Veterans Affairs Committee on May 31st, 2007

[The Chair, Conservative, Rob Anders]

We have a teleconference call this morning. We do have quorum. We have our witness online. According to my BlackBerry, we're still two minutes early, so I'm just going to give it another minute. That way no committee member can complain about the meeting starting early.

Is Dr. Dorothy Pringle there?

[Dr. Dorothy Pringle, Council member, Gerontological Advisory Council]

Yes, I am.

[The Chair, Conservative, Rob Anders]

I'll tell you what, then. We'll go ahead and get started.

Dr. Pringle, the way this usually works is that you have 20 minutes to present. You can take that full time if you wish, or not. That's entirely your prerogative. Then what happens is we open it up to questions from committee. The timing and the order, the rounds and all that type of stuff, are already predetermined. That's generally the way it works.

We're right now conducting a study of the veterans independence program and health care review. Dr. Pringle is with the Gerontological Advisory Council.

Dr. Pringle, the floor is yours.

[Dr. Dorothy Pringle]

Thank you very much. I really appreciate having this opportunity to talk with you. I very much appreciate your interest in this.

I've been a member of the Gerontological Advisory Council for about five years. I'm not one of the original members, but I chair the working group that developed the report Keeping the Promise. I'm a nurse, and my clinical and research areas really focus more on long-term care, particularly the quality of the daily lives of people with dementia who live in long-term care.

I also do work at the other end of the spectrum, and that's on health promotion. I've done a lot of work with public health and have taught health promotions to nursing students for many years. I'm chairing the health promotion committee of the advisory council and working with Veterans Affairs staff to determine how Veterans Affairs can put into place the programs and systems that are proposed in Keeping the Promise and those that will lead, we hope over the long run, to better health outcomes for all veterans. There's a second committee, chaired by Dr. François Béland, that is working on assessment of needs, the types of screening tools that will be used to assess individuals at various stages of their involvement with Veterans Affairs. Both of these committees met for a full day two weeks ago to begin the work of identifying how we should go about developing what our particular objectives are.

Veterans Affairs staff had done a lot of work in preparation for these meetings. Our aim is to have a fairly comprehensive report going to the Gerontological Advisory Council meeting the first week of July in Charlottetown.

I thought I would start by talking about the health promotions committee specifically. I want to review the principles that we've adopted to guide the committee's work as we identify how we are going to develop the programs and develop access to these programs across all of the areas in Canada.

Our first principle is that we be very pragmatic and realistic. We intend to recommend programs that are doable and how to get programs into place across the country. We're only going to recommend evidence-based programs; that is, programs for which there is sufficient researched evidence demonstrating that they are effective in achieving better health outcomes.

We shall take an incremental approach. We'll start with programs for which evidence exists now of their effectiveness, then develop a process whereby we or the staff of Veterans Affairs continually assess the research evidence, so that as other programs are demonstrated to be effective, they would be added to the repertoire of programs that Veterans Affairs has available.

We'll also be forward-thinking. In Keeping the Promise, as you know—because I've read the transcripts of your previous interviews—we were asked specifically to deal with war veterans, that is, World War I, World War II, and Korean war veterans, although we really focused on World War II and Korean war veterans.

I think the programs we are going to recommend have to be relevant for veterans and their caregivers. Initially, these folks are in advanced age, but we need to be laying the foundation for all veterans—those in their middle years. The average age of Canadian Forces veterans now I believe is 56, but there are much younger veterans as well. We need to put in place now the types of programs and processes that will serve veterans of all ages.

In Keeping the Promise we propose creating a new role: the early intervention specialist. These are the health promotion specialists. Let me tell you, I think that's still not the right name. We struggled with this, both within our working group and on the Veterans Affairs council. We quite liked the term “health navigator”, but it did not go over well with the veterans groups, so we're using the term “early intervention specialist”. That sounds a little too medical, I think, so that's an area where we still have to do some work. I will refer to the role as early intervention specialist because that's what we've documented in Keeping the Promise.

These individuals would be added to every team in every regional office. The number of individuals would be determined by the size of the office, both in terms of the number of veterans they serve and the geographic distances that the area is responsible for.

After an initial screening of a veteran who contacts Veterans Affairs, if the veteran has demonstrated that they do not need health services, the veteran would be referred then to the early intervention specialist. They would have an additional assessment at that point to determine what their health promotion activities were. What kind of nutrition did they have? What's their weight? What kinds of exercise activities did they participate in? Did they have chronic illnesses that they were managing? They would be with the early intervention specialist if they were managing those chronic conditions fairly well, but there might be additional work needed there.

There would be an additional screening, and if that early intervention specialist identified, on this more intensive screening, that the individual needed services, that individual would also be contacted by a care coordinator. When I say “individual”, I'm talking about the veteran and a caregiver. We are very much of the approach, and I hope you took that from the Keeping the Promise document, that you must provide services to both the veteran and his or her caregiver. With that, the early intervention specialist would then work with the veteran and his or her caregiver to determine what types of health promotion activities would suit them, and they would benefit from and then organize that with them. We are not going to leave it to the veteran to make all of these arrangements. People at 80 and 85 need somebody to attach them to programs.

We're focusing on programs for health promotion that can be established in every area office. We began by examining programs in four areas: nutrition, physical activity, falls prevention, and chronic disease management. We looked at the area of social integration because of its relevance for the mental health of veterans, but we decided that rather than treating it as a separate category, we would link it to physical activities and other areas, because social integration can frequently be realized by participating in other types of activities.

Again, we're identifying which interventions are most appropriate for the early intervention specialist and which are more appropriate for the care coordinator.

I'm going to focus most of the rest of my comments on the work we've done around physical activity, partly because there is more evidence in this area and because more programs designed particularly for older people have been evaluated in this area.

There is very strong research evidence about people who are physically active and engage in regular physical exercise, regardless of their age; it applies to people even in advanced old age. These people are healthier, they have lower blood pressure, they're at better weights, they have lower diabetic rates, and they have lower rates of frailty. If you can get younger people, or if younger people are actively engaged in regular physical activity and do it on a sustained basis, clearly there are better and more dramatic effects in terms of health outcomes than when you start with people who are already old. But when it comes to physical activity, the phrase “it's never too late” really does apply.

I'm pleased to say that a good deal of the evidence that links health outcomes to physical activity is Canadian research. We are looking a populations that we will be dealing with in the future. It's not specifically related to veterans, however.

It is critical that the programs we are recommending be evidence-based—I've said that several times now—but it's also very important that the programs be accessible and affordable. That's where Veterans Affairs really has a major role to play. It needs to establish the programs, monitor their quality, develop ways of making them accessible to veterans and their caregivers, and ensure they're affordable, either by paying the cost or by supplementing the cost.

We know that if we start with an 85-year-old veteran and his 82-year-old wife and get them both into exercise programs, it's not going to have huge effects, but it will have some. We know that if we can get the 50-year-old veteran into these programs, we can expect a much larger effect. We can get the 35-year-old veteran into programs. These programs have to be different, because different generations have different attitudes towards physical activity. We might expect the 35-year-old veteran to already be into physical activity programs, and even the 56-year-old. Baby boomers have a very different attitude toward physical exercise; a lot of these people will have personal trainers. That is not likely to be the case for the 85-year-old veteran.

There are four physical exercise programs we are looking at in depth because there is demonstrated effectiveness for all of them. One is called enhanced fitness; one is called active choices.

Enhanced fitness is an individually oriented program. This would be useful for veterans who are not interested in or do not want to participate in a group activity, but it is a prescribed exercise program with a lot of telephone contact with the veteran by that early intervention specialist to review how things are going and to discuss any effects, both negative and positive, that the veteran might be feeling. We're looking at that as one type of program.

PACE is another. PACE stands for People with Arthritis Can Exercise. We know that there's a higher prevalence of arthritis in older veterans than there is in the population at large. We believe there's good American research that demonstrates a link between military service and the subsequent development of arthritis. We want a PACE program in place in every area, as well as another program called “Growing Stronger”.

We would expect the early intervention specialist, within that specialist's area, to identify existing exercise programs wherever they're located. They may be offered by veterans organizations such as the Legion or the army, navy, and air force veterans organizations. They may be offered by the YMCA, by seniors clubs, or even by for-profit fitness clubs. The early intervention specialist needs to know what's already available. What kinds of programs are they? Do they conform to the evidence-based programs that we are going to mount or support?

If they are not available, then the specialist will work with veterans organizations, the YMCA, or private clubs to get them established and then link veterans to them through these screening processes. The early intervention specialist will determine the transportation needs of the veterans, will develop transportation for these programs, and will fund or supplement fees to make it possible for the veterans to access the programs.

The early intervention specialist would then stay in touch with those veterans. It's not a matter of linking them and then moving out. We see ongoing contact to see how things are going. If the program isn't working for the veterans, then they need to work with other programs.

When I say this, it's not about imposing this on the veteran. This would be worked out with the veteran and caregiver on what they're interested in and what's possible for them. They would then get them into those programs and stay in touch with them. We expect positive health benefits and positive social participation benefits from this.

We are proceeding to seek out and appraise research on other programs. It's going on right now. We'll be working hard at that over the month of June in preparation for our July meeting.

We've also had consultations with Dr. Mary Altpeter. She's worked with Victor Marshall at the University of North Carolina. She is really the American specialist on these kinds of health promotion programs. It's not only activity but health promotion programs that affect other health areas.

We will be coming forward with a recommended list. We expect it will not be very long. While we have lots of research linking nutrition and health outcomes, exercise and health outcomes, social participation and health outcomes, the programs that have been developed and assessed in terms of effectiveness and the research done on this are much more limited.

We are systematically reviewing that. A lot of work has been done in terms of bringing this research together. It's those kinds of summaries and critical appraisals that we're reviewing.

We recognize this will require additional resources. But we believe, and we've certainly had nothing but support from Veterans Affairs in believing, this kind of investment is what we need to do now in order to have better health outcomes for veterans in the future.

I know in earlier interviews with Victor and with Norah Keating, you discussed the need to identify veterans and to encourage them to contact Veterans Affairs. They can be screened and linked to programs for health promotion and to the health services they require.

We've spent quite a bit of time talking about how we can reach veterans, because, as you know, Veterans Affairs does not have a roster of all the veterans. For those who are already connected to services—and I think it's 40% of veterans who are already in the VIP program—that's not a challenge. But we do need to reach the 60% of veterans who are not connected. We've discussed using Salute! and other communications from Veterans Affairs, and using the organizations like the Legion and the army, navy, air force, etc.

I believe at an earlier meeting you suggested that it might be possible to work with the offices of members of Parliament to reach veterans in their constituencies, through their communication vehicles and other contacts. I think that's a wonderful idea, because it's been a challenge for us to identify how we would get to these people.

Rather than talking more about other programs, I think I'll stop so that we might move on to questions and discussion.

[The Chair, Conservative, Rob Anders]

You have impeccable timing.

[Dr. Dorothy Pringle]

Was that 20 minutes?

[The Chair, Conservative, Rob Anders]

It's 20 minutes and 20 seconds right now. That's very impressive.

[Dr. Dorothy Pringle]

Wow, I had no idea.

[The Chair, Conservative, Rob Anders]

Very impressive. You could teach a few things to our committee members.

Mr. Valley, for the Liberal Party, you have seven minutes, please.

[Roger Valley, Liberal, Kenora, ON]

Thank you.

Good morning, Dr. Pringle. I'm sure my chairman wasn't talking about me, because I'm known not to be long-winded. Thank you. You had very good opening remarks.

Actually, I'm going to go to my last point first, because you just touched on it. One of the struggles for members of Parliament has been, as you mentioned—and I was probably the guy who recommended it—to have a list of the veterans in our ridings.

I would ask you to consider something, and it was mentioned at a previous meeting, but I'll bring it up here. I was wondering if your group would make a recommendation that we could be provided a list in our ridings. We know the privacy laws. We deal with them every day, but we have access to all kinds of information. You just brought up a figure that I've been curious about for a while: that 60% of veterans are not connected to any organizations, or that we're not touching base with them.

A recommendation from your group that members of Parliament could be provided with this list.... We only have the best interests of these veterans at heart, and we want to be a point of first contact in many instances. We travel our ridings extensively. We would be the perfect people, but because of the rules that are in place right now, we can't do it. A recommendation from your group to start building that list and providing it for members of Parliament would go a long way.

[Dr. Dorothy Pringle]

Let me say that I believe 60% of veterans are not now receiving Veterans Affairs—They may very well be connected to the Legion or other veterans organizations, but they're not in a long-term care facility, in a veterans bed or a community bed funded by veterans, and they're not receiving the VIP program.

I read the transcript. I think you had that discussion with Brian Ferguson and Darragh Mogan. I'm happy. I think we can bring that forward and then look at how we overcome—and what needs to be done to manage the privacy side of things but also to make it possible for you people to be in touch with veterans that we're aware of.

It may be as simple as asking the veterans who are receiving services whether or not they're prepared to have their names released to you.

I don't see that as a huge problem.

[Roger Valley, Liberal, Kenora, ON]

Thank you for that. And from your side, if you'll follow up on that, we will do our part here.

I'm going to branch off just for a minute, and I don't do that too often.

The committee has not even been out of this room 12 hours. We had a fascinating night last night. We had probably 30-plus PTSD survivors and some professionals in the room.

We know your focus is on World War II and Korea, but you mentioned earlier that you look at all veterans and the different ages, realizing we have to serve them all.

One of the things I heard last night, which was quite surprising—we know there are always institutional problems and administrative problems—and I'd like a comment on it, is that all of these survivors deal with different challenges, and they meet them as well as they can to survive every day, but the administrative problems or the institutional problems inside Veterans Affairs are one of the hugest obstacles they face.

For health care providers, you've mentioned repeatedly that early intervention is important. Last night we heard that the lack of health care providers, the challenges of health care providers working with veterans who are suffering from any of a host of things, from PTSD to other issues, and their inability, really—this is what they feel, rightly or wrongly so—to get access—or if they have access it's cut off. They build up trust with the people who are working with them, through this early intervention, and then it's not carried on.

So it was a bit of a surprise for me—and I'm sure for the committee members—that we have this problem inside the system to the extent we do. I'm wondering if in your deliberations or your discussions with other professionals on the committee you have run into this. Do you know how widespread the problem is?

[Dr. Dorothy Pringle]

First, I don't know how widespread the problem is. I am not surprised to hear it, because it is a problem in our health care system that we're underresourced in a number of areas. That's the system.

You understand that Veterans Affairs really is a gap filler. They are not the first line of services. They build on what is available through our provincial health care systems. Because we run into shortages in those systems, veterans are going to run into them.

I have to say that we're so new at recognizing PTSD as a problem and its extent. If you go back and look at the history of the various wars, right back to the Civil War, there is documentation of PTSD, but it was never called that. It was never recognized in terms of how serious or long-standing it was, how much it affected people over a very long period of time, or just how prevalent it was.

We have not ramped up systems sufficiently to deal with the extent.... I know it's a high priority for veterans at Ste. Anne's, and they are developing and testing programs to be put in place across the country.

I regret that's the case, but I'm not surprised at hearing it.

I have to say that our council has recognized it. We haven't dealt with it to any great extent because we're dealing with Second World War and Korean War veterans.

[Roger Valley, Liberal, Kenora, ON]

Thank you, Doctor.

I'll be very brief, very quick.

Since you are dealing with those two groups, we heard repeatedly from the group last night that one of the biggest challenges they face is not necessarily in health care but the red tape.

Even at Veterans Affairs, through your group, I'm sure you've had to deal with red tape when dealing with the age of the veterans. So it's not necessarily health care.

Maybe a clerk could help them through some of the red tape. It's a part of government, but we have to find some way. This is a huge concern for these veterans and the ones you talked about.

[Dr. Dorothy Pringle]

You're absolutely right. We did hear that veterans need help, not relating to PTSD, but to other services within the VIP program. It's not just with funds to get snow clearance, groundskeeping, etc.; they need help to get that in place, not to be left on their own to make those arrangements. We've made that recommendation in Keeping the Promise.

The people who they are working with in Veterans Affairs, whether early intervention specialists or care coordinators, have to help them navigate the system and complete whatever forms they need to complete, so that they get the services.

[Roger Valley, Liberal, Kenora, ON]

Thank you.

[The Chair, Conservative, Rob Anders]

Thank you, Doctor.

Now over to Monsieur Perron of the Bloc, for seven minutes.

[Gilles-A. Perron, Bloc, Rivière-des-Mille-Îles, QC]

Good day, Madam.

I listened carefully to your presentation or rather, to your theory about early intervention specialists. I think it has some merit, but I wonder whether this approach is feasible. You talk about committing additional funds and hiring more individuals to work in this area, whereas we are already having trouble filling positions.

The second part of my question reflects a serious concern of mine. It is no secret that the Canadian population is aging. What do we do about the so-called regular population? Does your intervention plan for veterans also apply to miners, for example? They too have contributed to this country's growth and development.

Lastly, I would like to know what this proposal will cost?

[Dr. Dorothy Pringle]

The early intervention specialists—I'm addressing now your question about the potential difficulty in being able to recruit the people who will fill the early intervention specialist positions—will not be health care providers. We're not going to have nurses or physical therapists in these positions. We're likely to be hiring people who have degrees in ergonomics or in physical and health education. I think that's a different pool. It's a pool that I think is pretty vibrant across the country, and I think clearly it won't be easy—it never is—and in some of the areas that are more remote it will be more difficult. But I think it's doable, and we will find the individuals to do it because we have I think a clear idea of the backgrounds they require and know the sources of people with these backgrounds.

In terms of what we're recommending and its value to the population at large, I don't think there's any question about it; it's the kind of thing the Public Health Agency of Canada and public health departments across the country struggle with, which is how to get the population at large to take better care of their health and engage in health-promoting activities.

I was pleased to see that ParticipAction was started again, because I think it's the kind of organization that relates to the population at large and makes the same kinds of recommendations as we're making for the veterans population.

[Gilles-A. Perron, Bloc, Rivière-des-Mille-Îles, QC]

Madam, I can see that a double standard could be at play here. In your presentation, veterans and ordinary people who are getting older— people like me who are 66 years of age, and my father— are not treated the same way.

It is all well and good to want to help veterans, but it is important to think about the aging members of the general population as well. This is a problem in Quebec, in Ontario and in all other provinces, especially in remote areas. We need to remember that Canada is a country made up of remote areas. It is one thing to receive treatment in Toronto, Montreal or Vancouver, but it is quite another matter when you come from Elliot Lake, like one of my colleagues, or from Saint-Lin-des-Laurentides.

[Dr. Dorothy Pringle]

I think we made a decision as a country that we were going to honour the veterans by providing services to them that exceeded what is available to the Canadian population at large. That was a tribute to the fact that they put their lives on the line for us.

So I think there is a double standard. I think it's a double standard that as Canadians we have bought into and feel very strongly is deserved. The VIP program really is a double standard. It provides to veterans services that are not available across the country through our provincial programs. Some home care programs are more generous than others, in providing home-making and groundskeeping, but most of them do not—particularly the latter. That is a responsibility of people who live in their own homes.

So yes, there is a double standard, but one that we accepted.

Let me say that I know Elliot Lake—I lived in Sudbury for four years—and I know it has become a retirement town and that they need services there and have to rely on the services that are available in that region. I think we need to have very good home care programs across the country to meet the needs of all citizens, and we need to reach out on the health promotion side to all citizens. But we are reaching out farther for veterans.

[Gilles-A. Perron, Bloc, Rivière-des-Mille-Îles, QC]

Thank you, Madam.

[The Chair, Conservative, Rob Anders]

Eight seconds over, Mr. Perron.

[Gilles-A. Perron, Bloc, Rivière-des-Mille-Îles, QC]

I'm a hero.

[The Chair, Conservative, Rob Anders]

I know, and that's why we want to hear from you again.

Mr. Stoffer of the NDP for five minutes, please.