Veterans Affairs Committee on Dec. 4th, 2007

[David Pedlar]

Again, I don't have that kind of detailed information. However, caseload is complicated. It wouldn't simply be the number of cases divided by the number of case managers. It would be based on the number of clients who we think require different levels of intensity of service. The kinds of clients who would require the most intensive service would be ones who have high health care needs.

One of the factors in the veterans independence program is that we have a wide breadth and depth of need. So we have a considerable number of clients who have relatively lower care needs and therefore require less intensity in terms of how their caseload is managed, and we would have clients who were more in the middle, and then we would have clients who have high levels of health care needs.

[David Sweet, Conservative, Ancaster—Dundas—Flamborough—Westdale, ON]

That's fine. I knew there'd be different levels of intensity, but we don't have the data anyway.

[David Pedlar]

I don't have the direct answer to your question.

[David Sweet, Conservative, Ancaster—Dundas—Flamborough—Westdale, ON]

That's fine.

You say that in 2008 there are going to be some findings of this study. Mr. Shipley asked you a bunch of questions, and I have to admit that I might be a tad confused. In regard to this particular study that's going to be delivering its findings in the spring of 2008, when did it begin?

[David Pedlar]

The data collection started a year and half ago.

Marcus, is that correct?

[Marcus Hollander]

Yes. I think it started in 2006.

[David Pedlar]

The data collection started in 2006.

[David Sweet, Conservative, Ancaster—Dundas—Flamborough—Westdale, ON]

The other question I have is, in all the studies that have been done, has it ever been studied, looked at, or proposed, having a doctor involved and the cost of actual house calls? In other words, would there be a cost saving if, rather than the veteran having to get the physical capability to get to a doctor's office or a hospital, there were house calls to monitor the veteran's health?

[David Pedlar]

I don't have a direct answer to that question either. There are different ways that we use medical professionals. Medical professionals may be involved in pension medical exams, which is one way we may work with physicians. Another would be that we do have medical advisers involved in our care delivery teams who work with the veterans independence program at our district offices. So we actually do have physicians involved in medical care and in medical care decision-making; however, it's primarily the counsellor and other health professionals who visit the home.

I actually don't have a direct answer to the question. I don't know if Marcus has any experience with models that do direct doctor visits.

[Marcus Hollander]

No.

I think it's an important area and it's one that would in fact be good to study. I think that to do that more broadly you would want to be looking at making some connections between the primary care system and the continuing care system, really to see what options there might be for physicians to be encouraged to make these kinds of house calls or to work perhaps within the home care organization.

What has happened in some home care organizations across the country is that they have contracted with physicians. I believe in one case in Toronto it was with the person responsible for family medicine in the hospital. There is a recognition that there needs to be better linkages with physicians. So if you have a home care organization that has a physician, they can link with the physicians in the hospitals to facilitate discharge, and they can link with community physicians as well, in terms of issues related to care.

So the role of physicians is very important in this, but I'm not aware of a number of circumstances where there is an actual program of home visits. I believe there are some physicians who are doing it, but I think it's limited at this point in time.

But it is an important topic, and—

[David Sweet, Conservative, Ancaster—Dundas—Flamborough—Westdale, ON]

I just have one more question here.

I'm glad you thought it was advantageous to study.

[The Chair, Conservative, Rob Anders]

Thank you very much.

Bless your heart, Mr. Sweet. Six minutes and nine seconds.

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

[Roger Valley, Liberal, Kenora, ON]

Thank you.

I want to return, just a bit, to a question I didn't get an answer to, about urban, rural, and remote.

You mentioned in part of your answer back to me that there are different ways of identifying high-risk people. I'm concerned that maybe people who are out in the rural areas should start off rated at a higher risk. In your comments to me earlier, you mentioned that there are timelines and care has to be planned more ahead of time.

We're used to that when we live in the rural areas. We understand what it means to travel for services and everything else, but I would almost make the point that in rural areas they should be at a higher level, and the remote areas definitely should be at a risk because they have very few or no services, with almost no travel options. I'm talking about fly-in locations at the extreme level.

Going back to the two studies you mentioned, have we missed something with not putting more of a focus on studying how we serve in the rural areas?

[David Pedlar]

I agree that we should continue to focus on this issue. It's a challenge, and I think you've made a good point by underlining it as something we should continue to focus on. I appreciate that focus.

In terms of how risk is defined, I think that's more or less what I was saying. It's not so much to say that anyone in a rural area is at higher risk, but it could be said that for people in rural areas who have certain risk factors, like people who live alone or who have higher levels of health care challenges, at the equivalent level of need they could be at higher risk because of problems that might be related to their access to supportive services.

So I agree generally with the direction of your comments.

[Roger Valley, Liberal, Kenora, ON]

So as a committee, when there are two studies ongoing and we're waiting for a report, and we don't want to delay that in any way, how do we involve those people and get a study that will show some of the dramatic differences? I think they're there.

[David Pedlar]

One thing that had been briefly discussed earlier was that we do have an expert who is a member of our Gerontological Advisory Council, Norah Keating, who has done a study that we financed and worked on with the University of Alberta and the Royal Canadian Legion. The committee may want to hear about that study in more detail, and we'd be delighted to share that information with you so that you can look at the results of this work and discuss how it could better inform veteran care. We'd like to get your perspective on it as well.

[Roger Valley, Liberal, Kenora, ON]

Thank you. I think she has already testified before us. Maybe there could be a return visit.

I'm going to give you both an option. You're talking to politicians. If you could wrap it up in a couple of sentences each, tell us what needs to be fixed. You've outlined many things. You have a couple of studies going on and they're going to be provided. But what could we do right now that would make life better for these veterans?

You mentioned that we're losing quite a few, and their families, due to age and everything else. Tell us in a couple of sentences what you would do right now to change it, without all these studies in your way and with legislation, which takes time and action by government, which drags itself out. What would you do if you could flip a switch right now and make a change for these people we're trying to serve?

[David Pedlar]

I'll answer that question with a few points.

I think the “Keeping the Promise” document gave us a good template, and while it can't be done immediately, some of the key points included making a single integrated health care program. That can't be done overnight, but it can be done probably in a relatively quick period of time if the decisions are made to support that.

Simplification of eligibility is another point. It has been a long-standing barrier to veterans accessing our program.

Another area would be making sure that we have our assessment tools in place to measure care needs and care levels that are as well developed as possible. We do have good tools in place, but we could strengthen those tools over time.

Make the continuum of care more comprehensive. That's also consistent with the “Keeping the Promise” document. There are probably points on the continuum of care where we need to have more options and the flexibility to use those options, such as areas of assisted living.

In the kinds of studies I think Dr. Hollander is working on, he'll probably be able to tell us more about whether there are things we can do right now in terms of opportunities to do more substitution of care. Within our current care model, that would mean asking if there are any additional opportunities to substitute care, and that would mean keeping people home longer if that's where they want to be. I think these studies may help to identify some opportunities in that area as well.

Finally, informal care is an ongoing area, and there are ways we can support informal care. I think our study will help to inform that question as well.

[Roger Valley, Liberal, Kenora, ON]

Thank you very much.

[The Chair, Conservative, Rob Anders]

All right. Mr. Sweet didn't finish his last round of questions, and it is time to go back to the Conservative Party.

Mr. Sweet, for five minutes.

[David Sweet, Conservative, Ancaster—Dundas—Flamborough—Westdale, ON]

Thank you, Mr. Chair.

Doctors, I'm just going to follow up with one more question, then my colleague Ron Cannan will have some questions for you.

I'm glad you thought there might be some merit in including doctors for house calls, particularly in the kind of study that you have in metro Toronto, where you'd have a high density of veterans. But I can also see where Mr. Valley is concerned about the rule of having veterans saved of all the travel they would need to undertake to get to the medical care that only a doctor could provide.

But my final question was just this. You had mentioned in your opening remarks that you have some preliminary findings from the study you're working on, and you most kindly said that if we asked you, you would give them to us. Could you give us some of those preliminary findings from that report, which is going to be due in its entirety in the spring of 2008?

[David Pedlar]

Maybe I'll ask Marcus if he would be kind enough just to give a very high level of what some of the themes are in the preliminary or early findings, to help to support the work of the committee.

[Marcus Hollander]

I am happy to do that.

Here are some of the key findings, which are similar to what we found in other studies.

If you standardize the care need and you have a classification system that allows you to group people into similar categories of needs so that you can make apples-to-apples comparisons, it does seem to be less costly to provide care in the home. What that means in terms of possible implications for consideration by Veterans Affairs Canada is that it would be appropriate to look at whether there are any current policies that may limit the amount of resources available, and to explore whether Veterans Affairs would like to consider caring for people more actively within the community than they are currently.

Certainly the data seem to indicate that it would be less costly to care for people with similar levels of care if they were able to remain in the community, so there is an opportunity, I think, for the kind of substitution David has talked about. When doing so, one has to be somewhat careful, because just because it costs less doesn't meant it can apply to everyone. This would need to be done as part of an appropriate assessment process and so on, but the opportunity seems to be there.

The other thing is not a direct finding, but an indirect finding, as with other studies. It is that the opportunities for making those kinds of substitutions.... First of all, the data say that one can make those substitutions. Typically those substitutions are better done within an integrated program whereby you really match a program of services and procedures to the needs of the person so that it is supportive of the kind of direction that the “Keeping the Promise” document has indicated.

We've also found that the spouses make really quite a significant contribution to the care of individuals. Most of the people in the study are veterans and are men, and the spouses make a significant contribution, so if there's something that can be done to further enhance what may be done with spouses, that's something that could be considered. Certainly we now have some documentation about the contribution made by these individuals.

The other thing is that one of the key characteristics to be able to do good research, analysis, and planning is a good standardized assessment tool that has been validated, and a client classification system that's consistent across all types of care. We did use those kinds of tools in our study; we would think that consideration of that point would be very helpful. If you don't have those tools, you're not able to make the kinds of apples-to-apples comparisons that we've talked about.

The other thing that was found had to do with the kinds of services that Veterans Affairs pays for. They have a couple of programs, and there's a bit of a mixture of the kind of thing you'd usually see in a home care or continuing care program and some kinds of services that may be in an extended health benefits program. We simply point that out to see whether any consideration to perhaps recognizing those distinctions would be appropriate.

Those would be the main findings to date that we could comment on.

[The Chair, Conservative, Rob Anders]

Thank you very much.

Mr. Sweet's intention was to allow Mr. Cannan some time, but we're at five minutes and 24 seconds, so we're going to go over to Mr. Stoffer with the NDP. It's the Conservative Party's spot after that, so then Mr. Cannan will have an opportunity.

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

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

Thank you very much, Mr. Chairman.

Gentlemen, I appreciated your response to my colleague David Sweet's question.

We heard that 12,000 new clients have gotten on the VIP service, although we've never had documentation on that. You've indicated that you're not the data person, but if you could get the information for us, we'd appreciate it. Since the government came into power, how many people have actually gotten onto VIP who are new clients; and at the same time, can you tell us how many have gotten off, who've either passed away or just no longer qualify for the service?

Sir, I just heard you say, in conclusion there, that you now have some evidence of what the spouse has done for the veteran. You have some documented evidence. I believe that's what you said. I find that rather incredible, because I don't see why you need to have a study or evidence to know what a spouse does for a veteran. All you have to do is talk to them, go to a military family resource centre. The answer is quite simple. Without them, government wouldn't be able to do their job and a lot of these men wouldn't have been able to survive the horrors of what they went through during World War II, Korea, Bosnia, and now Afghanistan, and everything else. They play a very, very critical role in the care of our veterans.

To say you have documentation now that provides evidence of it is really quite incredible, to be completely frank with you. But if we go on your numbers that over 2,000 veterans die every month, and I figure at least half their widows or spouses die, then you're looking at 3,000 people a month. Since this government formed the government in February 2006, and by the time your report comes out in April, that means 78,000 veterans or their spouses will have died since the “Keeping the Promise” document.

And then, once that document hits the government, there has to be a study by the various department officials and the cabinet. If we get into an election, it's delayed even further—mind you, that's not your business—and the reality is that many thousands more will have passed on prior to receiving any kind of benefit from these studies. My frustration is that many people call up on a regular basis asking for the simplistic answer of groundskeeping and housekeeping services—not health care services but groundskeeping and home care services. That's really what they're after, and they're being denied left, right, and centre.

So could you tell me, why would groundskeeping and general maintenance of their house inside be considered under a health care review?