as if I was not in the room, and said he was sure Tom had ALS. That was it. The diagnosis became real and life changed. It was our new reality. It was all at once a relief to know and heartbreaking to hear.

We left the office hand in hand and went home. We didn’t cry, not then anyway. It would be a lie to say I didn’t cry later or don’t cry from time to time. It is a hard disease. It is a lot of days to live with it. It is a lot of days of waiting for the next part of his body to not work. It is a fact that crying is a useful release of pent up sadness.

Every day is not a sad day. Most days are good ones. Our love grows deeper, as it always has, when life has thrown us curve balls. This was the curvest ball we have had to field, ever. It is a beast. It will not destroy the tenderness we have for one another. It is fatal but it cannot kill our heart. It isn’t allowed.

May 1, 2018






Standing up for what you believe, that’s what I saw today when kids all across America participated in a walkout in solidarity for their 17 peers who were mercilessly gunned down in what should be a safe place for every young person.

Perhaps, over time, they can accomplish what adults seem incapable of fixing. Safe schools. It isn’t one problem that leads to violence in schools. It is multiple ones.

Their collective voices were heard today – if you disagree with them, you heard them – if you agree with them, you heard them. Peaceful disobedience is the very essence of what America was founded on. As a student of government, a teacher of government, as an American, I applaud them for taking a stand. #NationalWalkOutDay #NeverAgain