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Executive Summary

The purpose of this evaluation is to assess both the relevancy and performance of the Residential Treatment Clinic for Operational Stress Injuries (RTCOSI - hereinafter referred to as the RTC) at Ste. Anne's Hospital. The recent commencement of the RTC's operation in February 2010, has limited the assessment of performance to the immediate outcome of program reach.

Veterans Affairs Canada (VAC) defines an operational stress injury (OSI) as any persistent psychological difficulty resulting from operational duties performed while serving in the Canadian military or executing duties serving as a member of the RCMP. Psychological difficulties may include, for example, a diagnosis of post traumatic stress disorder (PTSD), major depression, alcohol/substance abuse, chronic pain, or various anxiety disorders.

In 2001, Ste. Anne's Hospital operated a pilot OSI outpatient clinic which, in turn, inspired a renewed vision for the facility and the subsequent establishment of an inpatient stabilization treatment program in 2002. The stabilization program offered third- or tertiary-level care for those suffering from a complex OSI condition requiring medical and psychiatric stabilization and necessitating inpatient care of up to 3 - 4 weeks.

Treasury Board approval in 2007 for the establishment of new OSI clinics under VAC's purview led to support for the RTC, designed to provide third-level, inpatient care to Veterans, CF and RCMP members and their families who present with a complex PTSD co-morbid with other OSI conditions such as those above-mentioned and for whom outpatient treatment was insufficient or ineffective. When the RTC commenced operation in February 2010, the existing inpatient stabilization treatment program was co-located with a new residential rehabilitation program in the new clinic.

VAC's Mental Health Directorate statistics reflect the dramatic rise over the March 2004 to March 2011 period in the number of clients with a favourable disability decision for a psychiatric condition. Of the more than 14,000 individuals identified with a psychiatric condition, close to10,000 are identified as having PTSD - representing a rise of 350% over the same timeframe. The size of the target population of the RTC is, however, relatively small. Subject matter experts consulted in Canada, Australia and the United States generally agree that the RTC's potential client-patients represent less than 10% of all those who suffer from PTSD. They also concur that for some of these individuals, inpatient care and treatment will continue to be necessary.

Statistics for the RTC indicate that in 2010, 92 percent of the client-patients directly entered the stabilization treatment program while 8 percent entered the rehabilitation track directly. For clients who entered the stabilization track, 52 percent were subsequently admitted to the rehabilitation track. RTC clinicians have indicated that individuals were presenting with more complex conditions than initially anticipated and taking longer in their recovery. The stabilization track appears to be the backbone program of the clinic and a prerequisite to further treatment. Annex D to this report features a comparison of respective approaches to combat-related PTSD mental health issues in Australia and the United States. The Australians have migrated their rehabilitation programming (similar to that of the rehabilitation track of the RTC) to an outpatient, day hospital model and, in some instances, to community-based outpatient clinics and are achieving similar, if not stronger, clinical outcomes.

Admission criteria for the RTC are constrained by virtue of its location within Ste. Anne's Hospital, primarily a long-term care facility. The facility is neither set-up structurally nor is the staff equipped to treat individuals presenting with primary level stabilization needs (which normally follow acute care emergency situations). The risk lies in losing track of these individuals. This is not an issue confined to the RTC; rather it presents a service challenge for the department as a whole and represents a “gap” in VAC's Continuum of Care. Efforts to address the needs of family members of client-patients, raised as a concern in a VAC 2008 OSI Network evaluation, remain inadequate. The evaluators noted that the inclusion of peer support staff within the RTC is a key contributing factor for achieving client-patient engagement, comfort, and trust. The peer support coverage within the RTC at the time of this evaluation however, was inadequate.

Despite these and other gaps in services related to accessibility and geographic displacement, the RTC is addressing the needs of a small, but significant segment of the target population commencing with the secondary stabilization of an acute mental condition. One of the noted strengths of the RTC is the level of commitment and dedication of its professional staff and their knowledge of the military culture which helps to establish immediate trust with the client-patient and strengthen the recovery process.

With respect to the core issue of relevance, the evidence attests to the RTC's alignment with federal priorities, roles and responsibilities and confirms that a demonstrable and continuing need exists for the RTC. In terms of the core issue of performance relative to program reach, the clinic is addressing the needs of a small, but significant segment of the target population and client satisfaction is rated as high.

The following recommendations have flowed from the evaluation team's findings and evidence-based conclusions:

Recommendations:

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)

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)

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)

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)

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