APPENDIX 1
QUESTIONS AND ANSWERS RELATING TO THE HEALTH CARE OF VETERANS OF WAR AND CANADIAN SERVICE
PERSONNEL
The following questions have guided the Subcommittee’s study of the level and uniformity of health care services offered across Canada to veterans of war and Canadian Service personnel. The answers are those provided by the Department of Veterans Affairs to which the Subcommittee has appended brief comments.
The questions and answers show the growing disparities in the scope and quality of provincial health care services provided to veterans. To maintain a semblance of equal service to veterans, the Department is increasingly having to supplement provincial levels of care and to closely monitor facilities providing service to veterans to ensure that the latter receive the services and quality of service for which the Department has contracted. The Department acknowledges that some of the premises on which existing contracts are based no longer reflect the realities of today’s health care environment, and that the agreements will have to be reviewed and re-negotiated.
The questions and answers also show that the Department is moving to supplement its highly successful Veterans Independence Program with an increased emphasis on health care assessment and health promotion, and on community-based health care delivery. The Department is moving, albeit slowly, to expand the services offered the spouses of entitled veterans. To date, however, the services offered spouses involve support services such as respite care, counselling and caregiver training, that will help them save the Department the costs of institutionalisation by looking after physically or mentally disabled veterans in the home. These services do not include entitlements in the years following the death or permanent institutionalisation of the veteran, except for the one year extension of VIP benefits following the death of the veteran.
Q1. Is a dollar spent on health care offering the same level of value in each and every province?
A1. Within Veterans Affairs Canada, a key determinate in assessing "value" is how well the service or benefit meets the specific needs of eligible veterans. Using this as our "common denominator," the Department has put in place a number of client-focused programs, including the Veterans Independence Program (VIP), the Treatment Accounts Processing System (TAPS), and institutional care extras such as arts and crafts programs and transportation, which are based on individual need. Departmental expenditures associated with these kinds of client-care initiatives differ from province to province, largely because of variations in the quality and scope of provincially insured health care services and benefits that are available to veterans as a residence of a province. Nevertheless, the careful allocation of departmental resources ensures that all eligible veterans have access to a comparable standard of quality care even though they live in different provinces with differing facilities and community care standards.
Comment: Without directly saying so, the departmental response admits that a significant portion of its expenditures on health care must be devoted to creating a "common denominator" among the provinces for the services needed by veterans. Thus, it must spend more per veteran in some provinces than in others. The Subcommittee must revisit this issue to determine how much must be spent, for which services, and in what provinces.
Q2. What level of priority do veterans hold when dealing with the provincial health systems?
A2. Generally, veterans are accorded the same priority in provincial health systems as their fellow citizens. Having said this, the Department has contractual agreements with 75 facilities across the country to provide veterans with priority access to approximately 3,372 long-term care beds. As well, 710 departmental beds are available at Ste Anne’s Hospital. Another 3,568 VIP eligible clients have been placed in long-term care community facilities throughout the country. The number of clients accessing this type of community care can vary from month to month.
Comment: The departmental response does not make it clear that veterans are entitled to priority when it comes to treatments and services mandated by federal legislation such as the Pension Act and the War Veterans Allowance Act. The Subcommittee must further study this question to determine what steps might be taken to ensure a veterans priority.
Q3. Are there equal levels of access to health services in each region and/or province across the country?
A3. In accordance with the Canada Health Act, veterans have the same access to insured services as do all citizens of any given province. Even so, it is well documented that access to services can vary between provinces, as well as between urban and rural regions within each province. To help ensure that veterans’ access to health care is not dictated by geography, the Department offers eligible veterans a broad range of service and benefits based on health assessment and client need. For many eligible veterans, the ability to access these services is further streamlined through a national automated service known as the Treatment Accounts Processing System (TAPS).
Comment: This response is clear and to the point, but the Subcommittee must check to ensure that "veterans’ access to health care is not dictated by geography" as the Department claims.
Q4. Are veterans being placed in an equal or superior grade of facilities?
A4. Even though health care infrastructures vary considerably between provinces, Veterans Affairs Canada is fully committed to providing all clients with access to quality facilities. To help facilitate this, the Department requires that each contractual facility be accredited and provide a level of care that meets accepted provincial standards. Once these criteria have been established to VAC’s satisfaction, the Department, as part of its Action Plan for Long-Term Care, monitors each institution to ensure that contractual obligations are being met. The Department also recognizes that veterans’ preferences are often as distinct as the facilities available to accommodate them. Departmental research indicates, for example, that better and more cost-effective health outcomes could be realized by ensuring that veterans have access to facilities in, or near, their own community. As such, the Department is actively pursuing partnerships with public and private providers to ensure that all clients are provided with the most appropriate care in the most appropriate environment.
Comment: Veterans organizations do not believe that the Department is doing everything possible to ensure that its clients have access to "quality facilities." They have strongly protested the lack of clear and public federal standards of institutional care for veterans, the relative infrequency of departmental visits to institutions in which veterans reside, and the decision to transfer the last departmental facility, Ste Anne’s Hospital, to a province. The Subcommittee must undertake a more profound study of standards of institutional care across the country.
Q5. Are the current contract provisions adequate in all provinces?
A5. As per the Constitution Act (1986), in which health care remains a responsibility of the provinces, Veterans Affairs Canada is committed to working with provincial authorities to meet its obligations for the care of eligible veterans. In keeping with this commitment, the Department has established an Action Plan on Long-Term Care to review the contractual agreements it holds with provincial departments of health and other ministries or agencies, including those relating to contract beds in facilities that have been transferred to provincial jurisdiction over the past 34 years.
A preliminary review of some existing contractual agreements indicates that some of the premises upon which they are based do not reflect today’s health care environment. Where this has been determined, agreements are being re-evaluated to ensure they continue to fully address the evolving needs of aging veterans with more complex health needs. It should be noted that the flexibility to initiate this kind of dialogue already exists within our contractual agreements. In addition, while VAC continues to recognize provincial standards of care, our contractual agreements do allow for the introduction of specialized facilities should client need be established. This type of contractual flexibility will be of increasing benefit to the Department as it proceeds to secure facilities appropriate to a variety of emerging needs, including dementia and palliative care.
To safeguard the quality of future veteran care, the Action Plan for Long-Term Care will ensure that contractual obligations continue to be met. In addition to improved fiscal monitoring procedures, strategies for monitoring client well-being will be established and future long-term care bed requirements by care types and numbers will be developed. This framework, together with the Department’s ongoing research in client care needs, will guide Veterans Affairs Canada as it explores new, and enhanced, partnering opportunities for alternative care options.
Comment: The response acknowledges that contract provisions are not adequate in all provinces. The Subcommittee must ensure that the Department, as promised, does re-evaluate and re-negotiate the contracts, and institutes improved methods of monitoring client well-being and future long-term care bed requirements by care types and numbers.
Q6. Are there developing health care trends or practices the Department has not been able to adequately address due to the devolution of service delivery?
A6. At present, Veterans Affairs Canada is proactively pursuing health care alternatives on behalf of clients who, for example, may be impacted by the reclassification of provincial care facilities or who may have been disenfranchised from provincial drug programs. In the interim, the Department is committed to allocating sufficient resources to ensure that provincial health reform and cost-cutting measures do not compromise the seamless continuum of care that veterans need, deserve and will continue to receive.
Comment: The members of the Subcommittee were impressed by the psychiatric and psychogeriatric programs at Ste Anne’s Hospital to aggressively treat veterans with different kinds of cognitive impairment. Equally impressive was the interest of medical staff in improving programs and experimenting with new treatments, whether for cognitive impairment or for Dysphagia. However, the Subcommittee must study the availability of successful new treatments across the country. Given the devolution of service delivery, how can the department ensure that all veterans benefit from advances?
Q7. Has the change in service delivery been negatively affected by geopolitical issues or federal intergovernmental policy?
A7. Veterans Affairs Canada has initiated a number of service delivery strategies to mitigate potentially negative consequences accruing from geopolitical and intergovernmental policies. Currently, for example, the Department is moving toward a client-centred approach to service whereby a "needs-based" continuum of care is employed to facilitate positive health measures. This initiative will complement administrative modifications now underway as part of the Benefits Redesign Program, as well as program refinements under consideration by the Review of Veterans’ Care Needs. The incremental adoption of a client-centred service delivery model, enhanced service standards and the promotion of standardized work processes will create an integrated health care environment that is more responsive to client needs in addition to enshrining clients’ rights to be more directly involved in the kinds of care and services they receive.
Comment: No comment.
Q8. How are veterans affected by provincial cost-cutting and cuts to transfer payments?
A8. Reductions in federal government transfer payments to the provinces ¾ and associated provincial health care reforms ¾ may have had a significant impact on the availability of services to veterans as residents of a province. In those instances where gaps in service have appeared to compromise veteran health outcomes, the Department has allocated additional resources. This means that veterans have continued to enjoy an uninterrupted level of health care services but at an additional cost to VAC.
To ensure that health care expenditures continue to meet veterans’ needs over the longer term, Veterans Affairs Canada has embarked on a comprehensive review of all its health care programs. As a result of this review, the Department has implemented changes to 10 of the Department’s 14 Programs of Choice (POC). These changes reflect the Department’s move toward a needs-based continuum of care that focuses on health promotion and which is capable of responding to veterans’ future health requirements. Where modifications to programs have resulted in cost savings (for example, through the elimination of overlaps or duplications), the savings have been re-invested in processes that add additional value to veterans.
To complement its internal program review, Veterans Affairs Canada, at the request of Treasury Board, has been asked to lead a study to examine the potential for achieving better value for money through the collective purchasing power of the federal departments and agencies involved with health care. A secretariat has been established and several collaborative activities among departments are underway.
Comment: Contrary to the tenor of the response, veterans’ organizations believe that veterans are already paying the price for provincial cost-cutting and for cuts to federal transfer payments. The veterans residing in the provincially-financed chronic care Kilgour Wing of the Sunnybrook Hospital must put up with overcrowding, understaffing and manual beds. Next door in the federally-financed, intermediate-care Hees Wing, veterans enjoy much more spacious accommodation and electric beds. Another impact has been the resort to "rethermalized" food rather than meals prepared on site. These examples point to the insidious nature of the impact of the cutbacks ¾ they deny institutions the funds to modernize their wards and equipment, and force them to cut costs by reducing quality. The response also fails to take into account the impact of cutbacks to departmental expenditures which have led to stricter interpretation of entitlements and have made it difficult to implement new or improved services other than those which are less costly. The Subcommittee must continue to monitor the impact of federal and provincial cutbacks on the welfare of veterans and the level of service they receive.
Q9. Has there been a superior level of service delivery since the Department privatized the Treatment Accounts Processing System (TAPS)?
A9. Yes. At present, TAPS is available to approximately 144,000 clients, nationwide, who use their card to access services without incurring out-of-pocket expenses. In addition to offering clients a simplified and uninterrupted level of service, TAPS has been well received by the more than 60,000 providers who accept the card and are reimbursed for veterans’ health care bills, on a timely basis, by our claims processor, Blue Cross. Enhanced program management, including more comprehensive auditing capabilities, now allows the Department to oversee supplier performance and ensure that health care expenditures meet veterans’ evolving needs in the most cost-effective manner.
Comment: A clear and simple response, supported by the testimony of veterans’ organizations.
Q10. Has there been any significant policy change affecting the eligibility of veterans for health care services?
A10. No. Eligibility is determined by Statute and Regulations. Indeed, since the inception of the Veterans Affairs Canada Health Care Program, the Department’s responsibilities have expanded to include Korean War veterans, Merchant Navy veterans, regular force personnel pensioned for illness or injury related to service and Special Duty Area pensioners. In keeping with this tradition, current initiatives by the Department to move toward a needs-based continuum of care are not intended to restrict eligibility. Rather, the Department is refining its administrative, program and service policies to respond appropriately to the challenges presented by all clients, including an aging veteran population with increasingly complex needs.
Comment: In a narrow sense, this response is accurate, but it does not speak to the spirit in which statutes and regulations are applied. The Subcommittee and veterans’ organizations have noted stricter policies governing such issues as hearing loss, entitlements under the VIP, etc.
Q11. What direction is the Department moving in with respect to out-patient care policies?
A11. Veterans Affairs Canada has long recognized the value that many veterans place on being able to access community-based services and benefits that add to their well-being as well as delay their admittance to long-term institutional care facilities. In keeping with the wishes of an increasing number of veterans to "age in place," the Department, in 1981, introduced the Veterans Independence Program (VIP). Today, under this program umbrella, a large segment of the veteran population is provided with a comprehensive level of home care, including meal preparation, housekeeping, groundskeeping, home adaptations and transportation. Financial assistance may be provided where local programs do not exist or where additional services are required to meet veterans’ health needs. Where care in community facilities is required, the Department also assists VIP-eligible veterans in arranging for care in appropriate accommodation. In all instances, these services are provided in response to client need as identified as part of a multi-disciplinary assessment.
In 1996, with the introduction of the Department’s client-centred approach to health care, the accent on community-based care has been further entrenched. As part of this approach, departmental services, programs and processes are being adjusted to form a cohesive framework through which veterans can be assured of receiving the right service or program, at the right time, from a dedicated health care employee with the authority to assess and direct resources on a needs basis. An emphasis on health care assessment and health promotion is anticipated to enhance preventative health care measures, thus minimizing or delaying the onset of serious illness or disability which typically threaten the ability of veterans to remain within their community.
To further strengthen VAC’s ability to provide veterans with quality care in Canada’s changing health care environment, the Department plans to make greater use of community-based providers as well as pursue additional partnering opportunities with provincial and community-based health care authorities. Over the next several months, information gathered this past year as part of the Review of Veterans’ Care Needs will also be analyzed with the expectation that it will provide a framework to simplify, streamline and enhance the Department’s current program infrastructure. Guidance on a wide range of concerns, including caregiver support, respite services and community-based health care housing alternatives, will be sought from the Department’s Gerontological Advisory Council.
Comment: The Veterans Independence Program has set the standard for out-patient care. As veterans age, there will be a need to offer more services and more intensive service. The Subcommittee must monitor the evolution of departmental out-patient care policies offered to both veterans and their long-term spouses/caregivers.
Q12. What provisions has the Department made for spouses of veterans, particularly those who acted as caregivers, and their future health care needs?
A12. Veterans Affairs Canada acknowledges the important support that veterans receive from their spouses and recognizes that many aging veterans would not be able to remain in their homes without spousal help. VAC’s program mandate does not extend to spouses, but our service mandate reflects the needs of the family unit in a manner which does not compromise our fiscal accountability to taxpayers. To illustrate, many spouses benefit from home care, housekeeping and groundskeeping support available to VIP-eligible clients. VIP benefits are extended to spouses for one year after the death of the veteran. In recognition of the emotional and physical stress which can affect caregivers, the Department also provides a number of support services to spouses, ranging from respite care, counselling and caregiver training and education through the Care for the Caregiver Pilot Project. Addressing the needs of informal family caregivers of veterans will be a priority for VAC activity in health programs.
To help guide the development of additional caregiver support strategies, the Department is now analyzing quantitative and qualitative information gathered as part of the Review of Veterans’ Care Needs. The Department has also formed a Gerontological Advisory Council, represented by leading members of Canada’s gerontology, geriatric and seniors’ communities. One of this Council’s immediate priorities is to consider issues impacting caregiver needs.
Comment: The Subcommittee believes that the program mandate of the Department must be expanded to include the long-term spouses/caregivers of aged veterans. The provision of caregiver support and respite care should be only the beginning of a program to assist those who have devoted themselves at home to the care of a disabled veteran. In future, this assistance must include eligibility for VIP benefits, for admission to a priority bed or for assistance in gaining access to a community care bed.
Name of witness |
Issue |
Date |
Mr. Ralph Annis |
02 |
97/12/16 |
Vice-President and Chairman |
||
Veterans Services and Legion Seniors Committees |
||
The Royal Canadian Legion |
||
Mr. Thomas H. Brooks |
02 |
97/12/16 |
Company of Master Mariners of Canada |
||
Mr. H.C. Chadderton |
02 | 97/12/16 |
Chairman |
||
National Council of Veteran Associations in Canada |
||
Mr. Brian Forbes |
02 | 97/12/16 |
Honorary Secretary General |
||
National Council of Veteran Associations in Canada |
||
Mr. Ian D. Inrig |
02 | 97/12/16 |
Dominion Secretary-Treasurer |
||
The Army, Navy and Air Force Veterans in Canada |
||
Mr. Ted Keast |
02 | 97/12/16 |
Assistant Director, Service Bureau |
||
The Royal Canadian Legion |
||
Ms. Faye Lavell |
02 | 97/12/16 |
Director, National Secretary |
||
National Council of Veteran Associations in Canada |
||
Ms. Muriel MacDonald |
02 | 97/12/16 |
Merchant Navy Coalition for Equality |
||
Mr. Jim Margerum |
02 | 97/12/16 |
Chairman,Ontario Command Veterans Services Committee |
||
The Royal Canadian Legion |
||
Mr. Gordon Olmstead |
02 | 97/12/16 |
National Chairman |
||
Merchant Navy Coalition for Equality |
||
Mr. Jim Rycroft |
02 | 97/12/16 |
Director, Service Bureau |
||
The Royal Canadian Legion |
||
The Subcommittee travelled to North York, Ste-Anne de Bellevue and Charlottetown and held in camera meetings on December 17, 18 and 19, 1997
At the Sunnybrook Health Science Centre, North York, the following people were heard:
Mr. Llew Anderson
Resident, President of the Veterans Committee
Mr. Tom Brent
Chair, Board of Trustees
Mr. Tom Closson
Chief Executive Officer Program
Mr. Ian Douglas, C.M., Q.C.
Trustee Emeritus, Member of Veterans Committee
Dr. Peter Norton, M.D.
Vice President (Medical) for the Aging Program
Mr. Arthur Plumb
Resident, Past President of the Veterans Committee
Ms. Marilyn Rook
Vice President (Operations) for the Aging Program
At Ste-Anne's Hospital in Ste-Anne de Bellevue, Québec, the following people were heard:
Ms. Judith Cohen
Nurse Clinician
Mrs. Thérèse Dufresne
Chief of Dietary Services
Mrs. Rachel Corneille Gravel
Executive Director
Dr. Bernard Groulx
Department of Psychiatry
Dr. Pierre Paquette
Director of Professional Services
Mrs. Suzanne Lalonde
Regional Director General - Quebec, Veterans Affairs Canada
In Charlottetown, the following officials from the Department of Veterans Affairs were heard:
Mr. J.D. Nicholson
Deputy Minister
Mr. Dennis Wallace
Assistant Deputy Minister, Veterans Services
Mr. Darragh Mogan
Director General of Health Care
Ms. Debbie Gallant
RVCN Project Member
Mr. John Conlin
District Director, Toronto Area Office
Mr. Simon Coakeley
Executive Director, Ste Anne's Transfer Project
NOTES
(1) National Council of Veteran Associations, Brief to the Senate Subcommittee on Veterans Affairs, 16 December 1997, p. 12-13, and the Subcommittee on Veterans Affairs of the Standing Senate Committee on Social Affairs, Science and Technology, Evidence, H. Clifford Chadderton, 16 December 1997 (hereafter, Evidence, witness, date).
(2) Report of the Auditor General of Canada to the House of Commons, May 1996, Chapter 12, Veterans Affairs Canada-Health Care (hereafter, Report, May 1996).
(3) Ibid., p. 14-15.
(4) Evidence, H. Clifford Chadderton, 16 December 1997. According to Mr. Chadderton, the waiting list was 27 at the Sunnybrook Hospital in Toronto, 104 at the Perley/Rideau Veterans Health Centre in Ottawa, 94 at Deer Lodge Hospital, 5 at the Brock Fahrni Pavilion in Vancouver, and 23 at the George Derby Centre. According to John Walker of the Department, the exact number of priority beds is 4,082, ibid., 19 December 1997.
(5) Ibid., The Royal Canadian Legion, Jim Margerum, 16 December 1997.
(6) Ibid., Jim Margerum and Ralph Annis, 16 December 1997.
(7) Ibid.
(8) Ibid.
(9) Ibid., Arthur Plumb, Past President of the Veterans and Community Residents Council, Sunnybrook Hospital, 17 December 1997.
(10) Ibid., Llew Anderson, President of the Veterans and Community Residents Council, Sunnybrook Hospital, 17 December 1997.
(11) Report, May 1996, p. 12-21.
(12) Evidence, Darragh Mogan, Director General of Health Care, Veterans Affairs Canada, 19 December 1997.
(13) Ibid.
(14) Ibid., Arthur Plumb, 17 December 1997.
(15) Ibid.
(16) Ibid., Marilyn Rook, Vice-President (Operations) for the Aging Program, 17 December 1997.
(17) Gisele Lapointe, RNO "Safety Audit of Sunnybrook by Veterans Affairs Canada," Veterans Affairs, Kirkland Lake, Ontario, and Sunnybrook Health Science Centre, "Review of Safety Policies and Procedures at the Kilgour Wing," Sunnybrook Health Science Centre, 13 November 1997.
(18) Evidence, Ms. Rachel Corneille Gravel, Executive Director, Ste Anne's Hospital, 18 December 1997.
(19) Ibid., Dr. Bernard Groulx, Department of Psychiatry, and Ms. Judith Cohen, Nurse Clinician, Ste Anne’s Hospital, 18 December 1997.
(20) Ibid., Ms. Corneille Gravel, 18 December 1997.
(21) Ibid., Dr. Pierre Paquette, Director of Professional Services, Ste Anne’s Hospital, 18 December 1997.