4.0 Evaluation Question 1:

Are there opportunities to streamline processes by using alignments between the Table of Disability medical impairment criteria for the Pain and Suffering Compensation, and the health-related assessment criteria for the Additional Pain and Suffering Compensation and Caregiver Recognition Benefit programs for Canadian Armed Forces (CAF) Veterans with more significant disabilities and impairments?

The Evaluation team has noted that there are alignments between the ToD medical impairment criteria for certain conditions and the existing APSC health-related assessment criteria.

The evaluation team has identified opportunities for alignments between the medical impairment criteria for certain conditions contained within the ToD^{Footnote 7}and the APSC Policy Definitions of Permanent and Severe Impairment (sec. 33, 34); the APSC Policy Grade Levels (sec. 44-46 [see Annex A]). These sections of the policies and procedures are being referenced in the work completed in sections 4.1 and 4.2.

4.1 Table of Disabilities (ToD) Medical Impairment Criteria

Once the initial PSC application is assessed and entitlement is granted by a medical adjudicator using the ToD medical impairment criteria, the client may go on to have this same impairment reviewed again for other VAC programs. The evaluation team saw benefit in considering how these initial impairment ratings, could be used to align with the program policies and procedures outlined in 4.0. During consultations with VAC’s Medical Advisory it was determined that there was potential for some ToD medical impairment criteria already determined during the PSC disability assessment for certain conditions to be used to inform APSC and CRB program decisions.

4.2 Potential Alignments for Consideration

The evaluation team examined a number of ToD chapters/tables and their associated medical impairment criteria and compared them with the program policies and business process outlined in 4.0.

The following examples (Table 4) were identified by the evaluation team as potential areas for alignment consideration. Additional alignments may exist but require further comparative analysis by Medical Advisory and the program areas.

4.3 Additional Pain and Suffering Compensation

To explore the relationship between the T0D medical impairment criteria and the APSC health-related assessment criteria, as previously indicated the evaluation team used the former CIA program as substitution.

Participation in the Rehabilitation Program was a requirement for the CIA program. This requirement effected the number of people who were entitled to apply for the CIA program. However, with the ending of the CIA and the introduction of the APSC, those clients in receipt of CIA were automatically transferred to the APSC program for the same condition and at the same grade level. For the APSC program, Rehabilitation Program participation is no longer a requirement for entitlement, but a barrier to re-establishment is. To determine whether a disability creates a barrier to re-establishment, the nature of the disability must be analyzed to determine how, and to what extent, the disability limits the Veteran’s performance in civilian life of their roles in the workplace, home, or community.

To better understand the relationship between the APSC program via the CIA program and the evaluation threshold, the evaluation team looked at 9,492 Rehabilitation participants who met the evaluation threshold^{Footnote 8}. The team identified 7,924 who had applied for the CIA program and 1,568 who did not apply. Of the 7,924 applicants, 96.9% received a favourable CIA program decision, highlighting the relationship between the evaluation threshold and the health-related CIA program assessment criteria. For the 1,568 clients who did not apply, the barrier to re-establishment requirement, a requirement for APSC, would have already been met through their Rehabilitation Program approval. Therefore, the analysis would suggest that this group of 1,568 clients would have a similar favorable rate to that of the 7,924 if they applied to the APSC program being that they meet the entitlement requirements.

The evaluation team identified 208 conditions that, when applying the evaluation threshold, would receive a favourable decision for the CIA program in excess of 90% of the time. Some examples of these conditions include osteoarthritis of the lumbar spine, alcoholism, amputation below the knee, and Amyotrophic Lateral Sclerosis (ALS). This demonstrates existing information could potentially be used to predict entitlement for additional programs for some of the more significantly impaired Veterans. These conditions would benefit from a more thorough review as a result of the recommendations from this evaluation.

4.4 Caregiver Recognition Benefit

A detailed analysis of the CRB program was completed in the summer of 2020 by the CRB program evaluation team and the recommendations from that evaluation were considered for this project. Specifically the recommendation: 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.

To explore the relationship between the ToD assessment criteria and the CRB program, the evaluation team reviewed data for clients who met both the evaluation assessment threshold and the following CRB eligibility criteria:

• the Veteran received a disability award (now replaced by Pain and Suffering Compensation); and
• the Veteran was not in a long term care facility.^{Footnote 10}

Upon review, 1,146 (or 19%) of the 5,894 Veterans who met the evaluation threshold criteria applied for the CRB program. Of those Veterans that did apply, 44% received a favourable decision (as shown in Table 5 below).

This would suggest that the correlation between the ToD medical impairment criteria for PSC and the CRB health-related assessment criteria is not as strong as the correlation between the ToD medical impairment criteria and APSC health-related assessment criteria. There are a low number of Veteran caregivers actually applying for the program (1,146) at the evaluation threshold. This may be because the type of impairment or the impact of the impairment on the Veteran’s ability to care for themselves does not require a caregiver.

Given the modest correlation between the ToD medical impairment criteria and the CRB health-related assessment criteria coupled with the different program intent/design and the caregiver requirement, the evaluation found that using the ToD assessment to identify potential CRB recipients would not realize efficiencies.

Health-related information is a fundamental contributor to overall CRB entitlement, but it is not the only requirement or variable for a favourable decision. Other key determinants include whether the Veteran requires ongoing care as a result of the health condition(s) for which the disability award application was approved; the presence of a caregiver providing care in the home or if the Veteran is residing in a long term care facility.

4.5 File Reviews

Interview data from APSC decision makers also highlighted the possibility of aligning APSC assessment criteria to certain disability conditions based on the criteria captured within the ToD. Interviewees suggested this could be done for certain psychiatric conditions and for hearing loss clients with audiograms showing 300 decibel hearing loss in both ears. To explore this further, the evaluation team conducted file reviews on these conditions for individuals who were not in receipt of the CIA program as of March 31, 2019.

4.5.1 Psychiatric Impairment File Review

Based on the decision maker feedback and the number of Veterans that meet the evaluation threshold for psychiatric conditions, the evaluation team explored the strength of the relationship between the ToD medical impairment ratings and criteria, and the APSC Grade Level determinations. The evaluation team identified those Veterans who had a psychiatric disability that met the evaluation threshold and who were not in receipt of the CIA^{Footnote 11} program as of March 31, 2019. Unlike the data presented in Table 5, participation in the Rehabilitation Program was not a consideration in this group. There was a total of 3,173 Veterans who met this criteria and data was pulled from a random sample of 100 of these Veterans.

Upon reviewing the ToD worksheet impairment criteria and ratings of the 100 Veterans (released) in the sample, it was found that there was sufficient evidence to grant a favourable APSC decision for 94% of the clients under review. The file review was validated by APSC decision makers, and considered impairment and associated barrier eligibility requirements. This finding further demonstrates the strength of the correlation between the PSC’s ToD medical impairment criteria and the APSC health-related assessment criteria.

The remaining 6% of the sample group were not eligible for APSC as they were already in receipt of the Exceptional Incapacity Allowance (EIA) and are therefore unable to also receive APSC entitlement.

4.5.2 Hearing Loss (HL) File Review

The same methodology was then applied to Veterans with a Hearing Loss disability. Of the 900 Veterans identified that met the criteria, the evaluation team reviewed the information contained within the ToD hearing loss impairment table, of a random sample of 100 clients. The team determined a favourable APSC decision could be made for 84% of the clients under review^{Footnote 12}. If the results are extrapolated to the whole cohort of clients who meet the review criteria, there could be 756 clients who may not have met CIA requirements that could be eligible for APSC. The 16% who did not meet the APSC assessment criteria did not have a 300DBL hearing loss in both ears as defined in the APSC policy.

Although not a formal business process, some adjudicators began sending work items to the APSC unit in 2019 to flag clients who met the policy definition of severe hearing impairment (300 DSHL threshold in both ears).

A sample of the two file review findings were validated by program decision makers.

4.6 Application Waivers

In 2018, the Application Waiver Policy came into effect for use with Veterans Well-Being Act^{Footnote 13} programs. The overall intent was to waive the requirement for applicable program applications so as to decrease administrative burden on Veterans, their families and VAC staff. The policy suggests a waiver can be used if information has already been collected or obtained as part of VAC’s ongoing administration of programs, services and daily operations, and that the individual may be eligible for the benefit (compensation, service or assistance) should they apply for it.

Application waivers can be applied to many VAC benefits including PSC, APSC, and CRB. A waiver of application is not a guarantee that a favourable eligibility decision will be made, rather a waiver removes the requirement for the person to submit a written application. The evaluation team was unable to find evidence or tracking information on application waiver use at VAC for the CRB or APSC program.

The Caregiver Recognition Benefit Evaluation found that the application waiver has not been used for the CRB, nor were there any specific guidelines or practices developed to use the application waiver for the program. Should the waiver be used, there is still the requirement of the delegated decision maker to follow all established processes for determining eligibility after contact with the Veteran has been made to ensure they wish to proceed with an application.

The evaluation team considers the use of application waivers as a positive start for reducing client application burden, but suggests that there are additional opportunities to create efficiencies and draw upon existing alignments that will further reduce this burden on clients as well as staff.

Recommendation 1a – The Assistant Deputy Minister (ADM) of Service Delivery explore opportunities to better align the Table of Disabilities (ToD) chapters/tables 9.1 (hearing loss), 17 (musculoskeletal), 21 (psychiatric), and other conditions as determined by Medical Advisory, with the existing health-related assessment criteria for the Additional Pain and Suffering Compensation (APSC) to facilitate program access for Canadian Armed Forces (CAF) Veterans assessed with more significant levels of disability and impairment.

Recommendation 1b - The ADM of Service Delivery, in consultation with the ADM of Strategic Policy and Commemoration, explore opportunities to streamline entitlement decisions for the Additional Pain and Suffering Compensation (APSC) (Recommendation 1a) by using the information captured during the initial/reassessment PSC entitlement decision.