4.1 Are processes currently in place to ensure the program is being administered as indicated in departmental guidance?
Improvements to the program policy and subsequent business processes are required to better explain and define eligibility criteria and to provide direction on how the policy requirements are to be assessed.
To assess the extent to which the program is being administered as indicated in departmental guidance, the evaluation team completed; a review of current departmental guidance, key informant interviews, a review of stakeholder feedback associated with the program , a review of literature, a comparison of program guidance to that of a similar program through the United States Department of Veterans Affairs, and completed a file review of previous program decisions.
4.1.1 Review of current departmental guidance:
As identified in VAC’s CRB Policy, to gain eligibility to the program, the Veteran requires Disability Award/Pain and Suffering Compensation for a medical condition which is determined to result in an ongoing care need at a level that meets at least one of the following:
- a level of care and supervision consistent with admission to an institution such as a long-term care facility;
- daily physical assistance of another person for most activities of daily living;
- ongoing direction and supervision during the performance of most activities of daily living; or
- daily supervision and is not considered to be safe when left alone (i.e. Veteran poses a risk to him/herself or others if not supervised on a daily basis).
The eligibility criteria listed in the policy uses the same language as already provided in the CRB Regulations. The policy provides information to define what is meant by “most activities of daily living,” however does not provide any further criteria or definitions to explain:
- What functional, physical and/or mental health needs/criteria should be considered when determining a Veteran has a level of care and supervision consistent with admission to an institution? (eligibility criteria i)
- What is the difference between “daily physical assistance (criteria ii)” and “ongoing direction and supervision (criteria iii)” and how should these differences be approached when assessing the Veteran?
- What functional, physical and/or mental health needs/criteria should be considered when determining that a Veteran requires daily supervision and is not considered safe to be left alone (eligibility criteria iv.)?
At the time of the evaluation, the evaluation team requested any further direction that Program Policy provided to decision makers relating to these questions, and was informed that it was being reviewed and that direction had not yet been provided.
4.1.2 Key informant interviews and program recipient data:
Through interviews with Field Operations (front-line) employees, the evaluation team was informed that there is a lack of information to be able to understand and/or provide Veterans with respect to eligibility to the program. Field staff are concerned that assessments they complete on Veterans are used to support decision making, and that since they do not understand which elements of the assessment are used, opportunities to highlight health needs in support of a Veterans eligibility consideration may be missed.
Interviews with Field Operations employees also indicated that there are concerns with which Veterans may be gaining eligibility versus those that are not, and that the decisions do not always align with who they would expect to receive the benefit. One key concern noted across the majority of field interviews was that Veterans with ongoing supervision requirements resulting from a serious mental health condition are often not gaining eligibility to the program. They feel that the focus on the basic “activities of daily living” is a limitation of the program eligibility criteria, in that it may not reach Veterans that have ongoing supervision needs resulting from their mental health condition.
The evaluation team was informed through interviews with program decision makers in the Centralized Operations Division (COD), that in the absence of clear direction within the policy and resulting business process, they established their own criteria to be considered in certain situations. As the decision makers for this program do not require a medical/health background, there is a risk that internal criteria may not align with and/or provide access in a way which considers all functional, physical and mental health needs. For example, for the eligibility criteria of “ iv. daily supervision and is not considered to be safe when left alone,” in the absence of policy direction/definitions, the evaluation team was informed that the program decision makers have been interpreting a “documented suicide attempt” as one form of evidence to support favourable decisions for this criteria. Another example includes episodes of wandering/disappearing from the home.
In analyzing program recipient data, the evaluation found that as of September 2019, 608 (83.5%) of the 728 CRB eligible Veterans had a mental health condition, and 633 Veterans with a mental health condition were denied CRB eligibility. In instances that Veterans with mental health conditions received eligibility for CRB, close to 95% of these Veterans also had other health conditions not relating to mental health. In these situations, although the mental health conditions may have led and/or contributed to the Veteran receiving eligibility, the evaluation cannot determine which specific condition(s) linked to the CRB Decision. In total, as of September 2019, there were 97 Veterans that applied for CRB who had only mental health related conditions, 33 (34%) were favorable, and 64 (66%) were unfavorable.
4.1.3 Stakeholder feedback
The evaluation team reviewed minutes from various ministerial stakeholder advisory committees and found feedback which noted concerns with current program eligibility.
At the Advisory Group on Families- Tuesday, April 30, 2019 and the Mental Health Advisory Group, April 30, 2019 meetings, minutes indicate that “there was extensive discussion on the eligibility criteria and that it is too restrictive given that fundamentally the Veteran would need to be institutionalized if the caregiver was not in place.”
In addition, minutes from the Policy Advisory Group, June 22, 2018 meeting revealed:
“The member co-chair of the Mental Health Advisory Group sent a letter to the Minister with concerns about access to the CRB for those with mental health issues. The letter outlined that the application questions focus on physical ability, whereas the most basic understanding of mental health issues would show that we understand that the person may be physically able to perform an activity, but due to mental limitations, he or she cannot. The concern is that the benefit, as structured, will not be granted to those who care for mentally injured Veterans…”
The minutes also noted:
“While a Veteran with a physical health condition may be more likely to qualify for the benefit based on the criteria of needing daily physical assistance with and/or direction and supervision during the performance of most activities of daily living, a mental health condition may be eligible in circumstances where the Veteran requires daily supervision and is not considered safe when left alone.”
The meeting minutes from the Policy Advisory Group did highlight that “a mental health condition may be eligible in circumstances where the Veteran requires daily supervision and is not considered safe when left alone,” however, the program policy does not provide guidance as to what the intended mental health needs are that could lead to this criteria being used, as such, the evaluation team finds there is a risk that decision makers could be missing key information that could better support them ensuring the program reaches Veterans with this level of needs.
4.1.4 Research relating to the assessment of Activities of Daily Living for physical vs. cognitive impairment
To further explore concerns raised by stakeholder advisory committees and Field Operations employees relating to the assessment of activities of daily living for Veterans with needs resulting from mental health conditions, the evaluation searched for available literature that studied this relationship. The literature noted below is consistent with concerns raised, and specifically notes that:
- ADLs “are mastered early in life and are relatively more preserved in light of declined cognitive functioning when compared to higher level tasks...Footnote 10”
- “IADL performance is sensitive to early cognitive decline, whereas physical functioning is often a significant driver of basic ADL ability (Boyle, Cohen, Paul, Moser, & Gordon, 2002; Cahn-Weiner et al., 2007).”
4.1.5 Program Comparison with United States of America (USA), Department of Veterans Affairs (DVA) Caregiver Support Program
In support of the evaluation, a review of caregiver programs offered by other countries was undertaken. It was found that a Caregiver Support Program offered by the USA DVA was the most similar to VAC’s CRB. A full comparison of eligibility criteria can be found in Appendix C.
Specific eligibility criteria and defining information for the program was found in the USA DVA Caregiver Support Program policy (VHA Directive 1152(1)). The key eligibility criteria and supporting definitions follow:
(a) An inability to perform one or more activities of daily living;
For purposes of this directive, activities of daily living means:
- Eating. Ability to feed oneself both meals and snacks.
- Grooming. Ability to safely tend to personal hygiene needs (i.e., washing face and hands, hair care, shaving, applying makeup, teeth and denture care, nail care of fingers and/or toes).
- Bathing. Ability to wash entire body safely.
- Dressing and Undressing. Ability to dress and/or undress upper and lower body with or without dressing aids.
- Toileting. Ability to maintain perineal hygiene and adjust clothing before and/or after using the toilet or bedpan; ability to manage an ostomy, including cleaning the area around stoma but not managing equipment; or ability to manage urinary catheter or urinal.
- Prosthetic Adjustment (Use of Assistive Devices). Ability to adjust special prosthetic or orthopedic appliances without assistance. The adjustment of appliances that any person (with or without a disability) would need assistance with should not be scored (for example, supports, belts, lacing at back, etc.).
- Mobility. Ability to transfer safely from bed to chair and/or chair to toilet, ability to turn and position self in bed, ability to walk safely on a variety of surfaces, or ability to go upstairs.
(b) A need for supervision or protection based on symptoms or residuals of neurological or other impairment or injury;
The need for supervision or protection based on symptoms or residuals of neurological or other impairment or injury means requiring supervision or assistance due to one or more of the following:
- Seizures. Unable to manage seizures independently (i.e., seizures are not well controlled with medication or Veteran is not able to independently manage the medications, blackouts, or lapses in mental awareness).
- Planning and Organizing. Difficult to plan and organize (i.e., complete daily tasks, make and keep appointments, adhere to medication regimen).
- Safety. Unable to maintain safety with self and others (i.e., Veteran is a risk to self or others and/or is at risk of falling or wandering, cannot safely use electrical appliances, stove top or oven).
- Sleep. Difficult to regulate sleep without intervention of caregiver.
- Delusions/Hallucinations. Unable to maintain safe behavior in response to delusions (irrational beliefs) or hallucinations (serious disturbances in perception).
- Impairment of Recent Memory. Difficult to remember recent events and learn new information.
- Affective/Behavioral Dysregulation (Self-Regulation). Unable to regulate behavior without exhibiting any of the following behaviors: aggressive or combative with self or others, verbally disruptive including yelling, threatening and excessive profanity, impaired decision making, inability to appropriately stop activities, disruptive, infantile or socially inappropriate behavior.
(c) The individual is a Veteran who is service connected for a serious injury that was incurred or aggravated in the line of duty in the active military, naval, or air service on or after September 11, 2001, and has been rated 100 percent disabled for that serious injury, and has been awarded special monthly compensation that includes an aid and attendance allowance.
Similar to the VAC CRB program, the USA Caregiver Support Program includes an eligibility criteria specific to the activities of daily living. In addition, the USA Caregiver Support Program has a separate criteria not relating to activities of daily living, criteria (b) which states “A need for supervision or protection based on symptoms or residuals of neurological or other impairment or injury” and provides specific definitions that result from symptoms or residuals of neurological or other impairment, relating to; seizures, planning and organizing, safety, sleep, delusions/hallucinations and impairment of recent memory. This indicates that the policy for the USA DVA Caregiver Support Program recognizes that symptoms or residuals of neurological or other impairment or injury need to be assessed separately from the basic “activities of daily living.”
The evaluation team finds the details defining “A need for supervision or protection based on symptoms or residuals of neurological or other impairment or injury” in the USA Caregiver Support Program policy could be approached in a similar manner/definition for the VAC CRB program criteria “iv. daily supervision and is not considered to be safe when left alone.” Such an approach could help to mitigate concerns raised by both field employees and stakeholders regarding mental health needs not being adequately reflected in the eligibility criteria.
It is also important to note, that the eligibility criteria in the USA Caregiver Support Program for “A need for supervision or protection based on symptoms or residuals of neurological or other impairment or injury,” aligns with how mental health medical impairments are assessed for VAC Disability Awards/Pain and Suffering Compensation within the Table of DisabilitiesFootnote 11Chapter 21 - Psychiatric Impairment. Medical impairment ratings within the Table of Disabilities and opportunities that may exist to align these decisions to eligibilities for other VAC Programs is being further examined through a 2020-21 Horizontal Evaluation of Program Eligibility Requirements.
4.1.6 File Review of Program Eligibility Decisions
The evaluation team, in collaboration with Program Analysts from VAC’s Service Delivery and Program Management Division (SDPM) completed a file review on a random sample of program eligibility decisions for the CRB. In total, 180 CRB decisions from the time period of April 1, 2018 to September 30, 2019.
Summary results shows that:
For the 75 favourable decisions reviewed:
- 43 decisions were for Veterans previously eligible for the FCRB, and were subsequently provided eligibility for CRB. In these instances, Veterans were able to gain eligibility without needing to submit new evidence. Considering this, the file review team was still able to find information to confirm the appropriateness of decisions for 20 (47%) of these decisions, however, 23 (53%) of these decisions found that there was insufficient evidence to support how the favourable decision was arrived at other than the previous approval for FCRB.
- Of the remaining 32 favourable decisions (not previously in receipt of FCRB), the file review team found that based on the information/evidence available, 29 (91%) of decisions were reasonable, 3 (9%) were either found not to be reasonable or there was insufficient evidence to support how the favourable decision was arrived at.
Of the 105 unfavourable decisions reviewed, the file review team found that:
- Based on the information/evidence available, 93 (89%) of decisions were reasonable;
- 12 (11%) of the unfavourable decisions did not fully align with the evidence available for the decision.
The results of the file review indicate that there is a need to reduce the risk that the evidence sources for CRB eligibility criteria are interpreted inconsistently.
Overall, the evaluation finds that for section 4.1, there is a significant need for VAC to improve the CRB program policy and subsequent business processes to better explain/define eligibility criteria and to provide direction on how the policy requirements are to be assessed.
Recommendation #2:
It is recommended that:
- The Senior Director, Program Policy undertake immediate efforts to update the CRB Policy to include evidence based medical direction and definitions with respect to each individual eligibility criteria, including details on:
- The health needs/impairments that should be considered when determining a Veteran has a “level of care and supervision consistent with admission to an institution (eligibility criteria i);”
- Details on the difference between “daily physical assistance (criteria ii)” and “ongoing direction and supervision (criteria iii)” and how should these differences be approached when assessing the Veteran for needs associated with the activities of daily living;
- The health needs/impairments (including those relating to mental health) that should be considered when determining that a Veteran requires “daily supervision and is not considered safe to be left alone (eligibility criteria iv).”
- Subsequent to program policy revisions, the Director General, Service Delivery and Program Management Division update the CRB Business Process to provide specific guidance to decision makers on what recent/new evidence sources are to be used to assess eligibility criteria. If evidence sources/methods currently available to the Department are not sufficient to assess the CRB criteria, a revised and/or new application/assessments/sources may need to be created.
- Subsequent to program policy revisions, the Director General, Service Delivery and Program Management promote/raise awareness of the revised program policy to Veterans and their caregivers.
Management Response:
Management agrees with this recommendation.
| Corrective Actions to be taken |
|---|
| With respect to Recommendation 2 a), i) ii) and iii): the Senior Director, Program Policy will:
a. Conduct research, including medical research and consultations, and environmental scans and draft recommendations for amendments to the Caregiver Recognition Policy to more clearly provide direction as to when the eligibility criteria i) to iv) are met as outlined in the Recommendation; |
| With respect to Recommendation 2 b) and c), the Director General, Service Delivery Program Management will:
b. Work in collaboration with Centralized Operations Division, Health Professionals, Field Operations, and Policy to update functional direction, including business processes, based on program policy revisions to support the assessment of eligibility criteria and decision making. Where necessary and following analysis of required changes, tools used throughout the process will be updated, or new tools created. c. Subsequent to program policy revisions, work in collaboration with the Communications Division to promote/raise awareness of the revised program policy to Veterans and their caregivers. |
4.2 Achievement of Expected Outcomes
The CRB Performance Information Profile (PIP) and logic model, which displays the outcomes for the CRB can be viewed in Appendix D.
Immediate Outcome: Seriously injured Veterans and their caregivers are aware of the CRB
As findings indicated in section 3.3, opportunities exist to ensure the most seriously disabled Veterans are reached for program eligibility consideration.
As previously noted in Section 3.3 of the report, approximately 70% of Veterans who have cumulative Disability Awards/Pain and Suffering Compensation of 98% or greater, and are not in long-term care, have either not applied or not yet received an eligibility decision for the program. In addition, it was found that for Veterans that have at least one Disability Award/Pain and Suffering condition that is individually assessed at 80% or higher, and are not in long-term care, 63% have either not applied or have not yet received an eligibility decision for the program. Recommendation #1 on page 17 is in response to these results.
In instances Veterans were approved for the benefit, the Caregiver Survey requested feedback from caregivers on how they became aware of the program. The results indicate that the most common source for becoming aware of the program is a VAC employee. Further results are reflected in Graph 3.
Graph 3: Caregiver Survey- How did caregivers become aware of the program?
Graph 3: Caregiver Survey- How did caregivers become aware of the program?
| Percentage | |
|---|---|
| Legion | 3.0% |
| Media | 3.5% |
| Other | 4.5% |
| Friend | 8.1% |
| Family Caregiver Relief Benefit | 11.6% |
| VAC Website | 15.2% |
| Veteran | 26.8% |
| VAC Employee | 27.3% |
Intermediate Outcome: Caregivers have timely access to CRB payments
The evaluation finds that caregivers are receiving timely access to CRB payments.
The CRB PIP includes two performance measures associated with the processing of payments to caregivers. These measures and performance results follow.
Payment Processing- CRB
| CRB First Applications | 2018-19 | 2019-20 (as of September 2019) | Total |
|---|---|---|---|
| # of favourable decisions | 683 | 93 | 776 |
| # of payments processed within 1 week of decisionFootnote 12 | 486 | 83 | 569 |
| % of payments processed within 1 week. | 71% | 89% | 73% |
| Average days to process payment | 6.6 | 4.1 | 6.3 |
Results show that although payment processing times fell below the 80% target in 2018-19, these improved to 89% during 2019-20, with an average days to process of 4.1.
| CRB First Applications | 2018-19 | 2019-20 (as of September 2019) | Total |
|---|---|---|---|
| # of favourable decisions | 683 | 93 | 776 |
| # of payments processed within 9 weeks of receiving application and necessary information | 431 | 48 | 479 |
| % of payments processed within 9 weeks of receiving application and necessary information | 63% | 52% | 62% |
| Average weeks between application and necessary information to the payment being processed | 8.8 | 10.4 | 9.0 |
Results show the overall time between a Veteran applying for the CRB and the caregiver receiving a payment have been increasing in 2019-20 when compared to 2018-19. The primary reason for this increase is the time it takes to render a CRB decision, which is further reviewed in Section 4.2.3 – Efficiency.
To identify if caregivers have concerns with awaiting payments, the evaluation team reviewed the Caregiver Survey response comments from caregivers who reported not being satisfied with the program, the concerns raised did not relate to the timeliness of payment processing. Further information on concerns raised by caregivers is provided in the following section which assesses the program’s Ultimate Outcome.
Ultimate Outcome: Caregivers feel recognized by the Government for the support they provide seriously disabled Veterans
The evaluation finds that the CRB meaningfully recognizes caregivers for their role in supporting the Veteran they care for.
Caregiver Survey results show that 79% of caregivers Agree/Strongly Agree that the “CRB meaningfully recognizes my role in supporting the Veteran I care for.” Further breakdowns of caregiver satisfaction responses are included in Graph 4.
Graph 4: Caregiver Survey Results- Caregiver satisfaction with the CRB.
Graph 4: Caregiver Survey Results- Caregiver satisfaction with the CRB.
| Percentage | |
|---|---|
| Do not know / NA / Prefer not to answer | 2% |
| Neither agree nor disagree | 6% |
| Agree | 33% |
| Strongly agree | 46% |
| Strongly disagree | 3% |
| Disagree | 10% |
Through the Caregiver Survey, program satisfaction results show that 74% of caregivers Agree/Strongly Agree that “Overall, I have been satisfied with the CRB.” Further breakdowns of caregiver satisfaction responses are included in Graph 5.
Graph 5: Caregiver Survey Results- Caregiver satisfaction with the CRB.
Graph 5: Caregiver Survey Results- Caregiver satisfaction with the CRB.
| Percentage | |
|---|---|
| Do not know / NA / Prefer not to answer | 2% |
| Neither agree nor disagree | 9% |
| Agree | 36% |
| Strongly agree | 38% |
| Strongly disagree | 4% |
| Disagree | 11% |
In instances that caregivers were not satisfied with the program, comments were reviewed to determine what issues/concerns may be causing this. The key themes associated with these concerns were that:
- the amount of money is inadequate and does not represent amount of care needed;
- caregivers have a loss of income/work due to their caregiver role;
- the benefit is difficult to be approved for/it does not reflect mental health problems;
When reviewing these concerns, it important to highlight that the purpose of the CRB is to provide recognition for the role an informal caregiver plays, and that it is not meant to replace employment or to be an income support program. In terms of providing financial support and recognition to the most seriously disabled Veterans, VAC offers programs to recognize and compensate these Veterans. The evaluation found that when Veterans have been approved for CRB:
- 82% are also in receipt of Additional Pain and Suffering Compensation (APSC). The APSC is a tax-free, monthly benefit. It provides recognition and compensation for any severe and permanent disability, related to your service, which creates a barrier to your life after service. The APSC is paid monthly in 3 different grades: Grade 1 = $1,528.50, Grade 2 = $1,019.00 and Grade 3 = $509.50.
- 73% have been deemed to have a Diminished Earnings Capacity (DEC) and are eligible to receive the the Income Replacement Benefit (IRB). The IRB is a taxable, monthly benefit that ensures the Veteran’s income is at least 90 percent of gross pre-release military salary, and when a Veteran is deemed to have Diminished Earnings Capacity, it is payable until the age 65. After age 65, the benefit provides 70 percent of the IRB amount payable prior to age 65.
It’s important to note that the evaluation did not assess the quality or level of care provided to Veterans or the impact the care is having on the Veteran. The Department could, however, use the results of the 2020 VAC National Survey to analyze to what extent Veteran outcomes are being achieved based on the various programs Veterans are accessing.
A review of the potential alignment of eligibility between VAC programs to determine if further efficiencies could be made will be undertaken as part of an upcoming Horizontal Evaluation of Program Eligibility Requirements.
4.3 Are there opportunities to improve the efficiency and economy of the program?
The current processing standard of 80% of CRB decisions being completed within eight weeks is not being achieved.
4.3.1 Processing Times
The CRB PIP targets that 80% of CRB eligibility decisions are rendered within eight weeks of all necessary information being available.
Processing results for the past two years (displayed in Table 7), show that approximately 55% of claims are being processed within eight weeks, with almost 80% of claims being processed within twelve weeks.
| CRB First Applications | 2018-19 | 2019-20 (as of September 2019) | Total |
|---|---|---|---|
| # of decisions overall | 1,455 | 350 | 1,805Footnote 13 |
| #/% of decisions processed within 8 weeks | 752 (52%) | 192 (55%) | 944 (52%) |
| #/% of decisions processed within 10 weeks | 910 (63%) | 241 (69%) | 1,151 (64%) |
| #/% of decisions processed within 12 weeks | 1,142 (79%) | 277 (79%) | 1,419 (79%) |
Although the processing times for the program currently exceed the eight week target, the evaluation team did not receive negative feedback from field staff and/or from caregivers within the Caregiver Survey relating to the length of time awaiting a decision. As identified in section 4.2, 74% of caregivers reported overall satisfaction with the program.
The evaluation team finds that this creates an opportunity, in that upon implementing actions in response to the recommendations in this evaluation, that VAC’s Service Delivery and Program Management Division should review the service standard to determine if it is appropriate/realistic, and if possible, adjust the target to reflect a standard which better reflects the decision making requirements for this program.
4.3.2 Operating Costs
On an annual basis, VAC’s Finance Division allocates the estimated operating costs to each VAC programs. The total program costs and estimated operating costs for the CRB are included in Table 8.
| CRB Expenditures by Fiscal Year | Program Expenditures | Salary and Operation & Maintenance (O&M) Expenditures | Total |
|---|---|---|---|
| 2019-20 (Forecast) | $7,070,000 | $2,140,808 | $9,210,808 |
| 2018-19 (Actuals) | $6,895,367 | $1,835,979 | $8,731,346 |
Overall, as a portion of total expenses, the operating costs (Salary and O&M) increased from 21% in 2018-19, to a forecast of 23% in 2019-20. As the program only has one full-year of actual data, further review of operating costs will be undertaken through future reviews. Future reviews will also be able to account for any process changes that results from the recommendations in this evaluation.
4.4 Are there any unintended impacts?
The practice of using assessments and reports currently on file is aimed at reducing the administrative burden on applicants and decision makers. However, when evidence is greater than three months old and leads to an unfavourable decision, up-to-date information should be obtained to ensure the Veteran’s current health needs are reflected.
4.4.1 Review of the age and types of source documents
In an effort to eliminate unnecessary administrative burden on the Veteran and given the relationship between the eligibility requirements for this benefit and the Veteran’s disability award or pain and suffering compensation, the CRB Policy indicates that VAC may use existing medical, nursing and/or other assessments/records to confirm the Veteran’s health condition. Additional information may be requested if required.
As part of the detailed file review, the file review team looked at the age of source documents used by decision makers:
- For favourable decisions, 39% of source documents were older than three months at the time of decision with 13% being greater than one year old.
- For unfavourable decisions, 53% of source documents were older than three months at the time of decision with 7% being greater than one year old.
Further analysis from the file review shows that 34% of the 105 files with unfavourable decisions contained evidence that the Veteran’s situation had worsened after the decision was made. A similar program offered by VAC for Disability Pension Recipients, Attendance Allowance, requires a current assessment within three months of the date of application. Although the intention is to reduce the administrative burden on the Veteran by using existing reports and assessments, it’s possible that unfavourable decisions are being made without a complete picture of the Veteran’s current health needs.
Through interviews with Field Operations (front-line) staff, the evaluation team learned that Case Managers were not always aware that a CRB decision was being made and this lead to concerns that the information on file did not always reflect the Veteran’s current health situation. There was also an acknowledgement that if they were aware of a Veteran applying, there would be a concerted effort to ensure that an up to date assessment was completed and on file to support the decision making process.
During the file review, the review team noted that more than fifteen different types of source documents could be considered as evidence. Some of these documents were completed by Health Professionals while others were self reported by the Veteran. There is an opportunity to refine the specific reports and/or assessments that are acceptable in supporting a CRB decision to ensure the best possible information is used to support decision making (relates to Recommendation #2).
Recommendation #3:
It is recommended that:
- The Senior Director, Program Policy update the CRB policy to provide specific guidance on the acceptable age of source documents, particularly for potentially unfavourable decisions, to ensure the Veteran’s current health situation is reflected in the decision making process.
- Subsequent to program policy revisions, the Director General, Service Delivery and Program Management work in collaboration with the Director General, Centralized Operations Division to complete process, tool and/or system updates to ensure age appropriate source documents are used in the CRB decision making process.
Management Response:
Management agrees with this recommendation.
| Corrective Actions to be taken |
|---|
| With respect to Recommendation 3 a) the Senior Director, Program Policy will:
Conduct intra-departmental consultations and amend the Caregiver Recognition Policy to provide specific guidance on the acceptable age of source documents, particularly for potentially unfavourable decisions, to ensure the Veteran’s current health situation is reflected in the decision making process. |
| With respect to Recommendation 3 b), the Director General Service Delivery Program Management will:
Work in collaboration with Centralized Operations Division, Field Operations, and IT to update processes, tools, and systems to support the use of age appropriate documents in decision making. |
4.4.2 Letters resulting from program decisions
When a decision is made, a letter is sent directly to the Veteran advising them of the decision. The evaluation team reviewed the content of current decision letters and although the letter to the Veteran advises them to contact VAC if anything changes, it would provide additional clarity to explain to the Veteran that they must re-apply if their situation changes (rather than submit an appeal). This is particularly important given that one in three Veteran files reviewed as part of the file review with unfavourable decisions contained evidence of a worsening of health condition after the CRB decision had been made.
When a decision letter is sent to the Veteran, a separate letter is sent to the caregiver which thanks them for their service as a caregiver for both favourable or unfavourable decisions. The evaluation team feels, as part of these letters, there is an opportunity to highlight more specifically the resources currently available to all caregivers (approved for the program or not) on the Veterans Affairs Canada website including the Caregiver Zone.
The need to provide information to caregivers regarding the services available to support them is further supported by the feedback received in the Caregiver Survey. Multiple caregivers indicated that they had a difficulty in accessing the CRB and caregiver services in general while other caregivers suggested that there are not enough resources available for caregivers.
4.4.3 Appealing a CRB decision
| CRB Appeals | # of Favourable Decisions | # of Unfavourable Decisions | Total Decisions | Favourable Rate % |
|---|---|---|---|---|
| 2018-19 – 1st level Appeals | 4 | 136 | 140 | 2.9% |
| 2018-19 – 2nd level Appeals | 4 | 16 | 20 | 20% |
| 2019-20 – 1st level Appeals | 9 | 64 | 73 | 12.3% |
| 2019-20 – 2nd level Appeals | 1 | 28 | 29 | 3.4% |
| Totals | 18 | 244 | 262 | 6.9% |
Analysis of application data revealed that more than 50% of applications are declined for the CRB. Within the decision letter, Veterans are provided with appeal rights if they are dissatisfied with the decision. Appeals are handled by VAC’s internal first and second level of appeal. As displayed in Table 9, less than seven percent of CRB decisions have been overturned at appeal since the implementation of the CRB.
The CRB is a recognition benefit and the evaluation team noted that other VAC recognition benefits such as: Pain and Suffering Compensation, Additional Pain and Suffering Compensation, Attendance Allowance, etc. have their appeals handled through the Veterans Review and Appeal Board (VRAB). Appealing through VRAB also entitles the Veteran to legal representation and guidance through the Bureau of Pension Advocates. There will be an opportunity to review this difference in approach in an upcoming Evaluation of VAC’s review and appeal and complaint resolution streams and processes.