Veterans Affairs Committee on March 10th, 2015

[The Chair, Conservative, Royal Galipeau]

Welcome, folks.

I call the 39th meeting of the Standing Committee on Veterans Affairs to order.

This morning we have two distinguished guests: Colonel Hugh MacKay, deputy surgeon general of the Canadian Forces;

and Col. Marc Bilodeau, Director of Medical Policy at the Canadian Forces Health Services Centre.

This morning, Colonel MacKay will have an opening statement of less than 10 minutes. After that, we will have rounds of questions.

I rather like the approach I took last week, with fewer constraints, and I propose to follow the same approach this week, except not quite so much. I would appreciate MPs, as they question the witnesses, keeping an eye on the chair and his twitchings, because I don't like to bring down the gavel. I appreciate the collegiality of the meeting and I'll do what I can to maintain it that way. But if you don't look at the chair, you might hear unpleasant sounds.

Thank you very much.

Colonel MacKay, the floor is yours.

[Colonel Hugh MacKay, Deputy Surgeon General, Canadian Forces, Department of National Defence]

Thank you very much, Mr. Chair and distinguished members of the House of Commons Standing Committee on Veterans Affairs.

I'm very pleased to have the opportunity to talk to you about the medical care offered to our Canadian Armed Forces, or CAF, members, the treatments and services offered to our members in the operational trauma stress support centres, known as OTSSCs, and the support they receive from the case management program when they are transitioning out of the CAF as the result of a medical condition that makes them unfit for military service.

Joining me today is Col. Marc Bilodeau, Director of Medical Policy.

The Canadian Forces Health Services Group's main objective is the provision of care to Canadian armed forces members both within Canada and abroad. In consideration of the fact that regular force members are excluded from the Canada Health Act, Canadian Forces Health Services Group is responsible for their care, as all provinces and territories are for that of their citizens.

In-garrison ambulatory care is provided through a network of more than 40 military clinics from coast to coast and overseas. Our interdisciplinary approach, consisting of a mix of military and civilian physicians, nurses, nurse practitioners, physician assistants, medical technicians, and a varying range of other health care providers, depending on the location, enables high-quality health care and is considered the way forward in the civilian sector. It is similar to the College of Family Physicians of Canada's “Patient’s Medical Home”. Should a service not be available in a military clinic, the patient is referred to the most appropriate civilian health care provider in order to ensure that they receive the care they need.

As long as a CAF member is serving, they will receive the care they require in accordance with the CAF Spectrum of Care document. The Spectrum of Care provides CAF members access to the types of care that are similar to those available to Canadians; however, when a member needs a very specific type of treatment that is not included in the Spectrum of Care, a process exists to provide for these exceptions where necessary.

The inclusions and exclusions are based on medical evidence and are reviewed as technology, medications and knowledge advance in the medical world.

To address the sometimes complex physical injuries that Canadian Armed Forces personnel face, Canadian Forces health services has undertaken the integration of additional physiotherapy personnel into our affiliated civilian rehabilitation centres of excellence, through the creation of the Canadian Forces rehabilitation program, to bolster the services normally provided by these centres. The acquisition of two CAREN, computer-assisted rehabilitation environments, located in Edmonton and Ottawa, has also added to the complement of standard therapies available to Canadian Armed Forces members. These measures aim to ensure that injured and ill Canadian Armed Forces members who wish to remain in uniform are provided with optimal conditions and opportunity to achieve that goal whenever possible.

The provision of care regarding mental health treatment is a priority. Canadian Forces health services has a comprehensive mental health system that provides evidence-based clinical care in most of our military clinics across Canada and in Europe. We continue to enhance our efforts to combat mental health stigma and prevention through our road to mental readiness program. Mental health care often starts in our primary care clinics. Where necessary, they are referred to our multidisciplinary mental health teams consisting of psychiatrists, psychologists, social workers, mental health nurses, addictions counsellors, and pastoral counsellors. These teams specialize in the diagnosis and treatment of all mental health conditions, which includes operational stress injuries, but also depression, anxiety, and addictions problems.

We also have seven specialized operational trauma stress support centres, centres of excellence specialized in the delivery of care of such operational stress injuries as post-traumatic stress disorder. Our OTSSCs are located on the larger military bases, but also serve as regional referral centres for military personnel from other bases. Additionally, the seven OTSSCs are part of a joint network of operational stress injuries, which also includes the Veterans Affairs Canada OSI clinics. Through a tripartite MOU, this network allows for care of military members, veterans, and members or former members of the RCMP in either military or Veterans Affairs Canada facilities when it is deemed appropriate for a given patient.

In an effort to enhance our mental health program, we're in the process of piloting CROMIS, the client-reported outcome management information system. It will allow for rapid treatment outcome assessment and will guide the optimization of individualized care. We are also in the process of implementing enhancements to the Canadian Forces health information system, which will add direct-entry capability for mental health notes. This will enable the improved timely communication between primary care clinicians and mental health professionals, further strengthening the collaborative care they provide.

Within the mental health program there's a strong research element. Currently the main research efforts are focused on the analysis of the 2013 Canadian Forces mental health survey and through the recently announced Canadian Military and Veterans Mental Health Centre of Excellence, where research is conducted on unique aspects of military and veterans mental health.

Canadian Armed Forces members with more complex medical needs also benefit from the case management program. This program was established more than ten years ago. It offers services in all Canadian Armed Forces clinics located in Canada. Case managers are specialized nurses who are integral to the care delivery team and facilitate ongoing care for patients through a complex period of medical care. The goal of the case management program is to assist the Canadian Armed Forces member to navigate the medical and administrative system. The primary goal, where possible, is to achieve a return to duty after a complex disease or injury. However, for those members who have chronic medical conditions that have led to permanent employment limitations and do not meet universality of service, they work closely with VAC to assist with transition to civilian life in the safest way possible.

There are presently 66 case managers working with and for Canadian Armed Forces members. They carry a heavy caseload, which requires prioritization of patients based on the complexity of their case and care requirements. Our case management program works very closely with their counterparts in VAC. Analysis and work are presently being done to optimize the transition of the releasing member from the DND program to the VAC program.

A working group under the VAC-CAF steering committee has been established and has the mandate to broaden the definitions of case management in order to analyze the elements associated with the continuum of care for soldiers and their families. The transition period around release is a critical time to ensure long-term continuity of care for releasing members. A standardized assessment of all transitioning CF members is being done to determine the level of complexity involved in their transition from DND to civilian life. Whenever a member is identified as having complex needs regarding transition, a multidisciplinary team meeting is convened with the goal of proactively eliminating the identified barriers to allow for a proper transition from a health, financial, occupational, academic, and/or psychosocial perspective. In certain circumstances, additional transition time will be requested by the team in order to secure a safe transition. Each case is handled individually, on its own merits.

The multidisciplinary team will facilitate the transition of care, including referral to specialists and to a family physician in the local community where the released member has decided to reside. A case manager will also help the releasing member to obtain a provincial health card before release and to apply for all other eligible benefits such as SISIP, VAC, CPP and vocational rehabilitation.

When a member reaches the release date, although there is no longer an entitlement to care through the CAF, everything possible has been put in place to ensure the continuity of care via the provincial health care system and/or VAC.

In conclusion, the Canadian Armed Forces are committed to optimizing the health of our members in uniform during their years of service and to maximize their chances of returning to duty after an illness or an injury. For those Canadian Armed Forces members who are unfortunately unable to return to duty, our commitment is to provide them with access to high-quality care and assist them the best way we can to ensure continuity of care through VAC or the civilian health sector as they transition to civilian life.

Thank you, Mr. Chair, for your attention.

[The Chair, Conservative, Royal Galipeau]

Thank you very much, Colonel MacKay. I thank you very much for this edification. I want to thank you also because it lasted less than 11 minutes.

Our Standing Orders give the next round of questions six minutes. I'm going to stretch it out not to 11 minutes like last week, but to seven minutes. Please look at me for a signal.

Now I recognise Mr. Stoffer.

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

Thank you, Mr. Chairman.

First of all, gentlemen, thank you for much for being here today. Thank you both for your service. I'm sure on behalf of the entire committee we send our condolences for the loss of one of your soldiers in arms in Iraq, Mr. Doiron. I know that this hits everyone very hard, so my sincere condolences to each and every one of you.

Sir, in your second to last paragraph you talked about how everything is in place to ensure the continuity of care via the provincial health care system or VAC. As you know, sir, almost five million Canadians don't have a regular doctor now. In our office we deal with an awful lot of people who are fearful of leaving the great health care service they receive from DND to go into the so-called public or private sector. In many communities they don't have access to that provincial care they were receiving beforehand. One of the things that has been suggested for quite some time is the ability of an individual when they release from the military to maintain those connections to CAF medical services until they find a doctor because, in many cases, as you know, sir, when they leave the military there is not a doctor or those types of services available in the public or private sector outside of DND. Has there been any consideration at your level of allowing CAF members when they release to have at least a year or two of continued access to CAF medical services while they transition to public or private services?

[Col Hugh MacKay]

Mr. Chairman, thank you for that question. I will say that at the present time as we look at the management of our patients and the complexity of their care, the way that we try to address the challenges they face with finding care in the civilian health sector is via the option of trying to extend the transition period. We try to maintain the patients within the Canadian Armed Forces for a period of time that will allow us to identify the care that may be accessed in the civilian health care sector. We have not taken into consideration engaging with the veterans once they have left the Canadian Armed Forces, but we have put in place a means to be able to extend the transition period to give us the best possibility of finding civilian health care providers.

I can tell you that I did confirm with our case managers that your point about finding primary care providers is probably their biggest challenge, and they work very hard to try to achieve that. They work in conjunction with the Veterans Affairs case managers to identify those care providers in the civilian sector.

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

When the individuals from the Department of Veterans Affairs were here the other day, the assistant deputy minister indicated that it was up to the DVA to determine who is case managed. Who determines within the military who gets case managed? The reason I ask that is if you have a case manager, you're usually much better off in accessing services, benefits, treatment, etc., than you are if you're not case managed. I'm speaking in terms of home visits, and those types of things.

Within the CF, who determines which CF members get case managed?

[Col Hugh MacKay]

The case management decision is made within the Canadian Forces health services. It's primarily the clinicians who are caring for individuals who look at the complexity of the needs of the patients and identify whether or not it will be necessary for them to be referred to a case manager. Oftentimes that is related to whether or not they have been placed on medical categories, temporary or permanent. We have an assessment process that is undertaken with referrals for case management to determine whether or not they should have their cases managed within our case management program.

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

Mr. Chairman, I'm just going to turn the rest of my time over to my colleague here, but I want to thank the CF members very much for the crew who went over to Africa to help with the ebola crisis. That was simply amazing. Our men and women who risked their lives on a daily basis to help eradicate, or at least stem, the tide of ebola deserve our great gratitude. If you could extend our congratulations to them for the tremendous work they did, that would be greatly appreciated.

[Col Hugh MacKay]

Thank you very much for that. I will extend those congratulations.

[The Chair, Conservative, Royal Galipeau]

Mr. Stoffer, Mr. Chicoine is....

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

I'm going to give him an extra minute.

[The Chair, Conservative, Royal Galipeau]

Go for it.

[Sylvain Chicoine, NDP, Châteauguay—Saint-Constant, QC]

Thank you, Mr. Chair.

I would also like to thank the witnesses for joining us this morning.

Could you explain, if you would, the process behind the decision to medically release a member who has experienced a service-related injury that leads to long-term disability? Could you also tell us whether the member has the opportunity to challenge the decision?

[Col Hugh MacKay]

We have in the military a process primarily run by the directorate of medical policy, whereby we assign employment limitations based on the nature of an illness or injury of a member. We in the health services do not make a decision as to whether or not somebody meets the universality of service standard. That decision is made by the chief of military personnel in the directorate of military careers administration, DMCA.

They look at the employment limitations that have been assigned based on the nature of the illness or injury, and make a determination with respect to universality of service. There certainly is a process where a member who is assigned employment limitations can question those employment limitations. The first step would be to do that with their health care provider. They can review the case, and seek specialist consultation if necessary to determine the nature of the employment limitations and the reasonableness of those employment limitations. If they're not satisfied with the decision from their primary care provider, they can also request a re-evaluation from our headquarters level in the Health Services Group, and we will then also consult further on the case and make a determination as to whether or not those employment limitations fit the illness or injury of the member.

At that point, the file will probably go over to DMCA, which will make a decision with respect to universality of service. If a member is not satisfied with the decision by the DMCA, they also have a further ability to grieve that decision, which could go all the way up to the level of the Chief of Defence Staff for a final determination.

[The Chair, Conservative, Royal Galipeau]

Mr. Hawn.

[Laurie Hawn, Conservative, Edmonton Centre, AB]

Thank you very much, Mr. Chairman.

And thank you both for being here and for your service, as Mr. Stoffer had said.

Just following up on that, we're seeing that it's quite a long process before somebody is determined not to fit the universality of service and that there are many methods for the member to seek redress if he disagrees with that.

Thank you very much.

Can you tell me the average time a member is spending before they're medically released? What's the average time from the determination a member might be medically released to the time the member is actually released?

[Col Hugh MacKay]

I think that for complex cases right now the average time we're looking at is about three years. For non-complex cases, we may not see a three-year transition period. It may be more like two years.

[Laurie Hawn, Conservative, Edmonton Centre, AB]

For the more seriously injured, there's quite a long time of transition, where some of the things you described are in play to condition the member to transition as smoothly as possible to civilian life. Is that a fair statement?

[Col Hugh MacKay]

That's right, sir.

[Laurie Hawn, Conservative, Edmonton Centre, AB]

Okay.

Maybe this is an unfortunately timely example, but there are the three fellows who were injured in Iraq. One is in Landstuhl, so I would assume he's the more seriously injured. Can you step through the process that happens from the time of injury in the field, in deployment—because that's where we're talking about a lot of bad things happening, obviously—to coming back to Canada for those three individuals, starting with the fellow in Landstuhl? For the other two, I don't know their conditions, obviously.

[Col Hugh MacKay]

Perhaps we can focus on the individual in Landstuhl, because that's the more complex case. The others may actually be able to return to their mission, depending on the nature of their injuries.

From the point of wounding, they will have buddy first aid applied. Then a medical technician will provide some advanced trauma care on the scene. They'll be picked up for medical evacuation and brought to a higher level of care, usually at a role 2 or role 3 facility within the area of operations. Once they receive some stabilization care in the role 2 or 3 facilities, a determination will be made as to their suitability for air evacuation back to Canada.

At the present time, we have access to the Landstuhl facility in Germany, which helps us step those casualties back in a safer manner. We step them into Landstuhl, where the patient may again receive further stabilization care, some more definitive care for their injuries. While they're in Landstuhl, we make arrangements for hospitals in what we call role 4 or back-in-Canada care, to be able to receive and manage the needs of patients who are in Landstuhl. I'm aware that we're right now arranging an intensive care unit to intensive care unit transfer from Landstuhl to Canada for this particular casualty.

[Laurie Hawn, Conservative, Edmonton Centre, AB]

Landstuhl played a major role during Afghanistan. Do we still have CF medical staff in Landstuhl routinely?

[Col Hugh MacKay]

Due to the nature of our operations at the present time, sir, we do not have a detachment in Landstuhl, but our medical personnel in Geilenkirchen are tasked to go to Landstuhl when we have casualties there, in order to help them manage and coordinate that care and the transfer back to Canada.

[Laurie Hawn, Conservative, Edmonton Centre, AB]

To switch gears, you mentioned a system called CROMIS. Could you talk a bit more about that and if it's able to speed up the assessment and so on. How does that work and how much is it speeding up the assessment?

[Col Hugh MacKay]

CROMIS is a mental health outcome measurement system. It's actually a system that Veterans Affairs Canada has been using in their OSI clinics. We recognize it as a valuable tool for us to be able to track the care of mental health patients.

As for what this does, patients present, and for each of their care appointments they fill in a questionnaire. We can map the results of that questionnaire on a graph and track the progress of symptomatology, because what the questionnaire measures is their symptomatology, and we know that there's a standard path that we expect patients to take with the improvement of their symptoms.

Should they not be seen to be following the path that we would like to see them follow, then we need to take a second look at what's going on with their care. It allows us the information to be able to tailor the care being provided and to more quickly adjust care if we're not achieving the effect we're looking for.