4.0 Findings – Performance

4.1 Performance Measurement

Performance measurement is generally described as the regular measurement of indicators and outputs established to track progress towards achieving the intended outcomes of a program. The preferred admission beds initiative was implemented as a short-term measure while the Department reviewed potential updates to its health care regulations (this work has not been completed). As a result, performance measures were not developed for the initiative. A performance information profile is currently in development for the Program as a whole.

With regards to preferred admission beds, data is kept on the number of beds in use on a monthly basis. A snapshot taken September 30, 2018 showed 172 out of 182 preferred admission beds were occupied on that date (95% occupancy). The evaluation team was unable to obtain additional evidence of performance data being regularly collected, reported, or monitored by program management and used to support decisions related to the initiative. Information relating to outputs, outcomes, and expenditures would provide value related to the initiative to inform decision making.

As stated above, formal outcomes were not identified for the preferred admission beds initiative. Planning documents state that the objective of the initiative was to negotiate preferred access for Veterans who are eligible for community beds, but are not eligible for contract beds in former federal Veterans hospitals.

In line with the objective of the initiative, preferred admission beds have provided Veterans with expedited access to long-term care in former Veterans hospitals. As of September 30, 2018 10 agreements for preferred admission beds have been signed and implemented. A further eight are in various stages of negotiations. Preferred admission beds are mostly full and agreements have been renegotiated for additional beds in some facilities. This is evidence of the initiative’s success. Growing waitlists are also an indicator of the success of the initiative. However, there remains a complement of contract beds that could be further utilized (see Appendix C).

Interviews with field staff indicated positive views of preferred admission beds. Staff view preferred admission beds as another option for assisting Veterans who need long-term care. VAC staff and facility staff indicated positive feedback from families and Veterans on the Veterans’ placement in these facilities. However, some interviewees questioned the use of the frail policy as the eligibility gateway to a preferred admission bed when there does not appear to be a link between the need for a bed and the Veterans service related disability.

4.2 Long-term Care Strategy

Interviews with VAC staff and long-term care stakeholders point to a growing need for VAC to reconsider its current long-term care strategy. Representatives from long-term care facilities indicated that there is a desire to expand the preferred admission beds initiative as the number of Veterans in contract beds continues to decline (see Section 1 Introduction, Figure 1) and the demand for preferred admission beds continues to grow. Also, the evaluation team heard of the need for longer term planning to better allow facilities to make their own operating plans (uncertainty leads to challenges related to staffing, occupancy, overhead, financial planning, etc.). This is especially relevant for facilities in which VAC pays the full operating costs irrespective of the number of beds occupied and the province is not using the excess capacity for their citizens.

VAC’s long-term care strategy has evolved since a 2008 central agency decision to decommission 300 contract beds by March 31, 2012, in anticipation of contract bed utilization declining in future years^{Footnote 16}. A 2012 LTC strategy document stated its purpose was:

"…to position the Department to implement a per diem approach to funding care for Veterans in certain facilities with contract beds. It does not envision any changes with respect to the nature or scope of current eligibilities as set out in the Veterans Health Care Regulations. More specifically, expanding Veterans’ access to long-term care does not form part of this discussion".

The strategy was developed during a period of strategic operating review and fiscal constraint and was aimed at cost control and containment. In recent years, the Department’s long-term care strategic direction has been to work bilaterally with provinces, health authorities and facilities to:

• monitor occupancy of contract beds and identify expected vacancies;
• release contract beds when there are ongoing vacancies and no waitlists; and
• alter funding to a per diem approach or re-align annual budgets based on occupancy.

The strategy does not fully take into consideration the Department’s focus on Care, Compassion, Respect, Veteran Centric Service^{Footnote 17}, and Service Excellence towards Veterans. Other factors that need to be considered include:

• VAC is not utilizing its full complement of contract beds;
• there are waitlists for preferred admission beds at most facilities;
• some facilities are seeking to expand their preferred admission complement beyond the agreed allocation;
• contract beds are, on average, significantly more expensive than community beds (see Appendix D). In addition, provincial subsidies for long-term care beds vary between provinces (e.g., VAC pays the full cost of beds in Nova Scotia and Prince Edward Island while in British Columbia VAC pays for enhanced programming only);
• changing Veteran demographics;
• complex eligibilities; and
• the impact of preferred admission beds on the sustainability of the Program has not been determined.

Recommendation

It is recommended that the Assistant Deputy Minister, Strategic Policy and Commemoration develop and implement a renewed long-term care strategy that takes into consideration, among other things:

1. Departmental focus on care, compassion, respect; Veteran centric service; and service excellence;
2. Authorities (e.g., regulations, eligibility groups, frail)
3. Changing demographics (e.g., aging CAF Veterans, aging Canadian population, bed requirements);
4. Funding arrangements with stakeholders (provinces, health authorities, and facilities, resource requirements);
5. Data requirements and performance measures; and
6. Agreements currently in place (e.g., contract beds, preferred admission beds).

Management Response:

Management agrees with this recommendation.

Management Action Plan:

4.3 Unintended Impacts

The evaluation team noted several unintended impacts surrounding the preferred admission beds initiative, as outlined below:

• The rate of uptake for preferred admission beds has resulted in expanded bed allocations. As previously mentioned, there are waitlists for preferred admission beds at most facilities.
• Veterans’ coverage of extended health care benefits varies when in a preferred admission bed and may not be the same as other Veterans in contract beds. This has led to some confusion for facility staff who are dealing with new rules surrounding the benefits VAC will approve. For example, Veterans in contract beds have full coverage for special equipment such as wheelchairs, vision care, and dental care while some Veterans in preferred admission beds may not.
• Veterans do not have equal access to preferred admission beds across the country as preferred admission agreements are only in place in 10 locations. There is opportunity to have preferred admission beds at all locations in which VAC has contract beds. Staff indicated families are asking why their family member cannot access beds in facilities with empty contract beds.
• Preferred admission beds have added complexity for staff to an already complex program (e.g., eligibilities, systems and processes, funding, federal/provincial responsibilities and waitlists).