3.1 Are VAC’s Case Management Services being provided to clients who require this level of support?
Clients who require the support of a Case Manager includes individuals that have complex needs or are finding it difficult to navigate a transition/change in their lives. The types of complex needs often supported through case management relate to mental health, physical health, employment, finances, social integration, housing, and/or life skills.
3.1(a) Are there Veterans who should be getting Case Management Services that are not receiving them?
There is an opportunity for VAC to increase screening and case management reach for subsets of CAF Veterans and former RCMP Members with complex needs.
This section of the evaluation report provides the findings associated with activities completed in support of assessing whether there are individuals who should be getting Case Management Services that are not receiving them (i.e. identified gaps).
Interviews and data analysis highlighted that the majority of case managed clients are participating in VAC’s Rehabilitation ProgramFootnote 4. As of March 2018, over 90% of clients receiving Case Management Services were in recipient of the Rehabilitation Program. Therefore, the majority of case management recipients are Canadian Armed Forces Veterans, as War Service Veterans and the RCMP do not have eligibility for VAC’s Rehabilitation program.
Overall, as of March 2018, 10.4% of all VAC’s Veteran clients were receiving Case Management Services (14% of CAF Veterans, 0.2% of War Service Veterans and 1.8% of RCMP Veterans). It is important to note, that all VAC clients with complex needs, regardless of service type, can access Case Management Services. Therefore, when assessing the reach of Case Management Services, the evaluation team looked at Veterans from all services types to identify if there are any gaps.
War Service Veterans
War Service Veterans make up a small portion of Veterans in receipt of Case Management Services at VAC (0.2% of the war service population at VAC are in receipt of Case Management Services). During interviews, Veteran Service Team MembersFootnote 5 and health professionalsFootnote 6 were asked if there are gaps relating to War Service Veterans. In most instances it was noted that the needs of War Service Veterans are being met through the work of Veteran Service Agents, Field Nursing Services Officers and Field Occupational Therapy Services Officers, and through traditional programs at VAC such as the Long Term Care Program, Health Care Benefits Program, and the Veterans Independence Program.
In order to better understand the War Service Veteran population’s needs, the evaluation team reviewed well-being related questions that were included within VAC’s 2017 National Survey. The survey included a sample of 185 War Service Veterans (not being case managed). The results of the survey were analyzed to determine whether there were any gaps with respect to War Service Veterans self-rated well-being and the reach of Case Management Services. The following table displays the results associated with this analysis:
| Satisfaction with Overall Well-Being: | War Service Veterans (not currently being Case Managed) |
|---|---|
| Satisfied/Very Satisfied | 170 (92%) |
| Neither Satisfied nor Dissatisfied | 8 (4.3%) |
| Very dissatisfied/ Dissatisfied | 7 (3.8%) |
| Total Veterans | 185 |
As reflected in Table 3, the vast majority of non-case managed War Service Veterans are satisfied/very satisfied with their well-being (92%). Of those that identified they were dissatisfied, none reported concerns with their mental health (one of the key factors that may indicate a case management need). This analysis does not indicate/highlight any apparent gaps for War Service Veterans that would require Case Management Services.
Through the July 2018 Case Manager Survey, 223 Case Managers were asked about specific groups and if there are any gaps with respect to the reach of Case Management Services. Interviews were also conducted with Veterans service team members and health professionals to assess any gaps with respect to Case Management Services. The results of the survey and interviewees did not indicate that there are any gaps in case management needs for the War Service Veteran client group.
In support of assessing the reach of Case Management Services, a file review was completed by subject matter expertsFootnote 7. The review examined 111 non-case managed clients based on a judgmental sample consisting of various client subsets. A subset of 24 files was extracted containing older Veterans that had a high risk score as per the Regina Risk Indicator Tool (RRIT), and high levels of interaction with VACFootnote 8. Although the judgmental sample was not representative of overall non-case managed War Service Veterans, none of the Veterans reviewed were deemed to have complex needs that required the support of a VAC Case Manager.
Section 4.1(a) of this report assesses the efficiency and effectiveness of various case management tools. This section identifies that the majority of War Service Veterans who were referred for case management consideration through the Regina Risk Indicator Tool (RRIT), were subsequently not deemed to have complex needs which required the support of a Case Manager.
Royal Canadian Mounted Police (RCMP)
As of March 2018, 1.8% of RCMP Veterans served by VAC were in receipt of VAC Case Management Services. In order to better understand the needs of the RCMP Veteran population, the evaluation team reviewed well-being related questions that were included within VAC’s 2017 National Survey. The survey included a sample of 195 Veterans who had RCMP service but were not in receipt of Case Management Services. An analysis of the survey questions revealed the following:
| Satisfaction with Overall Well-Being: | War Service Veterans (not currently being Case Managed) |
|---|---|
| Satisfied/Very Satisfied | 161 (82.6%) |
| Neither Satisfied nor Dissatisfied | 19 (9.7%) |
| Very dissatisfied/ Dissatisfied | 15 (7.7%) |
| Total Veterans | 195 |
As reflected in Table 4, the majority of non-Case Managed RCMP Veterans are satisfied/very satisfied with their well-being (83% of RCMP Veterans). There is however, 7.7% of non-case managed RCMP Veterans who reported being dissatisfied/very dissatisfied with their well-being, and 9.7% who reported that they were neither satisfied nor dissatisfied. Further analysis of these groups shows that many of these RCMP Veterans (73%) also self-reported as having fair/poor mental health (one of the key factors that may indicate a case management need). This analysis highlights that there may be a portion of RCMP Veterans that would benefit from the support of a Case Manager.
Further data analysis was conducted to determine if the RCMP Veterans were being appropriately reached. As of March 2018, 12,360 RCMP clientsFootnote 9 were in receipt of VAC’s services or benefits (representing 9.6% of the overall Veteran population served by VAC). In comparison, as of March 2018, RCMP Veterans represented 1.8% of the population of Case Managed Veterans at VAC. As mental health needs are one of the primary health factors that leads to case management support, the evaluation team compared the reach of Case Management Services for RCMP and CAF client groups that have mental health conditions. Data analysis shows that 40% of CAF Veterans with a mental health disability benefit condition are receiving Case Management Services, whereas, only 4% of RCMP with a mental health disability condition are receiving Case Management Services from VAC.
In the July 2018 Case Manager Survey, Case Managers were asked about specific groups and whether there are any gaps with respect to the reach of Case Management Services. The RCMP client group was identified as a gap. In addition, interviewees indicated that RCMP clients with complex needs may not be reached appropriately for Case Management Services.
To better understand potential reasons why the RCMP population may be less proportionally represented within case management, an analysis was conducted of VAC’s risk tools (RRIT and RRIT-R). The analysis found that RCMP Veterans are much less likely to receive a risk assessments (Regina Risk Indicator Tools)Footnote 10 for case management consideration than CAF or WS Veterans. Results are identified in Table 5.
| Service Type | Portion (%) of Veterans Served by VAC 2014-15 to 2017-18 | Portion (%) of RRIT’s & RRIT-R’s completed during 2014-15 to 2017-18 |
|---|---|---|
| WS Veterans | 21% | 24% |
| CAF Veterans | 70% | 73% |
| RCMP Veterans | 9% | 3% |
Table 5 shows that although RCMP Veterans represented approximately 9% of the overall Veterans served by VAC over the past 4 years, only 3% of risk assessments completed are for RCMP Veterans.
As noted previously, in support of assessing the reach of Case Management Services, a file review was completed by subject matter experts. The files of 24 former RCMP members were reviewed that had high levels of interaction with VAC. Of these files, 16 had enough information to be able to assess/draw conclusions relating to case management needs. Although the judgmental sample was not representative of overall non-case managed RCMP Veterans, it indicated that 3 of these clients had complex needs that appeared to meet the criteria for case management services.
Overall, the evaluation finds that there is an opportunity for VAC to increase screening and case management consideration for RCMP Veterans. Please see Recommendation #1 (page 20) relating to this finding.
Canadian Armed Forces Veterans
As of March 2018, 14% of CAF Veterans served by VAC were in receipt of VAC Case Management Services. To better understand the CAF Veteran population’s needs, the evaluation team reviewed well-being related questions in VAC’s 2017 National Survey. The survey included a sample of 199 CAF Veterans in receipt of case management, and 487 CAF Veterans not in receipt of Case Management Services. The results of the survey were reviewed to determine whether there were any gaps with respect to non CAF Veterans self-rated well-being and the reach of Case Management Services. The following table displays the results associated with this analysis:
| Satisfaction with Overall Well-Being: | CAF Case Managed Veterans | CAF Veterans (Non Case Managed) |
|---|---|---|
| Satisfied/Very Satisfied | 107 (54.3%) | 365 (74.9%) |
| Neither Satisfied nor Dissatisfied | 28 (14.2%) | 65 (13.3%) |
| Very dissatisfied/ Dissatisfied | 62 (31.5%) | 60 (12.3%) |
| Total Veterans | 197 | 487 |
As reflected in Table 6, 74.9% of non-Case Managed Veterans are satisfied/very satisfied with their well-being. There is, however, 12.3% of non-case managed CAF Veterans who reported being dissatisfied/very dissatisfied with their well-being, and 13.3% who reported that they were neither satisfied nor dissatisfied. Further analysis of these groups shows that many of these CAF Veterans (65%) also self-reported having fair/poor mental health. This analysis highlights that there may be a portion of CAF Veterans not currently being reached for Case Management Services, which could benefit from support of a Case Manager.
Although reach of Case Management Services for CAF Veterans as a group was not a gap highlighted through key informant interviews and the July 2018 Case Manager Survey, certain subsets of the population were identified, such as:
- Veterans with mental health conditions;
- Homeless Veterans; and
- Veterans with mental health needs associated with Special Duty AreaFootnote 11 service during the 1970’s/1980’s (Veterans 50-69 years old).
A review of departmental documentation found that recent strategies/approaches have been developed which should help mitigate reach concerns in relation to CAF Veterans’ Mental Health and Veteran Homelessness. However, the evaluation team did not find any documentation or data pertaining specifically to Veterans in the 50-69 age group. As such, the evaluation team conducted further data analysis which showed that 29% of CAF Veterans under the age of 50 and are receiving Case Management Services, which is more than double the 14% of Veterans in the 50-69 age group receiving Case Management Services. Similar results were found when analysing a subset of this group with mental health conditions. The evaluation found that 49.4% of CAF Veterans with mental health conditions under the age of 50 are receiving Case Management Services, compared to 34.7% of CAF Veterans with mental health conditions between the ages of 50-69.
The file review provides evidence there are Veterans that currently have complex needs and are not in receipt of Case Management Services. The department could benefit from enhanced screening and/or case management consideration for the following groups:
- Canadian Armed Forces Veterans deemed high risk (RRIT-R) and have high levels of interaction with VAC. It was found that 11 (50%) of the 22 cases reviewed identified Veterans with complex needs that could have been supported by a VAC Case Manager;
- Veterans who were previously in receipt of the Rehabilitation Program, however still have complex needs that may require case management. It was found that 6 (37.5%) of the 16 cases reviewed identified Veterans with complex needs that could have been supported by a VAC Case Manager.
Overall, the evaluation finds that there is an opportunity for VAC to increase the reach of case management for certain groups of CAF Veterans. Please see Recommendation #1 relating to this finding.
Gender Based Analysis
To better understand if Veterans who may require Case Management Services are currently being reached, an analysis was conducted using various Gender Based groupings such as gender, location, age and marital status.
Gender:
Through data analysis completed regarding Veterans currently in receipt of Case Management Services, it was found that 16% of VAC’s female Veteran clients are in receipt of Case Management Services, whereas 10% of VAC’s male Veteran clients are receiving Case Management Services. Although the results indicate that a higher portion of female Veterans versus male Veterans receive case management, cross-sectional analysis indicates that this is related to other key factors such as:
- Female Veteran clients having a higher incidence of mental health conditions, which are a key indicator for case management need;
- Female Veteran clients are more represented in younger age groups, and younger Veterans more likely to be reached for case management services;
- Female Veteran clients are more likely to be single than male Veterans, and single Veterans have been receiving case management at a higher rate than married Veterans.
Location:
An analysis was conducted to review the geographical composition of Veterans in receipt of Case Management Services. The analysis shows that rural Veterans in receipt of a benefit or service from VAC were slightly more likely to be in receipt of Case Management Services (11.2%) compared to Veterans in urban areas (10.2%). Interview’s and the July 2018 Case Manager Survey respondents noted limited concerns with regards to reach within rural or urban areas for those individuals who have already identified themselves to VAC. There were a few instances where interviewee’s noted potential reach concerns in remote locations of Canada where the Veteran has yet to identify them self to VAC. VAC has initiatives in place to help promote the services and benefits it provides to remote northern locations to help to encourage awareness in these areas.
| Demographical Indicator: | Reach (%) of Case Management compared to overall Veterans Served by VAC as of March 2018 | |
|---|---|---|
| Rural/UrbanFootnote 12 | 11.2% of Veterans that live in rural communities | 10.2% of Veterans that live in urban areas. |
Age:
Throughout the course of interviewing Veteran Service Team Members and analyzing July 2018 Case Manager Survey responses, it was identified that certain age brackets of Veterans may be missed by Case Management Services at VAC. Although age concerns may roughly translate to the various service types outlined in greater detail above in section 3.1(a), an analysis was conducted to see if there were any anomalies or age groupings of clients that could be being missed. Table 8 shows that as the age of a Veteran increases, the proportion of that age bracket in receipt of Case Management Services decreases.
| Demographical Indicator: | Reach (%) of Case Management compared to overall Veterans Served by VAC as of March 2018 | |||||
|---|---|---|---|---|---|---|
| Age | 35% of Veterans < 30 | 30% of Veterans 30-39 | 23% of Veterans 40-49 | 17% of Veterans aged 50-59 | 6% of Veterans aged 60-69 | 0.3% of Veterans aged 70 or more |
Marital Status and Families:
An analysis of the marital status of Veterans in receipt of Case Management Services (Table 9) showed that a slightly greater proportion of single Veterans compared to married Veterans were in receipt of services.
| Demographical Indicator: | Reach (%) of Case Management compared to overall Veterans Served by VAC as of March 2018 | |
|---|---|---|
| Marital Status | 13% of Single Veterans (including Divorced/Widowed) | 9% of married Veterans (including common-law) |
Interviewees and survey respondents noted that families could be one potential client group being missed by Case Management Services at VAC. It is the department’s practice to invite families to participate in the creation of a case plan for case managed Veterans. In addition, significant work is currently being undertaken in relation to Transition, and the department has recently committed $22.4 million over three years to better inform Veterans and their families of the supports available to themFootnote 13. These activities/initiatives should help to mitigate reach related concerns that were noted by Case Managers and other Veteran Service Team Members during the survey and/or interviews.
3.1(b) Are Case Management Services currently being provided to Veterans who do not require this level of support?
VAC should undertake further efforts to transition Veterans from case management that do not have complex needs and no longer require this level of support.
This section of the evaluation report provides findings associated with activities completed in assessing whether Case Management Services are currently being provided to Veterans who do not require this level of support.
Participants in the July 2018 Case Manager Survey were asked “considering your current caseload and indicators for disengagement, are you currently case managing any Veterans that should have already been disengaged (i.e. transitioning out of case management to another level of support)?” 83% (184 of 223) of Case Managers reported “Yes” that they are currently case managing Veterans that should have been transitioned out of case management to another level of support. Of these 184 Case Managers, 109 (59%) reported 3 or more Veterans on their caseload that should have been transitioned out of case management to another level of support.
Some potential reasons preventing Veterans from timely moving on from case management to a more appropriate level of support were further elaborated on in the survey. Such reasons included: the financial disincentive to leave case managementFootnote 14 is challenging for Case Managers and Veterans; documentation/time burden associated with the process, and that Veterans do not want to lose their Case Manager (single point of contact).
During key informant interviews, Case Managers noted challenges with respect to the amount of time it takes to complete the process for transitioning a Veteran out of case management and that Veterans want to have a single point of contact. There is potential with VAC’s guided support program that additional Veteran Service team members may be able to play a greater role and assist with the single point of contact concern raised by Veterans. Interviews also highlighted that there are opportunities for Field Nursing Services Officers, Field Occupational Therapy Services Officers, and Veteran Service Agents to play a greater role in supporting individuals who have needs but do not require one on one Case Management Services.
The file review provides further evidence supporting a need for increased efforts to move a Veteran from case management to a more appropriate level of support when they are ready. This component of the file review examined 123 active files (as of July 2018) based on a judgmental sample.Footnote 15 The review found that 36% of the selected files did not have needs that required the support of a Case Manager, and that an additional 15% had needs that were associated with obtaining a diminished earnings capacityFootnote 16 decision. Based on the groups targeted for this portion of the file review, additional efforts could be undertaken for:
- Veterans who already have been deemed to have Diminished Earnings Capacity (DEC) and who have low levels of risk and complexity;
- Veterans with minimal activity (progress notes) on their case plan; and
- Veterans with no current desired outcomes in-progress.
There are additional DEC decisions and eventually efforts to transition out of case management required for:
- Veterans who are accessing Vocational Services through the Service Income Security Insurance Plan (SISIP)Footnote 17 and do not have any VAC funded medical/psychosocial services; and
- Veterans who do not have disability benefits, are eligible for the Rehabilitation Program, and have had a case plan open longer than 2 years.
If the results were extrapolated to the case managed Veteran population existing within the criteria listed above it is estimated that over 800 Veterans could potentially be transitioned out of Case Management to a more appropriate level of support. This would include approximately 250 additional Veterans requiring DEC decisions who could also be moved to a more appropriate level of support.
The evaluation team also reviewed documents associated with previous file reviews completed by VAC’s Case Management Support Services Directorate in 2017. The review highlighted there were individuals receiving Case Management that did not have complex needs and met the criteria to no longer be case managed. Efforts as a result of this project resulted in approximately 1,800 Veterans transitioning from being case managed to a more appropriate level of support including guided support, targeted assistance, or self management.
The VAC 2017 National Survey included a section on well-being for case managed and non-case managed Veterans. Chart 1 shows responses to various well-being related questions by Veteran type.
Chart 1: VAC’s 2017 National Survey Results, Case Managed Veterans and by Service Type
Chart 1: VAC’s 2017 National Survey Results, Case Managed Veterans and by Service Type
| In general, would you say your health is? (% good / very good / excellent) | In general, would you say your health is? (% good / very good / excellent) | Satisfied with life in general? (% very satisfied / satisfied) | Your main job or activity? (% very satisfied / satisfied) | Your leisure activities? (% very satisfied / satisfied) | Your financial situation? (% very satisfied / satisfied) | Your overall Well Being? (% very satisfied / satisfied) | |
|---|---|---|---|---|---|---|---|
| Case Managed(n-199) | 30.8% | 31.0% | 53.8% | 42.% | 35.4% | 62.0% | 53.8% |
| CAF Non CM (n-487) | 54.6% | 71.3% | 81.2% | 74.6% | 65.3% | 74.6% | 74.9% |
| War Service (n-185) | 70.7% | 93.7% | 93.1% | 90.5% | 87.0% | 88.6% | 91.9% |
| RCMP (n-195) | 67.2% | 73.3% | 90.6% | 83.0% | 76.4% | 84.5% | 82.6% |
The trend lines above identify that surveyed individuals in receipt of Case Management Services have lower levels of self-rated health, mental health, and lower levels of satisfaction with life in general, main job or activity, leisure activities, financial situation, and overall well-being. However, as identified, there are portions (ranging from 30%-62%) of the Case Management Veteran group that reported satisfaction with various well-being questions and subsequently may present an opportunity for their needs to be met with a different level of support.
Overall, based on the multiple activities completed to assess the reach of Case Management Services, the evaluation finds that there is an opportunity for VAC to undertake further efforts to ensure that Veterans who do not have complex needs and no longer require a Case Manager are transitioned to a more appropriate level of support.
Recommendation #1:
It is recommended that the Director General, Service Delivery and Program Management, work in collaboration with the Director General, Field Operations to:
- Increase screening and case management reach for CAF Veterans and former RCMP members with complex needs; and
- Reduce barriers and provide additional support to further enable Case Managers to transition Veterans that do not have complex needs into a more appropriate level of support.
Management Response:
Management agrees with this recommendation. VAC implemented a new screening tool expected to improve the effectiveness of identifying Veteran risk levels and needs in January 2019. This new tool will result in more accurate triaging of Veterans to an appropriate level of service. The screening tool is expected to increase reach to specific groups that may not have been referred for case management consideration in the past.
| Corrective Actions to be taken | Office of Primary Interest (OPI) | Target Completion Date |
|---|---|---|
| In addition to the new screening tool, the Director General Service Delivery and Program Management will work in collaboration with the Director General Field Operations to: | ||
| i) Develop new service delivery monitoring and follow-up reporting processes to support the early identification/screening of Veterans that may have complex needs based on the Veteran accessing other VAC programing/services; | Director General, Service Delivery and Program Management Division and Director General, Field Operations Division | December 2019 |
| ii) Provide enhanced mental health training to Veteran Service Agents to support early identification and triaging of Veterans experiencing mental health concerns. | March 2020 | |
| The Director General Service Delivery and Program Management will work in collaboration with the Director General Field Operations to increase screening and case management consideration of former RCMP members by completing the following: | ||
| i) Increasing awareness of services available to RCMP by establishing an outreach program for RCMP / VAC. | Director General, Service Delivery and Program Management Division and Director General, Field Operations Division | March 2020 |
| ii) Developing a RCMP Veteran and Family Resource page, and providing enhanced training for VAC staff to help inform of the services and benefits available. | ||
| iii) Exploring ways for enhanced transition services to be offered to the RCMP. | ||
| iv) Implementing new monitoring reports to ensure RCMP are being screened/reached more proportionally. | ||
| v) Reviewing VAC's resource requirements needed to support RCMP transition and case management services, and if required, exploring options for increased resource allocation. | ||
| The Director General Service Delivery and Program Management and the Director General Field Operations will work in collaboration to reduce barriers and provide additional support to further enable Case Managers transition Veterans that do not have complex needs into a more appropriate level of support. | ||
| i) Conducting a review of case management and rehabilitation processes, including the processes around the decision related to Diminished Earning Capacity, with aim to identify and implement changes that will streamline the process and reduce burden on case managers. | Director General, Service Delivery and Program Management Division and Director General, Field Operations Division | March 2020 |
| ii) Developing a new monitoring, reporting and follow-up process to ensure Veterans are receiving a level of support that aligns with their needs. | ||
| iii) Establishing and implementing a strategy to support the transition of low risk/low needs Case Managed Veterans to guided support services and/or targeted assistance. | ||
| iv) Implementing a new team approach to Case Management that will result in Veterans with specific types of needs receiving service delivery support from VAC roles best suited to meet their needs, such as health professionals and/or Veteran Service Agents. If required, changes to delegated decision making authorities will be pursued to support this approach. | ||
| v) Conducting a qualitative research study to follow-up on the VAC National Survey results from 2017 in order to better understand the client experience of case management and inform the development of tools and processes. | June 2019 | |