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5.0 Findings

The presentation of findings of the evaluation is structured according to the core issues of relevance and performance (effectiveness, in terms of program reach). There are three core issues which respond to the question of relevance:

  • Alignment with Government Priorities;
  • Consistency with Federal Roles and Responsibilities
  • A Demonstrable, Continuing Need for the RTC

5.1 Relevance - Alignment with Government Priorities

In the Budget of March 2007, the federal government showed its support for Canadian troops "by providing $60 million to increase the field operations allowance, establishing five new trauma centres to help Veterans and their families deal with stress injuries related to their military service". In the Speech from the Throne, delivered on October 16, 2007, the federal government reiterated its commitment to "continue to improve support for our Veterans who have contributed so much to defending Canada in the past".

This commitment to supporting Canada's Veterans was further reinforced in the Speech from the Throne in March 2010, when the government stated in its broad agenda outline that one of its priorities was to stand up for those who helped build Canada by continuing to stand up for Canada's military and its Veterans.

The Residential Treatment Clinic for Operational Stress Injuries is one of the trauma centres established as a result of the Budget 2007 commitment. The RTC offers programs consisting of stabilization treatment and rehabilitation aimed at:

  • stabilizing a Veteran`s mental health condition;
  • optimizing autonomy and functional capacity; and
  • facilitating reintegration into the community through rehabilitation efforts to enhance autonomy, self-management and self-reliance and a sense of community and belonging.

These goals align the clinic with the broad objective of supporting our troops and specifically align the clinic with federal priorities by providing specialized care and treatment that assists Veterans and their families to deal with stress injuries related to their military service.

VAC`s 2010 - 2011 Strategic Outcome #1 states that "Eligible Veterans and other clients achieve their optimum level of well-being through programs and services that support their care, treatment, independence, and re-establishment". In terms of its efforts in pursuit of this outcome, VAC has developed a Mental Health Strategy in order to increase the Department's capacity to meet the needs of Veterans with a mental health condition. The thrust of this strategy is to develop a comprehensive continuum of mental health services that can support Veterans and their families. This includes providing appropriate care at various levels of intensity depending on the needs of the individual and their family.

In addressing OSIs, the RTC thus aligns with VAC's Strategic Outcome #1 and the Mental Health Strategy by providing intensive, integrated care and treatment for individuals experiencing severe/complex OSI symptoms and for whom other services provided in the continuum are not sufficient.

The RTC is a critical component in the provision of (a continuum of) services for Veterans.

5.2 Relevance - Consistency with Federal Roles and Responsibilities

5.2.1 Legislation

VAC's role in the care and treatment of Veterans of military service is clearly rooted in its founding Act and in various regulations which preceded the creation of VAC's OSI Clinics. Under the Department of Veterans Affairs Act, the Veterans Health Care Regulations define health as a state of physical, mental and social well-being. This Act outlines eligibility for multiple benefits including medical care, home adaptations, travel costs for examinations or treatment and other community health care services. The Pension Act defines disability as "the loss or lessening of the power to will and to do any normal mental or physical act." The Canadian Forces Members and Veterans Re-establishment and Compensation Act (the New Veterans Charter) authorizes the Minister to provide job placement assistance, rehabilitation services, vocational assistance and financial benefits, disability awards, and health benefits for Canadian Forces members and Veterans. The Department provides services to an eligible population which includes Veterans, released CF members and RCMP and their families as well as some still-serving CF and RCMP members who for a variety of reasons seek treatment from VAC. The RTC was established under Treasury Board authority in response to a VAC-identified need for additional facilities given the dramatic increase in demand for such services.

5.2.2 Rationale

Co-morbid conditions, such as depression and PTSD can interact and can compromise relationships, financial stability and/or overall quality of life. Issues that otherwise would be considered manageable can often escalate to a crisis level. The complexity of the interaction of these conditions makes them more challenging to treat and requires more than outpatient care. As such, a need was identified for an OSI inpatient clinic to treat these complex, co-morbid cases. A departmental analysis which preceded a 2007 Treasury Board submission determined that Ste. Anne's Hospital was best positioned to provide OSI inpatient services because it had an OSI clinic, stabilization beds, physical rehabilitation, a pain management clinic, and clinical expertise in dealing with complex PTSD cases.

5.2.3 VAC's Current OSI Services

As previously mentioned, the OSI clinics are a unique type of external health service provider as the operations of each OSI clinic is fully funded by VAC to provide exclusive services for Veterans, CF and RCMP members and their families through Memoranda of Understanding (MOU) with host organizations in various locations across Canada. While the OSI clinics offer primarily outpatient services, additional contracted services allow VAC to purchase inpatient services as necessary.

The RTC is a 24/7 inpatient facility which provides an integrated, highly structured, more intensive, multidisciplinary team response to the complex PTSD and co-morbidity mental health conditions of a Veteran, CF or RCMP member. The multidisciplinary team, using an interdisciplinary approach, is comprised of psychiatrists, psychologists, physicians, mental health nurses, social worker, occupational therapist, psycho-educator, addictions counselor, art therapist and peer support worker. The fact that the RTC incorporates the services of a peer support worker in the clinical team is unique.

The RTC offers a two-track approach ,firstly, a stabilization program wherein the Veteran's condition is medically re-assessed and stabilized and individual therapy is provided. Secondly, a residential program which focuses on rehabilitation provides more intensive group therapy aimed at developing more self- coping mechanisms and life skills. The residential rehabilitation program is designed around eight themes and each week is organized around a specific theme. Themes rotate through the cycle on an ongoing basis allowing individuals to enter the program at the beginning of any week. Admissions occur on Sunday afternoons allowing time for participants to familiarize themselves with the facility before engaging in the intensive treatment. Individual services and interdisciplinary case discussions are organized into three distinct phases: orientation/assessment, intensive treatment, and termination of treatment. All clinical programming is offered in both official languages. The Clinic is unique and aimed solely at the military and policing sector.

5.2.4 OSI Service Alternatives

Department of National Defence (DND)

With respect to service alternatives, the DND‘s OTSSCs provide treatment services for serving members of the Canadian Forces and, in certain circumstances, to their spouses and family members. The OTSSCs provide individualized assessment, education, and initial treatment for members suffering from Post Traumatic Stress Disorder; however, the services are operated on an outpatient basis. The OTSSCs are generally operating at full capacity assisting CF still-serving members.

Provincial Service Alternatives

  • Public hospitals

    Specialized psychiatric hospitals generally provide acute care only - our Veterans who don't usually meet their admissions criteria as they may be ill but do not present as acute. When they are in need of acute care, these facilities do provide the necessary care typically over very short term stays. Emergency services within provincial public hospitals also address those individuals in crisis mode.

  • Private clinics

    Private clinics across Canada, such as Homewood and Bellwood in Ontario and Edgewood in British Columbia, are primarily outpatient facilities as are all of the VAC OSI Network Clinics with the exception of the RTC. While Homewood in Ontario and Le Centre CASA in Quebec offer inpatient services as well, Homewood is usually for acute admissions and Le Centre CASA has a primary focus on addictions treatment.

Provincial Service alternatives are primarily outpatient operations. As indicated in VAC's 2008 evaluation of the OSI Clinic Network, "respondents identified that clients with a more complex OSI require the support of an interdisciplinary team approach, in order to properly address the multiple aspects of treating an OSI. Generally, services in the community do not offer this interdisciplinary team approach which is required to support clients with more complex OSI." Moreover, the current evaluation has determined that community services generally focus primarily on a single presenting mental health condition such as addiction or depression. The current practice of integrated multidisciplinary treatment which takes into account the benefits of the simultaneous treatment of PTSD and co-morbid conditions is not generally possible in these clinics.

Although inpatient services are available both publically and privately in a few provinces, in general, Veterans, CF and RCMP members are treated with civilians, as the numbers seldom justify distinct group treatment. However, respondents indicate that the efficacy of treatment for the Veteran is not as significant when co-mingled with civilians. The importance of treating the military as a cohort, which was also highlighted in the 2008 OSI Network Evaluation, was confirmed in all stakeholder interviews from subject matter experts to the Veterans themselves.

Conclusion

In summary, the combination of inpatient, bio-psychosocial treatment for patients with complex PTSD co-morbid with other conditions, which treats the military and policing culture as a cohort, offers peer support services and undertakes an integrated, multi-disciplinary approach, is not readily available in Canada. The RTC uniquely fulfills this combination. In the current absence of adequate provincial and federal alternatives, VAC has assumed the federal role and responsibility for providing the best possible care to its Veterans, CF and RCMP members and their families.

5.3 Relevance - A Demonstrable, Continuing Need for the RTC

To what extent does the OSI Inpatient Clinic (RTC) address a demonstrable need and is responsive to the needs of Veterans, CF and RCMP members and their families? This question is central to the core issue of relevance and was explored by:

  1. Determining the target population for the RTC within VAC's eligible population;
  2. Identifying the mental health needs of that population;
  3. Assessing the RTC's response to the needs of the target population; and
  4. Identifying any gaps in responding to those needs.

5.3.1 VAC's Eligible Population

VAC's Mental Health Directorate produces Mental Health Quarterly Statistical Reports amalgamating information provided from the Reporting Database, Federal Health Care Processing System and the National Centre for Operational Stress Injuries. In Figure 3, the historical data for VAC Veterans with a psychiatric condition as well as those specifically diagnosed with PTSD are illustrated.

Figure 3 depicts the dramatic rise in the number of Veterans and members being provided services by VAC. In March 2004 some 4,894 individuals received a favourable disability benefit decision for a psychiatric condition. As of March 3, 2011, the number had risen to 14,111 representing nearly a three-fold increase. Of the 14,111 individuals identified with a psychiatric condition, 70.4 percent are identified as having PTSD - representing a rise of 350 percent - from 2,824 in March 2004 to 9,928 in March 2011.

Modern-day released Veterans represent 63.8 percent (9,005) of those individuals with a psychiatric condition while those still-serving CF and RCMP members represent 19.3 percent (2,734). Of particular note is the upward trend which reveals a continual year-over-year rise in the number of those with a psychiatric condition since 2004.

Figure 3: Mental Health Quarterly Statistical Report – OSI Clinics 31 March 2011

Mental Health Quarterly Statistical Report – Data to March 31, 2011
Line Number VAC Client Information VAC West Ont. Que. Atl.
1 Clients/dependents/survivors 218,388 80,131 77,910 23,564 36,714
2 Dependents/survivors 78,086 28,047 28,904 8,070 13,035
3 Unique clients (see Note 2) 140,302 52,084 49,006 15,494 23,679
4 Unique clients – Regional percentage of national 37.1% 34.9% 11.0% 16.9%

Note 2: "Unique Clients" includes war service Veterans, CF released Veterans and CF still-serving and the RCMP but excludes survivors and dependents.

Clients with a Favourable Disability Benefit Decision for Psychiatric Condition - Current data – March 31, 2011
Line Number VAC Client Information VAC % West Ont. Que. Atl.
5 Clients with a psychiatric condition 14,111 10.1% 4,955 3,445 2,684 3,027
6 Regional percentage of national 35.1% 24.4% 19.0% 21.5%
Clients with a Favourable Disability Benefit Decision for Psychiatric Condition - Change Since Last Quarterly Report
Line Number VAC Client Information VAC % West Ont. Que. Atl.
7 Clients with a psychiatric condition, last report 13,711 4,796 3,354 2,644 2,917
8 New clients with a psychiatric condition 508 3.7% 198 125 61 124
9 Clients deceased who had a psychiatric condition 108 0.8% 39 34 21 14
10 Increase in clients with a psychiatric condition 400 2.9% 159 91 40 110
Clients with a Favourable Disability Benefit Decision for Psychiatric Condition - Historic data
Line Number VAC Client Information Mar. 11 Mar. 10 Mar. 09 Mar. 08 Mar. 07 Mar. 06 Mar. 05 Mar. 04
11 Clients with a psych. condition 14,111 12,689 11,888 11,045 10,250 8,385 6,491 4,894
12 Clients with PTSD 9,928 8,758 7,996 7,228 6,500 5,541 4,055 2,824
13 Clients with PTSD,
(percentage line 11)
70.4% 69.0% 67.3% 65.4% 63.4% 66.1% 62.5% 57.7%
VAC - Client Profiles
Line Number Primary Service VAC % West Ont. Que. Atl.
29 War Service Veterans 2,371 16.8% 794 707 538 332
30 CF released Veterans 7,714 54.7% 2,237 1,957 1,776 1,744
31 CF still serving 1,854 13.1% 485 579 258 532
32 RCMP released 1,291 9.1% 836 108 75 272
33 RCMP still serving 880 6.2% 603 94 37 146
34 Service missing 1 0% 0 0 0 1
VAC - Client Profiles - Reservists
Line Number Status VAC % West Ont. Que. Atl.
35 Reservists released 698 4.9% 243 168 146 141
36 Reservists still serving 49 0.3% 17 12 5 15
The top Psychiatric pension conditions were as follows (clients may have more than one condition)
Line Number Status VAC % West Ont. Que. Atl.
61 PTSD 9,928 70.4% 3,755 2,136 1,881 2,156
62 Depressive disorders 2,411 17.1% 753 749 340 569
63 Anxiety and depression 1,190 8.4% 296 336 277 281
64 Anxiety disorders (excluding PTSD) 1,035 7.3% 275 334 216 210
65 Adjustment disorder 478 3.4% 138 115 137 88
66 Schizophrenia 127 0.9% 31 44 30 22
67 Alcohol use disorder 188 1.3% 37 48 55 48
68 Chronic pain 180 1.3% 58 81 10 31
69 Bipolar condition 110 0.8% 30 31 26 23
70 All other psychiatric conditions 344 2.4% 110 123 57 54
The top Psychiatric pension conditions were as follows (Co-existing Conditions)
Line Number Status VAC % West Ont. Que. Atl.
71 Head/Brain Injury 107 0.8% 50 25 10 22
72 Hearing Loss 4,644 32.9% 1,706 1,117 920 901
73 Musculoskeletal 7,136 50.6% 2,480 1,728 1,375 1,553

Note 2: "Unique Clients" includes war service Veterans, CF released Veterans and CF still-serving and the RCMP but excludes survivors and dependents
Source: VAC's Mental Health Directorate

5.3.2 The Target Population of the RTC

A population profile

In general terms, and as stated in VAC's Continuum of Care (Figure 1, p.3), the Residential Treatment Clinic at Ste. Anne's Hospital, provides third-level or tertiary-level care aimed at providing treatment and residential rehabilitation services to Veterans, CF and RCMP members and their families who present with a complex PTSD co-morbid with OSI conditions such as depression, alcohol/substance abuse, chronic pain, sleep disorders or anxiety disorders, and for whom outpatient treatment was insufficient or ineffective. Studies reveal that "more than 50 percent of PTSD sufferers have symptoms of major depressive disorder Footnote5. Alcohol abuse or other substance abuse affects over 50 percent of those with PTSD Footnote6. An individual who has depression and anxiety simultaneously has greater functional and psychosocial Impairment. Co-morbid depression significantly increases suicide risk."

A 2005 study of 130 clients from the Ste. Anne's outpatient OSI clinic indicated that 86.9 percent were suffering a significant level of pain. Patients with co-morbid pain and PTSD experience more intense pain, more emotional distress, higher levels of life interference, and greater disability than pain patients without PTSD. Recent research from McGill University highlights the morphological changes which occur within the brain as a result of chronic pain and visually underscores the reduced psychosocial capacity to cope.

An observation cited in VAC's Life After Service Study (LASS) which examined co-morbidity of chronic physical and mental health conditions noted that 55.2 percent of NVC participants had both a mental and physical health condition compared to 9.8 percent of Veterans who were not VAC participants, thus supporting the long held contention that there is a high degree of co-existent physical and mental health issues present in NVC participants.

A file review, conducted in conjunction with the New Veterans Charter Evaluation – Phase III in 2010, noted an exceptionally high proportion of individuals reported pain at baseline functioning (83 percent). At least half of the sample self-reported a significant mental health issue (57 percent), a high stress level (51 percent) and presented with a type of operational stress injury (OSI) (49 percent).

5.3.3 Estimating Future Demand for Inpatient Services

Australian studies cite an historical figure of between 6 percent - 13 percent of troops returning from current conflicts in the Middle East will exhibit combat-induced PTSD. The term "combat-induced" refers to those individuals directly engaged in combat. These individuals also reflect a great propensity for a more complex/severe PTSD. On the other hand, the number of those individuals who present with a complex PTSD, i.e. with a severe PTSD and co-morbid mental health conditions, is a relatively small subset of the percentage and derived numbers above. A DND OSI study to be released in 2011 will use a stratified sample of 2,500 and will attempt to determine how many still-serving CF members have PTSD directly attributable to the military mission. DND firmly believes that one of the better measures for PTSD is the extent of combat. Thus, while they estimate that those suffering from combat-related PTSD will be in the range of 7 - 8 percent, they recognize that the study will be more conclusive. The study results should assist VAC in estimating the potential number of eligible future clients.

Other Considerations

  • OSISS peer support respondents unanimously felt that the number of those requiring PTSD care and treatment will increase in the near future. One respondent stated that "the water has not yet broken over the bow". This statement was endorsed by OSISS colleagues.
  • A CBC News report of June 14, 2011, quoted a former elite soldier in the CF as saying that "the numbers of soldiers who are diagnosed with post traumatic stress disorder will skyrocket in the next few years as Canada winds down its combat operations in Afghanistan." The soldier went on to state that "Now they'll have time to actually sit back and reflect on exactly what it is that they're going through,…They're not deploying so it's more time to actually consider what's going wrong in their lives. We are seeing the tip of the iceberg right now."
  • The manifestation period for PTSD ranges anywhere from one to several years according to the CF 2002 Canadian Community Health Survey Supplement Study. U.S. subject matter experts indicated that many older Veterans who are reaching retirement age are now coming in for treatment. The higher profile accorded PTSD and the outreach efforts by the United States Veterans Administration has brought these Veterans forward after years of trying to suppress such issues.
  • The mitigating efforts of DND in terms of early intervention should reduce the probability of PTSD escalating to a more complex/severe level. DND has a mandatory post-deployment screening for PTSD implemented at three and six month intervals which according to DND officials, captures about 80 percent of those with PTSD. Despite the identification of PTSD from this screening, it is recognized that the screening is only as effective as the number of individuals who subsequently receive treatment. To this extent, the commanding officers within DND are to ensure those individuals screened undergo treatment. It is also a reality that not all cases identified with PTSD are directly attributable to the conflict. Some have entered the military harbouring childhood trauma.
  • DND is also continuing its efforts to educate the soldier with respect to the signs and symptoms of PTSD. This is being accomplished in an increasingly more tolerant atmosphere which has seen significant progress in the de-stigmatizing of mental health issues within the military.
  • DND's enhanced post-deployment screening practice which includes a questionnaire followed by an interview with a mental health nurse represents a Canadian best practice and is more rigorous than that found in the U.S. An experienced mental health nurse can validate questionnaire responses from face-to-face questioning, probe for other mental health conditions such as depression, traumatic brain injuries and verify an assessment against tour of duty data.
  • The demographic and geographic issues that the Australians confront in terms of addressing the needs of its Veterans suffering from OSIs is more similar to the Canadian experience than is that of the United States. The Australian component to the comparative piece found in Annex D contributes two salient points to this discussion of estimating future demand for inpatient services:
    1. Less than 10 percent of those suffering from PTSD will likely require inpatient care and treatment (the American subject matter experts concur).
    2. Australia formerly treated many more in an inpatient program but found that the outcomes were almost the same in outpatient, day hospital programs. As a result, they began to treat most clients on a 4 week, 2-3 days per week outpatient, day hospital program within their own community. There was much less distance travelled by the Veteran and it helped him/her avoid the stigma of a hospital when the Veteran was treated in his/her own community. As a result, the outcomes, if anything, were a little stronger from the local program. This challenged the previous thinking on treatment.

Conclusion

Estimating the number of future client-patients for inpatient treatment with any precision is difficult at best given the preceding considerations, including the perspectives from different stakeholders, the mitigating measures of DND and the de-stigmatization efforts within the military and within Canadian society as a whole. Notwithstanding, given the relatively early Canadian experience and the views of subject matter experts in the United States and Australia based on a longer recent history, it is not unreasonable to assume that less than 10 percent of those individuals with PTSD will require inpatient care and treatment. Finally, the Australian experience suggests that their day hospital model which can operate at the local community level, which carries fewer stigmas, operates on a more cost effective basis and often achieves stronger clinical outcomes than inpatient facilities, is a model worthy of consideration for the Canadian context.

5.3.4 Meeting the Needs of the Target Population

The RTC Response

The creation of the RTC is a result of the evolution of an inpatient stabilization program implemented at Ste. Anne's in 2002 and growing support over the ensuing years from clinicians, OSISS and VAC administrators, all of whom had identified the need for residential treatment services. The latter was to consist of rehabilitation care with an emphasis on more intensive group therapy. With the new RTC to be housed in Ste. Anne's Hospital, a long-term care facility and not an acute care facility, the development of admission criteria of necessity, took into account the safety and security of the long-term care patients at Ste. Anne's. Accordingly, while the target population for the RTC is expressed on VAC's continuum of care chart (Figure 1, p. 3) in practice, the RTC further defined its target population through the following exclusions:

Admission exclusions for the RTC

  • Presenting with pathology – medical/psychiatric condition that precludes the benefits of the treatment. For example, the RTC's professional staff has indicated that those individuals who present with a moderate to high personality disorder will not be accepted for treatment.
  • Active substance use or abuse interferes with daily functioning and treatment.
  • Lack of up-to-date (last three months) comprehensive medical psychiatric/psychological (differential diagnosis) assessment report available.
  • Suicidal/homicidal ideation, presenting moderate or high risk of acting out (him/herself or others).
  • At risk of expressing, or engaging in physically and verbally violent behaviours or sexually inappropriate behaviours.
  • Awaiting trial on criminal charges and is under custody or preventive detention order.
  • Has been either released from detention on surveillance conditions, or found guilty of criminal charges and is serving a prison sentence or legal procedures significantly interfere with the treatment.
  • Under an administrative tribunal order further to a verdict of not criminally responsible on account of a mental disorder, a psychiatrist or hospital has been designated to provide psychiatric treatment.

These exclusions pertain to admittance into the RTC's Stabilization program. Admittance to the Residential Rehabilitation program includes all those above with the following two additions:

  • not able to manage own medication, and
  • medication requiring significant adjustments.

It should be noted that despite the special emphasis on the safety and security of Ste. Anne's Hospital's long-term care residents, the RTC's exclusion criteria are not unlike those adopted by clinics in Australia and the United States which serve to promote a safe, supportive and structured environment for those in inpatient residential rehabilitation programs .

The RTC's professional staff and NCOSI officials concur that the exclusion requirements cited above were developed, in part, around the need to maintain the security of the aging Veterans within Ste. Anne's Hospital and partly due to the fact that neither the facility nor the existing professional staff had the capacity to deal with acute care patients. As a result:

  • A significant portion of the target population - partially because of LTC location (not a psychiatric hospital/acute care) is excluded.
  • Psychiatrists responsible for the clients under their care have placed considerable restrictions on admittance criteria.
  • There are clients in crisis who don't meet provincial criteria for hospitalization but have a need and are also excluded from the RTC.

The number admitted to the residential rehabilitation program is low. It is not merely the fact that the rehabilitative program track of the RTC is new that accounts for the lack of direct entry into the program; rather, the emphasis on more intensive group therapy assumes that the participant is fully stabilized, has had some individual counselling, and is highly motivated and focussed. However, RTC clinicians have indicated that individuals are presenting with more complex conditions than initially anticipated and taking longer in their recovery. It is thus rare that the referral to the RTC does not require time spent in the stabilization track before entering the rehabilitation program. As a result, in 2010, 92 percent of admissions entered the stabilization track and only 8 percent entered the residential track directly as depicted in Figure 4.

Figure 4: Referrals and Admissions by RTC Program Track

Percentage of clients initially referred by Referral Agencies to each of the Programs
A pie chart showing the percentage of clients initially referred by Referral Agencies to each of the Programs.  Details in text adjacent to the image.

Stabilization Programs - 78%
Blue - Track A

Residential Programs - 18%
Pink - Track B

Stabilization/Residential - 4%
Orange - Track A/B

Percentage of clients admitted by Admissions Committee to each of the Programs
A pie chart showing the percentage of clients admitted by Admissions Committee to each of the programs.  Details in text adjacent to the image.

Stabilization Programs - 92%
Blue - Track A

Residential Programs - 8%
Pink - Track B

Source: Residential Treatment Clinic

Peer Support is Key

The positive influence of the peer support on the recovery process cannot be overestimated. Every stakeholder interviewed attested to the value-added of the peer support in assisting the RTC staff and more importantly, its client-patients in addressing their care and treatment needs. Peer support individuals have experienced and been successfully treated for mental health issues that the RTC patients are currently experiencing. They then become an immediate trusted resource, one who speaks the same language (military experience) and who offers encouragement when it is most needed. The passion and commitment to assisting their "brothers and sisters" in great distress is remarkable. The peer support at the RTC has been engaged on the basis of two 8-hour shifts per week. This coverage is inadequate as patients requiring peer support often must wait, sometimes several days, until the peer support's work shift occurs.

Gender Considerations

Women in the military can experience traumas that include military sexual trauma (MST) as well as combat-related trauma. VAC needs to take into account that in the military setting, women often have different experiences than men. It is vital that those women suffering from MST should be given female peer support to assist in their recovery efforts. The RTC does not currently have this capability.

Client Satisfaction

Participants in the longer running (since 2002) stabilization program indicated an overall satisfaction level of:

  • 91.83 percent on average (22 respondents) in 2008 - 2009;
  • 94.55 percent in 2007 - 2008 (17 respondents); and
  • 92.11 percent for the period from October 2004 - April 2007 (62 respondents)

The Ste. Anne's Hospital satisfaction norm is 75 percent; therefore, the participant satisfaction level is high for the stabilization track.

The residential rehabilitation program track in the RTC has been in operation for little more than a year. Participant satisfaction garnered from interviews with client-patients is also high and the feedback generally very positive.

Client - patients of the RTC have informed the evaluation team that without the RTC programs, their lives would be completely miserable. One respondent went so far as to emphatically state: "I would be dead". Another responded "I have my life back".

Conclusion

In short, the Inclusion/Exclusion criteria for admissibility to the RTC have, in part, been established to align with the capacity of the institution and staff, and not with the range of Veteran mental health needs. These exclusions serve to further narrow the field of eligibility for the RTC and thus the number of individuals who become patients of the facility. For participants in the RTC program tracks - stabilization and rehabilitation - satisfaction remains at a high level. The role of peer support in meeting the needs of the RTC client-patients is crucial and needs to be more than part-time. Provision of female peer support for RTC women client-patients also needs to be addressed. Despite its low numbers, the RTC is responding to a small segment of the target population and client-patient satisfaction is high. Testimonials underscore the value of the RTC to client-patients.

Recommendation 1

It is recommended that the Director of NCOSI, consider increasing the provision of peer support in recognition of the invaluable support and contribution to the RTC's multidisciplinary team and the need for such support from the client-patient perspective; and that consideration be given to the provision of female peer support for women Veterans who participate in the RTC programs. (Critical)

R1 Management Response

Management agrees with this recommendation. A budget adjustment for year 2011-12 has already been approved to increase peer support services to a Full Time Equivalent for clients in the RTC program.

Management Action Plan:
Corrective Action to be taken OPI (Office of Primary Interest) Target Date
1.1 Ensure the availability and timely accessibility to peer support services. Director, NCOSI December 31, 2011
1.2 Ensure the availability and timely accessibility to female peer support for those clients who require this service. Director, NCOSI December 31, 2011

5.3.5 Unmet Needs of the Target Population

There was no formal needs assessment undertaken in support of the design and development of the RTC. There was, however, extensive consultation with subject matter experts in Canada and abroad in the design of the programming for the RTC. While there are individuals who benefit from the RTC and its programs, there remain others within the target population who for a variety of reasons are unable to avail of the RTC and its programming. Two noteworthy groups of potential client-patients currently excluded are:

  • those individuals "in crisis" and requiring emergency acute care who are referred to local hospital emergency facilities where they are treated quickly and released immediately or are kept for a very few days and then released. While some of these individuals may require further care on an inpatient basis, the risk of losing track of them remains great; and,
  • other Veterans and members, not ill enough for emergency care but who still require first level stabilization of their OSI condition. Both these groups present a service challenge to, and a "gap" in, the department's Continuum of Care. A 2009 Special Project on the Stabilization and Emergency Services Needs for Operational Stress Injuries (SESN OSI) Working Group Report corroborates the gap and offers recommendations and a way forward.

There are, additionally, "gaps" in services for those individuals suffering from more complex PTSD and co-morbid conditions and for whom an outpatient program was insufficient or ineffective. Admission criteria, accessibility and family needs are key areas where impediments exist and needs go unmet.

By virtue of admission criteria

Those outside the admission criteria of the RTC would include, for example, individuals with:

  • moderate to high personality disorders;
  • active suicidal tendencies active addictions/substance abuse issues;
  • criminal/legal issues, and/or
  • high anger issues.

In terms of admittance refusals at the RTC, there were six (6) refusals in 2010 and three (3) from January to March 31, 2011. The reasons for these refusals by the RTC relate, in large part, to individuals presenting with moderate to high personality disorders.

Accessibility needs

In addition to the restrictions of the admission criteria, the fact remains that the combination of inpatient, bio-psychosocial treatment for individuals with complex PTSD co-morbid with other conditions which treats the military and policing culture as a cohort and provides an integrated, multi-disciplinary approach, is not readily available elsewhere in Canada. As a unique facility, the RTC presents an issue of accessibility and geographic displacement which factors into the willingness of individuals to participate in the RTC programs. This is particularly true for those individuals in Canada's far western provinces like British Columbia and Alberta. This issue is reflected in the client profile illustrated in Figure 5 which indicates that the preponderance of client-patients in 2010 was from Central Canada and the majority was French speaking. However, as the RTC has only been operating since mid-February 2010, a full trend analysis is premature. Client profile numbers for 2011 thus far indicate that 20 percent of clients are from Central Canada and 80 percent from the Atlantic and Western regions.

In Annex D, the Australian subject matter experts indicated that the drivers for their Afghanistan Veterans are accessibility and flexibility. The younger Afghanistan cohort is looking for care and treatment in their local setting delivered in a flexible way –outpatient, day hospital and at accommodating hours. The Americans agree with their Australian counterparts; however they indicate that the spouses of the young American Veterans are the main impetus for immediate care and treatment in the local setting. They identified another accessibility issue for these young U.S. Veterans, as recognized during field operations, and that is that the use of alcohol and drugs is a more normative practice among young Afghanistan Veterans. Substance abuse in these new Veterans really stems from the use of alcohol or drugs as a form of medication used to deal with the individual's PTSD. As a consequence of their viewing alcohol and drugs in a more normative sense, these young Veterans refuse to attend substance abuse clinics; on the other hand, they will more readily acknowledge PTSD and respond to PTSD clinic treatment. "Get them in any way we can, then we can treat them for both conditions" is the prevailing strategy.

It is not unreasonable to assume that returning Canadian Veterans of the Afghanistan conflict will have similar demands for care and treatment to be administered in their local setting.

Figure 5: The RTC Client Demographic Profile

Residential Treatment Clinic Demographics - Gender
Gender 2010 2011
Men 89% 100%
Women 11% 0%
Residential Treatment Clinic Demographics - Age Group
Age Group 2010 2011
20 - 29 15% 0%
30 – 39 22% 40%
40 – 49 37% 40%
50 – 59 22% 20%
60 – 80 7% 0%
Residential Treatment Clinic Demographics - Language
Language 2010 2011
French 59% 20%
English 44% 40%
Residential Treatment Clinic Demographics - Civil Status
Civil Status 2010 2011
Single or widowed 22% 20%
Married or Common law 70% 60%
Separated or Divorced 11% 20%
Residential Treatment Clinic Demographics - Region
Region 2010 2011
Western Canada 15% 20%
Eastern Canada 15% 60%
Central Canada 70% 20%
Residential Treatment Clinic Demographics - Provincial
Province 2010 2011
British Columbia 4% 0%
Quebec 56% 20%
Alberta 4% 20%
New Brunswick 4% 0%
Saskatchewan 4% 0%
Nova Scotia 0% 20%
Manitoba 4% 0%
Prince Edward Island 7% 20%
Ontario 14% 0%
NewFoundland 4% 20%

Source: Residential Treatment Clinic

Family Needs

Stakeholders acknowledged how critical it is to involve the family as part of the client-patient care and treatment. In many cases, the trauma that affects a Veteran with an OSI affects the entire family. Established rehabilitation best practices recognize the importance of involving families in all stages of rehabilitation, because they are the first source of support for Veterans facing an OSI. Where a Veteran suffers from an OSI, the effort to understand and support him/her can place an enormous burden on the family, which can lead to marital conflict, spousal depression, anxiety disorders, and/or child behavioural problems. While the reasons for involving the family are numerous, two specific examples are cited to encourage a better understanding of the issues confronting military families:

  • A CBC News report of March 2011 indicated that "Domestic violence on Canadian military bases has climbed steadily in recent years, coinciding with the return of soldiers who carry physical and psychological battle wounds home". This has been corroborated by family peer support workers who are dealing with these issues on a continuing basis.
  • Military families experience considerable isolation as a result of frequent moves and military deployments and are often away from their extended family as well. Issues arise when the partner may not want the spouse to talk about the OSI or symptoms for fear of adverse career implications.

Anecdotal evidence indicates that there is insufficient care and treatment available to children of military families who have a family member suffering from PTSD.

VAC's 2008 evaluation of the OSI Clinic Network disclosed that the "most common concern identified by respondents was the need to enhance services offered to family members of clients with an OSI". Currently, family members of a client are not receiving service at an OSI clinic unless the client is receiving treatment at the clinic.

The RTC was designed to include the involvement of family members; however, on a practical basis, the expectations for family involvement exceed the reality. Not only must spouses overcome geographical distance and parental responsibility concerns in order to participate, but these issues are further exacerbated by the same situation as alluded to in the 2008 evaluation: in instances where the Veteran or CF/RCMP member has not sought the services from VAC first, the family is not entitled to the reimbursement of expenses. Respondents indicated that the family involvement aspect related to the RTC is limited. Typically, if family members do come to the RTC, it is generally for a single week-end over the course of their loved one's treatment.

Conclusion

In summary, findings indicate that there are individuals who fall outside the admission criteria of the RTC. The RTC embedded within a long-term care facility (the primary focus of Ste. Anne's Hospital) is not equipped to treat those individuals "in crisis" and requiring acute care or those not ill enough for emergency care but who still require first level stabilization of their OSI condition. According to respondents, the risk of losing track of these individuals is high and their needs are great. This is not, however, merely an issue for the RTC; more significantly, it presents a service challenge for the department as a whole and represents a "gap" in VAC's Continuum of Care. The challenge is further complicated by the fact that while such treatment is often best provided, and preferred locally, for those with co-morbid conditions, first level stabilization services are generally not available locally.

Accessibility and flexibility are deemed to be significant for the younger Afghanistan cohort in Australia who are looking for care and treatment in their local setting and flexible program options. These are worthy of consideration within the Canadian context. Finally, the needs of family members in relation to their loved ones who are receiving care and treatment from the RTC are not being adequately addressed.

Overall Conclusion for 5.3

There are gaps in VAC's capacity to serve all those in need within the target population. Notwithstanding the limitations imposed by the RTC's admission criteria as well as the geographic accessibility constraints for potential client-patients and their families, the RTC is responding to the needs of a small, but significant number of the target population.

The number of individuals who will require inpatient care and treatment will likely remain small - in the area of less than 10 percent of those who suffer from PTSD alone. The Australian experience with their younger Afghanistan Veterans offers some noteworthy considerations for VAC as it plans for future treatment structures. The accessibility and flexibility drivers for the Australian Veterans align with VAC's mental health strategy to devolve care and treatment capacity to the community level.

The American subject matter experts concurred that accessibility and flexibility are significant for the U.S. Veteran as well; however, from their perspective, the Veteran's spouse was seen as the primary impetus. Although no evidence has been gathered for Canadian troops, it is not unreasonable to assume that the younger Canadian Veterans will have expectations of care and treatment similar to both the Australians and Americans. Toward this end, Australian studies referenced in Annexes C and D indicate the value of the day hospital program model which has demonstrated even stronger clinical outcomes for participants, among whom are those who would have been previously referred to the residential rehabilitation (more intensive group therapy sessions) track of inpatient programs because of severe PTSD and co-morbidity.

Recommendation 2

It is recommended that the Director of Mental Health, in collaboration with the Director of NCOSI, develop policy options to better serve and monitor individuals who require crisis and emergency support or acute stabilization services, thereby enhancing VAC's Continuum of Care for Operational Stress Injuries while at the same time addressing barriers to participation in RTC programming . (Critical)

R2 Management Response

Management agrees with the recommendation. The 2009 report of the Stabilization and Emergency Services Needs (SESN) for Operational Stress Injuries Working Group examined the needs of Veterans and other clients who require crisis and emergency support or acute stabilization services and provided recommendations for future direction. A working group of internal and external stakeholders will be established to review and update the SESN Working Group report with a view to developing recommendations and an action plan for consideration by VAC senior management on how best to meet these needs.

Management Action Plan:
Corrective Action to be taken OPI (Office of Primary Interest) Target Date
2.1 Review and update the 2009 SESN OSI report. Director, Mental Health Division April 2012
2.2 Develop an action plan for the recommendations. Director, Mental Health Division September 2012

Recommendation 3

It is recommended that the Director of Mental Health, in collaboration with the Director of NCOSI, assess a variety of mental health treatment models for community-level implementation and in doing so, leverage the knowledge, expertise and experience with the military cohort vested in VAC staff; and, furthermore, ensure that future model development is more inclusive of family members. (Critical)

R3 Management Response

Management agrees that the option of outpatient programming has the potential to be an effective alternative to residential treatment in some circumstances, that these circumstances should be determined to the fullest extent possible, and that expertise existent in the Residential Treatment Clinic should continue to inform client care. A review of the Australian, and other, experiences will be conducted to ascertain the extent to which programs of the Residential Treatment Clinic may be applied in an outpatient setting, what those settings might be, and how to leverage existing expertise.

Unlike the nine outpatient OSI clinics in the VAC network, the Residential Treatment Clinic does not treat family members. Management agrees that supporting families is essential to supporting Veterans, and agrees with providing supports to Veterans and their families to the fullest extent authorized by legislation. The planned review will ensure that future model development is more inclusive of family members.

Management Action Plan:
Corrective Action to be taken OPI (Office of Primary Interest) Target Date
3.1 A Literature review, consultation with Australian colleagues, and/or those familiar with their programs and an analysis of potential settings. Director, Mental Health Division April 2012
3.2 Draft Report. Director, Mental Health Division September 2012
3.3 Final Report. Director, Mental Health Division December 2012

5.4 RTC Performance

5.4.1 Client Satisfaction

Client satisfaction was discussed in the previous needs section 5.3.4. In summary, clients are generally satisfied with their experience at the RTC. Discussions with former participants and OSISS Peer Support Coordinators also revealed strong support for the program although several suggestions for improvements to the program and facility were offered. One overarching suggestion was that the development of a less risk adverse atmosphere would have enhanced the experience. Improved food quality and additional exercise opportunities were also cited.

Stakeholders in general recognized the competency of the RTC professional staff and were highly supportive of the RTC's interdisciplinary approach to care and treatment for these complex client-patients. They also noted that the RTC staff's sound understanding of the military culture has a positive impact on the recovery process. The evaluation team was also impressed with the level of commitment and dedication exhibited by the RTC staff.

5.4.2 Referral Metrics

The number admitted to the residential rehabilitation program is low and clinicians have indicated that individuals are presenting with more complex conditions than initially anticipated. In 2010, six clients were refused by the admissions committee and from January to April 2011, three individuals were refused admittance to the program.

Although these numbers are small they attest to a gap(s) in the continuum of mental health services as noted in section 5.3.

The VAC and DND's Joint Mental Health Strategy announced in 2002 created a model for the sharing of services. As a result, the RTC serves CF and RCMP Veterans and still-serving members. The following charts in Figure 6 indicate the percentage of program participants by referral source. In 2010, the majority of referrals came from VAC sources and presumably the majority of the referred individuals were Veterans. The DND referred 37 percent of the participants who represent still-serving members. The RCMP also referred a small number of individuals to the program representing still-serving RCMP members. For 2011, only the RCMP and VAC have referred individuals to the program (as of March 2011). In discussing their referrals to the inpatient program, DND representatives indicated that generally still-serving members are receiving treatment for OSI conditions early in the symptom development stage, before the condition becomes chronic, allowing the vast majority to be treated on an outpatient basis. This explains in part why there are no DND referrals evident yet in 2011.

Figure 6: Percentage of Program Participants by Referral Source

% of Clients Referred from Each Referral Sector in 2010
A pie chart showing the percentage of clients referred by Veterans Affairs Canada, the Department of National Defence and the RCMP in 2010.  Details in text adjacent to the image.

Veterans Affairs Canada - 59%
(Blue)

Department of National Defence - 33%
(Orange)

Royal Canadian Mounted Police - 8%
(Green)

% of Clients Referred from Each Referral Sector in 2011
A pie chart showing the percentage of clients referred by Veterans Affairs, the Department of National Defence and the RCMP in 2011.  Details in text adjacent to the image.

Veterans Affairs Canada - 60%
(Blue)

Department of National Defence - 0%
(Orange)

Royal Canadian Mounted Police - 40%
(Green)

Source: Residential Treatment Clinic

5.4.3 Program Reach

With the creation of the Residential Rehabilitation Program, the RTC clinic did some initial outreach to VAC staff and stakeholders to raise awareness of the clinic's two program tracks- stabilization and rehabilitation. The outreach approach included presentations and tours of the facility to VAC staff and other stakeholders including the DND personnel. Staff and stakeholders were pleased at the creation of additional rehabilitation resources for those suffering from an OSI. However, the referral process has been reported as a source of frustration, requiring a considerable amount of paperwork and resulting in frustrating delays in obtaining an admission date. When this was coupled with the rigid exclusion criteria of the program, many VAC staff and other stakeholders were reluctant to consider referring Veterans to the RTC programs, opting instead for a more expedient path to care and treatment.

The RTC management which has been under the governance of the Nursing Directorate at Ste. Anne's Hospital since January 2011, has begun to respond to these concerns and has developed a new streamlined admittance form, and undertaken measures to improve the process and functioning of the admittance committee to shorten the time delays noted in the referral process. These measures will be viewed positively by both internal and external referral sources.

Clinic management is currently developing a program marketing and outreach plan which includes efforts to ensure awareness of the clinic across Canada and to clarify the clinic's program and rehabilitation approach. Visits to VAC district offices, other OSI clinics, RCMP and other stakeholders to provide presentations on the RTC and develop enhanced working relationships form part of the marketing and outreach plan. Other tools such as the creation of a publicity brochure and a virtual visit to the clinic via the web also form part of this outreach plan. These outreach measures should improve knowledge of the clinic's programs but uptake will continue to be constrained by the existing exclusion criteria.

Conclusion

The number admitted to the residential rehabilitation program is low. In terms of program reach, the evaluation team found that the vast majority of interviewees were aware of the RTC, felt that the staff was very competent and dedicated and the program treatment structure well designed, but were frustrated as they were not able to refer many of those they felt could benefit from the program due to the admittance exclusions as well as an overly complex referral process. There are current efforts underway to streamline and improve the referral process. Many stakeholders remarked on the high level of professional expertise within the RTC multi-disciplinary team and expressed a desire to leverage their expertise in transferring knowledge and skills to VAC staff and the community of providers at large.

Recommendation 4

It is recommended that the Director of NCOSI, review and undertake improvements to the referral process affecting timely admission to the RTC. (Essential)

R4 Management Response

Management agrees with this recommendation. The current business process for referrals to the RTC is being reviewed. Once completed the business process will include a target for turnaround time for the decision of the admission committee and response to the referral organization.

Management Action Plan:
Corrective Action to be taken OPI (Office of Primary Interest) Target Date
4.1 Review and adjust the current OSI Clinic Business Process for Referrals including the Referral Form to reflect the uniqueness of the admission process to the RTC. Director, NCOSI November 30, 2011
4.2 Establish clear milestones and service delivery standards to monitor the referral process. Director, NCOSI January 31, 2012
4.3 Effectively communicate the client flow process from referral to admission into both the stabilization and rehabilitation tracks of the RTC to all stakeholders. Director, NCOSI January 31, 2012

5.5 Summation of Findings

With respect to the core issue of relevance, the evidence attests to the RTC's alignment with federal priorities, roles and responsibilities and confirms a continuing need for the facility exists. Given that the RTC's operation commenced in February 2010, the core issue of performance in terms of the immediate outcome of program reach was assessed. While there are gaps in the provision of care and treatment services, the RTC's inability to provide primary level stabilization to those individuals presenting in crisis (or after acute care emergency situations) is indicative of a larger issue - a "gap" in VAC's Continuum of Care. The early growing pains of the RTC, common to most new operations - referral delays, process impediments, modifications and adjustments have also contributed to program reach issues. Other key factors include geographic accessibility and the displacement from family which serve as barriers to family member counselling services.

Although the number of program participants is small, client satisfaction surveys have indicated a high level of satisfaction with both program streams. In 2010, 92 percent of client-patients entered the stabilization track directly, while only 8 percent entered the rehabilitation track directly. The longer running stabilization treatment track has a history of high client satisfaction since 2002 and is the backbone of the RTC. The comparison with respective approaches in Australia and the United States raises questions around the most appropriate treatment models going forward and provides insights into the characteristics of modern-day Veterans as well as their expectations. The trialed and tested day hospital model widely used at the community level in Australia is particularly noteworthy. The day hospital model has achieved the same, and in many cases, stronger clinical outcomes as the inpatient program. It is used to deliver programming at the community level in Australia similar to the rehabilitation track programming implemented on an inpatient basis within the RTC.

Despite its shortcomings, the RTC is meeting the needs of a small but significant segment of the target population. The experience of other countries and mental health experts suggests that there will be a continuing need to address this small segment with specialized care on an inpatient basis.

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