Chapter 5 - Attendance Allowance

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Table of Contents PDF Version

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Introduction

The purpose of this chapter is to provide criteria for use in determining the entitlement and assessment for an Attendance Allowance award.

Entitlement to Attendance Allowance is based on three legislative requirements of the Pension Act.

Assessment of Attendance Allowance is the grade level determination of the extent of attendance required for specific elements, as outlined in this policy.

Related Legislation

Subsection 38(1) of the Pension Act reads as follows:

A member of the forces who has been awarded a pension or compensation or both, is totally disabled, whether by reason of military service or not, and is in need of attendance shall, on application, in addition to the pension or compensation, or pension and compensation, be awarded an attendance allowance at a rate determined by VAC in accordance with the minimum and maximum rates set out in Schedule III.

Related Policy

Allowances

Entitlement

Definitions:

For the purposes of Attendance Allowance eligibility:

"awarded a pension or compensation" is defined as in receipt of a Disability Pension of 1% or more or Prisoner of War compensation.

"totally disabled by reason of military service or not" is defined as an applicant who meets the definition of "totally disabled" in accordance with Table 1 of this policy.

"in need of attendance" is defined as the need for assistance or supervision of another individual with feeding, bathing, dressing, toileting, mobility or medication administration, that is not already being met by benefits, services or care provided to the client by VAC pursuant to veterans' legislation or any other program, including but not limited to federal, provincial, municipal or community programs, whereby the benefits services or care is provided at no expense to the client.

Relevant Table:

• Table 1 is used to determine whether an individual is "totally disabled" for the purposes of establishing eligibility for Attendance Allowance.

Establishing Entitlement:

To establish entitlement, an applicant must meet all three legislative requirements. Use the following steps to verify that each requirement is met.

• Step 1: Is the applicant in receipt of Disability Pension of 1% or more and/or POW compensation?
• Step 2: Is the applicant "totally disabled"? Use Table 1 to establish this requirement. In accordance with Table 1, if the evidence establishes that the applicant suffers from a prolonged impairment which has lasted or is expected to last at least 12 months and the applicant meets the criteria outlined in Table 1, the applicant is determined to be "totally disabled" for the purposes of Attendance Allowance eligibility.
• Step 3: Is the applicant in "need of attendance"? If the applicant demonstrates a need for attendance in feeding, bathing, dressing, toileting, mobility or medication administration; then the applicant meets this requirement.

If any one of the three legislative requirements are not met, the applicant does not meet eligibility and entitlement to Attendance Allowance must be denied.¹

Assessment

As with any other award under the Pension Act, once entitlement is granted, an assessment determination is made for payment purposes.

With respect to Attendance Allowance, once the three legislated requirements are met and an applicant is found to be eligible for an award, the extent of the applicant's need for attendance is then assessed to determine the grade level for payment purposes. The extent of the need for attendance is expressed as the "grade level".

Attendance Allowance is assessed based on a record of factual information covering the applicant's actual need for attendance. The need for attendance is assessed using five grade levels ranging from Grade 5 (occasional attendance) to Grade 1 (total attendance).

The elements which are taken into consideration in the determination of a grade level include:

• The need for assistance or supervision with:
  • Feeding
  • Bathing
  • Dressing
  • Toileting
  • Mobility
  • Medication administration.

Relevant Tables

Assessment of grade levels for Attendance Allowance are to be determined by using Table 2, Table 3 and Table 4 of this chapter.

• Table 2 outlines the five grade levels ranging from Grade I to Grade V.
• Table 3 outlines Special Categories and their prescribed Grade Level assessments.
• Table 4 contains guidelines to be used in conjunction with Table 2. The guidelines help determine the extent of attendance required.

Establishing Assessment

• Step 1: If "Special Categories" exist, i.e. paraplegics, blindness or amputations, refer to Table 3 and establish the prescribed grade level. If no "Special Categories" exist, skip this step.
• Step 2: Refer to Table 2 and accompanying Table 4 Using Table 4 as a guide, rate the level of attendance required for each of the six elements indicated in Table 4.
• Step 3: Based on the ratings from Table 4, establish the grade level determination using the following instructions:

  • In cases where a client demonstrates a need for attendance at the same level for two or more of the elements found in Table 4, i.e. feeding, bathing, dressing, toileting, mobility or medication administration, and demonstrates a need for attendance at another level for two or more of these elements, assign the grade level that is most advantageous.

    Example: if a client demonstrates a need for attendance at level 5 for feeding, dressing and medication administration and a level 4 for toileting and mobility, the client will be awarded a grade level of Grade 4.

  • In cases where a client demonstrates a greater degree of attendance in only one of the elements of Table 4 i.e. feeding, bathing, dressing, toileting, mobility or medication administration, which is one or two levels higher than the remaining elements, the isolated higher level will not be used to establish the grade level determination. In such cases, the assessor will refer to the next highest degree of attendance required for the remaining elements in Table 4 to establish the grade level determination.

    Example: If a client demonstrates a degree of attendance at level 5 for feeding, bathing, and dressing, level 4 for toileting and level 2 for mobility, in accordance with this policy, the client will not be awarded Grade 2 on the basis of the degree of attendance for mobility alone, but will be awarded the next highest degree of attendance required, which in this example is Grade 4.

  • In cases where a client demonstrates a degree of attendance in only one element of Table 4, i.e. feeding, bathing, dressing, toileting, mobility or medication administration, and no need of attendance in any of the remaining five elements, a Grade 5 attendance allowance should be awarded.

    Example: If a client demonstrates a degree of attendance at level 4 for bathing only, the client will be awarded a Grade 5 attendance allowance.

  • In order for a client to be awarded a Grade 1 attendance allowance, the client must demonstrate a need for attendance at the Grade 1 level in all six elements found in Table 4, i.e. feeding, bathing, dressing, toileting, mobility and medication administration. In cases where a client demonstrates a need for attendance at the Grade 1 level for two to five of the elements, the attendance allowance must be awarded at one of the lower Grades, whichever the adjudicator determines is most appropriate.

    Example 1: If a client demonstrates a need of attendance at level 1 for dressing, bathing, toileting, and mobility, and level 2 for feeding and medication administration, the client should be awarded a Grade 2 attendance allowance.

    Example 2: If a client demonstrates a need of attendance at level 1 for bathing, dressing, toileting and mobility, level 2 for medication administration and level 3 for feeding, the client may be awarded either a Grade 2 or 3 attendance allowance, whichever is determined to be more appropriate.

    Example 3: If a client demonstrates a need of attendance at level 1 for bathing, dressing, toileting and mobility and level 3 for medication administration and feeding, the client may be awarded either a Grade 2 or 3 attendance allowance, whichever is determined to be more appropriate.

  • In cases dealing with "Special Categories", i.e. paraplegia; blindness or amputations, the applicant will be awarded the most beneficial grade level for which he/she qualifies using Table 3 and Table 2/Table 4.

    Example: Using the Special Categories Table 3, a Grade 4 is prescribed for blindness where an individual cannot count fingers beyond several feet. Using Table 2 and accompanying Table 4, the client demonstrates a need for attendance at level 4 for feeding, bathing and dressing and level 3 for mobility and medication administration. In cases such as this, compare the assessment resulting from Table 3 with the assessment resulting from the rating from Table 4 and select the higher assessment. In this example, Grade 3 would be awarded.

Table 1 - Definition of Totally Disabled for Attendance Allowance Eligibility

In establishing whether a person is "totally disabled" for the purposes of AA, there must be evidence of prolonged impairment - lasting 12 months or expected to last at least 12 months.

Persons in receipt of 100% Disability Pension ² from VAC are considered totally disabled for AA purposes; those in receipt of less than 100% pension must meet one of the following criteria:

1. Paraplegics, blindness and amputations as defined in Table 3 - Special Categories of Chapter 5 of the Table of Disabilities.
2. Has a single amputation of one upper limb (at or above the wrist) or of the lower Limb (at or above the ankle).
3. Requires life sustaining therapy to support a vital function, e.g. oxygen, clapping therapy to help in breathing, kidney dialysis to filter blood. Life sustaining therapy does not include implanted devices such as a pacemaker or special programs of diet, exercise, hygiene, or medication. Medical evidence must certify that you need, and dedicate time specifically for this therapy at least three times per week to an average of at least 14 hours per week. The need for this therapy must have lasted, or be expected to last, for a continuous period of at least 12 months.
4. Unable, all or most of the time, to feed oneself, or takes an inordinate amount of time to do so, even with the aid of medication, therapy or a device.
5. Is dependant on another individual to wash most of body i.e. may be able to wash face and hands independently.
6. Is dependant on another individual to dress entire body.
7. Unable, all or most of the time, to personally manage bowel or bladder functions, or takes an inordinate amount of time to do so. (i.e. requires assistance with ostomy care, catheter care, or the changing of incontinent pads or briefs).
8. Unable, all or most of the time, to walk 50 metres (164 feet) on level ground, or takes an inordinate amount of time to do so, even with the aid of medication, therapy or a device.
9. Unable, all or most of the time, due to a psychological or cognitive impairment, to perceive, think or remember, even with the aid of medication, therapy or a device, i.e. cannot initiate or manage basic personal care or take medications without constant supervision.

Related Definitions

Prolonged: An impairment is prolonged if it has lasted, or is expected to last, for a continuous period of at least 12 months. In cases where terminally ill clients are not expected to live more than 12 months, their impairment will still be considered prolonged because it is impossible to know with any degree of certainty if they will indeed die within a 12-month period.

Markedly Restricted: One may be markedly restricted if, all or almost all the time, one is unable (or it takes you an extremely long time) to perform a basic activity of daily living, even with therapy (other than life-sustaining therapy) and with the use of appropriate devices and medication.

For the purposes of establishing "total disability" for AA eligibility purposes, the following elements have been taken into consideration:

• walking
• perceiving, thinking or remembering
• basic personal care, i.e. washing
• feeding
• dressing
• toileting, i.e. bowel or bladder functions

In determining the Grade of AA, activities such as housekeeping, preparing meals, shopping/errands, laundry, grounds keeping, repair and maintenance, using transportation or driving, using the telephone, managing money and social or recreational activities, are not taken into consideration.

Life-sustaining Therapy: Life-sustaining therapy includes therapy to help in breathing, i.e. oxygen, or kidney dialysis to filter blood. Life-sustaining therapy does not include implanted devices such as a pacemaker or special programs of diet, exercise, hygiene, or medication. Medical evidence must certify that you need, and dedicate time specifically for, this therapy at least three times per week, to an average of at least 14 hours per week. The need for this therapy must have lasted, or be expected to last, for a continuous period of at least 12 months.

Inordinate amount of Time: An "inordinate amount of time" is defined as significantly more time than it would take an individual of the same age to complete an activity in the absence of the impairment.

Table 2³ - Grade Levels

• Needs total care.
• Needs significant supervision or assistance (either personal or mechanical with all activities of daily living.)
• Needs intermittent daily supervision or assistance in performing some activities of daily living.
• Needs minimal supervision or assistance on a daily basis with activities of daily living but is essentially independent within home environment and can be safely left unattended for significant periods of time, overnight or throughout the day.
• Needs occasional assistance or supervision with activities of daily living.

Table 3 - Special Categories

1. Paraplegics With complete cord lesion (Grade 1)
2. Blindness
   • Loss of both eyes or total - includes perception of light only, without projection. (Grade 1)
   • Light perception with some projection. Can distinguish light areas against dark. e.g. open doorways, windows. (Grade 2)
   • Cannot identify hand movements. (Grade 3)
   • Cannot count fingers beyond 1 foot. (Grade 3)
   • Cannot count fingers beyond several feet. (Grade 4)
   • Cannot distinguish more than big letters (1^st letter on chart 8 - 10 feet). (Grade 4)
   • Vision in better eye not more than 6/60 (20/200). (Grade 4)
   • Legally blind and/or accepted by CNIB for services. (Grade 4)
3. Amputations
   • Both Arms (at or above the wrist). (Grade 2)
   • One arm, or one leg at or above the knee. (Grade 3)
   • One limb at the knee or above the other below the knee but above a Syme's⁴. (Grade 3)
   • Both lower limbs below the knee, but above a Syme's. (Grade 3)
   • One Syme's and the other below the knee. (Grade 4)
   • Bilateral Syme's. (Grade 4)

These "Special Categories" shall be considered in conjunction with Table 2 and the applicant shall be awarded the most beneficial grade level for which he/she qualifies under the two systems.

Table 4 - AA Grade Level Guidelines for use with Table 2

Table 4 - AA Grade Level Guidelines for use with Table 2

Grade	Attendance
Element	Feeding
Not in Need of Attendance	able to feed self independently with or without special equipment and without assistance or supervision of another individual
Grade 5 "Occasional"	occasionally needs food cut up but is able to feed self - this may not be a daily need
Grade 4 "Minimal"	requires food to be cut up on a daily basis but is able to feed self independently or with minimal assistance and/or supervision (e.g. help holding glass; cuing, encouraging or motivating to eat; etc.)
Grade 3 "Intermittent"	requires food to be cut up on a daily basis and may require a greater degree of assistance and/or supervision while eating (e.g. help holding glass and placing fork in hand; supervision to prevent choking on certain foods; etc.)
Grade 2 "Significant"	must be constantly assisted and/or supervised while eating
Grade 1 "Total"	needs to be fed5
Element	Bathing
Not in Need of Attendance	able to bathe self independently with or without special equipment and without assistance or supervision of another individual
Grade 5 "Occasional"	occasionally requires assistance and/or supervision of another individual while bathing - this may not be a daily need
Grade 4 "Minimal"	requires some assistance and/or supervision while bathing (e.g help with bathing difficult to reach body parts such as back and feet; help getting in and out of tub; cuing or encouraging; etc.)
Grade 3 "Intermittent"	requires a greater degree of assistance and/or supervision while bathing - than in Grade 4 (e.g. help with bathing more than just back and feet, such as the entire upper or lower body; closer supervision while bathing; etc.)
Grade 2 "Significant"	able to wash own face and hands but requires constant assistance and/or supervision during remainder of bath (i.e. cannot be left unattended while bathing)
Grade 1 "Total"	needs total assistance with bathing5
Element	Dressing
Not in Need of Attendance	able to dress self independently with or without special equipment and without assistance or supervision of another individual
Grade 5 "Occasional"	occasionally requires assistance and/or supervision of another individual with dressing - this may not be a daily need
Grade 4 "Minimal"	requires some assistance and/or supervision while dressing (e.g. help with socks, zippers, and/or buttons; cuing or motivation; etc.)
Grade 3 "Intermittent"	requires a greater degree of assistance and/or supervision while dressing (e.g. help with putting on certain garments; supervision to prevent falls; etc.)
Grade 2 "Significant"	must be constantly assisted and/or supervised by and other individual while dressing
Grade 1 "Total"	needs total assistance with dressing5
Element	Toileting
Not in Need of Attendance	able to manage toileting independently with or without special equipment and without assistance or supervision of another individual
Grade 5 "Occasional"	occasionally needs assistance and/or supervision of another individual with toileting - this may not be a daily need (e.g. needs help with incontinent briefs from time to time)
Grade 4 "Minimal"	requires minimal daily assistance and/or supervision with toileting (e.g. assistance with wiping)
Grade 3 "Intermittent"	requires a greater degree of assistance and/or supervision while toileting (e.g. assistance with lowering under-garments and wiping; supervision to prevent falls; etc.)
Grade 2 "Significant"	must be constantly assisted and/or supervised by another individual while toileting (e.g. needs help with incontinent pads every night; needs constant reminders to toilet; etc.)
Grade 1 "Total"	totally incontinent or dependant on another individual for toileting (e.g. needs help with catheter, bedpan or incontinent pads at all times5
Element	Medication Administration
Not in Need of Attendance	requires no medications or is able to take prescribed medications independently from bottles or self-prepared dosett.
Grade 5 "Occasional"	is able to take prescription medications independently, including Insulin, but requires the use of blister packs or a dosett prepared by another individual; may need occasional reminders.
Grade 4 "Minimal"	is able to take prescribed medications independently, including Insulin, but requires the use of blister packs or a dosett prepared by another individual; may need daily reminders.
Grade 3 "Intermittent"	is able to take prescribed medications independently, including Insulin, but requires the use of blister packs or a dosett prepared by another individual; needs reminders with each dose.
Grade 2 "Significant"	requires medications to be administered to assure proper usage - (includes cases where a family member or nurse must come into home to administer meds (does not include cases where client is capable of managing own meds but someone, e.g. spouse, chooses to do so for the client.)
Grade 1 "Total"	is totally dependent on another individual to administer all medications5
Element	Mobility
Not in Need of Attendance	independent with mobility - with or without special equipment and without assistance or supervision of another individual (e.g. can walk, use cane, walker, scooter or wheelchair with no assistance or supervision).
Grade 5 "Occasional"	needs occasional assistance and/or supervision of another individual to be mobile (e.g. transferring).
Grade 4 "Minimal"	needs daily assistance and/or supervision of another individual to be mobile (e.g. with the use of a cane or walker indoors and outdoors and the use of a scooter or wheelchair for distance).
Grade 3 "Intermittent"	needs a greater degree of assistance and/or supervision of another individual to be mobile (e.g. with the use of a cane or walker indoors or the use of a wheelchair or scooter at all times outdoors).
Grade 2 "Significant"	needs constant assistance and/or supervision of another individual to be mobile (e.g. with the use of wheelchair at all times; cannot be left unattended, as would be the case with an Alzheimers patient).
Grade 1 "Total"	bedridden, if transferring to a chair, needs another individual to lift out manually or to operate a mechanical lift5