Related Health Services (POC 12)

This policy replaces the following VPPM 2 policy: 2.2.21 Related Health Services General (POC 12).

Purpose

The purpose of this policy is to provide guidance on the range of services and benefits that are available under Program of Choice 12 - Related Health Services (POC 12).  This document aims to establish policy, provide guidance and set forth basic principles that are to be applied in decision making on POC 12 issues. This document aims to provide direction; it is not to be interpreted as a list of rules.

Policy

Context

1. The purpose of this section is to illustrate the relationship between the relevant authorities and the policy principles contained in this document.
2. Part I of the Veterans Health Care Regulations (VHCR) grants authority to provide “treatment benefits”; sections 3-5 describe the eligibility criteria, the benefits included and the rates payable. Part IV includes general provisions to be followed in the administration of the VHCR.
3. Similarly, Part II of the Veterans Well-being Act and Regulations grant authority to provide “rehabilitation services” and describe the eligibility criteria as well as the relevant principles and other factors.
4. This policy provides guidelines regarding the approval of related health services, i.e. those types of services which are provided by health care professionals other than physicians, dentists and nurses. This grouping of related health services is commonly described as POC 12. The services described in this policy are available to clients as “treatment benefits” pursuant to the provisions of the VHCR and/or as “rehabilitation services” pursuant to the provisions of the Veterans Well-being Act and Regulations. Please refer to Rehabilitation and Vocational Assistance Program policies for guidance related to the rehabilitation program.

Objectives and Guiding Principles

5. The policy objective of the Related Health Services program is to offer eligible clients a range of health professional services aimed at improving, restoring, or maintaining physical and mental health.
6. The guiding principles of the Related Health Services program are:
   1. The services offered under this program are recognized by VAC as being treatments which are evidence-based and have proven efficacy such that they are reasonably expected to achieve positive treatment outcomes;
   2. The provision of services will be focused on addressing the needs of the client with consideration given to specific client outcomes;
   3. Services are to be provided as soon as reasonably possible; and
   4. As clients present with multiple needs requiring multiple service interventions and may require assistance accessing services, decision makers shall ensure that case management services are applied as appropriate.

Definitions

7. 1. Acute means having a short course of illness. There is a reasonable expectation that short term health care will produce positive treatment outcomes. Symptoms appear and/or change rapidly.
   2. Chronic means that a condition has existed for at least 6 months and that signs and symptoms are generally expected to persist despite health care, although they may wax and wane over the 6 month period and thereafter. A chronic condition is continuous or persistent over an extended period of time and is not easily or quickly resolved.
   3. Group Therapy means a form of therapy or treatment in which one or several approved providers treat a small group of clients together as a group.
   4. In-Home Treatment means that a health professional is delivering the treatment or providing the health service at the client's home.
   5. Maintenance Therapy is generally considered to be ongoing therapy which is applied to a chronic condition. That means that the therapy is not aimed at addressing the acute or flare-up phase of a condition. Maintenance therapy should produce an effect which minimizes or prevents further deterioration of a health condition. In some cases, maintenance would be a reasonable treatment  outcome.
   6. Prescription means a written or verbal order by a health professional authorized to prescribe in the jurisdiction where s/he practices that describes the treatment or services recommended in relation to the client’s health needs.
   7. Positive treatment outcome is one which is expected to result in improvement, restoration, or maintenance of health. This may include slowing the worsening of a condition or providing pain management. A positive treatment outcome would normally be expected to result in a reasonable level of daily functioning given the individual’s situation. In some instances, maintenance therapy may be a positive treatment outcome.
   8. Provider means a health professional approved by the Minister pursuant to the policy set out in the Health Professionals policy.
   9. Related Health Services are those services provided by health professionals other than physicians, dentists or nurses. Related health services generally include, but are not limited to, those services provided by health care practitioners such as chiropractors, massage therapists, acupuncturists, physiotherapists, chiropodists, podiatrists, osteopaths, occupational therapists, hearing and speech therapists and psychologists.

Eligibility

8. Eligible clients are those who are entitled to receive treatment benefits under the VHCR and clients who are entitled to rehabilitation services under the Veterans Well-being Act (VWA).

Approval Standard

9. The following principles apply:
   1. For A-line clients: The service or benefit that is provided must be in respect of the pensioned/awarded condition as outlined in the Treatment for a Disability Benefits Entitled Condition policy.
   2. For B-line clients: The need for the requested service or benefit must be clearly demonstrated. POC 12 services and benefits may then be approved to the extent that the requested service(s) is not available to the client as a member or former member of the CF nor available as an insured service under the provincial/ territorial health care system where the client resides.
   3. For Rehabilitation Program clients: The need for the requested service or benefit must be identified by an assessment of the rehabilitation needs and must be included as part of an approved Rehabilitation Plan.
       

Needs-based Approach

10. Eligible clients are to be approved for services under POC 12 based on need.
11. Generally, a need is demonstrated by having the service:
    1. prescribed by the attending physician; or
    2. identified in an approved Rehabilitation Program Plan; or
    3. identified in an VAC case plan for a non-rehabilitation client who is case-managed.
12. When a need for a service or benefit has been identified and supported in an approved VAC case plan or Rehabilitation Program Plan, clients do not need to present a prescription in order to be approved for the service. Rather, the need and legitimacy of the benefit would have been confirmed by the decision maker as being appropriate, based on the evidence available.
13. In the absence of a prescription, a VAC case plan, or a Rehabilitation Program Plan it may be reasonable to approve services when it has been determined that a need has been demonstrated by another means (e.g. treatment plan, VAC or other health professional assessment, etc.).

Prescription Requirement

14. The following provision applies only when there is no legal requirement for a prescription (e.g. pharmaceuticals as per VHCR section 4(c)).
15. The prescription requirements noted on the POC 12 benefit grids may be waived in circumstances where the need and appropriateness have been established by an alternate means. Examples may include but are not limited to:
    1. clients who do not have a family physician and who present to VAC with a medically justified treatment need; or
    2. clients who are transitioning from the Canadian Forces and are already in a course of treatment which was approved by CF; or
    3. those cases where adhering to the prescriber/recommender requirements would result in undue hardship to the client or in a detrimental delay in issuance of the service.

Standard POC 12 Services

16. The services which are ordinarily available under this program appear on the Related Health Services Benefit Grids. When eligibility and need have been established, these services can be approved.

Approval of Services not Appearing on Benefit Grids

17. Services not listed in the Benefit Grids may be approved in circumstances where the Departmental authority, based on information and medical justification provided by the treating provider, is of the opinion that:
    1. the service would qualify as a related health service; and
    2. the service is clinically necessary in order to maintain the client's health; or
    3. the client’s condition and/or general health would be negatively affected in the absence of this particular treatment; or
    4. there is no other clinically acceptable treatment available in this case; or
    5. other equally significant factors exist.
18. In all cases, it is desirable to have medical justification which describes that the client is a good candidate for the service being proposed and that the client's health is not expected to be negatively impacted by what is being proposed.

In-Home Treatment

19. Payment for in-home treatment by providers can be approved by VAC. These should be approved only when it has been demonstrated to the satisfaction of the designated VAC approval authority, that the client requires the benefit or service and the treatment needs cannot be met on an out-patient basis (because the client’s health or condition does not permit the client to attend the provider’s usual place of business, for example).
    1. The applicable fees for in-home treatment benefits provided by virtue of the VHCR are to be paid in accordance Section 5 those regulations.
    2. Payment for in-home treatment services provided to Rehabilitation Program clients through the Veterans Well-being Act should reasonably be made at the rate that is normally charged for non-Veteran clients accessing the same service.

Group Therapy

20. Group therapy or services can be covered by VAC when it has been identified by a client’s provider as an appropriate treatment modality and when facilitating group therapy is within the scope of practice of the provider.

Missed Appointments

21. Payment to providers for costs associated with a missed appointment will normally be the responsibility of the client.

Providers

22. Services provided under this program are to be provided by health professionals. The VHCR define a health professional as a physician, dentist, nurse or other health care practitioner approved by the Minister. In most cases, Related Health Services are provided by health care practitioners who are not physicians, dentists or nurses.  Therefore, providers must be health care practitioners approved by VAC. Approval of health care practitioners is subject to the policy, Health Professionals.

Treatment Extensions

23. The Benefit Grids and limits set out therein are to be used as intended; they are guidelines set at levels where most clients will have their needs met most of the time.  When additional sessions are justified, clients are eligible to receive those services which will address their needs. The policy objective and guiding principles outlined in section 5 of this policy are the prevailing factors when considering requests to extend benefits beyond what was initially provided.
24. In addition to the policy objective and guiding principles in section 5 of this policy, the following principles should be applied when making decisions on treatment extensions:
    1. Requests to extend treatment beyond what was initially approved should generally be based on a treatment plan provided by the health professional who is providing the service.
    2. Additional therapy must add value. If there is evidence which indicates that further sessions are not reasonably expected to result in positive treatment outcomes, then approving further sessions may be inappropriate or excessive.

Treatment Plans

25. Generally, the treatment plan should demonstrate how the intervention has been and is reasonably expected to continue to be effective in reaching the desired treatment outcomes.
26. Treatment plans should:
    1. Identify a specific anticipated treatment outcome.
       Some examples of specific outcomes may include:
       1. Relief of pain such that patient can return to work part-time.
       2. Restore normal range of motion at left shoulder.
       3. Increase mobility/flexibility such that the patient can transfer independently from wheelchair to bed.
       4. Maintain ability to cope with anxiety without medication.
    2. Describe how the progress is measured.
       The treatment plan should describe information such as:
       1. What is the state of the client’s condition at the beginning of treatment?
       2. How was it measured?
       3. How has it changed?
       4. How/why are additional sessions expected to achieve positive outcomes?
          Examples of outcome measurements may include:
          Patient’s pain will decrease from 5 to 3 on the pain scale.
          Patient will be able to sit for 6 hours rather than current 3 hours.
    3. Demonstrate that the desired outcomes are attainable/reasonable given the client’s circumstances.
       A treatment plan should indicate that consideration has been given to what is known of the client’s physical, cognitive, social and environmental barriers. For example, for a client with a degenerative condition such as Multiple Sclerosis, a goal of being able to transfer independently from wheelchair for the next month may be more realistic than being able to always transfer independently.
    4. Provide a time structure.
       Ideally a treatment plan should provide some context regarding the time structure such as:
       1. What is the anticipated frequency of treatments?
       2. What is the duration of treatment?
    5. Other considerations
       The following considerations may be relevant factors in considering a request for treatment extension. While this information may not appear on a treatment plan, it may be necessary to review the client’s VAC file and/or other treatment documentation or to request a medical or other health professional opinion.
       1. Whether the requested treatment is the most suitable form of treatment for the condition being treated;
       2. Whether a review of the client's case indicates that there could be a negative impact on the client' s independence or health status if provision of the treatment did not continue; and
       3. Whether alternative options such as home exercise programs, community support programs, etc., have been actively considered (if appropriate).

Swimming and Exercise Programs

27. Swimming and/or exercise programs can be provided to clients who need exercise or swimming therapy in response to an identified health need. Generally, swimming and/or exercise programs are not to be provided when they are being used strictly as a regular exercise, or as a preventative measure.
28. Swimming and/or exercise programs may be approved by VAC when:
    1. the program is part of a structured rehabilitation plan or the program is required for rehabilitation of an acute condition or of an acute flare-up of a chronic condition that requires a short period of rehabilitation; and
    2. it has been developed and is being monitored by an approved health care practitioner. Monitored means that the health professional periodically reviews the program and the client’s progress and adjusts the program as required; and
    3. the client’s participation in the program is being directly supervised by the approved health care practitioner who developed the plan or by an individual working under the guidance of the approved health care practitioner who developed the plan. Directly supervised means that the health professional or another designated individual is present to provide guidance and assistance when the client is carrying out the prescribed exercise or swimming plan.
29. Requests to extend a program beyond what has been initially approved can be approved when there is a continued need. Generally, VAC would expect that such a request be supported by documentation which confirms the client’s attendance and participation in the program and demonstrates the effectiveness of the intervention. The principles of section 7 (Treatment Extensions) of this policy should be applied.

Pain Management

30. Many of VAC’s clients suffer from some form of chronic pain which by nature will generally be expected to persist to some degree despite medical intervention. VAC will provide access to a wide range of services and interventions to clients to assist them in managing their chronic pain.
31. In addition to the policy objective and guiding principles in section 5 of this policy, the following principles should be applied when making decisions regarding addressing pain management issues:
    1. The fact that a condition is chronic in nature is not sufficient rationale to approve or decline a particular service or intervention. Rather, consideration must be given to the outcome that the intervention is expected to have on the condition being treated as well as to the effects on the client's overall health.
    2. Long-term treatment of a chronic condition should continue to be approved by VAC to the extent that there is evidence which demonstrates that the service results in a positive treatment outcome.
    3. While patients may desire relief of symptoms, this may be an unrealistic outcome. Complete relief for patients with chronic pain is often unattainable.  Therefore, it is important to consider incorporating supportive services that can help the client cope with and manage their chronic pain (e.g. pain management programs).
32. While decision makers are to be guided by POC 12 Benefit Grids and the specifications set out therein, the provision of benefits to clients is not to be unduly restricted when there are clear indications to exceed these limits. The section regarding Treatment Extensions provides guidance regarding approval of VAC’s standard benefits beyond limit levels.
33. In addition to medical and pharmacological treatment and the use of complimentary therapies, other interventions which are designed to assist clients in coping with and managing their pain can be beneficial. It is important to evaluate repeated requests for treatment extensions with a view to transitioning to supportive services that can help the client manage their chronic pain.(ex. pain management programs).
34. Pain management programs vary in the type of service(s) they provide and may be delivered on an out-patient basis or as part of an inpatient program at a hospital or at a specialized center.
35. The type of pain management program including the duration and cost that is to be approved for a client will depend on client need.
36. Pain management programs, interventions and services are to be provided to clients as identified in a VAC case plan or in an approved Rehabilitation Program plan. Requests for pain management programs from other clients should be pre-authorized.

Reference

Veterans Well-being Act Part II, sections 6-17;

Veterans Well-being Regulations, Part II, sections 6-16.

Veterans Health Care Regulations Part I, sections 3-5. and Part IV

Treatment in Respect of a Pensioned or Awarded Condition

Health Professionals

Related Health Services (POC 12) – Benefit Grid