Veterans Affairs Committee on Jan. 29th, 2008

[The Chair, Conservative, Rob Anders]

Good afternoon, ladies and gentlemen.

I'd like to welcome everybody back from our Christmas and holiday break. Happy new year to you all.

We are continuing, pursuant to Standing Order 108(2), the study of the veterans health care review and the veterans independence program.

Today we have two witnesses with us. We have Clara Fitzgerald, from the Canadian Centre for Activity and Aging, and we also have Mark Speechley, from the University of Western Ontario, Department of Epidemiology and Biostatistics, Faculty of Medicine and Dentistry.

Just for our witnesses' benefit, the way this generally works.... I don't know if you've been told that it's twenty minutes or ten minutes.

Good, you heard twenty minutes. That's what is usually standard. So you can split that as ten minutes apiece, or one of you can hog nineteen minutes and the other one will get one minute, as you see fit. Then after that, the committee members will take turns asking questions based on a strictly delineated, previously agreed to roster of the parties.

The floor is yours.

[Mark Speechley, Professor, Department of Epidemiology and Biostatistics, Faculty of Medicine and Dentistry, University of Western Ontario]

Thank you for inviting us here today.

I'd like to thank Veterans Affairs Canada for funding for the research we did into Canadian veterans. We did what we think is the largest study of falling among veterans of Canada.

I've summarized the results of our work in the brief I submitted. I won't take your time by re-reading it, but I'd like to point out three key points.

We found that falling is more frequent among Canada's veterans than in the general population of older adults. We know that Canada's veterans report poorer self-rated health than the general population, and we found that although it's a small number, 3.8% of the sample reported not having enough funds left over at the end of the month to meet their obligations. We found when we did analyses on that variable that those people also had an increased risk of falling.

I point out those, which might seem to be negative comments, but I want to start on the positive, because I know Veterans Affairs Canada has an excellent reputation for its compassionate care of veterans. I've read the Keeping the Promise document, and I want to compliment the agencies responsible for that document.

I will just go through what I think are some positive features of the Keeping the Promise document and then conclude with what I think are some things that have to be kept in mind as you go forward in revising this excellent program.

The positive features of the Keeping the Promise document are the single point of access and the coordination of services, particularly the coordination with provincial health care. In Ontario we have the CCAC, and I think that's essential.

Another positive feature is that these people will be working closely with primary care, which is absolutely essential. The team-based care and the case manager model is another positive benefit. The comprehensive assessment of older adults is evidence-based and appropriate.

I note with great approval the mention of physical activity and fall prevention. Fitness classes are specifically mentioned, and Clara will be talking about that, because that's her area of expertise.

Also, I was very happy to see evaluation and research mentioned in the document.

As you move forward revising this excellent program, I have some evaluation questions that I would encourage you to keep in mind. It's important that you are sure that the funds follow the veteran or older adult on a needs basis. It's one thing to have people eligible for a service, but if they don't need the service, the money may not be used to maximum benefit. I think we really have to be able to be sure that the funds are being used where they are most needed.

An evaluation question I have is, to what extent are VIS funds truly integrated with provincial funds? When I did my fall prevention study, I had doctors calling me. The evidence suggests that doctors should call back their patient to evaluate, say, the number of medications they're receiving. I had physicians tell me that they didn't think OHIP, in Ontario, would pay to call back a veteran to check on things based on what their questionnaire told us they should check.

That's a real concern to me, because that raises the question of funding. We know we have the evidence that we can prevent falls, but the question, as always, is who's paying, and are the funds travelling with the client the way they should be?

I think we have to ask, how does the early intervention specialist ensure that the veteran has a primary care provider? In Ontario, we know many people do not have a family doctor, so that's one question that I would raise. It's excellent that it's here in the document, but I would question how we will know that this good step is actually being done.

I see in the document that the veteran is encouraged to have a comprehensive health assessment. This is what we did in the second phase our project, which we haven't published yet but it's in preparation. We randomized people into two groups. One group got a comprehensive geriatric evaluation and an evidence-based set of recommendations for what should be done to prevent falls. We found no difference between that group and the group who just got a letter to their family doctor.

It's on that basis--not just my study, but others I've read in the literature--that we say comprehensive assessment and recommendations alone are not enough. It's a necessary but not sufficient step to prevent falls.

When I read your document, I see that the veteran will be encouraged to have a comprehensive health assessment. I would ask, how many do? Is simple encouragement sufficient to get the assessment done? I would ask what assessment is used, because there are several assessments that can be used.

If we do move towards a standardized assessment, I would encourage you to consider the minimum data set, which has been studied. It's an international suite of assessments that allow comparability, so we can compare Ontario, British Columbia, Quebec, etc., and the United States and other jurisdictions. It's a wonderful initiative.

Again, I've got a note here: Who pays? Who pays when these things all happen?

I've drawn a line across my page here and I'm just going to conclude with things that occur after the standardized assessment of an older adult.

It's most important that the veteran has regular contact with the care manager to see that the results of the assessment are put into action. I emphasize that an assessment and a recommendation, if that's all you do, I can almost guarantee you won't prevent falls or any of the other negative things we want to prevent.

I think once the assessment is done and the recommendations are made, and the case manager ensures the veteran is getting these things, then we have to ask, are the interventions evidence-based? There are many things that are done out there that are evidence-based and some that are not. So that's something I would put in your evaluation program.

The actions should not only be evidence-based, but they should be continuous, and you have to have regular follow-up. The assessment should be repeated. It's not just a one-time deal. It has to be repeated for two reasons. First of all, new problems can arise in older people quite quickly. And second, if the assessment is repeated, then you use it as an indicator of success of the program. If you don't do it, you really don't know if you're having any success at the individual level.

Similarly, with the referral to specialists, some evaluation questions I would have are how long does this take; are the appointments kept; is the referral appropriate; and are the actions taken appropriate and based on evidence?

In conclusion, to emphasize the positive, we know we can reduce falls by 25%. We know we'd better start doing a better job of it now, because we have a looming epidemic of falls as the population continues to age. We can use existing knowledge to create a uniform national fall prevention program, which, if funded and sustained, will have benefits for individual veterans, families, and society at large.

Thank you very much.

[The Chair, Conservative, Rob Anders]

Thank you.

That allows just under twelve minutes to Ms. Fitzgerald, if she wishes.

[Clara Fitzgerald, Program Director, Canadian Centre for Activity and Aging]

Thank you for recognizing the Canadian Centre for Activity and Aging as a national leader in the area of physical activity and aging. For those of you who are not familiar with the Canadian Centre for Activity and Aging, we are a national centre located in London, Ontario, at the University of Western Ontario. Our mandate is to conduct research in the area of physical activity and aging, and then to develop model programs and leadership training programs that support the research we've learned in order to help older people maintain as much of their functional ability as possible. The work we do is geared to both very well older adults living in the community and frail older adults living in a variety of different care facilities.

I think it's important for us to let you know that this is a wonderful opportunity for us to have a discussion with the members of this committee and to talk about the value of physical activity programming as an intervention to help many of the ill effects of aging that many of the veterans and older adults experience as they get older and have various levels of functional decline.

Like Mark, I took note of Keeping the Promise and the guide to access Veteran Affairs Canada health benefits and the VIP program. What I thought was quite interesting--I learned as I read--was that the VIP program in place and many of the services provided to the veterans are based on their veterans status as compared to their actual level of need. So I think there has to be better integration based on the service delivery model, on what the actual veteran needs, not so much based on their age and/or status but on their functional needs. I'm sure many of you can think of a variety of different older people who are younger than others and yet not as functionally capable.

I've noted in the documents as well the importance of physical activity and the need for increased and improved community-based programming. That was emphasized actually in both documents, and I thought that was encouraging.

When we were coming to Ottawa, I was trying to think of specific community-based interventions that assist veterans to maintain their functional mobility in the variety of communities I've worked in throughout the country. I couldn't really come up with many of these type of programs. I think that's a direction that the document indicates the group wants to move forward in, and yet we have to realize that many of these older people want to age in place. We need to ensure that programs and services are delivered to them within the communities they live in. The wonderful thing as well is that the work you're doing helps not only veterans but older adults in general.

Much of the work we do beyond the research phase of it is not funded. It ends up that many older people who are able to financially pay for programs and services that are evidence-based can attend those programs and services if they're up and running in their various communities. There are a couple of challenges here. In some communities, the funds don't exist to get these evidence-based programs in place. The other challenge is that some of the veterans might not qualify for the VIP funding or may not have the funds to offset these costs.

I can share with you an example of a veteran I know through our centre, where we have over 420 older people who access our programs and services. This veteran had been taking part in a chronic obstructive lung disease program for about ten years. The program was physician governed and monitored, and was run out of a hospital in London, Ontario. The hospital felt that this program could be run within a community model setting, and looked to the Canadian Centre for Activity and Aging, based on the expertise we had in delivering evidence-based programs, to implement this program.

Having said that, there are direct costs associated with taking part in a variety of functional mobility programs to first of all try to prevent functional decline; secondly, if a fall has happened or something else, to try to help these people recover--the rehabilitation phase of functional mobility programming; and thirdly, if rehab has taken place, to help these people maintain their functional gains in the long term, so that they can benefit from the purposeful activities that those programs have helped them be able to take part in.

This person was not aware of the level of funding that might be available through the VIP to access the service, and we were not in a position to be able to offer this service to this individual at no cost. Discussions began in early August, and to make a long story short, the person finally received funding through the VIP in middle to late December. I feel that timeframe is too long, and the older person didn't know how to navigate the system in order to benefit from these health promotion initiatives, even though they're indicated in the document. I wonder how aware these veterans are of these health promotion initiatives as compared to perhaps rehab initiatives after an incident such as a fall has happened. So it's really looking at how we can help prevent further functional decline in the long term.

I'm sure my brief has been circulated along with Mark's. I just want to address a couple of recommendations based on some of the points I've mentioned.

There's a lot of information and a lot of research that has been done to explain the benefits of physical activity for older people. If you're not aware of that information, when you had the Health Canada representatives speak to your standing committee, they would have highlighted Canada's Physical Activity Guide to Healthy Active Living for Older Adults. It's a great document. It summarizes briefly the importance of physical activity programming for older adults.

At this point, I think the emphasis really should be on taking a look at the vast amount of information out there, the research that has been published--and a lot of it being Canadian research--and looking at how we can translate that information into effective and accountable functional mobility programs for older adults and veterans, and to ensure that these programs are evidence-based and outcome-based.

What I mean by outcome-based is we don't feel it's good enough just to set up physical activity programs throughout the country for a variety of veterans and older people in general. It's essential that these programs are outcome-based, and we know what it is we're trying to measure and what risk factors they present, so that appropriate programs can be put in place to prevent furthering those risk factors.

There are a few key words: evidence-based programming, outcome-based programming, programming in place in a variety of communities throughout our country, and ensuring that many of these programs can be delivered within the home care infrastructure--so really supporting aging at home.

It's essential to develop cost-effective physical activity model programs for veterans and older adults based on research and led by competent leaders to ensure that funding and support for these programs in various communities is provided where older adults reside and ensure that physical activity programs, as I mentioned, are outcome-based, community-based, and foster aging at home.

As well, to help our older adults and veterans living in a variety of different care facilities throughout our country, it's important to note that these types of programs should also be in place in those types of facilities. Regardless of your age, it's always possible to maintain your functional mobility. We know that when we start losing functional gains, they're not necessarily due exclusively to aging, but inactivity plays a huge role.

The second recommendation is that if implemented as part of the routine primary care of veterans and older adults, the evidence demonstrates that physical activity has the potential to prevent functional decline and keep more people living at home longer with an improved quality of life. There are several cost savings later on, which we can talk about further.

Third is to provide assistance to veterans to navigate the health care pathway, so they're informed of the services available to them. From the experiences I've had with three veterans in particular, they didn't know what they didn't know. They didn't know these services were available to them, because they were health promotion services, as compared to rehab services. So it's important to make accessible evidence-based health promotion programs through the veterans independence program, and not solely rehab programs or programs based on veteran status but also based on their functional needs.

In closing, I think the key here is to look at the programs that already exist. Many of us have done research to develop these programs and to help them be implemented in a variety of communities so we can start the piloting of these programs to have an actual impact on the functional lives of these veterans and to help them become engaged in living independently as long as possible.

Thank you.

[The Chair, Conservative, Rob Anders]

Thank you.

Now we're over to Mr. Valley, with the Liberal Party of Canada, for seven minutes.

[Roger Valley, Liberal, Kenora, ON]

Thank you, Mr. Chairman.

Thank you to our guests for coming today to share some of your work. I'm sure if you've been following some of the work of the committee, you know we all have a great desire to improve things for our veterans, and we thank you for your information.

My first question is to either of you. You mentioned a study and where you were. Can you tell me how far out the study reached? In particular, was there involvement from the small towns, rural areas?

[Mark Speechley]

The first study was in the whole southwest region. We captured 1,300 veterans from ten counties of the southwest Ontario region. The intervention study could not be that widely distributed, because we had to have the comprehensive assessment and we only had so many people who could do the assessment. Some were done, though, as far away as Bruce County and down to Windsor.

It was a challenge finding people to do the assessments, because there was no funding in the project for that. It was funded by the system, which might be part of the reason it was not as successful as it might have been.

[Roger Valley, Liberal, Kenora, ON]

I probably should have clarified where my comments were leading. We're talking a little bit farther out. I'm from Kenora riding, which is about 30% of the province, more than 30% of the province, but it's a long way from there.

Realizing you have touched some rural communities, I was going to ask a question about remote sites. A lot of people don't realize how many remote sites we have, but we have over 90 that are accessed by air alone, which do have veterans. That's always a challenge. We know the challenges of serving veterans in the large cities, in the counties, but when you move out to those other areas....

That leads to my next question. Your recommendation--I think Mark made it--talked about a lot of good work done out there,and I think Clara mentioned it also. You mentioned there's some good work done by Canadians, but I assume there's been a lot of work done around the world. I'm wondering if you could just briefly touch on some of that and where it would be done. Is it the United States, is it Australia, is it Britain?

[Mark Speechley]

I think Australia and New Zealand are leading the world in this particular area right now.

[Roger Valley, Liberal, Kenora, ON]

By your comment and the first of your major recommendations, you're suggesting we have a lot to learn from the work that's already been done.

[Mark Speechley]

We don't have to reinvent the wheel, absolutely. We can take a lot of the stuff off the shelf and apply it in Canada. I know there are remote areas in Australia. I'm not sure how they solved the problem there, but that's something they might have some experience in.

[Roger Valley, Liberal, Kenora, ON]

I would like to think that at some point somebody started to work on some of the smaller places. How do you choose?

[Clara Fitzgerald]

If I can add to Mark's comments regarding the rural areas, some of the work that we've done, in particular the home support exercise program, is delivered by personal support workers in the homes of older people to help older people maintain their functional gains where they live. In these rural communities, these personal support workers are organized via the home care infrastructure. They provide services to these people at home through that home support exercise program. Although that work and that research was not done specifically with veterans, it was done with a variety of older people living in remote communities who were not able to access community-based programs and services that those living in larger cities were able to access.

We were able to demonstrate with that study that even using these health service providers who are providing care to these clients at home, we were able to improve strength, balance, flexibility, and cardio-respiratory fitness. We know that functional declines are associated with decreases in those physical components. So I think a lot of the effort in those rural communities is really to look at aging-at-home studies and implement some of the work that we've done and others have done and look at models that can replicate as much as possible the same model, but within the home care setting. It is not physically possible to bring these people, just due to the....

[Roger Valley, Liberal, Kenora, ON]

Nor would I want them to be moved. I would hope they get the service there.

You mentioned the focus of the study is falls, and how they happen. When we are visited by veterans, as constituents, one thing is fairly consistent, especially in an older veteran: it's a hearing issue. We're always fighting for pensions based on hearing; we're working on those aspects.

Is that a large part of why the veterans have more falls than the rest of the population? Is it because of their hearing?

[Mark Speechley]

That's a good question, and I'm probably not enough of an expert in that area to speak. I know that the inner ear is one of the three main parts of the balance system. I had never thought that maybe military service, which we know can cause hearing loss, might also affect balance.

Excellent question. I wish I had an answer. I don't want to speak beyond my expertise.

[Roger Valley, Liberal, Kenora, ON]

Because I think that consistently throughout you'll see that's one of the key points that they always have.

I suspect I'm getting close, I'm getting glared at, but I just want to highlight something.

Clara, you made a point your last—

[The Chair, Conservative, Rob Anders]

There's no glare. There's a minute and 30 seconds left. You can go ahead.

[Roger Valley, Liberal, Kenora, ON]

So I can talk for a minute and 29, because he won't cut you off.

Just lastly, then, on your last point, Clara, you just read it, “Provide assistance to navigate the healthcare pathway”. Over and over and over again, for the people who are coming before us, this is a huge problem. I would make the point, because you're only talking about an aging population—well, we're all aging, I guess. You're talking about a population that's Second World War, Korean War, and everything else, but just for your own information, we're getting it from the younger vets. We're getting it from the people who are still actively in the service, who are not able to carry out their duties but are still in the forces. Trying to get through the health care system is a huge problem. I'm very happy to see this here in one of your recommendations, and you can expand on it; he won't cut you off.

[Mark Speechley]

Well, again, I made the point that I was very happy to see this VIS is using that single point of access, and then you've got these people who are working together with the veterans to help them navigate the system. But then we also have the same thing in Ontario called the community care access centres. So then the first question I had was how is this single-point-of-access program going to work with Ontario's single-point-of-access program? Now we've got two single-point-of-access programs. If they're all working together, then it's a step in the right direction.

[Clara Fitzgerald]

I would agree with Mark. I think that the IS program should potentially work in collaboration with the CCACs so that there is not a duplication of services to older people, in general. I think there are opportunities there to learn from the work that the community care access centres in Ontario have developed. Again, it is a single point of entry. And their single point of entry is based on the functional needs of the client, not based on the status of the person. So the veteran's status wouldn't come into play.

I think as well—and I can only speak on behalf of the health care pathway—that the older adults need to become aware of various health promotion initiatives to prevent various areas of decline, in the area of functional decline, because sometimes people don't think about accessing services until something has happened, until they've fallen, they've fractured something, and now they need rehabilitation.

But the question is, after rehabilitation, what happens? What's in place for the residents--the veterans? I do a lot of work with long-term care facilities, and that's why I said “residents” there. What's in place for the residents to help them maintain their functional gains post-rehabilitation? What health promotion programs could potentially be in place? And then also, following rehabilitation, what follow-through programs are in place to help them maintain their functional gains post-rehabilitation? It's critical to think about, because most of the funds are invested in rehabilitation after a fall has happened, etc., to help the person regain as much of their functional potential as possible. But then what are we doing to help these people maintain these functional gains long term? I'm suggesting that efforts, programming, need to be put in place at those two ends more so than in the middle because programs in the middle are better understood because they're directed by the hospital care system, whereas these two at the outer end are community based, and oftentimes the veterans are not aware of what those programming services are for them. In many cases, they're not in place.

[The Chair, Conservative, Rob Anders]

Thank you very much.

And now it's on to Monsieur Perron with the Bloc Québécois, for seven minutes.

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

Welcome Ms. Fitzgerald and Mr. Speechley.

Your presentation was quite interesting. However, it only dealt with the southwestern part of Ontario. Do experts in different provinces or different regions communicate with one another? Can you give me a general outline? Do your studies reflect the situation in other provinces?

[Clara Fitzgerald]

If the question is are these types of programs and services in place in various parts of Canada as compared to southwestern Ontario, the answer is no. I can't speak to the study. Mark can speak to the study. When we look at the types of programs and services that I was recommending should be in place to help with the functional mobility of veterans and older people in general, for these types of programs and services, although they may exist in various pockets, the level of funding, the level of evidence to support these model programs is not consistently coordinated.

At the Canadian Centre for Activity and Aging, we are a national leadership training centre as well. So we certify people to become leaders of these types of programs nationally.

I was just mentioning to Mark on the flight over that we've never been contacted once at the Canadian Centre for Activity and Aging by Veterans Affairs Canada to ask us where these types of programs exist, where certified personnel to lead functional mobility programs exist in Canada. And we can give you a snapshot of where those programs are in place, but there is definitely a cost to those programs because they're not offered at no cost.

[Mark Speechley]

To answer your question, if our program weren't successful for southwestern Ontario veterans, there's no reason to believe it would be successful for veterans elsewhere in the country. But I'm not sure that was your question.

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

Did your study produce the same results as studies that were done elsewhere in Canada?