Mental Health (POC 12)

Issuing Authority: Director General, Policy
Effective Date: May 18, 2012
Document ID: 1104

Care has been taken to ensure these policies accurately reflect the acts and regulations. Should any inconsistencies be found, the acts and regulations will prevail.

Purpose

This policy provides guidance on the range of mental health services and benefits that are available under Program of Choice 12 (POC 12). This document aims to establish policy, provide guidance and set forth basic principles that are to be applied in decision making on POC 12 issues. This document aims to provide policy considerations for the decision maker and is not to be interpreted as a list of rules.

Policy

Mental Health Description

  1. Mental health outcomes are affected by many factors; therefore, Veterans Affairs Canada’s (VAC) provision of mental health services is based on the multiple determinants of health: access to health services, personal factors, social, economic and physical environments. Mental health services include phases such as: acute  interventions designed to ensure safety and stabilize functioning; rehabilitative services designed to restore mental health functioning, and mental health maintenance services that support and reinforce functioning in the community. Services provided will reflect best practices and treatment around mental health conditions, addictions, and comorbid disorders.
  2. VAC recognizes the importance of the family and its significance in the health and wellness of individuals. Established best practices recognize the importance of involving family in treatment plans as families are, in many cases, the first source of support for clients and are integral to successful recovery.

Continuum of Mental Health Services

  1. The mental health services available under POC 12 are those services which are provided by psychologists, addictions counsellors and social workers and include clinical care manager services.
    1. Examples of benefits which are available as part of the continuum of mental health services but which fall outside the scope of POC 12 benefits include:
      1. treatment by a psychiatrist and/or family physician (POC 6);
      2. specialized in-patient treatment programs e.g. provincial hospital and/or comorbid in-patient programs (POC 5);
      3. specialized residential treatment programs (POC 5);
      4. peer support through the Operational Stress Injury Social Support network;
      5. VAC Assistance Services - through Health Canada
        Note: Access to these programs and services depend on an individual’s eligibility and needs.

VAC Assistance Service

  1. The VAC Assistance Service continues to be available to all Canadian Forces (CF) Veterans and their families. The service provides confidential, short term mental health services at no charge and community referrals as needed. The toll free line can be reached on a twenty-four hour basis. The service may also be accessed by members and their families prior to or after release.
  2. For more information regarding referrals of VAC clients to VAC Assistance Services, please see the following link:  VAC Assistance Service - General Information

Mental Health Services Policy Objective and Guiding Principles

  1. The policy objective of providing mental health services to eligible clients is to offer a range of mental health services which are aimed at supporting the client in becoming and/or remaining independently functioning in the community.
  2. The guiding principles of the mental health services policy are:
    1. Mental health services are provided to clients based on need with a focus on positive client outcomes. The provision of services is to be in keeping with best practice principles in the field of mental health.
    2. The effective treatment for a client may include involving the family in certain components of the mental health services (i.e. counselling, psycho-education).
    3. The effective treatment for a client may include providing interventions that address comorbid mental health issues and/or comorbid substance abuse issues.
    4. Assessing a client's motivation and readiness for change may be instrumental in predicting effectiveness of interventions and deciding whether services should be provided.
    5. Clients presenting with complex needs shall be case-managed.

Mental Health Definitions

  1. Comorbidity describes the presence of other conditions/diseases an individual patient might have other than the primary condition/disease of interest. For the purposes of this policy, one of the health problems will include a mental health condition (e.g. an anxiety disorder and alcohol abuse; a chronic pain disorder and depression; PTSD and a gambling addiction, etc.).
  2. Mental Health is a state of psychological well-being characterized by continuing personal growth, a sense of purpose in life, an ability to focus, prioritize and plan effectively, self acceptance and positive relations with others. Our mental health is expressed through how we think, feel and act in response to the challenges of daily life.
  3. Operational Stress Injury (OSI) is any persistent psychological difficulty resulting from operational duties performed while serving in the Canadian Forces (CF) or as a member of the Royal Canadian Mounted Police (RCMP). It is used to describe a broad range of problems which include diagnosed medical conditions such as anxiety disorders, depression, and post-traumatic stress disorder (PTSD) as well as other conditions that may be less severe, but still interfere with daily functioning.

Mental Health Policy Application

  1. VAC will provide appropriate and effective interventions in a timely manner to address the mental health service needs of eligible clients.
  2. Mental health services are professionally planned and structured interventions that are designed to restore psychological well-being. Mental health services available under POC 12 include those services that are provided by psychologists and social workers when these providers are practising within their respective scope of practice. The services of clinical care managers are also included. Also, services may be provided by approved addictions counsellors as authorized in the Health Care Professionals policy. Some examples of POC 12 mental health services and benefits include, but are not limited to:
    1. Counselling (individual, couple, family, group);
    2. Psycho-education;
    3. Standardized psychotherapies (e.g.: Cognitive Behaviour Therapy; Eye Movement Desensitization and Reprocessing);
    4. Addictions counselling;
    5. Group therapy;
    6. Pain management; or
    7. Specialized care services from VAC’s Operational Stress Injury clinics.
  3. Mental health services may be delivered through one-on-one interventions, in small group settings, or with the family unit and can be delivered via telemental health if required.
  4. Clients’ family members may be included in mental health services when a client’s treatment or rehabilitation plan has established that doing so is required in order to achieve positive treatment outcomes for the Veteran’s condition. The Family members section of this policy provides further guidance. Family members are also to be provided with information from VAC regarding access to services that are available through community and government resources.
  5. A client who requires treatment for a mental health condition may also require treatment for comorbid issues (including substance abuse) in order to successfully treat the mental health condition that is the primary focus of the treatment.
  6. The health condition that is the primary focus would be:
    1. in the case of a client obtaining treatment benefits under the Veteran Health Care Regulations (VHCR), the pensioned/awarded condition or other health problem for which the client has treatment eligibility; or
    2. in the case of a client participating in the Rehabilitation program, the health problem primarily resulting from service or that health problem which lead to a career ending medical release.

Mental Health Policy Standards

  1. Mental health services provided by VAC under this policy are to:
    1. be provided by approved mental health professionals;
    2. be based on assessed need;
    3. be outcome-focussed;
    4. be evidence-based;
    5. be periodically reviewed;
    6. have reasonable probability of achieving a positive treatment outcome.

Furthermore, best-practices in mental health indicate that the client should demonstrate that he or she is ready and willing to engage in the proposed treatment. Decision-makers should consult with VAC’s Regional Mental Health Officers as appropriate.

Family Services - Treatment Benefits and Rehabilitation Program

  1. The Veterans Well-being Regulations (VWR) (sections 8 and 9) make reference to family members being involved in rehabilitation services. Further information regarding the extent of services that may be included as part of a rehabilitation plan can be found in the Rehabilitation policies.
  2. The VHCR, section 3-4 provides authority to provide treatment benefits for clients. While some clients are eligible for treatments benefits in relation to any condition, other clients are eligible to receive treatment benefits when they are ‘in respect of’ a pensioned/awarded condition. The Department’s view regarding the meaning of ‘in respect of’ indicates that treatment benefits are to be provided when they are expected to produce a positive treatment outcome for the pensioned condition; or when there is a reasonable expectation to alleviate symptoms and/or effects that are caused in whole or in part by the pensioned condition.
  3. VAC’s view in providing treatment benefits to eligible clients is based on achieving the best possible outcome for the condition that is being treated given the client’s circumstances. Best practices in the treatment of mental health conditions clearly establish that successful treatment of mental health conditions often require that a patient’s family participate in treatment. This may mean including the family in treatment sessions with the patient and/or providing sessions to family members on their own in order to address the impacts that the patients’ mental health condition is having on the other members of the family unit. Achieving a positive outcome can be compromised if the client is treated in isolation without addressing the effects that the mental health condition has on the family or the effects that the family dynamic have on the patient’s mental health condition.
  4. Provincial health authorities have the responsibility for addressing the health issues of these family members and it is not VAC’s intention to provide family members with access to programs to which they are not entitled.
  5. However, in being responsible for the treatment of the eligible Veteran client, the Department must ensure that the treatment that is being provided has a reasonable expectation to result in a positive outcome. Therefore, in the context of mental health conditions, the treatment required by the eligible Veteran may include addressing the impacts caused to - or by - the family and this cannot be accomplished without participation of the family member(s). While the perception is that an intervention is being provided to a non-client, the rationale in providing the intervention is that it is actually treatment of the client’s mental health condition.

Family Services

  1. There is no definition of the term "family" in VAC legislation. Situations where a Veteran requests a member of his/her "family" to participate in joint mental health services may be considered, even if they do not fall into the categories of "spouse", "common-law partner", "dependent child", "orphan", "mother" or "father".
  2. Mental health services may be provided to family members to the extent that they are required to achieve the treatment outcomes that have been established for the Veteran client. The need to include family members in a Veteran client's treatment plan must be established by the client's treating health professional in a treatment plan, or be identified in the VAC Rehabilitation Plan.
  3. Guidelines for approving mental health services for families:
    1. In all cases, services approved by VAC are intended for the treatment of the Veteran client’s mental health condition. In some cases, a portion of the mental health services approved for the Veteran client will include sessions with or for the family members.
    2. While the actual portion of the client's overall treatment which includes family participation can vary, all of the treatment must be focussed on achieving a positive treatment outcomes for the Veteran.
    3. The need to include family members in a Veteran client’s treatment must be established by the client’s treating health professional in a treatment plan, or be identified in a VAC case plan or in the Rehabilitation Program Plan.
    4. Mental health services for family members should be short-term and focussed on the anticipated outcomes which have been established for the client. This should be communicated to family members.
    5. Providing services to family members does not represent a commitment to provide ongoing health services beyond the time frame of the Veteran client’s treatment plan or beyond the duration of the client’s Rehabilitation Program Plan.  Therefore, coverage by VAC of services for family members is to terminate when:
      1. the Veteran client no longer requires services; or
      2. the services provided to the family member(s) are not contributing to the desired outcomes of the Veteran client’s treatment plan or rehabilitation plan.
    6. Family members may have needs for mental health services that are unrelated to the mental health problem for which the Veteran client is receiving treatment or rehabilitation services. These needs will not be covered by VAC, however information is to be provided about local/provincial resources.
    7. Geographical distance of the Veteran client’s family member is not considered an appropriate reason to exclude the family member from the treatment plan or the Rehabilitation Program Plan. If mental health services are to be provided to a family member who is geographically distant from the Veteran client, there should be evidence of communication between the treating health practitioners in order to ensure that the objectives of the treatment plan are being fulfilled.
      1. For example: A VAC client who requires treatment for PTSD resides in Toronto, Ontario and has a child who resides part-time in another town. If providing mental health services to the child is determined to be appropriate, they can be provided to the child by another health professional in the province where the child resides. There should be evidence of communication between the health professional who is treating the client and the one who is treating the child.

Family Services - Rehabilitation Program

  1. The purpose of this section is to set out guidelines for approving mental health services for family members under the Rehabilitation Program under the Veterans Well-being Regulations. This section does not pertain to Treatment Benefits under the VHCR.
  2. One of the principles of the Rehabilitation Program is to involve family members to the extent required to facilitate the rehabilitation needs of the client. Disability has a significant impact on individual Veterans, their families and their involvement in community life. For Veterans with serious mental or physical disabilities and involuntary career loss, research indicates the most common impacts on the family are conflicts in the marital relationship, spousal depression or anxiety disorders and child behavioural problems. In addition, research in rehabilitation services has established that a family's ability to adapt and function effectively is central to the success of the person's completion of his or her rehabilitation program plan.
  3. In accordance with regulation 8(b), a Veterans' rehabilitation program plan may need to include mental health services for the family as a whole, the couple, or individual family members when VAC determines mental health services for the family member/s is required to facilitate the Veteran's progress in rehabilitation.
  4. Once eligibility for the Rehabilitation Program has been determined for the CF Veteran, the Case Manager, in consultation with relevant members of the Client Services Team, will assess the medical, psycho-social and vocational rehabilitation needs of the Veteran. To successfully address the Veteran's rehabilitation goals, the Case Manager may determine that there is a need for marital counselling, individual mental health services for the spouse or common-law partner or child, or family counselling.
  5. In circumstances where the Veteran is otherwise participating in the Rehabilitation Program but is not ready or willing to participate in family or marital counselling due to the acute nature or instability of his/her health condition, the Case Manager may determine that other family members need individual mental health services. In these situations the family member may be provided mental health services as part of the Rehabilitation Program plan. Besides relieving immediate distress, assisting family members in this way can contribute to the family's capacity to contribute to the success of the Veteran's rehabilitation.
  6. Where a need for individual (e.g. spouse/common law partner or child), marital or family counselling services is identified and there is reason to believe that the need is caused or exacerbated by the career loss or health condition(s) for which a rehabilitation plan has been approved by the CF Veteran, appropriate mental health services for the family may be provided as a rehabilitation service under the Veteran's Rehabilitation Plan.
  7. The family services as outlined in this policy are available to family members after the CF Veteran has released from the military for the period of time that the Veteran is participating in the Rehabilitation Program.
  8. As participants in a Veteran's Rehabilitation Plan, family members may be eligible for reimbursement of certain costs to facilitate their access to family services. For details about coverage for family services travel, please refer to Rehabilitation policies.

Medically Releasing Clients with Complex Needs

  1. For medically released clients, where identified family issues may affect the success of the SISIP Vocational Rehabilitation Program, the case can be considered a "complex case". In this context, the term “complex case” refers to circumstances where clients require medical, pyscho-social and vocational rehabilitation interventions that must be co-ordinated between VAC, CF and SISIP. These cases may require active case management to enable coordinated delivery of medical, psycho-social, and/or vocational rehabilitation services in order to achieve optimal functioning for the client.

Family Needs for Mental Health Services Unrelated to Rehabilitation Plan

  1. Families may have needs for mental health services that are unrelated to the career loss or the health problem for which the Rehabilitation Case Plan has been approved. For these needs, information can be provided about local community resources.

Authorizing Services for Family Members

  1. Where a need for individual, marital or family mental health services is identified, the Department will pre-authorize a referral for an assessment and mental health services plan as a rehabilitation benefit.

Treatment of Co-morbid Health Issues

  1. VAC recognizes that mental and physical health problems commonly have interactions with one another and may prevent positive treatment outcomes if not addressed. While the provision of services will be related to a mental health condition that must remain the condition of primary focus, a practical and holistic approach shall be applied so as to not compromise the potential for a positive treatment outcome for the condition of primary focus.
  2. VAC shall ensure that clients are provided with information and assistance in accessing appropriate treatment services for co-morbid conditions. This may mean providing information regarding access to services that are available through community and government resources. As a last resort, when these resources do not appropriately meet the client’s needs, VAC may provide services to clients in respect of the health condition that is the primary focus of the treatment to the extent that such interventions are required to achieve the established desired outcomes of a client's treatment or rehabilitation.
  3. Guidelines for addressing comorbid conditions:
    1. When considering the appropriateness of providing treatment when co-morbid conditions are involved, the principles cited in the policy “Treatment in Respect of a Pensioned or Awarded Condition” should be applied.
    2. When considering eligibility to treatment benefits the full scope of the pensioned/awarded disability must be taken into consideration. In addition to the considerations included above, decision-makers may also refer to VAC’s Entitlement Eligibility Guidelines (EEG) which consist of current medical and scientific descriptions of injuries and diseases. In particular, decision-makers are to be familiar with section B of each EEG. Section B identifies those conditions for which separate entitlement need not be sought, and which will be included in the assessment of the primary condition. The conditions included here are added when:
      1. a disability progresses so as to develop different features which appear at different times and the different features are part of the same disease process and involve the same body part or organ system; and/or
      2. two or more disabilities have similar symptoms and effects which cannot be separated for assessment purposes, usually involving the same body part or organ system.

        Generally, it is accepted that treatment of those conditions listed in section B of a particular EE Guideline would be considered to be in respect of the primary condition.
    3. In all cases, treatment must always have a reasonable potential to result in a positive treatment outcome for the condition or the health problem which is the condition of primary focus. The health problem that is the primary focus would be:
      1. in the case of a client obtaining treatment benefits under the VHCR, the pensioned/awarded condition or other health problem for which the client has treatment eligibility; or
      2. in the case of a client participating in the Rehabilitation program, the health problem primarily resulting from service or the health problem which led to a career ending medical release

        For example: An A-line client is pensioned for Chronic Adjustment Disorder with Anxiety and was approved for mental health services. In the regular progress report, a need for continued treatment is identified. The available documentation indicates that the proposed treatment is necessary and appropriate given the severity of client’s symptoms. However, the treating psychologist has noted that PTSD, depression and social phobia are being treated. Therefore, in considering approval of the treatment, questions arise with respect to the link between the treatment and the pensioned condition. As the pensioned condition, and the non-pensioned conditions which are being targeted by the treatment have similar symptoms and effects which cannot be separated, approval of the request could be granted.
    4. Other examples of appropriate treatment of co-morbid conditions include, but are not limited to:
      1. treating sleep apnea and/or substance abuse if PTSD is the health problem of primary focus.
      2. treating substance abuse if Major Depressive Disorder is the health problem of primary focus.

Exceptional Approval of Other Mental Health Services

  1. Mental Health Services other than those listed in the Mental Health Policy Application section are generally not approved as POC 12 services. Exceptions may be made and non-standard services may be covered in circumstances where the delegated decision maker, based on information and medical/psychological justification provided by the treating provider, is of the opinion that:
    1. the efficacy of the service is evidence-based and one of more of the following:
      1. the service is clinically necessary in order to maintain the client’s health;or
      2. the client’s condition and/or general health would be negatively affected in the absence of this particular treatment; or
      3. there is no other clinically acceptable treatment available in this case; or
      4. other equally significant factors exist.
  2. In all cases, it is desirable to have clinical justification which describes that the client is a good candidate for the service being proposed and that the client's health is not expected to be negatively impacted by what is being proposed.
  3. Approval of non-standard services should occur in accordance with the Department’s policies and business processes on exceptional benefits.

Addiction Counselling and Treatment

  1. VAC will respond to clients’ needs for addictions treatment and counselling by ensuring that clients have access to a continuum of addiction and substance abuse treatment services.
  2. The types of services that may be provided to clients include, but are not limited to:
    1. assessment by a physician and/or a specialized counsellor, as authorized by VAC, to determine the presence of addiction and/or substance abuse and to determine the required treatment, as well as any supportive counselling and/or detoxification that may be required prior to treatment. This may also involve family members;
    2. formal in-patient and/or out-patient treatment programs involving individual, group and family therapy and/or education sessions;
    3. early intervention groups for counselling, for those not requiring the in-patient program; and
    4. follow-up sessions (group/and or individual sessions) after treatment, as required, with the referring physician and/or addiction counsellor.
  3. Whenever possible, assessment and treatment services are to be provided by health providers who have a clinical background and specialized training in addictions treatment and/or counselling. Providers must be approved by VAC as outlined in the Health Care Professionals policy.

References

Canadian Forces Members and Veterans Reestablishment and Compensation Act, Part II, sections 6-17; and

Canadian Forces Members and Veterans Reestablishment and Compensation Regulations, Part II, sections 6-16.

Veterans Health Care Regulations Part I, sections 3-5. and Part IV

Treatment in Respect of a Pensioned or Awarded Condition

Health Care Professionals  

Rehabilitation Related Expenses – Other Than Training

Authorization of Rehabilitation Service and Vocational Assistance Services

Sequence in Accessing Sources of Payment for Medical and Psycho-social Rehabilitation and Health Care Benefits

VAC Entitlement Eligibility Guidelines

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