Veterans Affairs Committee on June 5th, 2012

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

There's an automatic renewal there? Could you perhaps expand on that? Is it a speedier renewal?

[Anne-Marie Pellerin]

Automatic renewal—I believe you are referring to the treatment benefits, so the treatment benefit programs, whereas previously authorizations were required based on renewal of treatment benefits. The requirement for those renewals, pre-authorization, has been removed.

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

Okay, thank you very much.

Have you received feedback from the veterans on these new processes?

[Anne-Marie Pellerin]

We have anecdotal evidence from our veterans in terms of their satisfaction with the case management process and the earlier intervention. We haven't done a study, so to speak, but certainly the anecdotal evidence would suggest that there is certainly satisfaction with that earlier intervention, earlier access to needed benefits.

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

Thank you.

[The Chair, Conservative, Greg Kerr]

Thank you very much, Ms. Pellerin.

Now we go to Mr. Casey for five minutes.

[Sean Casey, Liberal, Charlottetown, PE]

Thank you, Mr. Chairman.

My first question is for Colonel Bernier.

I'm interested in your comment with respect to the profound difficulty you're having in the transition of CF members to civilian life and access to family physicians.

We've heard at least a couple of times in this committee—once was that fateful meeting on February 27 in Halifax with Dr. Heather MacKinnon, but we also heard from Dr. Alice Aitken. As you may know, she is the director of the Canadian Institute for Military and Veteran Health Research. She appeared before the committee on February 14. This is a quote from Dr. Aitken, someone who is an expert in the field:

My biggest challenge was in the transition to provincial health care, where I got the same treatment as a prisoner, and I was informed of that. When my husband transitioned out later, he was medically released and had served in both Bosnia and Afghanistan. The impact on our family was mitigated by the fact that we had both been military and knew what to do.

But I think his biggest struggle was in transitioning to a civilian health care system that didn't understand his needs.... Also his front-line service provided by Veterans Affairs…is sometimes a very difficult bureaucracy for the veteran to deal with.

This is from someone who is ex-military and who is now engaged full time in military and veterans health research; this is her personal experience.

I appreciate that it's difficult because of what's happening in provincial health care systems. Tell me what you think of this suggestion and whether it's workable or what we need to do to make it work. What about having a member of the forces obligating the medical caregivers looking after that person to continue his or her care until there is a successful transition or until there is a civilian doctor willing to accept that person as a patient? I realize that increases the workload on those within the employ of DND, but it seems to me that the workload is a worthwhile priority for us to invest in, even if we need to get more.

What are your thoughts?

[Col Jean-Robert Bernier]

Thank you for that question. I know Alice Aitken very well. She was a physiotherapist in the armed forces, in the medical service. She's currently an associate professor of rehabilitation at Queen's University and assists us in coordinating health research related to the military and veterans.

Things have changed a lot since she retired from the armed forces—and her husband, who I also know very well.

Obligating Canadian Forces medical staff to continue to provide health care to persons at the point of release would be ideal. It would mean, however, either a very significant increase in resources to the armed forces, if the government and society expects the armed forces to continue having its medical service fulfill the purpose for which it primarily exists, which is to serve military missions and support military operations, or, through the constitutional allocation of responsibilities, somehow enhance the capability of provincial health care for civilians and the resourcing of Veterans Affairs. There are various measures under way throughout the provinces to expand the availability of primary care through the use of alternative providers, such as physician assistants, significant expansion of medical schools, the use of nurse practitioners. There are various efforts ongoing within the provinces to fulfill their constitutional commitments and responsibilities to look after retired armed forces members.

One of the activities that I mentioned earlier, which the minister announced a while back, was the implementation of the integrated transition plan and up to three years of transition time, to permit the establishment to help find individuals.

Other things we do, as I mentioned, are through various fora such as the Canadian Medical Association, the academic deans of the faculties of medicine, to try to generate support. In some cases there have been successful pilots or successful establishment of a commitment by civilian provincial family health teams to reserve a certain number of positions in their clinics for armed forces families and retired members.

Most recently, the Chief of Defence Staff at the Canadian Conference on Medical Education in Banff met with the academic deans of the faculties of family medicine who are undertaking an initiative specifically for that purpose.

I mentioned the U.S. system, the U.S. defence department, where there's a congressional mandate for the U.S. armed forces to provide care to veterans and their families, and after release as well, before medicare takes over. Of the massive U.S. defence budget and the massive health budget, which exceeds that of all of Ontario, only the defence health budget...a few years ago, over 70% of that money went to provide non-military operational health care. So only 30% of that budget was going to actually support the purpose for which armed forces exist, fighting wars and conducting military operations. There would be a very significant bill that would come with that.

[The Chair, Conservative, Greg Kerr]

Thank you very much, Colonel Bernier.

Now we go to Mr. Chisu for five minutes.

[Corneliu Chisu, Conservative, Pickering—Scarborough East, ON]

Thank you very much, Mr. Chair.

Thank you very much for coming to our committee.

Ms. Pellerin, you made an affirmation in your presentation, which we have also noticed, that many modern-day veterans are being released from service with more complex health and re-establishment needs. I would like it if you could elaborate on this.

That will lead to a question to Colonel Bernier related to the Canadian Forces health services, the national case management program. In your presentation you made a statement that you have 57 case managers and that the mental health program accounts for a large portion of the case management workload and contributes enormously to the case complexity.

I would like to ask you about the prevention of substance abuse in the Canadian armed forces. When I was deployed in Afghanistan, more than a hundred soldiers were found positive for substance abuse and were not deployed. That created a big problem for our forces.

Those are the two questions I would like to ask for the moment.

[Anne-Marie Pellerin]

Thank you, Mr. Chair.

In terms of the release of modern-day veterans, we have been finding for a number of years that the complexity of the health and re-establishment circumstances of those releasing members is different, obviously, from the traditional clients with whom Veterans Affairs had been dealing with prior to that. What we are seeing is a combination of physical and mental health conditions among those being released in our modern-day veteran population.

For instance, at the present time, in our rehabilitation program we have participants, 55% of whom have both a physical and a mental health condition. You can appreciate that this combination presents significant challenges, not only for the veteran but for the veteran's family and for the re-establishment of that individual in civilian society. That complexity of physical conditions, often accompanied by pain, mental health conditions, the increase of substance abuse and addictions, have all increased the complexity of those who need case management services through Veterans Affairs.

So the importance of that case management relationship is critical in terms of working with a veteran, facilitating access to services within the community where the veteran resides, and supporting the family to deal with those complex issues. When the veteran is at a stage of readiness from a health perspective, and if the veteran needs support in terms of vocational re-establishment, it's putting those supports in place to assist him or her to attain suitable civilian employment.

That whole process, the engagement of the case manager, can take a fairly significant period of time.

For those reasons, we talk about the differences in terms of our modern-day as opposed to our traditional veterans.

[Corneliu Chisu, Conservative, Pickering—Scarborough East, ON]

Is it possible for DND, before they release the member to Veterans Affairs, to take a few more steps so that when you are presenting the case it is less burdensome for you? I'm just asking whether cooperation could be a little closer with DND.

[Anne-Marie Pellerin]

Yes.

[The Chair, Conservative, Greg Kerr]

Mr. Chisu, I was just going to say we're going to run out of time before our DND witness can actually answer.

Colonel Blais, please.

[Colonel Gerry Blais, Director, Casualty Support Management, Department of National Defence]

I'm happy to say that exact situation has now developed. For about six months now we have been ensuring that every person who is medically released is presented with what is called an integrated transition plan. All of the different partners sit together at the table: Veterans Affairs, the health services case manager, people who look after education needs and employment needs post-release. We sit down and include the individual in that conversation, and a transition plan is prepared for each one of them. The member signs off at the bottom of that before he's released, indicating that he understands what's in there and is happy with it.

In that plan we also have the flexibility, if there are more complex needs, for education or whatever. We can extend the service for up to three years to ensure this transition goes smoothly.

[The Chair, Conservative, Greg Kerr]

Did you want to add to that, Ms. Pellerin? You looked like you were going to jump in.

[Anne-Marie Pellerin]

No.

Colonel Bernier, I don't know if you want to comment on this question.

[The Chair, Conservative, Greg Kerr]

Just briefly, please.

[Col Jean-Robert Bernier]

May I comment on your question about mental health prevention efforts?

[Corneliu Chisu, Conservative, Pickering—Scarborough East, ON]

And substance abuse?

[Col Jean-Robert Bernier]

And substance abuse.

Back in the 1990s, things were not good. We've improved dramatically since then. We spend almost $40 million a year now just on mental health—$38 million and something a year—and we have spent over $100 million since 2006 in the increased health system budget.

We do a lot of screening and a lot of education and peer support. There are screenings for mental health conditions at enrollment, regular periodic health assessments pre-deployment and post-deployment, detailed assessments post-deployment at three to six months, third-location decompression, at which there are mental health professionals and education ongoing at that time as well, enhanced post-deployment screenings at the time of release, and ongoing research all the time at a global level to try to identify the problem.

For education, there are the Strengthening the Forces health promotion programs that cover all of the impacts and basically all of the issues that are symptomatic of or causative or that contribute to mental health conditions. In particular, there are programs on addiction awareness to help people identify not just the individuals themselves but supervisors and peers where people are having difficulties. We have in-patient treatment programs and we have a series of civilian programs to which we send folks.

There's a very detailed program called Road to Mental Readiness. That's an international model looked at around the world. It provides detailed education and enhances resilience as well as recognition—self-recognition and peer and supervisor recognition—of mental health issues. That begins right at the time of basic training and has components throughout all career courses now, and peri-deployment—pre-, during, and post-deployment.

Finally, we also have a very robust peer support network of people who personally have suffered mental health conditions in the past, to help individuals who may have an issue but are reluctant to present it, or who don't recognize that they have a problem, and to get them into care, which is the best thing we can do to resolve their mental health condition and prevent things like suicide.

[The Chair, Conservative, Greg Kerr]

Thank you very much for that, Colonel.

Ms. Mathyssen, for five minutes.

[Irene Mathyssen, NDP, London—Fanshawe, ON]

Thank you very much, Mr. Chair.

Thank you very much for your information.

I want to go back to some of the things Madam Pellerin said, just for clarification.

You indicated that there are approximately 250 VAC case managers across the country and that the goal or standard is 40 clients per case manager. Could you explain why that is important? What's the necessity of achieving that or of perhaps, as you indicated, being well within that target?

[Anne-Marie Pellerin]

Thank you for the question.

The case management function is a very critical and important function within Veterans Affairs, and we want to ensure that our case managers have a caseload that is reasonable within a standard of practice, so that they can dedicate the time required to individual veterans and ensure that they are able to provide the case planning, the monitoring, and the work with the family. We are endeavouring to ensure that the ratio of caseload to case manager is no more than 40 cases. In fact, at the present time we're exceeding that number. We're at an average of about 30 cases.

If I could at this juncture get back to the question Mr. Stoffer asked earlier, I'll note that we have just over 15,000 Veterans Affairs clients or veterans who are accessing benefits of the department for a mental health condition. That could be for a disability, a benefit, or accessing a rehabilitation program. But not all of those 15,000-plus veterans are being case-managed, nor do they require case management services, because the majority of those who have a mental health issue are in fact able to function well in society and in fact are doing that. So it's those who have the most complex mental health issues—and we're running at about 25% of that cohort—who are actually receiving case management services.

[Irene Mathyssen, NDP, London—Fanshawe, ON]

I understand how important it is to have that positive ratio in terms of managers to clients.

You also said that the modern-day veteran population numbers are on the rise, and that many of these modern-day veterans are being released from service with more complex health and re-establishment needs.

Last week the veterans' ombudsman was here. He gave us some statistics, and I want to run these by you.

The department's own life-after-service studies show that two-thirds of Canadian Forces former regular force personnel released between 1998 and 2007 are not receiving benefits. However, 54% of those report at least one physical health condition; 13% report at least one mental health condition; and many report chronic health conditions [following on] three decades of high operational tempo.

So potentially a lot of people are going to need services. You've indicated that it's important to keep the ratios down and to make sure those services are truly effective.

The ombudsman worried that needs would not be met.