Veterans Affairs Committee on June 5th, 2012

[The Chair, Conservative, Greg Kerr]

We're back in business. I appreciate your patience. We had some committee business we had to deal with.

As you know, we're continuing the study of transformation initiatives at Veterans Affairs Canada.

Today, we have Veterans Affairs and National Defence representatives. I want to say welcome and thank you very much, the four of you, for coming in. I think you know how this works: ten minutes to each pair and then we go to questions from committee members.

Ms. Pellerin, are you starting today? Carry on.

[Anne-Marie Pellerin, Director, Case Management, Rehabilitation and Mental Health, Department of Veterans Affairs]

Thank you, Mr. Chair.

Good afternoon, and thank you for the opportunity to participate in this session.

My name is Anne-Marie Pellerin, and I'm the director of case management, rehabilitation and mental health services. I'm joined by my colleague, Lina Carrese, who is the scientific director of the National Centre for Operational Stress Injuries. We also have with us today Raymond Lalonde, who is the director general of the operational stress injury national network, and Nathalie Pham, who is a client service team manager in our Montreal office.

We're happy to be here to support the committee's study on transformation at Veterans Affairs. We realize the time is tight and we have a lot to cover, so I'll get started.

Recently, Veterans Affairs Canada found itself facing an unprecedented shift in veteran demographics. Traditional veterans are, sadly, passing away in great numbers while the modern-day veteran population is on the rise.

We have also noticed that many modern-day veterans are being released from service with more complex health and re-establishment needs.

These factors have forced us to re-examine what we do and how we deliver service as a department in order to meet these changing needs and expectations. The results of this examination have led us into this process of transformation designed to improve the quality, timeliness, and efficiency of services, and to ensure that we are fully responsive to the diverse and changing needs of those we serve.

VAC case management services enable veterans and their families to establish and achieve mutually agreed upon goals through a collaborative, organized, and dynamic process. This interactive, problem-solving process is coordinated by the VAC case manager and includes six core functions: engagement and relationship-building, a process of building and establishing trust; comprehensive assessment, which is the gathering of information and identifying the needs of the individual; analysis, which is synthesizing information gathered from multiple sources; case planning and consultation, which is to establish mutually agreed upon goals with the veteran and family in consultation with health professionals and other experts; monitoring and evaluation, to identify whether the plan is working and to make adjustments as required; and finally, disengagement, which is ending the current case management relationship when goals are achieved. It is important to note that re-engagement in case management services is possible should the veteran's circumstances change at a future point.

The VAC case management model focuses on a holistic needs-based approach that is based upon the determinants of health as established by the World Health Organization. The model is dependent upon interdisciplinary consultation to support effective case management.

Over the past two years, we've made significant progress with our transformation initiatives and this is having a positive impact on our case management services.

For example, we've improved the timeliness of our decisions through a reduction in the turnaround time for rehabilitation program eligibility decisions. As a result, program participants are able to access needed benefits more quickly.

We have developed and implemented workload intensity tools that measure risk, need, and complexity of case-managed clients. These tools help to evaluate caseloads, based not only on the number of active cases but also on the level of complexity and intensity associated with each case.

We have developed a national case management learning strategy that focuses on development of skills and knowledge.

We have established national guidelines and protocols that support national consistency in case management practice.

The implementation of these tools and supports is enhancing the effectiveness of case management services, reinforcing standards and best practices, and assisting with the identification of training needs and resource allocation.

We have learned a great deal from academic institutions and other organizations with expertise in the field of case management.

Specifically, we've partnered with McMaster University and the Canadian Centre on Substance Abuse on the development of the competency profile for our case managers. This partnership has allowed us to draw upon the expertise, tools, and best practices that these organizations have developed.

We are also affiliated with the National Case Management Network, which allows us to share knowledge, expertise, and best practices with organizations across the country. Last year, Veterans Affairs Canada was invited to provide a key note presentation at the network's national conference on the topic of our core competency profile.

As of March 31, 2012, there were approximately 250 VAC case managers across the country. Our national standard is to ensure that the case manager to veteran ratio is approximately 40 to 1. Today, we are well within that target.

Our case managers come with a diversity of educational backgrounds. Our qualifications require that they have a degree from a recognized university, with specialization in social work, nursing, psychology, gerontology, sociology or some other specialty relevant to the position.

Almost two-thirds of VAC case managers have five years or more of case management experience. These factors indicate a varied and experienced workforce, something of which the department is very proud.

Before turning things over to my colleague, I would like to briefly highlight some of VAC's rehabilitation initiatives, an important stage for veterans and case managers, as more than 70% of our case-managed clients utilize our rehabilitation services and vocational assistance program.

The purpose of this program is to ensure that ill, injured, or disabled veterans and their families have access to professional rehabilitation services designed to facilitate the transition back into their homes, communities, and civilian workplaces. Funding is available for services that are not otherwise available through other health care systems.

Examples of services provided to address physical and mental health rehabilitation needs include: psychiatric and psychological treatment and counselling services, physiotherapy, occupational therapy, interdisciplinary pain management, and addictions counselling.

In closing, we see the transformation process that l've just described as an investment in case management, an investment that is already paying dividends. We are now more capable of identifying risks within our clients and much more able to shift the appropriate resources to quickly mitigate those risks. We have strengthened, and will continue to strengthen, case management services and will ultimately improve the outcomes for those we serve.

Thank you, Mr. Chair.

[Lina Carrese, Scientific Director, Department of Veterans Affairs]

Thank you, Ms. Pellerin.

Thank you, Mr. Chair.

The mental health and well-being of veterans and their families is indeed a priority for our department. We recognize the serious impact that operational stress injuries can have on Canadian Forces personnel, veterans and their families. That is why we work diligently to ensure that evidence-based services are in place to support veterans with mental health conditions, and their families, in their journey to recovery, and to help ensure their successful re-establishment in civilian life.

These initiatives are built around the Veterans Affairs Canada Mental Health Strategy that focuses on ensuring a continuum of programs and services based on the key determinants of health, such as economic, social and physical environments, personal health practices, coping skills etc., to help meet the holistic needs of veterans and their families.

The mental health strategy also aims to enhance awareness of the needs of veterans and their families in their communities, and build sufficient capacity among Veterans Affairs programs, provincial and community organizations, and providers to effectively treat veterans and their families, and ensure that there are no gaps.

Over the years, Veterans Affairs Canada has greatly expanded its mental health services. In 2006, the new Veterans Charter introduced a full package of transition programs and services that has significantly enhanced the department's capacity to support veterans and their families living with mental health conditions.

Since then, we have also doubled the number of operational stress injury clinics and successfully integrated telemental health services in all of our clinics. This ensures that all veterans in need, including those located in remote areas or who cannot otherwise easily access an OSI clinic in person, can nonetheless receive timely services. Today, between Veterans Affairs Canada and the Department of National Defence, there are 17 specialized clinics across the country that provide assessment and treatment services to Canadian Forces members and veterans with operational stress injuries.

In addition, there are approximately 4,000 registered mental health professionals across the country, 200 of whom are clinical care managers who can provide intensive day-to-day support to veterans who have particularly complex mental health needs. For veterans struggling with substance abuse problems and operational stress injuries, there are several in-patient programs available throughout Canada that specialize in the treatment of post-traumatic stress disorder, for instance, complicated by addictions.

Veterans Affairs Canada and the Canadian Forces have also developed what is now an internationally recognized peer support program, which includes specially trained peers, but also family peer support coordinators who have firsthand experience with operational stress. They provide the most vital support to fellow CF members, veterans, and their families. The department also provides, through the VAC assistance line, 24 hours a day, 7 days a week, access to counselling and referral services for mental health concerns. Also, pastoral outreach services, made up of a network of 200 chaplains, are made available by Veterans Affairs Canada. These chaplains provide spiritual guidance and support for veterans and their families in need.

Our approach is veteran and family centred. It is based on the latest scientific evidence and on the social determinants of health, and it is partnership-based. We work in strong collaboration with partners, both in the community and in government, including the Department of National Defence, and in this instance to also promote successful transition to civilian life for releasing Canadian Forces members and to stay abreast of trends in the domain of military and veteran mental health.

In short, veterans with mental health needs have access to specialized mental health care services across the country, for assessment, for early intervention, treatment, rehabilitation, and ongoing care via Veterans Affairs Canada, community service providers, and the VAC-DND network of operational stress injury clinics.

We believe that our approach is working. Today, Veterans Affairs Canada is assisting more than 15,300 veterans and their families with mental health conditions. As the needs of veterans and their families evolve, our mental health strategy is being revised to keep pace, so that we can continue to assist with the recovery process based on the key determinants of health.

The strategy will continue to support successful transition into civilian life, enhance awareness of the needs of veterans and their families in the communities where they live, further facilitate the veterans' rehabilitation as needed, contribute to the improvement of personal and family well-being, and build strong partnerships with provincial and community organizations and providers to ensure that there are no gaps in the support for our deserving veterans and their families.

Thank you for your time today, Mr. Chair. I would be happy to answer any questions you might have.

[The Chair, Conservative, Greg Kerr]

Thank you very much, Ms. Carrese.

We'll now go to Colonel Bernier, please.

[Colonel Jean-Robert Bernier, Deputy Surgeon General, Department of National Defence]

Mr. Chair, ladies and gentlemen, I am Colonel Jean-Robert Bernier, Deputy Surgeon General of the Canadian Forces. I am accompanied by Colonel Gerry Blais, the director of the Joint Personnel Support Unit and of Casualty Support Management.

I am very happy to be here today and to have the opportunity to talk to you about the Canadian Forces Case Management Program.

The Canadian Forces health services national case management program was implemented as a result of identified gaps in the health care system, especially for transitioning CF members to civilian life. Since its inception, registered nurses have been employed as case managers to help thousands of Canadian Forces members in coordinating the myriad services they need to cope with their physical and mental health challenges.

Although many challenges influenced the program's evolution over the past decade, dedicated nurses continue to deliver professional and high-quality services to Canadian Forces members. The feedback from the case management satisfaction surveys reveals that the program is extremely valuable, both to CF personnel and to their families.

The program currently employs 57 case managers who continue to meet the many challenges arising from the medical complexity of their clients' needs. Although the work environment and the demands are in constant transformation, the program's mandate remains the same: to assist our members either in returning to duty or in making the transition to civilian life.

CF health services nurse case managers lead the coordination of health care and support to serving CF members in partnership with the joint personnel support unit and its integrated personnel support centres, for which Colonel Blais is responsible. As part of the CF health care team, they are responsible for developing an integrated action plan in conjunction with their patients, Canadian Forces members, integrated personnel support centre personnel, partners such as Veterans Affairs case managers, and other outside agencies.

This plan helps CF members recover by ensuring continuity in the monitoring and coordination of in-hospital and home care support. Health services case managers continue to provide support and advice even after Canadian Forces personnel return to duty. If the CF member is leaving the forces, they help with the transition to Veterans Affairs services, if required, and to civilian life. The program is focused on the client and family and applies evidence-based treatments and best practices. Because it's integral to the military health care system, it provides continuity of care and acts as a bridge between health services and other elements of the Canadian Forces and its services.

Constantly striving to improve, the case management program is currently assessing a new work tool, Intermed, which is used to determine the degree of complexity of our clients' transition process. In addition, our case managers are in constant contact with our partners at Veterans Affairs Canada, whether through bilateral groups or on a routine basis in the joint personnel support units, ensuring that we share common work tools and providing for the best possible communications between our organizations.

We have many collaborative initiatives with Veterans Affairs to make transition to civilian life as seamless for CF members as possible. These include referral forms, a trial assessment tool, shared electronic and computerized tools, and a new process for disclosure of health information that will involve electronic tracking and transfer to Veterans Affairs. Following a pilot project currently initiated at bases in Edmonton, Valcartier, and Trenton, this process will eventually be nationally implemented.

Other initiatives will include the sharing of program processes and structure through common staff training, joint workshops, and symposia to enhance partnership, harmonization of program and policies in order to enhance continuity of care throughout the transition, online training for case managers for common subjects, shared working groups and committees, and development of a joint quality management review process to assess the transition process and strengthen continuity of care.

To further improve our case management program, we will seek its accreditation during our next cycle of review by the national health quality assessment authority, Accreditation Canada. We will jointly also pursue opportunities with Veterans Affairs to increase our program leaders' knowledge, increase networking through common service delivery training for program managers, maintain a national-level stakeholder committee, increase outreach activities, and link with other organizations, such as provincial and international case management learning networks and organizations, such as the National Case Management Network, and seek more innovative service delivery models. We will also share our information and training on quality improvement, identify outcome measures, and review our service delivery to improve efficiency and effectiveness.

Mental health problems account for a large portion of our case managers' workload and contribute enormously to our case complexity.

However, the mental health team, as an integral part of our health system, has access to the case management program. This allows for rapid access and intervention, ensuring that our members are quickly taken in hand and given access to our full range of services as soon as possible.

As well as assisting CF personnel on a daily basis, the CF health services case management program has long been working collaboratively with the directorate of casualty support management and Veterans Affairs in striving to provide CF members with the best services and benefits to meet their needs.

Our greatest challenge in the transition of CF members to civilian life is in helping them access family physicians and mental health providers within the provincial civilian health systems. Although we continually seek and receive support in this regard from local and regional civilian health authorities, the Canadian Medical Association, the academic deans of university faculties of family medicine, the Royal College of Physicians and Surgeons, and other health authorities, this is an area over which we have little influence in the context of national scarcity and limited access to these health professionals.

In summary, despite increasing demand and the growing complexity of the cases associated with the operational commitments of the Canadian Forces, the introduction of new policies and our new partnerships, Canadian Forces health services managers, through their commitment, are continuing to meet daily challenges, helping to perpetuate the success of the case management program.

Thank you for your attention. I would be pleased to answer your questions.

[The Chair, Conservative, Greg Kerr]

Thank you very much, Colonel, and all presenters.

We're now going to start the five-minute rounds. Mr. Stoffer starts off.

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

Thank you very much, Mr. Chairman.

Folks, thank you very much for coming today.

Colonel Bernier, you just indicated the complexity of trying to find civilian assistance for military personnel when they leave the forces. As you know, unfortunately, 20 military personnel committed suicide last year. That doubled the rate of last year. Even with all of the great efforts that DND and DVA are making to assist these people, it still is an unfortunate tragedy that our brave men and women, unfortunately, for whatever reason, decide to take their lives.

Would it not be advisable then, sir, in the context of that, and in the context of these severe PTSD and mental health challenges they and their families are going through, that if they exit DND on a 3(b) or medical release of some kind, they be able to keep—even though they are veterans—the access to DND, to keep that link with them until a particular private or provincial service is found? Right now, what happens is they leave DND and that's it. Then they get help and try to find another doctor. Five and half million Canadians don't have one now. It's very difficult for DND personnel to find one as well. Would it not be advisable to do that in order to assist them?

My question for Anne-Marie Pellerin—you indicated that 40 to 1 is now roughly the ratio. Are you almost there yet?

[Anne-Marie Pellerin]

Mr. Chair, we're actually exceeding that at the present time.

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

Great. That's good. So there are 215,000 veterans who are cared for under DVA right now in terms of its benefit.

In the brochure here, Ms. Carrese said there are 15,300 under mental health. I assume they are being case managed? There are 15,300 being case managed by 250. That's almost 60 per case worker. I'm just wondering if you can explain the difference, because 250 case workers with 40 is 10,000, so 15,300 means almost 60 per case worker. I'm just wondering if you could explain the difference there.

Very quickly, my last comment—and you don't have to comment on this one. I am always a bit amused when I hear officials like yourself and others say that you have discovered that the older veterans have been dying off recently. I think we have all known they have been doing that for quite some time.

I just throw that out there. Thank you.

[Col Jean-Robert Bernier]

Thanks for the question.

I'd first like to just address the suicide rate issue.

Every single one of the suicides is a huge tragedy for us because they're our family members in uniform. It's a very different society, very tightly integrated, so every CF member is a brother and sister. And it affects the medics as well as everybody else. So it's a very serious problem for us to address.

However, we continue despite these years of war.... We expected an increased rate. We've always expected an increased rate because of the stresses of operations. We haven't seen it happen yet. We still remain roughly 20% below the national average for the age and sex-adjusted rate.

We had 19 male suicides last year. Suicides are such a rare occurrence, happily—even though every single one is a tragedy—that statistically, epidemiologically, we need to eliminate chance as the cause of a spike in a rate. So we've been following carefully suicide rates since 1995.

We have to block them in five-year blocks to get an adequate numerator of suicides, in order to get a statistically significant outcome for a suicide rate. The 19 for last year are in the first year of the next five-year block. It is possible that it's the indication of an upward trend as a result of operations in Afghanistan. However, even if we had five years of 19 males, or a total of 20, it would still remain below the national rate.

The rate since 1995, if anything, has decreased, but it's remained the same. We've carefully analyzed, for any link to deployment, every single suicide since last year. We examine very carefully with psychiatric expertise. We essentially do a psychological audit of each individual suicide. So far, there is no specific trend; there is no link specifically to deployment. Up until last year, the majority of our suicides were people who had never deployed before.

So we're not sure, but we're cautious, because we've anticipated an increased rate. We can't yet determine that it's an increase. Statistically that would be irresponsible of us to state at this point. We could not scientifically state that there is an increase at this rate because the numbers are so low.

With respect to the transition to civilian life of soldiers who require ongoing care, last year the defence minister announced an integrated transition plan to be applied to every soldier being released for medical reasons. That provides us up to three years of transition time, not only to get their medical care in place with the provinces and with additional services provided by Veterans Affairs, but also vocational, social, and any other element that would help set them up for a successful transition to civilian life.

We'll never be perfect because there is a national shortfall in medical care, specifically in certain health professions across the country. Constitutionally, our society has decided that the armed forces are there to conduct military operations, and the other institutions—the provinces and the provincial health systems, supplemented by care from Veterans Affairs—are there to provide care to people after they've released from the armed forces.

We do continue, for example, our specialized mental health clinics, operational trauma and stress support centres, and the 10 Veterans Affairs operational stress injury clinics. We have a memorandum of understanding where we can continue caring for each other's patients even after release. So we can care for veterans, if it's convenient logistically and otherwise, and they can care for serving Canadian Forces members as well where it's convenient. We take advantage of that, but we still do have challenges that are not unique to the Canadian Forces but that affect all of the Canadian population.

[The Chair, Conservative, Greg Kerr]

Thank you very much, Colonel.

I'm going to have to ask if you will respond maybe next time in the NDP slot because we are quite a bit over time.

Ms. Adams, please, for five minutes.

[Eve Adams, Conservative, Mississauga—Brampton South, ON]

Thank you very much for appearing before us today.

Could you perhaps identify for us the role of the case manager and the evolving role of the case manager under transformation, please?

[Anne-Marie Pellerin]

Yes. Within Veterans Affairs, Mr. Chair, the case manager gets engaged during the transition process at the integrated personnel support centres, the 24 IPSCs across the country, where we are co-located with National Defence staff. The case manager gets engaged with the releasing member prior to release to get a sense of what the health or re-establishment needs are prior to release. That enables the case manager, together with the releasing member and the releasing member's family, to begin building a plan, putting a plan in place, so that upon release there is as little to no interruption in service as possible.

That plan will address not only the health needs from a medical and psychological point of view, but also the re-establishment needs in terms of assistance that may be required in finding civilian employment.

It's a comprehensive approach in terms of addressing the re-establishment needs.

As I said, the engagement begins pre-release. It's an ongoing, problem-solving relationship that's established between the case manager and the releasing member or veteran upon release. As I alluded to, we do encourage the family to be involved in that process because the family unit is important, and understanding the family dynamics, in terms of that re-establishment process, is critically important.

[Eve Adams, Conservative, Mississauga—Brampton South, ON]

What types of new authorities have been granted to case managers to make decisions on behalf of veterans? What types of authorities have devolved or have been brought closer to the veteran, and how does that reduce wait times for the veteran?

[Anne-Marie Pellerin]

Mr. Chair, I have a couple of examples whereby we have delegated decision-making authority to what we call the front line, making sure the decisions are made as close to the veteran as possible, whereas in the past, some of those decisions had to be escalated to either regional or central office for adjudication.

In the case of the rehabilitation program, we have delegated the decision-making authority for program eligibility to the case manager. We have also delegated authority to the case manager for making decisions on benefits within the rehabilitation plan.

That enables the case manager to put interventions into place very quickly. It enables the veterans to receive those needed benefits much earlier than they would have otherwise if the decision-making had remained at a higher level.

[Eve Adams, Conservative, Mississauga—Brampton South, ON]

You've empowered the case manager. The individual who interacts with the veteran is able to see the capabilities of the veteran as opposed to having that case manager document or make notations, and so on, and have somebody who's removed, perhaps at another office, make that final decision, an individual who had never even come in contact with the veteran previously.

Is that correct?

[Anne-Marie Pellerin]

That's correct.

[Eve Adams, Conservative, Mississauga—Brampton South, ON]

Do you have some metrics on the types of reductions to wait times that veterans are seeing now because of the delegated authorities?

[Anne-Marie Pellerin]

Yes, I do.

Mr. Chair, in terms of the rehabilitation program eligibility decisions, prior to the—I guess it wasn't so much the delegation of authority, but recently we've reduced the service standard around those decisions from four to two weeks. That means the veterans who apply to the rehabilitation program—

[Eve Adams, Conservative, Mississauga—Brampton South, ON]

Pardon me, you increase the service standard by reducing wait times, correct?

[Anne-Marie Pellerin]

We improved the service standard—let's put it that way—by cutting down the turnaround time on those key decisions.

Again, that enables the veteran to get access to needed benefits much sooner than had been the case before.

[Eve Adams, Conservative, Mississauga—Brampton South, ON]

They're half of what they were previously?

[Anne-Marie Pellerin]

They are half of what they were before, that's correct.

[Eve Adams, Conservative, Mississauga—Brampton South, ON]

That's rather remarkable.

[Anne-Marie Pellerin]

We are achieving that standard 85% of the time.

In other words, veterans are providing the needed documentation. Once we have that needed documentation to make a decision, those decisions are made very rapidly.