Veterans Affairs Committee on Dec. 4th, 2007

[The Chair, Conservative, Rob Anders]

All right, I've pounded the gavel already. According to some of the background noise we heard on our earphones here, obviously our guests are available and getting familiar. That's good.

Welcome to yet another committee of veterans affairs. I apologize to everybody for the lateness in assembling today, but another committee was previously using the room, and they went a little bit long, and then there was a matter of setting up extra tables here and reconnecting the sound system.

We are studying the veterans health care review and veterans independence program.

We apologize to Monsieur Perron, because he likes to have guests appear live, but unfortunately these individuals were snowed in. They have graciously been able to join us. Our guests today are Marcus Hollander with the Gerontological Advisory Council, and David Pedlar, director of research for the research information directorate with the Department of Veterans Affairs.

Without further ado, the way it works is that I generally allow 20 minutes. It can be 10 minutes apiece or however you wish. I'm assuming you've been offered 20 minutes. That's the standard operating procedure. After that, the committee members, in a prearranged order, have the ability to ask questions.

So I turn the floor over to our guests.

[David Pedlar, Director of Research, Research Information Directorate, Department of Veterans Affairs]

Thank you very much.

This is David Pedlar speaking from Charlottetown.

First, I want to extend my apologies for not being able to participate in person. I did make two efforts to get to Ottawa yesterday, and I failed on both counts due to flight cancellations, so I hope the committee will accept my apology.

Marcus and I are delighted to be here today to talk to you about what the evidence tells us about best practices in the organization of care delivery systems for the elderly, and the department's veterans independence program in the context of those practices.

I will be going into more detail later in this presentation, but as you have heard in previous presentations from the department, the veterans independence program, commonly referred to as VIP, provides services such as housekeeping and grounds maintenance, which are provided to eligible clients to help maintain their independence in their own homes and communities.

In addition, I will discuss an important research study being undertaken in partnership with the Ontario Seniors' Secretariat, which is nearing completion and is designed to contribute to our ongoing efforts to improve care for older veterans while also sharing lessons learned in veteran care with Canadians.

Currently Veterans Affairs is engaged in the veterans health services review--which you, of course, are aware of--the department's most comprehensive review of health care in over 60 years. The research we'll talk about today will be in support of that review.

In terms of the subject expertise before you today, I have a broad background in research for care of the elderly, as well as expertise in some topics in veterans and military health for our younger clientele as well. My recent expertise in the area of the veterans independence program is largely in the context of the research study that we'll be discussing with you today.

Dr. Hollander is a nationally and internationally recognized expert in care delivery systems for the elderly. He is also the scientific lead on a study of the veterans independence program that we will be discussing this morning.

We'll be doing a joint presentation, so I will now ask Dr. Hollander if he would be so kind as to start our presentation from here.

[Marcus Hollander, Member, Gerontological Advisory Council]

Thank you very much. I'm certainly pleased to be here. Again, I give our apologies as well.

I want to talk a little bit about the broader context of care delivery for the elderly, and then we can talk about the veterans independence program and how that fits into some of the parameters.

How care delivery systems are organized and structured can have a significant impact on how efficient and cost-effective they are in practice. The importance of integrated models of care delivery are now generally recognized, and many people in the continuing care industry support the need for preventive home care and home support for people needing care over the longer term.

An extensive program of research on the cost-effectiveness of home care, the national evaluation of the cost-effectiveness of home care, presented a number of policy recommendations regarding how home care services could be structured. The synthesis report of the project notes that if home care is to make more readily the types of substitutions required to achieve greater effectiveness, it needs to be part of a broader, integrated system of home care and residential care, often referred to as continuing care.

By having administrative and fiscal control over such a large integrated system of care, senior executives and policy-makers can take steps to ensure that appropriate and cost-effective substitution of home care services for acute care and residential care can in fact take place. Simply enhancing expenditures on home care per se may have a limited effect unless steps are taken to ensure that appropriate substitutions can be made of home care services for acute and/or residential care,

The history of home care and continuing care services is one of amalgamation of professional and supportive services. However, in our current national policy, the focus seems to be on shorter-term professional home care. Nevertheless, a recognition of the importance of preventive and supportive care is reflected in recent recommendations in Ontario and British Columbia to enhance home support services to allow people to remain in their homes.

There is some evidence about the extent to which long-term preventive home support services can reduce admissions to hospitals and long-term care facilities. A British Columbia study indicated that long-term home care can prevent or reduce the rate of admissions to hospitals and long-term care facilities. People who only received housekeeping services and were cut from service in two health regions were compared with people who were not cut from services in two similar regions in the mid-1990s. In the year before the cuts, the average annual cost per client for those cut from the service was a little over $5,000 compared with about $4,500 for the comparison group. These costs included hospital services, physician services, and drugs, as well as long-term and home care services.

In the third year after the cuts, the comparative costs were $11,900 and $7,800, respectively, for a net difference of some $3,500. Thus, on average, the people who were cut from care cost the health care system some $3,500 more in the third year after the cuts than people who were not cut from the service. Total costs over the three-year period after the cuts were $28,000 and $20,500, respectively, for those cut from care compared with those not cut from care. Most of the differences in the costs were accounted for by increased costs for acute care and long-term care services.

With regard to home support services providing a community-based alternative to residential care, a study of the cost-effectiveness of long-term home care found that over time and for all levels of care needs, home care on average was significantly less costly to government than care in a long-term care facility. It was also found that the savings from substituting home care services for residential services were not theoretical, but that actual savings were achieved in British Columbia from the mid-1980s to the mid-1990s by holding down future bed construction of long-term care facilities and by making investments in home care. Over a 10-year period, due to a policy of substituting home care for residential care, some 21 persons per 1,000 people aged 65 and over were shifted from residential care to home care.

What does not seem to be fully appreciated in the current policy discussion is a seeming paradox of service provision. While elderly persons with functional limitations have health conditions and need medically necessary care, the appropriate responses to their health care needs are, in large part, supportive services. Taking the time to give a bath to a senior who needs care, preparing a meal and feeding that individual, and ensuring a safe and sanitary environment in the home does not have to be done by a nurse. For people who are too frail to shop, cook, or take baths on their own due to their medical condition, this type of personal support allows them to maintain their independence for as long as possible, and may actually save the health care system money by avoiding repeated hospital admissions and premature entry into long-term care facilities.

A major strength of the veterans independence program—which David will discuss—is that the preventive care and home support services have remained a key focus of the VIP program over time, to the benefit of veterans and their families.

[David Pedlar]

Thank you, Marcus.

I'll continue and talk about the veterans independence program and the research study.

The veterans independence program, or VIP, which you're familiar with, serves just over 100,000 clients across Canada. About 6,400 of these receive nursing home care. It's our flagship program for seniors. It was designed to function as an integrated and coordinated continuum of care, including home care and institutional care components. There continues to be considerable interest in VIP as a care model among other groups such as the Royal Canadian Legion and also in jurisdictions across Canada and elsewhere.

VIP, first known as the aging veterans program, was started in 1981 as an alternative care model for aging WWII veterans. The program design was developed in the late 1970s to address the enormous challenge of planning for the care needs of over half a million WWII veterans who would be reaching old age in the 1980s. The new model would provide an alternative to the building of thousands of new long-term care beds, while also satisfying the preference of veterans to remain in the community with their families as long as possible.

The program was built on the cutting-edge notions of independence and care in the community. It has evolved and undergone a number of modifications, but there are several core principles I want to go over briefly.

One is comprehensiveness. The program is comprehensive in scope, with a wide range of services to promote choice and address a wide range of types and intensity of care need. I think you are familiar with the components: services for personal care, home-making, access to nutrition services, grounds maintenance, health and diagnostic services, home adaptation, nursing home care, transportation, as well as access to a broad range of treatment benefits.

The concept of early intervention has also been a hallmark of this program. The VIP is what we call a preventative and maintenance home care model. It provides a lower level of service intensity during the early stages of a client’s functional decline in order to promote well-being and independence and more successful adaptation in the longer term. In this way, services can be adjusted over time to compensate for changes in health circumstances as health needs increase with frailty or disability.

Home support services are another key part of the program, including basic housekeeping and grounds maintenance. These have been essential features of the VIP design. As Dr. Hollander has stated, home support is a critically important type of support that is based on the idea that a modest input of non-professional services like homemaking and grounds maintenance can play a pivotal role in supporting well-being, living at home, and functioning in the community as long as possible. It also plays an important role by supporting and leveraging the inputs of care provided by family caregivers, who are a cornerstone of veteran care.

Self-managed care is also an enduring theme of the VIP program design. In most jurisdictions VIP clients have the flexibility to choose their own provider of services for home-making, personal care, and grounds maintenance services, unless they want or need help making these decisions. This aspect of the program promotes independence and choice, as users often want to play an active role in decision-making about service choices.

Finally, case management is the fifth key point. It is also a central feature of the program. This is an approach that organizes client contact, needs assessment, planning for care, follow-up, and management of care transition. The human resource input to support this is called the client service delivery team, located in district offices. The team, led by a counsellor/case manager, works closely with a client service assistant, nurses, and medical advisers to problem solve, work on complex care plans, and approve certain service and equipment requests.

I'm going to talk a little about the overseas veteran pilot, which has also helped us confirm the effectiveness of the VIP program design as an alternative to costly institutional care.

In 1999 Veterans Affairs implemented the overseas service veterans at home pilot project in three sites that were identified as having significant wait times for admission to a contract bed. OSVs, which I think you are familiar with now, are a group of VAC clients who were not eligible for VAC programs except for our most expensive program, a contract care bed. The pilot sites were Camp Hill in Halifax, the Perley in Ottawa, and The Lodge at Broadmead in Victoria.

Under the pilot, veterans who had historically only been eligible for this most expensive option, a contract bed, if assessed as requiring long-term care and if a bed was not available, could receive interim benefits from the VIP program--in other words, home care benefits--while they were on wait list.

The pilot was successful, and after an internal assessment it was revealed that for the majority of participants, should a bed become available, their preference was to remain at home with the added home supports. Interestingly, housekeeping services were the most used element of the program. Families reported that the home care option played a key role in maintaining their independence and helping them continue in their role as caregivers.

Upon completion of the assessment of the pilot, it was extended nationally in November 2001, and formalizing legislation was passed in 2003.

In a nutshell, though, the pilot is kind of a dramatic illustration of how care substitution can work. If more desirable care options are available, it's possible to deliver care for less cost. As this project was not comprehensively evaluated at the time, it is part of the focus of an important research study, which I'll now briefly talk about, that's called the continuing care research project, to make informed decisions on continuing care policy at Veterans Affairs, as well as to make a contribution to national policy-making on continuum of care issues.

Veterans Affairs implemented a large-scale research study in partnership with the Ontario Seniors' Secretariat. The overall purpose of the study is to develop new knowledge to contribute to future policy and planning with respect to continuing care for veterans and to contribute to the broader policy debate regarding the provision of health services to the elderly.

The research project has two overlapping studies. Taken together, both studies feature a measurement strategy that includes a sophisticated economic analysis of financial costs and care outcomes for veterans independence program clients across three care contacts. That's in-home care and residential care, and also supportive housing. This will include measurement and costing of care contributions from VAC, but also from other sources, including informal primary caregivers. Level of care need is also carefully measured to ensure apple-to-apple comparisons of costs and outcomes.

The first study addresses the need for further study of the OSV pilot that I have just described. It is intended to provide a rigorous and independent evaluation of the OSV initiative. Information has been collected through hundreds of interviews at the sites of the original pilot: Halifax, Ottawa, and Victoria. Here the focus is on comparison of home care and institutional care, consistent with the pilot. Analysis of this information is now under way.

The second study is a broader and larger cost-effectiveness study of home care, supportive housing, and residential care. It's being undertaken in the Toronto area, in which three groups of veterans will be compared: clients in long-term home care, clients in supportive housing, and residential care clients. Over 1,000 interviews are completed, and analyses are well under way.

This study will address some key questions about the VIP and the continuum of care, including a rigorous review of the OSV pilot, including the overall strengths of the VIP model and our continuum of care and approach. We'll be able to look at levels of satisfaction with the program among veterans and family members. We'll be looking at the cost-effectiveness and efficiency of the continuum of care, and whether there are opportunities to improve effectiveness or encourage more care substitutions. Finally, we'll be understanding more about the contributions of family caregivers, who play an important role in veteran care.

Data collection for these studies is complete and analyses are under way by Dr. Hollander and his group. Final results of these studies are expected to be available in the spring of 2008. We'll be receiving feedback on these studies from a national advisory committee. It includes representation from three provinces as well as a number of groups with an interest in continuing care in Canada.

We would be able to describe today some of the preliminary findings, if members want to explore that in more depth.

Overall, the purpose of this kind of work is to learn more about how to organize care delivery systems and how to use resources effectively, because using resources effectively would be a key issue in the context of the veterans health services review.

To conclude, we believe the VIP has been a very effective program. Two key features of the program's design are emphasis on prevention and maintenance and on its recognition of the importance of basic home support services.

We look forward to the results of the research study we have discussed, to better understand the program and how it can be improved in the context of the veterans health services review.

I thank the chairman for the time we had available to us to present this morning. Thank you.

[The Chair, Conservative, Rob Anders]

Thank you very much.

To give you witnesses a sense of where we're going with this, and I'm sure you already largely understand it, I think pretty much everybody around the table is generally in favour of expanding the program. It's a question of to what extent, where the lines are drawn, and what we recommend, in a sense.

With that, I'm now going to the prearranged rotation for questions, first with the Liberal Party of Canada.

Mr. Valley for seven minutes.

[Roger Valley, Liberal, Kenora, ON]

Thank you very much

Thank you for joining us today. We appreciate the fact that weather kept you away from us, but we're glad to have the opportunity to talk to you.

You listed a number of things, and the main thrust of my questions will be about different areas of the country. I first want to go to the...and I'll use your words here. I think you said it's five key principles that have survived the test of time.You list them here and you mentioned them in your comments.

Briefly--we have heard this since it was touched on over and over again through your presentation--can you list the services VIP would provide? There's probably a half dozen to a dozen of them. Can you run through them quickly for us again?

[David Pedlar]

That would be my pleasure.

One area is personal care services. That would be services required in the performance of activity of daily living, such as eating, dressing, washing, grooming, toileting, and ambulation. Another is grounds maintenance. That's to assist with grass cutting, snow removal, and so on and so forth. Another area is housekeeping. These would be services for routine domestic tasks, such as laundry, vacuuming, cleaning floors, dusting, etc. Another would be access to nutrition. This would cover either going to sites to eat or delivery of food to the home, so that's wheels to meals or meals on wheels. Another is transportation costs. That's transportation to participate in social activities, to do banking, shopping, visiting, and so on and so forth. Another is called ambulatory care. That's to assist with health and social services outside the home, such as adult day care and respite care. Another area is called health and support services. These are health assessments, diagnostic services and personal care. Those are largely provided by a health professional. Home adaptations are also possible under the program to facilitate access to the home. I think there's a maximum dollar per residence for those kinds of services. Finally, of course, there's nursing home care, which is also part of the continuum.

Those are the main services that are available under the veterans independence program. Housekeeping would be the most used element of the program at the moment.

[Roger Valley, Liberal, Kenora, ON]

Thank you. I did catch in your comments earlier that housekeeping is the most...I'm not sure “popular” is the right word, but the one that's accessed the most.

On the ones that touch directly on health care services, these aren't provided by the department, then. They're provided by provincial workers, contract workers, obviously, if it's a professional service being applied.

[David Pedlar]

Yes. Different aspects of the program would have different approaches to accessing. For example, as I mentioned earlier, one of the models that are part of the program, one of the key principles I mentioned, is self-managed care, and that means, for many of the services we provide, that the veteran can play a key role in choosing providers in his or her community to provide the services. In many cases, we have a third-party payer who can actually handle the administration of the payment of the costs around the program.

Generally speaking, though, we don't have a team of housekeepers and health professionals who actually go out and provide the programs. The expertise or the support is found in members' communities. I know we have lists of providers, care lists and provider lists, in different communities to help veterans find providers who can provide support for them.

[Roger Valley, Liberal, Kenora, ON]

Thanks. That will get right to the point I want to bring up.

I'm looking at page 9 of your document. You talk a bit about the success in how you're providing the services in the urban areas. Is there any evidence on how successful we are out in the rural areas?

I notice that your study, too, is going to be in that very rural area of Toronto. So I'm trying to figure out how we make sure we're receiving some level of service that's equivalent to what happens in the big urban centres.

Then I have a second part to that question. Even lumping urban and rural together, you then get to remote areas—and I serve the riding of Kenora, which has a lot of remote sites.

Are there any studies or evidence on how successful we are in the rural areas and then, after that, in the remote areas, which would be very difficult?

[Marcus Hollander]

We actually did a study a few years ago with the Royal Canadian Legion and the University of Alberta that looked at issues facing rural seniors. This study focused not necessarily on our clients but on a group of veterans as a whole. The research study involved surveys, analysis of Statistics Canada information, and also some community case studies.

We do know that there are often problems with availability of services in rural versus urban areas. We also know that there are regional differences in the availability of services. So these are challenges we struggle with, and we don't always have simple answers in terms of how to address them.

One thing we do know, though, is that in terms of how we case manage clients--that would be how our counsellors work directly with clients in these kinds of environments--we have to be aware of high-risk groups, groups that we might have to pay more attention to. Those would be people without social support--in other words, people who have less of a social support network to help them. Those would often be people who are alone or isolated or who have more health challenges. We know that there are certain key things that can help us when we work with clients in those areas. We have to pay more attention to certain kinds of risk factors for clients who live in those areas in terms of how we deliver our program and how we case manage.

In terms of strategies for success in rural areas, we know that living in a rural area may require more planning ahead for services in order to access them. More effort may be required in seeking services. Therefore, the self-manage aspect of our program, which gives a client considerable flexibility in who they choose to provide services, could also be of assistance.

Also, as you would know, being able to drive and have transportation can also be critical and is often more important than it is for clients in urban areas, especially if public transportation is not available. Therefore, paying special attention to what we can do in transportation, whether it's social transportation to assist with banking or other social needs or whether it's medical transportation, can be especially critical in these areas.

We also know that connections to other people and social support can play a really important role for people who live in rural areas. So making sure that veterans can connect with social groups or Royal Canadian Legions or other opportunities that can help them connect with other people and build support systems can also be of great assistance.

This is an ongoing challenge for us.

I hope I've provided some helpful information to address your question.

[Roger Valley, Liberal, Kenora, ON]

Thank you.

[The Chair, Conservative, Rob Anders]

Thank you very much.

Now we're over to the Bloc Québécois. Monsieur Perron, you have for seven minutes.

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

Good morning, Mr. Chairman. Pardon me for not being very clear-headed this morning. I got up at 5:00 a.m. to get here. The road between St-Eustache and Ottawa wasn't pretty at all.

Gentlemen, I would like you to tell me about home care. I don't know whether you have conducted a study or whether you've gone to see how that works in Quebec. It seems you omitted Quebec from your presentation.

For the past 12 to 15 years in Quebec, local governments have decided to favour home care. That has been and is a not very successful operation. One fact is noteworthy. I don't know whether it's because of family solidarity, but it works better in rural and isolated communities than in the major centres. The major centres have problems.

In Quebec, the government helps by subsidizing residences housing a number of generations. For example, we could transform my house, either build another one, or build part of a house near mine, and my parents would live there with me. The government would assist me financially in modifying my house, as it provides financial assistance for modifying apartments, by adding ramps, for example, to assist seniors.

Personally, I've noticed—and this also appears to be the case in Quebec—that home care works well when both elderly partners are alive. When one of the two dies, the other goes first to the home of a son, then to the home of a daughter, then to that of another son, then to the home of another daughter. That causes all kinds of problems.

Care must be taken with regard to home care. Of course, your report talks about thousands of dollars saved, but what are the economic consequences for the person who receives this care at home? That isn't a question; it's simply a comment.

Since I find it very hard to speak into thin air, I'll stop my presentation here.

[Marcus Hollander]

My first response is, in terms of the study we're undertaking, that what you point out is correct. We're not undertaking the study in Quebec. But I want to emphasize that we have not forgotten Quebec.

If you look at the broader work that we're doing in the context of the health care review and if you look, for example, at the “Keeping the Promise” document and the work I've done myself over the last decade or so; in fact, the “Keeping the Promise” document relies heavily, in a lot of the service innovations that it talks about, both in the areas of screening and in some of the concepts around the single-entry model, on current cutting-edge practices in Quebec.

In many ways, in terms of the “Keeping the Promise” document and other work we're doing, we looked at Quebec as a model in many areas of our program designed for elderly people. So Quebec has not been forgotten. It actually plays a very important role in terms of the thinking we've undertaken around the veterans health services review.

I wasn't exactly clear on a specific question to address, outside of my general comment. I don't think I have anything more to add to that. However, if you could reformulate a question, I would be delighted to reply to it.

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

No, I've finished, my friend.

[Marcus Hollander]

Thank you.

If I could just add something to what David was saying, in the research we're doing and in the work nationally and in this study and other studies, the issue of family members, particularly the spouse, who may remain either after the person dies or certainly if the person goes into a long-term care facility, is an important aspect and one that needs to be addressed perhaps more actively.

What happens to spouses and the contribution that the spouses actually make to the care of individuals was something we did look at. Certainly the contribution of the spouses came up in terms of the work we're doing and the policy options or suggestions Veterans Affairs might consider to further support families and spouses, particularly in circumstances in which the person in care may go to a long-term care facility.

[David Pedlar]

If the time hasn't run out, I should just mention that we do provide considerable support to informal caregivers now. One of the best forms of support, though, is home support, like housekeeping. This is a major support for families. It reduces the burden on family members who might otherwise have to provide that care, and it allows them to continue their efforts.

We also provide various types of respite care to give caregivers a break. We extended VIP services to primary caregivers, or to a group of primary caregivers, as you're well aware. We can also pay for family members to provide care under certain circumstances, such as when they live outside the veteran's home, and occasionally when they live with the veteran, although criteria can be tighter for that kind of support.

Finally, caregiving is a major part of the study we're undertaking right now. We're actually going so far as to cost the contribution of caregiving. It will give us, as well, a more nuanced understanding of what caregivers' needs are. There's also a second study under way. It's a smaller-scale study, but we're looking at caregivers of younger disabled CF members. So caregiving and support to families is a major focus and a major concern of research and of the department.

[The Chair, Conservative, Rob Anders]

Fair enough. Just so the witnesses know, rarely does witness time run out. We extend a great deal of discretion to you. How much time the members each have is a question of respect for the rules and respect for each other in terms of our original agreement. So you often have greater latitude than the member asking the questions.

Now we're on to the New Democratic Party and Mr. Stoffer, for five minutes.

[Peter Stoffer, NDP, Sackville—Eastern Shore, NS]

Thank you very much, Mr. Chairman.

Thank you, gentlemen, for appearing before us today via telephone.

This is my first question for you. How many veterans and their spouses and/or widows or widowers do we have in this country?

[David Pedlar]

I actually don't have that number right at my fingertips. I'm sorry about that. I can provide that to you. There are different ways of slicing and dicing that one. I would want to make sure I had it correct.

[Peter Stoffer, NDP, Sackville—Eastern Shore, NS]

Okay. Then how many World War II and Korean veterans and the spouses and/or widows and widowers of that class of veterans would be around?

[David Pedlar]

I know that there are around 220,000 veterans of World War II and Korea. I think there are something like 260,000 survivors. But if we are getting down to numbers, my preference would be to confirm numbers and reply back to the committee.

[Peter Stoffer, NDP, Sackville—Eastern Shore, NS]

Okay. To receive the VIP program, one of the questions DVA asks individuals is about their income. Is that correct?

[David Pedlar]

Not necessarily. I think you've probably heard from other members that eligibility for our programs is sometimes complex, so there are different--