1. Issues of Leadership and
Government
A. Standards of Care
B. Standards of Institutional Care
(a) Staff
(b) Food
(c) Veteran Safety Issues
(d) Implementation of a Standard of Institutional Care
C. Standards of Care for the Independent Veteran
(a) The Veterans Independence Program
(b) Creative Housing Solutions
2. Turning 4082 beds
in 76 Institutions into a Network
3. Administrative Issues
(a) Consultations
(b) Funding for Training
(c) Billing the Treatment Accounts Processing System (TAPS)
(d) Recognition of Volunteers
GENERAL ISSUES
The case studies show how clearly the "quality of life" of veterans in a chronic care hospital or in an extended care facility depends on
- the quality and attitude of the staff, volunteers as well as management, professionals and service providers;
- the quality, variety, and presentation of food; and,
- the atmosphere, layout, equipment and amenities of the hospital or residence
Veterans and their families had few if any complaints about the quality and attitude of the management, staff and volunteers that looked after them. On the contrary, staff were highly praised for their professionalism, hard work and caring attitude and volunteers were credited with being essential to keep the hospitals and long-term care residences running in the face of staff cutbacks. As we have seen in the case studies , however, both management and veterans raised serious issues about the impact of funding freezes and cutbacks on the quality of food and standards of care.
Members of the fact-finding task force were struck by the mutual respect that marked the relationship between the management and residents of the individual facilities on the one hand, and the local officials of Veterans Affairs Canada on the other. Equally striking, however, was the impression that each hospital or residence stood alone and in isolation from the others, even within the same province; the Department seemed to give them no sense that they were part of a system dedicated to the service of veterans. Nor did the visits suggest that Veterans Affairs Canada was the source of creative new ideas in long-term care.
1. Issues of Leadership and Government
In the years following World War II the Department of Veterans Affairs won a reputation for leadership and creativity as it developed a departmental network of hospitals, long-term care residences and rehabilitation centres for disabled veterans. This network was thought of and administered as a system whose individual parts mutually reinforced each other through the exchange of experience and ideas and knew of their contribution to the whole.
The transfer of all the departmental hospitals (except Ste Anne’s Hospital in Ste Anne de Bellevue) and other facilities to the provinces in the years following 1970 ended direct departmental control of their administration. The sense of being part of a network of veterans care institutions disappeared as the institutions integrated themselves into the evolving health care systems of the provinces. Within these provincial systems devoted to the equal treatment of the whole population, veterans, with their priority beds, special needs and special entitlements, constituted a small minority.
In the 1990’s the provinces themselves moved to decentralised systems for the delivery of health care services to the population. Across the country hundreds of regional health care "authorities" have sprung up, operating under principles and guidelines which differ from province to province. The objective of these health care "authorities" is to make the delivery of health care services more responsive to "local" needs and priorities which do not necessarily reflect those of veterans. While about 14 regions (excluding the region in which Ste Anne’s Hospital falls) are responsible for hospitals and/or residences with 50 or more veterans, only a handful of the remainder are responsible for more than an individual or a few veterans. The net result is that a third level of "government" and bureaucracy now stands between veterans and the level of care they need and to which they are entitled.
Veterans Affairs Canada has made few efforts to offset the increasing isolation of facilities with veterans in their care from other similar facilities. As the system was transferred to the provinces over the years, the Department lost interest in the modernization of the facilities remaining under its administration, much less in replacing them with creative experiments in institutional care. How else can one explain the lack of interest, obvious for more than twenty years, in making the wards of the departmental Ste Anne’s Hospital "state of the art"? The Department also seems to have lost interest in compensating for the loss of a national system of veterans hospitals and long-term care facilities, by adopting a consistent national standard of acceptable care.
The First Report of the Subcommittee set out the reasons why it was necessary for Veterans Affairs Canada to adopt a formal standard of acceptable care. Visits to many more hospitals and residences have confirmed the validity of the conclusion that adoption of detailed standards of care is an essential complement to the "quality assurance" paragraphs of the Department’s "Action Plan for Institutional Long-term care".
The concept of standards of care must not be limited to institutions, but must be extended to veterans living outside institutions. The Subcommittee concludes that in establishing policy and making spending decisions for veterans health care programs, the "quality of life" of a veteran should become as important as the principal of "the benefit of the doubt" is in the pension adjudication process.
31. The Subcommittee recommends that Veterans Affairs Canada adopt the "quality of life" of a veteran as the guiding principle of departmental policy and spending decisions on veterans health care and that this principle underlie the standards of care adopted for veterans in institutions and for veterans living at home.
B. Standards of Institutional Care
The "quality of life" of a veteran who is forced to live in a permanent care facility is dependent on a whole series of inter-related conditions in the facility that must be given close attention. Some of standards that should be included in Veterans Affairs standards of institutional care are set out below.
(a) Staff
It is important that all staff who come into contact with veterans have a good knowledge of what a "veteran" is and how the wartime experience left them with physical and mental disabilities and influenced their post war lifestyle. New staff must come to understand the special medical conditions that set veterans apart from the population at large, conditions such as Post-Traumatic Stress Disorder or the problems arising from long-term abuse of alcohol and the addiction to tobacco. Staff must also be fully aware of the special treatment options and services provided to veterans that are not provided to other residents. The objective of this training must be to encourage staff to offer veterans a level of personal care that recognizes them as special people.
32. The Subcommittee recommends that Veterans Affairs Canada:
- make available a series of training videos which illustrate the service and sacrifices of veterans;
- prepare training videos that outline the qualities and medical conditions that may set veterans apart from the general population and summarise the various special treatments and services available to them; and,
- ensure that the standards of care refer to the need to have this material integrated into the training of new staff.
In almost all the hospitals and residences visited management admitted that staffing levels were adequate to meet little more than basic safety requirements. The "sunset shift" from late afternoon until night-time in particular is under tremendous pressure everywhere. Usually there are simply not enough care givers to help the veterans eat supper, engage in after supper activities, bathe and then get ready for bed. The night shift is also subject to understaffing, being barely able to deal with the routine turning of veterans who require it, answering calls for assistance and dealing with those who rise early. An emergency, and with patients or residents whose average age is over 80 emergencies are not rare, leads to call bells not being answered and to increasing levels of distress.
The Subcommittee has concluded that veterans wards in chronic care hospitals require higher staffing levels than the other wards. On average veterans are older than other patients, tend to have more severe disabilities and/or a combination of physical and mental disabilities, and are more likely to have behavioural problems. As a result they will require more intensive nursing and care.
The Subcommittee does not believe that the quality of life of veterans is compatible with staffing levels reduced to the level necessary to provide for little more than their safe warehousing.
33. The Subcommittee recommends that Veterans Affairs Canada review the staffing levels of hospitals and residences under contract, and in the Veterans Affairs standards of institutional care establish levels of acceptable staffing that exceed minimum safety levels and offer veterans the comfort margin necessary to maintain a high quality of life.
34. The Subcommittee recommends that Veterans Affairs Canada review the staffing levels on veterans wards of chronic care hospitals and ensure that the standards of institutional care provide for additional staffing on these wards.
The First Report outlined the labour situation at Sunnybrook hospital in Toronto where layoffs in another part of the hospital launched a tidal wave of staff "bumping" that had a major impact on the quality of life of the veterans. The experienced nursing staff on veterans wards was replaced by staff which had more seniority, but little or no experience in dealing with the elderly. The loss of continuity in care giving and the need to train the new staff in the individual needs of veterans were disruptive to all veterans and their families, and frightening to veterans suffering from cognitive impairment. The Subcommittee does not believe that the Department should permit this kind of situation to arise.
35. The Subcommittee recommends that Veterans Affairs Canada standards of institutional care ensure that in the event of layoffs, only the most junior staff on veterans wards are subject to bumping and that no staff with six months experience or more on dementia wards be subject to bumping unless by someone judged to have an equal degree of training and/or experience.
Another problem arises when a collective agreement prevents a hospital or residence from hiring part-time workers to help out at mealtimes by imposing unreasonable limitations on wage levels and minimum hours worked. Family members can arrange for private nurses to supplement hospital care or for private attendants to supplement nursing home care. The same right should be extended to Veterans Affairs Canada, to veterans organizations and to community charitable organizations.
36. The Subcommittee recommends that Veterans Affairs Canada standards of institutional care specify that Veterans Affairs Canada, a veterans organization, or a charitable organization shall have the right to hire part-time staff to provide extra care for veterans, under such terms and conditions as the department or the organization shall decide.
(b) Food
Complaints about the quality of food dominated the meetings with veterans and their families. Except for Sunnybrook where the meals were highly rated, the complaints arose from the quality of re-thermalised food served on individual trays. Introduced as a cost cutting measure, re-thermalised food systems have led to almost universal complaints about food quality, to the rejection of meals and attendant rapid weight loss, and to high levels of wastage.
The quality of life of veterans is very dependent on Veterans Affairs Canada ensuring that individual hospitals and residences, local health care authorities and provincial departments of health all understand a simple fact: food quality that is tolerable on an economy airplane flight or for a few days in an acute care hospital cannot, and should not, be tolerated by institutionalised veterans and their families.
Members of the fact-finding task force were not able to conduct a systematic study of how much each of the facilities visited spent on food and meal preparation per patient or resident per day, but the estimates they were given for the cost of re-thermalised meals ranged from about $5 per patient per day to $25 per patient per day. Thus there is at least some reason to conclude that veterans are suffering from the well-known fact of airplane travel – the traveller or veteran as the case may be, does not get better quality than the airline or regional health authority contracts for. If the contracting authority is primarily interested in reducing the costs of acute care, the lowest bid would be the best bid because acute care patients are discharged in a few days: efficiencies of scale and simplicity would then impose the same quality meals on chronic and extended care patients and residents, including veterans.
The handling of re-thermalised food is probably the second most important source of complaints. Most dissatisfaction was voiced about meals that the supplier "plated" in individual servings which were then assembled on trays and shipped to the ward where the trays were re-heated ( in sophisticated systems such as that employed at Sunnybrook, the trays have a hot side and a chilled side.) Bulk handling of the food to be "re-thermalised" and cafeteria or dining room style service would probably reduce complaints about watery and thin soups and sauces and uneven or extreme food temperatures. It would also reduce the number of items that had to be unwrapped or opened at the table.
While the facilities preparing their food on site reported few complaints about the meals, no centralised food preparation system has solved the morning toast problem. Toast was either too soft or too hard to satisfy the individual veteran. The only possible solution is to install commercial toasters in the ward wherever possible.
The Subcommittee believes that the quality of meals served to veterans in institutions is exceptionally important to the veterans’ quality of life. The experience of the task force leads the Subcommittee to conclude that meals prepared on site are superior to those prepared elsewhere.
37. The Subcommittee recommends that Veterans Affairs Canada encourage the on-site preparation of meals.
Where the on-site preparation of meals is no longer possible, Veterans Affairs Canada must take steps to ensure that the quality, variety and presentation of meals enhance the veterans’ quality of life rather than, as is too frequently the case, detract from it.
38. The Subcommittee recommends that Veterans Affairs Canada standards of institutional care establish a minimum standard of veteran satisfaction with the meals provided and that facilities meeting or exceeding this standard be rewarded with a premium equal to 10% of their per patient or per resident food expenses.
39. The Subcommittee recommends that wherever possible Veterans Affairs Canada supply veterans wards with commercial toasters.
40. The Subcommittee recommends that Veterans Affairs Canada study the steps Sunnybrook hospital has taken to improve the quality of meals and make this information available to all institutions with a re-thermalised food service.
Whether re-thermalised or prepared on site, institutional meals are not the same as home cooked meals. On their travels the members of the fact-finding task force remarked on the number of small kitchens that were available in wards, recreation rooms, staff rooms, etc. In only a few instances, however, were these being used by the veterans, their families, or by volunteers to prepare home-cooked meals. Properly supervised, cooking is as much a safe therapy as is weaving or woodworking.
41. The Subcommittee recommends that Veterans Affairs Canada encourage facilities to form "meal" clubs for veterans who are interested in food preparation and to encourage family and volunteers to reserve the small kitchens available to prepare special meals or treats for veterans. Veterans Affairs Canada should make a reasonable contribution to the equipment of the kitchens and pay for the food costs of these meal clubs.
Another way of relieving the boredom of a steady diet of institutional meals is either to occasionally allow veterans and visiting friends or family members to have a meal in a restaurant, if one is attached to the facility, or to "order out" for a meal if they prefer.
(c) Veteran Safety Issues
The timing of the First Report of the Subcommittee was determined by the fire in Kilgour Wing of Sunnybrook hospital in June 1997 that cost three veterans their lives and left a fourth charged with arson. More than eighteen months later, the reasons for the tragedy are still not known. Safety in general and plans for evacuating wards play an important role in the safety of veterans and in the family’s peace of mind. In every facility they visited, members of the task force questioned management about their plans to protect the lives and health of veterans in the event of fire or another disaster.
Without exception, the floors of all the buildings visited are divided into fire zones by fire doors that are supposed to delay the horizontal spread of fire indefinitely. Consequently, the most important element of the fire plan is to provide for the rapid evacuation of all the patients or residents living in the effected zone behind one of these fire doors. Although some facilities had experimented with special equipment such as EvacuSleds or had found that veterans seated on dining room chairs could be slid across the floors to safety, the most common technique used is to place the patient or resident on a sheet or blanket on the floor and pull him along the floor to safety. This system has the advantage of using immediately available materials, a sheet or blanket from the bed, of being simple to execute, and of keeping the person being evacuated as close to the ground as possible, thus avoiding both smoke and the risk of a fall. The disadvantages of this technique of evacuation are that two people must ease the patient to the ground, that the sheets used might not be strong enough, and that it is difficult, if not impossible for one person to drag a heavy patient across a rough floor.
It takes much longer to prepare a patient to be moved by an EvacuSled which wraps around the patient and the mattress, but one person can prepare the patient, slip the EvacuSled off the bed, tow him easily across any kind of flooring and then even slide him down a staircase. The major drawback to this form of evacuation, however, is that the mattress and EvacuSled combination is very bulky, is difficult to move through crowded rooms, and must be tipped up to pass through most doorways.
The Subcommittee is very concerned that not enough thought is being given to planning for the full evacuation of a facility and the possible need to re-locate veterans on an emergency basis. Management and security officials of the multi-story hospitals and long-term care facilities visited assured the task force that by the time a horizontal evacuation had removed patients or residents behind a fire door, a large number of police and firemen would have arrived. Thus the occupants of the building could be carried down the stairs quickly.
Many hospitals and residences are located in earthquake prone areas of the country, others are close to railway lines or major highways along which dangerous materials may move, and virtually all are subject to extreme weather conditions. Any one of these occurrences could delay the arrival and reduce the amount of additional assistance available to carry out a vertical evacuation and removal of veterans from the site to other locations. The Subcommittee believes that every hospital and long-term care facility with more than one floor should prepare a plan and rehearse its staff in carrying out a vertical evacuation of the building with the staff available.
42. The Subcommittee recommends that Veterans Affairs Canada standards of residential care include the requirement that facilities with more than one floor have a plan and the equipment necessary to carry out a vertical evacuation of the building with the staff available.
43. The Subcommittee recommends that Veterans Affairs Canada evaluate safety equipment that could be used to assist a limited number of staff carry out a successful vertical evacuation.
In the event of an emergency requiring the complete evacuation of a building, patients or residents of a hospital or long-term care facility will have to be sent to other institutions. Since many veterans suffer from some degree of cognitive impairment, it cannot be assumed that evacuees will be able to identify themselves, much less provide dietary and medical information, to the institution to which they are sent.
The task force was very impressed with the Food and Travel Pass that has been developed by Parkwood Hospital in London and adopted by Sunnybrook hospital in Toronto. The pass identifies the veteran and his or her dietary restrictions and is used at social functions and on outings. It does not include medical information about the condition, treatments and drug prescriptions of the veteran, and the pass is kept at the nurses’ station. It would be easy, however, to add emergency medical information in a form that could only be read by a hospital. Stored beside the room door, such a pass could accompany the veteran during emergency evacuations.
44. The Subcommittee recommends that the Veterans Affairs standards of residential care include a requirement that veterans have the equivalent of a Food and Travel Pass encoded with essential medical information, the Pass to accompany them during any evacuation of their ward.
(d) Implementation of a Standard of Institutional Care
The Subcommittee believes that it is necessary and practical to adopt a federal standard of institutional care for veterans. Organizations such as the Canadian Council of Health Services Accreditation Standards are constantly upgrading standards of care and inspecting facilities seeking accreditation. These standards should be studied by Veterans Affairs Canada and adopted as the basic requirement of signing a contract for the provision of a veteran’s priority bed. A supplementary "Veterans Charter", embodying the standards set out above, should be developed for each type of facility. Accreditation in good standing and acceptance of the "Veterans’ Charter" should then be entrenched in the agreements between Veterans Affairs Canada and the individual hospital or long-term care facility.
45. The Subcommittee recommends that Veterans Affairs Canada adopt accreditation in good standing by the relevant national organization as a condition of placing veterans in a hospital or long-term care facility.
46. The Subcommittee recommends that a "Veterans’ Charter" be developed to set out the additional standards which must be met by the individual hospital or long-term care facility. The Subcommittee further recommends that the terms of this "Veterans’ Charter" be included in the agreement between Veterans Affairs Canada and the individual institution.
The entrenchment of these "Veterans’ Charters" in the agreements with individual hospitals and long-term care facilities will require that the latter have a degree of autonomy from the local regional health care authority. The members of the fact-finding task force were impressed by the degree of autonomy George Derby Centre of Vancouver had to set its own priorities, including the right to abandon re-thermalised meals and institute on site meal preparation.
47. The Subcommittee recommends that Veterans Affairs Canada negotiate agreements with individual provinces to allow hospitals and long-term care facilities with more than 50 veterans a degree of autonomy from the regional health authority.
In some parts of the country there is a pressing need to provide more veterans’ priority beds or to renovate existing veterans’ wards. The local regional health authority or the province concerned may not give this work a very high priority in their spending plans, or may wish to spread the work over a number of years to keep it within budget. The Subcommittee believes that hospitals and long-term care facilities under contract with Veterans Affairs Canada should have sufficient autonomy to go ahead with such projects, if Veterans Affairs Canada is prepared to advance a substantial part of the capital necessary to carry out the construction on a priority basis.
48. The Subcommittee recommends that Veterans Affairs Canada offer designated facilities building loans to carry out construction, expansion or modernization of veterans care beds on a priority basis.
C. Standards of Care for the Independent Veteran
(a) The Veterans Independence Program
The Veterans Independence Program is justly recognized as one of the most creative departmental initiatives since the post-war era. It is also one of the most cost effective programs Veterans Affairs Canada runs because, as departmental officials pointed out, VIP can keep seven or eight veterans in their homes for the cost of keeping one veteran in hospital or in an extended care facility. In recent years, however, the scope of the program has been cut back and the department has become more strict in allowing additional benefits. The time has come to reverse this trend and to seek out ways in which the program can enhance the quality of life of the veteran and his or her spouse.
49. The Subcommittee recommends that enhancing the quality of life of the independent veteran and his or her spouse become the guiding principle of the Veterans Independence Program rather than incidental to the cost advantages of reducing the need for institutional care.
In some parts of Canada there are already long waiting lists for the available veterans priority beds. There is also a very real concern that a substantial percentage of the 160,000 overseas veterans entitled to a priority access bed will invoke this right. To meet existing local shortages of beds and to prepare for a possible surge in demand for beds, the department is experimenting with the extension of some VIP benefits to overseas veterans. In regions where the waiting lists are long, such as Victoria, British Columbia, Ottawa, Ontario and Halifax, Nova Scotia, the department will use VIP to deliver whatever services and benefits are necessary to make the veteran’s wait at home as comfortable as possible. The Subcommittee fully supports the extension of some form of VIP benefits to all those waiting for a priority access bed as part of the recommendation made above.
To get some idea of how many of the 160,000 overseas veterans entitled to a bed might eventually claim this right, these veterans should be encouraged to register with the department by offering them access to some form of VIP benefits. These veterans are now approaching the age when many will have outlived their partner and the quality of their lives is increasingly at risk. To maintain their quality of life and to avoid the necessity of institutionalisation, many of them will need help. Throughout their lives following their overseas service these veterans have asked Veterans Affairs Canada for nothing. It is time to offer them something in return for their service. Through the Minister of Veterans Affairs, the Government of Canada extended some Veterans Independence Program benefits to the Canada Service Only veterans. The Subcommittee believes that the Government should now take steps to include overseas veterans in the program.
50. The Subcommittee recommends that the Government of Canada take steps to extend some form of Veterans Independence Program benefits to those veterans with overseas service who are entitled to a veterans priority bed and are at risk of losing their independence.
It can be very expensive for spouses and other family members to visit institutionalised veterans on a regular basis. Increasingly, hospitals and long-term care facilities use parking fees as a means of raising money. The Subcommittee believes that spouses or family members should be compensated for the reasonable costs of parking while making regular visits to an institutionalised veteran.
51. The Subcommittee recommends that the Veterans Independence Program compensate a spouse or a family member for the cost of parking while making regular visits to an institutionalised veteran.
In every hospital and long-term care facility the fact-finding task force visited, there are some veterans whose spouses must travel substantial distances to visit them. The provision of overnight accommodation for those from out-of-town would allow them to spend more time with the veteran. Ideally, arrangements would be made for the visiting spouse to stay at the home of a local spouse whose husband was also a patient or resident in the facility and who was prepared to offer accommodation. The VIP program should be used to reimburse out-of-town spouses for reasonable transportation costs in excess of public transportation. Veterans Affairs Canada should study the possibility of using the VIP to encourage hospitals and long-term care facilities to arrange accommodation for visiting spouses who must stay overnight, perhaps by offering a modest per diem payment.
52. The Subcommittee recommends that Veterans Affairs Canada expand Veterans Independence Program benefits to cover the travel costs of out-of-town spouses who visit institutionalised veterans and, where necessary and desirable, to pay for the costs of overnight accommodation.
(b) Creative Housing Solutions
The cost of providing VIP benefits to overseas veterans waiting for a bed in an institution will be substantial on a per veteran basis. The life expectancy of veterans in their 80s is not more than a few years, a factor which will increase the per veteran per annum costs of undertaking the renovation of private homes. The costs of making house calls to scattered locations to deliver medical treatment and the other services necessary to keep the veteran at home also argue in favour of new solutions to keep the veteran at home. Finally, the experiment with the extension of basic VIP benefits to overseas veterans waiting for a bed is based on the assumption that the spouse of the overseas veteran is and will continue to be able to accept almost the whole responsibility for care giving. This will continue to be true in some cases, but the care giving spouses are themselves ageing and becoming more frail as the years go by.
A creative alternative to institutionalisation or to the renovation of private homes is to enter into agreements with private enterprise, the provinces and local hospitals and long-term care facilities to build special housing units. These would be designed to meet the needs of veterans increasingly handicapped by physical or mental disability, and the needs of spouses who will need more and more help to look after the veterans at home. The housing units should be part of an existing hospital or multi-level, long-term care facility with an interest in developing strong out-patient and outreach programs.
53. The Subcommittee recommends that Veterans Affairs Canada, as a millennium project, initiate a project to build at least two experimental "clusters" of housing for aged veterans and their spouses in regions of the country where waiting lists for veterans priority beds are already long and are expected to get longer.
As envisaged by the Subcommittee, each of these clusters would have a limited number of two bedroom living units, perhaps fourteen or so, arranged around a common and fenced off area sufficiently large to incorporate gardens and green spaces as well as paths and a covered patio. Each unit would open onto the courtyard and have a small enclosed back yard. Of course, each unit would be fully wheelchair accessible and designed to make it as easy as possible to care for a disabled person. Some units would be specially designed to allow patients suffering from dementia to wander safely.
Ideally, the clusters would be located in the grounds of existing long-term care facilities to make the most of the latter’s out-reach, out-patient, day care and respite programs. In this way, the clusters would contribute to the quality of life of the veteran and spouse. To the veteran accustomed to independent living, the units would offer the benefits of living at home; to the spouse, they would offer the benefits of immediate access to nursing and medical care, and to day care and respite care as needed. To both the veteran and the spouse these units would offer close proximity to other veterans and their spouses, and to social and recreational opportunities.
The net cost to Veterans Affairs Canada of underwriting the development of these clusters need not be great. Other federal departments can help with their design, private enterprise and charitable foundations can be drawn into helping to finance their construction, while the provinces and the local health authorities can contribute to their operating costs. Location of the units on land already owned by hospitals or multi-level care facilities would reduce the capital outlay while charging rent at the going rate to overseas veterans who occupied them would cover the mortgage.
What are some of the advantages of "cluster housing" to Veterans Affairs Canada? The cost of providing a bed would be avoided or at least postponed. The costs of delivering benefits and services under the VIP would be much reduced: there would be no outlay for home renovation; and, the ongoing costs of providing routine housekeeping and maintenance services, transportation, medical treatment, etc. would be reduced by the concentration of veterans in one place close to a care giving facility.
Cluster housing for veterans also has advantages for the local health authorities and provinces. In the coming decades Canada will face a huge crisis in the provision of housing for the very old. Before the clusters reach the end of their useful lives, the veteran population will be very small and the units that are not occupied by surviving spouses can be offered to non-veterans. Thus these clusters will initially serve to help ageing veterans and their spouses continue living at home, and then will help local levels of government meet the needs of "baby boomers" as the latter enter old age.
The construction of cluster housing will have immediate economic benefits. The concept should be spread as soon as possible to other communities in which there is a need for more veterans’ priority beds and in which the province or local regional health care authority has identified housing for the elderly as a priority. In these circumstances, Veterans Affairs Canada could explore the possibility of offering to enter into a partnership with the local health authority and/or private businesses to build cluster housing in return for a veterans’ priority for some units.
2. Turning 4082 beds in 76 Institutions into a Network
As already noted, the transfer of responsibility for the institutional care of veterans to the provinces has had a number of very damageing consequences:
- Veterans Affairs Canada no longer views these facilities as a whole, as a national system dedicated to delivering health care to veterans across the country; and
- While individual institutions are doing a good job, and sometimes a creative job, of grappling with the problems that they face in dealing with ageing veterans, management and professional staff have no means of drawing on each other’s experience and sharing their more creative solutions.
As a result each institution faces the unique problems of ageing veterans in isolation and, if management and staff do not give up the search for a solution because of time and cost, they frequently end up re-inventing the wheel. This isolation even exists among the health care centres of a single province: hospitals and long-term care facilities with substantial numbers of veterans rarely fall within the same regional health authority.
There is an urgent need to break down this isolation and to provide a number of ways in which management and professional staff can meet and exchange information. The Subcommittee believes that the department must learn again to view all the institutions which accommodate veterans as part of a whole – regardless of whether the institution is a community home with a single veteran resident, or a hospital or multi-level facility with hundreds of veterans.
The department should begin this process by organising a series of veterans’ institutional care conferences across the country. Regional conferences of management could discuss issues of common interest in the treatment and care of veterans and evaluate the desirability of setting up regular channels of communication among professional staff with similar interests.
Regular regional conferences, however, would be a costly means of establishing day-to-day channels of communication, and regular national conferences much more so. The production of a regular newsletter has merit, but again it is time consuming for the writers, editorial staff and readers.
Increasingly, video conferencing is being used to reduce the need for face-to-face meetings and consultations and to give remote regions access to the medical expertise of the large cities. Veterans Affairs Canada already uses video conferences in pension adjudication. This same technique could be developed to allow for confidential consultation about the treatment of an individual patient between departmental doctors at Ste Anne’s Hospital and the nursing staff of a long-term care facility.
The Internet was created to establish and maintain regular contact between busy professionals with special interests who worked in far-flung institutions. The Subcommittee envisages a veterans’ care network accessible to all institutions caring for veterans that would enable a community nursing home in northern British Columbia to discuss therapy for a veteran suffering from Post-Traumatic Stress Disorder with the staff of Ste. Anne’s Hospital outside Montreal, or the availability of "hip pads" with the inventors in Camp Hill, Nova Scotia.
The network would feature a series of web sites organised as chat rooms devoted to specific subjects. Staff across the country could quickly pose problems and gather in the experience of others who had faced the same or a similar problem. Once found, valid solutions to the problem could be posted for quick reference. Each chat room might be moderated by a professional staff member from a different institution who would also be responsible for updating the frequently asked questions and possible solutions.
Departmental experts in Charlottetown and Ste Anne de Bellevue could be asked to participate as could the academic staffs of interested universities. Occasionally, a staff expert could be asked to prepare an interactive seminar on a particular problem or research project.
If they were well organized and run, these web sites would bring together an exceptional balance between cutting-edge academic research and technology on the one hand, and day-to-day, experience on the other hand. On the basis of the fact-finding tour of facilities across the country, the Subcommittee knows that there is a wealth of knowledge and experience to be shared about the following subjects.
- How to manage waiting lists;
- Future shock: the local population of overseas veterans entitled to a veterans’ priority bed;
- Contributing to the local community and in turn, drawing on community resources;
- Building design and ward renovation. What are the best, most efficient etc. examples of new construction/renovation for the elderly and for the elderly with special needs?
Staff Training
- Training new staff to respect the special contribution veterans made to their country and to appreciate the reasons for their special entitlements;
- Up-grading staff qualifications on a regular basis and on site
Geriatric Medicine and Programs for long-term care facilities
- Treatment and programs for veterans with a history of long-term abuse of alcohol;
- Treatment and Rehabilitation of patients suffering from cognitive impairment;
- Dealing with the violent/potentially violent veteran
Food Services
- Dealing with the problems of re-thermalised food;
- Cost analysis of re-thermalised meals and bulk preparation on site;
- Breakfast toast;
- Meal clubs to get away from institutional food and back to home cooking, at least sometimes;
- Modifying meals and beverages to meet the needs of patients suffering from dysphasia
Safety and Emergency Measures
- Building evacuation, lateral and vertical;
- Emergency equipment which would aid in the rapid evacuation of the bedridden
- Disaster plans-present planning and staff training seems to be based on the assumption that existing staff will quickly receive support from large numbers of police and fire personnel. Any number of widespread events would disrupt this assumption – ice storms, floods, blizzards, earthquakes, major explosions etc. would paralyse road communications and draw off police, fire, etc resources. What plans exist to begin evacuation before large-scale arrival of police/fire, to draw on passers-by local resources;
- The Food and Travel Pass. Could it be improved by adding encoded medical information?
Recreation and Rehabilitation
- Weaving therapy;
- Animal therapy;
- Gardening therapy
Volunteers and visitors
- Volunteers are an essential part of the care-giving team, but many are getting old themselves;
- How to attract young volunteers from the local schools colleges and universities. (volunteer work could become part of the curricula for high school civics courses, sociology courses, geriatric studies programs, etc.);
- Visitors may bring inappropriate gifts candy for diabetics, cigarettes for heart patients. How to encourage respect for the dietary/health needs of veterans;
Management of the hospitals and long-term care facilities raised a number of administrative issues that Veterans Affairs Canada should address.
(a) Consultations
The residents of long-term care facilities have their own family doctors and many patients in a hospital also have a family doctor. These family doctors are not necessarily compensated for consultations with the medical and nursing staff caring for the veteran, or for consultations with the family of the veteran. As a result, family doctors can be reluctant to devote time to these consultations. Long-term care facilities in particular, feel that they would benefit from more of these consultations because their staff is oriented toward nursing and care giving rather than medicine, and because many veterans are dependent on family members to make decisions about treatment.
The Subcommittee believes that it is in the interests of the veteran to encourage close co-operation and the exchange of information between the family doctor of the veteran, the medical staff of the hospital or long-term care facility in which the veteran is resident, and the family of the veteran.
54. The Subcommittee recommends that Veterans Affairs Canada compensate family doctors for consultations with the medical or nursing staff looking after a veteran in a hospital or long-term care facility, and for consultations with family members making treatment decisions on behalf of the veteran.
(b) Funding for Training
The average age of veterans is approaching 80 and a large percentage can already be considered very old. As a society, however, we have as yet little experience in caring for large numbers of the very old. The care of the elderly and the very old is only now winning acceptance as a legitimate area of specialisation in nursing and care giving. As a result, there are few training programs available that serve as an introduction to the long-term care of the elderly or serve to upgrade existing experience and training to deal with the special problems of the elderly, such as dementia.
While the hospitals the task force visited referred to the need for more research into the impact a growing population of the very old will have in the 21st Century, management of the long-term care facilities everywhere across the country stressed the need for more training: basic training for untrained or inexperienced staff; training upgrades to keep pace with advances in treatment and techniques; and, specialised training to focus on specific problems. These institutions are already short-staffed and cannot afford to replace staff away on training.
Given the need to ensure veterans the best quality of care available, the Subcommittee believes Veterans Affairs Canada should help pay for training upgrades and, through Ste Anne’s Hospital, develop training videos and printed material for dealing with the special behavioural problems of veterans. As much as possible, the emphasis should be on developing relatively short, practical training modules each one of which can be taken at the institution itself in about two hours over an extended lunchtime or at the end of a shift.
55. The Subcommittee recommends that Veterans Affairs Canada provide long-term care facilities with funding to upgrade the training of the nursing and care giving staff looking after veterans. This funding should include the costs of replacing staff taking courses;
56. The Subcommittee recommends that Veterans Affairs Canada develop an inventory of recommended training courses and materials on caring for the elderly and the very old, and related subjects; and,
57. The Subcommittee recommends that Veterans Affairs Canada, in consultation with the professional staff of Ste Anne’s Hospital, develop new training videos and training material as necessary.
(c) Billing the Treatment Accounts Processing System (TAPS)
Institutionalised veterans continue to be eligible for certain kinds of Veterans Independence Program benefits. Many institutions do not know how to bill TAPS for the benefits the veterans are entitled to, or are unaware of what they can bill to TAPS. On the other hand, multi-level long-term facilities complain that billing TAPS is unnecessarily bureaucratic.
The Subcommittee believes that the TAPS system of paying for the medical benefits of an independent veteran works well, but that it must be revised to make it easier to use by facilities which may have veterans with different levels of entitlement.
58. The Subcommittee recommends that Veterans Affairs Canada revise the Treatment Accounts Processing System (TAPS) to simplify billing by institutions, and that all institutions be regularly briefed about what benefits can be billed.
(d) Recognition of Volunteers
Veterans and management in all parts of the country sang the praises of the work done by volunteers. To management, volunteers can be equated to large numbers of "hours" and "person years". They help enrich the day-to-day lives of veterans by raising money for luxuries (and sometimes necessities), by running canteens, by helping with activity and recreational programs, helping take veterans on trips, and by just caring about the individual veteran and listening to his or her stories. Discussing the impact of staff cutbacks, a veteran told the task force: "Volunteers, they deserve a medal. Without them, we’d be in sad shape".
The Subcommittee fully supports this view of the importance of volunteers to the quality of life of veterans. Veterans Affairs Canada must do everything in its power to find ways to show its continuing appreciation for their work.