3.0 Relevance

3.1 Responsiveness to evolving needs

VIP began as a pilot program in 1981 called the Aging Veterans Program which focused on supports for war pensioners with a need for support to age at home due to war-related disabilities. In the mid-1980s, the program was renamed the Veterans Independence Program and was made permanent. Over the years, eligibility for the program has been extended beyond war pensioners with a service-related disability.

In 1990, a provision was made to continue housekeeping and grounds maintenance benefits for survivors for one year following the Veteran’s death. In 2003, this was extended to lifetime benefits to certain qualified survivors (now known as Primary Caregivers (PCGs)). This group is only entitled to receive housekeeping or grounds maintenance or both if that is what the Veteran had been receiving, though the amount of the benefit(s) can change depending on their need.^{Footnote 13} Under the survivor expansion in 2008, a survivor is entitled to both elements (housekeeping and grounds maintenance), however only up to a $3,114.70 maximum (2021 rate).

Also in 2003, the frail policy was introduced which approved funding for VIP services for War Service and CAF Veterans with a disability pension or award if they are deemed frail, regardless of whether there is a direct relationship between the pensioned or awarded condition and their need for home care.

“VIP is an excellent program. Let’s fine tune it [to better address needs of] older and younger Veterans.”

~ VIP decision-maker

During the period under study, the number of VIP recipients has been decreasing and the profile of VIP clients is shifting. The average age of VIP clients who are Veterans has decreased over time from 76 years of age in 2015-16 to 70 years of age in 2019-20. The average age of clients who are spouses of Veterans has remained stable at 86 years of age. Veterans in receipt of VIP who are less than 50 years of age has increased from 9% in 2015-16 to 13% in 2019-20. This increase in applications from younger Veterans is a trend observed by half of key informant groups (Senior Mangers, VAC VIP Managers and staff as well as other VAC Managers).

Additionally, 65% of surveyed VIP decision makers indicated applications not related to aging are increasing and 88% indicated applications for VIP related to mental health are increasing. Program data indicates that the portion of VIP recipients that have a mental health condition increased from 16% in 2015-16, to 30% in 2019-20.

VAC forecasts the number of VIP recipients overall will increase by 9.0% from 2019-20 to 2024-25 while at the same time the number of Survivors and PCGs is expected to decrease by 12.5% from 30,165 to 26,400 recipients.^{Footnote 14} From 2019-20 to 2024-2025, expenditures are anticipated to increase by 28.6% to $436.1M, with highest increases anticipated for housekeeping grounds maintenance, and personal care services.

In addition to these client and program trends, the broader continuum of care landscape is evolving. The literature review found home care and long-term care (nursing home) systems in Canada are under pressure with an aging Canadian population.^{Footnote 15} Coupled with an increased preference among seniors to stay at home as long as possible, there are greater demands on provincial and territorial home care systems. VAC key informants and VIP decision-makers are observing greater reliance on VIP as clients experience delays or unpredictable delivery of provincial and territorial -funded home care. Additionally, 46% of surveyed VIP decision-makers did not agree that coordination with provincial and territorial care programs works well for VIP to provide a ‘top up’ to these programs. Specifically, comments from the survey explain that provincial and territorial care programs such as Nova Scotia and to some extent Ontario have shifted a greater share of the responsibility for Veterans’ personal care needs to VAC.

Although the program administrative data does not provide a clear picture of the nature or reasons for recipients’ need for VIP, the program delivery has adapted over time to address a number of gaps in VAC’s suite of programs and services. According to key informants, support for maintaining independence at home is now understood to include more than home care for the elderly and delaying entry into long term care. They point out that it now includes needs related mental health, disability and convalescence.

VAC management and staff interviewees views are mixed regarding this evolution. Some view the spectrum of needs addressed by VIP as ‘scope creep’ which could be better addressed by other initiatives. Others recognize the value of VIP as a flexible program to address gaps in the department’s suite of programs to ensure Veterans’ needs are addressed. This includes, for instance, the introduction of the frail policy that widens access to services. This policy allows the consideration of the cumulative effects of other conditions including aging with at least one condition linked to service that on its own would not have met the threshold for an applicant to receive a benefit.

“We don’t need to reinvent the wheel, but we need to streamline [the program]. Maybe have two paths: one for younger Veterans and one for older, traditional Veterans.”

~ VIP decision-maker

A more commonly held view is VIP’s functional guidance including business processes have not kept pace with the evolving needs of VIP clients, in particular, needs related to mental health. For example, the program response to the increased applications related to mental health is reported to be inconsistent across regions (59% of surveyed decision-makers say this process is not working well) due to insufficient functional guidance and standard processes for these types of claims. Similarly, key informants and VIP decision-makers pointed to a number of areas where needs are evolving. For example, VIP recipients who are younger Veterans may have different needs related to independence such as care of dependents.

In 2020, as a first step to improve VIP functional guidance documents, VAC undertook a comprehensive pilot to create clear and easy-to-follow functional guidance documents for staff (Veteran Service Agents) who decide on VIP benefits. The pilot involved an overarching review of 40 VIP functional direction documents to remove duplications, and outdated information. As a result, the functional guidance documents were clarified and reduced to eight. This included program management and policy collaborating to clarify VIP direction into a single policy. This policy continues to provide a flexible approach that is focused on meeting the needs of clients. These functional guidance documents were tested across Canada with VIP decision makers, specifically Veteran Service Agents, who reported spending less time searching for information. A strong next step would be to clarify functional direction for mental health needs and the needs of younger Veterans overall. The results from the pilot are set to be implemented in 2022-23.

Finally, where the need for VIP may be of a temporary nature (convalescence) or for conditions that may improve over time, business processes and program capacity to administer VIP for such needs is lacking. According to administrative data, VIP benefits rarely expire (1% of cases per year). According to focus group respondents and key informants, VIP is difficult to manage as a short-term benefit for a variety of reasons including lack of capacity to monitor such claims, unintended impacts on Veteran eligibility for other programs, and perception by employees and clients that VIP is a permanent benefit. According to key informants, neither the process nor system interface for the delivery of VIP benefits was designed with short term benefits in mind.

Additionally, a review of the VIP training module for VIP uncovered an opportunity to enrich the training around VIP. Although the module is user friendly, it is limited to guiding users on how to enter data and navigate the system interface. Depth could be added by underscoring the vision and intent of the program backed by performance measurements to demonstrate the effective and quality delivery of services.

Recommendation 1:

The Director General, Service Delivery and Program Management, work in collaboration with the Director General, Policy and Research and the Director General of Health Professionals enhance employee training and update the functional guidance for VIP to address clients’ evolving needs. Particular attention should be paid to:

• Guidance in support of VIP applications related to mental health issues; and
• Situations where VIP is required for short-term or temporary needs.

3.2 Role in continuum of care

According to the literature review and subject matter experts in the health care field, managing components along the continuum of care together can maximize benefits for the system as a whole. This is exemplified in the recent motion, Motion 77, proposed by the federal government to improve long-term/nursing home care. Motion 77 proposes several financially significant changes that looks at both long-term facility-based care and home care. Specifically, it would increase spending on home care to 35% of public spending on long-term care.^{Footnote 16} Additionally, the motion includes the types of services offered by VIP such as supports for independence as well as support for formal and informal caregiving.^{Footnote 17} Home care has been found to be less expensive compared to long-term/nursing home care and is typically preferred by clients themselves.^{Footnote 18} The National Institute on Aging recently estimated home care to cost $103 per day compared to $201 to support a person in a long-term care home.^{Footnote 19} However, there is a threshold of needs beyond which facility-based care can be more cost effective.^{Footnote 20}

In 2017, home care and community care was identified as a shared priority amongst federal and provincial and territorial governments who committed to invest in access to home and community support services and to reduce reliance on more expensive hospital infrastructure.^{Footnote 21} Other research suggests that home care may be especially relevant for Veterans as they are expected to live longer than Canadians overall while having greater activity limitations and mental health problems.^{Footnote 22}

Key informants echoed the research, noting the important role that VIP plays in the continuum of care for aging Veterans. Having aging Veterans well-supported to be independent at home is important for easing pressures on the department’s nursing home/long-term care programs and the overall cost-effectiveness of the system. It was also noted by key informants that the growth of assisted living options for aging Veterans is a challenge for the current VIP service delivery processes. Specifically, the grant determination tool which cannot easily calculate the amount of the grant if the facility is unable to separate the costs of VIP-eligible benefits and services such as housekeeping from the total cost of accommodation.

The Intermediate Care component of VIP and VAC’s Long Term Care program both fund beds in nursing home facilities which provide support for multiple levels of care (intermediate and chronic care). The 2011 evaluation of VIP recommended that its Intermediate Care component is more appropriate as part of the Long Term Care program^{Footnote 23} and the 2017 Office of the Veterans Ombudsman review of the continuum of care for Veterans recommended VIP and the Long Term Care program merge into one continuum of care program.^{Footnote 24}

VAC key informants and decision-makers in the interviews, survey and focus groups also pointed to similarities between some VIP services and other VAC programs (home adaptations under VIP and home adaptations under the Treatment Benefits Program, and VIP personal care and the Attendance Allowance for Veterans with a disability-related benefit or pension. However, the eligibility criteria for these programs are distinct from VIP and the potential for duplication is reportedly well-managed through internal processes and systems. For instance, if a Veteran receives the Attendance Allowance, they are eligible for a maximum of 59 days of VIP personal care. The similarities in the programs and the various criteria were perceived by some VAC staff to be confusing for Veterans who are trying to navigate access to these programs.

3.3 Unmet needs

VIP elements are comprehensive and were found to be similar to or exceed what is offered by other jurisdictions based on the comparative review. VIP decision-makers receive requests from time-to-time for informal supports to assist with functioning in the community, companionship or informal check-ins that are not covered by VIP. The US Veteran home health program offers services to prevent isolation and New Zealand references services related to Veterans’ relationships, and emotional needs.

The 2020 VAC National Client Survey found that 84% of recipients agreed that VIP meets their needs. This aligns closely with the VIP survey of clients for this evaluation in which 14% of recipients indicated unmet needs. These unmet needs often have to do with both a lack of access to service providers and affordable service providers. While the 2020 National Client Survey found most VIP recipients were able to find service providers (85%), surveyed VIP decision-makers and some key informants indicated clients living in northern, rural or remote areas are less well served by the program due to the lack of access to service providers.

Some key informants and surveyed VIP decision-makers expressed concern about the extent to which VIP adequately meets the needs of older Veterans. These respondents pointed out that as elderly VIP recipients are typically not case-managed and follow-up with recipients is limited to every three years, opportunities to identify changing needs for services are few unless the Veteran notifies the department of a change in needs. The Office of the Veterans Ombudsman review of the continuum of care for Veterans also pointed this out, finding that identifying Veterans’ changing needs as they age was inadequate.^{Footnote 25}

“. . . it’d be nice to see 80 or 85 [year-olds] added to frail criteria, especially in regard to grounds maintenance. Elderly veterans often inquire about [this], however they may not meet the current frail criteria and are fiercely independent, but still require assistance with snow removal in particular.”

~ VIP decision-maker

Key informants in this evaluation also raised concerns specific to the well-being of aging Veterans such as how VAC measures frailty. For example, a Veteran who is able to walk can be viewed as being mobile and not frail. As a result, the Veteran cannot access grounds maintenance support despite being unable to push a lawn mower or operate shears or pruners. Key informants also noted that it is important for aging Veterans to be aware of the full spectrum of VIP benefits especially given that their needs become more complex as they age and a potential reluctance to ask for support.

Finally, stakeholders recommended VAC streamline aspects of the eligibility criteria or move VIP toward a more needs-based program. Veterans’ organizations, the Office of the Veterans Ombudsman, and VAC Advisory Groups, both Policy as well as Care and Support, urged VAC to streamline the complex web of eligibility criteria that govern access to programs such as VIP.^{Footnote 26} This includes Veterans, PCGs and survivors who are first deemed eligible for VIP and then are assessed for their level of need. Some reports suggest that needs-based criteria should take precedence over service-related criteria for Veterans. With respect to survivors and PCGs, stakeholder organizations have called for eliminating the inconsistency in VIP eligibility between PCGs and survivors. It has been further recommended that PCGs have access to the grounds maintenance and housekeeping services they need regardless of what the Veteran received.^{Footnote 27}

In the comparative review, of the three jurisdictions that offer benefits to spouses or partners, Canada is the only jurisdiction that distinguishes between survivors and PCGs. However, other jurisdictions with spousal/partner benefits (Australia and New Zealand) offer these for only a limited period of time.