3.1 To what extent does the program continue to address a demonstrable need, now and in the future?
The evaluation finds that there is a continued need now and in the future, for the program to recognize caregivers for the informal support they provide seriously disabled Veterans.
In support of assessing the ongoing need for the CRB, the evaluation team reviewed published research, analysed operational and published program data, and obtained direct feedback from caregivers through a program recipient survey.
3.1.1 Published Research
The research reviewed provided evidence that caregivers are playing a significant role providing informal care for Veterans. It also highlighted the impacts and burden that results from caregiving responsibilities. Specific research studies and associated findings are noted below:
- “Research on Military/Veteran Families” Veterans Affairs Canada, Research Directorate 2015
- Family relationships were found to be important to the well-being and life satisfaction of CAF members. With respect to Veterans, families were found to be particularly important for those suffering from service-related conditions.
- “Qualitative Study on the Well-being of Families of Canadian Armed Forces Veterans with Mental Health Problems” Veterans Affairs Canada, Research Directorate 2015
- The study found that the imperative to care for the Veteran becomes the central, organizing facet of family experience.
- Family members are very involved with the unpredictable daily life of Veterans with moderate to severe mental health problems.
- Family caregivers are devoted but stressed psychologically and financially, in some cases making life and death decisions.
- Families of Veterans with mental health problems can feel socially, geographically and administratively isolated, and have difficulty learning about resources that could be available to them.
- “Continuing Care Research Project” Hollander Analytic Services Ltd, 2008
- The project documented the substantial role played by spouses, family members and other informal caregivers in allowing Veterans to continue to be cared for in their homes.
- “Wounded Veterans, Wounded Families”, Fast, Yacyshyn and Keating, 2008
- Caregiving supporters of Veterans with high levels of disability were more likely than the general population of caregivers to have reported almost every one of the major categories of economic and non-economic consequences of care.
- High proportions of caregiver supporters reported financial insecurity, stressful lives, and low levels of life satisfaction. They worried about their ability to sustain care.
- “The Impact of Operational Stress Injuries on Veterans’ Families”, Fikretoglu, 2008
- Existing literature on the impact of Veterans’ PTSD has found: increased mental health problems in spouses, increased caregiver burden for spouses, problems in marital adjustment, increased divorce rates, increased physical and verbal aggression against partners, adverse impacts on children’s behavioral and psychological adjustment.
3.1.2 Operational and Published Program Data
The evaluation team analyzed operational data, and reviewed program forecasts to confirm that there is an ongoing need for the program, now and into the future. As identified in Table 3, although decision volumes have been reducing since the program started, there is a continued demand for program decisions/new intake to the program.
| CRB First Applications | # of Favourable Decisions | # of Unfavourable Decisions | Total Decisions | Favourable Rate % |
|---|---|---|---|---|
| 2018-19: Quarter 1Footnote 6 | 303 | 51 | 354 | 85.6% |
| 2018-19: Quarter 2 | 178 | 350 | 528 | 33.7% |
| 2018-19: Quarter 3 | 103 | 213 | 316 | 32.6% |
| 2018-19: Quarter 4 | 99 | 159 | 258 | 38.4% |
| 2019-20: Quarter 1 | 66 | 137 | 203 | 32.5% |
| 2019-20: Quarter 2 | 27 | 120 | 147 | 18.4% |
| Totals | 776 | 1,030 | 1,806 | 43.0% |
The results show that less than 50% of First Applications are approved for program eligibility. In conducting gender and demographical analysis of program favorable rates, it was found that female Veterans were approved (46%) at a slightly higher rate than male Veterans (42%) and that married/common-law Veterans received favorable decisions in 48% of applications, compared to 34% for single/divorced/widowed Veterans.
The difference in favorable rates based on a Veterans marital status creates an opportunity for the Department to further review evidence sources used for decision making, and should be considered in response to Recommendation #2- Page 25. Additional information pertaining to program eligibility for seriously disabled Veterans can be found in Section 4.1 (Are processes currently in place to ensure the program is being administered as indicated in departmental guidance?).
Published program forecasts are available at Veterans Affairs Canada Statistics – Facts and Figures. Official departmental forecasts show a continued, and increasing demand based on program recipients and program expenditures, as displayed in Table 4.
| CRB | 2019-20 | 2020-21 | 2021-22 | 2022-23 | 2023-24 | Forecasted Increase % (2019-20 to 2023-24) |
|---|---|---|---|---|---|---|
| Forecasted Recipients | 640 | 780 | 840 | 890 | 950 | +48.4% |
| Forecasted Expenditures (in $ millions) |
$7.1 | $8.9 | $10.3 | $11.3 | $12.2 | +71.8% |
It should be noted that as of September 2019, the program had 723 recipients, already exceeding the 640 forecast for the end of the fiscal year (March 2020). Therefore, it can be expected that program forecasts will need to be adjusted in the future to account for this higher than anticipated intake.
3.1.3 Feedback from caregivers through a program recipient survey
In February 2020, a letter was mailed to recipients of the CRB (caregivers). The letter contained a web site link and recipients were asked to use the link to complete the survey online. Recipients also had the option to contact VAC’s Audit and Evaluation Division if they preferred to complete the survey in an alternate format (telephone, paper copy). Hereinafter, the survey will be referred to as the Caregiver Survey.
In total, 166 Caregiver Surveys were completed. The survey results demonstrated the critical role caregivers have in providing informal support to the Veteran, and highlighted the physical, mental, and level of effort (time) impacts this role has on caregivers. These results are displayed in further detail later in this section.
As identified in VAC’s CRB Policy, an informal caregiver plays an essential role in the provision or coordination of the ongoing care to a Veteran in the Veteran’s home if there is evidence that:
- the Veteran relies on the informal caregiver to provide or coordinate:
- daily supervision;
- direction and/or physical assistance with most activities of daily living (a set of activities necessary for self-care); or
- assistance with completion of instrumental activities of daily living (daily activities that individuals normally do, unassisted, to live independently); and
- the Veteran’s health and well-being would be placed at risk and the provision or coordination of the Veteran’s ongoing care would be compromised without the informal caregiver.
The Caregiver Survey provided results regarding the role caregivers are playing in providing/coordinating care for Veterans. Detailed results can be found in Appendix A (Basic Activities of Daily Living) and Appendix B (Instrumental Activities of Daily Living).
Overall, for the Basic ADLs, 70%-80% of caregivers report that they are providing care across those items. In terms of the frequency of care, caregivers were more likely to report providing care “sometimes” and “often” than to be providing care “always” for the Activities of Daily Living.
Overall, for the Instrumental Activities of Daily LivingFootnote 7, over 90% of caregivers report they are providing care across those items. In terms of the frequency of care, caregivers were more likely to report providing care “always” than to be providing care “often” or “sometimes” for the Instrumental Activities of Daily Living.
The Caregiver Survey highlights that the informal caregiver role is mentally and physically demanding. As displayed in Graph 1:
- 97% of caregiver respondents strongly agreed/agreed that “Providing care for the Veteran is mentally demanding.” (78% strongly agreed)
- 88.5% of caregiver respondents strongly agreed/agreed that “Providing care for the Veteran is physically demanding.” (55% strongly agreed)
Graph 1: Physical and Mental Demands on Caregivers
Graph 1: Physical and Mental Demands on Caregivers
| Strongly Agree | Agree | |
|---|---|---|
| Coordinating care for the Veteran is mentally demanding. | 50.6% | 31.3% |
| Coordinating care for the Veteran is physically demanding. | 21.7% | 34.3% |
| Providing care for the Veteran is mentally demanding. | 78.3% | 18.7% |
| Providing care for the Veteran is physically demanding. | 55.4% | 33.1% |
The Caregiver Survey also showed informal caregivers are expending a significant amount of their time supporting the Veteran as displayed in Graph 2:
- Approximately 70% of caregivers report they are providing and/or coordinating care for more than 30 hours per week.
- More than one third of caregivers report they are providing and/or coordinating care for more than 60 hours per week.
- Close to one quarter of caregivers report they are providing and/or coordinating care for more than 100 hours per week.
Graph 2: Physical and Mental Demands on Caregivers
Graph 2: Physical and Mental Demands on Caregivers
| Hours | Percentage |
|---|---|
| 100+ hours, including 24/7 responses | 23% |
| > 60 hours to 100 hours | 13% |
| > 30 hours to 60 hours | 33% |
| > 15 hours to 30 hours | 22% |
| 15 hours or less | 9% |
3.2 To what extent does the program align with Government of Canada priorities and with federal roles and responsibilities?
The CRB aligns with Government of Canada priorities as well as federal roles and responsibilities.
The Government of Canada’s 2015 speech from the throne highlighted the alignment of this benefit with Government of Canada priorities, stating “In gratitude for the service of Canada’s Veterans, the Government will do more to support them and their families”.
In addition, Budget 2017 reiterated the Government’s commitment to Veterans, stating “The Government is committed to ensuring that it delivers the programs and services our Veterans—and their families—need for a seamless and successful transition from military to civilian life”. It continued by stating that measures would be implemented to “… better support the families of ill and injured Veterans, including caregivers”.
Building on that theme, VAC’s 2017 ministerial mandate letter stressed the need to continue implementation of the “… Caregiver Recognition Benefit, paid directly to Veterans’ caregivers”.
In addition, VAC’s mandate to deliver the Program is derived from s. 4 (a) (1) of the Department of Veterans Affairs Act which assigns the Minister of Veterans Affairs the powers, duties, and functions to provide for:
“…the care, treatment or re-establishment in civil life of any person who served in the Canadian Forces or merchant navy or in the naval, army or air forces or merchant navies of Her Majesty, of any person who has otherwise engaged in pursuits relating to war, and of any other person designated by the Governor in Council…”
VAC’s responsibility to deliver the CRB is further outlined in Part 3.1, Section 65.1 of the Veterans Well-being Act.
Finally the 2019-20 Departmental Plan highlighted the core responsibilities of the Department as well as “… ensuring the well-being of Veterans and their families is placed at the centre of everything we do”.
3.3 To what extent is the Program responsive to the needs of its intended recipients?
The program has evolved to better meet the needs of caregivers, and to address concerns from stakeholders, however, further opportunities exist to reach intended recipients.
To respond to the needs of caregivers and concerns raised by stakeholders, the CRB was established in 2018 to replace the previous FCRB. The following details regarding this change were taken from the Regulatory Impact Analysis Statement prepared for the regulation amendments:
“In 2015, the FCRB was introduced under the New Veterans Charter suite of benefits. The benefit provides an annual grant to seriously disabled Veterans so that they are able to make alternative care arrangements and receive the necessary supports, normally provided by their informal (i.e. unpaid) caregivers, while these caregivers are unavailable. However, there have been issues raised with the FCRB’s design since it was introduced. Veteran caregivers and stakeholders feel the benefit does not recognize, in a direct tangible way, the contributions of caregivers, as the benefit is provided to Veterans and not the caregivers themselves. Further to this, the 2015 mandate letter of the Minister of Veterans Affairs and Associate Minister of National Defence provided overarching direction to do more to support the families of Canadian Veterans.
To address these issues, the FCRB has been replaced by the CRB. The CRB will recognize the contribution caregivers make to the health and well-being of Veterans with service-related physical and/or mental health disabilities who require continuous provision of care. The indexed benefit will be paid directly to the informal caregiver, in the amount of $1,000 per month. The CRB will not replace lost income or create an employment-like relationship; rather, it will recognize the contributions of those who care for seriously disabled Veterans with service-related disabilities. Eligibility criteria for the CRB will remain the same as that for the FCRB, and like the current benefit, will be paid until the Veteran permanently enters a long-term care facility or dies.”
To better understand if the program is responsive to the needs of its intended recipients, the evaluation team consulted with VAC’s Program Policy Directorate and the Senior Director responsible for the development of the program (responsible for establishing the program intent, and associated eligibility criteria). Based on documentation provided, and through interviews with program policy and its Senior Director, the intended recipients of the program are the most critically ill and seriously disabled Veterans. Although this has been informally communicated as the intent, clear written policy direction has not been developed or communicated for three of the four eligibility criteria for the program (criteria developed 5 years ago for the FCRB).
It is also important to note, concerns have been raised by stakeholders, through interviews with front-line VAC employees, and through feedback received in the Caregiver Survey, that Veterans requiring ongoing care resulting from mental health conditions are being missed within program eligibility. These concerns, along with further examining the impacts of limited policy direction are further explored in Section 4.1 (Are processes currently in place to ensure the program is being administered as indicated in departmental guidance?).
Additionally, through consultation with program policy and the Senior Director responsible for CRB program development, the evaluation team was informed that the Veterans targeted by this program are those that have significant needs, and should essentially already be known to the Department based on information from other programs being accessed. Considering this, the evaluation team finds there is an opportunity for VAC to establish a pro-active approach of reaching those most in need through an Application Waiver process. Section 78.1 of the Veterans Well-being Act authorizes the Minister to waive the requirement for an application. The Waiver of Requirement for Application Policy states the following:
- Applications for benefits made under the Veterans Well-being Act and the Pension Act should be made “in writing”. However, VAC may waive the requirement for an application if VAC believes, based upon information that has been collected or obtained by VAC as part of its ongoing administration of programs and services and daily operations, that the person may be eligible for the benefit (compensation, service or assistance) if the person applied for it.
- The overall intent of waiving the requirement for an application is to decrease administrative burden on Veterans, their families and VAC staff.
- VAC may choose to waive the requirement for an application in circumstances such as:
- VAC is in possession of all of the information necessary to complete an eligibility decision; or
- VAC is in possession of almost all of the information necessary to complete an eligibility decision and the person to whom the waiver applies agrees to submit any information or documentation necessary to complete the eligibility decision.
As the CRB is intended to reach the most critically ill and seriously disabled, many of whom are already known to the Department based on information collected or obtained for the ongoing administration of programs and services and daily operations, this presents an opportunity for the Department to better reach these Veterans. This would help to reduce burden on these Veterans and their families, and would help to ensure the program is appropriately reaching its intended audience. During the course of the program evaluation, the evaluation team was not informed of any situations in which the application waiver was utilized for the CRB, nor were there any specific guidelines or practices developed to use the application waiver for the program.
To further examine whether the program is reaching intended recipients, the evaluation team completed an analysis of seriously disabled Veterans. In alignment with the original proxy groupFootnote 8 that was used to forecast expenditures/clients for the program, the evaluation team analyzed “Veterans in receipt of Disability Awards, with a disability assessment of 98% or greater and who are not in a long-term care facility.” This group of seriously disabled Veterans is based on the cumulative disability assessment percentages for all entitled disability award conditions. In total, 1,161 living Veterans meet this criteriaFootnote 9, and as of September 2019, 225 (19%) were in receipt of the CRB, 130 (11%) were declined eligibility to the CRB, and 806 (70%) have either not applied or not yet received an eligibility decision for the program.
Through interviews, the evaluation team was informed that an indicator of 98% or higher is not always suitable, as this could result from numerous smaller disability amounts accumulating to 98%, which may not result in the Veteran being seriously disabled. Therefore, the evaluation team used an additional target group of Veterans for further analysis. It was found that 137 Veterans had at least 1 Disability Award (DA) condition that was individually assessed at 80% or higher. Of these 137 Veterans, as of September 2019, 40 (29%) were in receipt of the CRB, 9 (7%) were declined eligibility to the CRB, and 88 (63%) have either not applied or have not yet received an eligibility decision for the program. It is also important to note that of these 88 yet to apply/receive a decision, 8 are in receipt of a DA for Amyotrophic lateral sclerosis (ALS), 7 are in receipt of a DA for Chronic Obstructive Pulmonary Disease (C.O.P.D.), 24 are in receipt of a DA for Post Traumatic Stress Disorder (PTSD), with the remainder spread across various conditions such a cancers, paraplegia/ quadriplegia, Parkinsons, other psychiatric conditions, other lung conditions, etc.
Overall, the evaluation finds that there are opportunities for VAC to use existing program and operational data to help ensure it appropriately reaches targeted recipients (caregivers of seriously disability Veterans) for the program.
Recommendation #1:
It is recommended that:
- The Director General, Service Delivery and Program Management use existing program information/data to identify the Department’s seriously disabled Veterans who have not applied for the CRB and could be eligible for the program.
- Subsequent to identification of the additional potential recipients, the Director General, Service Delivery and Program Management work in collaboration with the Director General, Centralized Operations Division to determine who may be eligible, and reach them by using application waivers, where possible.
- Subsequent to identification and eligibility confirmation of the additional intended recipients and program policy revisions, the Director General, Service Delivery and Program Management work to develop guidance and a resulting process, including the necessary tool and system changes, to ensure the program continues reaching the most seriously disabled Veterans, and where appropriate, to utilize application waivers.
Management Response:
Management agrees with this recommendation.
| Corrective Actions to be taken |
|---|
| With respect to Recommendation 1, the Director General, Service Delivery and Program Management will:
a. Work in collaboration with Centralized Operations Division, Field Operations, and Policy to:
b. Work with Centralized Operations Division, Field Operations, and IT to:
c. Work in collaboration with Centralized Operations Division, Field Operations, and Policy to develop ongoing guidance and develop tools and system changes to allow VAC to proactively identify potential CRB clients and where applicable, implement application waivers, based on the clarified policy direction resulting from Recommendations 2 and 3. |