Veterans Affairs Committee on June 7th, 2012
A recording is available from Parliament.
On the agenda
- Nancy Murray Instructor, Case Management Program, McMaster University
- Joan Park President, National Case Management Network of Canada
- Ray Kokkonen National President, Canadian Peacekeeping Veterans Association
- Brigadier-General Retired) Joseph E. L. Gollner (Patron, Canadian Peacekeeping Veterans Association
- Colonel Retired) John Eggenberger (Vice-President, Research, Canadian Peacekeeping Veterans Association
The Chair Greg Kerr
I'll call the meeting to order. I know it's a challenging thing to do.
As I explained, we do have a vote pending. We will try to get the three presentations in before we go. It's a 30-minute bell. If the members are in agreement, we don't mind staying a few minutes into the bells to make sure we get the presentations. Then, we'll break for the bells, and we'll come back and we'll finish the question and answer session.
Welcome, on behalf of the committee. As you are well aware, we're studying transformation initiatives at Veterans Affairs. We're getting some good input, and we certainly welcome yours today. We have 10 minutes for each organization.
I think we're starting with McMaster University, Nancy Murray, with the case management program.
If you'd like to start now, please go ahead.
Nancy Murray Instructor, Case Management Program, McMaster University
Thank you, Mr. Kerr and the session organizers, for inviting me as a representative of McMaster University, Hamilton, Ontario, to briefly address today's topic on case management.
I would like to commend you on your study of transformation Initiatives at Veterans Affairs Canada, which includes your five themes—reducing complexity, overhauling service delivery, strengthening partnerships, sustaining the new Veterans Charter of October 2011, and adapting to changing demographics—all of which look as if they're very client-focused and will require the element of case management.
In light of this and as a focus for today's session, I would like to provide my comments under four sections: first, history; second, the McMaster University case management program; third, examples of home care—they're interspersed throughout the presentation—and finally, research.
In terms of history, case management in homes began in England in 1601 under social welfare legislation. In the United States, case management rehabilitation programs were started in the 20th century. George Welch is considered the father of U.S. modern case management, and really, the focus was controlling the spiralling costs of health care.
In 2000, approximately 68% of an estimated 80,000 case managers in the U.S.A. worked in insurance and rehabilitation, so 32% worked someplace else. The genius of case management is its extraordinary flexibility and endurance, under the premise that case management provides an individual with the opportunity to reach her optimum level of wellness, functional capacity, and living arrangements. Case management is a collaborative, client-driven process that focuses on quality health care and social support, through the effective and efficient use of resources.
Case management achieves client wellness, wholeness, and autonomy through respect, communication, advocacy, service identification, coordination, integrated planning, reflective evaluation, and research-based approaches.
Catherine Mullahy, one of the champions of case management several years ago, described case management as the only profession that looks at the gestalt. Certainly at McMaster University we take the focus it needs.
McMaster University's certificate program offers an online program to all parts of Canada. We have students from British Columbia, the east coast, the Northwest Territories, and outside Canada. There are five core courses, and they are completed in five years.
We begin with topics such as history: background, definitions. We focus on the legislation and regulations, which look at where the case manager works, such as B.C, the Northwest Territories, or Ontario. We add items of interest such as the Drummond report, where they spoke of case management and the systems navigators, and that all regions should have that quarterback.
The standards of practice, the competencies, roles, functions, processes, and reflective practice are other areas of case management. The CCAC offers as an example the electronic tools, scores, and algorithms that give an assessment of case management with key outcome indicators in order for the case manager to provide care in the home including: nursing, personal support, physiotherapy, OT, speech-language pathology, social work, nutritional counselling, and medical supplies and equipment.
They also have things such as medication reviews for the elderly in terms of risk management and safety. The case managers are considered the care connectors; they match clients in need with primary care providers. We look closely at the models of case management—and there are many—and we go through those details. A more recent example is an integrated and intensive model that the CCACs are looking at, which looks at clients who are high-complex or “chronic community-independent short-stay”. The model includes a high-risk need with fewer clients per case manager.
They also have an integrated client-care project, a multi-year initiative that looks at specific populations including: wound care, palliative care, frail seniors, chronic disease management, and medically complex children. The model is the work of Michael Porter from Harvard, and it looks at value-based care with coordination, integration, and specialization as the key features.
Other things they have are the rapid-response nurse, who is very solution-focused, for those who need attention and are complex in their transitioning from hospital to home.
Along with the models, we also teach the topologies of case management. One of the key ones that is featured is the problem-based topology. Again, in terms of the application, they are using that as a model in CCACs with integrated intensive models, along with a populated-based focus, which looks at seniors, child and youth, and palliative.
Other topics we include in our program are the elements of personhood, which is such an important feature in terms of individuality, wholeness, and integrity; and ethical issues in terms of ethical dilemmas, decision-making; and ethical, legal, and financial issues in case management. We view cultural competencies in looking at adequate health and social services without facing any discrimination.
The impact of mental health issues is another area. We see in many of the CCACs in Ontario, if the client has a primary diagnosis of mental health issues, that is assigned to a specialized case manager because of the complexity of that care. We do mention things, such as the Mental Health Commission of Canada's introduction of Changing Directions, Changing Lives, the first mental health strategy for Canada.
Other areas we focus on are the social determinants of health and their application in terms of case management; collaboration between sectors—public health, primary care, community care—and systems thinking and navigation. Because case management is a dynamic process, case managers act as a systems navigator, facilitator, in trying to balance the provision of services to produce optimal health, independence, client satisfaction, and fiscal responsibility.
I'd like to end with research. We do offer another course linking case management to policy, education, and evidence-based research to influence policy and program development. We encourage case managers to continue their professional development and to familiarize themselves with best practice and its application.
The most recent study being done is regarding case management. You can have all the tools, algorithms, and scores in the world, but when you are looking at teams and working together in an integrated specialized way, you have to have that excellent skill, that expert case manager. The study is a qualitative, phenomenological research that looks at the experience of experienced case managers. It's called “The Nature of Insight: Case Management”. It will be completed this summer.
The Chair Greg Kerr
Thank you very much, Ms. Murray. I'm not even going to ask you what “phenomenological” means. Maybe someone will ask about it in the round of questioning.
I appreciate that. Thank you.
Now I understand we have the National Case Management Network of Canada, Joan Park and Ruth Anne Campbell.
We're going to start your 10 minutes, please.
Joan Park President, National Case Management Network of Canada
Thank you, Mr. Chair.
Good afternoon. It's an honour to speak with you today about the National Case Management Network of Canada in relation to the work of this Standing Committee on Veterans Affairs.
I've reviewed the evidence presented at the first session, on May 8, as you studied transformation initiatives at Veterans Affairs Canada. I commend VAC on its commitment to improving service for Canada's veterans and their families by building on its greatest strength as a department: employees who care about their work and the people they serve.
I will begin with a brief overview of NCMN. Then I will speak to how a partnership with NCMN can assist Veterans Affairs Canada to have the right people with the right skills in the right places to meet the needs of veterans of all ages; to equip front-line VAC case managers with real-time access to the clinically relevant, evidence-based resources needed to do their jobs; and to connect front-line VAC case managers with case managers across the country who work with clients and families from similar and complementary target populations.
NCMN leads today for tomorrow. In a few short years, NCMN has emerged as a leading national organization that connects, supports, and sustains all providers of case management. The mandate of NCMN is to foster case management providers for the benefit of individual Canadians, their families, supporters, and the Canadian health care system. The mission and vision of NCMN is to promote excellence and professionalism for case management in Canada.
Established in November 2006, NCMN is federally incorporated as a non-profit professional organization that is membership based. Our membership embraces individuals and organizations in every province and territory. It represents diverse health and social service sectors that include academic and educational providers; acute care; community support agencies; the Department of National Defence and the Canadian Forces; disability management; first nations and Inuit health; home and community care; long-term care; mental health; private insurance; regional health authorities; rehabilitation; research; therapy services; Veterans Affairs Canada; and workplace safety and insurance boards.
In 2010, support from Health Canada's health care policy contribution program allowed NCMN to distribute Canadian standards of practice for case management, provide learning resources, and develop a professional association. This established the foundation on which to identify, attract, and prepare highly skilled interdisciplinary health and social service providers of case management. Health Canada's support also allowed for the initiation of the development of a national competency profile and the selection of a competency framework.
NCMN recently signed a second contribution agreement with Health Canada for the project called “Promoting Excellence and Professionalism for Case Management in Canada. Phase II: Core Competencies, Credentialing, and Sustainability”. This funding allows for the development and validation of national core competencies and the selection of a credentialing process to indicate competence in case management. The project also aligns with Health Canada's health human-resource policy framework to optimize Canada's health workforce for the increasingly demanding and complex health care needs of Canadians.
Leading today for tomorrow, NCMN seeks to identify case management best practices to steward these discoveries into meaningful standards of knowledge and to disseminate that knowledge nationwide. VAC members have served on the NCMN board, have contributed to the Canadian standards of practice, and have shared their experience at NCMN's national conferences.
What does NCMN offer to Veterans Affairs Canada? VAC case managers, like case management providers across the country, practise a collaborative, client-driven process for the provision of quality health and support services through the effective and efficient use of resources. They support the client's achievement of safe, realistic, and reasonable goals within a complex health, social, and fiscal environment.
VAC case managers, like case management providers across the country, are experts in care coordination and integrated care as communicators, collaborators, navigators, advocates, managers, and professionals.
The work of NCMN aligns with the intent of Veterans Affairs Canada to tighten the focus on case management and ensure that our employees will be supported so they are well equipped to do their jobs. In many ways NCMN addresses Keith Hillier's statement that “we have the right people with the right skills in the right places to meet the needs of veterans of all ages”.
First and foremost, NCMN is building a Canadian case management body of knowledge with its development of both national standards of practice and core competencies. Together the standards and core competencies form a distinct body of knowledge and provide a standard of care. A standard of care communicates the practice, knowledge, skills, and attitudes of case management providers to the many Canadian constituencies, including the health care system, government, commerce, the military, and the general public.
This body of knowledge establishes a foundation for case management providers to acquire the right skills, for educational institutions to develop curriculum, and for workers and employers to create job descriptions and performance appraisals. Secondly, given that practising front-line VAC case managers, like case management providers across the country, have limited time for engagement with educational materials, seminars, conferences, and other events that help to maintain their professional currency, NCMN is able to equip VAC case managers with real-time access to the clinically relevant evidence-based resources needed to do their jobs.
OvidMD is an online tool that allows NCMN members to perform a Google-type search of anything in the medical world. Ovid is an advanced search tool known to university librarians around the world, and access is generally a privilege of large academic and research institutions. OvidMD is a tool recently designed specifically for busy front-line health care providers. NCMN members have commented on its ease of use, functionality, and applicability to self, work colleagues, and clients. A mobile app is about to be released.
Professional Case Management journal is the official journal of NCMN, Case Management Society of America, and the Case Management Society of Australia. PCM is an international, evidence-based, peer reviewed journal with a readership of 13,000. NCMN members receive a hard copy of the journal and online access to journal archives. Each bimonthly publication includes “News from NCMN”. The July-Aug 2011 issue “News from NCMN” reported on the work of a Canadian case manager from the Interior Health Authority in B.C. and was the most read article around the world.
The third benefit NCMN offers to Veterans Affairs Canada is to connect front-line VAC case managers with case managers across the country who work with clients and families from similar and complementary target populations. NCMN members from other sectors are working with individuals and populations that VAC case managers are also working with, including: disability, return-to-work, seniors, child services, chronic illness, and mental health. As VAC clients and families transition from military to civilian life, there is strength in numbers and the benefits of case management increase exponentially when case managers integrate their knowledge, skill, and practice across these spectrums.
NCMN provides an opportunity for case managers to collaborate more closely with their peers in applying evidence and best practice to case management. A membership directory provides them with easy access to colleagues across the country and across sectors, and our national conference gives them the opportunity to meet with colleagues face to face to strengthen bonds and share their work.
NCMN encourages VAC case managers to continue to bring their voice and experience to affect the crucial national conversation on the future of Canadian case management.
With that, Mr. Chair, I would like to thank you and your committee for this time. I've provided an overview of the National Case Management Network of Canada and spoken to how a partnership with NCMN can assist Veterans Affairs Canada to tighten that focus on case management and show VAC case managers, who provide service to your most complex veterans, that they are well supported to make decisions that improve the care of veterans today for tomorrow.
The Chair Greg Kerr
Thank you very much, Ms. Park. I'm sure there will be questions flowing, after a bit.
We are now certainly very pleased to have the Canadian Peacekeeping Veterans Association as our final presenters of the day.
Mr. Kokkonen, Mr. Gollner, and Mr. Eggenberger, I understand you're going to split your time.
Ray Kokkonen National President, Canadian Peacekeeping Veterans Association
The Chair Greg Kerr
Please proceed. Thank you.
National President, Canadian Peacekeeping Veterans Association
Mr. Chair, committee members, ladies and gentlemen, my name is Ray Kokkonen. I'm the national president of the Canadian Peacekeeping Veterans Association, or CPVA. I sit as a member of the Veterans Affairs Canada stakeholders committee.
With me today is Brigadier-General Larry Gollner, retired, the patron of CPVA. Larry sits on the veterans ombudsman's advisory council now, and also served as a member of the new Veterans Charter advisory group. Colonel John Eggenberger, retired, is our vice-president of research. John has a doctorate in educational psychology from the University of Calgary. His main field of endeavour has been personnel applied research, making him an ideal VP of research.
Thank you for this opportunity to appear and to share our views. You have our written presentation. We do not intend to read it. However, we would like to offer some verbal supplements to the different sections, if I have your permission to do that, sir.
The Chair Greg Kerr
National President, Canadian Peacekeeping Veterans Association
Then I would like to proceed with Larry Gollner giving some comments on paragraphs two and three.
June 7th, 2012 / 3:50 p.m.
Brigadier-General Retired) Joseph E. L. Gollner (Patron, Canadian Peacekeeping Veterans Association
Mr. Chair, ladies and gentlemen, I want to focus on the spirit of our association.
Ours is first and foremost a veterans association that strives to support and sustain our members and all Canadian veterans. We are veterans who help other veterans, pure and simple.
We work cooperatively with other veterans associations and Veterans Affairs. We understand that cooperation is far more productive than confrontation. However, on occasion we have vigorously contested Veterans Affairs policies and practices, especially when we believe that the spirit of existing legislation is being diluted by bureaucrats who pay more attention to detail than to the spirit and the principles of the legislation.
Some of our fellow citizens do not understand that veterans legislation, our legislation, both the Pension Act and the new Veterans Charter, is based on Parliament's clearly defined understanding of service to Canada, an understanding that is predicated on the fact that those who serve in Canada's armed forces do so with an unlimited liability clause in place, and further, that its members are obligated by law to obey legal orders. Canada has acknowledged in legislation that it has a duty to provide care to its fallen, to its wounded, injured, sick, and aged veterans and their families so that they can live with dignity.
The mandate of Veterans Affairs is to provide for Canadian veterans, which it does very well, although frequently the service is not publicly recognized. To that end, last year CPVA created a national award program to recognize individual and collective groups of Veterans Affairs staff who do outstanding service for Canada's veterans. This program is ongoing and reflects the spirit of our association.
Thank you, Mr. Chair.
The Chair Greg Kerr
Thank you very much.
I would just point out that we started the proceedings by saying the bells would go. I mentioned it to the committee, and the committee seemed to agree that we would continue with the presentations and then break.
That's why the light is flashing, in case you folks are wondering.
Colonel Retired) John Eggenberger (Vice-President, Research, Canadian Peacekeeping Veterans Association
So there's no fire in the building.
The Chair Greg Kerr
You won't be interrupted. Please, carry on.
Col John Eggenberger
All right. Thank you very much.
I have been reliably informed that I have less than three minutes of conversation, so I'll try to make it go smoothly.
The transformation of Veterans Affairs Canada calls for changes in organizational structure. We three, among all veterans who have worked in large headquarters, can attest to the confusion between organizational units that inevitably ensues when changes are made.
Realizing that Veterans Affairs Canada has included this issue in their risk analysis methods, we still wish to place on record our concern that particular care be focused on assuring that there would not be a loss of communication between Veterans Affairs Canada and veterans, especially those veterans who are not Internet-savvy but depend upon snail mail or telephone.
How did I do?