Public Comments for 01/05/2023 Regional Public Hearing on the Governor's Proposed Amendments to the 2022-2024 Biennium Budget; Virtual Public Hearing - Central Virginia
The James River Association appreciates and supports the historic levels of clean water funding included in the Governor’s proposed amendments to the biennial budget for 2023 and 2024. These are a significant first step towards adequately prioritizing our natural resources and helping Virginians become more resilient in the face of climate change. With historic investments proposed in wastewater funding, we are optimistic that these dollars will make a tangible difference in Virginia’s efforts to restore our waterways, provide access to cleaner drinking water, and bolster our ability to achieve our Chesapeake Bay goals. Additionally, the proposed support for agricultural best management practices across the state is key to making the necessary improvements in this sector that are essential to staying the course for 2025 and beyond. Despite these transformative commitments, more work is needed to ensure a resilient future for Virginians. We urge you to consider an amendment to the budget that would allocate necessary monies for the Stormwater Local Assistance Fund; the SLAF is a critical vehicle to invest in pollution reduction projects and help localities meet their local water quality needs on time, and as such should not be cast aside as we forecast increasing, and routinely destructive rainfall events.
Invest in increasing teacher and staff pay. Fully fund the revised SOQs. Fund support services: before and after school care, free lunch, mental health services, etc Improve staff to student ratios for school nurses, guidance counselors, ESL, Special Ed. Don’t divert money to private schools!
I’ve worked with the elderly for five years as Assistant Director of Adult Care Center of Central Virginia, caring for older and/or disabled adults (most with dementia) during the day, providing their caregivers respite and the opportunity to continue in the workforce. That organization recently closed, and I’m now working with our local area agency on aging, Central Virginia Alliance for Community Living (CVACL). I’ve seen firsthand how difficult it can be for our seniors to get the assistance they need to remain in their homes. The current funding plan will make it even more difficult. While Virginia’s total population is expected to grow 22% by 2050 (1.9 million) our senior population, age 60 and over, will double over the same period… growing from 20% of the Commonwealth’s population in 2020 to 31% in 2050. Virginia’s most at-risk and vulnerable population, those 85 and older will more than quadruple by 2050 (157,882 in 2020 to 653,049 in 2050). The Area Agencies on Aging, like CVACL, serve every locality in Virginia helping older Virginians stay in their homes as they age. The costs of these AAA services are supported by a combination of federal, state, local, and private dollars. Not only is staying in their homes preferred by older Virginians it is the most cost-effective use of resources. The most recent Genworth Financial cost of care study can be found at https://www.genworth.com/aging-and-you/finances/cost-of-care.html. Virginia’s 25 Area Agencies on Aging are your front line in supporting our older residents who want to remain in their homes or the homes of family members. The AAA Network faces a dilemma in 2023 and requests $700,000 in supplemental funding to prevent negative impacts based on a federally-required reallocation of funding among the 25 AAAs. Without these funds, as was provided in past cycles, this once-each-decade reallocation of federal and state funds will cause uneven disruptions in services across the Commonwealth. As funds are shifted to areas where demands have grown the fastest, they will be shifted from other areas. Funds taken from a region means service reductions – a senior receiving services (meals, in-home care, etc.) on June 30, 2023, will be at risk of not being served after July 1. This includes the Central Virginia region. State supplemental funding will be essential to keep basic services in place in some regions of the Commonwealth as funds are redistributed according to the mandated formula revisions. Area Agencies on Aging serve tens of thousands of Virginians each year with healthy meals, community services, services addressing social determinants, transportation and other essential supports that protect against health declines, hospitalization, and placement in nursing homes and other congregate settings. For example, AAAs provide in-home services that avoid or postpone the need for more costly institutional placements. In 2020, prior to the pandemic, the known unmet need for in-home care (personal care, homemaker, and chore services) was over 1,800 individuals. Although the required redistribution will help 14 AAAs meet their growing needs, without $700,000 in supplemental funding, 11 AAAs will be eliminating services to seniors being served today. Please help us with continue to serve and support these vulnerable constituents in your jurisdiction and across the Commonwealth. Thank you for your consideration, Margaret McCanna
We are entering a period of mass extinctions worldwide. Virginia has a responsibility to do everything possible to protect our wildlife, particularly the endangered and threatened species. Corridors which allow these animals to move between undeveloped land is crucial.
The attachment contains my comments on Gov. Youngkin's Budget Amendment Proposals with regard to K-12 School Funding.
Hello everyone my name is Pastor Eric Cottrel and I live in Danville county. I'm a waver. Please support the additional 500 waivers.Its very crucial to have these waiver slots because people with intellectual and developmental disabilities need to be able to live on their own with supports and be able to work in the community and be able to make their own money in their community. People with intellectual and developmental disabilities should be allowed to attend virtual public meetings because it allows them to be engaged in issues and concerns that the person might have when listening or speaking. Please remove the handicapped word for people with intellectual and developmental disabilities because its a very hurtful word and people with intellectual and developmental disabilities want to be treated just like everyone else.
I live in the Sherando area on the edge of the George Washington National Forest at the base of the Blue Ridge. I am here to ask for funding for Wildlife Corridors in Virginia. The forests on either side of Skyline Drive and the Blue Ridge Parkway form a natural corridor that runs the entire length of Virginia but without crossings over or under the few roads that cross the mountains, it can not be used by the wildlife as a corridor. When I travel north to 64 and head over the mountain I access 64 at exit 96, Waynesboro. From that exit to the next, Rockfish Gap or the Afton exit which is approximately 5 miles between 2015 AND 2017 there were 17 deer and bear collisions. If you expand that area out, to include the towns around route 64 like Waynesboro and surrounding areas on either side the collision rate for the same period jumps to 78. This does not include fox, turtles or other wildlife. My guess is that the animals bump into 64 then those that can not find a way over or under, go further out trying to find a way around the highway and of course there is no way to go around so, they cross more roads. Recently when walking down Mt Torrey Road toward Coal Road to take a hike I passed a dead deer and a fox on the edge of the road. I am sure that there are many incidents with wildlife that go unreported such as these. The number of roads crossing the mountains North to South are relatively few based on the length of the state of Virginia. I ask that the next budget includes at least $5 million to be allocated to crossing implementation so that we can make the beautiful Blue Ridge an actual corridor. It IS a natural corridor which our roads have interfered with. VDot had proven that corridors work and are financially effective. Using simple inexpensive fencing leading to wildlife culverts under highways they have decreased collisions with wildlife by 92% in their experimental site and the savings exceeded the cost of implementation in less than 2 years. Please help protect our wildlife by funding the corridor project.
Hello everyone my name is Katerine Olson and i live in Chesterfield county . Im on a waver . im here today on behalf of people with intellectual and developmental disabilities. Please support the additional 500 waivers.Its very crucial to have these waiver slots because people with intellectual and developmental disabilities need to be able to live on their own with supports and be able to work in the community and be able to make their own money in their community. People with intellectual and developmental disabilities should be allowed to attend virtual public meetings because it allows them to be engaged in issues and concerns that the person might have when listening or speaking. please remove the handicapped word for people with intellectual and developmental disabilities because its a very hurtful word and people with intellectual and developmental disabilities want to be treated just like everyone else Please support the peer mentor rates. Because people with intellectual and developmental disabilities need to be paid equally.
I feel strongly that now is the time to increase funding for wildlife crossing corridors in Virginia's transportation system, allowing for the safe movement and migration of wildlife across our State's landscape and waterways. Virginia is a vital avenue for species adjusting their ranges and seeking refuge in a rapidly changing climate; indeed, a map published by the Nature Conservancy shows the Central Appalachians as perhaps the most highly concentrated migration corridor in North America, and areas of the Piedmont and Coastal Plain are also hot spots for biodiversity protection. Through my work as a member of the Albemarle County/Charlottesville-based environmental group Cville100, I am aware of decades-old efforts to improve habitat connectivity between the Piedmont areas of our region and the Blue Ridge Mountains, and with the opportunity to leverage project funding through the Federal Inflation Reduction Act, now is the optimal time from both biological and fiscal standpoints to fully fund wildlife-crossing corridors. Species and wildlife numbers are declining at an incredible rate throughout the world in the face of habitat-loss and climate-change impacts; my religious understanding instructs me that the Lord instructs us to steward the Creation with love and care to the best of our abilities. On a personal note, I have witnessed a deer having a major part of its right hindquarters torn off by a van on I-64 between Crozet and Charlottesville, and I wish that that kind of suffering and death to wildlife, and danger to motorists, be avoided to the maximum extent possible. Sincerely, Peter Gates
5 points on areas needed to be fully funded for PK-12 public education
These services have really made a difference in my life. Well to start off my accident took place on the last day of my sophomore year of High School. What happened was, me and some friends were wrestling. Oh I almost forgot to mention that my accident didn’t happen on school grounds nor did it happen during school hours. To pick up where I left off, one guy had me in this wrestling move called the sleeper-hold when all of a sudden my eyes started blinking fast. One of my friends said “hold-up man his eyes are blinking really fast, let him go.” When he did I fell hitting my head on the black-top. From the scene of my accident the ambulance took me to MCV Hospital where I spent the next few weeks comatose. When I started coming out of my coma I was then moved to Children’s Hospital where I spent the next 6 to 8 months receiving rehabilitative services. From there I returned to high school where I then earned my High School Diploma. One day when I was between jobs my mother came home from work with an article about The Mill House, someone left on her desk while she was on lunch break. When she got home from work that afternoon, she showed it to me, and asked if I was interested. The rest is as they say history. Since I started coming to The Mill House it has given me a reason to wake up and know that I have somewhere to go that will keep me out of trouble. I have also made all sorts of new, amazing, wonderful friends, who I like to think of as family. With additional funding it would continue to help a lot of people such as me have somewhere to go.
My name is Rebecca Hart and I got my brain injury while riding a four wheeler on the beach. I wasn’t wearing a helmet and the vehicle crashed on top of me and hit my head causing my brain injury. It helps me to be around other people who have been through similar brain injuries. I especially enjoy being around staff who are knowledgeable about brain injuries. This is m why it is important to have services available. Oftentimes, people dismiss my brain injury, and invalidate the trauma I went through. Going to the Mill House, it gives me purpose. My outlook on life was dim, to say the least, and now I’m bright and sunny. I think it’s important that people understand the severity of a brain injury. It’s not just a bump on the head.
Hello, My name is Alfred Fields III, a brain injury survivor, and a member of the Mill House. A little over three years ago, I was found unconscious on the living room floor after reaching the peak of an aggressive viral infection. I was unable to walk and had appointments with a Neuro physical therapist, ocular therapist, neurologist, and speech therapist. My speech therapist told me about the Mill House. At the Mill House, I participate in two units; the Kitchen Unit and the Communications Unit. In the Kitchen Unit, I assist the team with lunch preparation and kitchen cleanup tasks. In the Communication Unit, I perform business tasks, such as reception, member time entry, and other data entry tasks and overall running of the Mill House. I’ve also become a member of the QA Committee for IBICA. Through the Mill House I've become more social in and out of the clubhouse, reaching personal goals, and getting a new part time job at Staples. I really enjoy the time I spend at the Mill House, activities with community brain injury service, brain injury association of Virginia, and IBICA. We are asking for funding for a housing assistance position to help our population find safe housing. We are not under medical waivers and have a harder time finding a place to live than most others in need. This community is also looking for services to be expanded to reach areas of the state that lack access to aid , both physically and mentally. We could all benefit from having greater accessibility to people and services that could help improve our quality of life.
Good morning, My name is Grace Feazelle. I am a member of Our Voices and live in my own apartment independently with support paid by my Medicaid Waiver in the city of Chesapeake. My State Delegate is Barry Knight and my Senator is Lionell Spruill. I would like to express the importance of increasing the Medicaid Reimbursement rates to pay caregivers a higher wage. A lot of caregivers have to have more than one job or leave for higher paying ones. When they find higher paying jobs it usually means they leave the caregiving field completely. Without proper wages there are no caregivers to assist us in our own homes. Without caregivers we cannot have good care or services. We want to live in our own homes and not have to move to nursing or group homes in order to receive care. Please, approve budgets for higher Medicaid reimbursement rates in order to pay caregivers a better wage. Thank you for your time . Please also support the Arc of VA' s DD System Transformation Agenda
make sure you supportour arc of va action plan!!!! thnks!!!! been through stuffs like health scares stil no jobs but hey sitll doign ok soo thtts coool!! KUST PLEASE SUPPORT ARC OF VA ACTION PLAN!
Dear VA Legislative Body, Please add support for Wildlife Corridor. There isn't a day goes by on our roads that we see where an animal has suffered the fate of vehicular accident. We humans continue to shrink wild areas for animals to live and thrive, the building of a wildlife corridor would protect both humans and mankind from many collisions. A corridor will also allow the wildlife a safer way to cross over into their normal habitats. We also understand there are federal funds available to help VA build this wildlife corridor. A conservative number to add to the budget would be $5Million. Let's take care of both our Virginians and our wildlife.
The Dahlgren Railroad Heritage Trail: an addition to Caledon State Park. The Dahlgren Junction Line was constructed in 1942 by the US Navy to bring munitions and supplies to the Navy Base at Dahlgren. In 2006 the eastern section of the rail line, having been abandoned for rail use and coming into private hands, was turned into a trail for recreation and commuting. An active Friends group maintains the trail. The goal has always been to have it become a part of Caledon State Park; this goal is supported by the county. Last fall, the Dept of Conservation and Recreation (DCR) completed a study to determine whether the trail is suitable to become part of Caledon. The public input was supportive, and there were several visits by DCR personnel to the trail. The conclusion of the study was that the trail is suitable to become part of Caledon. We propose that an initial acquisition and minimum improvements be accomplished first, followed by public involvement in writing a new Master Plan for Caledon. The master plan process will give the public a chance to weigh in on what further improvements they would like to see. This initial cost would be $3.1M based on the cost estimates in the study. We would like to see a budget amendment to acquire the trail and incorporate it into the state park system as an addition to Caledon in the amount of $3.1M. The above-mentioned suitability study is found at: https://rga.lis.virginia.gov/Published/2022/RD541 Jim Lynch, President, Friends of DRHT, firstname.lastname@example.org
Please fund the EV rebate program. I bought a plug in hybrid in 2019 and an EV in 2022. I had to go to Maryland for both of these. Fund the rebate program to give dealers an even chance to get EVs to sell and for the approximately 50% of consumers who are interested in an EV. Now that I have an EV I am happy knowing I am not contributing to air pollution with tailpipe emissions.
Erica Wood 2318 N Trenton Street Arlington VA 22207 Ericawood2318@gmail.com Re: Funding for Nursing Home Staffing Standards January 4. 2023 Members of the House Appropriations and Senate Finance and Appropriations Committees: I am writing on behalf of the Northern Virginia Aging Network, which in its 2023 Legislative Platform urges the General Assembly to enact minimum hourly nursing home staffing levels per resident per day. NVAN states that such standards must be supported by a dedicated funding source linked to the salaries and benefits of nurses and nurse aides. I also note that the Commonwealth Council on Aging 2023 legislative recommendations include strengthening staffing and licensure requirements for Virginia nursing homes. https://sharepoint.wwrc.net/vdaBoards/council/_layouts/15/WopiFrame.aspx?sourcedoc=%7BEF4206BD-E3CB-46A6-BED5-A12137CDB082%7D&file=Annual%20Report%202022.pdf&action=default The 2021 Joint Commission on Health Care report on workforce challenges in the state’s nursing homes found that Virginia has more facilities with low staffing ratings than other states, with 43% of certified facilities receiving only a one or two star CMS staffing rating. Many studies over the past 20 years have shown that low staffing increases the risk of low quality care. Moreover, the JCHC said low staffing disproportionately affects facilities with low income residents, often residents of color. Virginia is one of only 12 states without a staffing standard. The budget committees should allocate sufficient funds to support nursing home staffing standards, as well as enforcement of such standards, in the full range of Virginia facilities – in order to directly improve the quality of care and quality of life of vulnerable residents. Sincerely Erica Wood NVAN member and elder advocate Ericawood2318@gmail.com
* Right now, there are about a dozen electric vehicles available for less than $40,000, which was the average price of an automobile in 2021. But the technology is out of reach for LMI communities that would benefit the most from the longer term cost savings of going electric as well as cleaner air. Yet no money has been designated to fund the EV rebate program that the General Assembly passed two sessions ago. Youngkin’s budget should set aside $10 million for the program, which is a fraction of the hundreds of millions of dollars that have been proposed to develop megasites that are intended to serve as carrots for economic development. Such development will inevitably spur more vehicle traffic, which could be powered by clean energy rather than dirty, more expensive fossil fuel. * The proposed state budget designates $10 million for the Virginia Power Innovation Fund. However, $5 million of this pot of money would be used to study the use of small modular nuclear reactors, which is an unproven technology that doesn’t address what happens to the waste. Other funds are allocated to carbon capture technology, which has been under development for decades but is still considered to be expensive and difficult to scale. Instead, 100 percent of this money should go towards battery storage (which enables the broader use of renewable energy that is already cheaper and scalable as well as supports a more sustainable model for transportation electrification), preserving wetlands and grasslands as carbon sinks (which could increase the amount of carbon taken from our atmosphere in the shortest space of time), and recapturing methane that is leaking from abandoned underground mine. * Also, the proposed budget reduces from $208.1 million to $76.3 million the money set aside for the Congestion Reduction and Air Quality program in FY 2024. The program uses federal dollars to fund projects that reduce emissions from transportation-related sources. It is a key funding mechanism to help urban areas meet air quality goals and support investments that encourage alternatives to driving alone. For example, state agencies and local governments in current or former specific air quality non-attainment, ozone attainment and/or maintenance areas may be reimbursed for incremental costs to transition to alternative fuels such as electricity
My name is William Way and I am a Commissioner with Arlington County’s Commission on Aging. In my community and statewide, the population of older adults is growing, and we must do more to support older adults and their caregivers. In Virginia the population of adults aged 60 and older is expected to double by 2050, increasing to 31% of the population. Virginia’s most at-risk and vulnerable population, those 85 and older, will more than quadruple by 2050 (157,882 in 2020 to 653,049 in 2050). The population is growing astronomically, but the funding and resources to support this population have lagged. Virginia’s 25 Area Agencies on Aging serve every locality in Virginia and are our front line in supporting our older residents who want to remain in their homes or the homes of family members in the community. Not only is staying in their homes preferred by older Virginians, but it is also the most cost-effective use of resources, far less expensive than nursing home or hospitalizations. Keeping older Virginians in their homes also helps our local economies and businesses. Area Agencies on Aging serve tens of thousands of Virginians each year with healthy meals, community services, services addressing social determinants of health, transportation, home health services, caregiver supports and other essential supports that protect against hospitalization, and placement in nursing homes. In 2022, the Arlington AAA served more than 2,300 older adults with over 200,000 units of service delivered through 20 distinct programs. The costs of AAA services are supported by a combination of federal, state, local, and private dollars. The allocation of federal and state funds to each of the 25 Area Agencies on Aging is determined by a funding formula that is administered by the Department of Aging and Rehabilitative Services. Due to changes in the funding formula, the Virginia AAA network faces a bureaucratic dilemma in 2023; a gap of $700,000 in funding. This gap in funding to provide vital services is largely attributable to a federally required update to the funding formula. State supplemental funding will be essential to keep essential home and community-based services in place in certain regions of the Commonwealth as funds are redistributed according to the mandated formula revisions. Without these funds this reallocation of federal and state funds will cause uneven disruptions in services in Arlington and across the Commonwealth. Funds taken from a region means service reductions, specifically, an older adult receiving services on June 30, 2023, will be at risk of not being served after July 1. Although the required redistribution will help 14 AAAs meet their growing needs, without Supplemental Funding, 11 AAAs across the Commonwealth will be eliminating services to older adults being served today. In Arlington, the impact of the proposed funding formula will result in an 8 percent reduction in federal and state funding. The reduction in funds translates into fewer meals delivered to older adults who are homebound, fewer in-home hours of personal care, less outreach and support to caregivers, and fewer transportation trips to get to and from the grocery store or to pick up medications. Virginia’s AAAs are vital resources to local communities, older adults, persons with disabilities and their caregivers. I urge you to provide $700,000 in supplemental funding and support to help us do this essential work.
Hello, Integrity Home Care LLC, would like to stress the importance to increase rate reimbursement rate for personal care agencies to allow competitive pay. Integrity Home Care LLC is struggling with shortage of staff because personal care applicants refuse to work for $12.00 an hour. Applicants for PCA position demand pay rate at $15.00- $17.00 per hour. When Integrity Home Care advertises on zip recruiter or other platforms potential applicants are calling Integrity Home Care to accuse agency of exploiting people by paying them minimum wage when fast food restaurants are paying more stating that the work that personal care aide performs require way more responsibilities than making a burger and must be reimbursed at $15-$17.00/hr rate. With current Medicaid reimbursement rate of $18.22/unit Integrity Home Care is unable to provide that pay rate to the new employees. Please consider increasing Medicaid reimbursement rate to $30.00 per unit to allow home care providers to pay competitively to personal care aides and be able to continue to run Home Care business. Thank you for considering, Yuliya Kvitko, RN
My name is Dr. William Sroufe, and I am the Superintendent for Colonial Heights Public Schools, I support the extension of reading specialists to four and fifth grades, math specialists, and paying to help teachers qualify to teach dual enrollment in the Governor’s budget. I would also like to see completing the removal of the support cap. Thank you.
Members of the House Appropriations and Senate Finance and Appropriations Committees: The Northern Virginia Aging Network (NVAN) 2023 General Assembly Priorities includes the following: Enact minimum hourly nursing home staffing levels per resident per day for nurses and nurse aides, along with acuity measures, supported by a dedicated funding source. It is time that Virginia, one of only 12 states without staffing standards, adopts nursing home staffing standards. Staffing standards are necessary to improve the quality of care in Virginia nursing homes. Numerous national studies over 20 years show a strong relationship between the number of direct care nursing home staff and the quality of care/quality of life of residents. Ongoing staffing shortages increase the risk of low quality care and disproportionately affect facilities with low-income and Black residents. Currently, there are two different nursing home staffing models: acuity and minimum hourly requirements. The Joint Commission on Health Care in its 2021 study recommended the acuity model. The minimum hourly model recommends 4.1 hours of resident care per day, which can be achieved by phasing in the increased number of hours. Implementation of any Virginia nursing home staffing standards requires funding support for nursing homes through General Funds, matched with Medicaid dollars, as well as other possible sources. Any dedicated funding must be linked directly to salaries/benefits nurses and nurse aides. The pandemic exacerbated the need for nursing home staffing standards in Virginia and brought it to the attention of the public. I ask the House Appropriations and Senate Finance and Appropriations Committees to find the money for passage of nursing home staffing standards this year. Joan McDermott NVAN Member 3601 N. Kensington St. Arlington VA 22207 703-536-9289 email@example.com
good morring my name is Paul Marretti , i am with arc of virginia self avavocey group. i know all of you that has supported special olympics virginia thur years. but please support the arc of virginia as and if you can please try and come to our aunnual confrence at the end of july/ aug and we can show all what people with disabitys are doing in commuinty
My name Michael Lundberg and I come to you today as a citizen of New Kent County, an advocate for Virginia’s critically important rivers and supporter of the Chesapeake Bay Foundation. Since I was 8 years, old I’ve lived along the Chesapeake Bay, Chickahominy River and Diascund Creek. I spent a lot of time on rivers and creeks swimming, skiing, fishing, enjoying fresh seafood and just exploring. I’ve seen blue crabs, oysters, mollusks, water grasses, Blue Herons, and many other flora and fauna thrive. Sadly, some are now under great pressure from development and other sources. We applaud Governor Youngkin’s proposed budget amendments supporting practical efforts to improve Virginia’s wastewater treatment plants and agricultural cost-sharing to help farmers to adopt important conservation practices including forested buffers, fencing livestock from streams, cover crops, and other practices. From the Chesapeake Bay, a blue crab stock assessment is a needed tool to help ensure an increase in a healthy blue crab population in the future. Likewise, support for Virginia fisheries will help ensure the availability of fresh and healthy seafood. We don’t have to look far to recognize the importance of improving these areas of our environment. Virginia waterways, including the Chesapeake Bay, are among the state’s most precious resources, providing recreation opportunities drinking water and many jobs. Thank you for your support of these measures. Michael T. Lundberg 651 Colony Trail Lanexa, VA 23089 804 690 6098
PLEASE SUPORT THE AR COF VA PLAN OK???? I NEED HELP I HAVE BEEN THROUGH LOTS OF HEALTH SCARES!!!! STILL WITHOUT A JOB OTHER THEN BEING A COOL ARC CLUB ADOVCATE BUT ANYWAYS PLEASE SUPPROT THE ARC OF VA PLAN!!!~!
With increased minimum wage and increased inflation, increasing the medicaid Reimbursement rates for long-term care services by only 5% in July is simply not sufficient for hard working caregivers.